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Gender Atypical Organisation in Children and Adolescents: Ethico-legal Issues and a Proposal for New Guidelines
... The medical, counselling, and ethics literature pertaining to trans youth care has primarily focused on issues related to endocrine care and has cited bioethics principles: autonomy, beneficence, non-maleficence, and justice. Issues of autonomy include youth rights to privacy and confidentiality, arbitrary age requirements to access care, and emerging capacity to consent to care (Giordano, 2007(Giordano, , 2013Milrod, 2014;Stein, 2012;Swann & Herbert, 2009). Benefits of endocrine care include relieving psychological suffering and preventing the development of unwanted secondary sex characteristics, which, coupled with the low risk of harm from this treatment and the potential risk of causing harm by withholding care, make a compelling case in support of endocrine care for trans youth (Antommaria, 2014;Baltieri et al., 2009;Giordano, 2007;Holman & Goldberg, 2006;Stein, 2012;Vrouenraets et al., 2015). ...
... Issues of autonomy include youth rights to privacy and confidentiality, arbitrary age requirements to access care, and emerging capacity to consent to care (Giordano, 2007(Giordano, , 2013Milrod, 2014;Stein, 2012;Swann & Herbert, 2009). Benefits of endocrine care include relieving psychological suffering and preventing the development of unwanted secondary sex characteristics, which, coupled with the low risk of harm from this treatment and the potential risk of causing harm by withholding care, make a compelling case in support of endocrine care for trans youth (Antommaria, 2014;Baltieri et al., 2009;Giordano, 2007;Holman & Goldberg, 2006;Stein, 2012;Vrouenraets et al., 2015). Some have questioned whether youth possess the maturity necessary to make decisions about endocrine care, especially given the lack of data on long-term outcomes and potential impacts on future fertility (de Vries et al., 2006;Vrouenraets et al., 2015); however, many have concluded that youth do, as in other areas of health care, have the capacity to make these decisions (Holman & Goldberg, 2006;Giordano, 2007;Kreukels & Cohen-Kettenis, 2011). ...
... Benefits of endocrine care include relieving psychological suffering and preventing the development of unwanted secondary sex characteristics, which, coupled with the low risk of harm from this treatment and the potential risk of causing harm by withholding care, make a compelling case in support of endocrine care for trans youth (Antommaria, 2014;Baltieri et al., 2009;Giordano, 2007;Holman & Goldberg, 2006;Stein, 2012;Vrouenraets et al., 2015). Some have questioned whether youth possess the maturity necessary to make decisions about endocrine care, especially given the lack of data on long-term outcomes and potential impacts on future fertility (de Vries et al., 2006;Vrouenraets et al., 2015); however, many have concluded that youth do, as in other areas of health care, have the capacity to make these decisions (Holman & Goldberg, 2006;Giordano, 2007;Kreukels & Cohen-Kettenis, 2011). Finally, systemic barriers that negatively impact access to gender affirming medical care for trans youth have been cited as issues of justice in the ethics literature (Giordano, 2007). ...
Issues that arise in child and youth care practice with transgender (trans) youth and their families can be complex and ethically challenging. While many trans youth are thriving and have strong family and social supports, others face family conflict and experience negative health outcomes linked to societal stigma. The purpose of this paper is to explore how four ethical approaches — bioethics, rights-based ethics, relational ethics, and justice-doing — may be applied to practice situations involving trans youth and their families. This paper is grounded in the gender affirmative model of care and integrates empirical evidence, critical thinking, and explicit argumentation in ethical analysis. Following a brief overview of evidence related to trans youth care, case vignettes are analyzed using diverse ethical approaches. These approaches draw on a variety of philosophical and disciplinary traditions. However, the analyses consistently lead to three imperatives: providing support and affirmation for trans youth; supporting families to support their youth; and fighting injustice where it impedes these goals.
... 31 Proponents of early treatment emphasize the suffering of those who were treated as adults, the poor mental health and distress of adolescents who are denied treatment before adulthood, the risks a delay might involve, the advantage of 'buying time' in the diagnostic phase and the advantage of having a physical appearance in accordance with the desired gender. [32][33][34][35] ...
... In the UK, following the Gillick case it was established that a minor <16 years can give informed consent to medical interventions when the minor has reached sufficient understanding and intelligence to be capable of making such a decision (Gillick competence). 33 In The Netherlands, the consent of parents as well as the child is needed between the ages of 12 and 16 years. ...
The use of gonadotropin-releasing hormone analogs (GnRHa) to suppress puberty in adolescents with gender dysphoria is a fairly new intervention in the field of gender identity disorders or transsexualism. GnRHa are used to give adolescents time to make balanced decisions on any further treatment steps, and to obtain improved results in the physical appearance of those who opt to continue with sex reassignment. The effects of GnRHa are reversible. However, concerns have been raised about the risk of making the wrong treatment decisions, as gender identity could fluctuate during adolescence, adolescents in general might have poor decision-making abilities, and there are potential adverse effects on health and on psychological and psychosexual functioning. Proponents of puberty suppression emphasize the beneficial effects of GnRHa on the adolescents' mental health, quality of life and of having a physical appearance that makes it possible for the patients to live unobtrusively in their desired gender role. In this Review, we discuss the evidence pertaining to the debate on the effects of GnRHa treatment. From the studies that have been published thus far, it seems that the benefits outweigh the risks. However, more systematic research in this area is needed to determine the safety of this approach.
... This compounds not only the gaps in the study of medical interventions for trans adolescents but also the significant shortcomings in the literature on trans gender identities in general (Olson-Kennedy et al., 2016). Nevertheless, even though such interventions carry long-term uncertainties, not accessing them drives far more immediate uncertainties for the adolescents requiring them (Giordano, 2007;Murphy, 2019). ...
As a result of family rejection, harassment and social exclusion, transgender adolescents are prone to suffering from symptoms of depression, anxiety, eating disorders, self-harm and even suicidal ideation. In gender binary and heteronormative social contexts, as in Chile and Portugal, such adolescents may feel pressured to conform to dominant gender normativities, seeking to align their bodies according to the socially imposed ideals of female and male. Although Chile and Portugal have advanced in the legal recognition of self-determination of gender identity in recent years, they have also encountered problems in implementing health policies aimed at the adolescent transgender population, which would thereby imply a failure to guarantee the fundamental right to health.
... In general, the arguments against the use of blockers are based on the concern that gender dysphoria in childhood may go into remission in adolescence [59,60]; on the impossibility of making a certain diagnosis of gender dysphoria in developmental age given the variability of gender identity in childhood and adolescence [17,33]; and on the lack of knowledge of the long-term effects on the organism and psychological functioning [60,61]. Furthermore, therapy can inhibit the spontaneous formation of a compliant gender identity, which sometimes develops through the "gender crisis" [62], and reduce libido, negatively affecting the adolescent's sexual experiences and limiting exploration of one's sexual orientation [17,33]. Finally, for trans adolescents AMAB, the arrest of the development of the penis and testicles reduces the amount of skin tissue needed to perform a better vaginoplasty [63]. ...
Gender identity does not always develop in line with biological sex. Gender dysphoria at young age implies a strong incongruence between gender identity and the assigned sex; the rejection of one\'s sexual attributes and the desire to belong to the opposite sex; and a significant clinical suffering or impaired individual functioning in life spheres. The purpose of this chapter is a narrative review of the literature available on puberty suppression therapy through GnRH analogues. Biological puberty provides intense suffering to the adolescent with gender dysphoria who does not recognize himself in his own body. These drugs suppress the production of endogenous gametes and sex hormones. Although the effects of therapy are reversible, and biological development resumes spontaneously once the medication is stopped, the administration of GnRH analogues at a young age has fueled a scientific debate on the matter of the ethics of pharmacological intervention with minors. In conclusion, the studies considered show that GnRH analogues do not have long-term harmful effects on the body; prevent the negative psychosocial consequences associated with gender dysphoria in adolescence (suicidal ideation and attempts, self-medication, prostitution, self-harm); improve the psychological functioning of young transsexuals; and are diagnostic tools that allow adolescents to buy time to explore their gender identities.
... Several articles published in recent years focus on ethical issues arising in clinical practice with trans youth and specifically on the emerging capacity of youth and their legal authority to both access, and consent to, hormone therapy treatment (e.g., Abel 2014;Baltieri, Prado Cortez, and de Andrade 2009;Carroll 2009;Giordano 2007;Shield 2007;Stein 2012;Swann and Herbert 2009). In addition to questions of capacity to consent to hormone therapy, ethical concerns surround determination of youth best interests (e.g., balancing benefits of treatment against potential future harm of fertility implications). ...
Inherent in providing healthcare for youth lie tensions among best interests, decision-making capacity, rights, and legal authority. Transgender (trans) youth experience barriers to needed gender-affirming care, often rooted in ethical and legal issues, such as healthcare provider concerns regarding youth capacity and rights to consent to hormone therapy. Even when decision-making capacity is present, youth may lack the legal authority to give consent. The aims of this paper are therefore to provide an empirical analysis of minor trans youth capacity to consent to hormone therapy and to address the normative question of whether there is ethical justification for granting trans youth the authority to consent to this care. Through qualitative content analysis of interviews with trans youth, parents, and healthcare providers, we found that trans youth demonstrated the understandings and abilities characteristic of the capacity to consent to hormone therapy and that they did consent to hormone therapy with positive outcomes. Employing deontological and consequentialist reasoning and drawing on a foundation of empirical evidence, human rights, and best interests we conclude that granting trans youth with decisional capacity both the right and the legal authority to consent to hormone therapy via the informed consent model of care is ethically justified.
... Presumably related to the Infants Act (Infants Act, 1996) and evaluation of decisionmaking capacity, youth were frequently centered as the primary decision maker, by both themselves and the adults supporting them. Parent involvement in decision making was frequently present and consistently encouraged by health care providers, as would be expected from the review of literature (Swann and Herbert, 1999;Holman and Goldberg, 2006;Giordano, 2007;Bernal and Coolhart, 2012). Parents who participated in the study, as well as parents described by youth and health care provider participants, varied in their level of support for their youth initiating hormone therapy and in their overall involvement in the young person's life. ...
Information is lacking on the role shared decision making plays in the care of transgender (trans) youth. This qualitative, descriptive study explored how trans youth, parents and health care providers engaged or did not engage in shared decision-making practices around hormone therapy initiation and what conditions supported shared decision-making approaches in clinical practice. Semi-structured interviews were conducted with 47 participants in British Columbia, Canada, and analyzed using a constructivist grounded theory approach. While formal shared decision-making models were not used in practice, many participants described elements of such approaches when asked about their health care decision-making processes. Others described health care interactions that were not conducive to a shared decision-making approach. The key finding that emerged through this analysis was a set of five conditions for supporting shared decision making when making decisions surrounding initiation of hormone therapy with trans youth. Both supportive relationships and open communication were necessary among participants to support shared decision making. All parties needed to agree regarding what decisions were to be made and what role each person would play in the process. Finally, adequate time was needed for decision-making processes to unfold. When stakeholders meet these five conditions, a gender-affirming and culturally safer shared decision-making approach may be used to support decision making about gender-affirming care. Implications for clinical practice and future research are discussed.
... Complex ethical issues arise in the medical care of trans youth, specifically regarding youth capacity to consent to care; confidentiality; benefits and harms of providing, delaying, or withholding hormone therapy; and equitable access to care (Ashley, 2019;Bernal & Coolhart, 2012;Carroll, 2009;Cavanaugh, Hopwood, & Lambert, 2016;Chen & Simons, 2018;Gerritse et al., 2018;Giordano, 2007;Nahata, Campo-Engelstein, Tishelman, Quinn, & Lantos, 2018;Oliphant et al., 2018;Rosenthal, 2014;Stein, 2012;Vrouenraets et al., 2015;Wren, 2019). Many ethical concerns remain unresolved in the literature despite growing awareness of the health-care needs of trans youth and increasing availability of gender health care. ...
Health-care providers frequently face clinical ethical dilemmas when working with transgender youth who require hormone therapy but lack parental support for this intervention. Through semi-structured interviews and grounded theory analysis, we explored ethical and clinical decision-making processes of health-care providers, as well as the health care experiences of trans youth with family discordance. We analyzed responses in relation to North American bioethics principles, best interests standard, and the harm principle, exploring issues of autonomy, evidence, and anti-trans bias. We propose an ethically acceptable clinical approach termed parallel process hormone therapy initiation to address the needs of transgender youth with complex family situations.
... The bioethical, legal, and medical literature focusing on children's rights in health care generally centres on extreme cases such as a child's right to refuse life-saving treatment (Rosato, 1996;Weir and Peters, 2007), or seek treatment without parental knowledge (Committee on Adolescence, 1996;Sanci, Sawyer, Haller, Patton and Kang, 2005), and on parental-child conflict in life-changing decision-making (Giordano, 2007;Shaw, 2001). However, discussions of children's rights in everyday practices on a smaller scale are lacking. ...
Research on children's rights in oral health care is lacking, and this study aims to partially fill this gap. In 2015, we conducted research in one region of New Zealand using video methods to explore the rights of 22 children during a specific oral health treatment, the placement of stainless steel crowns. Our findings show that many children did not receive a professional standard of care, there were gaps in the delivery and standard of care, and there were numerous examples of children's rights' violations. At the same time, however, some of the children's dental practitioners' actions may have been acceptable practice within the profession if children's rights have not yet fully been embedded into the practice of oral health care workers. We conclude with a discussion of the implications of our findings and suggestions for a more rights based standard of oral health care.
... The bioethical, legal, and medical literature focusing on children's rights in health care generally centres on extreme cases such as a child's right to refuse life-saving treatment (Rosato, 1996;Weir and Peters, 2007), or seek treatment without parental knowledge (Committee on Adolescence, 1996;Sanci, Sawyer, Haller, Patton and Kang, 2005), and on parental-child conflict in life-changing decision-making (Giordano, 2007;Shaw, 2001). However, discussions of children's rights in everyday practices on a smaller scale are lacking. ...
Research on children’s rights in oral health care is lacking, and this study aims to partially fill this gap. In 2015, we conducted research in one region of New Zealand using video methods to explore the rights of 22 children during a specific oral health treatment, the placement of stainless steel crowns. Our findings show that many children did not receive a professional standard of care, there were gaps in the delivery and standard of care, and there were numerous examples of children’s rights’ violations. At the same time, however, some of the children’s dental practitioners’ (CDPs) actions may have been acceptable practice within the profession if children’s rights have not yet fully been embedded into the practice of oral health care workers. We conclude with a discussion of the implications of our findings and suggestions for a more rights based standard of oral health care.
... 15 Another study has suggested that hormonal suppression could prevent the spontaneous development of a stable and established gender identity, which sometimes matures through the occurrence of a gender crisis. 22 This is supported by other studies showing that symptoms of GD at prepubertal ages decrease or even disappear in a substantial percentage of children (estimates range from 80% to 95%). 23,24 However, GD continuing into early puberty has been shown to be highly persistent. ...
Introduction:
Gender dysphoria is a mismatch between a person's biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty).
Aims:
To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period.
Methods:
Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported.
Main outcome measures:
Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery.
Results:
One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period.
Conclusion:
Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period.
... Many of these adolescents experience their entire puberty in their corrective gender outwardly without disclosing the birth sex to peers. The fact that peer interactions can uncover the individual's transgender status can have dramatic consequences (Giordano, 2007) and result in (cyber and other) harassment and peer victimization. Moreover, another influential factor that drives the (mostly) female adolescent wish for genital congruence is the desire for romance and dating. ...
The WPATH Standards of Care (SOC) Revision Committee are reassessing criteria for sex reassignment surgery. The major points of discussion for which WPATH might provide additional guidelines are: (1) gender binary defying surgery, (2) gonad retention for fertility preservation prior to hysterectomy in transmen and castration (+ vaginoplasty) in transwomen, (3) the necessity for two referrals from qualified mental health professionals who have independently assessed the patients, prior to performing genital surgery, especially for hysterectomy and salpingo-oophorectomy, (4) the minimum age of 18 as eligibility to undergo irreversible (genital) surgery procedures. We have performed a literature search focussing on these subjects in order to formulate a supported opinion for changing the SOC regarding these topics.
... Adolescents experience refusal for treatment as psychological torture [65] and not treating these youngsters might lead to risky behaviors (for example, prostitution, self-mutilation, self-medication or suicide) [65][66][67][68][69]. ...
Young people with gender dysphoria are increasingly seen by pediatric endocrinologists. Mental health child specialists assess the adolescent and give advice about psychological or medical treatment. Provided they fulfill eligibility and readiness criteria, adolescents may receive pubertal suspension, consisting of using gonadotrophin-releasing hormone analogs, later followed by cross-sex hormones (sex steroids of the experienced gender). If they fulfill additional criteria, they may have various types of gender affirming surgery. Current issues involve safety aspects. Although generally considered safe in the short-term, the long-term effects regarding bone health and cardiovascular risks are still unknown. Therefore, vigilance is warranted during and long after completion of the last gender affirming surgeries. The timing of the various treatment steps is also under debate: instead of fixed age limits, the cognitive and emotional maturation, along with the physical development, are now often considered as more relevant.
Copyright © 2015. Published by Elsevier Ltd.
... However, it should be considered that in some opinions, gender identity may still be fluctuating in this development phase and it would therefore not be possible to make a definitive GD diagnosis. Furthermore, others fear that preventing secondary sex characteristics to develop will inhibit a ''spontaneous formation of a consistent gender identity'' [51]. However, recent Dutch observations report that, while GD in childhood includes a wide range of outcomes, when it persists in the beginning of puberty, it will rarely desist in later adolescence and adulthood [38]. ...
Purpose:
Despite international guidelines being available, not all gender clinics are able to face gender dysphoric (GD) youth population needs specifically. This is particularly true in Italy. Centers offering specialized support are relatively few and a commonly accepted Italian approach to GD youth has still not been defined. The aim of the present Position Statement is to develop and adhere to Italian guidelines for treatment of GD adolescents, in line with the "Dutch Approach", the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH) guidelines.
Methods:
An in-depth brainstorming on the application of International guidelines in the Italian context was performed by several dedicated professionals.
Results:
A staged approach, combining psychological support as well as medical intervention is suggested. In the first phase, individuals requesting medical help will undergo a psycho-diagnostic procedure to assess GD; for eligible adolescents, pubertal suppression should be made available (extended diagnostic phase). Finally, from the age of 16 years, cross-sex hormonal therapy can be added, and from the age of 18 years, surgical sex reassignment can eventually be performed.
Conclusions:
The current inadequacy of Italian services offering specialized support for GD youth may lead to negative consequences. Omitting or delaying treatment is not a neutral option. In fact, some GD adolescents may develop psychiatric problems, suicidality, and social marginalization. With access to specialized GD services, emotional problems, as well as self-harming behavior, may decrease and general functioning may significantly improve. In particular, puberty suppression seems to be beneficial for GD adolescents by relieving their acute suffering and distress and thus improving their quality of life.
... These factors would provide protection against a charge of negligence were any complaint made[32].The guidelines that specifically prohibit early suspension of puberty in the UK are under review[33]. The failure to provide treatment early enough to block full pubertal development in response to a competent minor's request , risks being unethical [34]. ...
A pesar de que muchos médicos, quizás incluso sin saberlo, tratan a jóvenes pacientes que sufren de trastornos de identidad de género importantes, es raro que se vean enfrentados a un caso en el que este estado parece grave y persistente. Existen fuertes presiones sociales, en la familia y en la escuela, que inhiben generalmente todo intento de revelar estos trastornos. Cuando las familias identifican este tipo de trastornos de identidad y recurren a una asistencia médica, la respuesta prudente debería consistir en orientar al joven hacia un servicio pediátrico especializado que ofrece cuidados multidisciplinares garantizados por profesionales expertos en salud mental y endocrinólogos, conformes a las normas internacionales reconocidas. Sin embargo, en numerosos países, este tipo de servicios no existe o bien el servicio disponible tiene un enfoque que los jóvenes o sus familias no aceptan. Ante esta situación, el médico se enfrenta a una serie de problemas prácticos. Incluso los profesionales de salud mental más experimentados no pueden prever la persistencia del estado observado en la fase anterior a la pubertad. Al inicio de la pubertad, a menudo es posible establecer un pronóstico fiable. La respuesta clínica de muchos países avanzados consiste en interrumpir la pubertad, lo cual alivia el estrés provocado por los cambios corporales que están en conflicto con la identidad de género del/de la joven. Además, de este modo, tanto pacientes como médicos disponen de más tiempo para corroborar el pronóstico, tras lo cual puede empezar el trabajo de adaptación del cuerpo a la identidad de género. Inicialmente, se suministran hormonas de conversión sexual. Una vez que la persona ha alcanzado la edad adulta, es posible recurrir a la cirugía para terminar la transformación física. El médico que contemple un tratamiento de este tipo para un adolescente debe tener en cuenta una serie de parámetros: las cuestions jurídicas y éticas vinculadas con los cuidados médicos para este grupo de pacientes; las necesidades corrientes en el campo educativo y de apoyo a las familias y los colegios de los jóvenes; el empecinamiento de algunos padres, sobre todo en Gran Bretaña, a quienes se rechaza una intervención física para su hijo adolescente y que viajan a otro país para obtenerla; la facilidad con la que algunos adolescentes a quienes se ha rechazado la intervención encuentran información y tratamientos médicos en Internet y que a veces pagan protituyéndose. Finalmente, si el médico decide proponer cuidados locales, debe saber que existen médicos experimentados en otros países dispuestos a brindar su ayuda.
... A report published by an expert in the field of medical ethics (Giordano 2007(Giordano , 2008 critiqued medical practice in the UK, arguing that UK doctors are 'depriving children relief from "extreme suffering" caused by their condition, leading to self harm and suicide and forcing their families into seeking help outside the UK'. The publication of this report, and two subsequent conferences in 2008, led to considerable press attention, debate and activism around the treatment of 'gender variant adolescents' and highlighted the difficulties faced by young transgender and transsexual people who often embody gender expressions which are not clearly male of female. ...
This article is based on empirical research which was undertaken as part of the Sci:dentity project funded by the Wellcome Trust. Sci:dentity was a year-long participatory arts project which ran between March 2006 and March 2007. The project offered 18 young transgendered and transsexual people, aged between 14 and 22, an opportunity to come together to explore the science of sex and gender through art. This article focuses on four creative workshops which ran over two months, being the ‘creative engagement’ phase of the project. It offers an analysis of the transgendered space created which was constituted through the logics of recognition, creativity and pedagogy. Following this, the article explores the ways in which these transgendered and transsexual young people navigate gendered practices, and the gendered spaces these practices constitute, in their everyday lives shaped by gendered and sexual normativities. It goes on to consider the significance of trans virtual and physical cultural spaces for the development of trans young peoples' ontological security and their navigations and negotiations of a gendered social world.
Introduction:
This study explored how transgender (trans) youth and parents of trans youth made decisions around hormone therapy initiation as well as trans youth experiences of barriers to care.
Methods:
Participants included 21 trans youth (ages 14-18) and 15 parents of trans youth who resided in British Columbia, Canada. Data for this grounded theory research consisted of transcripts and lifeline drawings collected through semi-structured interviews conducted August 2016 through February 2017.
Results:
The decision-making processes of youth and of parents are illustrated in three-phase temporal models, starting with discovery, leading to (inter)action while seeking care, and reflection after hormone therapy initiation. Youth who sought hormone therapy were clear about their decision to access this care. Throughout these processes, youth experienced numerous parent- and system-related barriers to care. Youth with the lowest levels of parent support experienced more system barriers, with non-binary/genderfluid youth experiencing greater barriers and less support for hormone therapy than youth with binary genders. A new barrier identified in this study was health care provider imposed requirements for parental involvement and/or approval, which rendered some youth unable access to hormone therapy.
Conclusions:
Health care providers should be aware of the deliberation and information-seeking in which youth engage prior to seeking care as well as the temporally misaligned decision-making processes of youth and parents. Understanding the challenges trans youth experience due to insufficient parental support and system barriers can provide important context for health care providers striving to provide accessible, gender-affirming care and decision-making support for trans youth.
Studies suggest that the majority of gender diverse children (up to 84%) revert to the gender congruent with the sex assigned at birth when they reach puberty. These children are now known in the literature as ‘desisters’. Those who continue in the path of gender transition are known as ‘persisters’. Based on the high desistence rates, some advise being cautious in allowing young children to present in their affirmed gender. The worry is that social transition may make it difficult for children to de-transition and thus increase the odds of later unnecessary medical transition. If this is true, allowing social transition may result in an outright violation of one of the most fundamental moral imperatives that doctors have: first do no harm. This paper suggests that this is not the case. Studies on desistence should inform clinical decisions but not in the way summarised here. There is no evidence that social transition per se leads to unnecessary medical transition; so should a child persist, those who have enabled social transition should not be held responsible for unnecessary bodily harm. Social transition should be viewed as a tool to find out what is the right trajectory for the particular child. Desistence is one possible outcome. A clinician or parent who has supported social transition for a child who later desists will have not violated, but acted in respect of the moral principle of non-maleficence, if the choice made appeared likely to minimise the child’s overall suffering and to maximise overall the child’s welfare at the time it was made.
In the case of controversial interventions there is a need for clinical guidelines to be founded on ‘expert opinion’ and an evidence base, in order to minimise individual clinicians making subjective decisions influenced by bias or cultural norms. This paper considers international clinical guidelines that through recommendation effectively prohibit the provision of genital-alignment surgery for competent adolescents with gender dysphoria. I argue that although the rationale for this particular guideline is based on serious concerns, these need to be better understood to allow reconsideration of this unilateral prohibitive recommendation. I do not propose that genital-alignment surgery should be prima-facia provided for any adolescent with gender dysphoria. Instead I argue that by developing our understanding of the current concerns, we can allow guidelines to incorporate a margin of clinical discretion, to allow clinicians to provide genital-alignment surgery to some adolescents, where clinically appropriate. In facilitating this we can move towards establishing a solid evidence-base. The basis of this position is that clinical guidelines and medical practice should treat these young people with the same standards of evidence-based care as others who have less controversial conditions. Whilst this paper uses English law and UK professional regulation for context, many of the ethical, legal and professional issues highlighted are applicable to other jurisdictions.
In recent years, the use of gonadotropin-releasing hormone (GnRH) analogues in adolescents with gender dysphoria (GD) to suppress puberty has been adopted by an increasing number of gender clinics, generating controversial debate. This short essay provides an overview of the difficulties associated with this heterogeneous group of adolescents and discusses arguments for and against the suspension of puberty. Further, it reviews the main follow-up studies conducted in some of the world's largest clinical centres for gender-variant children and adolescents.
How should we understand transgenderism, especially as it affects children and adolescents? Psychiatric manuals include transgenderism among mental illnesses (Gender Identity Disorder). Such inclusion is relatively recent, and even the words transsexual and transgender were coined only a few decades ago. Yet stories of children with an in-between gender have always been, albeit symbolically, a part of popular culture. Drawing on fairy tales, as well as from personal narratives and clinical studies, this book explains how “Gender Identity Disorder” manifests in children, critically evaluating various clinical approaches and examining the ethical and legal issues surrounding the care and treatment of these youths. The book argues that Gender Identity Disorder is not pathology, and that medicine and society should assist children in expressing themselves, without attempting to force them to adapt to a gender that does not match with their perceived identity.
This paper introduces the readership of The Psychoanalytic Study of the Child to the topic of transgender children, which will be investigated in the papers that follow. A flashpoint in the recent discourse that escorts children who self-describe as gender nonconforming is whether or not to support the practice of the medical suspension of puberty of these children by the administration of hormonal treatment. Relevant up-to-date research findings on this subject will be reviewed here. Despite those advocates and opponents who swarm around both poles, any reliable conclusions as to the long-term safety and psychological effects of puberty suppressants will remain provisional untilfuture studies proffer more definitive answers. While we await further study, the journal sees the necessity to press for dialogue concerning this conundrum. Anchoring this section is a clinical paper by Diane Ehrensaft, Ph.D., which documents the psychotherapeutic treatment of a transgender child who was prescribed puberty suppressants. The commentaries that follow and that are briefly summarized in this introduction will accent the psychoanalytic developmental point of view. This will provide the principal framework for the study of this controversy, which underscores the complementary dimensions of linear and nonlinear progressive hierarchical growth. In this context, features such as the developmentally normative fluidity of self-structures, including gender role identity, and the evolution of concrete thinking toward metaphoricity and figurative meaning-making in middle childhood and adolescence will be examined and applied to the clinical data. In addition, the argument that the use of puberty suppressants exacts a premature foreclosure on the reorganizing potential of developmental growth, and the proposed efftcts of the crosscurrents of the sociocultural body politic on these children and on the decision to opt for the suspension of pubertal growth will be explored.
This issue of the Journal of General Internal Medicine showcases an intriguing and uncommon article: “Electronic Health Records and Transgender Patients—Practical Recommendations for the Collection of Gender Identity Data.”1 Readers who currently see no transgender or transsexual (now commonly referred to as "trans") patients may wonder why this paper was selected for publication. While the common belief has been that trans patients needed to be referred to endocrinologists or other specialists, there is now increasing recognition that quality primary care can be provided by general internists and others who are willing to expand their practice by engaging in dialogue with the patient and others committed to caring for trans patients. Another common belief in the past was that trans people were universally committed to full medical and surgical transition. The trans patients seeking care now appear to vary widely on how few or how many transition services they seek. Significant expansi ...
Introduction
During the last decade, the age of youths presenting for gender confirmation has steadily fallen. Transgender adolescents are being treated with gonadotropin‐releasing hormone analogues and subsequently cross‐sex hormones at early or midpuberty, with genital surgery as the presumed final step in treatment for female‐affirmed (male‐to‐female) individuals. Despite the minimum age of 18 as eligibility to undergo irreversible procedures, anecdotal reports show that vaginoplasties of female‐affirmed patients under 18 have been performed by surgeons, thereby contravening the World Professional Association for Transgender Health Standards of Care.
Aim
The purpose of this article is (i) to provide a review of salient factors regarding genital surgery in transgender adolescents; (ii) to review various ethical protocols for determining maturity in gender dysphoric individuals under 18; and (iii) to present a new systematic set of ethical principles largely derived from the surgical management of youths with disorders of sex development and adapted to the needs of transitioning adolescents.
Methods
A literature review of the topic was performed. Ethical guidelines derived from applied treatment protocols of children with disorders of sex development were written.
Main Outcome Measure
Progressing from the current state of ethical standards and clinical assumptions, a new development of ethical guidelines for genital surgery in the female‐affirmed transgender adolescent was created.
Results
There were no controlled studies of vaginoplasties performed on female‐affirmed adolescents under 18 years of age. A new set of ethical guidelines was created in order to support treatment professionals in their decision making process.
Conclusions
Professionals across disciplines treating female‐affirmed adolescents can utilize the proposed ethical guidelines to facilitate decision making on a case‐by‐case basis in order to protect both patients and practitioners. These guidelines may also be used in support of more open discussions and disclosures of surgical results that could further the advancement of treatment in this emerging population. Milrod C. How young is too young: Ethical concerns in genital surgery of the transgender MTF adolescent. J Sex Med 2014;11:338–346.
Gender Identity Disorder (GID) is regarded as a mental illness and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It will also appear in the DSM-V, due to be published in 2013. The classification of GID as a mental illness is contentious. But what would happen to sufferers if it were removed from the diagnostic manuals? Would people lose their entitlement to funded medical care, or to reimbursement under insurance schemes? On what basis should medical treatment for GID be provided? What are the moral arguments for and against funded or reimbursed medical care for GID? This paper starts out with a fiction: GID is removed from the diagnostic manuals. Then the paper splits in two, as in happened in the Howitt's 1998 film Sliding Doors. The two scenarios run parallel. In one, it is argued that GID is on a par with other body modifications, such as cosmetic and racial surgery, and that, for ethical reasons, treatment for GID should be privately negotiated by applicants and professionals and privately paid for. In the other scenario, it is argued that the comparison between GID and other body modifications is misleading. Whether or not medical treatment should be funded or reimbursed is independent of whether GID is on a par with other forms of body dissatisfaction.
Transgender children who are not treated for their condition are at high risk of violence and suicide. As a matter of survival, many are willing to take whatever help is available, even if this is offered by illegal sources, and this often traps them into the juvenile criminal system and exposes them to various threats. Endocrinology offers a revolutionary instrument to help children/adolescents with gender identity disorder: suspension of puberty. Suspension of puberty raises many ethical issues, and experts dissent as to when treatment should be commenced and how children should be followed up. This paper argues that suspension of puberty is not only not unethical: if it is likely to improve the child's quality of life and even save his or her life, then it is indeed unethical to defer treatment.
Treatment of individuals with gender identity disorder (GID) has in medicine nearly always met with a great deal of skepticism. Professionals largely follow the Standards of Care of the World Professional Association for Transgender Health. For adolescents, specific guidelines have also been issued by the British Royal College of Psychiatrists.
To describe the stepwise changes in treatment policy which, in recent years, have been made by the team of the Gender Identity Clinic at the VU University Medical Center in Amsterdam, The Netherlands.
The first step taken to treat adolescents was that, after careful evaluation, (cross-sex hormone) treatment could start between the ages of 16 and 18 years. A further step was the suppression of puberty by means of gonadotropin-releasing hormone analogs in 12-16 year olds; the latter serves also as a diagnostic tool. Very recently, other clinics in Europe and North America have followed this policy. Results. The first results from the Amsterdam clinic show that this policy is promising.
Professionals who take responsibility for these youth and are willing to help should yet be fully aware of the impact of their interventions. In this article, the pros and cons of the various approaches to youngsters with GID are presented, hopefully inciting a sound scientific discussion of the issue.
Understanding Eating Disorders is an original contribution to the field of healthcare ethics. It develops a new theory concerning the moral basis of eating disorders, and places such disorders for the first time at the centre of philosophical discourse. The book explores the relationship that people have with food and their own body by looking at genetics and neuro-physiology, sociology and family studies, clinical psychology and psychiatry, and frames abnormal eating at the extreme of a spectrum of normal behaviours, directed by moral values. Giordano argues that abnormal eating is not a psycho-pathological phenomenon, but the coherent implementation of ordinary moral values with a long tradition in Western culture. The book also contains a detailed analysis of UK legislation, accompanied by a timely critique of the law on treatment of mental disorders in general and of eating disorders in particular.
This article describes the misery and frustration of young people for whom the external reality of the body is at odds with their gender identity. As hormonal and surgical treatments to alter the sexual body increase in sophistication, clinicians may be under pressure to provide this treatment to the under-18s – if only for the postponement of puberty. This pressure is especially powerful in the absence of evidence for the effectiveness of psychological treatment in reconciling cross- gendered youngsters to their bodies. Current practice is outlined and the legal context is described briefly. The clinician’s dilemmas are explored with particular reference to conflicting views of adolescent development, our limited understanding of the aetiology of gender dysphoria, the lack of empirical data on the impact of early physical intervention and changing cultural attitudes to transsexuality.
Eating Disorders, particularly anorexia and bulimia, are of immense contemporary importance and interest. News stories depicting the tragic effects of eating disorders command wide attention. Almost everybody in society has been touched by eating disorders in one way or another, and contemporary obsession with body image and diet fuels fascination with this problem. It is unclear why people develop eating disorders. Clinical and sociological studies have provided important information relating to the relational systems in which eating disorders are mainly found. This paper shows that their explanations are not conclusive and points out that the reasons why people develop eating disorders should not be found in the dysfunctional interactions occurring in both familial and social systems, but in the moral beliefs that underlie these interactions. Eating disorders are impossible to understand or explain, unless they are viewed in the light of these beliefs. A moral logic, that is a way of thinking of interpersonal relations in moral terms, gives shape to and justifies the clinical condition, and finds consistent expression in abnormal eating behaviour. The analysis offered here is not mainstream either in philosophy (eating disorders are in fact seldom the subject of philosophical investigation) or in clinical psychology (the methods of philosophical analysis are in fact seldom utilised in clinical psychology). However, this paper offers a important contribution to the understanding of such a dramatic and widespread condition, bringing to light the deepest reasons, which are moral in nature, that contribute to the explanation of this complex phenomenon.
The normally developed child whose gender identity and anatomic sex disagree is referred to as a transgendered child, or as used subsequently in this text, a transsexual. The ramifications of this disagreement include a high risk of psychiatric conflict and maladjustment, for both the individuals themselves and their families. Despite the efforts of researchers to systematically study this group of children, many fundamental questions remain. In many respects, those lingering questions are shared by patients with physical intersex who have been cared for by pediatric endocrinologists. In intersex and transsexual patients, the medical community, although sincerely interested, remains wary to intervene in ways that may lead to further inconsistency between anatomic sex and adult gender identity. A perspective on the problems of differentiating permanent from transient gender identity, some thoughts on the most appropriate management of the transsexual child/adolescent as well as remaining questions are discussed. Both the flexible and therefore potentially misleading gender identity in children and the medical communities' pledge to first do no harm (primum non nocere) have regrettably fostered disharmony between gender disordered patients, their families, and the practitioners who want to help them.