Commentary on the Treatment of Gender Variant and Gender Dysphoric Children and Adolescents: Common Themes and Ethical Reflections

Abstract

This commentary offers preliminary ethical reflections on the range of treatments for gender variant and gender dysphoric children, adolescents, and young adults described in the preceding five clinical articles. After clarifying the terminology used to discuss these issues, this commentary reviews several common themes of the clinical articles. Focusing on ethical values of informed consent, full disclosure, the minimization or avoidance of harm, and the maximization of life options, the commentary expresses concerns about various treatment options endorsed by some of the articles. In particular, this commentary focuses on how these practices problematically reproduce social prejudices and stereotypes and how they fail to acknowledge and embrace the multiple pathways for expressing one's gender. It also compares and contrasts the ethical issues related to gender variant and gender dysphoric youths and youths who identify as lesbian, gay, bisexual, or queer.

Keywords:

• ethics
• gender
• gender identity
• gender identity disorder
• gender identity disorder of childhood
• gender identity disorder of adolescence
• gender variance
• transgender
• transsexual
• treatment

Acknowledgments

The author thanks Eva Stein for research assistance at various stages of the writing of this article. Detailed and thoughtful comments on earlier drafts of this article by William Byne and Jack Drescher—as well as conversations with Adrienne Asch, Morris Kaplan, Steve Lin, and Gary Marcus—were also helpful in its completion.

Notes

1. I adopt this term from de Vries and Cohen-Kettenis (this issue) who define natal sex as biological sex at birth. This term, while not without problems, is, I think, more appropriate than biological sex as used by other authors in this issue and elsewhere in a manner intended to be synonymous to natal sex, because biological sex could also mean bodily sex at times other than at birth. See below for further discussion of biological sex and natal sex. Given the problems I have with the term biological sex, I do not ultimately accept the definition of natal sex offered by de Vries and Cohen-Kettenis (this issue).

2. Compare Littleton v. Prange, 9 S.W.3d 223 (Tex. 1999), holding that sex—for purposes of access to marriage in a jurisdiction that only allows marriages between people of different sexes—is defined as genital or chromosomal sex at birth, with M.T. v J.T., 355 A.2d 204 (N.J. App. 1976), holding that sex—for purposes of access to marriage in a jurisdiction that only allows marriages between people of different sexes—is defined as the sex the person identifies and presents as at the time of marriage.

3. The term transgender (trans, for short) is an umbrella term for a person whose gender identity and natal sex differ. This is more of a social and gender identity term, in contrast to gender variant, which is more of a behavioral term. The term cisgender is used by members of the transgender community and Ehrensaft (this issue), for people whose gender assigned at birth, gender typically associated with the type of body they have, and their sense of what gender they are all match; in others words, a person who is not transgender is cisgender.

4. Note that despite my skepticism about biological sex as a scientific term, I do continue to use standard locutions such as “sex reassignment surgery” rather than the less standard put perhaps more appropriate “gender (or gender identity) affirming surgery.”

5. Menvielle (this issue) says that “fewer than 20% of children who meet the diagnostic criteria for gender identity disorder of childhood before puberty will continue to experience gender dysphoria during and after puberty” (p. 362); Zucker et al. (this issue) found “a persistence rate of 12% for GID girls … and … 13.3% for GID boys” (p. 392); and de Vries and Cohen-Kettenis (this issue) report that recent studies show persistence rates between 12% and 27% (p. 305).

6. A person's sexual orientation concerns the sex of the people to whom a person is sexually attracted. One's sexual orientation is distinct from one's gender identity although some gender variant individuals see themselves as attracted to people of the same sex. Lesbians, gay men, and bisexuals are not—simply by virtue of their sexual orientations—gender variant individuals.

7. None of the clinicians represented in this issue who offer SRS will offer such intervention for children younger than 18, although de Vries and Cohen-Kettenis (this issue) seem to favor making such treatment options available for even younger children. They say that “withholding [early physical medical] intervention is even more harmful for the adolescents' wellbeing during adolescence and in adulthood” (p. 315).

8. The American Academy of Pediatrics, Committee of Bioethics (1995) found that the mature minor doctrine was of limited application to the practice of pediatrics, saying that typically parents and guardians should provide “informed permission” for pediatric procedures while children should provide “assent,” which is compliance with a medical procedure when the child is not of an age or does not have the maturity to make true consent possible. Assent requires an age-appropriate explanation of the child's condition and the treatment. The child, by assenting, agrees to the procedure and may feel empowered (in either the short or long term) by being able to play a role in the decision making, but does not provide true informed consent, which would be obtained from the parents or guardians.

9. Another exception that is invoked only in extreme instances allows the state, on a temporary or even a permanent basis, to replace the parent with a guardian for the child, or, through a judge, order life-saving medical treatment to be provided against a parent's wishes. This is only done when a parent acts in a manner inimical to a child's health and wellbeing. See, for example, Custody of a Minor, 393 N.E.2d 836 (Mass. 1979), in which the court gave the state agency the power to administer chemotherapy to a 3-year old child with leukemia whose parents wanted to give him alternative—and unproven—therapies.

10. In the case of O.G. v. Baum, 790 S.W.2d 839 (Tex. Ct. App. 1990), a 16-year-old Jehovah's Witness severely injured his arm and needed surgery to save it; the parents refused to consent to a blood transfusion that was likely to be needed during surgery. Rather than allowing the child to make a decision about the surgery by applying the mature minor doctrine, a Texas court appointed a temporary guardian for the child with the authority to consent to a transfusion if necessary.

11. Edwards-Leeper and Spack (this issue) cite the 2009 guidelines of the Endocrine Society (of which Cohen-Kettenis and Spack were among the authors). While these guidelines represent the consensus within an established subspecialty within the practice of medicine, these guidelines do not discuss the ethical issues raised herein.

12. Some jurisdictions require the more extensive surgery before they will amend a birth certificate to indicate a person's new assigned sex. New York City (but, oddly, not New York State) has such a law requiring genital surgery for a legal sex change. This law is currently being challenged in lawsuits by two trans people (Eligon, 2011).

13. Similar worries can be raised about hormone therapy. Hormone replacement treatment in postmenopausal women is controversial, partly because of a possible link to cancer and other complications. There might be such complications involved in the use of hormone therapy on gender variant and gender dsyphoric individuals, although this is not discussed in the clinical articles.