Medical, Ethical and Legal issues re Transitioning.

[Ali1cedowntherabbithole]

Have been discussing issues around consent on the Rod Liddle thread (today's oh fuuuuuuuuck moment) and thought it would be worth having a separate thread.

Among the many issues, two stand out to me as a registered nurse.

How can someone - either a child or their parent - give legal consent for a procedure if they are in denial about the potential risks, and unrealistic about the expected outcomes?

Specifically, how can consent be given for genital surgery if the person believes it is possible to "change sex"?

How can someone be deemed to have demonstrated that they have capacity to consent if they are in denial about the potential long term consequences? I'm not referring to someone who acknowledges there may be risks and choose to have treatment in spite of this, I'm thinking about people who are adamant that there are no risks to them.

I'm also thinking through my own professional practice. Would I administer potentially harmful testosterone injections to a child who didn't understand the consequences? Who I didn't believe had given consent? And in the current climate, would there be a backlash if I refused?

Isn't it the case with transexuals like Miranda Yardley that in order to have the surgery they had to show that they understood and accepted that they were not changing sex?

This is a fab idea for a thread. Reading with interest (though sadly have little to contribute)

I wasn't aware Jelly but that would be a good thing.

Where does it leave adolescents though? From what Suzy Green seems to be saying, there are less safeguards for children.

I'm hoping some people with more knowledge will enlighten me too Ewe.

And I'm also trying to get these issues talked about. We all need to keep asking questions don't we?

It's basically experimentation isn't it Spartacus. And that had implications for professional practice and health providers.

There could be an awful lot of lawsuits in future.

So many issues. First, no one knows effects of puberty blockers (long term use as in TG kids) but evidence suggests reduction in IQ, increased likelihood of proceeding to full transition (not just putting on the brakes) and who the hell knows re. Cardiovascular, bone health etc.
Secondly, the prefrontal cortex doesn't fully develop till around 25, how can kids who have not gone through puberty decide on cross sex hormones which will irreversibly change their immature bodies. Committed to infertility, sexual dysfunction and a much reduced likelihood of finding a sexual partner.
It is really shocking that we are allowing this to happen on so little evidence when you compare with the ethical approval you need for any research involving meds in children.

It comes down to the issue of informed consent. How informed is informed enough though? The basic ethical framework of it is that in order to give informed consent one has to be able to understand the information given, believe it, use that information to make a decision and be able to convey that decision.
Legally a parent or person with parental responsibility can consent on behalf of a minor although in practice this is a much less black and white position. How much do we take into consideration the wishes of older children and teenagers for example? And in some cases, it will be appropriate to allow a child’s direct consent to be sufficient. Clearly that is dependent on both the child and the situation.
My answer to your questions would be that in the case of a child, or indeed an adult,, who has firmly held beliefs that are not compatible with proven risks or outcomes to treatment despite adequate explanation (in multiple forms and on multiple occasions and given sufficient time to process it) then they cannot have given informed consent.
Where do you stand ethically or indeed legally? Much greyer area. I’m not sure what the NMC would say. For me, if I had concerns about prescribing or administering a medication on the advice of a specialist that I was unsure about the ethics of I’d discuss it with my colleagues and probably my defence organisation. I’m yet to have it happen and I really wouldn’t like to say what the advice would be and I really wouldn’t fancy betting on which way the GMC would go if I said I had ethical objections given their somewhat conflicting advice on this issue.
I have no doubt there will be a backlash against this treatment in future and a lot of litigation against those responsible (either as individuals or wider organisations such as the NHS).
This is a really interesting article discussing some of the issues of medical ethics:
pmj.bmj.com/content/80/943/277

When I had a planned csection, I had to explain that I understood the risks and demonstrate understanding.

If someone thinks they can change sex - and not purely by having a bit of paper - they are demonstrating they do not properly understand the nature of the surgery and therefore can not properly consent to it. And certainly not if they are a minor.

The child has got the impression it's a magic bullet from somewhere...

At this point if the parent is still insisting on surgery being the best option, the child should become a subject of a court case to determine the child's best interests because there is obviously an issue over ability to consent, pressure to consent and deliberate misinforming going on in there somewhere.

Have been discussing issues around consent on the Rod Liddle thread (today's oh fuuuuuuuuck moment) and thought it would be worth having a separate thread.
thread:
www.mumsnet.com/Talk/womens_rights/3541332-Rod-Liddle-thinks-Susie-Green-should-be-jailed

Maybe consent forms should state explicitly that surgery can only proceed if the patient understands that no human can ever change sex and that what the surgery can only deliver is a simulacrum [an unsatisfactory imitation or substitute]?

Muststop my expectations of the NMC and the GMC at this point are similar to yours. I'm in a position where this is a hypothetical question for me, but I'm aware for some professionals it is reality and I honestly think I'd struggle in their shoes.

Thank you for the article.

These body modifications, whether by drug, surgery or accessory, used to be available only to mature, consenting adults, after extensive interactions with specialists from various relevant medical fields. There was substantial gate-keeping before any irreversible steps were taken.

Removing the gate-keeping and making these procedures available to juveniles and immature adults is utterly irresponsible.

Slightly off point but if 1 - 3% of 'high school' children consider themselves transgender than it would seem likely that there will many of these children who also have other serious illnesses such as cystic fibrosis. Surely it follows that 1-3% of children with cystic fibrosis will also consider themselves as transgender.

I would imagine that there would be very considerable risks to a child or young person with cystic fibrosis of attempting to transition through the use of breast binding, puberty blockers, cross sex hormones or surgery.

I would also imagine that the medical and nursing teams involved would recommend to these young people that they avoid all 'gender affirmation' treatment with the exception of changes in name and stereotypical clothing. I think that those who are caring for this young person would hope that they are one of the majority who naturally stop feeling that they need to change their gender. In fact it could be argued that it would be best for such a child's health that they are given counselling to support them in choosing to avoid any form of medical transition, especially as the child may be being encouraged to medically transition by their peers and social media.

However, anything other than helping the child or young person to 'affirm their true gender' could leave a medical or therapeutic practitioner open to criticism or even accusations of conversion therapy.

If the only model of transgender care put forward to teenagers is one of affirmation and medical transistion, then where does this leave the many young people for who this appproach will mean serious and potentially life-threatening and life-limiting consequences?

American but similar concerns.

where does this leave the many young people for who this appproach will mean serious and potentially life-threatening and life-limiting consequences?

Doesn't this apply to all young people undergoing medical transition?

Maybe consent forms should state explicitly that surgery can only proceed if the patient understands that no human can ever change sex and that what the surgery can only deliver is a simulacrum [an unsatisfactory imitation or substitute]?

Absolutely.

The focal point being achievement of surgery in a target based way of thinking is blinkered and actively encourages tunnel vision.

Surgery does not solve underlying problems. Indeed if you have complications it creates new physical ones. Failure to be honest about this by the medical profession and failure of them to stress this is a neglectful oversight.

It's not anti trans by failing to be fully affirmation. It's about preparation for the reality of having surgery.

It also has consequences for later life. For example where someone insists to medical professionals that they are male when they are female. Or vice versa. Since males and females present differently for different diseases and conditions it's crucial that there is honesty and transparency over sex. Otherwise diagnosis and/or treatment might be slower or miss crucial information completely.

If this isn't being done, it leaves the NHS exposed to being sued too, because they are failing to properly meet the criteria of making sure patients have given their informed consent and at risk for not treating to the standard that everyone else expects as a basic level. It's a hole a good solicitor could drive a bus through.

It also has consequences for later life. For example where someone insists to medical professionals that they are male when they are female. Or vice versa. Since males and females present differently for different diseases and conditions it's crucial that there is honesty and transparency over sex. Otherwise diagnosis and/or treatment might be slower or miss crucial information completely.

NHS has in aceeding to some TRAs demands to replace the sex marker on patients' record with their 'gender identity' potentially put some transpeople at risk of not being appropriately treated when biological sex is a key differentiating factor for treatment options.

For example female transpeople whose sex marker is changed to 'Male' and who have not had total hysterectomies may not be automatically called for routine cervical screening tests, females present with very different heart attack symptoms to males, blood tests may automatically test against standard ranges for sex etc

The wokeness harms trans health.

That's the bitter irony.

Given that there may be an increased risk of gyny cancers & cardiovascular problems for people who are taking long-term cross sex hormones, the examples above represent serious potential risks in 'trans health care'
That some TRAs have focussed on dismantling what should be a safeguard in NHS is quite extraordinary.

”Isn't it the case with transexuals like Miranda Yardley that in order to have the surgery they had to show that they understood and accepted that they were not changing sex?”

Pretty sure I read that it used to be part of the treatment that patients had extensive counselling so that they understood the limitations of treatment and that changing sex was not possible.

I believe there was also a process during which they were advised when it would be appropriate to begin to use women’s spaces, and how to do so without causing alarm.

So many problems now are caused by the suggestion that it is possible to “be trans” as opposed to “transitioning as a treatment for a (related) mental health disorder”.

Doctors thinking they’re god and pretending to patients that there is such a thing as “sex change” have done so much damage.

I believe there was also a process during which they were advised when it would be appropriate to begin to use women’s spaces, and how to do so without causing alarm.

So some (mostly male doctors) acted as gatekeepers not just for medical surgical 'treatments' but also gave advice / permission and requirement that some males access women's spaces.

God complex / male entitlement indeed!

Muststopfaffing I have just read your article properly (weekend reading). I found the discussion around consent on behalf of children especially interesting. I wouldn’t like to say how much self-interest affects the decisions of parents to consent for gender reassignment treatments on behalf of their children, only that I think it merits much wider discussion.

From the media, it would appear that Suzy Green believes she had her child’s best interests at heart, but has nonetheless arrived a conclusion that validates her position. She seems to have settled on the wrong sex belief very early in her child’s life and sought evidence to affirm it before searching for treatment to a problem, that objectively, we don’t know existed.

I can’t help wondering what would have happened if Suzy has had more support.

Doctors thinking they’re god and pretending to patients that there is such a thing as “sex change” have done so much damage.

Also, how much of the drive to medicate children from an early age is just an unethical experiment with the aim of discovering what happens to children who never go through puberty, nicely disguised as 'helping' transgender kids?

I am confused as to why medicalisation is now considered good practise

If we accept that trans is inate, we must accept that it affects a fixed proportion of the population. And always has done

Based on my experiance, In the past girls , were expected to just come to terms with the mismatch between their body and their essence.

Where is the evidence that those girls, now women , have poor life outcomes such that any kind of medicalisation can be supported? Are these women less satisfied with their life? Where is the evidence that we needed to change how we treat girls with gender dysmorphia?