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New way of being a person?
  1. Bernadette Wren
  1. Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, London, UK
  1. Correspondence to Dr Bernadette Wren, Gender Identity Development Service, Tavistock and Portman NHS Foundation Trust, London, UK; bwren{at}

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In many countries grappling with the politics of equal recognition, the experiences, beliefs and reasons for action of people who identify as non-binary are starting to be seen as valid and intelligible.1 And, despite some gender clinics still responding cautiously to requests for non-standard medical interventions, their treatment needs are now recognised in major clinical guidelines. This is the current social context in which Notini and colleagues outline the case of ‘Phoenix’, an 18-year-old birth-assigned woman, who has requested the indefinite continuation of puberty suppression (OPS), a treatment that was initiated when the client was 11 years old to mitigate their intense distress at the onset of puberty.

Drawing on a conception of health as overall well-being, the authors conclude that OPS is ‘consistent with the proper goals of medicine’, and that there are ‘equity-based reasons’ for offering OPS to adults as a group. They concede that the physical risks are greater for OPS than for hormonal interventions generally provided to people with a binary gender identity. They also acknowledge the need for ‘a fine-grained ethical evaluation of Phoenix’s particular situation’ to assess whether the potential benefits of OPS outweigh the potential harms for this individual.

Here I respectfully raise three points to amplify the authors’ discussion. First, there seem to be significant ethical issues of a general, not a particular, kind arising from the type of individual evaluation they call for. Following initial screening for significant mental distress and other major vulnerabilities, the key undertaking …

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  • Contributors I am the sole author of this manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

  • The authors do briefly mention, in closing, the question of whether a patient has, or should have, a right to OPS in situations where the treatment is not expected to provide benefit or is expected to lead to harm, but where the patient makes an autonomous decision to pursue it. In the UK’s National Health Service, there is no right to a particular treatment, and a patient cannot insist on a treatment that a clinician does not think is indicated.

  • While the relationship between puberty and neural development is not well understood, recent neuroimaging research plus evidence from non-human animal studies indicates that the hormonal events of puberty exert profound effects on brain maturation and behaviour.

  • While it is the case that body-related and sexuality-related anxieties are normative experiences for adolescents, especially for birth-assigned women, such a voluntary and continuous closing-down of pubertal development is rarely seen clinically other than in young people with severe eating disorders.

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