The care and treatment of children and adolescents in relation to their gender identity in the UK (2021)

Section 5: Understanding benefit and harm

As with other medical interventions, decisions about treatment can be seen through the lens of benefit and harm: what is most likely, given the available information, to prevent the greatest harm and yield the greatest overall benefit for a child? There are differences in opinion as to what those benefits and harms are, and the extent to which the available evidence can be used to draw conclusions. Some believe that the existing evidence base provides a definitive answer as to whether medical interventions are beneficial or harmful, while others believe that the long-term risks and benefits have not yet been fully established.

Some of the suggested benefits associated with medical interventions in relation to gender identity include:

• in the case of puberty blockers, the prevention of irreversible development of secondary sex characteristics, making any further surgical intervention easier or unnecessary;
• in the case of cross-sex hormones, the development of physical features which complement one’s gender identity;
• the alleviation of distress associated with gender dysphoria;
• greater social acceptance and improved relationships;
• improved psychological functioning; and
• reduction of risks of suicidality and self-harming behaviours.

These need to be weighed against a number of suggested harms, which include:

• unknown or uncertain long-term adverse effects of puberty blockers;
• in the case of puberty blockers, the risk of decreased bone density and increased risk of osteoporosis;
• adverse effects on brain function by blocking puberty’s normal role in cognitive development;
• loss of fertility;
• the negative consequences of disrupting physiological puberty, given the role it might play in the formation and development of a consistent gender identity;
• adverse impacts on social and emotional function - for example, the feeling of being ‘left behind’ or ‘out of sync’ with peers who will be going through puberty;
• inhibition of age-appropriate sexual and romantic development and exploration;
• later regret and distress at an earlier decision; and
• for some individuals, a decision to desist or detransition if gender identity subsequently changes - with no reliable way of distinguishing between those individuals who will persist in their gender identities and benefit from treatment and those who will not.

11. How should the possible benefits and harms of treatment and non-treatment be weighed?

12. How should we balance the needs of young people who will become trans adults (‘persisters’) with those who will not (‘desisters’) if we cannot reliably distinguish between the two?

13. How should the evidence on desistence and detransitioning be factored into decisions on whether and when children and adolescents should be permitted to embark on different stages of treatment?

14. What are the ethical implications of providing treatment that children and adolescents might later regret or reconsider?