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Levine SB. What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria. JOURNAL OF SEX & MARITAL THERAPY 2024; 50:773-786. [PMID: 38856025 DOI: 10.1080/0092623x.2024.2362774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
The rising incidence of trans youth throughout the world and the new policy of many European countries and 25 US states that psychotherapy should be the first therapeutic response to Gender Dysphoria have made a reexamination of a comprehensive psychiatric evaluation (CPE) urgently relevant. Two conflicting views of the purpose of the CPE exist based on etiologic beliefs and convictions about the best therapeutic approach. This paper provides one clinician's synthesis of the elements, processes, goals, values, benchmarks of CPE and its usual recommendation for psychotherapy. The CPE recommended herein provides cogent hypotheses about the origins of the intrapsychic creation of a trans identity that are to be strengthened, weakened, or supplanted by explanations that emerge from psychotherapy. It also strengthens familial bonds and clarifies the intention to improve the mental health, social function, and autonomy of the minor. The inescapable ethical tensions that surround trans minor health care are discussed. The recommended CPE does not prevent subsequent medical interventions.
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Affiliation(s)
- Stephen B Levine
- Clinical Professor of Psychiatry, Case Western Reserve University, Cleveland, Ohio, USA
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. "I Should've Been Able to Decide for Myself, but I Didn't Want to Be Left Alone." A Qualitative Interview Study of Clients' Ethical Challenges and Norms Regarding Decision-Making in Gender-Affirming Medical Care. JOURNAL OF HOMOSEXUALITY 2024; 71:1757-1781. [PMID: 37097132 DOI: 10.1080/00918369.2023.2201972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.
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Affiliation(s)
- Karl Gerritse
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Casper Martens
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Liaison Psychiatry, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Fijgje de Boer
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert C Molewijk
- Department of Ethics, Law, and Humanities, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Vrouenraets LJJJ, de Vries ALC, Arnoldussen M, Hannema SE, Lindauer RJL, de Vries MC, Hein IM. Medical decision-making competence regarding puberty suppression: perceptions of transgender adolescents, their parents and clinicians. Eur Child Adolesc Psychiatry 2023; 32:2343-2361. [PMID: 36115898 PMCID: PMC10576681 DOI: 10.1007/s00787-022-02076-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 08/31/2022] [Indexed: 11/30/2022]
Abstract
According to international transgender care guidelines, transgender adolescents should have medical decision-making competence (MDC) to start puberty suppression (PS) and halt endogenous pubertal development. However, MDC is a debated concept in adolescent transgender care and little is known about the transgender adolescents', their parents', and clinicians' perspectives on this. Increasing our understanding of these perspectives can improve transgender adolescent care. A qualitative interview study with adolescents attending two Dutch gender identity clinics (eight transgender adolescents who proceeded to gender-affirming hormones after PS, and six adolescents who discontinued PS) and 12 of their parents, and focus groups with ten clinicians was conducted. From thematic analysis, three themes emerged regarding transgender adolescents' MDC to start PS: (1) challenges when assessing MDC, (2) aspects that are considered when assessing MDC, and (3) MDC's relevance. The four criteria one needs to fulfill to have MDC-understanding, appreciating, reasoning, communicating a choice-were all, to a greater or lesser extent, mentioned by most participants, just as MDC being relative to a specific decision and context. Interestingly, most adolescents, parents and clinicians find understanding and appreciating PS and its consequences important for MDC. Nevertheless, most state that the adolescents did not fully understand and appreciate PS and its consequences, but were nonetheless able to decide about PS. Parents' support of their child was considered essential in the decision-making process. Clinicians find MDC difficult to assess and put into practice in a uniform way. Dissemination of knowledge about MDC to start PS would help to adequately support adolescents, parents and clinicians in the decision-making process.
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Affiliation(s)
- Lieke Josephina Jeanne Johanna Vrouenraets
- Department of Medical Psychology, Willem Alexander Children's Hospital, Leiden University Medical Center, Leiden, The Netherlands.
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Emma Children's Hospital, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Marijn Arnoldussen
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Sabine E Hannema
- Department of Paediatric Endocrinology, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ramón J L Lindauer
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Medical Ethics and Health Law, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Paediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Vries ALC, Molewijk BC. GenderJourney: Participatory development of an ethics support tool to foster dialogue and reflection on shared decision-making in gender-affirming medical care. PATIENT EDUCATION AND COUNSELING 2023; 114:107854. [PMID: 37356115 DOI: 10.1016/j.pec.2023.107854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 05/19/2023] [Accepted: 06/13/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE To describe and reflect on the development process of GenderJourney: an ethics support tool that seeks to foster (dialogue and reflection on) shared decision-making (SDM) in gender-affirming medical care (GAMC). METHODS Part of a larger project, this study used a participatory design. We included transgender and gender diverse (TGD) clients and healthcare professionals (HCPs) throughout the study in co-creation workshops. In an iterative process, we (1) established stakeholders' needs, (2) reached a consensus on the aims, content, and design, (3) developed and tested successive renditions, and (4) presented the final version of the tool. RESULTS The final tool aims to (A) elucidate the client's care request and corresponding treatment preferences, (B) foster an explicit dialogue between TGD client and HCP about expected/preferred decisional roles and collaboration, (C) stimulate a systematic joint reflection on and handling of SDM-related ethical challenges. CONCLUSION The GenderJourney provides non-directive ethics support to jointly reflect on and foster good SDM, including its inherent ethical challenges. Future studies should focus on its implementation and actual contribution to good SDM. PRACTICE IMPLICATIONS GenderJourney may be used in GAMC to support the dialogue on what good SDM entails and the identification, discussion, and handling of SDM-related ethical challenges.
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Affiliation(s)
- Karl Gerritse
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Casper Martens
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Marijke A Bremmer
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Psychiatry, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Medical Psychology, Amsterdam UMC location VUmc, location Vrije Universiteit Amsterdam, the Netherlands.
| | - Annelou L C de Vries
- Center of Expertise on Gender Dysphoria, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands; Child and Adolescent Psychiatry, Amsterdam UMC location University of Amsterdam, the Netherlands.
| | - Bert C Molewijk
- Ethics, Law, and Humanities, Amsterdam UMC location Vrije Universiteit Amsterdam, the Netherlands.
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Gerritse K, Martens C, Bremmer MA, Kreukels BPC, de Boer F, Molewijk BC. Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals' ethical challenges and norms regarding decision-making in gender-affirming medical care. BMC Med Ethics 2022; 23:139. [PMID: 36575401 PMCID: PMC9793857 DOI: 10.1186/s12910-022-00880-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands. METHODS In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents' explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged. RESULTS Respondents' ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC's guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI. CONCLUSIONS This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.
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Affiliation(s)
- Karl Gerritse
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Casper Martens
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Marijke A. Bremmer
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Psychiatry, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Baudewijntje P. C. Kreukels
- grid.16872.3a0000 0004 0435 165XCenter of Expertise on Gender Dysphoria (CEGD), Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands ,grid.16872.3a0000 0004 0435 165XDepartment of Medical Psychology, Amsterdam UMC, Location VUmc, De Boelelaan 1118, 1081 HZ Amsterdam, The Netherlands
| | - Fijgje de Boer
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
| | - Bert C. Molewijk
- grid.509540.d0000 0004 6880 3010Department of Ethics, Law and Humanities (ELH), Amsterdam University Medical Center (UMC), Location VUmc, De Boelelaan 1089a, 1081 HV Amsterdam, The Netherlands
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Bell JAH, Salis M, Tong E, Nekolaichuk E, Barned C, Bianchi A, Buchman DZ, Rodrigues K, Shanker RR, Heesters AM. Clinical ethics consultations: a scoping review of reported outcomes. BMC Med Ethics 2022; 23:99. [PMID: 36167536 PMCID: PMC9513991 DOI: 10.1186/s12910-022-00832-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 08/30/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics consultations (CEC) can be complex interventions, involving multiple methods, stakeholders, and competing ethical values. Despite longstanding calls for rigorous evaluation in the field, progress has been limited. The Medical Research Council (MRC) proposed guidelines for evaluating the effectiveness of complex interventions. The evaluation of CEC may benefit from application of the MRC framework to advance the transparency and methodological rigor of this field. A first step is to understand the outcomes measured in evaluations of CEC in healthcare settings. OBJECTIVE The primary objective of this review was to identify and map the outcomes reported in primary studies of CEC. The secondary objective was to provide a comprehensive overview of CEC structures, processes, and roles to enhance understanding and to inform standardization. METHODS We searched electronic databases to identify primary studies of CEC involving patients, substitute decision-makers and/or family members, clinicians, healthcare staff and leaders. Outcomes were mapped across five conceptual domains as identified a priori based on our clinical ethics experience and preliminary literature searches and revised based on our emerging interpretation of the data. These domains included personal factors, process factors, clinical factors, quality, and resource factors. RESULTS Forty-eight studies were included in the review. Studies were highly heterogeneous and varied considerably regarding format and process of ethical intervention, credentials of interventionist, population of study, outcomes reported, and measures employed. In addition, few studies used validated measurement tools. The top three outcome domains that studies reported on were quality (n = 31), process factors (n = 23), and clinical factors (n = 19). The majority of studies examined multiple outcome domains. All five outcome domains were multidimensional and included a variety of subthemes. CONCLUSIONS This scoping review represents the initial phase of mapping the outcomes reported in primary studies of CEC and identifying gaps in the evidence. The confirmed lack of standardization represents a hindrance to the provision of high quality intervention and CEC scientific progress. Insights gained can inform the development of a core outcome set to standardize outcome measures in CEC evaluation research and enable scientifically rigorous efficacy trials of CEC.
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Affiliation(s)
- Jennifer A H Bell
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada.
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.
- The Institute for Education Research, University Health Network, Toronto, ON, Canada.
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada.
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
| | - Marina Salis
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Department of Philosophy, University of Toronto, Toronto, ON, Canada
- William Osler Health System, Brampton, ON, Canada
| | - Eryn Tong
- Department of Supportive Care Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Erica Nekolaichuk
- Gerstein Science Information Centre, University of Toronto Libraries, University of Toronto, Toronto, ON, Canada
| | - Claudia Barned
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Pragmatic Health Ethics Research Unit, Institut de Recherches Cliniques de Montreal, Montreal, QC, Canada
| | - Andria Bianchi
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation, Toronto, ON, Canada
| | - Daniel Z Buchman
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kevin Rodrigues
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ruby R Shanker
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Ann M Heesters
- Department of Clinical and Organizational Ethics, University Health Network, Toronto, ON, Canada
- The Institute for Education Research, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health and Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
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de Snoo-Trimp J, de Vries A, Molewijk B, Hein I. How to deal with moral challenges around the decision-making competence in transgender adolescent care? Development of an ethics support tool. BMC Med Ethics 2022; 23:96. [PMID: 36138384 PMCID: PMC9494804 DOI: 10.1186/s12910-022-00837-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 09/13/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Decision-making competence is a complex concept in the care for transgender and gender diverse adolescents, since this type of care concerns one's developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to assist care providers when dealing with moral challenges around decision-making competence in transgender adolescent care. METHODS The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers in transgender adolescent care. RESULTS Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mental health difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. DISCUSSION Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The 'Competence Consultant' for transgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support.
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Affiliation(s)
- Janine de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Annelou de Vries
- Department of Child and Adolescent Psychiatry, Center of Expertise on Gender Dysphoria, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
- Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Irma Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, Location AMC, University of Amsterdam and Levvel, Amsterdam, The Netherlands
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Senghor AS, Racine E. How to evaluate the quality of an ethical deliberation? A pragmatist proposal for evaluation criteria and collaborative research. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2022; 25:309-326. [PMID: 35679005 DOI: 10.1007/s11019-022-10091-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 06/15/2023]
Abstract
Ethics designates a structured process by which important human values and meanings of life are understood and tackled. Therein, the ability to discuss openly and reflect on (aka deliberation) understandings of moral problems, on solutions to these problems, and to explore what a meaningful resolution could amount to is highly valued. However, the indicators of what constitutes a high-quality ethical deliberation remain vague and unclear. This article proposes and develops a pragmatist approach to evaluate the quality of deliberation. Deliberation features three important moments: (1) broadening and deepening the understanding of the situation, (2) envisioning action scenarios, (3) coming to a judgment based on the comparative evaluation of scenarios. In this paper, we propose seven criteria to evaluate ethical deliberations: (1) collaborative diversity, (2) experiential literacy, (3) organization of experiences, (4) reflective capacity to instrumentalize the experiences of others, (5) interactional creativity, (6) openness of agents, (7) quality of the reformulation of scenarios. These criteria are explained and applied to the three moments of deliberation. Based on these criteria, three kinds of outcomes for deliberations are identified and discussed: good ethical deliberations, partial ethical deliberations, bad ethical deliberations. Our proposal will guide researchers and practitioners interested in the evaluation of the quality of ethical deliberations. It provides a reference tool that allows them to identify the possible limitations of a deliberation and to implement actions aimed at correcting these limitations in order to achieve the desired qualitative objectives.
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Affiliation(s)
- Abdou Simon Senghor
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, QC, Canada.
- Division of Experimental Medicine, McGill University, Montréal, QC, Canada.
- Department of Neurology and Neurosurgery, McGill University, Montréal, QC, Canada.
- Department of Medicine, Department of Social and Preventive Medicine, Université de Montréal, Montréal, QC, Canada.
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Feldman SL, Sankary LR, Morley G, Mabel H. Clinical Ethics Support for Gender-Affirming Care Teams: Reflections from a Scoping Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00332-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Abstract
Purpose of Review
This review aims to provide gender-affirming providers and ethics practitioners with up-to-date knowledge regarding the models of clinical ethics support (CES) available in the transgender care setting, the activities of CES services, and the benefits and limitations of CES in this context.
Recent Findings
Literature related to CES in transgender care is limited at present but will likely expand as the number of both transgender care centers and CES services continues to grow internationally. All literature substantively addressing the review question derives from the USA or the Netherlands and describes an “integrative” or “embedded” model of CES, in which ethics practitioners work regularly and collaboratively with multidisciplinary transgender care teams to provide preventive and responsive ethics support.
Summary
A scoping review of the literature shows that, at some transgender care programs in the USA and the Netherlands, embedded or integrative CES is available to highlight the ethics issues in everyday practice and to help clinicians navigate ethically complex cases. Other forms of CES available to gender-affirming providers include ethics consultation services and ethics committees. CES in transgender care can involve ethics consultation or moral case deliberation for particular cases; participation in clinical meetings to draw attention to and clarify ethical issues at play; and input into treatment protocol development. To further illustrate how ethics practitioners can contribute to a multidisciplinary approach to gender-affirming care, the authors also provide examples of embedded ethics support in one transgender care center in the USA based on their experiences. Clinicians working in transgender care may benefit from engaging with their organization’s CES service or reaching out to local and regional healthcare ethics organizations for support.
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Levine SB, Abbruzzese E, Mason JW. Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. JOURNAL OF SEX & MARITAL THERAPY 2022; 48:706-727. [PMID: 35300570 DOI: 10.1080/0092623x.2022.2046221] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In less than a decade, the western world has witnessed an unprecedented rise in the numbers of children and adolescents seeking gender transition. Despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. The many risks of these interventions, including medicalizing a temporary adolescent identity, have come into a clearer focus through an awareness of detransitioners. The risks of gender-affirmative care are ethically managed through a properly conducted informed consent process. Its elements-deliberate sharing of the hoped-for benefits, known risks and long-term outcomes, and alternative treatments-must be delivered in a manner that promotes comprehension. The process is limited by: erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents. We discuss data on suicide and present the limitations of the Dutch studies that have been the basis for interventions. Beliefs about gender-affirmative care need to be separated from the established facts. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals' ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain.
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Affiliation(s)
- Stephen B Levine
- Department of Psychiatry, Case Western Reserve University, Cleveland, OH, USA
| | - E Abbruzzese
- Society for Evidence-based Gender Medicine (SEGM), Twin Falls, ID, USA
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Hartman L, Inguaggiato G, Widdershoven G, Wensing-Kruger A, Molewijk B. Theory and practice of integrative clinical ethics support: a joint experience within gender affirmative care. BMC Med Ethics 2020; 21:79. [PMID: 32847572 PMCID: PMC7448443 DOI: 10.1186/s12910-020-00520-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 08/13/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Clinical ethics support (CES) aims to support health care professionals in dealing with ethical issues in clinical practice. Although the prevalence of CES is increasing, it does meet challenges and pressing questions regarding implementation and organization. In this paper we present a specific way of organizing CES, which we have called integrative CES, and argue that this approach meets some of the challenges regarding implementation and organization. METHODS This integrative approach was developed in an iterative process, combining actual experiences in a case study in which we offered CES to a team that provides transgender health care and reflecting on the theoretical underpinnings of our work stemming from pragmatism, hermeneutics and organizational and educational sciences. RESULTS In this paper we describe five key characteristics of an integrative approach to CES; 1. Positioning CES more within care practices, 2. Involving new perspectives, 3. Creating co-ownership of CES, 4. Paying attention to follow up, and 5. Developing innovative CES activities through an emerging design. CONCLUSIONS In the discussion we compare this approach to the integrated approach to CES developed in the US and the hub and spokes strategy developed in Canada. Furthermore, we reflect on how an integrative approach to CES can help to handle some of the challenges of current CES.
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Affiliation(s)
- Laura Hartman
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands.
| | - Giulia Inguaggiato
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
| | - Annelijn Wensing-Kruger
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universitieit Amsterda, Amsterdam, The Netherlands
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
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