Treatment for gender dysphoria in children has come under increased scrutiny in recent years. As of January 2021, no states in the U.S. prohibited youth gender-affirming care. Since then, however, 26 states have passed bans. In December 2024, Wes Streeting, the current Health Secretary of the United Kingdom announced that a previous emergency measure prohibiting new prescriptions of puberty blockers to underage patients would now become an indefinite ban. On Tuesday, January 28th, the White House announced an executive order directing federal agencies to cease supporting gender affirming care for anyone younger than 19. Now, the United States Supreme Court is considering Tennessee’s ban on gender affirming care for minors, including puberty blockers and other hormone therapy.
Why the push to halt the use of these drugs in gender-affirming care? Advocates of the bans cite worries about the potential for long-term harm. The brain undergoes significant development during puberty and it is not clear what role sex hormones play. Unfortunately, the data are just not there – long-term studies of human patients observing the effects of puberty blockers on their development are only just underway and it will take literal decades to determine life-long effects, if there are any. As a result, there is a plausible mechanism by which puberty blockers and other hormonal treatments could produce harm, but the data are insufficient to firmly establish this.
That said, some data suggest that those who take puberty blockers experience changes in body composition, are shorter and have slower rates of growth than their peers. Research in animal models suggest that puberty blockers may produce cognitive deficits – male sheep treated with puberty blockers were significantly slower to progress through a familiar maze, even after treatment ceased.
There are two things worth noting, though. First, reactions in animal models, particularly in pharmacology studies, are not always reliable indicators of human reactions. Second, some of the currently available data on hormone replacement therapy complicates the picture of potential long-term consequences. Animal models provide data suggesting that some consequences of puberty blockers, including infertility, may be reversible with future hormone therapy.
Of course, negative consequences are just one part of the picture. We must also look at the reasons why underage patients seek prescriptions for hormonal treatment. Undergoing puberty causes numerous changes to one’s body. For individuals suffering from gender dysphoria, these changes may produce significant distress. The data show that gender non-conforming youth are significantly more likely to experience symptoms of anxiety and depression, to confront suicidal thoughts, and to attempt suicide. But those who seek and receive gender affirming treatment, including puberty blockers experience positive psychological outcomes, including greater life satisfaction and fewer symptoms of depression and anxiety, after beginning treatment.
As of now, the data suggest these treatments are a mixed bag. There are potential negative consequences associated with puberty blockers and other hormonal treatments, specifically, interference with growth. Negative cognitive consequences are possible, but the data are, at best, suggestive. More research is necessary. But casting a further cloud over the possibility of clarity is that gender dysphoric individuals are more likely to experience comorbid conditions such as depression and anxiety than members of the general population. Troublingly, these conditions correlate with worse performance on cognitive assessment measures.
So, what does this mean for hormonal treatments? If we take it for granted that there are potential long-term negative consequences, then it seems like they offer a trade-off. Specifically, a trade-off between physical health, cognitive function, and mental health.
But just because we regard some initial consequences as negative does not mean that they will prove harmful in the long run. Consider the following case. Imagine that, while crossing the street one day, I am hit by a car and break several bones. The recovery requires surgery along with many months of physical therapy and rehab. While I regain independence, I never quite reach my prior physical capability. Further, having suffered a head injury after hitting the ground, I now have permanent deficits in my long-term memory recall. Nonetheless, I find that the perseverance I developed during rehab serves me well throughout my life; I feel that I am more resilient, better able to regulate my emotions during trying times, and work harder through adversity.
Imagine now that a time traveler offers to travel back in time and push me out of the way of the car, preventing my accident. Should I accept her offer? It seems that either choice would be reasonable. One could hardly blame me for wanting to avoid the suffering, the surgery and the recovery (along with the medical bills), and to undo the deficits which now affect me. Yet, simultaneously, it seems like a rational person may still accept the offer. Perhaps I think my newfound character is worth the negative consequences of the accident.
What does this example show us? It displays the complexity of the idea of harm. This is revealed in two interlinked ways. First, establishing a negative consequence is not by itself enough to demonstrate that something is harmful. It may be the case that something’s positive aspects outweigh its negative aspects. Second, whether the positives do outweigh the negatives may sometimes be best determined by the individual who experiences it. Outright bans on gender affirming care seem to set aside both of these facts. They view the potential for negative consequences as sufficient grounds to eliminate the treatments entirely, not taking seriously the potential positives, nor the possibility that one receiving the treatment might think the risk is worth taking.
Of course, detractors may point out that the bans target these treatments for children only. Perhaps, even if a reasonable adult could judge these treatments as beneficial, a child is not yet a competent enough decision maker for that choice.
Two points are worth raising in response. First, legal adulthood is an arbitrary threshold. The frontal lobe, the portion of the brain that deals with complex decision making and problem solving, does not finish developing until the mid-20’s at the earliest. Yet children in the U.S. may be competent enough to drive at 16, to vote at 18, to buy alcohol at 21, etc. We seem to view competent decision-making as a spectrum, not a binary. It is not immediately obvious why 18 is the appropriate threshold for when one has become competent enough to consent to gender-affirming treatment. Second, legal guardians already serve as the surrogate decision-makers in this context. If they cannot make competent informed decisions regarding gender-affirming care, then this implies that no one can. If the worry is that the many unknowns eliminate the possibility of informed consent, this view would call into question much of currently acceptable medical practice. Few treatments, if any, have their lifetime consequences known before approval. From 2001 to 2010, about one-third of all drugs approved by the FDA were found to have unexpected side-effects, some of which were life threatening. A purely precautionary approach would require a radical revision of how we think about medicine.
In closing, some perspective is warranted. Proponents of bans on gender-affirming care for underage patients, such as Tennessee’s Attorney General Jonathan Skrmetti, often cite European nations like Finland, Sweden, and the Netherlands beginning to walk back the use of hormonal treatments for minors seeking gender-affirming therapy as evidence supporting bans. Yet this willfully misrepresents the situation. These nations are ensuring that their current treatments more carefully adhere to the “Dutch Protocol,” not altogether banning the treatments. With a matter as intimate as a patient’s relationship to their own body, any universal approach seems like wielding a machete when a scalpel is required. Given the complexity of the issues involved, including the tradeoffs regarding uncertain consequences, decisions about these treatments seem best left to the particular parties involved – parents, patients, and medical providers – not the government.