The Clinician’s Role in the Ethics Behind Gender-Affirming Treatments
One of the most progressive areas of modern medicine is that which involves gender-affirming treatments. In recent years, as its availability has increased, many ethical questions have emerged. Is the diagnosis of gender identity helpful to the patient or does it prove to be more harmful than not? When is the best time to start the course of treatment, and should the patient’s age be a factor in determining whether they are suitable for receiving it? How can a family go about considering such a transformative and impactful choice for one of their own? A clinician must thus thoroughly inform the patient of the risks, effectiveness, limitations and the physiological and psychological effects associated with gender-affirming treatment before following through with it.
This was the case with Alex Bertie, a biologically female child of 15 years, who started to feel that she had a mismatch between her sex and gender due to the fact that she seemed to be expressing interests that were often associated with the male gender. She began to wear basketball shorts and t-shirts, cutting her hair short and wanting to play more with the males in her class. Bertie felt as though she was a male trapped in a female’s body. To rectify this situation, she had to pursue advice from a medical professional.
Upon consultation with a psychiatrist, the young girl was diagnosed with gender dysphoria (GD) wherein one feels that their gender identity does not correspond with their biological sex. After diagnosis, the individual may undergo hormone therapies and even surgeries in an attempt to alter their physiological identity to sync it with their psychological identity.
The family of the individual could then decide to meet a clinician to discuss the next course of action that their son or daughter should proceed with. It is ultimately the family’s decision as to whether they should obtain treatment for this condition, but it is the clinician’s responsibility to explain the many long-term risks associated with such treatment.
However, as Bertie was just 15 years old, she was still experiencing puberty. This meant that in order to undergo the procedure she would have had to initially undergo puberty suppression to allow her more time to explore her feelings and gender identity. Such a gender-affirming treatment mainly serves to relieve some psychological distress, but it also carries a heavy impact on the body. For example, it is possible the patient may experience a stunt in their growth, weight gain, fertility issues, menopause-type symptoms and even depression. Additionally, the androgen (a male sex hormone) therapy that she would have had to undergo carries risks, which include the development of insulin sensitivity, hyperlipidemia, and an increased hematocrit, which would compromise her metabolic health.
In this case, it is important to recognize that the treatment itself further carries great physiological risks. The clinician is faced with the task of weighing the pros and cons to determine whether the psychological relief outweighs the negative side effects of hormone therapy before giving his or her suggestion. The child is able to back out of the treatment at any time, but the hormonal imbalance which would result upon termination can carry many negative physical and psychological implications. It was found that women using hormone therapy presented more depressive and anxiety symptoms than non-users, according to a study done in association with the North American Menopause Society.
The diagnosis phase of the consultation prior to the actual treatment requires a balanced ethical consideration. Gender dysphoria is defined as a mental condition and not a disorder; labeling it as the latter is stigmatizing and carries a rather negative connotation. However, herein lies the dilemma: only when it is labeled as an illness or disorder will the patient be allowed access to required care in many of the healthcare systems around the world, according to the American Medical Journal.
Next, it is necessary to consider whether or not the patient should actually be treated for this condition, based on the diagnosis and the context in which they operate. According to the Standards of Care (SOC) of the World Professional Association for Transgender Health, GD during puberty can just be a phase which may remit during adulthood as the adolescent later identifies as gay, lesbian or bisexual. Much time remains for the child to mature and develop emotionally; thus, rash pre-emptive decisions to commit the patient to treatment should be avoided.
Age is a critical factor. Although treatments are available for individuals who have just entered puberty, it does not necessarily mean that the onset of puberty is the ideal time to treat the patient. Moreover, the age of consent is not sufficient in deciding whether the adolescent is able to receive the treatment. The psychological maturation of the individual and proof of whether they can understand the magnitude of the consequences of such a treatment should be the main factors. These considerations may be discussed through appointments with a psychiatrist. Such appointments should serve to thoroughly inform the parents and patient of what gender-affirming treatment entails. This should ultimately be the determining factor as to whether the parent/legal guardian gives consent to proceed with hormone therapy. Such a criterion would be a much better determinant of one’s eligibility for treatment rather than simply age, as it would prevent impulsive or reckless decisions resulting from a child’s psychological immaturity from being the deciding factor.
Cases of gender dysphoria are inherently highly complex and multi-layered. Because of this nature, it is thus necessary that the patient and their family be well informed of all the risks, limitations, and overall effectiveness of the treatment prior to it by the clinician. There are many cost/benefit analyses which must be performed at each step by the clinician in order to determine whether the adolescent is eligible for treatment. The goal of these measures is to prevent impetuous decision-making which could carry profound psychological and physical implications for the future. One notable question remains, despite the availability of therapy and professional consultation: is the satisfaction of altering one’s physical constitution to match the dictations of a social construct ultimately worth the potential negative physical and psychological traumas which proceed from the treatment?
Edited by Shirley Wang
