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Lives in a chiaroscuro. Should we suspend the puberty of children with gender identity disorder?
  1. S Giordano
  1. Dr S Giordano, CSEP/IMLAB, and the Manchester Institute of Science, Ethics and Innovation, The University of Manchester, Williamson Building, The School of Law, Oxford Road, Manchester M13 9PL, UK; simona.giordano{at}


Transgender children who are not treated for their condition are at high risk of violence and suicide. As a matter of survival, many are willing to take whatever help is available, even if this is offered by illegal sources, and this often traps them into the juvenile criminal system and exposes them to various threats. Endocrinology offers a revolutionary instrument to help children/adolescents with gender identity disorder: suspension of puberty. Suspension of puberty raises many ethical issues, and experts dissent as to when treatment should be commenced and how children should be followed up. This paper argues that suspension of puberty is not only not unethical: if it is likely to improve the child’s quality of life and even save his or her life, then it is indeed unethical to defer treatment.

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  • Competing interests: None.

  • i Suspension of puberty can also be used for other conditions. In 2004 it was used in the “Ashley case”. See

  • ii Administration of hormones facilitate the restoration of puberty and return to the biological phenotype.4

  • iii These are sometimes called hypothalamic blockers. I am grateful to Mike Besser for clarifying the real nature of these hormone suppressant drugs. I owe the specifications contained in these lines to him.

  • iv The Royal College of Psychiatrists guidelines also recommend that adolescents have some “experience of themselves in the post-pubertal state of their biological sex”, before any treatment commences, but contemplate the possibility that “for clinical reasons, it is […] in the patient’s interest to intervene before this [time]”.18

  • v It is possible to determine pubertal development accurately by measuring testicular and breast growth as well as the levels of circulating hormones.21

  • vi I do not discuss arguments that say that SP is wrong because it is a violation of nature, or arguments that appeal to God’s plans and the sanctity of suffering. I have dismissed them elsewhere.25

  • vii It has been suggested that prostate cancer drugs may increase the risk of heart diseases. Experts in the field of paediatric endocrinology comment that similar risks cannot be found in the adolescent transgender population, for a number of reasons, one of which is that while testosterone is inhibited in this population, other hormones, like oestradiol, in males, are administered.27