Not a Minor Decision
To build public support for gender-affirming care, parents should be full partners in decisions about children
Last week, the Supreme Court upheld Tennessee’s ban on gender-affirming healthcare for minors in US v Skrmetti. This ruling cements similar bans in 27 other states and could lay the groundwork for future restrictions on adult care.
In hindsight, the case was a strategic error. Successful social movements advance incrementally, picking battles where the public is sympathetic. Yet 71% of Americans oppose gender-affirming medical care for minors and 87% for children under 15, according to a recent NYT/Ipsos survey.
The public doesn’t yet grasp how valuable this care can be—granting trans youth a fleeting opportunity for self-fulfillment. Building understanding and support will be a long road. A vital step is for clinicians to stop marginalizing parents and to abandon scare tactics that strong-arm consent.
In the opening episode of The Protocol, a New York Times podcast released this month, we meet “FG,” the first patient to receive puberty blockers and hormone therapy at a pioneering Dutch clinic. Terrified that impending puberty will radically alter his body, FG contemplated suicide until his doctors and parents intervened. Since then, thousands of trans adolescents have been rescued from similar despair.
Puberty blockers are widely considered reversible and safe, long used to treat children with precocious puberty. Subsequent hormone therapy appears to improve mental health; numerous studies indicate higher life satisfaction and less depression and suicidal ideation.
Yet most of the evidence remains observational rather than drawn from randomized controlled trials. More research is needed to identify which patients are most likely to benefit over the long term. Still, the potential upsides are substantial.
Blockers enable trans youth to stave off biological changes that would irrevocably transform them beyond self-recognition. Hormone therapy aligns their bodies with their identity and helps prevent lifelong discrimination and stigma. Even if bans are constitutional, states shouldn’t deny patients this lifeline.
The Protocol goes on to recount the Dutch origins of youth medical transition. Patients were offered treatment only if they exhibited early-onset gender dysphoria, underwent extensive psychological evaluation, and had supportive parents. When this practice spread to US clinics, first in Boston and then in Los Angeles, many guardrails fell away.
Some rules—such as those requiring a year or more of therapy before treatment—amounted to needless gatekeeping and were rightly abandoned by clinicians, as Dr. Johanna Olson-Kennedy argues in episode three.
Standards of care improved in other ways too, especially with more trans experts at the table. Clinicians began to accommodate non-binary patients and provide fertility counseling. Yet as some professional organizations were captured by ideologues, other revisions went too far.
The family-led model became child-led. Clinicians accepted children’s self-diagnoses without carefully exploring alternatives, such as discomfort with stereotypical gender roles, same-sex attraction, or abuse. Parental hesitation was countered with worst-case-scenario suicide rhetoric.
In the words of Olson-Kennedy, the director of a leading clinic: “We often ask parents: Would you rather have a dead son than a live daughter… These kids have a suicide rate that is astronomical compared to any other group.” In fact, completed suicides among trans youth are vanishingly rare.
In healthcare and beyond, free and informed parental consent is necessary for minors to make life-changing decisions. Transition care should follow the same standard: thorough, evidence-based counselling in which doctors, parents, and children weigh risks and benefits together.
When parents of trans adolescents are not supportive, clinicians must help them find their way to the right decision. Inevitably, some kids who need care will lack parents who are willing to help them receive it. This is tragic. But we need a system that works for everyone and can garner public support. Current legal bans already leave kids without necessary care. Over time, this clinical standard could bring public opinion—and courts—on side.
Progress will require additional reform. Treatment should be prioritized for youth whose trans identity is early-onset and persistent. Screening is essential; no one should be prescribed blockers after only their first clinical visit. Clinicians and other professionals should be honest about the state of the current evidence. Researchers should practice open science, rather than fearing that null results will be weaponized. Detransitioners should not be demonized.
Bigger picture, trans activists should prioritize goals where they enjoy public support, such as legal protections from discrimination in jobs, housing, and public spaces. And following Sarah McBride, the first trans member of Congress, the strategy should be to persuade rather than police.
After winning battles like these, activists can leverage public opinion to advance further struggles—not just removing bans on youth medical transitions but also increasing trans adults’ access to medical care and making women’s sports trans-inclusive. Many activists are likely to be frustrated by this incremental approach, but better to move slowly than continue to slide backwards.
Many lawmakers exploit trans healthcare as a culture-war wedge, equating treatment with child abuse. Yet some critics raise legitimate concerns. Medical transition hinders reversal to natal sex, increases the risk of adult sterility, and can disrupt sexual function. It’s reasonable to wonder what share of adolescents will ultimately experience regret or detransition, though current estimates suggest fewer than 1%.
Doctors have an obligation to minimize harm, to be sure, but the potential benefits of youth medical transition are enormous. To achieve political reform that gives more young people the option, parents must be given a central voice in the decision.
This piece undermines its own argument. Kumar acknowledges that “completed suicides among trans youth are vanishingly rare”. This fact directly undercuts the main urgency used to justify fast-tracking medical interventions.
If suicidality isn’t as widespread or extreme as commonly portrayed, then what’s the harm in slowing down and seriously exploring other explanations? Some of these youth might be gay, gender-nonconforming, autistic, or responding to social and peer dynamics.
Kumar also treats several unsettled scientific debates as if they’re closed. He omits the literature on desistance, ignores rapid-onset presentations, and assumes the Dutch protocol applies cleanly to today’s very different cohort. But even the Dutch model was cautious, narrow, and highly screened.
He calls for “evidence-based counseling” while selectively citing only evidence that supports transition. An honest evidence-based approach would admit we’re in uncharted territory, and that many interventions are being adopted before long-term outcomes are known.
Framing healthy adolescent bodies as “wrong” may actually create the distress we’re trying to solve. The strategic failure here is also medical, not just legal.
Detransition among minors who accessed pubertal suppression or hormonal therapy is currently estimated at 1-30% with higher figures in the US. No robust studies of regret among minors or young adults have ever been conducted. I lead the largest study on detransition in North America. @theonepercent