Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria

What is the Purpose of the Initial Psychiatric Evaluation of Minors with Gender Dysphoria

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.

Current Challenges for Conscientious Objection by Physicians in Spain

The College of Physicians of Madrid organized an open debate on conscientious objection (CO) in the medical profession on September 14, 2022. We summarize here the main arguments discussed. CO is defined as the right to raise exceptions to the performance of legal duties when they involve a contravention of personal convictions, whether religious, moral, or philosophical. It is not insubordination. Some authors contend that any decision by elected authorities should be uniformly followed by all citizens, physicians not being an exception. However, suppressing the ethical dimension of medical care may have an unacceptable cost with harm to physicians, their patients, and ultimately society. Health professionals are not blind instruments or mere "executors." The practice of medicine must follow the aim of the profession, namely the pursuit of the patient's good. Medical care must conform to medical ethics, which was first defined twenty-five centuries ago in the Hippocratic oath, and summarized with the triad of precepts "cure, relief, accompaniment." Since then and particularly in light of the Nuremberg trials, most medical declarations have highlighted the duty of defending human life and the importance of CO. In modern societies, there may be medical services that are not health care, even if they are legal. Then, which comes first law or ethics? Ultimately, CO is the tool that protects the freedom of the physician to refuse to perform actions that go against the values of medical ethics. With respect to the recent Spanish laws on abortion, euthanasia, and sex re-assignment of minors, if administrators want to know who is available for a health service that raises issues of conformity to medical ethics, requesting a list of volunteers is preferable to producing an objector list. Asking for registration of conscientious objectors goes against the right to privacy and is coercive, intrusive, and abusive.

A systematic review of psychosocial functioning changes after gender-affirming hormone therapy among transgender people

This systematic review assessed the state and quality of evidence for effects of gender-affirming hormone therapy on psychosocial functioning. Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. Evidence for quality of life was inconsistent, with some trends suggesting improvements. There was some evidence of affective changes differing for those on masculinizing versus feminizing hormone therapy. Results for self-mastery effects were ambiguous, with some studies suggesting greater anger expression, particularly among those on masculinizing hormone therapy, but no increase in anger intensity. There were some trends toward positive change in interpersonal functioning. Overall, risk of bias was highly variable between studies. Small samples and lack of adjustment for key confounders limited causal inferences. More high-quality evidence for psychosocial effects of gender-affirming hormone therapy is vital for ensuring health equity for transgender people.

Caring for Our Human Nature

The care for creation is an important call for all. Our human bodies form part of this created reality and should be treated with dignity and respect. Pope Benedict XVI underlined the ecology of man. Pope Francis took up this teaching in his pontificate, encouraging us to welcome the gift of our body, and critiquing ideologies which undermine the respect due our bodies. Proponents of the so-called "gender ideology" affirm surgery on the body, which generally involves the removal of healthy functioning tissues and organs, is largely mutilating, and can involve exorbitant costs. The voices of those who have "detransitioned" such as Keira Bell need also to be heard. The Congregation for Catholic Education, in its document "Male and Female He Created Them: Toward a Path of Dialogue on the Question of Gender Theory in Education" warns us against theories that aim to annihilate the concept of "nature," that is, everything we have been given as a pre-existing foundation of our being and action in the world. Our growing awareness of the importance of the environment and nature can lead us to a greater respect for our own human nature. We are all called to participate in the care for nature and creation, especially of our bodies as part of the created reality.

Non-technical summary

Many voices today remind us to take care of nature and creation. Our bodies are part of this created reality. Proponents of gender ideology do not hesitate to promote surgery which radically alters and even mutilates the body. Our increasing ecological awareness can help us grow more sensitive to the ecology of man and woman, and value the gift of the nature and body given to each one of us.

Short summary

Let us take care of nature and creation, including our own bodies.

Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient's well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.

Defining Desistance: Exploring Desistance in Transgender and Gender Expansive Youth Through Systematic Literature Review

Background

Desistance is a concept that has been poorly defined in the literature, yet greatly impacts the arguments for and against providing gender-affirming care for transgender and gender expansive (TGE) youth. This literature review aims to provide an overview of the literature on desistance and how desistance is defined.

Methods

A systematically guided literature review was conducted on March 27, 2020, using CINAHL, Embase, LGBT Life, Medline, PsychINFO, and Web of Science to identify English language peer-reviewed studies, editorials, and theses that discuss desistance concerning TGE pre-pubertal youth for a minimum of three paragraphs. Articles were divided based on methodology and quantitative data were quality assessed and congregated. Definitions of desistance were compiled and analyzed using constant comparative method.

Results

One qualitative study, 2 case studies, 5 quantitative studies, 5 ethical discussions, and 22 editorials were assessed. Quantitative studies were all poor quality, with 83% of 251 participants reported as desisting. Thirty definitions of desistance were found, with four overarching trends: desistance as the disappearance of gender dysphoria (GD) after puberty, a change in gender identity from TGE to cisgender, the disappearance of distress, and the disappearance of the desire for medical intervention.

Conclusions

This review demonstrates the dearth of high-quality hypothesis-driven research that currently exists and suggests that desistance should no longer be used in clinical work or research. This transition can help future research move away from attempting to predict gender outcomes and instead focus on helping reduce distress from GD in TGE children.

Referral vs Transfer of Care: Ethical Options When Values Differ

Conscientious objection (CO) in medicine is where a healthcare professional (HCP) firmly opposes, with an expression of reasoned disapproval, a legally available procedure or treatment that is proscribed by one's conscience. While there remains controversy regarding whether conscientious objection should be a part of medicine, even among those who support CO state that if the HCP does not provide the requested service such as abortion, physician assisted suicide, etc., there is an obligation on the part of the objecting HCP to refer to someone who will provide it. However, referral makes the referring HCP complicit in the act the referrer believes to be immoral since the referrer has a duty to know that the HCP who will accept the patient is not only able to do the procedure but is competent in its performance as well. The referrer thus facilitates the process. Since one has a moral obligation to limit complicity with immoral actions when it cannot be avoided, the alternative is to allow the patient to transfer care to another when the patient has made the autonomous decision to reject the advice of the HCP.

The Bioethical Dilemma of Gender-Affirming Therapy in Children and Adolescents

Since the establishment of the first transgender clinic in the United States in 2007, over sixty clinics associated with children's hospitals have opened across the nation and are seeing very young children and adolescents with a diagnosis of gender dysphoria (GD). Once known as gender identity disorder, GD has been redefined by the latest version of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) not as a mental illness but as the distress experienced by individuals related to their biological sex. The widely accepted practice of gender-affirming therapy (GAT) to treat a vulnerable population despite the associated health risks, the lack of supportive scientific evidence for the pharmacological and surgical interventions, along with the unqualified claim that these interventions will decrease the rate of suicide in these individuals presents a significant bioethical dilemma. The growing trend of GD not only impacts the individuals diagnosed but also society, culture, and the integrity of the profession of medicine. This article utilizes the five-box method, an ethical decision-making framework, to address the implications of the proposed treatment. Once applied, it becomes clear that the hormonal and surgical approaches used are not scientifically or ethically justified. The patient's autonomy and preferences should be respected, yet constrained, if there exists a considerable risk to the well-being of the individual without proven benefits. The quality of life of those receiving this treatment has not been shown to be significantly improved long term, and the mental, physical, and spiritual health of individuals with GD is not thoroughly addressed in these clinics. The important social and contextual factors, on both microcosmic and macrocosmic scales, are minimized in favor of promoting an ideology. Ultimately, Catholic moral teaching reveals that this widely recommended treatment violates the body-soul union, disregards the principle of totality and integrity, and debases the dignity of humanity.

SUMMARY

This article examines GAT, the paradigm used in treating individuals identifying as transgender, through the lens of an EDMF. Each stage of this widely proposed treatment - social affirmation, pubertal blockade, administration of cross-sex hormones, and sex reassignment surgery - poses harms and risks that are not fully disclosed to minors and families, creating a bioethical dilemma. Dialogue utilizing science and reasoning must be encouraged to assist individuals who experience a gender identity that rejects their biological sex. This approach would also contribute to the well-being of society.

Gender Identity Disorders: Current Medical and Social Paradigm and the ICD-11 Innovations

Introduction

This article presents a review of current concepts of gender identity under normal and pathological conditions.

Aim

To analyse the impact of the medical and social paradigm shift for clinical practice.

Results and discussion

The modern academic literature devoted to gender identity disorders is characterized by a variety of terminology, a shift in emphasis from clinical judgement to a socially beneficial normocentric approach and a relatively few advanced, evidence-based research. There is also a lack of evidence for the gender theory underlying the new approach, which raises serious doubts about the validity of the medical and social paradigm revision. In the same time, the position of Russian psychiatrists remains to be more clinically oriented.

Conclusion

Patients who declare the desire to reassign their gender have to be assessed by psychiatrists for differential diagnosis to exclude a mental disorder. In such cases, the destigmatization of mental disorders is more critical than the depathologization of gender identity disorders.

The Vatican Opinion on Gender Theory

This article is a reasoned response to the article by Timothy F. Murphy, recently published in the prestigious journal Bioethics, on the supposed opposition between the views of the Catholic Church and what he calls "contemporary science" in relation to certain anthropological issues linked to the gender perspective. To point to "the Vatican" as anchored in an unscientific and anachronistic position, using the term contemporary science to which he attributes a unanimous representation of current scientific thinking on the subject is, in our view, unfounded and completely unacceptable. In his reflection, he does not adequately distinguish between intersex and transgenderism, two clearly different realities with different needs. The author defends the obsolescence of the binary sex/gender model that, in his view, "betrays human sexuality." Furthermore, he does so without providing a plausible justification or a definition of human nature that is able to support the plurality and indeterminacy of sexual conditions, without falling back on untenable dualisms or relativism devoid of scientific objectivity. In our response, we highlight how the dialogue between Faith and Reason, as developed in the recent Magisterium of the Catholic Church, is essential to explain nature, the human being and, in general, all creations. Finally, contemporary science does not provide a monolithic and unquestionable view of the nature of human beings and their sexual identity, as the author claims, with many scientists confirming evidence of a binary human sexuality genetically and phenotypically determined.

Summary

This paper is a reasoned response to the supposed opposition between the views of the Catholic Church and "contemporary science" in relation to certain anthropological issues linked to the gender perspective.The dialogue between Faith and Reason, as developed in the recent Magisterium of the Catholic Church, is essential to explain nature, the human being and, in general, all creation, against the opinion of those who defend the obsolescence of the binary sex/gender model that, in their view, "betrays human sexuality".

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

OBJECTIVE

To explore some of the emerging complexities in the management of childhood gender dysphoria.

CONCLUSION

The authors raise questions about the gender-affirmation approach and highlight concerns about informed consent and research ethics.