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Not words, but data: guidance on healthcare dilemmas for transgender young people

There are differing opinions, including among practitioners, about healthcare for transgender young people. This is especially true for puberty suppression and the potential consequences. Psychologist Lieke Vrouenraets (LUMC) investigated the ethical dilemmas and aims to give healthcare providers and policymakers tools with her dissertation.

The number of transgender children and adolescents enrolling at a gender identity clinic has increased exponentially in recent years. Treatment of children before they reach puberty is mainly psychological. But if their feelings persist after the onset of puberty, the option of puberty suppression (treatment with gender-affirming hormones) is a relatively new but controversial form of treatment.

Cover page of Vrouenraets’s dissertation
Vrouenraets’s dissertation

Five themes

Vrouenraets wanted to understand more about the root of the often sceptical or cautious attitude towards this treatment. She identified the ethical dilemmas, grouping them into five themes that consistently emerged in the context of political and public discussions:

  1. The decision whether or not to start puberty suppression.
  2. The medical decision-making competence of adolescents.
  3. The role of psychosocial problems.
  4. The social context.
  5. Clinical ethics support.

The Dutch Protocol

When an individual experiences distress because their gender identity does not match the gender assigned to them at birth, we call that gender dysphoria. In the Netherlands, we have agreed that teenagers diagnosed with gender dysphoria can receive puberty suppression treatment under certain additional conditions (according to ‘the Dutch protocol’).

Puberty suppression prevents the (further) development of secondary sexual characteristics that the young person does not want. It gives them time to explore their gender identity and consider starting gender-affirming treatment involving hormones and/or surgery. The effects of treatment with puberty suppression are reversible: once a person stops using the hormones, puberty development resumes in line with the birth-assigned sex.

‘Not treating is not a neutral option.’

Long-term effects of puberty suppression

 ‘There are also drawbacks to treatment’, says Vrouenraets. ‘For example, the hormones used in puberty suppression affect bone density, and a person may experience hot flushes and mood swings. And we still know little about the long-term effects of these hormones. What effects do they have on the brain, for example? And what else do they do physically to the body? Because gender-affirming hormones have only been used in transgender care for about 35 years, we have little long-term data on them. These are arguments against giving the treatment.’

But: ‘Not treating is not a neutral option’, she continues. ‘Because a body continues to develop in line with the birth-assigned sex. This can be incredibly stressful and psychologically damaging. We must also factor that in.’

Transgender young people are mentally competent

Another theme is the medical decision-making competence of these teenagers. Are they able to fully understand the consequences of their choice to start (or forego) puberty suppression? For example, what about possible consequences for fertility? Vrouenraets’s research found that about 90 per cent of the 74 transgender adolescents who participated in her study were competent to make this decision. But, according to Vrouenraets, that does not mean they cannot regret it later in life.

‘The vast majority continue transition after puberty suppression.’

Talking to teenagers about fertility

The vast majority continue transition after puberty suppression; only about 6 per cent stop. This is a small number but, according to the psychologist, it shows that at least some young people consider the option of discontinuing puberty suppression. But there is also another side. ‘Because we know that the vast majority continue transition after puberty suppression, we need to talk about the potential consequences for fertility at an early age. Do teenagers have any concept of that?’

Guidance for a polarised debate

The dilemmas associated with transgender care for children and adolescents are not new. However, these were originally mainly a topic of discussion between healthcare professionals, teenagers and their parents. Now, many more people are speaking out on the topic, and politicians, the media and the judiciary are playing an ever-greater role. The aim of the dissertation is to provide stakeholders with guidance for navigating the polarised debate about transgender care.

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