Feel free to scroll to the bottom of the page for some definitions if you are ever confused!
Join me in discussing the pros and cons of a treatment for Transgender teens called Puberty Blockers! Through this page I will explore the ways in which recent legislation, specifically in Arkansas, does not reflect the suggestions and wishes of some of the most acclaimed pediatric associations. Why is there this disconnect? How do the ethical principles of Autonomy, Justice, Beneficence, and Non-maleficence apply to this global dilemma?
“The single most extreme anti-trans law to ever pass through a state legislature.”– Chase Strangio, deputy director for transgender justice at the American Civil Liberties Union LGBT & HIV Project (qtd. in Yurcaba).
Background: First off, what are the important aspects of trans healthcare?
As mentioned above, there is no specialty in the medical field for transgender healthcare since it is a very new field of healthcare. Mental health providers, endocrinologists, and general healthcare providers working with transgender patients have learned while practicing. Most doctors never went to school to treat transgender patients. Part of the problem is that doctors are not adequately informed or trained for the treatments they have to provide. There is a major lack of knowledge as the doctors themselves are not even fully informed on what options transgender patients have. This brings up a multitude of issues including conflicts with informed consent and access to care. Since doctors don’t have an adequate understanding of transgender healthcare, they aren’t able to adequatley inform patients of options for treatment. They likely wouldn’t suggest a patient have treatment at all. This treatment could be the answer to a patient’s problems, and yet there is a disconnect between them and the care they need.
Now to talk about what it means to be transgender. Trans patients must receive a gender dysphoria diagnosis to receive any treatment. Gender dysphoria is categorized as a medical condition, while being transgender is currently considered a mental illness by the World Health Organization (Love, Chicago Tribune). Once they have this diagnosis, patients may choose between several treatments should they want to continue with medical intervention. To start, prepubescent patients can go on puberty blockers if they have not progressed too far into puberty. This treatment option is evaluated based on guidelines about how long a patient has been in puberty. By 16, teens are typically too far along to go on blockers. The point of blockers is to stop pubertal growth by halting the secretion of hormones in a patient’s body.
So, how reversible are “reversible” puberty blockers?
Hormones will return to normal after a patient stops treatment. Things like breast or hair growth would return to how it was before the patient went on blockers. The biggest question of blockers is what are the effects on genitals if a patient were to stop treatment. So far, they simply seem to stunt growth, but have not shown effects on fertility (Cortes). This introduces the dilemma of time. There is little research on any of this because it is such a new field of study. Another option, reserved for patients who have completed puberty, is Hormone Replacement Therapy (HRT). This is where the larger ethical debate lies, despite the fact that puberty blockers are making all the headlines. Surgery, the last treatment option, is not common in minors under 18 since they are not done with puberty. Despite confusing language in the Arkansas legislation, minors under the age of 18 rarely opt for surgery. “Children,” as the bill labels them, do not have surgery. The only options for minors under the age of 14 are puberty blockers, with the exception of the rare transgender male who can receive HRT at an early age, of around 14, due to their advancement in puberty.
Is there a difference between Transgender Females or Transgender Males in treatment?
Transgender Males (Female to Male) are more likely to opt for HRT earlier on than Transgender Females (Male to Female). Due to the faster progression of female puberty, transgender males are often not candidates for blockers. The term transgender male indicates that an individual was born as a female and their affirmed gender is male. They are often too far into puberty and too far matured to stop it. Transgender Females, on the other hand, are more likely to be put on puberty blockers because they have the time since puberty progresses slower and starts later in males (Cortes).
Background: What happened in Arkansas?
Arkansas became the first state in the US to restrict access treatment to transgender youth. The bill prohibits healthcare officials from providing transgender youth state funds for gender-affirming health care. It also allows private insurers to refuse to cover this care. This legislation impacts the mental health of transgender teens specifically increasing depression, anxiety, and suicidal tendencies (CDC). The American Academy of Pediatrics, the American Psychological Association, the American Psychiatric Association, the Pediatric Endocrinology Society, and the American Medical Association all opposed this bill. Once the bill was passed in both the Senate and House in Arkansas, it went to the governor, Asa Hutchinson. Unexpectedly, Hutchinson vetoed the bill. His rationale can be found in an opinion article for the Washington Post (Hutchinson, Washington Post). Despite Hutchinson’s efforts, the veto was quickly overridden and Arkansas became the first state to harshly restrict treatment as of April of 2021.
“While in some instances the state must act to protect life, the state should not presume to jump into the middle of every medical, human and ethical issue. This would be — and is — a vast government overreach.”-Asa Hutchinson, Republican governor of Arkansas (Hutchinson, Washington Post)
Check out this video for a little more information on Arkansas!
The banning of treatment in Arkansas not only stigmatizes trans treatment by making it illegal, but also completely strips teens of their autonomy. It also invalidates transgender identity especially in young teens. The Arkansas legislature’s defense for this is that “Arkansas has a compelling government interest in protecting the health and safety of its citizens, especially vulnerable children” (AR HB1570). But the reality is the decision to take puberty blockers is not taken lightly. The combination of parents having to consent, teens having to receive a gender dysphoria diagnosis, and teens having to meet with a therapist before receiving treatment all ensure that there are safety nets for these “vulnerable children.” If anything, this so-called “protection” is costing them their mental health by forcing them to continue in the gender roles in which they know they don’t belong. Presenting the debate of puberty blockers as infringing on the vulnerable children’s best interests, takes away from the true reason of going on blockers in the first place. Children opt to take blockers solely based on the fact that they are confused. They don’t know what to do (Kerrigan). Blockers don’t change their bodies or add anything to their current physiological structure at all. They just pause it from furthering the course of puberty. This pause buys teens time to evaluate how they truly feel and how they want to proceed (Mayo Clinic Staff, Mayo Clinic). Once they have had the time to explore their options, they may be ready to decide if they want to continue in their affirmed gender. Then, they can evaluate which course of action is best for them whether that be Hormone Replacement Therapy or something else. Another debate with blockers is whether or not parents should have the final say and if treatment should be automatically stopped if one parent vetoes it. Though these are extremely important conversations and essential to the puberty blockers ethical debate, they are not explicitly addressed in the Arkansas bill, so I will not review them in depth.
A major concern with puberty blockers is how expensive they are. This interferes with the principle of justice because so many of the teens who need to be on this treatment cannot afford it. Blockers can cost up to $20,000 to $40,000 a year depending on which mode of treatment for a patient. But, since Arkansas banned treatment, trans youth are being stripped of their right to care entirely. There is no opportunity for equal distribution of care or cheaper costs, because it does not exist anymore. This creates a major inequality in access to care; therefore, interferes with the principle of justice. The patients being treated are part of the LGBTQ+ community which begs the question of whether or not they are being discriminated against. Healthcare providers should treat their patients with equal care no matter their culture, race, sexual orientation, or gender. Policy also should reflect that respect.
Puberty blockers’ main benefits lie in their impact on the mental health of patients. Unfortunately, there is not enough research to prove if puberty blockers benefit patients 100% of the time. Though medical providers support the access to blockers and have documented the positives they bring, there is no absolute guarantee of anything whether that be positives or negatives. This begs the question of whether it is right to continue treatment if positive outcomes are not guaranteed. An opposing argument would be that teens gain a sense of relief in knowing that they have time to come to terms with this major decision. Also, blockers give them the opportunity to reverse their decision, if they feel it is necessary. Although, this is very rare according to professionals (Cortes). The only proven negative effects of halting treatment and going back to their birth sex is smaller growth of genitals. It has not been proven to consistently affect fertility. Side effects of blockers are not nearly as harmful for teens as the prospect of undergoing the unwanted physical changes of their biological sex. On the other hand, suppressing puberty may reduce anxiety, depression, suicidal thoughts, and decrease the characteristics of gender dysphoria over all (Mayo Clinic Staff, Mayo Clinic).
There is not an overwhelming amount of research that has been done on the long term effects of puberty blockers since it is such a new form of treatment. But, doctors are confident that most side effects of blockers are relatively reversible. Blockers do not destroy the organs and hormones they interact with, but rather put a pause on their effects and production. It virtually “turns off” growth until turned on again. Another argument is that the only way to accumulate data and research is to actually administer and track treatments for their effects. Opposing perspectives say that, since there is not enough research to guarantee the safety of patients entirely, the risk is not worth the possible reward. On the other hand, most medical providers view treatment as a life-saving procedure, and not providing that, majorly interferes with nonmaleficence (Yurcaba, NBC News).
Conclusion of ethical debate and My Perspective:
Transgender youth should have access to puberty blockers because the positives outweigh the negatives. According to the bioethical principle of utility, which states that the most ethical course of action is the one that produces the most positive outcomes, healthcare providers and legislation should allow transgender youth to access puberty blockers. The positives and relief that arise from receiving this treatment far outweigh the possible negatives and risks. Most teens would opt for this treatment solely based on the fact that it would give them a second to breathe and reevaluate. One of the best forms of treatment transgender teens in early stages of puberty could receive is time. All they want is more space between them and the uncomfortable and terrifying changes that will be exacerbated by puberty (Kerrigan). The blocker’s nature allows them to be almost entirely reversible and don’t pose any seriously permanent issues (Cortes). The whole point of the blockers is that they provide time to allow for the big decisions that choosing to go on hormones or undergoing surgery are. The true issues arise around HRT and surgery, not blockers. Blockers give young patients the piece of mind of knowing they don’t need to know where they are headed. Legislation that prevents this pause not only interferes with nonmaleficence by increasing the rate of suicidal behavior, but also sends a harmful message to confused teens (Mayo Clinic Staff, Mayo Clinic). These teens are already looking to adults to give them answers, but even adults and healthcare professionals don’t have concrete answers. It is not beneficial to the teen to place strict laws limiting the very care that may help support them. Providing them access would support the bioethical principle of beneficence. Also, it is simply a choice. No one is interfering with autonomy by forcing these children to go on any medications. It is a choice, and allowing them access to the treatment further respects their autonomy and remains in line with the mature minor doctrine.
Some of the states currently passing anti-trans bills include those shaded in the map shown below.
The darker states indicate the ones that have the most bills in circulation.
Cases like the Arkansas bill are being passed daily both in the United States and the entire world. As these cases continue to arise, transgender rights, especially those of minors, are in jeopardy. Their voices are being silenced and their needs not met. Transgender teens should have access to life-saving puberty blockers based on the fact that denying them this treatment would interfere with all the principles of bioethics. Not only would it silence their voices as minorities, interfering with justice by rejecting treatment based on gender identity; but it would also interfere with autonomy by taking away their choice. At the very least, puberty blockers don’t hurt patients enough to use it as a valid argument for denying treatment. They do more to protect a patient’s future autonomy. That is all the blockers do, allow more time for the major and exciting shift that may be undergone later in life: transitioning to their affirmed gender. Refusing to acknowledge nearly every major medical association’s endorsement of puberty blockers only further displays the importance of overturning this harmful legislation. There is so much action we can take as allies and global citizens to combat this infringement on peoples’ rights.
Any way you can help is greatly appreciated and will surely make a difference in the big picture!
Whether that is…
- Educating family and friends on proper dialogue and word choice around LGBTQ+ and transgender issues
- Calling out harmful language when you hear it, both slurs and subconsciously harmful language
- Writing letters and making phone calls to your local governments to make sure laws are being passed with transgender youth’s best interests at heart
- Donating to LGBTQ+ legal organizations and nonprofit healthcare providers
- Some examples from my hometown of Chicago include Equality Illinois and Howard Brown Health Center or nationally, Lambda Legal and the National LGBTQ Task Force
Here are some resources (links!) to help:
- A list of the states attempting to pass anti-trans healthcare bills and options to take action
- Some more anti-LGBTQ+ bills
- An interactive tracker and map
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