Transsexuality: Legal and ethical challenges.

Sex-change procedures, better described as gender-change procedures, involve preparing patients psychologically and surgically for gender transition to treat their gender dysphoria. Physical treatment might include hysterectomy for female to male transition, and post-castration fashioning of an artificial vagina for male to female transition. Conservative opposition to accommodating and recognizing such procedures remains in some countries, and where treated, transgender individuals might face social hostility and oppression. However, human rights laws increasingly provide for transgender non-discrimination and government re-issue of official documents such as birth certificates and social insurance cards in the changed gender. A UK legal decision required a transgendered male who retained his ovaries and uterus to be registered as mother on the birth certificate of the child he bore. Most challenging are decisions on adolescents' requests for gender transition, especially over parents' objections. Laws increasingly recognize that legal minors with sufficiently evolved intellectual and emotional capacity can make decisions for themselves.

The complexity of childhood gender dysphoria.

OBJECTIVE: To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care. CONCLUSION: Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.

Informed consent and childhood gender dysphoria: emerging complexities in diagnosis and treatment.

OBJECTIVE: To explore some of the emerging complexities in the management of childhood gender dysphoria. CONCLUSION: The authors raise questions about the gender-affirmation approach and highlight concerns about informed consent and research ethics.

The Medico-Legal 'Making' of 'The Transgender Child'.

Thirty years ago, the transgender child would have made no sense to the general public, nor to young people. Today, children and adolescents declare themselves transgender, the National Health Service diagnoses 'gender dysphoria', and laws and policy are developed which uphold young people's 'choice' to transition and to authorize stages at which medical intervention is permissible and desirable. The figure of the 'transgender child' presumed by medicine and law is not a naturally occurring category of person external to medical diagnosis and legal protection. Medicine and law construct the 'transgender child' rather than that the 'transgender child' exists independently of medico-legal discourse. The ethical issue of whether the child and young person can 'consent' to social and medical transition goes beyond legal assessment of whether a person under16 years has the mental capacity to consent, understand to what s/he is consenting, and can express independent wishes. It shifts to examination of the recent making of 'the transgender child' through the complex of power/knowledge/ethics of medicine and the law of which the child can have no knowledge but within which its own desires are both constrained and incited.

Sex reassignement with or without surgery. New ethical and juridical pathways.

INTRODUCTION: The access to sex-reassignment surgery is based on the existence of an unequivocal dyscrasia between the morphological sex and the objective evidence that emerges from in-depth analysis of the individual's personality. In Italy, such type of surgical intervention is subject to the authorization of a judge. MATERIAL OF STUDY: Authors examine the recent Italian Constitutional judgement which has addressed the right to change legal sex status without the need for sex-reassignment surgery. DISCUSSION: The Italian approach is in line with scientific evidence that the physical and mental well-being of an individual does not always require the surgical rectification of primary sexual features. Thus, sex reassignment surgery is not to be considered mandatory; rather, it should be aimed at ensuring the transsexual individual's stable psychological and physical good. From an ethical point of view, the Court's decision is very important, since it does not subordinate such fundamental rights as gender identity, healthcare and equality to prior, highly invasive surgery. CONCLUSIONS: The authors point out that critical issues and obstacles to the full implementation of the right to gender identity remain, in that this right is still subject to the authorization of a judge. This approach does not seem to be in line with the recent World Health Organization (WHO) decision to remove the "gender incongruity" from the list of mental and behavioural disorders (as it is in the current International Classification of Diseases-10, so far), to decrease the stigma surrounding such a condition. KEY WORDS: Gender identity, Sex reassignment, Surgery, Stigma, Transsexualism, Transgender.

Adolescents and Body Modification for Gender Identity Expression.

As a matter of ethics and law, adults enjoy wide berth in securing hormonal and surgical interventions to align their bodies with their desired gender appearance. In contrast, the exercise of choice by minors is more constrained, because they can be less well situated to grasp the nature and consequences of interventions having life-long effects. Even so, some minors hope for body modifications prior to adulthood. Starting very young, some minors may assert atypical gender identity: those with female-typical bodies assert a male identity and those with male-typical bodies assert a female identity. This assertion of identity is atypical only in a descriptive sense, because it is uncharacteristic, not because it is normatively unacceptable. Not all minors persist in their atypical gender identities, but some do. For those who do, it is desirable to minimize unwanted secondary sex characteristics and to maximize desired secondary sex characteristics. I outline here a theory of respect for decisions by minors in regard to hormonal and surgical interventions that help align their bodies with their gender identity. Of particular ethical interest here are body modifications for fertility preservation since certain interventions in the body can leave people unable to have genetically related children. In general, I will show that the degree of respect owed to minors in regard to body modifications for gender identity expression should be scaled according to their decision-making capacities, in the context of robust practices of informed consent.

Informed Consent for Transgendered Patients.

The request of a transgendered-identified patient for psychiatric, medical, or surgical services creates ethical tensions in mental health professionals, primary care physicians, endocrinologists, and surgeons. These may be summarized as follows: Does the patient have a clear idea of the risks of the services that are being requested? Is the consent truly informed? While this question is starkly evident among cross-gender identified children contemplating puberty suppression and social gender transition and young adolescents with rapid-onset gender dysphoria, it is also relevant to young, middle-aged, and older adults requesting assistance. Many patients cannot tolerate detailed discussion of the risks. This article reviews the history of informed consent, presents the conflicts of ethical principles, and presents three categories of risk that must be appreciated before informed consent is accomplished. The risks involve biological, social, and psychological consequences. Four specific risks exist in each category. The World Professional Association for Transgender Health's Standards of Care recommend an informed consent process, which is at odds with its recommendation of providing hormones on demand. With the knowledge of these 12 risks and benefits of treatment, it is possible to organize the informed consent process by specialty, and for the specific services requested. As it now stands, in many settings informed consent is a perfunctory process creating the risk of uninformed consent.

Gender Dysphoria: Bioethical Aspects of Medical Treatment.

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

¿La identidad sexual es una opción? Un estudio sobre la basegenética de la Transexualidad / Is sexual identity optional? A study of the genetics of transsexuality

La Transexualidad según el ICD-10 (Clasificación Internacional de Enfermedades, décima edición), o Disforia de Género en adolescentes y adultos en el DSM-5 (Manual Diagnóstico y Estadístico de Desórdenes Mentales, quinta edición), se caracteriza por una marcada incongruencia entre género y sexo biológico. La etiología de la Disforia de Género (DG) o Transexualidad es compleja. Algunas hipótesis señalan una discrepancia entre sexo cerebral y sexo biológico. Otras evidencias sugieren una vulnerabilidad genética. Henningsson y col, (2004) encontraron diferencias estadísticamente significativas cuando examinaron el receptor de estrógenos Beta (ERß) y el receptor de andrógenos (AR) en una población MtF (del inglés male-to-female). Los autores sugieren que en la población MtF son más frecuentes las formas largas de los genes ERBeta y AR. Hare y col, (2009) también encontraron una asociación significativa entre el tamaño del gen AR y la DG. Nuestro grupo replicó los trabajos de Henningsson y col, (2004) y Hare y col, (2009) en una de las poblaciones con DG más grande analizada hasta el momento, confirmando la implicación de los receptores de estrógenos formas alfa y Beta) y el receptor de andrógenos, en la base genética de la DG. Nuestros datos apoyan la existencia de una vulnerabilidad genética de la DG tanto en la población MtF como en la FtM. Corroboran la implicación de los receptores de estrógenos alfa y beta y el receptor de andrógenos en la masculinización del cerebro en humanos. Confirman así mismo que la identidad sexual no es una opción, sino que viene determinada genéticamente, aunque posee un componente hormonal muy importante. Su substrato por tanto, no es ideológico, sino cerebral

Transsexualism in the ICD-10 (International Classification of Diseases, Tenth Revision), Gender Dysphoria in adolescents and adults in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), is characterized by a marked incongruence between one’s experienced gender and biological sex. The etiology is complex, but some hypotheses suggest that Gender Dysphoria (GD) arises from discrepant cerebral and biological sexual differentiation. Increasingevidence supports the idea of genetic vulnerability. Henningsson et al, (2004) found significant differences when they examined estrogen receptor Beta (ER Beta) in a male-to-female (MtF) population. They suggested that a long ER Beta polymorphism is more common in MtFs. Hare et al, (2009) also examined an MtF population and found a significant association between the androgen receptor (AR) and GD. Our group analyzed the same polymorphisms and found an association between ER alfa, ER Beta and AR in GD. Our results suggest a genetic basis of GD in MtF and FtM populations. Our data corroborate the implication of the two estrogen receptors, ERalfa and Beta, and the androgen receptor in the genetic basis of GD, and advise the importance of estrogens and androgens in cerebral masculinization. Our data also confirm that sexual identity is not optional, but is determined prenatally by the genes, although it has a very importanthormonal component. Therefore, its substrate is cerebral, not ideological

Philosophical Provocation: The Lifeblood of Clinical Ethics.

The daily work of the clinical ethics teacher and clinical ethics consultant falls into the routine of classifying clinical cases by ethical type and proposing ethically justified alternatives for the professionally responsible management of a specific type of case. Settling too far into this routine creates the risk of philosophical inertia, which is not good either for the clinical ethicist or for the field of clinical ethics. The antidote to this philosophical inertia and resultant blinkered vision of clinical ethics is sustained, willing exposure to philosophical provocation. The papers in this clinical ethics issue of the Journal of Medicine and Philosophy provide just such philosophical provocation related to core topics in clinical ethics: the distinction between clinical practice and clinical research; telemedicine, or medicine at a distance; illness narratives; the concept of the placebo effect; and sex reassignment.

Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?

Some people want to modify their bodies through hormonal and surgical treatments in order to resolve gender dysphoria, the distress they experience when their bodies do not align with their gender identity. The World Professional Association for Transgender Health (WPATH) offers guidelines to clinicians regarding treatment of people wanting to modify their bodies for this reason. Prior to these modifications, WPATH advises that mental health screening is needed and that psychotherapy is recommended though not a requirement. In fact, these advisories allow clinicians some freedom in applying the standards to specific cases. Although some variation from the WPATH Standards of Care can be clinically acceptable, informed consent remains an essential component of clinical encounters involving body modifications.

Should Psychiatrists Prescribe Gender-Affirming Hormone Therapy to Transgender Adolescents?

Gender-affirming hormone therapy is a safe and effective way to improve quality of life and mental health outcomes for transgender adolescents. Access to this treatment is limited, with the most vulnerable transgender people experiencing the greatest gaps in care. Because some psychiatrists help transgender patients receive needed medical interventions, we analyze the ethical values they must balance when deciding whether to provide hormone therapy to patients who seek it.

Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients.

Informed consent as a model of care has evolved as an alternative to the standard model of care recommended by the World Professional Association for Transgender Health's Standards of Care, version 7, which emphasizes the importance of mental health professionals' role in diagnosing gender dysphoria and in assessing the appropriateness and readiness for gender-affirming medical treatments. By contrast, the informed consent model for gender-affirming treatment seeks to acknowledge and better support the patient's right to, and capability for, personal autonomy in choosing care options without the required involvement of a mental health professional. Clinicians' use of the informed consent model would enable them both to attain a richer understanding of transgender and gender-nonconforming patients and to deliver better patient care in general.

Changing and Unchanging Perspectives regarding Intersex in the Last Half Century: Topics Presented in the Lawson Wilkins Lecture* at the 2015 Pediatric Endocrine Society Meeting.

The understanding, care and treatment of patients born with intersex or disorders of sex development conditions has evolved considerably over the last five decades. Regarding those who require evaluation before gender assignment is made, each "generation" of approach has been based upon and reflects the contemporary biological, social and psychological understanding. The most recent generation needs to consider the dramatically changed societal viewpoints regarding the acceptance and expansion beyond a binary perception of sexuality. This together with advances in genetic etiologies, surgical refinements and psychological support should result in better care and quality of life (QoL) outcomes for patients with these conditions. This paper reviews the successive generations of approach and discusses the multiple challenges facing the multidisciplinary teams caring for these patients today.

Transexualidad: una alteración cerebral que comienza a conocerse / Transsexualism: a brain disorder that begins to known

La transexualidad describe la condición de una persona cuyo sexo psicológico difiere del biológico. Las personas con trastorno de identidad de género sufren de forma persistente por esta incongruencia y buscan un cambio de la anatomía sexual, mediante tratamiento hormonal y quirúrgico. Esta revisión, desde una perspectiva ética, ofrece una visión de las correlaciones neurobiológicas estructurales y funcionales de la transexualidad y los procesos de cambio cerebrales por la administración de las hormonas del sexo deseado. Varios estudios demuestran un aumento de la conectividad funcional entre regiones de la corteza cerebral, que son huellas de la angustia psicosocial generada por la discordancia entre el sexo psicológico y el biológico. Tal angustia se puede atribuir a una imagen corporal incongruente debida a los cambios en la conectividad funcional de los componentes clave de la red de representación del cuerpo. Parte de los cambios de la conectividad suponen un mecanismo de defensa puesto que disocia la emoción sentida de la imagen corporal. Las personas transexuales presentan signos de feminización o masculinización de estructuras y procesos cerebrales con dimorfismo sexual y que durante la administración hormonal se desplazan parcialmente aún más hacia las correspondientes al sexo deseado. Estos cambios permiten una reducción de la angustia psicosocial. Sin embargo, un modelo de 'reasignación del sexo' no resuelve el problema, puesto que no se trata la alteración cerebral que lo causa. Se trata de una grave cuestión de ética médica. La liberación de los prejuicios para conocer lo que ocurre en el cerebro de los transexuales es una necesidad médica, tanto para definir lo que es y no es un tratamiento terapéutico, como para guiar las acciones legales

Transsexualism describes the condition when a person’s psychological gender differs from his or her biological sex. People with gender identity disorder suffer persistently from this incongruence and they search hormonal and surgical sex reassignment to the desired anatomical sex. This review, from an ethical perspective, intends to give an overview of structural and functional neurobiological correlations of transsexualism and their course under cross-sex hormonal administration. Several studies demonstrate an increased functional connectivity between cortex regions reaffirming psychosocial distress of psychologicalbiological sex incongruity. Such distress can be ascribed to a disharmonic body image due to changes in the functional connectivity of the key components of body representation network. These brain alterations seem to imply a strategic mechanism dissociating bodily emotions from bodily images. For a number of sexually dimorphic brain structures or processes, signs of feminization or masculinization are observable in transsexual individuals, who during hormonal administration seem to partly further adjust to characteristics of the desired sex. These changes allow a reduction of psychosocial distress. However, a model leading to a 'gender affirmation' does not solve the problem, since brain disorders causing it are not corrected. This is a serious medical ethics issue. Prejudices should be left aside. To know what happens in the brain of transsexuals is a medical need, both to define what is and what is not, and so to choose an adequate treatment, and to decide and guide legal actions

Treatment for gender dysphoria in children: the new legal, ethical and clinical landscape.

Gender dysphoria is a condition in which a child's subjectively felt identity and gender are not congruent with her or his biological sex. Because of this, the child suffers clinically significant distress or impairment in social functioning. The Family Court of Australia has recently received an increasing number of applications seeking authorisation for the provision of hormones to treat gender dysphoria in children. Some medical procedures and interventions performed on children are of such a grave nature that court authorisation must be obtained to render them lawful. These procedures are referred to as special medical procedures. Hormonal therapy for the treatment of gender dysphoria in children is provided in two stages occurring years apart. Until recently, both stages of treatment were regarded by courts as special medical treatments, meaning court authorisation had to be provided for both stages. In a significant recent development, courts have drawn a distinction between the two stages of treatment, permitting parents to consent to the first stage. In addition, it has been held that a child who is determined by a court to be Gillick competent can consent to stage 2 treatment. The new legal developments concerning treatment for gender dysphoria are of ethical, clinical and practical importance to children and their families, and to medical practitioners treating children with gender dysphoria. Medical practitioners should benefit from an understanding of the recent developments in legal principles. This will ensure that they have up-to-date information about the circumstances under which treatment may be conducted with parental consent, and those in which they must seek court authorisation.