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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
What Could Justify Physician Refusal of Puberty Suppressive Therapy? D. Micah Hester
a
a
University of Arkansas for Medical Sciences and Arkansas Children's Hospital Published online: 14 Jan 2014.
Click for updates To cite this article: D. Micah Hester (2014) What Could Justify Physician Refusal of Puberty Suppressive Therapy?, The American Journal of Bioethics, 14:1, 46-48, DOI: 10.1080/15265161.2014.862409 To link to this article: http://dx.doi.org/10.1080/15265161.2014.862409
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics
Meyer-Bahlburg, H. F. 2010. From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior 39(2): 461–476. North Coast Women’s Care Med. Group, Inc. v. San Diego County Super. 2008. Ct., 189 P.3d 959 (Cal. 2008). O’Donovan, O. 1983. Transsexualism and Christian marriage. Journal of Religious Ethics 11(1): 135–162.
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Wicclair, M. R. 2000. Conscientious objection in medicine. Bioethics 14(3): 205–227.
Zucker, K. J. 2008. On the “natural history” of gender identity disorder in children. Journal of the American Academy of Child and Adolescent Psychiatry 47(12): 1361–1363. Zucker, K. J. 2010. The DSM diagnostic criteria for gender identity disorder in children. Archives of Sexual Behavior 39(2): 477–498. Zucker, K. J., P. T. Cohen-Kettenis, J. Drescher, H. F. MeyerBahlburg, F. Pfafflin, and W. M. Womack. 2013. Memo outlining evidence for change for gender identity disorder in the DSM-5. Archives of Sexual Behavior 42(5): 901–914.
What Could Justify Physician Refusal of Puberty Suppressive Therapy? D. Micah Hester, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital In his commentary on Andrea’s case, Alex Kon (2014) enumerates well the professional position papers that concern transgendered individuals. Kon’s survey is quite useful and germane to the case, and yet, I believe his analysis misses an important element of the case that I attempt here to address—namely, the ethical status of the physician’s refusal to provide hormone treatments to retard the onset of puberty. I briefly lay out why the physician’s response is ethically unsupportable. Moral support for physician refusals of relevant medical treatments may be ethically justified in relatively few ways: a. b. c. d. e. f. g. h.
The medical treatment is unlikely to achieve or help achieve the goals of care. The physician is not knowledgeable enough to provide the relevant treatment. Providing the treatment would cause unacceptable risk. The treatment violates medially acceptable practice. Providing the treatment would violate the professional moral integrity of the physician. Providing the treatment would violate the personal moral integrity of the physician. The outcomes of the treatment would violate the essential nature or inherent worth of the patient. The treatment is morally repugnant.
A prima facie glance at this list quickly eliminates a–b as morally problematic in Andrea’s case. Given her desires and her parents’ support, the “pubertal suspension” treatment seems well-suited to providing Andrea and her family more time to develop experientially, cognitively, and emotionally
in order to make a long-term decision on her behalf. Further, as an endocrinologist, the physician should be highly experienced with the drugs to be used. The physician’s claim that the medications’ risks are so troubling as to warrant his refusal to participate in the process is where we must address directly the ethical warrant of refusals. While it is certainly inappropriate to ignore the risk profile of any drug, like all risks in medicine, the specific meaning of a pharmacological risk cannot be divorced from the specific context of a patient’s near-term and long-term interests, which in this case include the potential harms—physical, psychological, and social—of not providing the desired therapy. We are not told which medications are being considered, but puberty-suppressing drugs tend to have similar side-effect profiles, including discomfort (from hot flashes, headaches, and muscle pain) and mood alterations (such as depression). Also, some worry that treating a phenotypic male child as a female creates negative long-term psychological consequences. Evaluating these risks shows that the medication side effects are typically quite minimal and can be mitigated and controlled if well monitored (Hewitt et al. 2012), and existing studies do not support the negative speculations about psychological outcomes in relation to puberty suppression; in fact, negative psychological outcomes seem to relate to both the experience of and inattention to gender dysphoria in children (de Vries et al. 2011; Spack et al. 2012). Not providing the treatment means that Andrea will, in fact, go through puberty at this time, a developmental process with attendant risks of negatively impacting her psychological reaction to her bodily changes and the social responses to them (de Vries et al. 2011). With more time for Andrea’s cognitive and
Address correspondence to D. Micah Hester, University of Arkansas for Medical Sciences, Division of Medical Humanities, 4301 W. Markham St., #646, Little Rock, AR 72205, USA. E-mail: [email protected]
46 ajob
January, Volume 14, Number 1, 2014
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Pubertal Suppression
emotional development before those changes occur, better conditions for decision making are likely to emerge. Given that many children with gender dysphoria at a young age will no longer be gender dysphoric later in life (Wallien, Swaab, and Cohen-Kettenis 2008; Steensma et al. 2013), surely, providing more time to work through these issues and experiences is an outcome worthy of pursuit. Given the larger context of risk and reward that may follow from providing puberty suppressing medications, therefore, the physician’s attempt to use medication risks to ground ethically his refusal is without sufficient merit. Now, in one respect we could stop here. That is, once we have addressed and dispensed with the physician’s claim that the medications are “risky,” this would seemingly be all that is needed to undermine the moral authority of the physician’s claim. However, we would be remiss if we stopped short of a more complete analysis of moral warrant. For example, what if the physician accepted our argument regarding the force of “risk” in this case but then noted that he should still be entitled to refuse because what is requested falls outside acceptable medical practice? It is here that Kon’s commentary is most poignant (and, as such, I will let it speak for itself), for it is clear in his survey of professional positions that the physician would be wrong to rely on the scope of acceptable medical practice to support a morally justified refusal. Of course, the physician may be well aware of the professional papers and guidelines in relation to gender dysphoria but may still have a concern that providing the treatments violates some aspect of moral integrity—whether construed as “professional” or “personal.” According to Mark Wicclair, moral integrity relies, in part, on a set of “core moral beliefs” (2011, 25) and a predisposition to act on those beliefs. As such, we can ask what moral beliefs might reasonably be under siege in Andrea’s case. Having run through several practice-based values already (valuing goals-achievement, valuing content expertise—neither of which held up to scrutiny), we also noted the importance of avoiding undue harm. Again, the claim that puberty suppression is, in fact, harmful to Andrea would seem to rely on one of two things: empirical evidence or reasoned speculation. With no scientific research on how gender dysphoric children do when undergoing and living with the ramifications of puberty suppression, any claim that the process is harmful is left to rely on speculation. However, that speculation must be justified through some reasonable grounding, and the only ones that seem relevant are “essentialist” claims about the nature of medicine, human beings, or gender. This essentialism is well characterized by bioethicist Anthony Ozimic, commenting on the case of a UK child undergoing puberty suppression for gender dysphoria. Ozimic (quoted in White 2011) claims: This procedure would seem to be contrary to a basic principle of medical ethics, namely that the purpose of medicine is the treatment of illness . . . . In addition, the intentional blocking of puberty by chemical means is analogous to sterilisation, which
January, Volume 14, Number 1, 2014
is an unethical mutilation of the human body. This procedure, and any attendant facilitation of sex change operations, would seem to be contrary to the individual’s innate possession of either the male or the female sex.
In other words, according to Ozimic, the “essence” of medicine is the treatment of illness; the “essence” of humans is to go through puberty on the body’s own schedule; and the “essence” of individuals is to be one of two sexes (male or female) innately. Aside from such essentialist claims implying inviolability of categories and infallible knowledge about those categories, each specific claim can be readily called into question. Should comfort of dying patients not be provided by physicians if illness cannot be alleviated? Are physicians who provide medications for idiopathic short stature beyond the scope of practice? Is gender dysphoria not an illness? Should we not provide these same drugs for precocious puberty in the 6-year-old? Are persons born with Kleinfelter syndrome (XXY) not “real” individuals or persons? In this brief commentary I cannot address all the issues raised by these questions, but they suffice to indicate that the essentialist position has significant work to do in order to make its case in support of the physician’s refusal. Now, while we cannot entirely dispense with concerns regarding moral integrity as a justification for the physician’s refusal, the essentialism necessary to ground such a justification does have its own dubious grounding. And yet, there remains one more possible justification to address: moral repugnance—the “yuck” factor. That is, our physician could claim, a` la Leon Kass, that his aversion to puberty suppression in Andrea’s case arises from a repugnance to the idea of boys acting like girls, and that this “repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it” (Kass 1997, 17). An advocate of the moral authority of repugnance, Kass’s claim amounts either to a claim regarding innate moral character of repugnance or an evolutionarily derived role for disgust. In fact, though, whichever it is, both fail to meet with the science of repugnance. As Daniel Kelly has argued, the evolutionary psychological research of the last 20 years shows that “a large part of what disgust responds to has nothing to do with morality but is a reaction to cues likely to mark poisons and parasites” (Kelly 2013, 147). He continues, “it is unconvincing that feelings of disgust suffice to justify an ethical evaluation” (147). Moreover, consider one’s own experience: We know that we are repulsed, for example, by the taste of some foods. But taste has no moral force whatsoever, and thus, repulsion based on taste would not either. Furthermore, different people and communities are repulsed by (and attracted to) very different things. Who, then, would be said to have “deep wisdom” into a practice or situation when one person is attracted to, and another repulsed by, the very same situations or practice? Having now run through eight possible justifications for the physician’s refusal of Andrea’s treatment request, it would seem, then, that the physician’s refusal lacks sufficient moral warrant, and yet, it is clear that we cannot
ajob 47
The American Journal of Bioethics
compel him to provide the treatment. While there are good reasons to protect a physician’s own professional autonomy, in a case like Andrea’s it is not only lamentable, it is ethically unacceptable. REFERENCES de Vries, A. L. D., T. A. H. Doreleijers, T. D. Steensma, et al. 2011. Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry 52(11): 1195–1202. Hewitt, J. K., C. Paul, P. Kasiannan, et al. 2012. Hormone treatment of gender identity disorder in a cohort of children and adolescents. Medical Journal of Australia 196(9): 578–581.
Steensma, T. D., J. K. McGuire, B. P. C. Kreukels, et al. 2013. Factors associated with desistence and persistence of childhood gender dysphoria: A qualitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6): 582– 590. Wallien, M. S. C., H. Swaab, and P. T. Cohen-Kettenis. 2008. Psychiatric comorbidity among children with gender identity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40(10): 1307–1423.
Kelly, D. 2013. Yuck! The nature and moral significance of disgust. Cambridge, MA: MIT Press.
White, H. 2011. Puberty-preventing drugs to be given to 12 year-olds in UK gender identity study. LifeSiteNews.com. Available at: http://www.lifesitenews.com/news/puberty-preventingdrugs-to-be-given-to-12-year-olds-in-uk-gender-identity (accessed August 16, 2013).
Kon, A. 2014. Transgender children and adults. American Journal of Bioethics 14(1): 48–50.
Wicclair, M. R. 2011. Conscientious objection in health care. New York, NY: Cambridge University Press.
Kass, L. 1997. The wisdom of repugnance. New Republic 216(22): 17–26.
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Spack, N. P., L. Edwards-Leepr, H. A. Feldman, et al. 2012. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3): 418–425.
Transgender Children and Adolescents Alexander A. Kon, University of California San Diego and Naval Medical Center San Diego Being transsexual, transgender, or gender nonconforming is a matter of diversity, not pathology. (World Professional Association for Transgender Health)
In 2010, the World Professional Association for Transgender Health (WPATH) urged de-psychopathologization of gender noncomformity (World Professional Association for Transgender Health 2010). Subsequently, the American Psychiatric Association (APA) removed the term “Gender Identity Disorder” from the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, the DSM-5 uses the term “Gender Dysphoria” (GD) to characterize the distress often felt by individuals whose physical appearance does not match their gender identity. According to the APA, this shift in terminology was introduced to (a) clarify that individuals with GD are not disordered, (b) use language that is consistent with international terminology, and (c) provide a diagnosis that facilitates access to appropriate treatment and insurance coverage (American Psychiatric Association 2013). The WPATH has published guidelines for the care of adults, adolescents, and children with GD that supports early intervention in the case of children and adolescents.(Coleman et al. 2011). Additionally, the American Medical Association (AMA) states that mental health care,
hormone therapy, and sex reassignment surgery are a “medical necessity” for many people with GD (American Medical Association 2008). In the care of younger children, it is important to note that many prepubertal children with GD may not require gender reassignment. Although limited studies have been performed, data suggest that GD persists into adulthood for a minority of prepubertal phenotypic boys who selfidentify as girls (6–23%), and that these children are actually more likely to identify as homosexual in adulthood than as transgender (Coleman et al. 2011). In contrast, however, one publication noted that children whose GD persisted into early puberty and who received puberty suppression hormone therapy generally had persistent GD and required gender reassignment hormone therapy and surgery when older (de Vries et al. 2011). The WPATH guidelines have been supported by the American Academy of Pediatrics (AAP) (American Academy of Pediatrics 2013) and recommend hormone therapy (with gonadotrophin-releasing hormone [GnRH] analogues) to suppress puberty in adolescents with GD in the early Tanner stages (generally Tanner stage 2 to 4) who meet specific criteria (Coleman et al. 2011). The recommendation to withhold such therapy until Tanner stage 2 is based on data showing that many children with GD may cease their
This article is not subject to U.S. copyright law. Address correspondence to Alexander A. Kon, MD, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Building 1, 2nd Floor, Pediatric Intensive Care Unit (PICU), San Diego, CA 92134, USA. E-mail: [email protected]
48 ajob
January, Volume 14, Number 1, 2014
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
What Could Justify Physician Refusal of Puberty Suppressive Therapy? D. Micah Hester
a
a
University of Arkansas for Medical Sciences and Arkansas Children's Hospital Published online: 14 Jan 2014.
Click for updates To cite this article: D. Micah Hester (2014) What Could Justify Physician Refusal of Puberty Suppressive Therapy?, The American Journal of Bioethics, 14:1, 46-48, DOI: 10.1080/15265161.2014.862409 To link to this article: http://dx.doi.org/10.1080/15265161.2014.862409
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics
Meyer-Bahlburg, H. F. 2010. From mental disorder to iatrogenic hypogonadism: Dilemmas in conceptualizing gender identity variants as psychiatric conditions. Archives of Sexual Behavior 39(2): 461–476. North Coast Women’s Care Med. Group, Inc. v. San Diego County Super. 2008. Ct., 189 P.3d 959 (Cal. 2008). O’Donovan, O. 1983. Transsexualism and Christian marriage. Journal of Religious Ethics 11(1): 135–162.
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Wicclair, M. R. 2000. Conscientious objection in medicine. Bioethics 14(3): 205–227.
Zucker, K. J. 2008. On the “natural history” of gender identity disorder in children. Journal of the American Academy of Child and Adolescent Psychiatry 47(12): 1361–1363. Zucker, K. J. 2010. The DSM diagnostic criteria for gender identity disorder in children. Archives of Sexual Behavior 39(2): 477–498. Zucker, K. J., P. T. Cohen-Kettenis, J. Drescher, H. F. MeyerBahlburg, F. Pfafflin, and W. M. Womack. 2013. Memo outlining evidence for change for gender identity disorder in the DSM-5. Archives of Sexual Behavior 42(5): 901–914.
What Could Justify Physician Refusal of Puberty Suppressive Therapy? D. Micah Hester, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital In his commentary on Andrea’s case, Alex Kon (2014) enumerates well the professional position papers that concern transgendered individuals. Kon’s survey is quite useful and germane to the case, and yet, I believe his analysis misses an important element of the case that I attempt here to address—namely, the ethical status of the physician’s refusal to provide hormone treatments to retard the onset of puberty. I briefly lay out why the physician’s response is ethically unsupportable. Moral support for physician refusals of relevant medical treatments may be ethically justified in relatively few ways: a. b. c. d. e. f. g. h.
The medical treatment is unlikely to achieve or help achieve the goals of care. The physician is not knowledgeable enough to provide the relevant treatment. Providing the treatment would cause unacceptable risk. The treatment violates medially acceptable practice. Providing the treatment would violate the professional moral integrity of the physician. Providing the treatment would violate the personal moral integrity of the physician. The outcomes of the treatment would violate the essential nature or inherent worth of the patient. The treatment is morally repugnant.
A prima facie glance at this list quickly eliminates a–b as morally problematic in Andrea’s case. Given her desires and her parents’ support, the “pubertal suspension” treatment seems well-suited to providing Andrea and her family more time to develop experientially, cognitively, and emotionally
in order to make a long-term decision on her behalf. Further, as an endocrinologist, the physician should be highly experienced with the drugs to be used. The physician’s claim that the medications’ risks are so troubling as to warrant his refusal to participate in the process is where we must address directly the ethical warrant of refusals. While it is certainly inappropriate to ignore the risk profile of any drug, like all risks in medicine, the specific meaning of a pharmacological risk cannot be divorced from the specific context of a patient’s near-term and long-term interests, which in this case include the potential harms—physical, psychological, and social—of not providing the desired therapy. We are not told which medications are being considered, but puberty-suppressing drugs tend to have similar side-effect profiles, including discomfort (from hot flashes, headaches, and muscle pain) and mood alterations (such as depression). Also, some worry that treating a phenotypic male child as a female creates negative long-term psychological consequences. Evaluating these risks shows that the medication side effects are typically quite minimal and can be mitigated and controlled if well monitored (Hewitt et al. 2012), and existing studies do not support the negative speculations about psychological outcomes in relation to puberty suppression; in fact, negative psychological outcomes seem to relate to both the experience of and inattention to gender dysphoria in children (de Vries et al. 2011; Spack et al. 2012). Not providing the treatment means that Andrea will, in fact, go through puberty at this time, a developmental process with attendant risks of negatively impacting her psychological reaction to her bodily changes and the social responses to them (de Vries et al. 2011). With more time for Andrea’s cognitive and
Address correspondence to D. Micah Hester, University of Arkansas for Medical Sciences, Division of Medical Humanities, 4301 W. Markham St., #646, Little Rock, AR 72205, USA. E-mail: [email protected]
46 ajob
January, Volume 14, Number 1, 2014
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Pubertal Suppression
emotional development before those changes occur, better conditions for decision making are likely to emerge. Given that many children with gender dysphoria at a young age will no longer be gender dysphoric later in life (Wallien, Swaab, and Cohen-Kettenis 2008; Steensma et al. 2013), surely, providing more time to work through these issues and experiences is an outcome worthy of pursuit. Given the larger context of risk and reward that may follow from providing puberty suppressing medications, therefore, the physician’s attempt to use medication risks to ground ethically his refusal is without sufficient merit. Now, in one respect we could stop here. That is, once we have addressed and dispensed with the physician’s claim that the medications are “risky,” this would seemingly be all that is needed to undermine the moral authority of the physician’s claim. However, we would be remiss if we stopped short of a more complete analysis of moral warrant. For example, what if the physician accepted our argument regarding the force of “risk” in this case but then noted that he should still be entitled to refuse because what is requested falls outside acceptable medical practice? It is here that Kon’s commentary is most poignant (and, as such, I will let it speak for itself), for it is clear in his survey of professional positions that the physician would be wrong to rely on the scope of acceptable medical practice to support a morally justified refusal. Of course, the physician may be well aware of the professional papers and guidelines in relation to gender dysphoria but may still have a concern that providing the treatments violates some aspect of moral integrity—whether construed as “professional” or “personal.” According to Mark Wicclair, moral integrity relies, in part, on a set of “core moral beliefs” (2011, 25) and a predisposition to act on those beliefs. As such, we can ask what moral beliefs might reasonably be under siege in Andrea’s case. Having run through several practice-based values already (valuing goals-achievement, valuing content expertise—neither of which held up to scrutiny), we also noted the importance of avoiding undue harm. Again, the claim that puberty suppression is, in fact, harmful to Andrea would seem to rely on one of two things: empirical evidence or reasoned speculation. With no scientific research on how gender dysphoric children do when undergoing and living with the ramifications of puberty suppression, any claim that the process is harmful is left to rely on speculation. However, that speculation must be justified through some reasonable grounding, and the only ones that seem relevant are “essentialist” claims about the nature of medicine, human beings, or gender. This essentialism is well characterized by bioethicist Anthony Ozimic, commenting on the case of a UK child undergoing puberty suppression for gender dysphoria. Ozimic (quoted in White 2011) claims: This procedure would seem to be contrary to a basic principle of medical ethics, namely that the purpose of medicine is the treatment of illness . . . . In addition, the intentional blocking of puberty by chemical means is analogous to sterilisation, which
January, Volume 14, Number 1, 2014
is an unethical mutilation of the human body. This procedure, and any attendant facilitation of sex change operations, would seem to be contrary to the individual’s innate possession of either the male or the female sex.
In other words, according to Ozimic, the “essence” of medicine is the treatment of illness; the “essence” of humans is to go through puberty on the body’s own schedule; and the “essence” of individuals is to be one of two sexes (male or female) innately. Aside from such essentialist claims implying inviolability of categories and infallible knowledge about those categories, each specific claim can be readily called into question. Should comfort of dying patients not be provided by physicians if illness cannot be alleviated? Are physicians who provide medications for idiopathic short stature beyond the scope of practice? Is gender dysphoria not an illness? Should we not provide these same drugs for precocious puberty in the 6-year-old? Are persons born with Kleinfelter syndrome (XXY) not “real” individuals or persons? In this brief commentary I cannot address all the issues raised by these questions, but they suffice to indicate that the essentialist position has significant work to do in order to make its case in support of the physician’s refusal. Now, while we cannot entirely dispense with concerns regarding moral integrity as a justification for the physician’s refusal, the essentialism necessary to ground such a justification does have its own dubious grounding. And yet, there remains one more possible justification to address: moral repugnance—the “yuck” factor. That is, our physician could claim, a` la Leon Kass, that his aversion to puberty suppression in Andrea’s case arises from a repugnance to the idea of boys acting like girls, and that this “repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it” (Kass 1997, 17). An advocate of the moral authority of repugnance, Kass’s claim amounts either to a claim regarding innate moral character of repugnance or an evolutionarily derived role for disgust. In fact, though, whichever it is, both fail to meet with the science of repugnance. As Daniel Kelly has argued, the evolutionary psychological research of the last 20 years shows that “a large part of what disgust responds to has nothing to do with morality but is a reaction to cues likely to mark poisons and parasites” (Kelly 2013, 147). He continues, “it is unconvincing that feelings of disgust suffice to justify an ethical evaluation” (147). Moreover, consider one’s own experience: We know that we are repulsed, for example, by the taste of some foods. But taste has no moral force whatsoever, and thus, repulsion based on taste would not either. Furthermore, different people and communities are repulsed by (and attracted to) very different things. Who, then, would be said to have “deep wisdom” into a practice or situation when one person is attracted to, and another repulsed by, the very same situations or practice? Having now run through eight possible justifications for the physician’s refusal of Andrea’s treatment request, it would seem, then, that the physician’s refusal lacks sufficient moral warrant, and yet, it is clear that we cannot
ajob 47
The American Journal of Bioethics
compel him to provide the treatment. While there are good reasons to protect a physician’s own professional autonomy, in a case like Andrea’s it is not only lamentable, it is ethically unacceptable. REFERENCES de Vries, A. L. D., T. A. H. Doreleijers, T. D. Steensma, et al. 2011. Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry 52(11): 1195–1202. Hewitt, J. K., C. Paul, P. Kasiannan, et al. 2012. Hormone treatment of gender identity disorder in a cohort of children and adolescents. Medical Journal of Australia 196(9): 578–581.
Steensma, T. D., J. K. McGuire, B. P. C. Kreukels, et al. 2013. Factors associated with desistence and persistence of childhood gender dysphoria: A qualitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52(6): 582– 590. Wallien, M. S. C., H. Swaab, and P. T. Cohen-Kettenis. 2008. Psychiatric comorbidity among children with gender identity disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 40(10): 1307–1423.
Kelly, D. 2013. Yuck! The nature and moral significance of disgust. Cambridge, MA: MIT Press.
White, H. 2011. Puberty-preventing drugs to be given to 12 year-olds in UK gender identity study. LifeSiteNews.com. Available at: http://www.lifesitenews.com/news/puberty-preventingdrugs-to-be-given-to-12-year-olds-in-uk-gender-identity (accessed August 16, 2013).
Kon, A. 2014. Transgender children and adults. American Journal of Bioethics 14(1): 48–50.
Wicclair, M. R. 2011. Conscientious objection in health care. New York, NY: Cambridge University Press.
Kass, L. 1997. The wisdom of repugnance. New Republic 216(22): 17–26.
Downloaded by [University of Iowa Libraries] at 19:23 13 March 2015
Spack, N. P., L. Edwards-Leepr, H. A. Feldman, et al. 2012. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics, 129(3): 418–425.
Transgender Children and Adolescents Alexander A. Kon, University of California San Diego and Naval Medical Center San Diego Being transsexual, transgender, or gender nonconforming is a matter of diversity, not pathology. (World Professional Association for Transgender Health)
In 2010, the World Professional Association for Transgender Health (WPATH) urged de-psychopathologization of gender noncomformity (World Professional Association for Transgender Health 2010). Subsequently, the American Psychiatric Association (APA) removed the term “Gender Identity Disorder” from the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Instead, the DSM-5 uses the term “Gender Dysphoria” (GD) to characterize the distress often felt by individuals whose physical appearance does not match their gender identity. According to the APA, this shift in terminology was introduced to (a) clarify that individuals with GD are not disordered, (b) use language that is consistent with international terminology, and (c) provide a diagnosis that facilitates access to appropriate treatment and insurance coverage (American Psychiatric Association 2013). The WPATH has published guidelines for the care of adults, adolescents, and children with GD that supports early intervention in the case of children and adolescents.(Coleman et al. 2011). Additionally, the American Medical Association (AMA) states that mental health care,
hormone therapy, and sex reassignment surgery are a “medical necessity” for many people with GD (American Medical Association 2008). In the care of younger children, it is important to note that many prepubertal children with GD may not require gender reassignment. Although limited studies have been performed, data suggest that GD persists into adulthood for a minority of prepubertal phenotypic boys who selfidentify as girls (6–23%), and that these children are actually more likely to identify as homosexual in adulthood than as transgender (Coleman et al. 2011). In contrast, however, one publication noted that children whose GD persisted into early puberty and who received puberty suppression hormone therapy generally had persistent GD and required gender reassignment hormone therapy and surgery when older (de Vries et al. 2011). The WPATH guidelines have been supported by the American Academy of Pediatrics (AAP) (American Academy of Pediatrics 2013) and recommend hormone therapy (with gonadotrophin-releasing hormone [GnRH] analogues) to suppress puberty in adolescents with GD in the early Tanner stages (generally Tanner stage 2 to 4) who meet specific criteria (Coleman et al. 2011). The recommendation to withhold such therapy until Tanner stage 2 is based on data showing that many children with GD may cease their
This article is not subject to U.S. copyright law. Address correspondence to Alexander A. Kon, MD, Naval Medical Center San Diego, 34800 Bob Wilson Drive, Building 1, 2nd Floor, Pediatric Intensive Care Unit (PICU), San Diego, CA 92134, USA. E-mail: [email protected]
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January, Volume 14, Number 1, 2014
