Ana Lita & Rasita Vinay

Would you live your life in a body you feel is unwanted to you? Gender identity disorder, the original term coined for this mental state, was deemed unfit to label a specific group of individuals with a persistent feeling of discomfort with their anatomical sex.

Gender dysphoria, as defined by the American College of Pediatricians, is a “psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological self”. According to the UK National Health Service, is a condition of distress or discomfort experienced in response to a mismatch between an individual’s biological sex and gender identity. The negative psychological effects of such distress include anxiety disorders, depression, and an increased risk of suicide. For transitioning males (biological females transitioning their sex-specific body features to those of a biological male) these negative effects may be relieved by chest reconstruction in the form of a double mastectomy.

A comprehensive study on chest reconstruction and chest dysphoria, was conducted by a group of experts based at the Centre for Transyouth Health and Development at Children’s Hospital, Los Angeles (the largest transgender clinic in the United States), whose medical director is Dr. Johanna Olsen. The study was conducted on 68 transitioning males aged 13-25. Two of the girls (transmales) were aged 13, and five aged 14. A study by Dr. Lisa Littman at Brown University, discusses Rapid Onset Gender Dysphoria (ROGD) as “a phenomenon where the development of gender dysphoria is observed to begin suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood”. According to Littman, ROGD causes a deterioration of mental well-being and parent-child relationships, leading to isolation from families and friends. Some internet sources of information might also contribute to ROGD, and all these aspects are particularly concerning. Michael Cook, the editor of BioEdge/Mercatonet, cites the case of 22-year-old Youtuber named Carla who identifies as a “detransitioner”.

This consideration of possible harm to self through a voluntary action is very important in such an ethical debate. The legal age of consent in most US states is 18. However, recent studies show that the brain continues to develop until our mid-20s or even early 30s. The debate over whether the informed consent can be given before brain development has fully halted is beyond the scope of this article. However, it is a relevant question when considering whether a child of only 13 or 14 can give consent to a surgical procedure whose effects are as permanent and severe as a double mastectomy. Moreover, with documented experiences of detransitioners outlining the exact scope of the debilitating harms of late on-set regret, the question of whether such a procedure should be performed on a minor even assuming that informed consent is possible also requires particular attention. There is no expert clinical consensus on treating prepubescent children with gender dysphoria.

The World Professional Association for Transgender Health has noted in their Standards of Care, that gender dysphoria experienced in childhood does not necessarily continue into adulthood. They have reported that only 6-23% of boys and 12-27% of girls treated in gender clinics, continued to experience gender dysphoria into adulthood.

Alongside the consequences of ‘transitioning’, there is also an important social aspect of the issue at hand that should be considered. In the United States, the transgender community is discriminated against in the form of some policies banning transgender individuals from chosen-gender restroom usage. Associating a scandal caused by mastectomies performed on minors with the goals of the transgender-rights movement only sets back the social achievements of this marginalized community. It also advances a well-circulated rhetoric of the transgender community as comprised of irrational individuals in denial of basic science. The social harms of these attitudes on a large and growing community are significant enough to be an important consideration in this ethical debate.

Considering the growing scope of medical ethics and transgender rights, we need to assess the distinction between what society labels as an ethical issue and what is medically possible and/or permissible. While both sides of this debate present legitimate arguments, the long-term findings of the study by Dr. Olsen’s group remain yet to be seen.

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Ana Lita, Ph.D, Executive Director.

Rasita Vinay, M. Bioethics Candidate, Monash University.