Biological Cost-Benefit Analysis: Why Legislation Should Forbid Child Gender Transitioning Procedures

Children Celebrating New York City Pride. (Photo by Christopher Gagliardi)

October 13, 2021

“There are no solutions. There are only trade-offs.” Rarely have other thinkers packaged up wisdom like Thomas Sowell. Sowell was right—every action has a trade-off. If you buy a cheap product you benefit by saving money, but you risk buying a subpar product for your needs. If you buy an expensive product, you benefit because the product is (usually) solid, but your monetary cost is higher. The choice lies where one wants to allocate risk.

Actions, in whatever form, come with more nuanced consequences than what are usually considered. There is no free lunch, and it’s imperative to choose the one with a better cost–benefit profile. But it’s complicated when our actions involve human lives because actualized risks can be costly—Government legislation, for example. All else being equal, it would be morally unconscionable to enact a bill that subjects children to certain, impending harm. Any potential benefits, like introducing responsibility early in life, would be overshadowed by the looming cost and low risk tolerance. 

Conservatives and liberals won’t fret about gender transition procedures after the age of 18. Once legal adulthood is reached, conservatives seem to lean towards a libertarian position on the decision of surgically transitioning. But recently the landscape has changed, and leftists now question whether any limit of when one can undergo transition should be imposed. 

In their argumentation, both sides will make deontological claims, and little conservation investigates the trade-offs involved with government permitting these procedures or not. After a cost benefit analysis, a deontological “ought” is easier established. In deontological ethics, actions are determined as “oughts” or “ought nots” based on a set of rules. I have my own deontology about children and gender transition procedures, admittingly, though it’ll be absent herein.

This question is not only of moral significance because children are involved, but because of the number of children this legislative action will impact. There aren’t many transgender children on a percentage basis, but small percentage values equate to many individuals. In 2019, the CDC published a paper reporting about 2 percent of high school students identify as transgender out of a sample of 19 school districts. 

There’s a plethora of gender transition procedures, but they’re all either pharmacologic or surgical in nature (saving the obviously reversible type when one changes their outward appearance). This term, “gender transition procedure”, is usually all-encompassing in the literature, used to describe all methods and levels of intervention. Because there aren’t abundant data on surgical interventions and transgender adolescents, I’ll only speak on the pharmacologic procedures to avoid constructing a straw-man.

The pharmacologic procedures either inhibit puberty—popularly called “puberty blockers”—or induce cross-sex characteristic development with exogenous hormones. In some cases, blocking the patient’s molecular sites where their endogenous hormones bind can be done. For example, in transgender males, androgen-receptor antagonists prevent the masculinizing effects from their endogenous testosterone. But cross-sex hormones are the most common procedure.

Bona-fide, transgender children experience mental health benefits after transitioning procedures. There’s a swath of peer-reviewed studies in support. The data aren’t clear if transgender children suffer mental health declines from societal discrimination or psychological aberrancies, though it’s irrelevant in a cost-benefit analysis. It’s only relevant that transitioning procedures alleviate the anxiety and depression that happens to accompany transgender children. In 2015, The Lancet Diabetes and Endocrinology published an extensive review indicating the literature is mostly in agreement with this conclusion. Other studies could be mentioned, too, but an inundation of the supporting data would be redundant.

Indeed, one could argue governing bodies should permit transitioning procedures for children on grounds they improve mental health. But what are the risks of them? What are the costs of actualized risk? Surely, medical professionals ask similar questions before more generic procedures.

Infertility, cardiac complications, and decreased bone mineral density z-scores are risks on the table. Sex-steroids are integral in bone turnover, thus, when puberty is blocked bone mineral density z-scores drop over time. During the time when puberty is blocked, other children are going through puberty, effectively outpacing the puberty-blocked children. Z-scores compare one’s bone mineral density to the average of the same gender and age. 

In 2019, Davidge-Pitts & Clarke conducted a meta-analysis to investigate the relationship between puberty blockers and bone-mineral density. They concluded cross-sex hormones given post-puberty inhibition recovers much of the BMD z-score loss, but on average, the scores don’t recover back to pre-treatment levels. The authors advised that the physiological state onset by puberty blockers should be avoided for long periods of time. Moreover, this month a study was published in Pediatrics wherein the authors found lumbar spine BMD z-scores dropped after puberty-blocker treatment. A BMD z-score is the comparison of an individual’s bone mineral density to the average within the same age and sex cohort.

The risk of infertility is substantial. Exogenous estrogens cease spermatogenesis and cause testicular atrophy in transgender females. Likewise, when transgender men are given testosterone, ovaries collagenize, hypertrophy and potentially turn polycystic. A study published in Reproductive Biomedicine Online reported various cellular pathologies in a sample of 112 transgender females who were given testosterone. Transitioning procedures don’t cause infertility by necessity, but the risk is grand enough that the most liberal institutions recommend fertility counseling before any transition procedure. The University of California, San Francisco states on their transgender care webpage: “It is recommended that prior to transition all transgender persons be counseled on the effects of transition on their fertility as well as regarding options for fertility preservation and reproduction”

The causality between cross-sex hormones and the cardiac complications seen in transgender individuals isn’t understood very well. Though, in the few peer-reviewed studies myocarditis, ischemic stroke and cerebrovascular disease cases are reported at statistically higher levels. Some scientists think it could be related to the worsened lipid panels and increased hematocrit that follows cross-sex hormone therapy, but it could also be behavioral factors. The relationships are unclear, but it’s certain transgender individuals suffer cardiac problems more than “cis” individuals. The cause isn’t as relevant in risk assessment if the data suggest one might be susceptible to the effect.

Transitioning children take on biological risk, but they benefit by alleviating mental health declines. Transgender children forgoing these procedures avoid the biological risk, but their mental suffers. Indeed, those in favor of permitting child gender transition have somewhat of an argument. 

However, opportunity cost ought to be considered. This year, a study was published reporting out of 139 transgender children 88 percent desisted from transgenderism. Similar studies have been published in 2008 and 2013, both reporting over 60 percent desisted. In other words, they eventually grew out of it.

So, if transgender children will likely desist (outgrow it), the trade-offs begin to shift. Children who transition likely could have avoided the biological costs if they decided not to go through with it. And they likely would’ve desisted from their transgenderism if gender transitioning procedures weren’t opted for, so they could have gained back the mental health costs associated with not transitioning. If it turns out their mental health continues to decline past legal adulthood, they could always opt to transition with only acute cost accrual.

Furthermore, the costs of transitioning as a child are of a chronic nature. Bone-mineral density z-scores don’t return to pre-treatment levels even after cross-sex hormone treatment, on average. In transgender females, prolonged hypogonadism increases the likelihood of sterility, and for transgender men, the ovarian pathologies associated with androgen exposure are permanent. One could argue fertility preservation options are available before transitioning but rarely do any adolescents use them, and commonly they end up wanting to conceive in adulthood. This is not to say the acute mental health costs of forgoing transition aren’t significant, but they aren’t of the same chronic, dilapidating nature.

Lawfully permitting gender transition procedures for children is morally unconscionable because it would subject thousands of children to irreversible biological costs. Yes, they would benefit in their mental health, but less children will be harmed from irreversible biological changes if these procedures are forbidden before adulthood. 

Transgender children may want to follow through with a life-altering transition, but medical professionals and legislative bodies would knowingly subject children to procedures that cost them long term—when they could have otherwise accrued less cost. 

This is why some guardrails are better left unquestioned.

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