writing a response

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T ransgender issues and transgender rights have become increasingly a matter of media atten- tion and public policy debates. The movement

for transgender civil rights has followed in the wake of the larger lesbian, gay, and bisexual (LGB) rights move- ment, and, for the last two decades, trans inclusion has become a focus of LGBT civil rights organizations. The movement has had mixed success. For example, in 2013 California passed legislation—now being challenged in the courts—that “guarantees transgender students access to interscholastic sports, gym classes, locker rooms and bathrooms based on their gender identity, irrespective of their biological sex.”1 By contrast, many states and the federal government deny civil rights protections and ac- cess to care to transgender individuals.

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 (when the ICD was in its ninth edition) and shortly thereafter, in 1980, in the Diagnostic and Statistical Manual of Mental Disorders (DSM, then in its third edition).2 Since that time, in- ternational standards of care have been developed,3 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 2014.4

In contrast to the relative lack of controversy about treating adolescents and adults, there is no expert clinical

consensus regarding the treatment of prepubescent chil- dren who meet diagnostic criteria for what was referred to in both DSM-IV-TR and ICD-10 as gender identity disorder (GID) in children and now in DSM-5 as gender dysphoria (GD).5 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 (WPATH)6 notes in their latest Standards of Care, gen- der 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 trans- gender.7

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. Due to the ab- sence of any randomized controlled treatment outcome studies of gender dysphoric children, the task force con- cluded that “the highest level of evidence available for treatment recommendations for these children can best be characterized as expert opinion.”8

However, there are sharp disagreements among the ac- knowledged experts. One of the oldest gender clinics do- ing research in this area is Toronto’s Centre for Addiction and Mental Health. There, clinicians work with children and caregivers to lessen gender dysphoria and decrease cross-gender behaviors and identification. For example, natal boys are not permitted to dress in princess outfits and are discouraged from playing with Barbie dolls. The

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

by Jack Drescher and Jack Pula

Jack Drescher and Jack Pula, “Ethical Issues Raised by the Treatment of Gender-Variant Prepubescent Children,” LGBT Bioethics: Visibility, Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5 (2014): S17-S22. DOI: 10.1002/hast.365

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clinic claims its approach decreases the likelihood that GD will persist into adolescence, leading to adult transsexual- ism, which, for various reasons, such as social stigma and a lifetime of medical treatment, is an outcome the clinic considers undesirable.9

Another long-standing research clinic, the VU University Medical Center in Amsterdam, makes no direct efforts to lessen gender dysphoria or gender atypical behav- iors. Given that GD diagnosed in childhood usually does not persist into adolescence and no reliable markers exist to predict when it will or will not persist, there is no thera- peutic target with respect to gender identity outcome, but the developmental trajectory of gender identity is allowed to unfold of its own accord. Those in whom it persists are assisted in transitioning in later adolescence, and those who desist are assisted in adjusting to their natal gender.10

A more recent entry in this area is the gender clinic af- filiated with the University of California, San Francisco, where a child is supported in socially transitioning to a cross-gendered role without medical or surgical interven- tion. As in the other two clinics, only at the onset of puber- ty are medications administered to suppress development of unwanted secondary sex characteristics.11 This approach presumes that an adult transgender outcome is to be ex- pected, that these children can be identified, and that chil- dren who transition but then desist can revert to their natal gender if necessary with no ill effects.12

The State of Empirical Research

Research on gender dysphoric/gender variant (GD/GV)13 children and adolescents is still sparse. Some findings are emerging, however:14

• The children and adolescents (collectively referred to as “minors”) who present for clinical evaluation or treatment are a heterogeneous group.

• For some of these minors, the major issue is cross- gender behaviors or identifications; for others, the gender issues seem to be epiphenomena of psycho- pathology, exposure to trauma, or attempts to re- solve problems such as lacking higher social status or other benefits they perceive to be associated with the other gender.

• In general, a minor’s notions of gender and gender identity will vary according to the minor’s age.

• Until children master the capacity for operational thought (between the ages of five and seven), they tend to conflate gender identity with surface expres- sions of gender.

• The gender dysphoria of the majority of children with GD/GV does not persist into adolescence, and when it does not, the children are referred to as “de- sisters.”

• Prospective studies indicate that the majority of those who desist by or during adolescence grow up to be gay, not transgender, and that a smaller propor- tion grow up to be heterosexual.

• There is at present no way to predict in which chil- dren GD/GV will or will not persist into adoles- cence or beyond. 15

• GD/GV that persists into adolescence is more likely to persist into adulthood.

• GD/GV may be mimicked by gender confusion that occurs as an epiphenomenon of other problems (e.g., gender confusion as the result of sexual trauma or delusions in the context of psychotic disorders).

Much remains unknown, however. In particular, re- search has yet to show

• how either a cisgender identity16 or a transgender identity develops;

• the relative contributions of biology and psycho- social environmental factors in the development of gender identity, whether cisgender or transgender;

• the extent to which gender identity in individuals with GD/GV does or does not develop along the same lines as gender identity in cisgender individu- als; and

• why the gender dysphoria of most children desists around puberty, while it persists in others into ado- lescence and adulthood.

Given the absence of strong empirical data regarding the best GD treatment outcomes in children, each of the three treatment approaches outlined above raises ethical ques- tions. The rest of this paper does not purport to answer the questions it presents. Instead, these questions are intended to stimulate discussion in a wider range of interested par- ties about the ethical issues with which the experts treating these children are or should be engaging. Hopefully, such discussions can serve to improve care for all children and their families regardless of which gender clinic they choose.

The ethical principles that underlie the questions and discussions that follow are from The Principles of Medical

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Ethics: With Annotations Especially Applicable to Psychiatry,17 specifically, section 1.2 and section 5. The first of these reads, “A psychiatrist should not be a party to any type of policy that excludes, segregates, or demeans the dignity of any patient because of ethnic origin, race, sex, creed, age, socioeconomic status, or sexual orientation” (p. 3). Section 5 states, “A physician shall continue to study, apply, and advance scientific knowledge, maintain a commitment to medical education, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when in- dicated” (p. 8).

Clinical Ethics

Is Preventing Transsexualism an Acceptable Clinical Activity?

It could be construed, as some in the transgender com- munity maintain, that clinical attempts to prevent trans- sexualism, no matter how well meaning, are unethical because they demean the dignity of gender-variant chil- dren.18 Although the principles of ethics do not comment specifically on “gender identity” or “gender expression” —the usual terms used in laws and position statements aimed at protecting transgender rights—the rapid cultural acceptance of gender diversity and psychiatry’s unfortunate history of trying to “cure” homosexuality raise questions of whether “prevention of transsexualism” is a benign medical activity or an attack on an individual’s identity.

This question raises another: is there empirical evidence that childhood treatment can reduce the rate of persistence and prevent adult transsexualism in some individuals?

Should Parents Be Told That Adult Transsexualism Is Preventable?

Kenneth J. Zucker and colleagues note that while many of the parents with whom they consult do not mind if their gender-variant children grow up to be gay, they see having a child who grows up to be transgender as more problematic.19 It is therefore reasonable to assume that their clinical approach of representing adult transsexualism as preventable stems from an effort to satisfy the wishes of the parents. However, there are presently no controlled studies that demonstrate that discouraging cross-gender behavior and interests in childhood does in fact reduce per- sistence or prevent transsexualism. In addition, there are

no proven, reliable indicators to distinguish children whose dysphoria will desist from those in whom it will persist. Since no clinician can accurately predict the future gender identity of any particular child, shouldn’t we assume that efforts to discourage cross-gender play and identifications may be experienced as hurtful and possibly even traumatic, since, for some children, gender dysphoria will persist into adolescence and adulthood? If so, is it ethical to offer such treatment without informing parents of the current state of the research or of possible harmful side effects (which may be experienced by desisters as well as persisters)? And if some children may be harmed, do the benefits outweigh the risks, and are these risks and benefits sufficiently clear to parents? Are the harms so unknown or so great that it is unethical to offer such treatment at all? Mental health pro- fessionals should look to other areas of medicine to under- stand standards for informed consent regarding treatments whose efficacy and safety are unproven.

Is It Okay to Steer a Child away from a Gender-Variant Position?

In considering whether to support or promote the gen- der-variant position of a child, parents, family members, pediatricians, and mental health clinicians should consider how any action or inaction will affect the child and how it may result in beneficence (doing what is in the interest of the child) or maleficence (harm). They also need to consid- er the ethical principle of autonomy even though children are not considered autonomous in the eyes of medicine and the law because they are deemed developmentally imma- ture and unable to fully understand the risks and benefits of medical decision-making. When it comes to compli- cated decisions regarding treatments for severe childhood diseases such as leukemia that have profound impacts on the child’s immediate emotional and physical well-being, families and clinicians have constructed creative strategies to respect the dignity and relative autonomy of the child who has to bear the pain of difficult treatments.

Since research shows that a relatively low percentage of children persist and that those who socially transition one way may need to transition back to their natal gender, a cautious approach is warranted. Also, given that certain en- vironments (a school, church, or playground, for example) may be unsafe spaces in which to express gender variance, protecting a child from overt threats by modifying gender expression in those settings is a common-sense approach.

There is no expert clinical consensus regarding the treatment of prepubescent children who meet diagnostic criteria

for gender dysphoria.

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Yet, should caution and modification for safety reasons rationalize as-yet-unproven efforts to steer a child’s gen- der identity in a cisgender direction? Given that how any gender identity develops is an unknown, is it not possible that opposing a wish to explore cross-gender expression is harmful to some children? Whether they persist or desist in their transgender behavior or identity, children may in- ternalize disapproving attitudes toward atypical gender be- havior and expression (transphobia), with possible negative consequences for adult development.20

What are the ethical implications of delaying social transition for children who persist?

Unlike Zucker et al., Annelou L. de Vries and Peggy T. Cohen-Kettenis do not discourage cross-gender play, although they do discourage social transition in prepu- bescent children because most children with GD will not remain dysphoric through adolescence. They aim to pre- vent youths with nonpersisting gender dysphoria from hav- ing to make a complex change back to the role of their natal gender. They cite the qualitative follow-up study in which several youths indicated how difficult it was for them to realize that they no longer wanted to live in the role of the other gender and to make this clear to the people around them.21

However, another ethical question is raised by this ap- proach: Since the clinicians freely admit that they are un- able to distinguish persisters from desisters, what are the risks and benefits of delaying the social transition of per- sisting children in order to prevent possible psychological harm to those who will desist? Put another way, are the children who will grow up to be trans being subjected to unnecessary stress in order to preserve the well-being of the majority who will not?22

Further, increasing numbers of young children are mak- ing social transitions sanctioned by families before they even come to a gender clinic. Schools and other commu- nity settings are helping children adapt to these changes as well. That some children may be supported in transition before they know what their natal sex is or what it means is a complex issue that deserves further investigation. Does this complexity increase the burden on medical and child- care systems, as well as families, to fully evaluate and weigh the factors for and against transition of any child?

What are the ethical implications of permitting early transition in children who desist?

Diane Ehrensaft makes a case for early social transition that appears to be based on the belief that those who will be persisters can be distinguished from other individuals who present signs of gender dysphoria. She states, “Once allowed to transition, these children [persisters] typically relax and the signs of stress, distress, and disruption dissi-

pate, if not disappear altogether.”23 “Although not a univer- sal phenomenon,” she asserts, “one simple rule of thumb is that if the assessment is correct, the child shows signs of getting better; if the assessment was incorrect, the child gets worse, or at least no better” (346-47).

While Ehrensaft notes correctly that there is little em- pirical data demonstrating harm in transitioning twice, there is also no empirical evidence demonstrating that a prepubescent child who is permitted to socially transition but then desists can simply and harmlessly transition back to the natal gender. Given the complexity involved in the first social transition, should we accept at face value the claim that transition back to the original gender is entirely without risks and pitfalls? Furthermore, in the absence of empirical studies, is permitting early social transition with- out a verifiable system of distinguishing persisters from de- sisters an ethically appropriate treatment?

A Work in Progress

Obviously, more research is needed to help understand the biological, cultural, and psychological factors of gender identity formation, as well as outcomes for those who persist, desist, transition socially or medically, take on normative gender (cisgender) identity, or adopt atypi- cal, gender-queer, or nonbinary identities. It would also be helpful to the affected populations if there were more col- laboration and comparison of results between specialized gender clinics with treatment methods.

As discussed by other authors in this special report, the Institute of Medicine has commented on the significant lack of research on the health and mental health needs of transgender populations.24 However, the ability to conduct research on transgender individuals in itself raises ethi- cal concerns. In this era of evidence-based medicine, the demand to produce rigorous research data can hamstring clinical efforts in the field of transgender medicine. While clinicians struggle to help patients and families make dif- ficult and often painful decisions in the here and now, they cannot always wait for research-based conclusions to guide them. That is not to say that it is impossible to do research or that it should not be attempted, but that current clini- cal needs must respect the nuance and subjectivity of gen- der identity, as well as the ethical standards of beneficence, nonmaleficence, and autonomy. At this juncture, reason- able informed consent would involve telling parents that (1) the best treatment approach for these children is a sub- ject of controversy; (2) that there is presently no way to predict whether their transgender child will desist or persist into adolescence and adulthood; (3) that it is unclear if an adult transgender outcome can be prevented; (4) that if the child is socially transitioned to the experienced gender, there is a possibility that the child might transition back

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to the natal gender; and (5) that intervention and nonin- tervention both may carry risks to the welfare of the child, requiring that providers and families examine and weigh predictable risks and benefits in a given situation to the best of their ability.

With that in mind, we know that the experience of being a gender-variant child is challenging, possibly char- acterized by distress and dysphoria, that it can persist or desist, and that it can open up options for social and later medical transition that involve serious ethical and practi- cal concerns for clinicians and families. We know that these children are in our midst now, that their numbers are increasing at gender clinics and elsewhere, and that their presence is putting greater pressure on the medical and mental health systems to create standards and clini- cal practice, research, and model approaches that adhere to modern medical ethical standards. As these standards are created, evaluated, and modified, it will be essential to continuously reflect on the ethical questions, concerns, and limitations raised above—and others that may arise in the future—to best ensure that the medical field is doing its best to help and not harm gender-variant children, adoles- cents, and their families.

1. I. Lovett, “California: Rights Guaranteed for Transgender Students,” New York Times, August 13, 2013, p. A12.

2. Some trans advocates see the medicalization of transgender- ism as contributory to this state of affairs (see D. B. Hill et al., “Gender Identity Disorders in Childhood and Adolescence: A Critical Inquiry,” International Journal of Sexual Health 19, no. 1 (2007): 57-74; K. Winters, “Gender Dissonance: Diagnostic Reform of Gender Identity Disorder for Adults,” Journal of Psychology & Human Sexuality 17, no. 3/4 (2005): 71-89. Yet, while the gay rights movement can attribute much of its advancements to the removal of homosexuality from the DSM in 1973, transgender rights have progressed, albeit at a slower pace, despite the appearance of gender diagnoses in both the DSM and the ICD.

3. World Professional Association for Transgender Health, Standards of Care for the Health of Transsexual, Transgender and Gender Non-Conforming People, 7th version, 2011, at http://www. wpath.org/.

4. A. E. Cha, “Ban Lifted on Medicare Coverage for Sex Change Surgery,” Washington Post, May 30, 2014, http://www.washing- tonpost.com/national/health-science/ban-lifted-on-medicare- coverage-for-sex-change-surgery/2014/05/30/28bcd122-e818-1 1e3-a86b-362fd5443d19_story.html.

5. At the time of this writing, a proposed name change for ICD-11 is “gender incongruence of children.”

6. This was formerly known as the Harry Benjamin International Gender Dysphoria Association.

7. See World Professional Association for Transgender Health, “Standards of Care for the Health of Transsexual, Transgender and Gender Non-Conforming People,” 11.

8. W. Byne et al., “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder,” Archives of Sexual Behavior, 41, no. 4 (2012): 759-96, at 762.

9. K. J. Zucker, “Children with Gender Identity Disorder: Is There a Best Practice?,” Neuropsychiatrie de l’enfance et de l’adolescence, 56 (2008): 358-64; K. J. Zucker et al, “A Developmental,

Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder,” Journal of Homosexuality, 59, no. 3 (2012): 369- 97.

10. A. L. de Vries and P. T. Cohen-Kettenis, “Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach,” Journal of Homosexuality 59, no. 3 (2012): 301-20.

11. All three clinics mentioned here offer puberty suppression to children when clinically indicated, either to “buy time” in case they desist after puberty or to prevent development of secondary sex characteristics in those who persist. However, the approach here acts under the assumption that they are better able to distinguish desisters from persisters.

12. D. Ehrensaft, “From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy,” Journal of Homosexuality 59, no. 3 (2012): 337-56.

13. Further illustrating the controversies, some clinicians (includ- ing Ehrensaft) eschew the use of psychiatric diagnoses when evaluat- ing and treating these children. Consequently, the nonmedical term “gender variance” is an alternative, nonpathologizing way of describ- ing them.

14. Since it often appears that child GD experts talk past each oth- er, Jack Drescher and William Byne invited several of them to pub- lish their clinical approaches in one volume. However, rather than critique each other, which they often do, the clinicians were asked to present their own approaches, which would then be discussed by experts (child psychiatrists, ethicists, attorneys, trans advocates, and gender scholars) who did not treat GD themselves but who had an interest in issues related to gender. See J. Drescher and W. Byne, Treating Transgender Children and Adolescents: An Interdisciplinary Discussion (New York: Routledge, 2013).

15. In a most recent study, Thomas D. Steensma et al., found a link between the intensity of GD in childhood and persistence of GD, as well as a higher probability of persistence among natal girls. Psychological functioning and the quality of peer relations did not predict the persistence of childhood GD. Formerly nonsignificant factors (e.g., age at childhood assessment) and unstudied factors (a cognitive or affective cross-gender identification and a social role transition) were associated with the persistence of childhood GD and varied among natal boys and girls. Steensma et al. concluded, “Intensity of early GD appears to be an important predictor of persis- tence of GD. Clinical recommendations for the support of children with GD may need to be developed independently for natal boys and for girls, as the presentation of boys and girls with GD is different, and different factors are predictive for the persistence of GD” (T. D. Steensma et al., “Factors Associated with Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-up Study,” Journal of the American Academy Child & Adolescent Psychiatry, 52, no. 6 [2013]: 582-90, at 589).

16. “Cisgender” is used in the transgender community to describe those who are not transgender.

17. American Psychiatric Association, The Principles of Medical Ethics: With Annotations Especially Applicable to Psychiatry (Arlington, VA: APA, 2009). One caveat should be noted: these comments are made with the understanding that many of the mental health prac- titioners offering treatment to prepubescent children are not physi- cians.

18. S. D. Pickstone-Taylor, letter to the editor (“Children with Gender Nonconformity”), Journal of American Academy Child & Adolescent Psychiatry 42, no. 3 (2003): 266.

19. K. J. Zucker et al., “A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder,” Journal of Homosexuality 59, no. 3 (2012): 369-97; see 391-92.

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20. K. E. Bryant, “The Politics of Pathology and the Making of Gender Identity Disorder,” PhD diss., University of California, Santa Barbara, 2007.

21. T. D. Steensma et al., “Desisting and Persisting Gender Dysphoria after Childhood: A Qualitative Follow-up Study,” Clinical Child Psychology & Psychiatry 16, no. 4 (2011): 499-516.

22. A similar question can be raised about the treatment of adult trans individuals. Does the present system of “gate keeping” before allowing medical and surgical treatment exist for the benefit of those

wishing to transition or to protect those individuals who, after transi- tion, might express regrets?

23. Ehrensaft, “From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy,” 354.

24. Institute of Medicine, Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding (Washington, DC: National Academies Press, 2011).