By Lauren Notini
The use of medications to suppress puberty (puberty suppression or puberty blockers) in young people who identify as transgender (trans) or gender diverse (TGD) has generated ongoing debate in the media and bioethics literature. Puberty blockers are typically recommended as a treatment option for TGD young people who are experiencing gender dysphoria (roughly, distress associated with their body not matching their gender identity). Many TGD young people who take puberty blockers later decide to start hormone (testosterone or estrogen) treatment to bring about desired changes in their body. Others decide to stop taking puberty blockers, meaning that their body will re-enter the puberty consistent with the sex they were categorised as at birth (their ‘biological sex’). But what if a young person starts puberty blockers, and wishes to stay on them indefinitely?
We examine such a case in our Feature Article published in the Journal of Medical Ethics, titled ‘Forever young? The ethics of ongoing puberty suppression for non-binary adults.’ In this blog post, we explain how we became interested in this topic, summarise our key arguments, and highlight some of our related research.
Our article is only intended to apply to cases where the patient has decision-making capacity. We do not consider cases involving younger adolescents—whose decision-making capacity may be in question—who request ongoing puberty suppression (OPS), although some of us have addressed this scenario in a previous article.
Recent surveys suggest that approximately one in two TGD young people identify as gender non-binary (not entirely or exclusively male or female). Non-binary individuals may identify as bigender (both male and female), agender (no gender), gender fluid (where gender identity changes over time or across different circumstances), or in other ways.
Our interest in this topic began when we started hearing anecdotal reports from clinicians that some non-binary young people were requesting to remain on puberty blockers long-term, and did not wish to start gender identity-affirming hormones or discontinue blockers and restart their ‘natural’ puberty. This is a novel scenario that is underexplored in the bioethics literature. To date, discussion of the ethics of puberty blockers has usually focused on binary trans young people (trans males or trans females) who later wish to start gender identity-affirming hormones. Puberty blockers have typically not been discussed as a standalone treatment option for non-binary individuals.
In our Feature Article, we describe and analyse a hypothetical case scenario involving Phoenix, a non-binary 18-year-old who started puberty blockers soon after beginning puberty at the age of 11, and who wishes to stay on them throughout adulthood. Although this case is hypothetical, it includes features of several cases we have heard about from practicing clinicians. While Phoenix was categorised as female at birth, they have consistently identified as non-binary since a very young age. Phoenix wishes to look ‘genderless’. They believe that the use of OPS is the only way that their body can accurately reflect their non-binary gender identity to others. Although puberty suppression is expensive (approximately $5,200AUD per year in Australia), Phoenix can afford the annual cost.
Should doctors offer OPS as a treatment option for non-binary adult patients like Phoenix? We argue that they should, for two main reasons. First, OPS aims to promote wellbeing, and this is consistent with the proper goals of medicine. Second, binary TGD individuals are commonly offered various medical interventions (including puberty suppression, and gender identity-affirming hormones and surgeries), even though these interventions involve various risks, which are still being studied. Although OPS also involves risks (including risks of low bone density due to lack of sex hormones), we usually allow capable adults to make decisions involving risk in other areas of medicine and life. For reasons of fairness and consistency, the same should hold true when considering OPS requested by non-binary adults who have decision-making capacity.
While we argue that OPS should be on the table as a treatment option for non-binary adults as a group, we claim that whether or not OPS is left on the table for a particular patient will need to be decided on a case-by-case basis. Decisions about individual patients will need to consider the patient’s circumstances and values. While we argue that OPS is ethically justifiable in Phoenix’s case, the principled approach to ethical analysis we use in our paper might lead to different conclusions when considering other non-binary adult patients.
Although Phoenix is not a real person, their story is not completely hypothetical. Lauren Notini has recently interviewed 14 clinicians from multiple states and territories across Australia who work with TGD youth. Twelve of the 14 reported that they have received requests for puberty suppression from non-binary young people. Some of these clinicians reported that some non-binary young people who start puberty suppression wish to continue it on an ongoing basis (i.e., into adulthood). Our paper aims to shed light on this issue, and equip ethicists and clinicians with a practical approach to ethical analysis that they can use when deliberating about similar cases.
Blog post written by Lauren Notini, on behalf of, and with input from, article co-authors.
Authors: Lauren Notinia, b, Brian D. Earpc, d, Lynn Gillame, f, Rosalind McDougalle, Julian Savulescug, d, b,h, Michelle Telferi, j, k, Ken C. Pangi, j, k, l
a Melbourne Law School, University of Melbourne, Melbourne, Victoria, Australia
b Biomedical Ethics Research Group, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
c Yale-Hastings Program in Ethics and Health Policy, Yale University, New Haven, Connecticut, USA and The Hastings Center, Garrison, New York, USA
d The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
e Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
f The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
g University of Oxford, Oxford, UK
h University of Melbourne, Melbourne, Victoria, Australia
i Department of Adolescent Medicine, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
j Murdoch Children’s Research Institute, Parkville, Victoria, Australia
k Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
l The Walter and Eliza Hall Institute of Medical Research, Melbourne, Victoria, Australi
Competing interests: None.
Social media accounts of authors:
Brian D. Earp: @briandavidearp
Julian Savulescu: @juliansavulescu