The moral case for non-medical interventions in adolescents with gender dysphoria

In most European countries, medical interventions including puberty blockers and cross-sex hormones are still the first-line treatment for gender dysphoria (GD) in adolescents. This paper presents a cumulative case for instead adopting non-medical interventions as the first-line intervention. These include awaiting further identity development, psychosocial support, and psychotherapy aimed at relieving gender-related distress, while respecting the adolescent’s gender identity. The cumulative case is built from the following considerations. First, there is a significant lack of knowledge of the natural history of GD. Second, the causes of the changed profile of patients referring to gender clinics, now relatively many more natal females with adolescent onset GD and co-occurring mental health problems than before 2010, are poorly understood. Third, there are clear indications that puberty blockers may impede adolescent identity development, rather than providing relief and facilitating reflection, as intended. Fourth, despite insufficient and inconsistent evidence on both harms and benefits of medical treatment of GD, most likely the harms and risks outweigh any potential benefits. Fifth and finally, non-medical interventions are not inherently unethical, but rather the least invasive potentially effective intervention. Together, these five considerations constitute a strong case against early medical intervention and in favour of non-medical interventions.