Third Rail Bioethics: Gender Treatments for Minors
When Beneficence, Autonomy,and Non-maleficence are on a collison course, when do we slam on the brakes (or, at least, slow down?)
I know, I know, a little late but better late than, you know.
Photo by Priscilla Du Preez 🇨🇦 on Unsplash
One topic I wanted to include in Practical Bioethics (PB) was the controversy over transgender treatments for minors. Alas the book was already getting to be longer than what a professor could cover in a semester. “Next edition,” I told myself.
Two new studies/papers, one in Sweden and the other in Australia, have me thinking about the topic again. Both studies are expressing reservations about some transgender treatments for pre-adolescents.
Sweden decided in February 2022 to halt hormone therapy for minors except in very rare cases, and in December, the National Board of Health and Welfare said mastectomies for teenage girls wanting to transition should be limited to a research setting.
"The uncertain state of knowledge calls for caution," Board department head Thomas Linden said in a statement in December.
And in Australia,
There is a range of recommendations regarding the care of children and adolescents with gender incongruence/gender dysphoria. These include caution on the use of hormonal and surgical treatment, screening for potential coexisting conditions (e.g., ASD and ADHD), arranging appropriate service provision for these conditions, and offering psychosocial support to explore gender identity during the diagnostic assessment.
The first quote uses the phrase “putting on the brakes” that’s a good metaphor for what is going on. Neither Sweden nor Australia is calling for a halt to gender therapy or treatments. However, for the brakes to be “put on” it implies a need to slow down or stop from a higher rate of speed.
Bing AI, them some snazzy shoes!
There are three main types of treatments for gender dysphoria and transgenderism in children and teens.
Hormone therapy (testosterone/estrogen)
puberty blockers
surgical intervention
Most of the controversy here in the U.S. is about the use of hormones with children and pre-teens and the use of puberty blockers after age 12 which can cause permanent damage like osteoporosis.
And that’s about the limit of my understanding of the medical complexities. I can however speak some to the moral complexities. In one important way, the argument over “putting the brakes” and the argument over Kate Cox’s abortion are similar.
The thing they have in common is what is the moral thing to do when a uncertain amount of risk of harm meets an autonomous agent. Even the World Health Organization admits, “The evidence base for children and adolescents is limited and variable regarding the longer-term outcomes of gender-affirming care for children and adolescents.”
This raises the disagreement over treating the risk of harm as morally equivalent to actual harm. Opponents of trans-gender treatments for minors will point to documented harm shown by studies of the recent phenonmena of regret for transitioning and the concerns over detransitioning as justifying putting on the brakes. Proponents will respond by minimizing the impact of these phenonomena against the risk of psychological harm (and the corresponding data).
Then both sides start brandish dueling studies and rationalizing the data documenting actual harm.
The question remains, just as in the case of Kate Cox: how much evidence of risk is enough to override other moral considerations like autonomy, parental consent, etc? How much data of psychological harm of transition regret and the act of detransitioning is needed to justify restraint when it comes to elective procedures on minors?
(of course the response from the other side is how much psychological harm due to preventation of transition including attemped and actual suicide is needed to justify lifting those restraints?)
Another ethically relevant fact in this case is the difficulty with partial autonomy. Chapter 3 of Practical Bioethics points out that children and adolescents are always difficult when it comes to consent. Their wishes matter but they don’t have full autonomy. Some are able to plan an act on reasons better than others. How should this affect guidelines.
Finally, both cases also have an undeniable political component. As one columnist described the controversy over gender therapy for minors, “What should be a medical and psychological issue has be morphed into a political one. It’s a mess.” The sort of thing that leads to bad laws.
All of this to say that until the second edition of Practical Bioethics comes out, I hope this gives you some discussion grist for the debate mill.
Thanks for this discussion, Dr. Miles. It's unfortunately a highly politicized topic, as you acknowledge. I think I want to share this with my students, because it does such a good job of showing how principles like autonomy and non-maleficence apply and sometimes conflict.