Ethical Considerations of Medical Gender Affirming Treatment on Children

If there were to be mass consensus on the complicated issue of prepubescent and adolescent gender affirmation treatment, it would be that there is a lack of consensus in many facets of the matter. However, much progress has been made since the first treatment of gender dysphoria (GD) decades ago, and from that progress a few concrete claims have been made. One, gender affirmation treatment (GAT) is beneficial to children who have legitimate and lasting GD. Two, GD can dissipate during adolescence or be conflated with other psychopathology, consequently harming the child with unnecessary gender affirmation treatment. Finally, it is very difficult to differentiate between the two groups stated above. 

Gender dysphoria is described in the DSM as “a condition where a person’s gender assigned at birth and the gender with which they identify themselves are incongruent,” leading to a sense of discomfort and dysphoria (Bizic et al., 2018). This discomfort is alleviated through social transitioning and oftentimes through GAT, which is considered medical transitioning. GAT involves three stages; puberty blocking, cross-sex hormone therapy, and then surgery (Kaltiala-Heino et al., 2018). Following the “Dutch protocol,” a leading approach to GD based in Amsterdam, the average timeline for using puberty blockers is at 14.75 years, followed by cross-sex hormone therapy at minimum of 16 years, and then reassignment surgery at minimum of 18 years (de Vries & Cohen-Kettenis, 2012).

While puberty suppression, typically via GnRH analogues, does not treat GD, it does reduce “behavioral and emotional problems,” reporting “fewer depressive symptoms” and “feelings of anxiety” among adolescents (de Vries et al., 2011). This is useful given that a large portion of children referred to specialized gender identity services have clinically significant psychopathology such as self harm and suicide, and children with GD unable to express their gender are “at risk for developing a downward cascade of psychosocial events” (Hidalgo et al., 2013). Likewise, hormone therapy and surgery are useful in that they generally absolve GD and its associated psychopathology. It is also important to note that puberty suppression and hormone therapy are generally safe. Puberty suppression using GnRH agonists has been used for decades in the treatment of precocious puberty and research has shown that with more modern methods hormone therapy appears to be safe as well (Seal, 2016; Weinbauer et al., 1987).  

Figure 1. Transgender adolescents generally have other psychological comorbidities, which are generally improved with the use of puberty blockers

While it may be clear to treat GD with GAT, that approach is complicated by the fact that the majority of children with GD desists, meaning their GD does not continue, typically around the ages of 10-13, or when puberty starts (Panagiotakopoulos, 2018). Also not all gender variant expressions imply GD, as GD may be “mimicked by gender confusion” occurring from “an epiphenomenon of other problems,” such as sexual trauma or other psychopathology (Drescher & Pula, 2014). Thus, by Dutch protocol, puberty suppression is only offered at Tanner stages 2-3, typically at age 14-15, after the child has had time to explore puberty. However, some children may still need more time after the ages of 10-13 to determine persistence or desistence. While puberty blockers are reversible, there are concerns that childhood transition may be forcing adolescents to proceed to generally irreversible biomedical interventions as stepping back may be psychologically troublesome, even if identity development has taken a new direction. Additionally, while research on medical intervention has “shown reasonable safety,” many “professionals have doubts because of the lack of data regarding long-term physical and psychological outcomes” (Kaltiala-Heino et al., 2018). Moreover, further research has shown that hormone therapy, specifically for transgender women, caused “gain in fat, a decline in lean body mass, and an increase in insulin resistance,” increasing BMI, which is linked to cardiovascular disease (Suppakitjanusant et al., 2020, p 5). 

Figure 2. BMI increases for transgender women upon use of GAHT hormone therapy (p-value = 0.004)

Currently, there is no clear approach to determining which children will have their GD will persist or desist. While there is research correlating the intensity of GD in childhood to the likelihood of persistence, each GD case can be vastly different and complicated, as even the idealized Dutch protocol requires extensive psychodiagnostic assessment that may require years (Steensma et al., 2013; De Vries & Cohen-Kettenis, 2012). Furthermore, due to the lack of “any randomized controlled treatment outcome studies of gender dysphoric children,” treatment recommendations are largely guided by expert opinion (Drescher & Pula, 2014). In the end, these “experts” must use the principles of autonomy, beneficence, and nonmaleficence to guide their treatment. While minors have little legal autonomy, physicians are obligated by beneficence to treat the child’s GD, but by nonmaleficence they cannot unnecessarily harm their patient. This line between benefit and harm makes the “expert opinion” incredibly subjective, shown by the multitude of different approaches to GD not only in Amsterdam, but also in Toronto and UCSF. 

The best way forward is treatment with informed consent. There must be a thorough conversation and examination with the child and parent, indicating risks involved with intervention and non-intervention, while looking towards expert opinions and waiting for extensive research. 

Edited by Richard Lee

References

Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., Rakic, V., & Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed research international, 2018, 9652305. https://doi.org/10.1155/2018/9652305

de Vries, A. L., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of homosexuality, 59(3), 301–320. https://doi.org/10.1080/00918369.2012.653300

de Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. The journal of sexual medicine, 8(8), 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943.x

Drescher, J., & Pula, J. (2014). Ethical issues raised by the treatment of gender-variant prepubescent children. The Hastings Center report, 44 Suppl 4, S17–S22. https://doi.org/10.1002/hast.365

Hidalgo, M. A., Ehrensaft, D., Tishelman, A. C., Clark, L. F., Garofalo, R., Rosenthal, S. M., Spack, N. P., & Olson, J. (2013). The Gender Affirmative Model: What We Know and What We Aim to Learn. Human Development, 56(5), 285–290. https://doi.org/10.1159/000355235

Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisén, L. (2018). Gender dysphoria in adolescence: current perspectives. Adolescent health, medicine and therapeutics, 9, 31–41. https://doi.org/10.2147/AHMT.S135432

Panagiotakopoulos L. (2018). Transgender medicine – puberty suppression. Reviews in endocrine & metabolic disorders, 19(3), 221–225. https://doi.org/10.1007/s11154-018-9457-0

Seal, L. J. (2016). A review of the physical and metabolic effects of cross-sex hormonal therapy in the treatment of gender dysphoria. Annals of Clinical Biochemistry, 53(1), 10–20. https://doi.org/10.1177/0004563215587763

Steensma, T. D., McGuire, J. K., Kreukels, B. P., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016

Suppakitjanusant, P., Ji, Y., Stevenson, M. O., Chantrapanichkul, P., Sineath, R. C., Goodman, M., Alvarez, J. A., & Tangpricha, V. (2020). Effects of gender affirming hormone therapy on body mass index in transgender individuals: A longitudinal cohort study. Journal of clinical & translational endocrinology, 21, 100230. https://doi.org/10.1016/j.jcte.2020.100230

Weinbauer, G. F., Respondek, M., Themann, H., & Nieschlag, E. (1987). Reversibility of long-term effects of GnRH agonist administration on testicular histology and sperm production in the nonhuman primate. Journal of andrology, 8(5), 319–329. https://doi.org/10.1002/j.1939-4640.1987.tb00970.x

Image Citations

Chang, C, (2021). Differences in mental health among Dutch adolescents. ScienceNews. Society for Science. Retrieved February 24, 2022, from https://www.sciencenews.org/article/transgender-youth-mental-health-gender-affirming-care-laws

Stevenson, M. Ol. (2020). Boxplots for course of BMI levels in four cohorts of transgender men and women receiving gender affirming hormone therapy over the period of 7 years. NCBI. Elsevier. Retrieved March 12, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358708/figure/f0010/.

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