Feb 262014

Got ethics ?Summary: Evaluation and review of proposed ethical principles for genital surgery for minor transgender women.

The WPATH Standards of Care are the international guidelines for health care for transgender people. Among other items, the standards detail requirements, risks and expected results for various therapies. The most recent version of the SOC, version 7, requires that transgender people be at least the age of majority to have genital surgery. In the United States, this is age 18. This presents a problem for trans adolescents who may want genital surgery earlier.

The paper I’m reviewing today took a look as some of the factors involved in deciding the ethics of genital surgery for young trans people. With more trans people transitioning at an earlier age than ever before, demand for surgery at a younger age seems to be going up. There have been cases, some prominent and some not, where a trans person (usually a trans girl) received genital surgery before they reached the age of majority.

As the author, Dr. Christine Milrod (PhD) points out, there are no ethical standards for determining if surgery is the right choice for a minor trans person. In this article Dr. Milrod discusses factors related to genital surgery, relevant background for an ethical standard, and tentatively proposes a set of standards. Because the article itself is behind a paywall, I’m going to roughly summarize the points she brings up as well as summarize her proposed standards.

Dr. Milrod seems to be focusing on young trans girls because they seem to be the ones accessing surgery as minors. Much of what she says is applicable to trans boys as well.

Issues and factors relating to genital surgery in adolescent trans people

  • Lack of genital surgery exposes them to a potential accidental exposure of their trans status, which may not be to the young person’s benefit. Stigma, shame, and feelings of inadequacy may result.
  • Trans youth are at very high risk for discrimination and harassment, which impacts both their physical and mental health. The ability to pass (including surgery) may reduce or eliminate the risk of discrimination/harassment.
  • Genital status may impact a young trans person’s ability to start a romantic or sexual life.

So what’s the current status when it comes to Standards?

WPATH states that an individual must be the age of majority for genital surgery. The Endocrine Society generally agrees. However, Dr Milrod points out that this is not necessarily always followed. She points to some Dutch clinics where the policy is essentially “no genital surgery until age 18” even though the age of majority in the Netherlands is 16.

Dr. Milrod points out that the current standards try to find a balancing point between minimizing the waiting time for a trans youth with limiting chances of post-surgical regret. However in the same section she points out that studies of Dutch youth 1-4 years after surgery finds no regret whatsoever.

Some quick background information on age of majority and informed consent from my own research, courses, and so on…

The age of majority is the age at which a person can legally give informed consent to a medical treatment. Informed consent means that the individual has been told all the possible risks and benefits of an activity/treatment/research, has understood them, and is agreeing to the activity/treatment/research. It’s an extremely important concept in medicine, psychology and human-related research, one that has emerged out of human rights abuses. An important part of informed consent is that the person being asked for consent has to be capable of giving it, and giving it freely. A person who is mentally altered, such as a person who’s consumed a large amount of alcohol, is not considered able to consent because their judgment is altered. A person who is mentally disabled or who has something like dementia is also considered not to be able to give consent.

And then there are minors. Because their ability to comprehend and judge accurately all the risks/benefits may not be fully developed yet, a minor is not considered able to give consent. Before the age of majority, it is the legal guardians of the young person who give consent on behalf of the young person. The young person instead gives assent – they can agree or not agree to something, but it doesn’t have the full meaning of consent.

So what does informed consent have to do with genital surgery? A lot. Can a person under the age of majority agree to something as irreversible as genital surgery? Does it do more harm than good, or is there more harm in making them wait? Surgeons, physicians, therapists, parents, and young people themselves are currently wrestling with these issues.

Dr. Milrod points out some things on informed consent in addition to my summary. The regulations and laws on informed consent vary very heavily from country to country and from region to region, and vary depending on the procedure involved. For example, in Australia a minor cannot receive genital surgery even with parental consent without a court order. However in some areas of the United States, a minor could petition to become an emancipated minor and thus be legally responsible for themself and consent to treatment. In other words… whether or not a young person can consent is heavily debated. Can a person at age 16 consent? 14?

Proposed “Principles for Decisions Concerning Genital Surgery of the Adolescent”

First, Dr. Milrod notes that recommendations regarding the surgical treatment of intersex infants and children were part of the framework for her principles

  • The Principle of Psychological Support and Education: The young person and their parents/guardians should be given both full education regarding the surgery and full emotional and psychosocial support. They should be given all the information: all the risks, benefits, potential side effects, permanency, and alternatives. They should be given room to sort through emotions and pressures. This heavily implies and almost requires the presence of a therapist for both the young person and their family members.
  • The Principle of Medical Management: Only a surgeon experienced in transgender genital surgeries should perform a vagina surgeron on an adolescent, and that surgeon is responsible for providing complete information on the procedure and post-operative management. If the surgeon approached declines to perform the surgery, they should offer a reasonable explanation and a referral.
  • The Principle of Risk: Naturally, all risks should be minimized as much as possible. The physicians and surgeons involved are responsible for evaluating the physical risks of surgery for the young person. The psychosocial risk (of either performing surgery or delaying) falls to the therapist and/or other mental health professionals involved. The familial and social standards surrounding the young person also need to be taken into account.
  • The Principle of Human and Legal Rights: The young person must have given “full, free, and informed consent” to the surgery. All professionals involved must be in agreement that the young person is capable of giving such consent and has given it. The young person should be treated as any other patient with regard to privacy laws.

These aren’t exactly earth shattering. Rather, I think they’re very conservative measures. Conservative is not necessarily a bad thing. In my clinical experiences so far, I’ve come to view any hard and fast rule about transition with suspicion. One person may truly need a year of “real life experience” before hormones, for another that may be dangerous, and for yet another that may simply be an unnecessary postponement of hormone therapy.

This seems to me to be especially true for minor trans people, who have their families and schools and their vulnerable legal status to contend with. So I think Dr. Milrod did right in setting such conservative principles/guidelines. Each person must be treated individually – the possibilities are simply too broad and too serious to be treated otherwise.

If you’re interested in finding out more about issues facing transgender and gender nonconforming youth and their families, please check out Gender Spectrum. A more loving, kind, knowledgeable organization on the topic I have yet to find. Their professionals and family conference is wonderfully informative and supportive. I’ll be there this year if my medical school plans allow.


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