By: Katelyn Tijerina

If middle schoolers are not allowed to get painkillers from the front office at school, should they be allowed to make lasting medical decisions? This is a question that drives some legal systems to oppose puberty blockers for minors. Puberty blockers are a type of hormone therapy that prevents pre-adolescents from developing secondary sex characteristics as a result of puberty. This treatment has risen in popularity alongside the LGBT+ movement. Early adolescents may decide to use puberty blockers to postpone puberty. The goal of this is for adolescents who are unsure about their gender identity being given time to consider their identity. Additionally, this is an attempt to reduce the number of surgeries an adolescent going into a full transition in adulthood would need to go through. 

Gender dysphoria, as described by the American Psychiatric Association,  is a “psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex”(What Is Gender Dysphoria? 2023). These are children who believe they are a different sex than the one they are born with. However, the same association in the 5th edition of the American Psychiatric Association claimed the opposite. They claimed that gender dysphoria was “not due to the discrepancy between an individual’s thoughts and physical reality but due to the presence of emotional distress that hampers social functioning.” This claims that gender dysphoria is more of a mental illness than a condition. These contradictions reflect the opposing viewpoints in regard to this topic, including occasionally within the same organizations. 

Children who are diagnosed with gender dysphoria may opt for puberty blockers in the form of the Gonadotropin-Releasing Hormone or GnRH. A study done in 2015 measured the effects of GnRH on children with “central precious puberty” (Peltek Kendirci et al., 2015).  These are children who are developing to early. GnRH is used for endocrinal disorders other than transgender minors. GnRH suppresses the Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), and gonadal sex steroids like androgens and estrogens. The National Library of Medicine is the world’s largest medical library, and they report that LH triggers hormones in the body like testosterone in men and steroid hormones in women which control parts of the menstrual cycle (Nedresky & Singh, 2022). FSH also plays a role in sexual development and reproduction in both men and women. In women they produce estrogen, and in men they maintain sperm count and function (Orlowski & Sarao, 2023).  GnRH is something everybody has in their body, but because its purpose is regulation of sex characteristics, introducing more of it prevents puberty from occuring. In the study on children with precious puberty, they acknowledged that “limited data is available on the effects of long-term treatment with GnRH analogs on pituitary hormones” (Peltek Kendirci et al., 2015, pg.1145). Though the study found that there were pretty limited effects on the preadolescent girls it was used on. The children in the study were subjected to; “leuprolide by intramuscular injection with monthly or once every three month dosing formulations, and histrelin, a subcutaneous impact with yearly dosing (Peltek Kendirci et al., 2015, pg 1146)” 

GnRH is most popularly administered in two ways, injection and implant. The injection can be either intermuscular or subcutaneous. Subcutaneous is what the general public is familiar with. This is the same as a flu shot or a COVID shot. An intramuscular shot injects the medication just below skin level. It is also administered directly into muscle. Depending on the treatment the rate may change. The implant for GnRH is similar to the implant birth control. The implant is a small flexible rod that contains medication. It is typically inserted in the upper arm. 

The issue with GnRH being used on transgender pre-adolescents is the age that it is used. The children in the Kendirci study taking GnRH are in Tanner stage 2 or 3 and 8 years old or under (Peltek Kendirci et al., 2015, pg.1146). As long as the children are taken off the medication in a timely manner, their bodies can return to their natural state of developing their sex organs. However, transgender children may decide to continue from GnRH into gender-affirming hormones. This means their bodies will never get the chance to mature sexually.  If puberty suppressors are later followed by hormone treatment, these children will be left sterile for life. 

For transgender children who use GnRH well into adolescence, there can be side effects. In 2017 the American College of Pediatricians released a report titled Gender Dysphoria in Children. In this report, they found symptoms and side effects include, but are not limited to, arresting bone growth, decreased bone accretion, prevention of the organization and maturation of the brain, and inhibition of fertility (“Gender Dysphoria in Children,” 2017). A study published in the Oxford Press by  Sebastian E.E. Schagen et al. in 2020 found that bone markers decreased in both transgender girls and boys. Bone markers are found in blood and urine and the DNA in them shows the health and bone growth. A decrease in these suggests reduced formation of new bones and reduced reabsorption of old bones. However, Psychologist Daniel Mauer, a clinical psychologist in North Carolina reports that most effects of puberty blockers are positive and the effects of them are minimal (D. Maurer, personal communication, October 2023). 

Additionally, there are disputes over whether early adolescents are able to give informed consent. In most cases, children are started on puberty blockers between ages of 11 and 12 (D. Maurer, personal communication, October 2023). The High Court declared that children 16 years old and under are unable to give informed consent. They claim that children are unable to understand the long-term effects of these medications (Barbi & Gianluca Tornese, 2021). They declared this after being sued by an individual who claims they should have had more obstacles to overcome before being allowed on puberty blockers. Psychologist Holly Schofield, a professor at CCCC, adds to this discussion “The adolescent brain isn’t through developing until their 20s.” (H. Schofield, personal communication, October 13, 2023). This is important to add when considering an adolescent’s ability to understand the results of their actions. Contrasting, Daniel Mauer says “Most 12-year-olds can give consent” (D. Maurer, personal communication, October 2023). He is not alone in this. Many people think that adolescents are developed enough to give consent. 

Most adolescents who are receiving puberty-blocking therapy are, what is known in psychology as, Early Adolescence. Adolescence by Laurence Steinberg is a psychology textbook published by McGraw Hill concerning adolescence. In this, early adolescence is defined as “The period spanning roughly ages 10-13 corresponding roughly to junior high or middle school years” (Steinberg, 2016). This age is when most individuals are prepubescent which is when puberty blockers are most commonly used in an attempt to stop or postpone puberty. During this time adolescents’ brains are more malleable “for better or for worse, by experience during adolescence than at any other time other than the first few years of life”  (Steinberg, 2016). Because of this advertisement companies are not legally able to use characters to sell things to children. Our legislature has identified that children are easily manipulated. This is important when it comes to medical circumstances. Dr.Maurer is strictly against this kind of legislation. Among other reasons he states that “These legislators clearly motivated by religious beliefs. They are forcing their specific brand of Christianity upon the entire state. Individuals should have the right for religious freedom.” (D. Maurer, personal communication, October 2023). 

There have been noted times when transitioning may be for an ulterior motive conscious or not. Dr.Maurer claims that the examples of detransitioning is mainly due to external factors (D. Maurer, personal communication, October 2023). If it is in the realm of possibility that an individual would detransition because of external factors then it must also be true that there is a possibility that an individual would transition due to similar factors. 

There is evidence that psychopathology may precipitate gender dysphoria in adolescents (“Gender Dysphoria in Children,” 2017, pg292). Oftentimes a mother will wish for a certain gender of her baby and when that baby’s gender doesn’t align, the mother may fall into depression. This depression has been shown to alleviate in the instances when their child falls into the preferred gender role  (“Gender Dysphoria in Children,” 2017, pg292). Furthermore, in instances where a female child witnesses domestic abuse against her mother, she may subconsciously view “being female is unsafe and psychologically defend against this by feeling that she is really a boy” (“Gender Dysphoria in Children,” 2017, pg292). In our patriarchal society, it is not unlikely that a girl will see the praise, power, and privileges of being a boy and start to associate masculinity with freedom and/or happiness. Holly Schofield from CCCC recounts a similar situation she went through as a child: 

“I’m the older child of two…my mother was just obsessed with having a son and the whole time she was pregnant with me I was “Mark” and she was kind of disappointed when she ended up with a girl… I can remember thinking boys had a cooler life and I wanted to be a boy when I was 4 or 5 I would have cowboy boots and play with GI Joe, things like that, but as I got older and started socializing more and as relationships outside the family grew it went away … this was not so much me wanting to be male but just the privileges, the Cub Scouts did cooler stuff than the girl scouts. I remember thinking that in sports there were more opportunities for boys back then, then there were for girls and you got to wear pants to school… I thought boys had it made. So is it sexually wanting to be a male? No, it was wanting the privileges” (H. Schofield, personal communication, October 13, 2023)

Not only did she mention this, but she mentioned a case in the 70s where a female biology professor transitioned to male to gain a reputation in her field. She succeeded in her field, but when she retired she detransitioned into being female again. 

Many studies show that the overwhelming majority of adolescents who start GnRH continue to become fully transitioned adults. A study done in 2020 monitored 143 adolescents who started puberty suppressors. 87% of them went on to taking gender-affirming hormones after a year (Brik et al.). Another study published in 2010 looked at 70 adolescents with a shocking 100% continuing on to gender-affirming hormones (de et al., 2011). Part of the concern of this is there is a possibility that the adolescent will feel that there is no going back. It is difficult enough to socially transition, to have to transition back, would most likely be embarrassing. Schofield adds “ I mean it’s almost to say that you put yourself in a position of having to decide I’m doing this” (H. Schofield, personal communication, October 13, 2023). 

Puberty blockers are a complex issue with conflicting ideas on autonomy, safety, effects, and decision-making. The issue may be addressed in various ethical theories and explored through these viewpoints. Puberty blockers may not have an easy yes or no answer. Regardless, it is important to view them through various lenses to facilitate a well-rounded understanding. 

Kantism comes from Immanuel Kant. Kant was a German philosopher who made contributions to various philosophical disciplines. Many of his ideas continue to be discussed today. Kant said, “It is not God’s will merely that we should be happy, but that we should make ourselves happy.” (Weaver; 2022).  He believed that a good life is led both happily and nobly. Kantism says that the ultimate point of morality is to improve well-being rather than do justice (Shafer-Landau, 2021). Kantism asks two important questions to decide whether something is ethical or not; What if everybody did that? And how would you like that if I did that to you? 

First, what if everybody went on puberty blockers? While there are shown side effects of GnRH, none of them are fatal. The result of everyone in the world going on puberty blockers would be fairly limited. If everyone followed similar steps to a gender dysphoric adolescent of receiving hormone therapy for a few years and then stopping the side effects would be limited enough as to not prevent the downfall of humanity therefore according to Kantism it is ethical. 

The second question “How would you like it if I did that to you” can be interpreted in two ways in this discussion. Looking at this question as it applies from a transgender individual to another individual the question becomes moot. Since the transgender person is in no way affecting anyone other than themselves. Regardless, if this question is interpreted as others of higher ranking gaining medical autonomy over someone’s adolescent the question would be answered. One would not like it if the medical decisions of their offspring lay in someone else’s hands, especially one that does not personally know the child. Therefore, the court’s rights over transgender adolescents is unethical.

Consequentialism is the idea that one is morally required to do as much good as one can. The popular science fiction character Spock sports this ethical theory. Spock is famously quoted saying “the needs of the group outweigh the needs of few or the one.” Consequentialism is about doing ethical math. To find out the net balance of good by determining the good and subtracting the bad to determine the ethicality. Consequentialism utilizes the principle of utility which says an action is morally required just because it does more to improve overall well-being than any other action (Shafer-Landau, 2021). 

To decide whether puberty blockers are ethical according to Consequentialism the net good of this must be determined. There are two ways to go about this. One, the positive impact a (in the best circumstance) happy and healthy fully transitioned adult would add to the world and the good the money that would potentially go towards treatment could do. 

Ann Travers published a book in 2018 titled The Trans Generation where she explored the change in society around transgender culture by interviewing families with transgender children. In it she finds that one of her interviewee’s annual cost for hormone treatment is $25,000 (Travers, 2019). In some circumstances, insurance will cover parts of this fee but not all. Regardless, this money whether being spent by the family or the insurance company will be used specifically for this one individual. 

A singular individual can make big differences in the world. Assuming our individual does not cure cancer or become the second Mother Theresa and leaves what would be generally assumed as an average life would that justify the cost? This is disregarding the cost of hormone treatment after puberty blockers and the lifelong commitment to these hormones. 

According to Consequentialism, individuals must compare this to what $25,000 could do for other people. Remember that in Consequentialism the good of the many outweighs the needs or wants of the individual. So it doesn’t matter if this person will be happier if the good they could do with that money outweighs the good their own personal happiness can do. Consider a single example, Nohungrykid.org claims that a $50 donation can give 500 meals to hungry kids (Donate Today, 2023). Assuming this is true, with $25,000 one could feed either 500 children one meal or feed one child for 166 days. 

To find the answer to this ethical dilemma one must decide whether more good will be done with a singular happy life or feeding 500 children. The average person meets around 10,000 people. If a happy transgender individual positively impacts half of these people, one can argue that Consequentialism agrees that puberty blockers are ethical. Contrasting, while this healthy transgender individual is making others happy they are not saving lives like potential meals could. In this argument, Consequentialism would say the cost of puberty blockers are unethical. 

Hedonism is a popular ethical theory. It is also one of the most villainized ethical theories. A famous example of a Hedonistic character is Dorian Grey from Oscar Wilde’s Picture of Dorian Grey. In this novel, Wilde writes, “No civilized man ever regrets a pleasure and no uncivilized man knows what a pleasure is.”  Hedonism is about doing what you want when you want it. It is the high school senior of theories. Hedonism is the belief that happiness is the combination of pleasure and the absence of pain. Epicurus was one of the first Hedonists. He thought that the goal of human life is happiness which is the absence of pain. 

Ethical Egoism is similar but not identical to Hedonism. Ethical Egoism is a moral theory that there is one ultimate moral duty and that is to improve your own well-being as best you can. Ethical egoism claims that “If an action makes you better off,  then there is a good reason for you to do it and if there is a good reason for you to do an action, then doing it must make you better off,” (Shafer-Landau, 2021). 

Both of these focus on the individual. The difference is that Ethical Egoism acknowledges that occasionally things that are in your best interest in the long run may not immediately give you pleasure. This is the idea of delayed gratification​​. 

Daniel Maurer claims that puberty blockers lead to “improved psychological well-being, increased satisfaction with body image, treatment satisfaction, decreased depressive symptoms, and increased comfort gender identity” (D. Maurer, personal communication, October 2023). However, self-harm and mental health issues are rampant across the transgender community. The American College of Pediatricians found that transgender adults are overwhelmingly depressed with nearly one-third of their study attempting suicide. This is further executed by Ann Travers’ interviews. Her interviews include many discussions about depression and suicide. One 11-year-old, Stef, was reported attempting suicide and cutting himself before starting puberty blockers (Travers, 2019, pg 167). Another 15 year old Nathan started cutting at 10 years old and at the time of the interview hadn’t stopped. His mother remarked, “me and my husband said ‘Well, if he’s cutting himself, he’s not trying to kill himself’” (Travers, 2019, pg 168). Mental health seems to be an ongoing issue in not only the transgender community but also the LGBT+ community. This can be a combination of external and internal factors. However, there seem to be links between being transgender and the accompanying mental health issues. Whether correlation equals causation is undecided. 

Both of the main options for taking GnRH are considerably painful, the base idea of Hedonism is to avoid pain. Therefore, neither of these options would be ethical. However, if we ignore the basis to avoid pain to the effects that some people enjoy pain and sometimes people go through painful processes to gain something else like a tattoo or piercing and focus on the happiness part, then Hedonism would consider puberty blockers ethical (again we are assuming there are no issues and the psychological impacts from transitioning both physically and socially do not outweigh the good). 

Returning to the previous statement from Ethical Egoism “if an action makes you better off, then there is a good reason for you to do it and if there is a good reason for you to do an action then doing it must make you better off,” (Shafer-Landau, 2021, 115).  This can be applied to puberty blockers. If puberty blockers make you better off (as in promotes better mental health and body image as Dr.Muerer states) then there is good reason to do it. Additionally, if having better mental health and a better body image (providing it does) is a good reason to take puberty blockers then doing it must make you better off. Therefore, ethical egoism agrees that providing the statement is true, puberty blockers promote one’s own self-interest which one is ethically required to do. 

Conclusively most times in ethics there is not one right answer. These theories overall support puberty blockers but only in the best circumstances. If puberty blockers are used recklessly, if the outwards transition is demeaned, if they have negative long-lasting side effects then most of these theories would be against them. There are many unknowns when it comes to puberty blockers as they are more of a new medication. Puberty blockers should be a last resort. Adolescents, when it can be avoided, do not belong in hospitals and doctors’ offices more than is strictly necessary. The potential unnecessary stress of going through painful procedures is enough to traumatize most anyone. This is not to mention that whether the adolescent decides to continue transitioning or not, they become almost completely biologically isolated. Since their body will be going through puberty at a different rate and time than most of their peers. School is difficult enough for most, adding to the stress with constant therapy, doctors’ visits, and a visible difference between them and their peers opens them up to being more vulnerable. Additionally, if these adolescents continue to become fully transitioned adults because of this treatment, they will be effectively sterile for the rest of their life, leaving no opportunity for biological children. 

Adolescents and children are not meant to be dealing with heavy topics like this at such a young age. Even in the scenario where they are able to give informed consent their motivations may not be ideal. In the case that an individual decides to continue with gender-affirming hormones, they will be taking them for the rest of their life. Oftentimes, society pities people who are burdened with taking a certain medication for the rest of their lives. Society looks at people with things like HIV and type 1 diabetes with sympathy. Is this really a fate to which children should be unnecessarily subjected? In a society where eleven-year-olds are prohibited from taking pain medication at school, they shouldn’t be allowed full medical autonomy. This comes down to a hypocritical society which is unlikely to produce healthy adults. 

References

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