Doing the right thing by transgender kids is not easy

Michael Cook
April 2, 2016
Reproduced with Permission

A US$5.7 million study of the long-term outcomes of medical treatment for transgender youth begins recruiting in May. But knotty ethical questions remain unanswered.

The study will be located at four academic medical centres with dedicated transgender youth clinics and will include 280 young people with gender dysphoria in two age groups.

Younger children in early puberty will receive hormone blockers, called GnRH agonists, to suspend the process of puberty - preventing the development of undesired secondary sex characteristics.

Older adolescents will begin use of masculinizing or feminizing cross-sex hormones that allow them to go through the "right" puberty - consistent with their gender of identification.

Feelings about the ethics of gender dysphoria run high, although little is really known about the condition. "People are making declarations of knowledge that are their belief systems, that aren't also backed up by empirical research," Jack Drescher, a psychiatrist at the William Alanson White Institute in New York City, told Nature . In this case, a number of ethicists regard hormone treatment itself as unethical, while those directing the study assume that it is.

Some studies say that 80% of children under with gender dysphoria abandon the idea by the time they enter puberty. However, it appears that children who identify as transgender in adolescence seldom change. Therefore, denying them the ability to transition is unethical, bioethicist Simona Giordano of the University of Manchester, UK, told Nature . "Not treating adolescents is not being neutral," she says. "It means exposing children to a lot of harm."

However controversial Giordano's view is, even more controversial is how to treat younger children. The number in early childhood who identify as the opposite sex seems to be rising almost exponentially. The trend among doctors is to encourage them to live as if they were the opposite sex, an approach which is called "social transitioning". Trans activists claim that any other approach is equivalent to the reviled "gay-conversion therapy".

What Nature's article did not cover is the ethical complications of treating children with powerful drugs for a condition which is poorly understood. The research project involves give 14-year-olds puberty blockers when the current position of the Endocrine Society is to wait until they are 16.

"There are people within the transgender community who are pushing to do things even more quickly. And patients are requesting irreversible treatments at younger and younger ages," says endocrinologist Courtney Finlayson . "We're walking this line in between. This is the forefront of medicine, and we can't go too fast."

Even the lead doctor in the study, Rob Garofalo of Lurie Children's Hospital, in Chicago, has some misgivings .

"The pushback in my own mind is my Hippocratic oath: 'Do no harm.' How can I know that I'm doing no harm in the absence of scientific data to support these interventions? I wish we had generations of outcomes research to fall back on, but right now we don't. We ask these families questions that they can't really know the answer to. No one can."