April 3, 2024

Puberty Suppression for Pediatric Gender Dysphoria and the Child’s Right to an Open Future

Right to "Open future" is most consistent with letting children become adults before proceeding with gender transition, conclude study authors

A new peer-reviewed article published in the Archives of Sexual Behavior examines the clinical and ethical implications of puberty blockers for children with gender dysphoria through the lens of “the child’s right to an open future.” As the authors explain, the open future principle refers to “rights that children do not have the capacity to exercise as minors, but that must be protected so they can exercise them in the future as autonomous adults.” It was introduced by Joel Fienberg, an American legal and political philosopher more than 40 years ago and has since been applied to multiple bioethical issues in pediatrics. 

The authors note that under the gender-affirming care framework, a normal physiological process of puberty is viewed as a disease that must be treated with endocrine and surgical treatments. Puberty blockers are the first step in what is effective a "cascade" of interventions. Those advocating for the use of puberty blockers for gender-dysphoric children have argued that allowing endogenous puberty to proceed unimpeded could foreclose a child’s “right” to achieve their “gender embodiment goals.” The authors examine this framing, noting that it rests on two key assumptions: "(1) puberty blockers are a low-risk, reversible intervention, and (2) that suppressing puberty will improve physical and psychological outcomes in later life."

The authors note that these claims are not supported by evidence. For example, while the adverse effects of puberty blockade for a short time may be minimal, many children remain on puberty blockers for years, which can lead to harm (e.g., negative effects on bone and brain development, inability to have children of their own, or experience sexual pleasure as adults). There are also significant unknowns associated with interrupting a vital step of human development. The authors ask, "​​​​​​What are the consequences of not reaching psychosocial developmental milestones with peers when puberty is arrested?"

Further, they argue that puberty suppression is not a reversible, standalone intervention, but instead it triggers a cascade of increasingly invasive medical interventions. Rather than buying time for children to explore their feelings about gender and weigh risks and benefits of various treatment options, as proponents of puberty suppression have often claimed, the authors point to multiple studies that demonstrate nearly all children who undergo puberty suppression proceed to cross-sex hormones.*

Even if achieving "embodiment goals" is a valid therapeutic endpoint (a question the authors grapple with in their paper), the authors point out that there is no way to predict how "any certainty how a child’s gender self-image and embodiment goals will evolve over time." Noting Feinberg's observation that a child’s long-term interests “cannot be established by determining [their] present desires," the authors conclude that delaying "medical transition until the child has had the chance to grow and mature into an autonomous adult would be most consistent with the open future principle." The authors note that the same reasoning can be applied to treating youth with cross-sex hormones and surgeries (although the latter are not the subject of the publication). 



The full study can be read at the link below: 

  • https://link.springer.com/article/10.1007/s10508-024-02850-4


* The authors reference several studies to support the point that the vast majority (over 95%) of youth treated with puberty blockers proceed to cross-sex hormones. The point is valid and is indeed supported by at least 4 studies. However, the 2011 study by de Vries et al., referenced by the authors, is not an ideal citation. The study was only recently fully understood to be a retrospective, rather than a prospective study (contrary to the study's title, which asserts it is  "prospective."). A recent detailed analysis demonstrated that a key requirement for participation in the 2011 "puberty blockers" study was that a young person had to have been imminently starting cross-sex hormones.

Since all the 2011 study participants were pre-screened for having an intention to start cross-sex hormones and, indeed, had been approved to do so by their clinical team prior to being included in the study, the 2011 reference is not ideal to demonstrate that puberty blockers nearly invariably lead to cross-sex hormones. However, the 4 studies below do demonstrate this point of high rate of persistence/continuation with cross-sex hormones following puberty blockade:

  • Brik, T., Vrouenraets, L. J. J. J., de Vries, M. C., & Hannema, S. E. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2611–2618. https://doi.org/10.1007/s10508-020-01660-8
  • Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, S., & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in aselected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLOS ONE, 16(2), e0243894. https://doi.org/10.1371/journal.pone.0243894
  • van der Loos, M. A. T. C., Klink, D. T., Hannema, S. E., Bruinsma, S., Steensma, T. D., Kreukels, B. P. C., Cohen-Kettenis, P. T., de Vries, A. L. C., den Heijer, M., & Wiepjes, C. M. (2023). Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: Trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol. The Journal of Sexual Medicine, qdac029. https://doi.org/10.1093/jsxmed/qdac029
  • Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., de Jongh, R. T., Bouman, M.-B., Steensma, T. D., Cohen-Kettenis, P., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine, 15(4), 582–590. https://doi.org/10.1016/j.jsxm.2018.01.016