In yesterday’s essay, I explained the state of so-called “gender-affirming treatment” (GAT) and the rocky landscape of ethical considerations for GAT practitioners. In his two papers, “Informed Consent for Transgendered Patients” and “Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria,” Dr. Stephen Levine lays out the risks that patients should understand.
Levine describes three categories of risk that must be explained before administering GAT: biological, social, and psychological (mental health). Without explaining these risks and determining that the patient fully understands them, the practitioner has shown inadequate respect for patient autonomy and has violated the ethical obligation of avoiding harm.
A significant problem with explaining physical risks of GAT is that many are as yet unknown. This, of course, calls into question the ethics of physicians who are willing to administer GAT without understanding long-term dangers. But much is known about real and potential consequences, and Levine lays out what every patient must be told.
Some of the risks can be easily explained but are highly unlikely to be processed by patients, especially children and adolescents. Two of these are loss of reproductive capacity (infertility/sterility) and impairment in physiological sexual capacity in the future. Young patients—especially those who are convinced they are living in the wrong body and need to transition immediately—simply cannot grasp the enormity of these losses. What twelve-year-old seriously understands the void that could come from childlessness, or the frustration of never being able to achieve intimacy with a loving partner? Levine thus points out that even discussing these consequences will probably not achieve real understanding, and therefore interferes with informed consent.
Other biological risks created by use of puberty-blockers and cross-sex hormones include a plethora of pathologies that could shorten the patient’s life expectancy or otherwise interfere with good health: cancer, cardiovascular disease, and joint pain, to name just a few. Levine includes infections such as HIV, the rate of which is up to seventeen times higher than in the non-transgender population; substance abuse and addiction; and increased suicide. Although “hope-based” practitioners await the day when “the world becomes more accepting [of trans-identifying individuals], psycho-social stressors will be less destructive, health habits will improve, addictions will lessen, access to health care will improve, and transgendered people will live longer,” Levine warns that this transgender utopia “cannot be depended upon.”
Another biological risk that should be explained to patients stems from the fact that, despite plastic surgery and changes in hormone levels, biological sex cannot be changed. This means patients who are now living as members of the opposite sex are still vulnerable to sex-linked illnesses (gynecologic diseases, prostate cancer, etc.). They will also remain in their masculine or feminine bodies (“trans men” will probably be shorter and less muscular than the average man, and “trans women” will probably be taller and more muscular than the average woman). Over time, Levine says, this bodily dissonance may cause psychological distress.
Even assuming that the GAT practitioner discusses all these physical consequences with the patient, Levine identifies social risks that should be (but frequently are not) thoroughly revealed and understood. Explaining these risks is part of treating the patient as a full human being, whose entire life will be permanently altered by completing GAT. Levine describes a serious social risk of “emotional distancing and isolation from family members.” He emphasizes that the practitioner must consider the dynamics of the entire family, without assuming (as too many GAT practitioners do) that the family will easily accept a “transitioning” member and that in the post-GAT family, happiness will bloom like flowers.
While Levine divides the patient population into pre-pubertal children, older adolescents, and adults, and describes what the practitioner must discuss with each group to obtain fully informed consent, he notes that many considerations apply to patients of all ages. All will come from a variety of family situations and will almost certainly find that some family members will resist, perhaps vigorously, the transition process, and will distance themselves from the patient. All patients should be given the opportunity for therapy that may uncover the psychological source of the GD—despite objections from politically minded activists that this constitutes the dreaded (and in some states legally banned) “reparative” or “conversion” therapy. Moreover, “[i]t is important for parents to be told that the majority of cross-gender-identified children desist from their current identities after puberty.”
The dream that GAT will solve all the patient’s problems rarely comes true; it may turn out that in the social realm, the problems are just beginning. Teenagers and their families, Levine states, should be warned that the stresses of normal adolescence will be magnified by transition-related social isolation from friends and family. Adults should prepare themselves to be “disowned” by spouses, children, siblings, and other relatives.
Another social risk identified by Levine is “[e]xchange of existing friends for friends from the transgender community.” Child patients will find making friends more difficult over time. Adolescents will find themselves sucked into a trans community whose members they may not even know personally: “It is exceedingly rare to encounter a trans teenager who has not developed ‘friends’ through the Internet, where they are often counseled that they are trans and directed to numerous websites that help them stabilize their identities.” The shifting of peer groups at school as GAT progresses may cause either a return to acceptance of the patient’s biological sex, or increased isolation and consolidation in the trans identity. As for adults, “[f]riendships via the Internet and within the local trans support communities are typical. . . . They form a new family with friends to replace or augment their family of origin.” But “[t]his is not the case for many previously socially phobic, autistic, schizoid, or chronically depressed individuals,” who find themselves increasingly isolated.
Another social risk (essentially beyond the comprehension of child and adolescent patients) is the “[g]reatly diminished pool of individuals who are willing to sustain an intimate physical and loving relationship.” Children, obviously, have no concept of this at all. As for adolescents, Levine warns that intimate partners may be indifferent to them as persons but simply curious about a sexual experience with a trans-identifying partner. Levine thus emphasizes that adolescent patients should be given the bleak warning that “most people in society should be expected to avoid them as love objects.”
Rounding out the list of social risks is that of social discrimination. This boils down to seeing the world as it is and not as patients and their advocates wish it were. Patients and activists may hope that all people, in all places, and in all situations, and at all socio-economic levels, will come to treat trans-identifying people with absolute acceptance and kindness; but Levine warns that this is an unrealistic expectation. Patients should understand that GAT will not help them fit in with society and may in fact exacerbate those problems.
Finally, Levine addresses the psychological (mental health) risks that patients should understand. He describes from his extensive experience with such patients that many of them, especially young ones, are so preoccupied with transitioning that they fail to develop in other areas that are critical to success in life, including “overcoming social anxiety, accepting one’s sexual impulses toward others, learning in school, learning how to handle money responsibly, and mastering work tasks.” According to Levine, the laser focus on transitioning can stunt developmental growth in other critical areas, replacing one set of socio-psychological problems with another.
Other psychological risks that Levine identifies stem from becoming disappointed that living in the “new gender” does not meet expectations. The patient may feel inauthentic and uncomfortable in the new status. A patient who suffered depression, anxiety, and perhaps suicidal thoughts before GAT must be led to examine his or her sense of reality to diminish post-GAT disappointment. And the newly transitioned individual may find it difficult to sustain new contacts in the LGBT social and political community, particularly the trans community, that is so focused on political advocacy. “Even transgendered individuals can become tired of the rhetoric of their community over time,” Levine writes. “Outsider status in one’s society reverberates with outsider status from family rejection.”
Experimenting on Children
Gender dysphoria and its treatment raise a host of issues that are too often minimized or ignored by agenda-driven clinicians. Levine’s analysis demonstrates that the appropriate view of treatment must be research-based, long-term, and holistic. Only the patient who thoroughly understands all risks should even be considered for GAT. But as Levine warns, such an explanation is rarely forthcoming when the patient is anxious for immediate treatment and the physicians are driven by other motives (either political or financial).
Levine’s discussion, though, shows the ultimate futility of obtaining truly informed consent from patients considering GAT. Especially for children and adolescents, many consequences are simply beyond their comprehension. Lifelong sexual dysfunction is meaningless to such patients. The inability to have children and the difficulty of finding a loving mate may be barely within their realm of understanding, but they cannot possibly grasp the pain and emptiness that will come with those conditions. So explaining these outcomes may accomplish nothing beyond “checking the box” on a consent form.
The known risks are daunting enough, but the other reason why consent can never be “informed” is that so many of these interventions are new and experimental. Long-term studies are minimal or non-existent. The practitioner must therefore resort to catch-all warnings that various unpredictable bad things may happen. Of course, patients are allowed to consent to new and experimental treatments—that’s how medicine advances. But from an ethical perspective, it can be argued that only when the alternative to treatment is a devastating or terminal disease should the patient be allowed to consent to interventions that can ruin his physical or mental health and perhaps even shorten his life.
Finally, Levine does not address the propriety of allowing parents to consent to GAT on behalf of their minor children. Parental consent to minors’ medical treatment is appropriate when the benefits of treatment are reasonably considered to be worth the known risks. GAT, uniquely among medical practices, involves purely speculative benefits balanced against severe known, and potentially devastating unknown, consequences of treatment—consequences that children and adolescents cannot possibly understand. Yet gender clinics and other complicit practitioners routinely allow parents to greenlight GAT on behalf of innocent children, who depend on mom and dad to exercise their greater maturity and wisdom to protect those children from harm.
A well-established principle of law is that, while a person can waive liability on behalf of himself or herself, parents generally cannot waive causes of action on behalf of their children. Because the issue of gender dysphoria and GAT is so novel, the interplay of this concept with parental consent for such medical interventions is as yet unexplored. Regardless of legal requirements, though, basic morality would dictate that neither the insistence of young patients nor the acquiescence by their parents (who in many cases have been emotionally blackmailed by threats of suicide if GAT is not pursued) can justify allowing parents to consent to harm inflicted on their children.
The only way to rationalize proceeding with GAT, with or without informed consent, is to adopt the paradigm that decrees the absolute autonomy of the patient: the patient is entitled to any intervention to help achieve the desired gender expression, even if that intervention will be harmful. This model has traditionally not been adopted in American medicine, but more and more it is taking hold in the profession (not only in interventions related to gender ideology but in other areas such as the purported right of patients to assisted suicide). That the model is now being adopted to the detriment of innocent children and troubled adults bodes ill not only for the medical profession but for the health of our culture at large.