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Abstract

Objective:

This article aims to explore ethical tensions in pediatric gender-affirming care and illustrate how these tensions arise in the clinical setting.

Method:

This article utilizes two de-identified cases of transgender youth—Emma and Jayden—as a framework for discussing ethical principles in pediatric gender-affirming care. Case summaries detail the medical history of these two patients, their familial context, and their encounters with healthcare providers. Subsequently, the ethics of both cases are synthesized. As represented in this work, these cases do not constitute Institutional Review Board-regulated human subjects research.

Results:

Emma’s parents want to forgo pubertal suppression and pursue hormone therapy, effectively skipping a step in the gender-affirming care standard for youth presenting in early puberty. Jayden’s parents, on the other hand, are skeptical of their son’s identity and resistant to pursuing treatment. Both cases reflect disparate health goals between youth and parents and offer insight into the ethical tensions of gender-affirming care for pediatric patients.

Conclusions:

Key ethical discussions center on the standard of care, treatment reversibility, and pediatric decision-making. Jayden’s parents resist the standard of care for pediatric transgender patients. In contrast, Emma’s parents seek an acceleration of the staged progression recommended in the standard-of-care guidelines. The degree of reversibility of the treatment option in question influences the deliberation of these cases because it is the provider’s ethical obligation to preserve the future rights and autonomy of pediatric patients. Finally, while capacity in children is not presumed, providers should actively involve pediatric patients in treatment decisions that are increasingly subjective.

Implications for Impact Statement

The standard of care, treatment reversibility, and pediatric decision-making are three important considerations in the ethical provision of gender-affirming care for pediatric patients. Clinicians and decision-makers, including parents, ought to weigh the impact of each consideration on patient autonomy. Although the autonomy of pediatric patients is necessarily limited, steps should be taken to safeguard these patients’ future decision-making capacity and align with their healthcare goals and values to the fullest extent possible.

Recent estimates suggest that the number of high school-aged youth in the United States identifying as transgender or nonbinary is increasing, with studies reporting prevalence rates of 1.8% (Johns et al., 2019), 2.7% (Rider et al., 2018), and 9.2% (Kidd et al., 2021). A subset of these youth experience gender dysphoria (i.e., persistent affective distress stemming from gender incongruence) and seek gender-affirming medical care to address dysphoria and increase gender congruence. Gender-affirming medical interventions typically available to adolescents include pubertal suppression using gonadotropin-releasing hormone analogs (GnRHa) to suppress gender-incongruent endogenous puberty, gender-affirming hormones (GAHs; testosterone or estrogen) to induce gender-congruent secondary sex characteristics, and such surgeries as mastectomy and masculinizing chest contouring.

Despite the decades-long clinical experience and published standard-of-care clinical guidelines from the World Professional Association for Transgender Health (WPATH; Coleman et al., 2012) and the Endocrine Society (Hembree et al., 2017), there remain limited prospective, longitudinal studies documenting outcomes of gender-affirming medical care among pediatric populations. Existing studies of youth receiving pubertal suppression treatment reported significant decreases in depressive symptoms and improvement in overall functioning (Costa et al., 2015; de Vries et al., 2011, 2014). Longitudinal studies examining outcomes of GAHs found reductions in body dissatisfaction (Kuper et al., 2020), depression (Achille et al., 2020; Chen et al., 2023; Kuper et al., 2020), anxiety (Chen et al., 2023; Kuper et al., 2020), and suicidality (Achille et al., 2020; Allen et al., 2019); improvements in general well-being (Allen et al., 2019) and quality of life (Achille et al., 2020); and improvements in appearance congruence, positive affect, and life satisfaction (Chen et al., 2023).

While existing studies provide support for improved mental health and psychosocial outcomes following gender-affirming medical interventions, they have been criticized for comprising small sample sizes drawn from individual clinics, which may introduce bias. Additionally, some have argued that the positive long-term outcomes observed in the Dutch sample (de Vries et al., 2011, 2014) may not generalize to the current population of adolescents accessing care in the U.S., who are being treated medically at younger ages and developmental stages and typically with less comprehensive assessment than the Dutch approach (de Vries & Cohen-Kettenis, 2012). The single prospective study examining outcomes of chest surgery among transgender adolescents and young adults designated female at birth found improved chest dysphoria, gender congruence, and body image satisfaction three months after surgery, but long-term outcomes data are still needed (Ascha et al., 2022).

The lack of long-term prospective studies of gender-affirming medical care for transgender youth has contributed to the increasing politicization of and attempts to criminalize gender-affirming medical care in the United States (Martin et al., 2021). A number of ethical questions related to gender-affirming medical care have been raised, both in academic circles and in the public sphere, including assessing youth’s readiness for treatment, capacity to assent or consent for care, the role of parents in treatment decision-making, and implications for care when two parents disagree on the treatment approach.

To highlight common ethical challenges that may arise and provide recommendations to support gender-affirming, patient- and family-centered care, we present two de-identified cases of youth seeking gender-affirming care. Both cases reflect disparate health goals between youth and parents and offer insight into the ethics of gender-affirming care for pediatric patients. Although these de-identified cases are grounded in the actual clinical histories of two transgender patients presenting to their pediatric psychologists, certain details—including personal identifiers (e.g., name and age), family structure, and aspects of their unique clinical history—have been altered to maintain the patients’ confidentiality. This confidentiality is especially important in light of the vulnerability of transgender and nonbinary patients and the politicization of their health care. Due to the de-identified nature of these two cases, this approach does not constitute human subjects research, and therefore Institutional Review Board oversight was not required.

We address three ethical considerations underpinning these cases: pediatric decision-making, the standard of care,¹ and treatment reversibility. These three considerations illuminate tensions within the core ethical principle of autonomy, namely, the tensions between the autonomy of parents as proxy decision-makers, the protection of pediatric patients’ future autonomy, and the expression of those patients’ care goals and values. By separately discussing the three aforementioned considerations, we hope to illustrate the nuances of patient autonomy and enrich our understanding of this classic pillar of clinical ethics.

Despite parental pressure to deviate from WPATH Standards of Care (SOC) guidelines, clinicians have an ethical obligation to advocate for and adhere to the standard of care unless there are strong medical reasons to diverge. The degree of reversibility of treatment—pubertal suppression does not cause irreversible physical changes, whereas hormone therapy can—influences the deliberation of these cases because it is the provider’s ethical obligation to preserve the future rights and autonomy of pediatric patients. Finally, while capacity in children is not presumed, providers should actively involve pediatric patients in treatment decisions that are increasingly subjective, especially when those decisions implicate something as deeply personal as gender identity.

Case Illustration: Emma

“Emma,” a nine-year-old, white, transgender girl (designated male at birth), and her parents first presented to an interdisciplinary gender health program seeking decision-making support for social and medical transition. Emma lived with her parents, who were supportive and affirming of her gender, and attended third grade at a public school, where she had begun exploring options for social transition (e.g., use of chosen name and pronouns). Her psychiatric history was notable for diagnoses of attention deficit hyperactivity disorder, combined type (ADHD-C), and generalized anxiety disorder (GAD), and her parents described her as often inattentive and easily distracted in all settings. Parents described long-standing gender nonconformity starting at age three when Emma expressed preferences for stereotypically feminine clothing and toys (e.g., wearing dresses at home and sometimes in public) and girl playmates. By age eight, Emma labeled her gender as “girl” and stated that she did not want a penis. She reported distress and discomfort associated with wearing “boy clothes” to school and being gendered as a boy in school activities. Her distress and insistence about her gender led her parents to facilitate social transition changes at home, at school, and in public shortly before the clinic visit.

Clinical Communication

During the first appointment with the pediatric endocrinologist and psychologist, Emma’s parents inquired about the range and timing of medical transition interventions. The care team described the typical approach to pubertal suppression (“puberty blockers”) and the process for completing a readiness evaluation prior to initiating pubertal suppression, following the WPATH SOC, Version 7 (v7; Coleman et al., 2012) and the Endocrine Society Clinical Practice Guideline (Hembree et al., 2017). Pubertal suppression is a reversible intervention initiated in the early stages of puberty using GnRHa to suppress the development of unwanted secondary sex characteristics and allows a young person time to mature before making decisions about GAHs during adolescence (Coleman et al., 2012).

Emma met the criteria for a diagnosis of gender dysphoria, and the treatment plan included annual appointments with the pediatric endocrinologist to assess her pubertal progression and ongoing supportive therapy with a community-based, gender-affirming therapist to help the family navigate Emma’s social transition, explore her interest in medical interventions, and address symptoms associated with ADHD and GAD.

Emma’s parents expressed concern about the potential impact of GnRHa on neurocognitive development. There is limited research evaluating the impact of pubertal suppression treatment on structural and functional neurocognitive changes during adolescence, and existing studies are inconclusive regarding long-term effects (Chen et al., 2018, 2020). To avoid any potential negative impact of GnRHa on neurocognitive development, Emma’s parents proposed an alternative treatment approach that would replace pubertal suppression with estrogen therapy when Emma starts puberty—an approach that is not consistent with the staged recommendations of the WPATH SOC that explicitly identifies pubertal suppression as the medical treatment of choice at Tanner stage II of pubertal development.

At age 11, pubertal development progressed to Tanner stage II, and Emma and her parents initiated care with a psychologist in the gender health program to discuss decision-making about future medical interventions. The psychologist provided psychoeducation about treatment reversibility and timing, noting that pubertal suppression with GnRHa is a fully reversible intervention initiated at a younger developmental stage than estrogen, which is an intervention with some irreversible effects. To address Emma’s limited understanding of pubertal development, treatment included psychoeducation about expected pubertal changes with no medical intervention. Education about reproduction focused on the impact of puberty blockers and estrogen on sperm maturation and future family formation options (e.g., experimental cryopreservation of immature tissue and adoption). Emma and her parents determined they were not interested in experimental fertility preservation and understood that the decision to proceed with puberty blockers would stop sperm maturation.

Emma described limited discomfort with her body (i.e., her penis) but reported worries about eventual pubertal changes such as growing a beard, developing an Adam’s apple, and a deeper voice. She understood the feminizing effects of estrogen (e.g., breast development) but did not express urgency to achieve these changes, stating that few of her cisgender peers had developed breasts. Emma’s parents observed that her mood and behavior improved significantly after she transitioned socially, and they believed estrogen would help maintain these gains. Her parents considered the unknown effects of pubertal suppression on neurocognitive development to be a significant risk and believed it was unnecessary to delay estrogen initiation given Emma’s stable gender identity. Her parents also noted that starting estrogen rather than GnRHa would allow Emma to progress through puberty at the same developmental pace as her cisgender peers.

Ethical Considerations

The WPATH SOC v7 specifies that youth may be eligible for pubertal suppression as soon as pubertal changes have begun (Tanner stage II) if they have a long-lasting pattern of gender nonconformity; gender dysphoria that worsens with the onset of puberty; stable psychological, medical, and social functioning; and informed consent from parents for patients who have not reached the age of medical consent (Coleman et al., 2012; Table 1). The care team agreed that Emma appeared to meet the criteria for initiating pubertal suppression. Though she expressed an interest in the feminizing effects of estrogen in the future, Emma’s primary focus was preventing the masculinizing effects of testosterone. The care team observed that Emma’s parents were strong advocates for interventions that would allow Emma to progress through pubertal development consistent with her gender. Clinicians sought to balance her parents’ focus on future outcomes with Emma’s focus on her immediate priority (i.e., stopping pubertal progression) without presuming she would inevitably choose to initiate estrogen when she is older. For context, across four prospective studies of GAHs, the average age of GAH initiation is 16 years (Allen et al., 2019; Chen et al., 2023; de Vries et al., 2014; Kuper et al., 2020), though these samples included youth starting GAHs as young as 12 years. Given that Emma was 11 years old, the care team deliberated about whether there should be a higher threshold of understanding when considering a partially reversible intervention (e.g., estrogen) versus a reversible intervention (e.g., pubertal suppression) and the relative importance of a child’s versus their parents’ urgency to start an intervention. The medical team shared with the family that estrogen therapy would likely need concurrent GnRHa or anti-androgens to effectively suppress testosterone in the later stages of puberty and recommended that Emma initiate GnRHa therapy with a plan to continue working with the program psychologist to reassess her interest in estrogen in three months.
Table 1
Summary of WPATH SOC v7 Criteria for Initiating Gender-Affirming Medical Interventions

Criteria for pubertal suppression Criteria for hormone therapy Criteria for surgery

Eligibility: Recommend onset of puberty to at least Tanner stage II in order to make an informed decision about pubertal delay Eligibility: Recommend initiating cross-sex hormones at approximately age 16, and recognize that initiating prior to 16 may have psychosocial benefits Eligibility: May be done earlier than age of majority, preferably after ample time socially adjusting to and living in desired gender role

Gender dysphoria which emerged or worsened with the onset of puberty

Long-lasting and intense pattern of gender nonconformity or gender dysphoria Persistent, well-documented gender dysphoria Persistent, well-documented gender dysphoria

Coexisting psychological, medical, or social problems that could interfere with treatment (i.e., compromise treatment adherence) have been addressed and adolescent’s psychosocial functioning is stable enough to start treatment Coexisting medical or mental health concerns, if present, are reasonably well-controlled and individual is stable enough to start treatment Coexisting medical or mental health concerns, if present, are reasonably well-controlled and individual is stable enough to start treatment

Adolescent provides informed assent Individual has capacity to make an informed decision and consent to treatment Individual has capacity to make an informed decision and consent to treatment

Legal guardian consents to treatment and is involved in supporting adolescent throughout treatment If not age of majority, legal guardian consents to treatment and is involved in supporting patient throughout treatment If not age of majority, legal guardian consents to treatment and is involved in supporting patient throughout treatment

Note. Summarized from the WPATH SOC v7; Coleman et al. (2012). WPATH SOC = World Professional Association for Transgender Health Standards of Care.

Case Illustration: Jayden

“Jayden,” a 15-year-old, white, transgender boy (designated female at birth), presented to a multidisciplinary pediatric gender health clinic with his parents after a referral from his pediatrician. Jayden began experiencing gender dysphoria when he was 12 years old, coinciding with pubertal onset. Soon after, he began to socially transition (i.e., use his chosen name and pronouns) with select friends and at school but did not discuss his gender identity or dysphoria with his parents until he was 14 years old. Jayden’s parents, who were divorced and shared legal custody, expressed significant skepticism regarding the validity of Jayden’s transgender identity and whether affirmation of his gender was the most appropriate course of action. However, they had recently allowed Jayden to receive an etonogestrel implant for purposes of menstrual suppression, and he wore a binder to minimize the appearance of his chest. Jayden’s primary goal in seeking services through the gender health clinic was to begin testosterone. He also planned to pursue “top” surgery (i.e., gender-affirming mastectomy) but had not yet discussed this goal with his parents.

At the time of Jayden’s initial appointment with the team psychologist, he was participating in twice-monthly therapy with a community-based therapist, with reported diagnoses of GAD and major depressive disorder and a history of non-suicidal self-injury. After multiple psychiatric medication trials, he was prescribed duloxetine and reported a high degree of adherence, despite perceiving limited therapeutic benefit. He felt he could not truly live a happy life unless he was able to medically transition, as he believed this would help others to accurately perceive his gender.

Clinical Communication

During Jayden’s initial visit, the team psychologist addressed his parents’ questions about his gender development and goals for social and medical gender affirmation. The treatment plan, developed in collaboration with Jayden and his parents, included ongoing follow-up with the team psychologist for gender-specific support and continued involvement with his local mental health team for the management of his depression and anxiety. Despite their initial concerns about the validity of Jayden’s gender experience and associated goals, his parents agreed to schedule an initial consultation with a physician to gather additional information about testosterone.

After multiple visits with the physician and reviewing the risks, benefits, and limitations of hormone treatment with Jayden and his father, the physician determined that Jayden met the eligibility criteria for initiation of testosterone. With his father’s consent, Jayden began testosterone injections and soon reported improvements in his mood, as well as increased affirmation from his parents regarding his gender and associated goals. However, Jayden’s father later informed the psychologist that he felt he had not been fully consulted by the physician about beginning testosterone and that he was in “reluctant agreement” with Jayden’s current treatment plan.

Several months later, Jayden expressed a desire to start the referral process for “top” surgery with a plan to pursue surgery at age 16. He requested the psychologist provide a referral letter so that he could schedule a consultation with a plastic surgeon. Jayden’s father stated that he would not prevent Jayden from pursuing this plan; however, he was also not willing to provide any financial assistance, as he felt Jayden was too young to make the decision to pursue surgery. Jayden also had not yet discussed his surgical plans with his mother, who was also his legal guardian and the policyholder of Jayden’s health insurance. While the subject of health insurance is indeed an important caveat, it is beyond the scope of this article to pursue here.

Ethical Considerations

According to the WPATH SOC v7, eligibility criteria for chest surgery include persistent, well-documented gender dysphoria; capacity to make a fully informed decision and to give consent for treatment; and, if significant medical or mental health concerns are present, they must be reasonably controlled (Coleman et al., 2012; Table 1). The guidelines also emphasize that refusing timely medical interventions for adolescents is not a neutral option and might prolong gender dysphoria and contribute to gender minority stress experiences, although this statement is made in direct reference to the potential consequences of withholding pubertal suppression and GAH therapy, rather than surgical intervention per se.

The psychologist determined that Jayden appeared to meet the above-mentioned eligibility criteria for surgical intervention. However, given Jayden’s legal status as a minor and financial dependence on his parents, the irreversible nature of the intervention, and parental skepticism and ambivalence toward previous medical interventions, the psychologist communicated to Jayden that the level of parental support and its potential impact on Jayden’s surgical decision-making and postoperative well-being needed to be explored further prior to providing the referral.

Discussion

These cases both involve transgender minors seeking gender-affirming medical care, yet differ regarding patient age, history of gender nonconformity, and the degree of parental support of gender identity and medical interventions. Emma reported a long-standing history of gender nonconformity and presented for care prior to the onset of puberty with parents who were supportive of her gender identity and medical interventions. In contrast, Jayden reported pubertal onset of gender dysphoria and presented for care with parents who were skeptical of his gender identity and the need for medical interventions. Both cases demonstrate disparate health goals between youth and parents, albeit in opposite directions. Emma’s parents seek treatment beyond the standard of care—an accelerated timeline—whereas Jayden’s parents are resistant to that standard. Despite these differences, three ethical themes are present in both cases: pediatric decision-making, the standard of care, and the reversibility of treatment options. These themes provide a richer appreciation of the nuances of patient autonomy.

Pediatric Decision-Making

In general, parents consent to medical treatment on behalf of their minor children because capacity in children is not presumed (Campo-Engelstein & Chen, 2016). The American Academy of Pediatrics recommends children participate in medical decision-making through a process of “assent to treatment ‘to the extent of their capacity,’” and the child’s known wishes and values should inform parental proxy decision-making (Campo-Engelstein & Chen, 2016, p. 260). Child assent is especially important in situations that are more subjective and personal (i.e., deeply connected to one’s identity and values). Conditions like pneumonia, for example, can be diagnosed objectively using a physical exam, laboratory tests, pathology, and radiological imaging that confirm the presence of a pulmonary infection, and pharmaceutical treatments can be determined based on these objective findings. Gender dysphoria, in contrast, is a more subjective diagnosis based on a young person’s self-report of distress associated with the discordance between intrinsic gender identity and designated sex at birth. When “treatment decisions become increasingly subjective,” commensurate deference to the child ought to be given because the child is the best source of information to identify and clarify their wishes, values, and preferences (Campo-Engelstein & Chen, 2016, p. 260).

This means that, in Emma’s case, we should prioritize Emma’s preference for pubertal suppression over her parents’ request to proceed with hormone therapy. Emma is best situated to know if and when she is ready for hormone therapy; a decision to irreversibly alter one’s body to align with one’s gender identity is so deeply personal that Emma is the only one who can and should make this decision. As her proxy decision-makers, Emma’s parents could dismiss her wishes, but to accede to their treatment of choice would violate a near-universal principle in medicine: negative autonomy rights. These are the rights to noninterference and refusal of care, which court cases have “established as nearly inviolable” (Orr, 2013, p. 245). Patients with capacity are permitted to decline care even if it is lifesaving. Although Emma probably lacks capacity given her age, patient preferences are morally valuable and should still guide decision-making (Navin & Wasserman, 2019). We should be cautious about overriding patients’ preferences regarding bodily integrity, particularly when subjective preferences and values figure prominently.

At age 15, Jayden may have the capacity to make decisions regarding his care but lacks parental support to access care as a minor. If we approach the age of majority as a somewhat arbitrary cutoff, we can appreciate a nuanced view of decisional capacity in minors in which capacity is gained gradually. The literature on child and adolescent decision-making capacity is compelling; from a neurodevelopmental vantage, children as young as 12 can demonstrate the capacity to make medical decisions in a context-dependent manner with adequate support (Grootens-Wiegers et al., 2017). In another study, an overwhelming majority of adolescents were assessed as competent to consent to pubertal suppression (Vrouenraets et al., 2021). Jayden could be emotionally and cognitively mature enough for decisional capacity, and it may seem unfair to deny him decision-making solely because of his age, especially when someone only a few years older would be automatically assumed to have capacity.

Furthermore, there are some situations in which minors can make medical decisions without parental consent, including mental health, substance use disorder, reproductive health, and sexual health (AMA Council on Ethical and Judicial Affairs, 2014). Although laws vary by state, one may contend that gender-affirming treatment can reasonably be subsumed under existing exemptions for reproductive and sexual health. One may also argue that gender-affirming medications should fall under the purview of the state, as do other treatments for which there is a compelling reason, such as public health, to protect and provide them (Priest, 2019).

Jayden’s situation is also complicated by the fact that his parents are divorced and are not equally informed of Jayden’s surgical plans. Ideally, all involved parties—Jayden, his parents, and his healthcare team—should agree on a way forward. If this is not possible, however, then alternative legal recourse may need to be pursued. In some states, only one parent’s consent is required to pursue treatment, even if the other parent objects.

Standard of Care

Standard-of-care guidelines ensure that treatment follows best practices and adheres to ethical norms. Courts have ruled that the standard of care refers to “what a minimally competent physician in the same field would do in the same situation, with the same resources” and that violating the standard of care is a “breach of duty,” an aspect of medical malpractice (Moffett & Moore, 2011, pp. 109, 112). Ideally, parents would choose standard medical care for their children, but this is not always the case for a variety of reasons, including values, medical distrust, and financial limitations. In such cases, clinicians should ensure that parents and children understand the consequences of declining or deviating from standard treatment.

Despite the fact that Jayden meets the WPATH SOC v7 criteria for gender-affirming surgery (Table 1), his parents do not fully support this intervention. Emma’s parents express apprehension about the standard of care (i.e., staged progression from puberty-suppressing medication to estrogen therapy) due to concerns about the potential effects of the intervention on neurocognitive development. Emma’s parents propose a treatment timeline that accelerates the progression at an earlier developmental stage than recommended, and following this proposed treatment timeline may be classified as medically inappropriate.

While there may be instances when it is appropriate to deviate from the standard of care, such deviations should not be taken lightly since the standard of care serves as a safeguard for all involved parties. Positive autonomy rights—the rights to something—are limited in medicine. In other words, the argument “that a patient’s demand obligates a physician to provide a treatment” is uncompelling due to physicians’ right to conscience (Orr, 2013, p. 245). Thus, physicians are not required to honor the requests of patients (or their surrogates) to provide care that is considered unnecessary, unreasonable, harmful, or beyond an acceptable standard of care. Since healthcare professionals are not legally or ethically obligated to provide treatment deemed medically inappropriate, Emma’s healthcare team does not have to acquiesce to her parents’ request for accelerated hormone therapy.

Reversibility of Treatment Options

One of the challenges with providing gender-affirming care for minors is that certain decisions, including care options with permanent consequences, sometimes need to be decided before minors reach the age of majority. Whereas pubertal suppression suspends endogenous pubertal changes in the body, GAHs and surgeries do lead to changes, some of which are irreversible. The degree of reversibility of these treatments is important with respect to patient autonomy. Reversible treatments such as pubertal suppression preserve the future autonomy of minor patients until they are mature enough to make medical decisions involving some degree of irreversibility. By maintaining an “open future” in which no options are permanently closed to the child, reversible treatments uphold children’s current and future autonomy (Feinberg, 1980); children receive the medical care they want and need now (e.g., puberty blockers) while being able to make fully informed decisions when they are more emotionally and cognitively mature. In short, the reversibility of pubertal suppression protects the future autonomy of pediatric patients.

However, we do not claim that irreversible treatments are less ethically permissible—for instance, removing a malignant tumor from a child’s body is ethical even though it is a permanent change. GAHs and chest surgery may indeed have irreversible effects, but both are offered and appropriate for minors who meet relevant criteria. We instead argue that the degree of treatment reversibility should play a role in our ethical deliberation. Partially reversible or irreversible treatments should be approached more cautiously because such decisions made on behalf of the minor child could be unwanted in the future. Careful consideration of hormone therapy is warranted to maximize minors’ current and future rights and options. Since children’s capacity increases with age, older children may be better equipped to make informed decisions regarding such treatments. However, continuing to delay hormone treatment due to concerns about a minor’s decision-making capacity can also lead to psychosocial harm given that the minor will be one of the only in their peer group who has not begun puberty.

Conclusion

The ethical dilemma of who should be making medical decisions for pediatric patients—the patient themselves, the patient’s parents or guardians, healthcare professionals, or someone else—pervades all pediatric healthcare. It can sometimes be delicate to balance the developing autonomy of minors with decisions that are in their best interest. This can be especially difficult in rapidly evolving areas of medicine like transgender healthcare. For instance, whereas most adolescents are not concerned about the lack of data on the long-term effects of pubertal suppression (Vrouenraets et al., 2016), their parents and healthcare providers may be more hesitant. As this field continues to grow, we are sure to see other ethical dilemmas emerge.

In this article, we have touched upon some common ethical quandaries that healthcare professionals treating transgender minors currently face. Specifically, we compared two de-identified cases to illuminate how tensions between pediatric autonomy and paternal beneficence can manifest and unfold in different ways. The value of a case-based approach to ethical analysis is that it allows us to acknowledge contextual features and highlight nuances between cases. Our discussion builds upon the growing academic literature addressing ethical considerations in pediatric transgender care, such as what professionals should do if they doubt that minors understand treatment options and under what circumstances are psychiatric disorders so serious that gender-affirming care should not be initiated (Vrouenraets et al., 2020). Given the importance of involving youth in decision-making (Grootens-Wiegers et al., 2017), providers should consider how they create therapeutic space for discussions about medical decision-making when there are disagreements between parents and youth. Healthcare professionals should continue to share the ethical dilemmas they face in providing pediatric transgender care so that we can work collectively to find ways to address them and improve overall outcomes.

Criteria for pubertal suppression	Criteria for hormone therapy	Criteria for surgery
Eligibility: Recommend onset of puberty to at least Tanner stage II in order to make an informed decision about pubertal delay	Eligibility: Recommend initiating cross-sex hormones at approximately age 16, and recognize that initiating prior to 16 may have psychosocial benefits	Eligibility: May be done earlier than age of majority, preferably after ample time socially adjusting to and living in desired gender role
Gender dysphoria which emerged or worsened with the onset of puberty
Long-lasting and intense pattern of gender nonconformity or gender dysphoria	Persistent, well-documented gender dysphoria	Persistent, well-documented gender dysphoria
Coexisting psychological, medical, or social problems that could interfere with treatment (i.e., compromise treatment adherence) have been addressed and adolescent’s psychosocial functioning is stable enough to start treatment	Coexisting medical or mental health concerns, if present, are reasonably well-controlled and individual is stable enough to start treatment	Coexisting medical or mental health concerns, if present, are reasonably well-controlled and individual is stable enough to start treatment
Adolescent provides informed assent	Individual has capacity to make an informed decision and consent to treatment	Individual has capacity to make an informed decision and consent to treatment
Legal guardian consents to treatment and is involved in supporting adolescent throughout treatment	If not age of majority, legal guardian consents to treatment and is involved in supporting patient throughout treatment	If not age of majority, legal guardian consents to treatment and is involved in supporting patient throughout treatment

Footnotes

1

Although the WPATH Standards of Care, Version 8, were published in the fall of 2022, this article refers to the Standards of Care, Version 7; the seventh version was the most recent guideline available at the time these cases occurred.

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Ethics of Pediatric Gender-Affirming Care: A Case Study Comparison

Abstract

Objective:

Method:

Results:

Conclusions:

Implications for Impact Statement

Case Illustration: Emma

Clinical Communication

Ethical Considerations

Summary of WPATH SOC v7 Criteria for Initiating Gender-Affirming Medical Interventions

Case Illustration: Jayden

Clinical Communication

Ethical Considerations

Discussion

Pediatric Decision-Making

Standard of Care

Reversibility of Treatment Options

Conclusion

Footnotes

1

References