S23S P E C I A L R E P O R T L G B T B i o e t h i c .docx

S23S P E C I A L R E P O R T: L G B T B i o e t h i c s :
V i s i b i l i t y, D i s p a r i t i e s , a n d D i a l o g u e
Hormone Treatment of Children and
Adolescents with Gender Dysphoria:
An Ethical Analysis
by Brendan S. Abel
C
hildren are generally unable to provide au-
tonomous, independent informed consent for
medical treatments. This long-standing tenet of
pediatric care protects children who often do not pos-
sess fully developed cognitive decision-making capacity
by preventing rash, permanent, and potentially regret-
table medical decisions. As pediatric patients become
adolescents and approach adulthood, their involvement
in medical decision-making often increases to take into
account their values and preferences.1 But until a youth
reaches the age of majority, the medical decision-making
process generally includes permission from parents or
guardians and informed assent from the patient to the
degree appropriate.
In the context of transgender health, most people are
not comfortable with allowing a twelve-year-old child
with gender dysphoria to elect to undergo gender reas-
signment surgery. The likelihood is too high that the
child would be unable to fully comprehend the scope
of a decision that carries significant, permanent conse-

quences, particularly because the decision to surgically
change gender is based upon a conception of gender that
can fluctuate during adolescent years. Conversely, how-
ever, most people would not contend that this fluidity is
reason to wholly deny certain medical care such as hor-
monal treatments to transgender youth, a demographic
with extremely high rates of violent behavior, self-harm,
and suicide. This paper will explore ethical consider-
ations relevant to this emerging debate of what therapeu-
tic options should be offered to transgender children and
adolescents.
Pediatric endocrinologists have been treating gender
dysphoric adolescents with puberty-suppressing drugs
and, to a lesser extent, with cross-sex hormone therapies
for more than twenty years. Clinicians and thought lead-
ers have mentioned ethical components of this emerg-
ing practice in the few cohort studies and clinical review
articles about the subject. However, ethics have generally
been a secondary consideration in the medical academic
literature. In this paper, I will provide a brief overview of
the practice, summarize the current research on hormone
treatment for transgender minors, and provide an ethical
analysis of the practice.
Clinical Overview
Gender dysphoria, termed “gender identity disorder” in prior
iterations of the Diagnostic and Statistical
Manual of Mental Disorders, is marked by an incongru-
ence between one’s experienced or expressed gender and
the gender to which the person has been assigned (usu-
ally at birth, referred to as the natal gender).2 The new
DSM-5 defines an individual with gender dysphoria as
a person who fulfills six of eight enumerated character-
istics including a strong desire to be the other gender,

a strong desire to dress as typical of the other gender, a
dislike of one’s sexual anatomy, and a desire to have the
sexual anatomy of the opposite sex. The diagnosis addi-
tionally requires a finding of clinically significant distress
or impairment in important areas of social functioning,
such as difficulties maintaining social relationships or
performing age-appropriate tasks (household chores or
homework, for example), and it requires all of these diag-
nostic elements to be manifested for at least a six-month
duration. The presentation and corresponding treatment
of gender dysphoria differs greatly from children to ado-
lescents and adults, with children being more focused on
Brendan S. Abel, “Hormone Treatment of Children and
Adolescents
with Gender Dysphoria: An Ethical Analysis,” LGBT Bioethics:
Visibility,
Disparities, and Dialogue, special report, Hastings Center
Report 44, no. 5
(2014): S23-S27. DOI: 10.1002/hast.366
qqq
q
S24 September-October 2014/ H A S T I N G S C E N T E R
R E P O R T
their behavioral gender differences as opposed to anatomi-
cal differences. Nonetheless, gender dysphoria can be diag-
nosed in childhood—at as young as three years old—even
though only 10 to 20 percent of these children will still
have gender dysphoria by the time they reach adulthood.3
While many young children will ultimately decide to re-
vert to their natal gender—known as desisting—children

whose gender dysphoria continues to adolescence are more
likely to have it persist into adulthood.4
For years, children and adolescents presenting to medical
professionals with nonconforming gender identities were
considered outside of the realm of clinical management.
Over the past twenty years, the possibility of a hormonal
suppression of puberty and, more recently, of cross-sex hor-
mone therapy, have provided a newfound ability to control
a child’s sexual development. Gonadotropin-releasing hor-
mones (GnRH)—which have been prescribed to suppress
the onset of puberty for children with precocious puberty
for thirty years—are now the first line of treatment of chil-
dren with gender dysphoria.5 They are used to delay the
onset of puberty for children with gender identify disorder
to prevent secondary sexual characteristics in order to “buy
time” to consider next stages of therapy.6 This treatment
can provide welcome relief to a twelve-year-old natal boy,
for example, allowing the child to delay any male second-
ary sexual characteristics until approximately age sixteen.
In some circumstances, the child will become comfortable
with his natal gender, discontinue the GnRH, and progress
through puberty as one would absent hormonal interven-
tions. Yet other individuals can develop the secondary sex-
ual characteristics of the opposite gender through cross-sex
hormone therapy—androgens for natal females and estro-
gens for natal males—and have the option of gender-reas-
signment surgery at the age of majority. While the scope
of such hormone therapy for children is limited (and dis-
cussed in additional detail below), the practice of hormone
therapy for gender dysphoria was formally recommended
for adult and adolescent populations by the Endocrine
Society, the European Society of Endocrinology, and re-
lated professional societies via consensus clinical guide-
lines in 2009.7 Aside from the psychological reprieve that
hormone therapy can provide for adolescents with gender

dysphoria, pubertal suppression allows, many argue, for
optimal results of the potential cross-gender transition, as
secondary sex characteristics of one’s natal sex are difficult
to undo. In other words, if a natal male with gender dys-
phoria can receive GnRH before pubertal changes such as
the development of an Adam’s apple and the deepening of
the voice, the transition to the female gender appearance
will be better, as the cross-sex hormones cannot effectively
undo characteristics of the original gender that have already
progressed.8
Psychological counseling is an additional important ele-
ment to the clinical treatment of all persons with gender
dysphoria. Since the earliest protocols for treatment, psy-
chological counseling has been emphasized, particularly
given that a long diagnostic window can allow for effective
long-term mental health care.9 In fact, the 2009 clinical
guidelines suggest that an independent diagnosis of gen-
der dysphoria be made by a mental health professional to
ensure that a patient’s behaviors leading to the diagnosis
are not influenced by mental health comorbidities.10 A cor-
roborating diagnosis by a mental health expert can miti-
gate misdiagnosis and help identify related mental health
concerns that should be addressed as part of any treatment
plan.
Data of Children and Adolescents Treated for
Gender Dysphoria
For an area of clinical treatment that carries such sig-nificant
long-term effects for pediatric patients, gen-
der dysphoria has been subject to relatively little academic
research. Possibilities for research are inherently limited
by ethical restrictions on interventional research and by
relatively low populations for cohort studies. After a case
study was published in 1998 of a sixteen-year-old patient

with gender dysphoria at the Amsterdam Clinic in the
Netherlands,11 Peggy T. Cohen-Kettenis and Henriette A.
Delemarre-van de Waal reported in seminal publications
the results of cohort studies—which simply observe a spe-
cific population over time—of children and adolescents
with gender dysphoria who were treated at their clinic.12
The first study concluded that seventy patients, none of
whom discontinued the hormone therapy, reported that
the pubertal suppression improved their psychological
functioning.13 A follow-up study by the same researchers
found that the adolescents who underwent GnRH re-
ported improved behavioral, emotional, and psychological
functioning.14 In 2012, Norman Spack and others at the
Boston Children’s Hospital Gender Management Service
clinic reported the first cohort study in the United States,
observing ninety-seven children and adolescents con-
secutively undergoing treatment for gender dysphoria at
the clinic.15 Of the cohort, which had an average age of
14.8 years, fifty-six patients received a medical interven-
tion within the first week of presentation, with thirty-nine
receiving cross-sex hormone therapy, whereas eleven were
treated with GnRH.16 Notably, forty-three patients pre-
sented with a significant psychiatric history.17 While these
studies are an important starting point and generally high-
light improvements in psychological function and a lack
of reported adverse events, more detailed research in larger
populations with greater follow-up is essential.
Ethical Analysis
The ethical analysis in existing academic medical lit-erature of

hormone treatment of minors with gender
dysphoria has largely been relegated to passing assertions
about risks and subsequent justifications. While this ap-
proach does not imply thoughtlessness, it often indicates a
lack of thoroughness because of inadequate analytic struc-
ture. The field of bioethics is historically dominated by
discourse about best ethical theories by which to analyze a
given problem, but few would disagree that a straightfor-
ward and oft-applied framework using the widely adopted
principles of biomedical ethics18 is a pragmatic entry point
into an ethical discussion of pediatric gender dysphoria
treatment decisions. Thus, my analysis relies on accepted
principles of bioethics including respect for autonomy, be-
neficence, and nonmaleficence.19
Respect for Autonomy. Respect for autonomy tradition-
ally refers to a general right to be free from interferences
and limitations that prevent an ability to act freely in accor-
dance with one’s wishes, with certain important caveats and
restrictions. One legally imposed restriction to the right to
autonomy is being below the age of minority. This is not
a wholesale restriction, however, as pediatricians regularly
try to consider a minor patient’s assent, with the weight of
the patient’s contribution dependent upon the individual
patient’s capacity to make rational, informed decisions.20
Despite a minor’s inability to provide legal informed con-
sent for a medical procedure (with certain important ex-
ceptions), the ethical principle of respect for autonomy
cannot be dismissed in this analysis. In fact, the lack of
legal authority may actually enhance a nuanced consider-
ation of the autonomy of a child with gender dysphoria.
Respect for autonomy is the strongest factor supporting
progressive hormone treatments, including cross-sex hor-
mone therapy, as the practice is justified through a desire to
respect a child’s expressed gender ideation by helping align
it with his or her outward sexual manifestation. Additional

weight should be given to the respect for a child’s auton-
omy to elect this treatment because of the importance of
acting during adolescence to achieve optimum results in
adulthood. In other words, respect for a child’s autonomy
should be emphasized with respect to his or her desire to
undergo hormone therapy because the same results will not
occur if the patient is left to make the same decision at
age eighteen. Additionally, it can be argued that the great-
est step towards respecting a child’s autonomy is expanded
access to and education regarding various treatment plans
for persons with gender dysphoria to allow patients in all
geographic locations and of all socioeconomic positions to
gain a full understanding of options and to advocate for
their preferred treatment.
Nonmaleficence. Nonmaleficence—which reflects the
medical maxim of “first, do no harm”—imposes an obliga-
tion to not inflict harm on others. This principle offers the
strongest ethical argument against cross-sex hormone treat-
ment because the long-term effects of this therapy are not
well known: only a single patient has been the subject of
long-term follow-up.21 Additionally, cross-sex therapy has
the known side effect of rendering most patients sterile.
Puberty-suppressing hormones, by contrast, have largely
been considered free of long-term harm; this assertion is
supported by many generations of follow-up studies with
the large population of individuals prescribed such drugs
for precocious puberty.22 The ability to use puberty-block-
ing hormones to prolong the decision to commence cross-
sex hormones should not be undervalued, as this practice
allows patients to mature and develop their power of judg-
ment. Of course, “harm” as it relates to medical maleficence
should go beyond the standard construction of physical
harm and encapsulate a holistic approach that would con-
sider emotional, social, and spiritual values and harms. For

many adolescents, the eventual feeling of comfort within
one’s body far outweighs the “harm” of losing the ability
to procreate. However, there is a portion of the population
of children undergoing cross-sex hormone therapy that
will eventually decide not to live as that cross-gender. In
these cases, the deprivation of fertility can be devastating
and must be strongly considered. Still other persons with
gender dysphoria will persist with their new gender, take
comfort with the effects of the hormone treatment, yet still
feel loss associated with infertility.
For supporters of greater access to cross-sex hormone
therapies for adolescents, additional research in under-
standing which factors can predict gender dysphoria persis-
tence could significantly mitigate some of these concerns.
A recent review article of relevant literature acknowledged
“a surprising lack of knowledge on adolescent gender iden-
tity development.”23 Additional insight into the complex
interplay between psychosocial and biological factors could
foster tools to better determine likelihood of persistence.24
Each advance in the field could substantially weaken argu-
For many adolescents, the eventual feeling of comfort within
one’s
body far outweighs the “harm” of losing the ability to procreate.
Others, however, may be devastated by the loss of fertility.
R E P O R T
ments about maleficence that are based on the concern that
children could turn out to be desisters but will be sterile if
they have undergone cross-hormone therapy.

Beneficence. The principle of beneficence refers to a
moral obligation to act for the benefit of others—by ei-
ther actions that do good or those that prevent harm. In
the context of medical ethics, beneficence obligates phy-
sicians to help their patients. Determining how a physi-
cian should “do good” in cases of childhood or adolescent
gender dysphoria is an unenviable task because of the vari-
ability of persistence in such cases. Given the possibility
of desistence, physicians must consider, in the name of
beneficence, the not unlikely situation where cross-sex
hormone therapy renders permanent harms in a desisting
child. Prescribing cross-sex hormones is ethical only under
the theory of beneficence when a physician believes that
the facts of a certain patient—given age, maturity, length
of dysphoric ideations—merit a decision that the child will
more likely than not benefit from the treatment rather than
regret the consequences at a later date. Physicians are thus
also under an obligation to help children and adolescents
properly weigh considerations. In this context, helping an
adolescent appreciate the seriousness of infertility is an
important ethical obligation and one complicated by the
fact that the adolescent’s developing brain is generally more
limited than the adult brain in its ability to weigh long-
term consequences.
A common argument against the hormone therapy for
gender dysphoric children is that the failure to provide
such treatment will not cause harm. Hormone therapy
can be initiated at the age of majority, and at that time
gender reassignment surgery can be a viable, legal option.
The principle of beneficence can be used to counter this
argument because, while delaying hormone therapy may
conform with the principle of nonmaleficence, the practice
does not support beneficence if one assumes that a child’s
desire to have his or her outward gender conform to his

or her self-perceived gender is a valid good. A finding of a
high prevalence of desistence detracts from the argument
for beneficence. But, again, this argument may depend
upon the findings of ongoing research on gender identity
development and gender dysphoria persistence.
A Complex Issue, a Holistic Approach
A s this analysis demonstrates, hormone treatment for children
and adolescents with gender dysphoria is eth-
ically challenging: ethical principles point toward differing
outcomes. A respect for a child’s autonomy combined with
an emphasis on beneficence suggests that not only GnHR
hormone treatment to suppress puberty but also cross-sex
hormone therapy should be supported because such treat-
ment would respect a patient’s growing right to be involved
in medical decision-making and because it offers the high-
est likelihood for the preferred results of gender transition.
But a counterargument is provided through an examina-
tion of the principle of nonmaleficence, particularly in light
of the likelihood that desisting minors would be left sterile.
Regardless of individual conclusions, additional research
into gender identity development and into the long-term
safety of cross-sex hormone therapy is imperative. And all
ethical analysis must acutely consider the age and cognitive
development of the person with gender dysphoria. While
long-term safety and reversibility of puberty-suppressing
hormones make the first-stage treatment justifiable for
many assenting children, the second-stage treatment of
cross-sex hormones—with the long-term fertility implica-
tions—are generally justifiable only with adolescents that
can provide fully informed assent.
Lastly, one cannot complete the analysis of such a
practice without acknowledging the realities of denying

treatment options. Transgender youth have high rates of
self-harm and suicide.25 This must dictate continued sup-
port of proactive therapies and research for gender dys-
phoric children and adolescents. We must concurrently
push for increased understanding and acceptance of LGBT
people through education and outreach, as well as in the
nonmedical therapeutic realm through school- and com-
munity-based support groups.
A holistic approach to ensuring the wellness of transgen-
der youth is essential and must be supported by an ethical
medical approach. With additional research and a con-
tinued emphasis on the ethical components of hormone
therapy, minors with gender dysphoria should be granted
access to hormone therapies to allow for fulfilling, healthy,
and secure lives.
1. Committee on Bioethics, “Informed Consent, Parental
Permission, and Assent in Pediatric Practice,” Pediatrics 95
(1995):
314-17.
2. American Psychiatric Association, “Gender Dysphoria,”
Diagnostic and Statistical Manual of Mental Disorders, 5th
edition,
doi:10.1176/appi.books.9780890425596.997927.
3. W. C. Hembree, “Guidelines for Pubertal Suspension and
Gender Reassignment for Transgender Adolescents,” Child and
Adolescent Psychiatric Clinics of North America 20 (2011):
725-32,
at 725.
4. N. P. Spack, “Management of Transgenderism,” Journal of
the American Medical Association 309 (2013): 478-84;
Hembree,

“Guidelines for Pubertal Suspension and Gender Reassignment
for
Transgender Adolescents,” at 725, 729.
5. N. P. Spack et al., “Children and Adolescents with Gender
Identity Disorder Referred to a Pediatric Medical Center,”
Pediatrics
129 (2012): 418-25.
6. S. F. Leibowitz and C. Telingator, “Assessing Gender
Identity
Concerns in Children and Adolescents: Evaluation, Treatments,
and
Outcomes,” Current Psychiatry Reports 14 (2012): 111-20, at
118.
7. Hembree, “Guidelines for Pubertal Suspension and Gender
Reassignment for Transgender Adolescents,” 3132.
8. Spack et al., “Children and Adolescents with Gender Identity
Disorder Referred to a Pediatric Medical Center,” 419.
9. H. A. Delemarre-van de Waal and P. T. Cohen-Kettenis,
“Clinical Management of Gender Identity Disorder in
Adolescents:
A Protocol on Psychological and Paediatric Endocrinology
Aspects,”
European Journal of Endocrinology 155 (2006): 131–37.
Reassignment for Transgender Adolescents,” 3132.

11. P. T. Cohen-Kettenis and S. H. van Goozen, “Pubertal Delay
as an Aid in Diagnosis and Treatment of a Transsexual
Adolescent,”
European Child and Adolescent Psychiatry 7 (1998): 246–48.
12. M. S. C. Wallien and P. T. Cohen-Kettenis, “Psycho-sexual
Outcome of Gender Dysphoric Children,” Journal of the
American
Academy of Child and Adolescent Psychiatry 36 (2008): 1413-
23; A.
L. de Vries et al., “Puberty Suppression in Adolescents with
Gender
Identity Disorder: A Prospective Follow-up Study,” Journal of
Sexual
Medicine 8 (2011): 2276-83.
13. Wallien and Cohen-Kettenis, “Psycho-sexual Outcome of
Gender Dysphoric Children,” 1421.
14. De Vries, “Puberty Suppression,” 2282.
15. Spack, “Children and Adolescents with Gender Identity
Disorder Referred to a Pediatric Medical Center,” 419.
16. Ibid., 421-22.
17. Ibid.
18. T. L. Beauchamp and J. F. Childress, Principles of
Biomedical
Ethics, 6th edition (Oxford: Oxford University Press, 2008).
19. Ibid.
20. See D. Lambelet Coleman and P. M. Rosoff, “The Legal
Authority of Mature Minors to Consent to General Medical
Treatment,” Pediatrics 131 (2013): 786-93.

21. P. T. Cohen-Kettenis et al., “Puberty Suppression in a
Gender-
Dysphoric Adolescent: A 22-Year Follow-Up,” Archives of
Sexual
Behavior 40 (2011): 843-47.
Reassignment for Transgender Adolescents,” 725, 726.
23. Leibowitz and Telingator, “Assessing Gender Identity
Concerns in Children and Adolescents: Evaluation, Treatments,
and
Outcomes,” 118.
24. See T. D. Steensma et al., “Desisting and Persisting Gender
Dysphoria after Childhood: A Qualitative Follow-up Study,”
Clinical
Child Psychology and Psychiatry 16 (2011): 499-516.
25. R. T. Liu and B. Mustanski, “Suicidal Ideation and Self-
Harm
in Lesbian, Gay, Bisexual, and Transgender Youth,” American
Journal
of Preventive Medicine 42 (2012) 221-28.
T
ransgender issues and transgender rights have
become increasingly a matter of media atten-

tion and public policy debates. The movement
for transgender civil rights has followed in the wake of
the larger lesbian, gay, and bisexual (LGB) rights move-
ment, and, for the last two decades, trans inclusion has
become a focus of LGBT civil rights organizations. The
movement has had mixed success. For example, in 2013
California passed legislation—now being challenged in
the courts—that “guarantees transgender students access
to interscholastic sports, gym classes, locker rooms and
bathrooms based on their gender identity, irrespective of
their biological sex.”1 By contrast, many states and the
federal government deny civil rights protections and ac-
cess to care to transgender individuals.
Reflecting changes in psychiatric perspectives, the
diagnosis of “trans-sexualism” first appeared in the
International Statistical Classification of Diseases and
Related Health Problems in 1975 (when the ICD was in
its ninth edition) and shortly thereafter, in 1980, in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM, then in its third edition).2 Since that time, in-
ternational standards of care have been developed,3 and
today those standards are followed by clinicians across
diverse cultures. In many instances, treatment of older
adolescents and adults is covered by national health care
systems and, in some cases, by private health insurance.
Most recently, the Medicare ban on coverage for gender
reassignment surgery was lifted in 2014.4
In contrast to the relative lack of controversy about
treating adolescents and adults, there is no expert clinical
consensus regarding the treatment of prepubescent chil-
dren who meet diagnostic criteria for what was referred
to in both DSM-IV-TR and ICD-10 as gender identity

disorder (GID) in children and now in DSM-5 as gender
dysphoria (GD).5 One reason for the differing attitudes
has to do with the pervasive nature of gender dysphoria
in older adolescents and adults: it rarely desists, and so
the treatment of choice is gender or sex reassignment.
On the subject of treating children, however, as the
World Professional Association for Transgender Health
(WPATH)6 notes in their latest Standards of Care, gen-
der dysphoria in childhood does not inevitably continue
into adulthood, and only 6 to 23 percent of boys and 12
to 27 percent of girls treated in gender clinics showed
persistence of their gender dysphoria into adulthood.
Further, most of the boys’ gender dysphoria desisted, and
in adulthood, they identified as gay rather than as trans-
gender.7
In an effort to clarify best treatment practices for
transgender individuals, a recent American Psychiatric
Association Task Force on the Treatment of Gender
Identity outlined three differing approaches to treating
prepubescent gender dysphoric children. Due to the ab-
sence of any randomized controlled treatment outcome
studies of gender dysphoric children, the task force con-
cluded that “the highest level of evidence available for
treatment recommendations for these children can best
be characterized as expert opinion.”8
However, there are sharp disagreements among the ac-
knowledged experts. One of the oldest gender clinics do-
ing research in this area is Toronto’s Centre for Addiction
and Mental Health. There, clinicians work with children
and caregivers to lessen gender dysphoria and decrease
cross-gender behaviors and identification. For example,
natal boys are not permitted to dress in princess outfits
and are discouraged from playing with Barbie dolls. The

Ethical Issues Raised by the Treatment of
Gender-Variant Prepubescent Children
by Jack Drescher and Jack Pula
Jack Drescher and Jack Pula, “Ethical Issues Raised by the
Treatment
of Gender-Variant Prepubescent Children,” LGBT Bioethics:
Visibility,
Disparities, and Dialogue, special report, Hastings Center
Report 44, no. 5
(2014): S17-S22. DOI: 10.1002/hast.365
qqq
q
R E P O R T
clinic claims its approach decreases the likelihood that GD
will persist into adolescence, leading to adult transsexual-
ism, which, for various reasons, such as social stigma and
a lifetime of medical treatment, is an outcome the clinic
considers undesirable.9
Another long-standing research clinic, the VU
University Medical Center in Amsterdam, makes no direct
efforts to lessen gender dysphoria or gender atypical behav-
iors. Given that GD diagnosed in childhood usually does
not persist into adolescence and no reliable markers exist
to predict when it will or will not persist, there is no thera-
peutic target with respect to gender identity outcome, but
the developmental trajectory of gender identity is allowed
to unfold of its own accord. Those in whom it persists are

assisted in transitioning in later adolescence, and those who
desist are assisted in adjusting to their natal gender.10
A more recent entry in this area is the gender clinic af-
filiated with the University of California, San Francisco,
where a child is supported in socially transitioning to a
cross-gendered role without medical or surgical interven-
tion. As in the other two clinics, only at the onset of puber-
ty are medications administered to suppress development
of unwanted secondary sex characteristics.11 This approach
presumes that an adult transgender outcome is to be ex-
pected, that these children can be identified, and that chil-
dren who transition but then desist can revert to their natal
gender if necessary with no ill effects.12
The State of Empirical Research
Research on gender dysphoric/gender variant (GD/GV)13
children and adolescents is still sparse. Some
findings are emerging, however:14
• The children and adolescents (collectively referred to
as “minors”) who present for clinical evaluation or
treatment are a heterogeneous group.
• For some of these minors, the major issue is cross-
gender behaviors or identifications; for others, the
gender issues seem to be epiphenomena of psycho-
pathology, exposure to trauma, or attempts to re-
solve problems such as lacking higher social status
or other benefits they perceive to be associated with
the other gender.
• In general, a minor’s notions of gender and gender
identity will vary according to the minor’s age.

• Until children master the capacity for operational
thought (between the ages of five and seven), they
tend to conflate gender identity with surface expres-
sions of gender.
• The gender dysphoria of the majority of children
with GD/GV does not persist into adolescence, and
when it does not, the children are referred to as “de-
sisters.”
• Prospective studies indicate that the majority of
those who desist by or during adolescence grow up
to be gay, not transgender, and that a smaller propor-
tion grow up to be heterosexual.
• There is at present no way to predict in which chil-
dren GD/GV will or will not persist into adoles-
cence or beyond. 15
• GD/GV that persists into adolescence is more likely
to persist into adulthood.
• GD/GV may be mimicked by gender confusion
that occurs as an epiphenomenon of other problems
(e.g., gender confusion as the result of sexual trauma
or delusions in the context of psychotic disorders).
Much remains unknown, however. In particular, re-
search has yet to show
• how either a cisgender identity16 or a transgender
identity develops;
• the relative contributions of biology and psycho-
social environmental factors in the development of
gender identity, whether cisgender or transgender;

• the extent to which gender identity in individuals
with GD/GV does or does not develop along the
same lines as gender identity in cisgender individu-
als; and
• why the gender dysphoria of most children desists
around puberty, while it persists in others into ado-
lescence and adulthood.
Given the absence of strong empirical data regarding the
best GD treatment outcomes in children, each of the three
treatment approaches outlined above raises ethical ques-
tions. The rest of this paper does not purport to answer the
questions it presents. Instead, these questions are intended
to stimulate discussion in a wider range of interested par-
ties about the ethical issues with which the experts treating
these children are or should be engaging. Hopefully, such
discussions can serve to improve care for all children and
their families regardless of which gender clinic they choose.
The ethical principles that underlie the questions and
discussions that follow are from The Principles of Medical
Ethics: With Annotations Especially Applicable to
Psychiatry,17
specifically, section 1.2 and section 5. The first of these
reads, “A psychiatrist should not be a party to any type of
policy that excludes, segregates, or demeans the dignity of
any patient because of ethnic origin, race, sex, creed, age,
socioeconomic status, or sexual orientation” (p. 3). Section

5 states, “A physician shall continue to study, apply, and
advance scientific knowledge, maintain a commitment to
medical education, make relevant information available to
patients, colleagues, and the public, obtain consultation,
and use the talents of other health professionals when in-
dicated” (p. 8).
Clinical Ethics
Is Preventing Transsexualism an Acceptable Clinical
Activity?
It could be construed, as some in the transgender com-
munity maintain, that clinical attempts to prevent trans-
sexualism, no matter how well meaning, are unethical
because they demean the dignity of gender-variant chil-
dren.18 Although the principles of ethics do not comment
specifically on “gender identity” or “gender expression”
—the usual terms used in laws and position statements
aimed at protecting transgender rights—the rapid cultural
acceptance of gender diversity and psychiatry’s unfortunate
history of trying to “cure” homosexuality raise questions of
whether “prevention of transsexualism” is a benign medical
activity or an attack on an individual’s identity.
This question raises another: is there empirical evidence
that childhood treatment can reduce the rate of persistence
and prevent adult transsexualism in some individuals?
Should Parents Be Told That Adult Transsexualism Is
Preventable?
Kenneth J. Zucker and colleagues note that while many
of the parents with whom they consult do not mind if
their gender-variant children grow up to be gay, they see
having a child who grows up to be transgender as more

problematic.19 It is therefore reasonable to assume that
their clinical approach of representing adult transsexualism
as preventable stems from an effort to satisfy the wishes
of the parents. However, there are presently no controlled
studies that demonstrate that discouraging cross-gender
behavior and interests in childhood does in fact reduce per-
sistence or prevent transsexualism. In addition, there are
no proven, reliable indicators to distinguish children whose
dysphoria will desist from those in whom it will persist.
Since no clinician can accurately predict the future gender
identity of any particular child, shouldn’t we assume that
efforts to discourage cross-gender play and identifications
may be experienced as hurtful and possibly even traumatic,
since, for some children, gender dysphoria will persist into
adolescence and adulthood? If so, is it ethical to offer such
treatment without informing parents of the current state
of the research or of possible harmful side effects (which
may be experienced by desisters as well as persisters)? And
if some children may be harmed, do the benefits outweigh
the risks, and are these risks and benefits sufficiently clear
to parents? Are the harms so unknown or so great that it is
unethical to offer such treatment at all? Mental health pro-
fessionals should look to other areas of medicine to under-
stand standards for informed consent regarding treatments
whose efficacy and safety are unproven.
Is It Okay to Steer a Child away from a Gender-Variant
Position?
In considering whether to support or promote the gen-
der-variant position of a child, parents, family members,
pediatricians, and mental health clinicians should consider
how any action or inaction will affect the child and how it
may result in beneficence (doing what is in the interest of
the child) or maleficence (harm). They also need to consid-

er the ethical principle of autonomy even though children
are not considered autonomous in the eyes of medicine and
the law because they are deemed developmentally imma-
ture and unable to fully understand the risks and benefits
of medical decision-making. When it comes to compli-
cated decisions regarding treatments for severe childhood
diseases such as leukemia that have profound impacts on
the child’s immediate emotional and physical well-being,
families and clinicians have constructed creative strategies
to respect the dignity and relative autonomy of the child
who has to bear the pain of difficult treatments.
Since research shows that a relatively low percentage of
children persist and that those who socially transition one
way may need to transition back to their natal gender, a
cautious approach is warranted. Also, given that certain en-
vironments (a school, church, or playground, for example)
may be unsafe spaces in which to express gender variance,
protecting a child from overt threats by modifying gender
expression in those settings is a common-sense approach.
There is no expert clinical consensus regarding the treatment of
prepubescent children who meet diagnostic criteria
for gender dysphoria.
R E P O R T
Yet, should caution and modification for safety reasons
rationalize as-yet-unproven efforts to steer a child’s gen-
der identity in a cisgender direction? Given that how any
gender identity develops is an unknown, is it not possible
that opposing a wish to explore cross-gender expression is

harmful to some children? Whether they persist or desist
in their transgender behavior or identity, children may in-
ternalize disapproving attitudes toward atypical gender be-
havior and expression (transphobia), with possible negative
consequences for adult development.20
What are the ethical implications of delaying social
transition for children who persist?
Unlike Zucker et al., Annelou L. de Vries and Peggy
T. Cohen-Kettenis do not discourage cross-gender play,
although they do discourage social transition in prepu-
bescent children because most children with GD will not
remain dysphoric through adolescence. They aim to pre-
vent youths with nonpersisting gender dysphoria from hav-
ing to make a complex change back to the role of their natal
gender. They cite the qualitative follow-up study in which
several youths indicated how difficult it was for them to
realize that they no longer wanted to live in the role of the
other gender and to make this clear to the people around
them.21
However, another ethical question is raised by this ap-
proach: Since the clinicians freely admit that they are un-
able to distinguish persisters from desisters, what are the
risks and benefits of delaying the social transition of per-
sisting children in order to prevent possible psychological
harm to those who will desist? Put another way, are the
children who will grow up to be trans being subjected to
unnecessary stress in order to preserve the well-being of the
majority who will not?22
Further, increasing numbers of young children are mak-
ing social transitions sanctioned by families before they
even come to a gender clinic. Schools and other commu-
nity settings are helping children adapt to these changes as

well. That some children may be supported in transition
before they know what their natal sex is or what it means
is a complex issue that deserves further investigation. Does
this complexity increase the burden on medical and child-
care systems, as well as families, to fully evaluate and weigh
the factors for and against transition of any child?
What are the ethical implications of permitting early
transition in children who desist?
Diane Ehrensaft makes a case for early social transition
that appears to be based on the belief that those who will
be persisters can be distinguished from other individuals
who present signs of gender dysphoria. She states, “Once
allowed to transition, these children [persisters] typically
relax and the signs of stress, distress, and disruption dissi-
pate, if not disappear altogether.”23 “Although not a univer-
sal phenomenon,” she asserts, “one simple rule of thumb
is that if the assessment is correct, the child shows signs of
getting better; if the assessment was incorrect, the child gets
worse, or at least no better” (346-47).
While Ehrensaft notes correctly that there is little em-
pirical data demonstrating harm in transitioning twice,
there is also no empirical evidence demonstrating that a
prepubescent child who is permitted to socially transition
but then desists can simply and harmlessly transition back
to the natal gender. Given the complexity involved in the
first social transition, should we accept at face value the
claim that transition back to the original gender is entirely
without risks and pitfalls? Furthermore, in the absence of
empirical studies, is permitting early social transition with-
out a verifiable system of distinguishing persisters from de-
sisters an ethically appropriate treatment?

A Work in Progress
Obviously, more research is needed to help understand the
biological, cultural, and psychological factors of
gender identity formation, as well as outcomes for those
who persist, desist, transition socially or medically, take
on normative gender (cisgender) identity, or adopt atypi-
cal, gender-queer, or nonbinary identities. It would also be
helpful to the affected populations if there were more col-
laboration and comparison of results between specialized
gender clinics with treatment methods.
As discussed by other authors in this special report, the
Institute of Medicine has commented on the significant
lack of research on the health and mental health needs of
transgender populations.24 However, the ability to conduct
research on transgender individuals in itself raises ethi-
cal concerns. In this era of evidence-based medicine, the
demand to produce rigorous research data can hamstring
clinical efforts in the field of transgender medicine. While
clinicians struggle to help patients and families make dif-
ficult and often painful decisions in the here and now, they
cannot always wait for research-based conclusions to guide
them. That is not to say that it is impossible to do research
or that it should not be attempted, but that current clini-
cal needs must respect the nuance and subjectivity of gen-
der identity, as well as the ethical standards of beneficence,
nonmaleficence, and autonomy. At this juncture, reason-
able informed consent would involve telling parents that
(1) the best treatment approach for these children is a sub-
ject of controversy; (2) that there is presently no way to
predict whether their transgender child will desist or persist
into adolescence and adulthood; (3) that it is unclear if an
adult transgender outcome can be prevented; (4) that if
the child is socially transitioned to the experienced gender,
there is a possibility that the child might transition back

to the natal gender; and (5) that intervention and nonin-
tervention both may carry risks to the welfare of the child,
requiring that providers and families examine and weigh
predictable risks and benefits in a given situation to the best
of their ability.
With that in mind, we know that the experience of
being a gender-variant child is challenging, possibly char-
acterized by distress and dysphoria, that it can persist or
desist, and that it can open up options for social and later
medical transition that involve serious ethical and practi-
cal concerns for clinicians and families. We know that
these children are in our midst now, that their numbers
are increasing at gender clinics and elsewhere, and that
their presence is putting greater pressure on the medical
and mental health systems to create standards and clini-
cal practice, research, and model approaches that adhere
to modern medical ethical standards. As these standards
are created, evaluated, and modified, it will be essential to
continuously reflect on the ethical questions, concerns, and
limitations raised above—and others that may arise in the
future—to best ensure that the medical field is doing its
best to help and not harm gender-variant children, adoles-
cents, and their families.
1. I. Lovett, “California: Rights Guaranteed for Transgender
Students,” New York Times, August 13, 2013, p. A12.
2. Some trans advocates see the medicalization of transgender-
ism as contributory to this state of affairs (see D. B. Hill et al.,

“Gender Identity Disorders in Childhood and Adolescence: A
Critical Inquiry,” International Journal of Sexual Health 19, no.
1
(2007): 57-74; K. Winters, “Gender Dissonance: Diagnostic
Reform
of Gender Identity Disorder for Adults,” Journal of Psychology
&
Human Sexuality 17, no. 3/4 (2005): 71-89. Yet, while the gay
rights
movement can attribute much of its advancements to the
removal
of homosexuality from the DSM in 1973, transgender rights
have
progressed, albeit at a slower pace, despite the appearance of
gender
diagnoses in both the DSM and the ICD.
3. World Professional Association for Transgender Health,
Standards of Care for the Health of Transsexual, Transgender
and
Gender Non-Conforming People, 7th version, 2011, at
http://www.
wpath.org/.
4. A. E. Cha, “Ban Lifted on Medicare Coverage for Sex Change
Surgery,” Washington Post, May 30, 2014, http://www.washing-
tonpost.com/national/health-science/ban-lifted-on-medicare-
coverage-for-sex-change-surgery/2014/05/30/28bcd122-e818-1
1e3-a86b-362fd5443d19_story.html.
5. At the time of this writing, a proposed name change for ICD-
11
is “gender incongruence of children.”
6. This was formerly known as the Harry Benjamin International
Gender Dysphoria Association.

7. See World Professional Association for Transgender Health,
“Standards of Care for the Health of Transsexual, Transgender
and
Gender Non-Conforming People,” 11.
8. W. Byne et al., “Report of the American Psychiatric
Association
Task Force on Treatment of Gender Identity Disorder,”
Archives of
Sexual Behavior, 41, no. 4 (2012): 759-96, at 762.
9. K. J. Zucker, “Children with Gender Identity Disorder: Is
There
a Best Practice?,” Neuropsychiatrie de l’enfance et de
l’adolescence,
56 (2008): 358-64; K. J. Zucker et al, “A Developmental,
Biopsychosocial Model for the Treatment of Children with
Gender
Identity Disorder,” Journal of Homosexuality, 59, no. 3 (2012):
369-
97.
10. A. L. de Vries and P. T. Cohen-Kettenis, “Clinical
Management
of Gender Dysphoria in Children and Adolescents: The Dutch
Approach,” Journal of Homosexuality 59, no. 3 (2012): 301-20.
11. All three clinics mentioned here offer puberty suppression
to children when clinically indicated, either to “buy time” in
case
they desist after puberty or to prevent development of secondary
sex
characteristics in those who persist. However, the approach here
acts

under the assumption that they are better able to distinguish
desisters
from persisters.
12. D. Ehrensaft, “From Gender Identity Disorder to Gender
Identity Creativity: True Gender Self Child Therapy,” Journal
of
Homosexuality 59, no. 3 (2012): 337-56.
13. Further illustrating the controversies, some clinicians
(includ-
ing Ehrensaft) eschew the use of psychiatric diagnoses when
evaluat-
ing and treating these children. Consequently, the nonmedical
term
“gender variance” is an alternative, nonpathologizing way of
describ-
ing them.
14. Since it often appears that child GD experts talk past each
oth-
er, Jack Drescher and William Byne invited several of them to
pub-
lish their clinical approaches in one volume. However, rather
than
critique each other, which they often do, the clinicians were
asked
to present their own approaches, which would then be discussed
by
experts (child psychiatrists, ethicists, attorneys, trans advocates,
and
gender scholars) who did not treat GD themselves but who had
an
interest in issues related to gender. See J. Drescher and W.
Byne,
Treating Transgender Children and Adolescents: An

Interdisciplinary
Discussion (New York: Routledge, 2013).
15. In a most recent study, Thomas D. Steensma et al., found a
link between the intensity of GD in childhood and persistence
of
GD, as well as a higher probability of persistence among natal
girls.
Psychological functioning and the quality of peer relations did
not
predict the persistence of childhood GD. Formerly
nonsignificant
factors (e.g., age at childhood assessment) and unstudied factors
(a
cognitive or affective cross-gender identification and a social
role
transition) were associated with the persistence of childhood
GD
and varied among natal boys and girls. Steensma et al.
concluded,
“Intensity of early GD appears to be an important predictor of
persis-
tence of GD. Clinical recommendations for the support of
children
with GD may need to be developed independently for natal boys
and
for girls, as the presentation of boys and girls with GD is
different,
and different factors are predictive for the persistence of GD”
(T. D.
Steensma et al., “Factors Associated with Desistence and
Persistence
of Childhood Gender Dysphoria: A Quantitative Follow-up
Study,”
Journal of the American Academy Child & Adolescent
Psychiatry, 52,

no. 6 [2013]: 582-90, at 589).
16. “Cisgender” is used in the transgender community to
describe
those who are not transgender.
17. American Psychiatric Association, The Principles of
Medical
Ethics: With Annotations Especially Applicable to Psychiatry
(Arlington,
VA: APA, 2009). One caveat should be noted: these comments
are
made with the understanding that many of the mental health
prac-
titioners offering treatment to prepubescent children are not
physi-
cians.
18. S. D. Pickstone-Taylor, letter to the editor (“Children with
Gender Nonconformity”), Journal of American Academy Child
&
Adolescent Psychiatry 42, no. 3 (2003): 266.
19. K. J. Zucker et al., “A Developmental, Biopsychosocial
Model
for the Treatment of Children with Gender Identity Disorder,”
Journal of Homosexuality 59, no. 3 (2012): 369-97; see 391-92.
R E P O R T
20. K. E. Bryant, “The Politics of Pathology and the Making
of Gender Identity Disorder,” PhD diss., University of
California,

Santa Barbara, 2007.
21. T. D. Steensma et al., “Desisting and Persisting Gender
Dysphoria after Childhood: A Qualitative Follow-up Study,”
Clinical
Child Psychology & Psychiatry 16, no. 4 (2011): 499-516.
22. A similar question can be raised about the treatment of adult
trans individuals. Does the present system of “gate keeping”
before
allowing medical and surgical treatment exist for the benefit of
those
wishing to transition or to protect those individuals who, after
transi-
tion, might express regrets?
23. Ehrensaft, “From Gender Identity Disorder to Gender
Identity
Creativity: True Gender Self Child Therapy,” 354.
24. Institute of Medicine, Committee on Lesbian, Gay,
Bisexual,
and Transgender Health Issues and Research Gaps and
Opportunities,
The Health of Lesbian, Gay, Bisexual and Transgender People:
Building
a Foundation for Better Understanding (Washington, DC:
National
Academies Press, 2011).

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