GIRES Research Award for 2001 – Synopsis

See the GIRES Annual Research Awards page to read about the awards and the criteria used by the GIRES trustees in evaluating entries for the annual award.


Awarded to Bernadette Wren, Consultant Clinical Psychologist

EARLY PHYSICAL INTERVENTION FOR YOUNG PEOPLE WITH ATYPICAL GENDER IDENTITY DEVELOPMENT

“Clinical Child Psychology and Psychiatry Vol 5:2 pp 220-231.”

Synopsis, written by Bernadette Wren

Physical interventions in gender identity disorders – current practice
There is not an established tradition within the NHS of providing hormone treatment to the under 18s either for the postponement of puberty or for the engendering of cross-gender bodily characteristics. Guidance on the treatment of children and young people with gender identity problems has recently been published by the Royal College of Psychiatrists (1998), advocating a ‘cautious evolving approach’, with reversible and partially reversible physical interventions being delayed ‘as long as it is clinically appropriate’. It is precisely the issue of what is ‘clinically appropriate’ that is contentious.

Cohen-Kettenis, van Goozen, & Cohen(1998) have reported on their treatment, both hormonal and surgical, of certain carefully selected under-18-year-olds. Their follow-up suggests that, given pre-operative psycho-logical stability and supportive parents, these young people make very good adjustments following their treatment.

Identity issues in adolescence

In adolescence identity beliefs – about politics, religion, vocation – can be held with enormous conviction and give a false impression of irreversibility. There is no evidence, however, that young people’s conviction about their gender identity is, typically, as unstable as other value-laden convictions. If the consolidation of an adult identity is the goal of the adolescent process, we must ask whether the pressures on gender dysphoric young people to live in the sex role they abhor prevents them from engaging in that adolescent process in any fruitful way.

An ‘unnecessary’ intervention?

In hormonal interventions to postpone puberty or to alter the sexual body the usual goals of physical medical intervention are absent. The principle is sometimes invoked that in an ethical health service physiologically unnecessary interventions should not be undertaken. However, there are widely accepted exceptions to this putative principle, reflecting the increasingly prevalent view that the effectiveness of a healthcare intervention may best be measured in terms of quality of life for patients.

Consent to treatment

In the Royal College of Psychiatrists Guidance the issue of ‘informed consent’ is given some prominence. One of the key issues here is whether the experience of puberty may itself affect the gender identity and therefore needs to be undergone before the young person can make an informed choice. The second issue is the extent to which, with our limited knowledge about the physiological sequelae of (and psychological adjustment to) early physical intervention, a young person can truly be said to be giving informed consent to treatment. The third key issue is whether a young adolescent has the emotional and cognitive maturity to give consent and involves the consideration of a young person’s cognitive age and emotional functioning.

The legal context of withholding treatment

The legal context in Britain with regard to children’s rights to consent to (and refuse) treatment is framed by the Children Act of 1989, which gives considerable autonomy to children. This is related to the Gillick decision of 1985, a landmark ruling around the rights of adolescents to take responsibility for decisions affecting their well-being. However, recent High Court decisions have established the precedent that it would be unlawful to stand by and let a minor do grave or irreversible mental or physical harm to herself. The nub of the matter is how to determine what would constitute a full understanding of the personal health and welfare implications of such a far-reaching body-altering decision.

Emerging evidence and evolving discourses

The debate about early physical treatment for transgendered adolescents throws up a host of issues that directly challenge thinkers and practitioners in the fields of endocrinology, medical ethics, child development, politics and human rights. Views will shift as our empirical knowledge increases about both causes of the cross-gender experience, and the effects and outcomes of various treatments. But our views will also be influenced by less obviously scientific or evidence-based considerations.

One huge shift in cultural thinking over the last fifty years has been in the way that particular social groups are described and positioned. The social movements of multi-culturalism and feminism have shaped changing attitudes towards the autonomy of the individual. The Children Act responded, and contributed, to new thinking about the entitlement of children and young people to be prime voices in any decisions regarding issues relevant to their well-being.

A second important shift in cultural attitudes and beliefs increasingly places sex-reassignment treatment on a par with other strictly non-essential physical interventions, such as fertility treatment of various kinds. These are medical interventions that serve to meet pressing psychological/emotional needs and provide people with the opportunity for a more valuable and rewarding life.

Recommendations

1.) We must acknowledge the complexity of the issues raised by adolescents with atypical gender identity development and the inappropriateness of imposing a simple model of diagnosing pathology and choosing a treatment modality.

2.) The clinician has a responsibility to be clear about:

  • The physical and psychological consequences for the young person of not intervening and therefore the problems associated with a ‘cautious’ approach
  • The lack of clear empirical findings on outcome to guide decision-making
  • The legislation relevant to treatment

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