Ethics of Management of Gender Atypical Organisation in Children and Adolescents
Atypical gender identity organisation (AGIO) is a serious medical condition in which the phenotypical appearance is experienced as alien by the person affected. AGIO is source of great distress, and obtaining medical treatment is for many a life-or-death matter. Many of those who cannot receive treatment are at high risk of suicide. AGIO is not only a problem of personal health, but also a public problem, because sufferers are often exposed to discrimination, abuse and violence, and each act of discrimination, abuse and violence is a public issue. Thinking about AGIO represents a great challenge for us all. It involves rethinking about gender identity in a more comprehensive way, inclusive of phenomena that go beyond the classic gender divide ‘male-female’, and thinking of ways of ensuring all citizens, whatever their gender identity, a secure and peaceful place in society. I explain what AGIO is, how it manifests itself, and provide a brief history of AGIO. I offer an overview of risks and benefits of available treatments. I analyse the ethico-legal issues that surround AGIO. In particular, ethics of interfering with natural development, competence in minors, validity of informed consent, role of the family, moral and legal responsibility of professionals for omission of treatment and ageism. I conclude that medical treatment should be offered, even to minors just after the onset of puberty, if the child has a profound and persisting AGIO, if she/he is competent to make a judgement on the matter, and if treatment is likely to enhance his/her quality of life. Deferring treatment till adulthood is not a morally neutral option, and it is indeed unethical, if the child is likely to be harmed by pubertal development.
KeywordsGender identity disorder suspension of puberty acts/omission ageism competence in minors informed consent international guidelines for treatment of gender identity disorder
Unable to display preview. Download preview PDF.
- Istar Lev, Arlene (2006) Disordering Gender Identity – Gender Identity Disorder in the DSM-IV-TR, Journal of Psychology and Human Sexuality, 17 (3–4) pp. 35–39.Google Scholar
- Brazier, M. (1992) Medicine, Patients and the Law, London, Penguin.Google Scholar
- BSPED–British Society of Paediatric Endocrinology & Diabetes (ANNO) Guidelines for the management of Gender Identity Disorder (GID) in Adolescents and Children. Specific Endocrinological Recommendations. Available at http://www.bsped.org.uk/professional/guidelines/docs/BSPEDGIDguidelines.pdf. These guidelines have now been withdrawn.
- Cohen-Kettenis, T. P. and Delemarre-van de Waal, H. (2005) Clinical management of adolescents with gender dysphoria, presented at the congress Endocrine Treatment of Atypical Gender Identity Development in Adolescents, London, 19–20 May 2005.Google Scholar
- Cohen-Kettenis, T. P. and Pfäfflin F. (2003) Transgenderism and Intersexuality in Childhood and Adolescence. Making choices, London, Sage Publications.Google Scholar
- Connolly, P. (2003) Transgendered Peoples of Samoa, Tonga and India: Diversity of Psychosocial Challenges, Coping, and Styles of Gender Reassignment, Harry Benjamin International Gender Dysphoria Association Conference, Ghent, Belgium.Google Scholar
- Department of Health (2000) Mental Health Act 1983 Revised Code of Practice, issue date 1 March 1999, revised 1 March 2000.Google Scholar
- Delemarre-van de Waal A. Henriette and Cohen-Kettenis T. Peggy (2006) Clinical management of gender identity disorder in adolescents: A protocol on psychological and paediatric endocrinology aspects. European Journal of Endocrinology, 155(suppl 1) pp. 131–137. Available at: http://www.eje-online.org/cgi/content/full/155/suppl_1/S131#F2.
- Dreger, Alice (2006) ‘Really Changing Sex’ 8 November, Bioethics Forum. Available at http://www.bioethicsforum.org/New-York-City-plan-to-change-gender.asp.
- De Sutter, P. (2005) Adolescents and GID. Fertility issues, presented at the congress Endocrine Treatment of Atypical Gender Identity Development in Adolescents, London, 19–20 May 2005.Google Scholar
- De Sutter, P. (2006) Infertility Centre, University Hospital, Gent, Belgium, personal communication.Google Scholar
- Di Ceglie, D. (1995) Reflections on the nature of the atypical gender identity organization, in Zucker, K. and Bradley, S. (eds.) Gender Identity Disorder and Psychosexual Problems in Children and Adolescents, New York and London, Guilford.Google Scholar
- Di Ceglie, D. (1998a) Reflections on the nature of the “atypical gender identity organization”, in Di Ceglie, D. (ed.) A Stranger in My Own Body, London, Karnal Books, Chapter 2, pp. 9–25.Google Scholar
- Di Ceglie, D. (1998b) Management and therapeutic aims in working with children and adolescents with gender identity disorders, and their families, in Di Ceglie, D. (ed.) A Stranger in My Own Body, London, Karnal Books, Chapter 12, pp. 185–197.Google Scholar
- Di Ceglie, D. Freedman, D. McPherson, S. and Richardson, P. (2002) Children and Adolescents Referred to a Specialist Gender Identity Development Service: Clinical Features and Demographic Characteristics, The International Journal of Transgenderism, 6(1). Available at http://www.symposion.com/ijt/ijtvo06no01_01.htm.
- Farias Fernanda de Albuquerque and Janelli, M. (1994) Princesa, Rome, Sensibili alle Foglie.Google Scholar
- Fenner, B. and Mananzala, R. (2005) Letter to the Hormonal Medication for Adolescent Guidelines Drafting Team, presented at the congress Endocrine Treatment of Atypical Gender Identity Development in Adolescents, London, 19–20 May 2005.Google Scholar
- Freeman, M. (2006) Rethinking Gillick, in Freeman, M. (ed.) Children’s Health and Children’s Rights, Leiden/Boston, Martinus Nijhoff Publishers, pp. 201–217.Google Scholar
- Ghosh, S. and Walker, L. (2006) Sexuality: Gender identity, E Medicine. Available at http://www.emedicine.com/ped/topic2789.htm
- Giordano, S. (1999) Il principio di autonomia nel trattamento e nella cura dei malati di mente, una prospettiva deontologica, Bioetica, rivista interdisciplinare, 3, pp. 482–491.Google Scholar
- Giordano, S. (2008a) Gender atypical organisation in children and adolescents:Google Scholar
- Ethico-legal issues and a proposal for new guidelines, International Journal of Children’s Rights, 15(3/4) pp. 365–390.Google Scholar
- Giordano, S. (2008b) Lives in a Chiaroscuro. Should we suspend puberty of children with gender identity disorder? Journal of Medical Ethics (in press).Google Scholar
- GIRES (2005) Developing Guidelines for Endocrinological Intervention In the Gender Identity Development Treatment of Adolescents, Progress Report, August 2005. Available at http://www.gires.org.uk/Web_Page_Assets/Hormonal_Medication.htm
- GLSEN’s 2005 National School Climate Survey Sheds New Light on Experiences of Lesbian, Gay, Bisexual and Transgender (LGBT) Students. Available at www.glsen.org/cgi-bin/iowa/all/library/record/1927.html
- Harris, J. and Giordano, S. (2003) On cloning, The New Routledge Encyclopaedia of Philosophy, Edward Craig Edition, publication online.Google Scholar
- Jones, M. (2006) Adolescent gender identity and the courts, in Freeman, M. (ed.) Children’s Health and Children’s Rights, Leiden/Boston, Martinus Nijhoff Publishers, pp. 121–148.Google Scholar
- Korsgaard, C. (1993) Capability and well being, in Nussbaum, M. and Sen, A. (eds.) The Quality of life, Oxford, Oxford University Press.Google Scholar
- Lee, P. and Houk, C. (2006) Diagnosis and care of transsexual children and adolescents: A pediatric endocrinologists’ perspective, Journal of Pediatric Endocrinology & Metabolism, 19, pp. 103–109.Google Scholar
- Mason, J. K. and McCall Smith, R. A. (2006) Law and Medical Ethics, 7th ed., London, Butterworths.Google Scholar
- Mason, J. K. McCall Smith, R. A. and Laurie, G. T. (2006) Law and Medical Ethics, 7th ed., Oxford, Oxford University Press. MHA 1983, Mental Health Act, Department of Health, Her Majesty’s Stationery Office, London.Google Scholar
- McHale, J. and Fox, M. (1997) Health Care Law, London, Maxwell.Google Scholar
- Morris, J. (1974) Conundrum, London, Faber & Faber, 1974.Google Scholar
- Royal College of Psychiatrists (1998) Gender identity disorders in children and adolescents, guidance for management, Council Report CR63, January. Available at www.rcpsych.ac.uk/publications/cr/cr63.htm
- The Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders (2001) Sixth Version, February. Available at www.hbigda.org/Documents2/socv6.pdf
- Whittle, S. and Downs, C. (2000) Seeking a gendered adolescence: Legal and ethical problems of puberty suppression among adolescents with gender dysphoria, in Heinze, E. (ed.) Children’s Rights: Of Innocence and Autonomy, Aldershot, Dartmouth Press, Chapter 9, pp. 195–208.Google Scholar