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The U.S. Department of Health and Human Services (HHS) is currently considering publishing regulations that will push for potentially irreversible medical and surgical interventions for people with gender dysphoria in the name of health care. In April, HHS Assistant Secretary Rachel L. Levine stated “gender affirming care is medical care” and included children and adolescents in that equation. 

Levine also reaffirmed a principle articulated by Hippocrates that physicians should do no harm. Can a physician provide interventions like potentially sterilizing hormones and surgeries for children and adolescents without doing harm? Research on adolescent brain development and decision-making indicates these two concepts are contradictory.

Our society is encouraging adolescents to make crucial decisions with lifelong consequences as research continues to document the immaturity of the adolescent brain. It does not utilize the strategizing and planning center, the prefrontal cortex, in the same manner as adults.

The American College of Pediatricians, of which I am a board member, just published a new position statement entitled “The Teenage Brain: Under Construction” with research showing that adolescents’ brains are not developed enough to make sound decisions, and this should inform potential medical and surgical interventions on minors with gender dysphoria because of their lifelong consequences.  

Neuroscientists studying decision-making have found adolescents are much more likely to rely upon emotions and peer pressure and less likely to consider future consequences. Researchers now talk about two systems for decision-making in the brain: a socioemotional system and a cognitive-control system. 

The socioemotional system often involves intuitive responses that are made rapidly as the person responds to feelings and emotions, while the cognitive-control system is much more reasoned and deliberate. Coordination between both systems is important in order to make good decisions, but neither system is mature during adolescent years.

Unfortunately, emotionally charged and high-risk situations present the most challenges for adolescent decision-making, especially when influenced by peer pressure. Even individuals between 18 and 21 years of age demonstrated “diminished cognitive performance” compared with older adults when they were exposed to emotionally charged situations. 

Adolescents are also less likely to incorporate and integrate their personal ethics and values when making important decisions. This means they do not improve their decision-making strategies when faced with more significant and important decisions, as adults do.

Given this research on the immature processing that occurs in the adolescent brain, it is crucial that adults assist with decision-making, especially those decisions that involve lifelong consequences.  Practically, this means that adolescents who are struggling with gender dysphoria should not be allowed to make decisions that contribute to permanent, unnecessary surgical procedures, mutilation, and infertility. 

The research on brain development indicates that adolescents should wait until they are 25 before attempting to make such significant decisions with lifelong consequences. This would mitigate the potential influence of peer pressure and emotions, while allowing the adolescent to experience natural puberty and associated hormonal influences on brain development. When allowed to do so, 85 to 90 percent of adolescents with gender identity concerns will accept their biological sex.  

In addition, evidence is demonstrating that those who are allowed to undergo hormonal blocking of puberty, followed by surgical procedures, may experience regret and criticize the adults who did not properly warn them of the consequences of their immature decisions. An article published in Pediatric News on March 17, 2022, reported on a Zoom conference of people who had “transitioned” back to their natural sex.

They said “the medical establishment initially failed them when they transitioned to the opposite gender, and again, when they decided to go back to their natal gender.” This was confirmed in a 2021 study of 100 “detransitioned” patients in which over half felt they had not received appropriate information or evaluation prior to transitioning.  

The American College of Pediatricians promotes an attitude of “Best for Children” and agrees that physicians should avoid causing harm. Using current research on adolescent brain development and decision-making, therefore, physicians should not encourage children and adolescents to make decisions with damaging and lifelong consequences.


Dr. Jane Anderson, MD, FCP is a board member of the American College of Pediatricians and retired faculty in Pediatrics at University of California San Francisco.  For more information, please visit www.acpeds.org.