Brazilians ask: Should children be allowed to make life-changing 'gender transition' decisions?

by Arsenio Wall

The decision to undergo “gender transition” can be a life-altering choice. In the past, “gender transition” surgeries were done on adults, after a multi-disciplinary team of doctors, psychologists, and social workers had evaluated the individual for several years. However, some clinics now allow children to make the decision to undergo “gender transition” without necessarily first properly assessing their psychological maturity and comorbidities. This raises questions about whether this decision should be taken away from parents and left in the hands of children. In this article, we will explore the ethical implications of allowing children to make such a life-altering decision without thorough assessment. We will discuss potential risks associated with “gender transition” surgery for children and explore the views of leading scientists and doctors on the subject. Finally, we will explore ways in which people can act and demand a thorough evaluation and debate on the human rights implications of this issue.

It was reported that the Hospital das Clínicas of the University of São Paulo in the city of São Paulo in Brazil is treating 280 of young people for gender dysphoria[1]. Among them, 100 are children from 4 to 12 years old; while 180 are adolescents from 13 to 17 years old that are undergoing treatments whose stages involve blocking puberty, cross-hormone treatment and, in some cases, even sexual reassignment surgery[2]. Such practices are in line with a current prevailing ideological inclination, following a controversial international trend. But, before jumping into this band wagon, there was a time in such medical facilities, that “gender transition” surgery was done on adults, after following them for 4 years or more, with a multidisciplinary team including doctors, psychologists, social workers. There were home visits, and the family was involved in the process whenever possible. Have values and professionalism gone so far out of whack that they are now doing sex “transition” even on 4 years-old children and teenagers? If they are naïve and immature enough to answer for crimes, why are they mature enough to decide what sex they want to have in a definitive way to the point of undergoing a “transition” procedure?

Wouldn't it be crucial by those involved in this service, paid by people’s taxes, to consider that there are papers such as the one by Cecilia Dhejne[3] from the Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institute, Stockholm, Sweden that states that: “people with transsexualism, after sex reassignment, have considerably higher risks of mortality, suicidal behavior and psychiatric morbidity than the general population. These facts suggest [at least] that sex reassignment, while alleviating gender dysphoria, may not be sufficient as a treatment for transsexualism, and should inspire better psychiatric and somatic care after sex reassignment for this group of patients.”

In essence, that paper raises important questions about the ethical implications of performing “gender transition” surgeries on children and teenagers. The author expresses concern about the potential risks associated with such surgeries. The authors concluded that these facts suggest that sex reassignment, while alleviating gender dysphoria, may not be sufficient as a treatment for transsexuals, and should at least lead to better psychiatric and somatic care after sex reassignment for this group of patients. Nevertheless, this study looked at adult subjects that still showed severe outcomes and the author's argument is supported by good research and is presented in a thoughtful and reasoned manner.  Moreover, a great part of the literature, mainly indifferent to the issue of premature decision while looking at younger subjects, add to the importance of children and adolescents being offered mental health care, by comparing the mental health of transgender adolescents who had received gender-affirming medical care to those who had not. Mitigation literature of this kind, for example, Olson and Durwood (2020)[4] and Olson et al. (2016)[5] studies claim that adolescents who received gender-affirming care had significantly lower rates of psychiatric morbidity than those who had not.

What about serious preliminary evaluation and regard for the importance of children’s limitations in being left with the responsibility of such a highly likely age-inadequate decision? There is a great deal of research that suggests that children and adolescents may not be mature enough to make such a decision. For example, a study by O'Connor et al. (2019)[6] looked at the psychological adjustment of transgender/gender diverse children and adolescents and found that, while they had generally good psychological adjustment overall, they also had lower levels of psychological functioning compared to their cisgender peers.  This suggests that more research needs to be done to assess the psychological maturity of transgender/gender diverse children and adolescents before allowing them to make such a life-altering decision.

Moreover, there are several scientists and doctors conducting vocal and well-informed criticism on taking away from parents the decision making on these issues. Prominent figures include Dr. Kenneth Zucker, a psychologist and gender specialist based in Canada, and Dr. Paul McHugh, a former psychiatrist-in-chief at Johns Hopkins Hospital. Both have expressed concerns about allowing children to make such a decision without first assessing their psychological maturity. Moreover, Dr. Zucker has argued that gender dysphoria is a “developmental issue” that requires a “developmentally informed approach” and has expressed concern that a “one-size-fits-all” approach to “gender transition” may not be appropriate for all children. He has made his views public in numerous articles, including this one from the National Post[7]. Likewise, Dr. McHugh has expressed similar concerns, arguing that sex reassignment surgery should be avoided in adolescents until they are mature enough to make such a decision. He has made his views public in numerous articles, including in the Wall Street Journal[8].

Crucially, the issue of allowing children making such a life-altering decision, without first assessing their psychological maturity, could also be understood as a human rights violation. According to the United Nations Convention on the Rights of the Child[9], children have the right to adequate medical care, as well as the right to be heard and to have their opinions considered in all matters affecting them. Allowing children to decide about “gender transition” without first assessing their psychological maturity could be seen as a violation of these rights, as the child may not have the necessary emotional and intellectual maturity to make an informed decision about such a life-altering procedure.

I would argue that the current situation violates the four principles of Beauchamp and Childress, which guide medical ethics - autonomy, non-maleficence, beneficence and justice[10] –. When we consider a child on its first teething being subjected to procedures that will alter his hormonal homeostasis, surgery that will cause irreversible alterations of his sexual organs and his body, at an age when he may not be completely aware of future implications and consequences, it is difficult not to raise an ethical objection. This is aggravated by the fact that some clinics may only discuss the potential benefits of gender affirming surgery, without taking potential risks into consideration. This should be taken as a violation of the patient's right to informed consent. The patient should be aware of all potential risks and benefits before deciding regarding gender affirming surgery and should be adequately informed about the potential risks of undergoing the procedure. In addition, it is important for clinics to assess the psychological maturity of the patient before allowing them to make such a decision, as children and adolescents may not be mature enough to make such a life-altering decision.

In the United States, “gender affirming surgery” is allowed to be decided by children in several states, including California, Oregon, New Jersey, and Washington[11]. Institutions such as the Gender Health Center in Sacramento, California[12], and the Gender Clinic at Seattle Children's Hospital in Washington[13].  In the United Kingdom, gender affirming surgery is allowed to be decided by children in several countries, including England[14], Scotland, and Wales. Institutions such as the Tavistock (see below) and Portman NHS Foundation Trust in London, England, and the Gender Identity Development Service (GIDS) in Leeds[15], England offer gender affirming surgery for children, so far.

On the other hand, there are institutions and federal governments which condemn these policies of passing along to children the burden life-altering decision. In the United States, the Trump administration expressed opposition to the practice, with the Department of Health and Human Services having issued a proposed rule that would bar doctors from performing gender-affirming surgery on minors. However, this position was understood by some as a denial of life-saving protections against discrimination[16], not as a way to prevent violence against the vulnerable.

In the United Kingdom, a recent survey[17] showed that 78% of the respondents oppose gender reassignment surgery and 68% opposed young people hormone treatment for under-16s. Likewise, the government has expressed greater care when allowing children to make such a decision without first assessing their psychological maturity and has called for more research in this area.  The changes in tack include the shutting down NHS specialist youth gender-identity clinic in England, the GIDS at the Tavistock foundation trust in London, which will be replaced by eight regional centers where gender services will mental-health services will be integrated[18], not only because GIDS had long waiting lists, but also due to concerns the affirmation of gender identity was hasty and several other considerations were ignored, including comorbidities, such as eating disorders, autism, depression, etc.

To show how the issue is controversial, several professional bodies, such as the American Academy of Pediatrics, allegedly won’t even allow a debate and “prefer a dubious Transgender Science” when “hormones and surgery are being rejected by other countries”[19] and the Royal College of Psychiatrists[20], based on published material states that: “psychiatric disorders (particularly anxiety, depression and acts of self-harm) in treatment-seeking transgender people are much more common than in cisgender people” and raised concerns allowing children to make such a decision without first assessing their psychological maturity, by affirming: “While gender-affirming medical interventions improve wellbeing and mental health in transgender and gender diverse adults, more evidence is needed on management of gender-diverse children, particularly those who are pre-pubertal”. They acknowledged and wisely took in consideration the publication by Dhejne et al., 2016 to reach this sane position.

People could organize an objection to this policy by contacting their local, state, and federal elected representatives and appointed officials and express their concerns about allowing children to make such a life-altering decision without first assessing their psychological maturity. They should also reach out to organizations such as the American Civil Liberties Union (ACLU)[21] and the Human Rights Campaign (HRC)[22] and ask for their support in raising awareness about this issue and demanding a thorough evaluation and debate on the human rights implications of allowing children to make such an untimely decision. In addition, people should contact organizations such as the American Academy of Pediatrics[23] and the Royal College of Psychiatrists[24] and ask them to provide their best expert opinions on the issue and to advocate for more research in this area.

People in Brazil could organize an objection to this policy by contacting their local, state, and federal elected officials and expressing their concerns about allowing children to make such a life-altering decision without first assessing their psychological maturity. They should also reach out to organizations such as the Brazilian Association of Transvestites and Transsexuals (ABGLT)[25] and the Association of Transvestites and Transsexuals[26] to consider their position and see if they are interested in providing support in raising awareness about this issue and demanding a thorough evaluation and debate on the human rights implications of allowing children to make such a considerable decision. In addition, people could contact organizations such as the Brazilian Society of Pediatrics[27] and the Brazilian Association of Psychoanalysis (ABP)[28] and ask them to provide their expert opinions on the issue and to advocate for more research in this area. Finally, people should use social media to share their views and engage in conversations around this relevant and pressing issue.

‍