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For those new to this issue it’s best to know these terms before reading.

3) Are children & teens old enough to give consent FOR medical gender transition?

Given that Lupron may have some permanent cognitive/health/sexual function consequences, that puberty blockers to cross-sex hormones cause sterility, and that surgeons perform mastectomies and bottom surgery on minors, it seems essential to explore if children and teens can give what is called “informed consent” (the patient decides with the doctor informing them of the risks). This concern is so great the Swedish Pediatric Society recently issued a letter (in English) supporting the National Counsel of Medical Ethics’ ongoing investigation (in English) into the affirmative model that states:

The physical and psychological maturation process of children and adolescents is individual, but for most people, it involves searching for and experimenting with their identities; this is natural and needs to be done with nuanced support by the child's relatives. Society's rules need to balance children´s own rights against the necessity to protect them. Giving children the right to independently make life-changing decisions at an age when they cannot be expected to understand the consequences of those decisions, lacks scientific evidence and is contrary to established medical practice.

The following two studies, as well as many examples throughout this website, demonstrate doctors provide surgery and cross-sex hormones to minors.

“Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts.”

“Age Is Just a Number: WPATH-Affiliated Surgeons' Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States”

Despite most studies showing high rates of comorbid conditions in gender dysphoric teens, some affirmation model advocates don’t believe youths need mental health counseling, as their problems are related to denial of transition. A quote from Johanne Olson-Kennedy:

 As she put it when we talked, “I don’t send someone to a therapist when I’m going to start them on insulin.”

Olson-Kennedy also believes 13-year-old girls can make logical decisions about testosterone use and mastectomy:

And while the debate over whether sex is a mere social construct (it’s not) or whether biologically male brains can exist with female bodies (they can’t) may seem abstract, there are concrete, real-world effects when girls as young as 13 are being told by US physician Johanna Olson-Kennedy that they “have the capacity to make…reasoned, logical decision[s]” about whether they want their breasts removed—because if they “want breasts later on in [their] life, [they] can go and get them.” This sort of casual attitude to body mutilation—and re-mutilation—helps explain why many enterprising doctors have become de facto transgender activists, since they get paid on both ends of the transformation.

The problem with this is that most people recognize adults have a moral obligation to protect their youth from decisions they make as children and teens who do not have the full cognitive capacity to weigh the costs and benefits. Children are prone to magical thinking, and teenagers are prone to impulsive risk-taking. Both children and teenagers are likely not to understand long-term consequences. There is ample research demonstrating that young people’s cognitive function does not fully mature until 25 years old.

Research on trans adults, all of whom transitioned as adults, shows low regret rates. With the recent increases in younger people, many of whom are female, it may be that the satisfaction rates won’t be as high with lax gatekeeping and transition appearing to be a socially contagious condition (especially in girls) being made popular in the culture. This survey seems to suggest transition does not really improve the psychological function in these increasing numbers of females. 

Studies of cohorts who transitioned under much stricter gatekeeping and less societal cheerleading still show high rates of health complications and mental illness. It appears that these young people are at risk of viewing medical transition as a panacea to all of their problems and body discomfort.

Due to the reality of the outcomes highlighted above, Bernadette Wren, a psychologist from the UK, expresses that managing expectations is crucial,

It is really important to be checking with people their expectations of physical interventions as it is obviously true they are not the panacea to all things

Early social transition, they believe, can create a false impression: children start to believe growing up as the opposite gender will automatically follow putting on a dress and changing a name. “When, actually, we know it requires a lot of hard work and medical intervention to change the body,” says Dr Wren. “That’s not to be negative about it, because people go through it and have great lives. But the child might think, ‘Well, I’m growing up as a girl, aren’t I?” And you don’t want to shatter that and explain vaginoplasty to a six-year-old.”

Another UK psychologist, Polly Charmichael, expresses more concern about minors romanticizing transition here:

Or she wonders, if, for some, it could be a misplaced sense of self, a belief that their unhappiness or ability to fit in is solely down to their gender, and if that was changed, their lives would be transformed.

Dr Carmichael said this is something they always explore as, just with anyone undertaking plastic surgery, a change of appearance will not automatically make someone happier and more popular.

Lisa Littman’s recent ROGD study (trans-identified youth without a history of serious childhood GD) also indicates young people have a utopian view of medical transition. 

More than half of the AYAs (55.9%) had very high expectations that transitioning would solve their problems in social, academic, occupational or mental health areas…

One parent, in response to the question about if their child had very high expectations that transitioning would solve their problems elaborated, “Very much so. [She] discontinued anti- depressant quickly, stopped seeing psychiatrist, began seeing a gender therapist, stopped healthy eating. [She] stated ‘none of it’ (minding what she ate and taking her Rx) ‘mattered anymore.’ This was her cure, in her opinion.”

This paper reviews case studies of surgeries performed on minors and discusses that sticking to a neovaginal dilation schedule is a problem for youth. Johanna Olson-Kennedy confirmed this problem in a presentation at Gender Odyssey in 2017. She argues that it’s good that genital surgery is performed on youth before they go to college so parents can ensure they follow their dilation schedule because if it isn’t, dire consequences are likely. So, irreversible medical techniques are being performed on minors incapable of sticking to a neovaginal dilation schedule. This should call into question if they are old enough to consent to these procedures.

Listed below is information that shows brain development in young people isn’t complete until age 25, and that youth are prone to impulsivity, poor decision-making, and an inability to understand long-term consequences.

This study discusses the profound changes in the brain during puberty.

Puberty onset is also associated with profound changes in drives, motivations, psychology, and social life; these changes continue throughout adolescence…Almost all of these studies have defined development by chronological age, which shows a strong—but not unitary—correlation with pubertal stage. 

An article “Dude, Where’s My Frontal Cortex? There’s a method to the madness of the teenage brain” sums up maturity issues below:

The frontal cortex is the most recently evolved part of the human brain. It’s where the sensible mature stuff happens: long-term planning, executive function, impulse control, and emotional regulation. It’s what makes you do the right thing when it’s the harder thing to do. But its neurons are not fully wired up until your mid-20.

This NPR interview is an interesting discussion on youth brain development and how even an 18-year-old brain is only ½ through the maturation process.

So, the changes that happen between 18 and 25 are a continuation of the process that starts around puberty, and 18 year olds are about halfway through that process. Their prefrontal cortex is not yet fully developed. That’s the part of the brain that helps you to inhibit impulses and to plan and organize your behavior to reach a goal.

And the other part of the brain that is different in adolescence is that the brain’s reward system becomes highly active right around the time of puberty and then gradually goes back to an adult level, which it reaches around age 25 and that makes adolescents and young adults more interested in entering uncertain situations to seek out and try to find whether there might be a possibility of gaining something from those situations…one of the side effects of these changes in the reward system is that adolescents and young adults become much more sensitive to peer pressure than they were earlier or will be as adults.

Susceptibility to peer pressure is a topic explored here and here in relation to trans identification.

And this quote about how more freedoms cause more problems:

AAMODT: Many of the costs of adolescents are actually - what we think of as the costs of adolescence, the risks of crime and car accidents and all the crazy things that adolescents do are actually more issues with young adults, people in the 18 to 25 age range, largely because they have more opportunities to get into these kinds of trouble because they have less parental supervision than the younger adolescents do.

Here is another quote in Scientific American in regards to the impulsivity of teens:

Psychologists would describe this skill as the ability to adjust one’s cognitive performance to environmental demands, whereas business gurus would refer to it as “cost-benefit analysis”. Colloquially we might decide whether or not “the game is worth the candle.”

So is it possible that the adolescent brain organization is not yet up to the task of this careful balancing act? This would come from an unsophisticated reward system, which has not yet been dampened by input from a more conservative, forward-planning prediction system based on cognition.

Effectively, this study demonstrates the emerging efficiency of a “cool” cognitive control system moderating a “hot” motivational assessment system, resulting in the appropriate balance between the rewards offered and the actions required to maximise performance. If your brain is younger, you are simply not very good at matching what you need to do with what you will gain if you get it right or lose if you get it wrong. This is indeed evidence of an adolescent lack of the necessary fine-tuning in the reward system which (thankfully) appears to emerge with age.

© Gender Health Query, 6/1/2019

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