Improving Our Understanding of Medical Decision-Making Competence in Puberty Suppression

* Abbreviations: GnRHas — : Gonadotropin Release Hormone analogs MacCAT-T — : MacArthur Competence Assessment Tool for Treatment MDC — : medical decision-making competence PS — : puberty suppression In this issue of Pediatrics , Vrouenraets et al1 present findings on an important study assessing transgender adolescents’ medical decision-making competence (MDC) to give informed consent for starting puberty suppression (PS) among a sample of youth receiving care at 2 specialized gender identity clinics in the Netherlands. This study has significance for 2 important reasons: (1) PS has gained increased use in care for transgender adolescents2; and (2) recent legislation in several US states, as well as a recent court decision in the United Kingdom, seek to severely limit access to all gender-affirming care.3 PS using Gonadotropin Release Hormone analogs (GnRHas) has been shown to be reversible, when treatment is suspended, and has been a long-standing standard of care for children with precocious puberty.2 The benefits of PS include reducing the psychological distress of developing secondary sexual and other physical characteristics that may be incongruent with one’s gender identity. PS may also diminish the need for future surgical gender-affirming interventions, although a retrospective study in Pediatrics by van de Grift et al4 noted the possibility of limiting successful vaginoplasty for transfemale patients. The impact of long-term use of GnRHas on an adolescent’s future fertility and on bone development and growth is less clear.5 As described by Vrouenraets et al,1 PS allows transgender adolescents to “mature and accrue life experiences” before deciding about gender-affirming treatments, which have irreversible changes. Although the data collection for this study by Vrouenraets et al1 was initiated in 2016, the authors point to a 2020 decision handed down by the High Court of Justice in London, United Kingdom that youth 15 years and younger are “highly unlikely to understand puberty suppression (using GnRHas), and therefore cannot give … Address correspondence to Neal D. Hoffman, MD, Division of Adolescent Medicine, Children’s Hospital at Montefiore, 3415 Bainbridge Ave, Bronx, NY 10467. E-mail: nhoffman{at}montefiore.org