• ethics
• decision-making
• capacity

We applaud Notini and colleagues for highlighting the clinical and ethical complexities of a case in which a non-binary individual desires indefinite treatment with puberty blockers.1 While we agree discontinuing treatment may cause psychological distress, we believe there are potential physical and neurocognitive harms caused by prolonged treatment that have been underestimated given the limited research conducted to date. Specifically, the impact of permanent pubertal suppression on the brain and decision-making capacity should be considered. In this context, we outline the potential risks of ongoing pubertal suppression (OPS) on bone and cardiovascular health, sexual and reproductive function, and brain development—all noted in the article but perhaps in an overly simplistic manner.1

First, the authors’ note OPS will almost certainly result in reduced bone density.1 Although we agree the absolute fracture risk is low in studies among older adults, there is less clarity about implications during adolescence and young adulthood when peak bone accrual occurs.2 Further, the authors propose ongoing monitoring with bone density scans, but no clear guidelines for clinicians if bone density becomes critically low—so we ask, at what point would a potential fracture risk outweigh the proposed benefits …