Rabu, 9 Oktober 2019

JOURNAL READING

GENDER DYSPHORIA : BIOETHICAL ISSUE

Pembimbing : dr. Mustika Chasanatusy, Sp.F

Disusun Oleh : Makmun Nawil Liem Sahal

Muhammad Rubangi
Hafizh Al-Amanah
Muhammad Sholihuddin
GENDER DYSPHORIA : BIOETHICAL ASPECTS
OF MEDICAL TREATMENT
Marta R. Bizic, Milos Jeftovic, Slavica Pusica, Borko Stojanovic, Dragana Duisin, Svetlana Vujovic,
Vojin Rakic and Miroslav L. Djordjevic

Received 11 January 2018; Accepted 26 March 2018; Published 13 June 2018

Introduction

• Gender dysphoria (GD) represents a condition where a person’s gender assigned at

birth and the gender with which they identify themselves are incongruent.
• The prevalence of gender dysphoria is 0.005-0.014% for adult natal males and 0.002-
0.003% for adult natal females
• To take the edge of their state, one can choose to go through a social transition
• A more radical approach is the medical transition that includes hormonal and surgical
treatment
Medical Treatment

• Psychiatric assessment is the frst step and • With unknown etiology and questionable
is very complex defnition (mental/medical illness, social
construct, and variation of sex) who can
• The next step is hormonal treatment,
decide, with 100% certainty, what treatment is
under the care of an endocrinologist
in the best interest of a particular patient?
• Continue to gender-affirming surgery
(GAS) ?
• Treatment of gender dysphoria always
raised numerous ethical issues

The seventh edition of the Standards of Care of the WPATH offers fexible guidelines  link downlad
https://www.wpath.org/publications/soc
 The most prominent challenges and ethical
questions pertain to the treatment of underage
individuals, fertility after GAS, and possibility of
regret after GAS

Main ethical principles are autonomy, beneficence, nonmalefcence, and

informed consent
Autonomy
• Because sometimes the individual’s
desires, hopes, and expectations might
not correlate with reality

Beneficence Always keeping these principles in mind,

WPATH Standards of Care and criteria for
• Beneficence implies doing only good,
diagnosis might not be enough to be
only what is in the patient’s best interest
ascertain that we are doing the right thing

Nonmalefcence
• Nonmaleficence must ensure that the
treatment does not harm the individual
in an emotional, social, or physical sense
 Transgender Youth
• Children represent a small number of • Viable treatment options vary from fully
individuals with gender dysphoria and in only reversible treatment :
10-20% of the children
1. Puberty-suppressing gonadotropin-
• Psychological therapy and support are releasing hormone analogues (GnRH)
highly recommended
2. Gonadal steroid treatment
• Inadequate management of children with
• Irreversible treatment :
persistent gender dysphoria can lead to :
1. Surgical removal of genitalia and
1. Isolation
reconstruction of new ones  according
2. Feeling of self-hatred to the desired gender
3. Suicidal ideas and attempts

Surgery includes bilateral mastectomy with chest reconstruction, hysterectomy with oophorectomy followed by either
metoidioplasty or phalloplasty for trans-male individuals, and bilateral orchiectomy with penectomy followed by vulvoplasty and
vaginoplasty in trans-female individuals
 Transgender Youth

• De Vries et al. were the frst to introduce the concept Finally, the decision about implementing GnRH
and research on the use of puberty blockers for treatment is very difficult and cannot be made without
treatment of transgender youth (2011) ethical dilemmas

• Viner et al. proposed that GnRH therapy can be

physically damaging for teenagers and can lead to
unfavorable psychological consequences. (2005)
“Are guided by the same ethical
principles, beneficence,
• Results from Steensma et al. showed that majority of nonmalefcence, and autonomy”
children developed homosexual orientation afer
completion of the GnRH treatment. (2013)
Hormonal Treatment  Transgender Youth
• Indications :
1. Confirmed persistence of gender
dysphoria
2. Adequate mental capacity
3. To initiate sex hormonal therapy before
16 y.o (14-12 y.o ) (Hembree et al, 2017)
• Main Goals :
1. Suppression of endogenous sex
hormone secretion
• Harmonizes the external appearance with
affirmed gender, :
1. In transgender men, male-sounding
voice, diferent fat distribution, increase in
muscle mass and,
2. in transgender women, breast growth,
decreased facial and body hair, more
feminine fat redistribution, and
decreased muscle mas
 “Hormonal therapy was safe, with necessary
follow-up for potential complication”

Complications include :

In trans-men In trans-women
1. Increase in hemoglobin, 1. lower testosterone and
2. Increase in hematocrit, and 2. lower alanine aminotransferase
3. Increase in body mass index (ALT)
with lowering of high-density
lipoprotein levels

“Hormonal therapy is safe for transgender youth over a period of

approximately two years.”
 Based on bioethical principles, children usually do not have the
power to make legal decisions and actions at the initiation of cross-
hormonal therapy.

Proper education of the patient and pointing out advantages

and shortcomings of such treatment are of crucial important
Gender affirmation surgery (GAS)

• Is the last step in the medical transition  to be irreversible

• According to WPATH Standards of Care  a criterion for eligibility for GAS is : “reached
legal age of maturity in a given country.”
• Beneficence principle VS nonmaleficence
• “Doing nothing is doing harm” or “the treatment plan that involves less extensive surgery or
none at all”,

And then…
• The main concern is the possibility of regret after the GAS
• is it better to sufer the consequences of GD or GAS ? Are children or teenagers mature
enough to make these decisions ?
Fertility
• Members of the transgender population have the same desire for
offspring and fertility presents one of the most delicate issues.
• Infertility in trans-women is caused by orchiectomy as a part of the
GAS. Conversely, hysterectomy and oophorectomy eliminate the
chance of pregnancy in trans-men.
• Cross-sex hormonal therapy also has an impact on fertility, but such
treatment is not a definitive cause of infertility.
• Estrogen in trans-women leads to the reduction of testicular volume
and has a strong suppressive effect on sperm motility and density.
Testosterone therapy for trans-men leads to reversible amenorrhea.
• The possibility of sterility following the use of puberty blockers and cross-
sex hormones gives rise to further controversy and ethical dilemmas, as
do options of cryopreservation prior to the start of cross-sex hormonal
therapy and uterus transplantation for trans-women.
• In cases where the hormonal transition has already started, they
suggest an interruption of hormone treatment for minimum 3 months
with a goal to revert any potential therapy-induced effects.
Regret and Revision Surgery

• There are various levels of regret after GAS. Definite regret happens
when the patient wants to get back to their gender assigned at birth
after the GAS is performed.
• Reasons for regret vary greatly :
• Inadequate social adaptation,
• Comorbidity with certain psychiatric disorders,
• Poor psychological and psychiatric evaluation, and
• Dissatisfaction with aesthetic or functional outcome of GAS.
Conclusion
• All physicians included in gender dysphoria treatment are facing great
bioethical challenges and dilemmas.
• The most sensitive issues are the treatment of transgender youth, fertility
and parenting in transgender individuals, and the risk of regret after
the irreversible part of the treatment, the gender affirmation surgery.
• In order to avoid the complex issue of regret, proper preoperative
evaluation by experienced professionals, psychologists, and
psychiatrists is necessary.
GENDER DYSPHORIA IN ADOLESCENCE:
CURRENT PERSPECTIVES
Gender dysphoria and related
concepts
• DSM-5 defines gender dysphoria (GD) as a condition in which a person has marked
incongruence between the expressed or experienced gender and the biological sex
at birth.
• Individuals with GD experience a strong desire to be treated as the other gender (or
some alternative gender different from their assigned gender) and/or to be rid of their
sex characteristics, and/or the strong conviction of having feelings and reactions
typical of the other gender (or some alternative gender).
How common are GD and
transgender identity among adults
and adolescents?
• The number of people who seek treatment suggest that male to female transsexualism
has a prevalence of 6.8/100,000 and female-to-male transsexualism has a prevalence
of 2.6/100,000 among adults.
• In the Netherlands, 0.6% of men and 0.2% of women (aged 15–70 years) reported
incongruent gender identity and a desire to undergo sex reassignment.
Gender identity
• Identity is the way one understands, describes and expresses oneself and the reflection
of those entities to others.
• Gender identity concerns the individual’s core sense of being “female”, “male” or
another gender.
• The development of gender identity is a complex process affected by multiple factors.
• psychodynamic theories, gender variant behavior was hypothesized to derive from
parent–infant interpersonal issues or trauma.
• Other theories on processes of gender typing have focused on proximal and distal
biological influences, genetic and epigenetic or hormonal and neural mechanisms as
well as brain anatomy differences in the etiology of gendered behavior and gender
variance.
Childhood GD and puberty
development
• GD in childhood (GDC)1 describes a feeling of incongruence between the
experienced (psychological) gender and the sex assigned at birth.
• The outcomes of GDC have been discussed in terms of its persistence and desistence.
• For most children with GDC, whether GD will persist or desist will probably be
determined between the ages of 10 and 13 years.
Treatment of GD intensifying in
puberty: the Dutch model
• The most commonly used guidelines for the treatment of GD in children and adolescents are
those of The Endocrine Society.
• The Dutch protocol recommends medical treatment if GD intensifies in puberty, while the
care for children with GD and their families consists of providing information, psychological
support, parental or/and family counseling.
• In adolescents, medical treatment is recommended at age 12 years and older for those
who are in or beyond the early stages (Tanner II–III) of puberty and are still experiencing
persistent GD.
• Puberty suppression with gonadotropinreleasing hormone analogs is part of the protocol for
these patients.
• Cross-sex hormones are used for adolescents aged 16 years and older who continue to
experience persistent GD.
• People aged 18 years and older with a diagnosis of GD may undergo SR surgery.
Outcome of and ethical debates
around medical interventions for
GD in adolescence
• The Dutch protocol is largely used, but it has its critics.
• Controversy regarding the use of drugs for puberty touches on fundamental ethical
concepts in pediatrics: the best interests of the minor, autonomy and the role of social
context. Professionals recognize the distress of young people with GD and feel an urge
to treat them.
• Reports of the outcomes of puberty suppression treatment in adolescents have shown
reasonable safety and good outcomes regarding patient satisfaction and
psychosocial functioning, but research is still scarce.
Psychiatric disorders among
adolescents with GD
• in Europe and North America have mainly suggested that ~40%–45% of these young
people present with clinically significant psychopathology.
• The most commonly reported disorders are depression and anxiety disorders. Self-harm
and suicidal ideation/behavior are also common, whereas conduct disorder and
antisocial development do not appear central in this population.
• Likewise, community-level information suggests that transgender-identifying youth
present four to six times more often with depression and three to four times more often
with self-harm and/or suicidal behavior compared with cisgender adolescents.
GD and the developmental tasks of
adolescence
• Developmental tasks” refer to the normative developmental milestones that should be
reached during a given developmental stage.
• The developmental tasks of adolescence were first formulated by Havighurst57 and
comprise accepting one’s body, adopting a masculine or feminine social role,
achieving emotional independence from parents, developing close relationships with
peers of the same and opposite genders, preparing for an occupation, preparing for
marriage and family life, establishing a personal value or an ethical system and
achieving socially responsible behavior.
GD in adolescence and relationships
with parents
• Parents of adolescents with GD and/or transgender identity may face special
challenges that are shaped by a variety of factors, such as ethnicity, religious
background, social class and the prevailing attitudes in their community and society.
These challenges likely shape the support that a nonconforming adolescent can
receive.
• In a Canadian community study of transgender-identifying youth,63 of those who had
disclosed their gender identity to their parents, 34% considered their parents “very”
supportive and 25% considered their parents “somewhat” supportive.
• Forty-two percent reported that their parents were “not very” or “not at all” supportive.
Gender nonconformance and peer relationships
in adolescence
• During adolescence, peer relationships are critical for psychological well-being.
Loneliness and social isolation from peer relationships is associated with
developmental diffculties and impaired mental health. An important peer
network-related risk factor is bullying.
• Clark et al found that transgender-identifying adolescents had 4.5x increased
odds of being bullied and were approximately twice as likely to report being
afraid for their personal safety, having been in a serious physical fight and having
been hit or otherwise harmed by others, They also less commonly felt that their
friends cared about them and that school was okay.
• That may need attention.
• However, in Finland, not all the diffculties the gender dysphoric adolescents, other
factors such as not being slim, being successful at school or having unfashionable,
hobbies and interests.
GD, transgender identity and sexuality in
adolescence
• Sexual orientation and gender identity are different entities, and
transgender people present with a variety of sexual orientations.
• During adolescence, the different facets of sexual orientation –
attraction, behavior and identity – may still be developing.
• Bungener et al, from the Netherlands. They compared the sexual
experiences of 137 transsexual adolescents. Transsexual adolescents
had fewer sexual experiences than the same-aged population in all
areas measured (falling in love, romantic relationships, kissing, petting,
intercourse).
• However, a majority of the transsexual adolescents had fallen in love
and approximately half had been involved in romantic relationships.
• Korchmaros et al, compared the romantic relationships of lesbian, gay,
bisexual, transgender and questioning (LGBTQ) adolescents and those of
adolescents with mainstream sexual and gender identities. Contrary to
expectations, the LGBTQ adolescents were more experienced with
romantic relationships and more active in initiating relationships both online
and offline.
• Robinson and Espelage reported that LGBTQ adolescents were more likely
to display risky sexual behaviors than same-aged non-LGBTQ youth.
• Sexual harassment is a common problem among adolescent populations.
Transgender-identifying adolescents appear to be at the greatest risk of
sexual harassment and to experience the greatest distress due to it. Sexual
harassment is suggested to function to maintain heteronormativity, which
transgender adolescents likely challenge.
• Transgender adolescents and young adults, particularly trans females, are
at a disproportionately high risk of contracting HIV and other sexually
transmitted diseases.
• Sexual education is an important way to promote positive and responsible
Preparing for occupation: academic
performance and socioeconomic status
To the best of our knowledge, research has not specifcally focused . Aspects of social
relationships are relevant to well-being in school, school performance and pathways to
occupation.
• Transgender youth have been reported to experience bullying and discrimination in
schools, not only by peers but even by teachers; consequently, they perceive schools
as unsafe places, which again increases the risk of non-attendance and poorer results.
• Gender- and sexuality-related victimization may impair academic performance
through, for example, decreased motivation, concentration and self-effcacy and the
resulting school avoidance and harmful coping strategies. School dropout is strongly
linked to social exclusion.
• Jacob and Cox also pinpointed transgender people’s greater risk of having a
disadvantaged socioeconomic status (in the USA), associating this with increased
unemployment, and employment in low-paid jobs, because of stigmatization.
Why the increase in referrals?
• Zucker et al, observed an increase in the number of adolescents presenting at gender
identity services in the early 2000s. Since then, several gender identity services for
minors from across Western countries have reported increases.
• The increase in referrals could be attributable to enhanced provision of services, or the
threshold for seeking help may now be lower due to increased knowledge and
improved societal acceptance.
Comments
• Research regarding the clinical treatment of adolescents with GD has mainly focused on
childhood-onset GD that intensifes during puberty.
• More empirical research is needed regarding virtually all aspects of GD in adolescence to
create treatment approaches that optimize these young people’s future psychosocial
health and well-being.
• The etiology of gender incongruence remains unknown.
• It seems unlikely that all the psychopathology observed in the referred samples is
secondary to gender identity issues and would resolve with hormonal and later surgical
treatments.
TERIMAKASIH
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