The right to best care for children does not include the right to medical transition

The right to best care for children does not include the right to medical transition

Summary of paper

The right to best care for children does not include the right to medical transition


Michael Laidlaw, Michelle Cretella & Kevin Donovan (2019) The right to best care for children does not include the right to medical transition, The American Journal of Bioethics, 19:2, 75-77, DOI: 10.1080/15265161.2018.1557288

Here are the key points of this recently published paper on gender dysphoria in children

  1. Watchful waiting with support (and therapy, if indicated) for gender-dysphoric children and adolescents up to the age of 16 years is the current standard of care worldwide, not gender affirmative therapy (GAT).
  2. Puberty blocking agents (PBA) lower testosterone and estrogen to below normal levels, thus stopping normal puberty. There are no high-quality studies on the short and long-term effects of puberty-blocking agents.
  3. Continued suppression of puberty maintains male and female gonads (i.e., sex organs) in a state of immaturity. The addition of cross sex hormones does not reverse this situation. 


  • There are no objective (laboratory, imaging etc) or psychological tests that can reliably diagnose a “true transgender child.”
  • By adulthood, between 61-98% children desist from a transgender identity. There is no way of predicting who will remain gender dysphoric. Therefore, many children will be irreversibly harmed by gender affirmation therapy.
  • Social contagion has been identified as a mechanism of transmission of gender dysphoria.
  • PBA derail the path of natural desistance – once children are placed on PBA, most, as adolescents, desire to progress to cross-sex hormones because of the physiologic and/or psychological effects of PBA.

Comorbid psychiatric conditions

  • Psychological conditions co-occurring in up to 75% of young people with gender dysphoria affect their judgement about proceeding with PBA, particularly when these conditions are not properly considered or treated.



  • Involuntary infertility in adults creates psychological distress and depression and reduces quality of life. Infertility is the outcome of puberty suppression. Children do not have the maturity to understand the implications of lifelong infertility. 
  • Fertility preservation rates are low – fewer than 5% adolescents attempt cryopreservation.
  • Children receiving puberty-blockers cannot preserve eggs or sperm. The only options are experimental procedures such as ovarian and testicular tissue cryopreservation. 

Impaired sexual function

  • Early blockade of puberty stops genital development which results in limited to absent sexual function in adulthood.
    • In men, erection, orgasm, and ejaculation are impaired or absent
    • In women, puberty blockers induce menopause and reduce sexual desire
    • Reduced sexual desire in both men and women is associated with decreases in general health and mental wellbeing

Disruption of normal bone development

  • Puberty blocking agents cause a decline in bone mineral density that may result in early onset osteopenia or osteoporosis.


  • Children cannot give informed consent to GAT as they cannot fully appreciate the consequences of infertility and loss of sexual function and pleasure, nor the myriad complications of the treatment, including surgical complications if they proceed to breast removal or genital reconstruction.
  • Denial of parental involvement is dangerous