Transgender Children — a Risk Management and Ethical Perspective

The author is an ex-Risk Manager for a U.K. Mental Health Trust , not a doctor or psychologist.  Views here reflect the author’s understanding of this issue from a Risk Management and Allied Health perspective.

I am concerned at the perceived lack of clarity, ethics and judgement regarding assessment, diagnosis and treatment protocols for transgender people, especially children.

Terminology & assessment criteria: There is no agreed, organic, definitive test for Gender Dysphoria – the feeling that your sex assigned at birth and gender identity do not match. DSM V says that a patient can have a diagnosis of GD if the distress caused by the feeling that they are in the wrong sexed body for their I.D. is ‘consistent, insistent and persistent’ in children and if it carries on over 6 months for adults. Gender is defined as the social norms accepted for sex – male/female according to culture. Yet we hear there are multiple genders, not just ‘man/woman’ including ‘gender-fluid’ and ‘agender’- by definition not consistent, insistent and persistent. There is research to suggest that many gender non-conforming children grow out of the feeling that they are the opposite gender to their body by adolescence. I would like to add, from a professional point of view, that the feeling of ‘being in the wrong body’ for one’s sex must be especially difficult to assess when it is applied to babies and toddlers who do not yet have an understanding of objects, words and language.

Differential diagnosis: In order to be ethical and for treatments to work, clinicians must be able to establish the nature of a disability or health problem, including a mental health problem. They must be able to discount other factors including for example, social contagion, emotional trauma, schizophrenia, body dysmorphia associated with sensory difficulties, Autism Spectrum Disorder, effects of medication, brain injury etc. This does not appear to be happening in the case of people who think they may be transgender. We seem to be relying on self-diagnosis for this group, especially regarding case histories coming from the U.S.  We also need to look at the qualifications, skill-set and autonomy of specialist gender professionals who are making the diagnosis, to ensure consistency and efficacy. I am concerned that diagnosis is being made on the basis of one or two visits to counsellors who are then able to confirm distribution of medication which could permanently affect patients e.g. Testosterone.

Medical ethics, Clinical Governance, Risk Assessment, Informed Consent.

Medical ethics has four main principles:

  • Autonomy

Requires that the patient have autonomy of thought, intention, and action when making decisions regarding health care procedures. Therefore, the decision-making process must be free of coercion or coaxing.  In order for a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success.

The idea that the burdens and benefits of new or experimental treatments must be distributed equally among all groups in society. Requires that procedures uphold the spirit of existing laws and are fair to all players involved.

  • Beneficence
    Requires that the procedure be provided with the intent of doing good for the patient involved.
  • Non-maleficence
    Requires that a procedure does not harm the patient involved or others in society.

These appear to be breached in some cases:

Autonomy:

    1. The decision making process can be demonstrably proven NOT to be free of coercion or coaxing, if the choice is being given to parents of possibly transgender children, ‘Would you rather have a dead son, or a transgender daughter?’ as has been reported.
    2. Fully informed decision: this ties into another medical principle of informed consent. You cannot give informed consent if you have not been given full information and you do not understand what you are consenting to. Basically, what are the outcomes of social transitioning on children/adults? What are the outcomes and possible side-effects of puberty blockers e.g. Lupron? What are the outcomes of adult surgery? Does it relieve psychological pain? Where are the clinical trials to show effectiveness/non-effectiveness in short-term and long-term follow-up studies?
  • As medical, allied health and social work professionals, are we acting effectively and ethically when we are advocating a course of action, are we giving our patients/clients full information so that they can make a clear and informed autonomous decision?

Justice: Existing laws show that medical, allied health and social work professionals must give full information to patients based on risk and clinical governance protocols. We need to be informed of and explain trials and their outcomes. Are we giving full information based on clinical trials i.e. Does this intervention work? What are the risks involved? What are the risks of doing nothing? I would argue that we do not yet have clear evidence from clinical trials.

Beneficence: The procedure is provided with the intent of doing good. How can we measure this if we do not have the medical and social evidence that social and medical transitioning is effective and not harmful?

Non-maleficence: Procedure does not harm the patient involved or others. Surgical and medical intervention on otherwise healthy bodies is a harm in and of itself unless it can be proven otherwise.

SUMMARY:  Risk Assessment: Clinical, Non-Clinical and Financial. 

For risk managers, there appears to be a clear risk to legal, medical and ethical cover from referral to treatment and follow-up with transgendered clients, as outlined above. We need to look at the legal implications of informed consent. We must ask ourselves the question: Is it legal or ethical to obtain a signature for intervention from a potential patient who has not undergone a full assessment and consultation process, who has not been informed of likely clinical outcomes and/or long-term effects of intervention and who also may be unfit to consent because of coercion, language comprehension, cognition or mental health difficulties.