Ethical Issues Raised by the Treatment of Gender‐Variant Prepubescent Children

Abstract

Transgender issues and transgender rights have become increasingly a matter of media attention and public policy debates. Reflecting changes in psychiatric perspectives, the diagnosis of "trans-sexualism" first appeared in the International Statistical Classification of Diseases and Related Health Problems in 1975 and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders. Since that time, international standards of care have been developed, and today those standards are followed by clinicians across diverse cultures. In many instances, treatment of older adolescents and adults is covered by national health care systems and, in some cases, by private health insurance. Most recently, the Medicare ban on coverage for gender reassignment surgery was lifted in 2014. In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred to in both DSM-IV-TR and ICD-10 as gender identity disorder in children and now in DSM-5 as gender dysphoria. One reason for the differing attitudes has to do with the pervasive nature of gender dysphoria in older adolescents and adults: it rarely desists, and so the treatment of choice is gender or sex reassignment. On the subject of treating children, however, as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood. Further, most of the boys' gender dysphoria desisted, and in adulthood, they identified as gay rather than as transgender. In an effort to clarify best treatment practices for transgender individuals, a recent American Psychiatric Association Task Force on the Treatment of Gender Identity outlined three differing approaches to treating prepubescent gender dysphoric children.

A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children

“…A second ethical concern is that many of the children in the Toronto studies (Drummond et al, 2008;Zucker & Bradley, 1995) were enrolled in a treatment program that sought to "lower the odds" that they would grow up to be transgender (Drescher & Pula, 2014;Zucker, Wood, Singh & Bradley, 2012;Paterson, 2015). Zucker et al (2012) wrote: "…in our clinic, treatment is recommended to reduce the likelihood of GID persistence" (p. 393).…”

Moral Challenges in Transgender Care: A Thematic Analysis Based on a Focused Ethnography

“…Indeed, they have been the subject of various publications. Some authors made use of composite case narratives based on the authors’ experience working with the transgender community (Bernal & Coolhart, 2012; Swann & Herbert, 2008; Tishelman et al, 2015), others drew retrospectively from case histories without systematic data collection (Giordano, 2008; Wiseman & Davidson, 2012) or did not use empirical data to support the moral challenges they raised (Drescher & Pula, 2014; Pomora et al, 2015). However, moral challenges and themes are intricately linked to the context in which they arise and how they are experienced (Molewijk, Abma, Stolper, & Widdershoven, 2008).…”

Challenges in the LGBTQI+ Community

“…There is a great deal unknown, such as how identity developments occur, the effects of biology and environment, and if there are differences between development in cisgender and gender dysphoria or variant people. 13 Different treatment approaches with different goals are used, ranging from trying to decrease gender dysphoria to letting the gender dysphoria find its own trajectory to providing support for gender transition. All approaches, however, support children with gender dysphoria in their decisions as they the approach puberty.…”