This editorial can be found in the August 2024 issue of the American Journal of Bioethics
As we’ve seen with the anti-abortion movement’s attacks on access to reproductive healthcare (including abortion), the safe and well-established field of gender-affirming care has increasingly come under attack by anti-trans extremists, including lawmakers. As is the case with the anti-abortion movement, these attacks rely on the spread of misinformation and obfuscation to legitimize themselves. Otherwise, these attacks would be clearly seen as attacks on a vulnerable community, intended to strip them of their dignity, their personhood, and their bodily autonomy.
Over the last 5 years, anti-trans lawmakers have launched an escalating and unprecedented series of attacks on the transgender community. In 2023, the National Center for Transgender Equality tracked 500+ bills introduced in state legislatures, targeting transgender Americans, an estimated 147 of which attempted to restrict or ban access to age-appropriate, evidence-based transition-related healthcare for transgender youth. It was estimated that 144,500 transgender youth had lost access or were at risk of losing access to gender-affirming care. To date (May 2024), 24 states have passed bills banning access to lifesaving transition-related care for transgender youth.
Calling gender-affirming care “lifesaving” may sound like hyperbole, but when trans youth can’t access this care, they’re at greater risk of depression and suicidality. Attempts to restrict access to this medically necessary care rely on misinformation regarding the safety and efficacy of the medications provided to trans youth. Anti-trans extremists exploit the public’s unfamiliarity with trans youth and the relative inaccessibility of medical literature to the public, to falsely characterize trans youth as a new phenomenon, citing fake diagnoses of “rapid onset gender dysphoria” and making false claims that this evidence-based healthcare is “experimental”. But, it’s fear, not scientific fact, that underpins these attacks on transition-related healthcare.
“Transition-related healthcare” is a multidisciplinary field focused on alleviating the distress caused by gender dysphoria and affirming the gender of a transgender person. The Fifth Edition Diagnostic and Statistical Manual of Mental Disorders describes “gender dysphoria” as the distress caused by the incongruence between a person’s gender and how they’re perceived/treated by others and/or how they perceive aspects of their bodies. This diagnosis does not refer to being transgender itself though. There has been discussion regarding the degree to which this diagnosis contributes to the pathologization of trans people, but the diagnosis is also crucial for trans people relying on insurance coverage to make this care accessible, due to healthcare costs in the U.S.
When adolescents receive treatment for gender dysphoria, it’s typically after counseling with parents and patients by medical and behavioral health professionals. Often though, the first aspects of adolescent transition are social affirmations like using a new name, changing how they dress, and using new pronouns. Children don’t receive transition-related surgery and teens receiving surgical treatment are rare.
The most commonly prescribed treatment of gender-dysphoria in adolescents are puberty-pausing medications [GnRH Analogues] or “puberty blockers”, which are generally prescribed at the onset of Tanner Stage 2 (age 12-13). These medications pause (not block) changes to the body caused by pubertal development, affording adolescents more time to explore their gender identity, without the risk of unwanted, irreversible changes brought on by puberty. Once treatment begins, side effects are monitored and patients’ health is evaluated frequently.
Far from “experimental”, since the early 1990s these medications have been prescribed to trans adolescents and for the last three decades, they’ve been the gold-standard treatment for gender dysphoria in adolescents. They were initially developed to treat precocious puberty in children, for which they’ve received FDA approval. This practice began in the early 1980s, through a collaboration between Massachusetts General Hospital and Boston Children’s Hospital, where they were demonstrated to be effective, safe, and reversible in pausing the effects of puberty.
Additional academic literature has continued to find that the utilization of pubertal pause, not only had positive impacts on outcomes of subsequent transition of trans adolescents during their adult transitions, but given its relative reversibility, it was a crucial diagnostic tool to afford adolescents more meaningful time to consider their gender.
These types of medications are also used in a variety of other medical contexts such as fertility treatment plans, treating endometriosis, and the treatment of hormone-sensitive cancers.
Claims that these medications or their use in treating adolescent gender dysphoria/incongruent are “experimental” are simply incorrect. That is why the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association the American Psychological Association, and the Endocrine Society, along with nearly every legitimate medical organization affirm the safety and efficacy of these medications as well as their lifesaving capacity for transgender youth.
The lifesaving impact of this healthcare cannot be overstated, as trans youth already experience higher levels of depression and suicidality compared to cisgender youth, due to factors such as gender-dysphoria, lack of support, and discrimination. However, access to this care reduces rates of suicidality and improves overall psychological functioning.
Going through the wrong puberty can cause severe psychological distress, anxiety, depression, and suicidality that may persist into adulthood. Compared to people beginning hormone replacement therapy (HRT) later in life, those who began in their teens showed lower levels of suicidality the earlier they began.” Clearly, timely access to these medications can have exponentially positive impacts on their overall well-being.
While the effects of puberty-pausing medications are reversible the effects of pubertal development generally are not. Beginning hormonal treatment in adulthood may remedy some sources of dysphoria, but there are changes that hormones cannot remedy. There may be surgical options available but what surgical options there are can be financially inaccessible. Pausing puberty may eliminate the need for surgery altogether or make them less invasive, and result in overall greater levels of satisfaction with one’s transition.
Legislation attacking the provision of puberty-pausing medications are bad-faith attempts to mischaracterize a well-established form of healthcare as “experimental”. While this legislation infringes upon the rights of both parents and providers, it’s trans adolescents, who have the most to lose from such restrictions. The prohibition of this care will have lasting consequences for trans adolescents, well into adulthood, and well after these lawmakers will recall attacking the healthcare rights of adolescents. Countless medical professionals, major medical associations, and advocates have warned of the dangerous impact that legislation could have on trans youth.
Given the benefits of this reversible treatment, the risks of withholding it, and the irreversible nature of pubertal development, withholding these medications from adolescents violates the ethical principles at the heart of the healthcare field.