Ethical Considerations Regarding Children with Gender Dysphoria: Do younger people have the ethical right and cognitive ability to make decisions about treatment?


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Are children affected by gender dysphoria any different from adolescents and adults affected by the same condition? If so, should they maintain the same autonomy and ability to make decisions in situations regarding treatment options, and what role do other stakeholders play in this issue? Recently there has been an increase in diagnosed cases involving children with gender dysphoria, the condition of feeling one’s emotional and psychological identity as male or female to be opposite to one’s biological sex. These cases have brought medical professionals to reconsider common pediatric practices, and involve close counseling and monitoring until signs of puberty emerge. At this point, a child has many options for treatment. However, there are still many restrictions on which treatments can be utilized by younger children– for example, hormone therapies can only be undergone if the patient is sixteen years or older. How can we determine when a child is legally mature to make such decisions? And how do we handle situations in which different stakeholders have conflicting opinions in the matter?


Introduction

What if you had to live your life in a body that was unwanted to you? This is the life a person with gender dysphoria must lead, a life in which one feels that they were born into the body of the wrong sex. Gender identity disorder, the original term coined for this mental state, was deemed derogatory and unfit to label this specific group of individuals. As a result, gender dysphoria is the term we use today to describe this persistent feeling of severe discomfort with one’s anatomical sex. This is because many view gender dysphoria as an identity or way of life rather than a disorder, as this word implies that the condition is an abnormality, a “problem” that needs to be fixed. This paper will explore the decision-making capacities of children 10-12 years of age and the various treatments and stakeholders that play a role in the decision-making process. This age group is particularly significant because the issues of manipulation, lack of autonomy and representation for minors in legal situations, and the drastic emotional and social consequences that arise from this condition are much more significant at these ages and have the potential to affect these children in the future. Gender dysphoria is also more common in young children than in adolescents, as 80 to 90 percent of cases involving children with gender dysphoria resolve once children experience the effects of sex hormone treatment (Child Healing: Strengthening Families).

Children diagnosed with gender dysphoria at an extremely young age must consider whether or not to undergo therapies such as hormone blockers, as well as how to present themselves socially (as the gender they were assigned at birth, or the gender they wish to be). Parents may feel the responsibility to make decisions and control those of their children, and this can lead to prematurely labeling a child as transgender when this may not necessarily be the case. Many of these rash decisions are a result of increased coverage of affected individuals’ experiences in the media. The Family Court, the legal system, poses another issue entirely, for it is given immense power over a child’s legal guardian and has the ultimate say when there is a discrepancy between a child’s decision and that of a parent. Therefore, we must ask ourselves this: Can we, as a society, give children decision making power? Or should parents and the legal system have the power to decide the course of these children’s lives? Overall, the challenges that gender dysphoria presents are numerous and must be addressed by professionals in the field of science, medicine, law and psychology to assure that individuals affected by this condition are able to live happy, conflict-free lives without fear of manipulation.

Factual Background

Gender dysphoria is specifically defined as the condition of feeling one’s emotional and psychological identity as male or female to be opposite from one’s biological sex. According to the DMS 5, the Diagnostic and Statistical Manual of Mental Disorders, gender dysphoria can only be diagnosed when observed behaviors continue for a duration of at least six months. Gender dysphoria manifests itself from many criteria and behaviors, such as a strong desire to be of another gender, a strong preference for cross-dressing or refusing to wear typical clothing assigned to a certain gender, a strong preference for the toys, games, or activities stereotypically used by the other gender, and a strong preference for playmates of the other gender. In boys an avoidance of rough play may be present, and in girls a strong rejection of typically feminine toys, games, and activities may be present. Other “symptoms,” or signs, of gender dysphoria include a strong dislike of one’s sexual anatomy and possible association with clinically significant distress or impairment in social, school, or other areas of functioning. However, can we really use these signs to determine whether or not a child is affected, and is doing so ethical? Establishing these stereotypes may blur the lines even more between children who have gender dysphoria and children who are gender atypical or non-conforming, meaning that they simply do not conform to the societal norms set in place for a certain gender. As it is, the difference between gender dysphoric children and those who do not conform to society’s labels is confusing and often difficult for an outside party who is not educated or experienced with such matters. These stereotypes may prove to be more of an issue for these individuals. For example, a child who may not prefer toys or clothes stereotypically associated with their gender may still feel comfortable in their own skin biologically. Another issue that we must consider when examining these symptoms is which treatments are most beneficial to the child affected; for example, are puberty blockers necessarily beneficial to a child? Or can the dysphoria be helped simply by “gender reassignment,” when one lives and presents themselves as the opposite sex? These issues will be further examined in Ethical Issue Section III of this paper.

Gender dysphoria is an affliction that may influence an individual’s identity in regards to both sexual orientation as well as gender and sex. Gender, sex, and sexual orientation are distinct from one another in a gender dysphoric patient. Gender refers specifically to cultural or learned significance of sex. For example, females may wear dresses and skirts, while men may wear pants more often. However, sex refers to physical characteristics of either gender. For example, women have breasts and can become pregnant. Males have deeper voices than females. These are physical characteristics that define an individual’s sex physically. It is a biologic character or quality that distinguishes male and female from one another as expressed by analysis of the person’s gonadal, morphologic (internal and external), chromosomal, and hormonal characteristics. (Medical News Today). Finally, an individual’s sexual orientation is specifically the gender to which they are attracted; for example, one may be bisexual, homosexual, heterosexual, etc. These terms relate directly to a person’s attraction to a certain gender. A young child affected by gender dysphoria may not be affected by sexual orientation as greatly as an adolescent or mature adult. However, discussion of the role sexual orientation plays in decision making is a valid and significant consideration. For example, it may be difficult to determine a child’s decision making capacity in regards to reproductive anatomy and possible removal or addition of genitals if the child is not yet sexual. Many children may grow up and undergo puberty only to find that they wish to pursue a different sexual orientation, such as homosexuality, rather than to change gender or live as a different gender. This is yet another important ethical consideration.

Before examining the decision-making abilities of children in this age group, we must explore the treatment options that are legally viable for these individuals. Such options include psychological counseling and close monitoring until the first signs of puberty emerge, around the age of 11 or 12. At this point, children are given puberty-blocking drugs in the form of injections. The drug’s effects are reversible and have not caused complications in patients, and this is therefore considered to be a relatively low-risk therapy (Center of Excellence for Transgender Health). The aim of such blockers is to give children time to mature emotionally and to make sure they want to undergo a more permanent sex change in the future. Interestingly enough, only 1 out of 97 children opt out of permanent treatment after taking these blockers, thereby proving such measures to be essential throughout this difficult process (NY Daily News).  This statistic gives more permanent changes merit, and proves that most children change their sentiment after puberty. This may be a justification for more irreversible treatments, such as cross sex hormones. Still, these hormones in high doses and used on a long term basis can have serious side effects, including blood clots and cancer. Finally, the issue of social presentation plays a large role in these types of decisions. Many children are encouraged to live their lives as the gender they wish to be, and to present themselves socially as this chosen gender. This can be considered another course of treatment, as the effects of such a lifestyle give the child more control over their life and desires.

The ethical implications of allowing young children to present themselves as the gender they desire in public may be evaluated through the recent nation-wide issue of the Houston Equal Rights Ordinance in Houston, Texas. The Houston Equal Rights Ordinance (HERO) established protections for transgender people– one section of HERO, nicknamed the “bathroom ordinance” by those who oppose it, has created significant controversy (The New York Times). Jared Woodfill, Houston lawyer and a Texas Republican Party leader, began a campaign to oppose HERO under the basis that cross-dressing men may violate women in public bathrooms if transgender individuals were permitted to use the bathrooms of the gender they identified as. This narrative has stretched all the way to the highest positions in government, and prevented HERO from being passed due to this fear which, many advocates of HERO argue, is unfounded. This is just one example of the difficulties that accompany social presentation and the additional problems a child must face if allowed to present as the gender they desire to be– such difficulties include opposition from those unwilling to accept the child as the gender they present themselves to be, or general refusal to allow these individuals to occupy these designated public spaces.

There are many ethical issues tied to the topic of decision-making in regards to gender dysphoric children. The issue of autonomy, the role of stakeholders in the decision making process, and the effectiveness of treatment options are just a few of the ethical considerations that will be further explored in the next sections of this paper.                

Ethical Issue Section I: Autonomy

In situations involving young children who have limited legal autonomy to make decisions for themselves, we must first consider the decision making capacity of the child, as this can bring to light major issues concerning competence. In order to make sure that a child is capable of making decisions about their course of treatment, we must evaluate the maturity and cognitive abilities of children in this age group.

One popular opinion on the autonomy of younger children is that they do not have the basic cognitive ability to be able to make decisions. In a study done by the Department of Pediatrics in Jonkoping, Sweden, the cognitive and decision-making abilities of children were tested by reading ability, age, and understanding of, and ability to remember, a text. The study found that, as expected, older children had greater knowledge and cognitive abilities, as well as heightened ability to retain information, than younger children, as they had more exposure to new learning experiences. This relates to the idea of informed consent– having greater mental capacity directly corresponds to a greater ability to make competent decisions, as well as the ability to understand information regarding treatments that can be examined in the decision making process.  Another significant finding of this study was that pediatric nurses often involved children with disabilities or other disorders who were older in the decision-making process and gave them more information, generally, about their treatments and procedures than younger children, for the very reason that older children are deemed automatically “more competent.” While this may be based largely on the perception of these individuals, it is a common belief that those who are older are more capable of making such decisions, and these assumptions inform and affect the way medical professionals treat patients. Given these findings, one may conclude that a child’s decision making capacity depends largely on their age and relationship with parents, health care professionals, and others. Depending on the level of the child’s maturity, they may wish to allow the parent to make most medical decisions, whereas others may wish to choose their own course of treatment. Still, age is not the only consideration when determining maturity, and many other factors affect a child’s capacity to make decisions..

Another significant argument against granting children in this age group full decision making capacity highlights the fact that as many as 52 percent of children between ages 4 to 11 have one or more diagnosed mental conditions alongside their gender dysphoria, such as clinical depression or suicidal thoughts (Diagnostic and Statistical Manual of Mental Disorders). These shocking statistics bring into consideration the implications and effects of these conditions on a child’s decision-making abilities. Depression could lead to a difference in the way a child makes decisions about their course of treatment. In fact, according to research conducted by Dr. Rudnick at the Department of Behavioral Sciences at Tel Aviv University in Israel, major depression, which is often associated with gender dysphoria in children and adolescents, can “disrupt appreciation of the benefits of [certain] treatments due to undervaluing positive outcomes while focusing on negative outcomes of treatment and thus skewing the weights given to treatment outcomes in favor of treatment risks.” This could be a potential argument against granting individuals the power to make possibly life-altering decisions about treatment; a child may focus more on the negative aspects of treatment as a result of depression or other closely associated mental illnesses, causing the child to advocate for riskier treatments that may not be medically beneficial.

There may also be other risks associated with allowing young children to make decisions about treatment for themselves. For example, a child may make a decision rashly, or without considering the long-term effects of such a choice– this is an issue that we see today quite often, especially in regards to adolescents and drunk driving. A child may also make a decision that is largely influenced or manipulated by a parent, guardian, or other stakeholder in the child’s life. A more realistic example of this is children who have rather controlling parents, or parents who want their child to participate in certain extracurricular activities or hobbies at school. Parents who wish for their children to engage in certain activities for the sake of improving their college applications place a significant amount of stress upon a child, and often disregard the interests and passions of the child in doing so. Finally, a child does not have legal consent to make a decision that goes against that of a parent or guardian, if the individual is under eighteen years of age. This means that, if there is a discrepancy between a parent’s interests and those of a child, the conflict could become a legal struggle. We see this issue repeatedly in situations where an adolescent seeks legal emancipation from a parent or guardian, so that they may live their life independently and with the ability to make their own legal decisions.

On the other hand,  not allowing children to make decisions for themselves is ultimately disregarding their desires, which could lead to worse outcomes in the future. For example, not allowing a child to take hormones or puberty suppressors could have a long term impact on the child– the child may grow up to wish that they had more decision-making power, or if a more permanent treatment is chosen, a child may regret such irreversible effects and wish to reverse them. This would cause more pain and struggle for the child in the long run. If a child is able to make decisions for themselves, one may argue that they will be content with any decision made because it was their own decision. In addition, it can be argued that children living with terminal or other severe illnesses may mature drastically throughout the treatment process. Thus, they may become more viable to make decisions for themselves, especially after undergoing numerous life-threatening or serious treatments. This is because a child that has undergone such experiences knows the suffering and pain that is associated with these illnesses, and therefore may make decisions more carefully or thoughtfully than they would otherwise.

The effects of puberty on a child also play a large role in determining an individual’s autonomy.  Puberty, and the mental and physical changes that accompany it, may have a large effect on the long-term wishes of a child. Using this logic, is puberty a “necessary evil”? That is to say, is it beneficial for a child to be able to experience puberty, for the emotional and physical changes it could bring to the child? And beyond this, can a child have autonomy if they have not yet been through puberty? One argument is that a child does not have the mental capacity to make decisions before puberty, because the child’s sentiment may change along with physical or bodily changes. However, studies show that children with gender dysphoria before puberty that is not directly addressed simply persists throughout puberty, and rather than desisting, becomes even more prevalent as the child experiences unwanted changes (European Society of Endocrinology). Thus, one may argue that puberty is simply a nuisance to a gender dysphoric child, and the easy solution is to heed a child’s wishes before puberty so that GnRH can be administered. In this case, the child’s autonomy trumps all other considerations and opinions.

In conclusion, autonomy is an extremely significant consideration in these situations, due to the fact that the affected child is most often the one requesting a change in gender, and at prepubescent ages it is hard to know what is best for the child medically, socially, and emotionally. Thus, we must have a system in place to determine when a child is competent to make a decision about the course of treatment he or she should follow. Also, one may argue that no one but the child themselves will be affected by a decision made, since the child is the only one experiencing these feelings and emotions. After all, no third party can possibly empathize with or understand the immense pain and discomfort, both physical and psychological, a child with gender dysphoria must face. This is a legitimate reason for giving a child complete autonomy; only the child will have to deal with the consequences of whatever decision is made. Therefore, from the research that I have conducted, I believe that a child struggling with gender dysphoria should always have a significant say in matters involving presentation or treatment. A child cannot be forced to live as a gender that he or she does not wish to, as this could lead to regrets in the long term. At the same time, the decision-making capacities of a child may vary based on different levels of maturity and ages, as well as different life experiences and relationships with family members or doctors. The decision-making capacity and competence of a child should be measured through his or her maturity, which is largely a function of the child’s age. In certain situations where a child is younger than the legal age of 18 for autonomy and consent but has the maturity and mental capacity to make decisions, maturity should trump age. For this reason, the dynamic between a child and a guardian as well as a legal third party should not be drastically impaired by differences in age; a parent may be much older, but a child holds a unique perspective and personal experience that a guardian, who is in a completely different position, may not hold. Finally, a child may choose to hand decision-making power over to a guardian they trust. In this case, the wishes of the child should be honored, as long as the child is not manipulated by another stakeholder with contrasting interests. Based on these conclusions, I believe that the process that pediatricians and social workers undergo when communicating with gender dysphoric patients could be improved through a closer association between the wishes of the child and the goals of medical professionals. A doctor, in this situation, should be responsible for finding treatment solutions that are safe for the child, but also take into account their wishes. If such a solution does not exist, the child should be fully informed, and should always have other resources to turn to– social workers, medical staff, and legal guardians must ensure that the treatment process is as inclusive toward the child as possible, while also considering the best interests of the individual medically, socially and emotionally.

Ethical Issue Section II: Decision Making Power of other Stakeholders

In this section, the roles of parents, media, and the legal system in the decision-making process will be examined and discussed. This first subsection will discuss the power parents and legal guardians hold in the decision making process. When a child is young, their parent is most responsible for them as a guardian and caretaker. A parent also has legal power over the child as a guardian, and one may argue that if a parent is legally responsible, he or she may be responsible for making medical decisions for a child as well. However, at times parents may not know what is best for their child. They may simply wish to make the child happy, which could lead to premature therapies or procedures even though a child may not require such drastic measures. For example, a mother who simply wants her child to be happy may believe that undergoing hormone or GnRH treatment is the best solution to satisfy the child’s desires. However, this may not be the most medically or ethically sound decision. The pressure and difficulty of the decision on the parent is also an important consideration.  Sometimes there may be too much power and reliance on one person or two people’s decisions– those of the parents or parent. This is an incredibly difficult burden to place on an individual’s shoulders, and, of course, a parent is still human. A parent is still an individual with biases, opinions, personal experiences, and unique perspectives that could cause them to make a harmful decision. For example, let us examine a situation involving a mother with a young boy, about 10 years of age. Her son tells her that he is unhappy being a boy and wants to be a girl. He plays with dolls, dresses in feminine clothing, and many of his friends are female. The mother, only wishing to see her son content, decides to seek medical help. However, as a Christian she does not believe in surgery to alter a child’s genitalia. The doctor informs her that puberty blockers are administered as a transition to something more permanent, such as surgery. Unhappy with this outcome and feeling that it is against her own beliefs, she cuts her son off from these possibilities and attempts to constrain his discontent by encouraging him to behave “more like a boy.” In this case, the parent’s beliefs are placed above the psychological wellness of the child, which may present an issue in regards to the child’s welfare. Finally, parents inexperienced or uneducated in issues surrounding gender can lead to a discrepancy between children with gender dysphoria and gender nonconforming children (i.e. not dressing like a boy, not playing with monster trucks or other stereotypically “male” toys, having friends of another gender), which could lead in some cases to irreversible consequences.

However, there are also many considerations when examining the competence and ability of parents and legal guardians to make decisions for their children. A parent knows their child better than anyone else in the world and often understands their child’s perspectives and opinions better than any other third party. Most parents do not wish to be the “villain” in the situation; they simply want what is best for their child, and ultimately have the child’s best interests in mind. Also, it is extremely difficult to be placed in a situation in which a child is seeking, for example, medical emancipation from their parent, and the parent or parents’ power rests directly in the hands of the court. It can be frustrating to feel as though one’s own child is no longer one’s own responsibility. As one who has taken care of, fed, clothed, and bathed a child for many years, it is logical that a parent should be responsible for making decisions that are more life-changing or serious. This could be an argument for granting greater decision making power to parents and legal guardians.

Another issue that must be discussed is that of parental abandonment, a significant consideration when examining the stakeholders involved in the decision-making process. Parents who abandon their children do not offer them the protection and resources they need to live happily and successfully as the desired gender. This is a serious problem in society today. Without a guardian to allow a child access to therapies or medical supplies that are needed, a child may grow up to find their self identity lost, or even worse, may be confused about their gender role and position in society. In a study done at the Endocrine Center of the Children’s Hospital in Boston, a sample of children and adolescents were treated for gender dysphoria. This study found that children who did not actually receive treatment, whether for financial reasons or because their parents were not supportive, had a higher rate of psychiatric complications before receiving treatment at the hospital. In fact, 57% of transgender or gender-nonconforming adolescents possessed the desire to commit suicide when their families chose not to speak or spend time with them as a result of their gender dysphoria. These are dangerously high rates, and are very much related to the pain and abandonment felt by gender dysphoric or transgender youths who feel as though they are alone in this conflict. Necessary steps must be taken to ensure that a child affected in this situation is given support and psychiatric aid to alleviate signs of emotional trauma or suicidal thoughts. No one in this situation should ever have to make decisions alone, and it is the job of legal and medical professionals to make sure that children feel comfortable and supported in their environment.

One important solution to problems in the media and issues involving parental abandonment is addressing the issue of education. This means stifling the media’s portrayal of transgender support as being solely action-based. There are many other options that are viable for treating this mental affliction; a change in social presentation, psychological counseling and other treatments can be much more beneficial in the long run than permanent hormone treatments or surgeries in certain individuals. However, because they are not as “exciting” and common in the media, they are often forgotten. Because of the overlap between gender dysphoria in children and its portrayal in television shows, magazines, movies and even toys, the media plays another significant role in the decision making process. Newspaper articles and reality television shows often portray hormone treatments or puberty blockers as the only way to support a gender dysphoric child. A parent who does not undergo such extensive treatment is not considered supportive enough. This may have a potentially harmful effect on parents simply wishing to do the best thing for their child. It also places less of the spotlight on other treatment options, such as social presentation as another gender and other methods that may be more medically beneficial and less drastic or psychologically burdensome for the child.

In the next subsection, the power of legal stakeholders in the decision making process will be examined, in order to determine whether or not this power is unchecked. When there is a discrepancy between a parent’s desires and those of a child, the first course of treatment can be decided by the parent, but further decisions must be made by the child (University of New South Wales Law Journal). In a legal situation, this could place much power in the hands of a judge, one who does not necessarily know the child’s interests and desires. This is an individual who is not as personally affiliated with the child as their own parent– no one else possesses a relationship of this dynamic. Thus, it may not be in the best interest of the patient to place such an issue under the power of the court.

Now we will examine a case study in order to  fully understand the power of the court in these situations. In “Marion’s Case,” the parents of a child with a disability sought her sterilization so that she would not have to deal with menstrual cycles and other bodily changes that accompany puberty, since it would be difficult for her to manage with her disability. The court ruled that such a procedure could not be undergone because the requested treatment was deemed “non-therapeutic.” In this case, the parents’ decision making power was suspended altogether by the court. Therefore, no matter what the basis for their decision, legal opinion was favored over familial relations. However, in terms of what is in the best interests of the child, a legal third party may not be the most beneficial stakeholder. This is very much related to the issue of gender dysphoria. The court denied Marion’s parents decision making power because the treatment was deemed unnecessary and “non-therapeutic,” meaning that the treatment was not medically beneficial. Based on this criteria, the court may argue that treatments for gender dysphoria are non-therapeutic as well, or could allow a child to undergo treatment that may not be beneficial from the perspective of the child’s guardian. This could set a dangerous precedent for transgender and gender dysphoric individuals from a legal standpoint, as they and their families may not have as much power under current regulations as is ethically permissible when compared to the power of the court.

In conclusion, many different stakeholders play significant roles in determining the course of a young child’s treatment. It is important to establish the relationship a child has with its parent or guardian before granting full legal rights to this guardian. In some situations, the court may be able to offer better representation or protection of the child’s rights. We may ethically determine that in situations where a child does not have full legal autonomy, it is the responsibility of these stakeholders to act with the child’s best interests in mind, in order to ensure that any treatment pursued is desired by the child his or herself. From the evaluations I have made and the issues discussed above, I believe that in any decision, a child’s relationship with the parent must first be examined to determine the power that the parent should hold in the decision making process. If the relationship between a child and their parent is strong, a third party may safely assume that the parent has the child’s best interests in mind. However, if this is not the case, the court has not only a right to interfere, but an obligation to represent a child in situations where they cannot represent themselves. However, the legal system should only be involved in this process when it is directly beneficial to the child. For example, in situations where, as in Marion’s Case, a child is unable to provide their own perspective, the court is needed to make an objective decision so as to represent a child who needs representation. If the court is involved solely because of a discrepancy between a parent’s decision and a child’s decision, the court should not be given utmost power. In these types of decisions, the child should be given more autonomy than in situations where they are incompetent to make decisions for themselves, and are therefore represented by the court. In terms of decision-making abilities of the child versus those of the legal guardian, it is difficult to determine which stakeholder should have the final say. It is ethically permissible, however, for us to examine each particular situation and determine how much power parents should have depending on their presence in the child’s life and the status of the relationship between parent and child.

Ethical Issue Section III: Effectiveness of Procedures at Younger Ages

This subsection will explore the effectiveness of early treatment, as well as the different options for children who are 10-12 years of age. Cross-sex hormones are often not advised for children under the ages of 12-13 years old, due to the fact that they may have more permanent effects on a child than puberty blockers. However, for children above these ages about to experience pubescent changes, puberty blockers as well as cross-sex hormones may be administered, with parental consent, so that a child may delay the effects of unwanted changes while undergoing new changes as a result of hormones, thereby allowing the child to transition to the desired gender or sex. For younger children, most families pursue one of two treatments: puberty blockers, or GnRH, or simply allowing children to present themselves socially as the gender they desire to be. Cross-sex hormones are commonly administered alongside GnRH, and are more physically permanent for a child than puberty blockers.

The use of GnRH to slow down or delay the effects of puberty does not have drastic effects on a patient. However, it may affect an individual’s bone deposition, possibly making a child more susceptible to diseases such as osteoporosis in the future (Center of Excellence for Transgender Health). When GnRH analogues are administered, bone mineral density has been shown to diminish– however, there is still little research in the field about the effects on transgender patients of using GnRH to suppress puberty in regards to peak bone mass. Patients with conditions that cause them to be predisposed to poor density, such as anorexia, neuromuscular disease, Vitamin D deficiency, and others are not good candidates for pubertal suppression using GnRH. Still, GnRH is a mild treatment in comparison to others that may have more irreversible effects. The main goal of such treatment is to ensure that children truly wish to undergo treatments that would affect them in the long run, and therefore the effectiveness of such treatment is evident. GnRH gives the child and other stakeholders the opportunity to explore possible alternatives in the long term, as well as consider the physical and emotional implications on the psychological well being of the child.

Cross-sex hormones are administered in the form of estrogen or testosterone in order to induce masculinizing or feminizing characteristics. This induction of secondary sex characteristics of the desired gender may allow a child to feel more comfortable in their own skin when given the ability to express their identity as their chosen gender. While this treatment is not completely irreversible, it is still more permanent and may have significant psychological effect on a child of this age. This could be either beneficial or harmful to the individual.

After exploring the key differences between more reversible treatments offered to children in this age group, such as a change in social presentation, as opposed to directly effective and more permanent treatments, such as GnRH or cross-sex hormones, can we determine that one is more effective than the other? In terms of long-term effectiveness, GnRH is more beneficial to children who are still unsure of their decision and have not yet decided whether or not to make a full transition to the desired gender. Some individuals, as mentioned in earlier sections, may wish to pursue a different sexual orientation, rather than to change their sex entirely. Because puberty suppressors are used primarily as a means of transitioning to more permanent treatment, a child may be given more time, as the effects of puberty are delayed, to consider their options. This may be more beneficial for a child who is unsure about how they feel,  and less so to a child who is absolutely certain of their identity. In these cases, it may be a burden on the child and the family to have to wait to undergo more concrete procedures. The effectiveness of such procedures varies depending on the individual being treated. Some may find that presenting themselves as their chosen gender suffices in making them feel comfortable and happy with their identity. Others may wish to undergo procedures that alter their physical appearance. Thus, the effectiveness of such treatments is rather subjective and cannot be precisely determined without examining all possible scenarios and situations.

Medical guidelines recommend taking puberty blockers, or GnRH, until about age 16 before pursuing more permanent changes such as cross sex hormones. However, if a child wishes to undergo more permanent changes before this age, they cannot do so legally without further investigation done into why such drastic measures are desired, the effects of which may be traumatizing to the patient. In my conclusion, I will further discuss the proposition of adjusting these laws to be more flexible for transgender children who have expressed repeated and devoted desire to undergo more permanent treatments. Still, one may argue that this may not necessarily be a more effective solution– a child’s psychological needs must also be monitored, and this should be prioritized before any more permanent treatments are administered.

In conclusion, the effectiveness of treatments in a young child is an important ethical consideration. Parents need to know what options are safest and most reliable for their loved ones, and at times misinformation can lead to discrepancies between interests or a child not being fully aware of the decision that he or she is making. As a result, I have determined that GnRH is the most effective course of treatment for a child ages 10-12, though regulations should be put into place to allow a child younger than 16 to have access to hormones if a proper trial period has been undergone. From my findings when evaluating the issue of effectiveness and the treatment options available to children 10 to 12 years of age, I believe that in terms of treatments most effective for children in this age group, GnRH is a top contender. This is because, while not considered a drastic or risky treatment, puberty suppressors provide a child time to truly consider the implications and consequences of the decisions they are making. Without added pressure from the body and its confusing changes, a child may discuss questions and concerns with medical professionals, psychologists, and guardians to determine what will truly make them happy in the long run. Ultimately, the happiness and well-being of the patient is the most significant consideration. Rushing into irreversible and high-risk surgeries may not be beneficial to a child, especially when their body is changing and they feel the pressure to make a decision quickly. Decisions about gender are life-changing decisions, and should be evaluated with much thought and consideration. Thus, it is ethically permissible for a child to be able to make a decision to take GnRH at a young age, and earlier intervention is beneficial to the individual both physically and mentally. However, there are also fewer options for individuals who decide that they would prefer more permanent treatments; these may not be offered to children under the age of 16, especially cross-sex hormones. Thus, medical professionals are solving an issue for the small percentage of children who wish to pursue a less permanent course of treatment, or are still unsure of their identity, and excluding the percentage of children who are sure of their identity and do not wish to wait. See the conclusion for proposed solutions to this issue.

Conclusion

In the issue of decision making regarding gender dysphoric children 10 to 12 years of age, many significant perspectives and values must be considered. The power of guardians, the legal system, children, and treatment options all play a significant role in deciding the course of an individual’s life. I have drawn from the research I have conducted that a child, in any situation, must be supported by a legal guardian who has their best interests in mind medically, in terms of which treatments are most medically beneficial to the child, and emotionally, in terms of what is possible emotionally and psychologically for a child of that age to handle, as deemed by medical and child care professionals. If this is not the case, the court is responsible for stepping in and representing a child who is not legally able to him or herself. This is an obligation owed to every patient. Autonomy should be the most important consideration, and a child’s mental capability, in terms of cognitive development and capacity for informed consent, should be fully examined to deem whether or not decision making power can be given. Finally, new rules and regulations would allow children to have greater access to treatments that may not be legally viable for them. Thus, I propose an adjustment to the age at which children have access to hormone therapy, as this may be beneficial overall to children with gender dysphoria, granted that they have taken puberty suppressors for a period of more than a year and still possess the same desire to live as the other gender. A year of living without the bodily changes that are familiar to a member of the affected child’s gender would guarantee that the child is sure of what they want, and does not feel truly connected to the identity of the gender which they wish to abandon. Still, I believe that GnRH is a necessity for children in this age group, as it allows them the time and space to examine their options for the future in order to ensure a healthy, happy life free of psychological and physical struggle.

Another possible solution to this issue is improving communication and the process that psychiatrists undergo when dealing with gender dysphoric patients. While thought should be given to medical benefits and the wishes of the child, other stakeholders play an important role in the decision making process; each stakeholder possesses a unique perspective on a child’s well-being, and these perspectives should be heard. The process of communication between medical professionals, children and legal guardians should be reexamined to ensure that, given the larger population of gender dysphoric and transgender children in society today than ever before, pediatric examinations and processes are being constantly improved to cater to the needs of children and families in these situations.

While this issue may be resolved through new policies and changes in the medical process, these resolutions may have drastic effects on stakeholders involved in the decision making process. Under these new suggested legal regulations, parents and medical personnel may have less of a say, as such policies prioritize the ethical value of autonomy above all else. This could have consequences of its own, given that adolescents may not have the life experience or maturity to make such decisions for themselves (see Ethical Issue Section I for ethical considerations regarding autonomy). Furthermore, by placing new rules and regulations and adjusting old ones, we may be creating a bit of a “slippery slope.” This is a topic that is still debated constantly today. It is virtually impossible to deem exactly what age at which a child matures, or becomes “legally mature” to undergo certain procedures. There are many exceptions to every bit of criteria. However, by forming these types of policies, we could be creating a dangerous precedent for other laws to be adjusted which may not be safe or acceptable in society; for example, if children can make well-informed and life-changing decisions, why shouldn’t they be able to drive a car, or drink alcohol? Why shouldn’t they be able to make the decision to get married? There are many other significant considerations linked to the issue of child autonomy, and we must examine all of these in order to determine the most ethically sound course of action for these individuals.

Another significant aspect of solving the issue of gender dysphoria in our society today is eliminating the stereotypes associated with those who have the desire to change gender, as well as changing the overall cultural view of those who are transgender as different, as people who need to be immediately labeled and placed in a “box.” As a society, we generally tend to want to label ourselves. Thus, it can be difficult for us to accept individuals who do not do so, such as those who are transgender or gender dysphoric– these individuals cause us to question our societal norms and put them into perspective. This is not something to shy away from; if society can shift its perspective on a cultural and sociopolitical level to become more accepting of these individuals, the issue of gender dysphoria and decision making processes associated with it would be a less prevalent problem. In fact, it is possible that this is the reason gender dysphoria has emerged in our society. Individuals who do not wish to conform to the strict gender and social regulations that we as a society put into place are those who are currently taking steps to raise awareness and acceptance across the globe. This is a significant aspect of solving the issues of gender-based discrimination and mistreatment as well.

Finally, this issue does not only apply to the topic of gender dysphoria. Such considerations can be applied to any issue that falls under the broader umbrella of distinction between social constructs and medical realities. As a general rule, one must be able to assess the significant distinction between what society labels as an issue, and what is medically permissible or possible. These themes can be applied across the board, whether in terms of embryo selection, longevity, euthanasia laws, or organ allocation. No matter what the topic, these ethical issues bring important ideas to the table and provide Bioethics researchers with the key to unlocking a future of possibility, societal development, and greater technologies in the fields of Biology and medical ethics.

By Neha Bhardwaj

adobe-WorksCited-Reg

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