“Can the request of someone who wants to block their organic development to remain in a prepubertal — immature — state indefinitely, undergoing untested treatments, with risks and irreversible side effects in many cases, with the sole intention of satisfying a desire, be ethically acceptable?”

Introduction

The “gender dysphoria” that often accompanies transsexual persons at some point in the process should be understood as the possible psychological imbalance that can arise when there is antagonism between the desired and perceived body image. This psychological imbalance, which can manifest as distress, anxiety, depression, etc. can be permanent or may resolve at some point in time, especially after adolescence.

Generally, people who experience this dysphoria wish to undertake a transition process to assume the phenotypic characteristics of the opposite sex. To this end, treatments are proposed that seek, first of all, to block the sexual maturation of adolescents, and later to develop the phenotypic characteristics of the other sex. Both treatments involve associated risks that must be properly assessed before considering their use.

In the case of hormone-blocking treatments, the risks involved have been detailed in previous papers (see more).

The profound changes that occur during puberty, which lead the individual to physical and mental maturity, are drastically altered when drugs are given, usually reversible gonadotropin-releasing hormone analogs (GnRH), whose role is to block the action of sex hormones on the development of sexual characteristics, as well as others of a biochemical, anatomical, endocrine or neurological nature.

These hormone-blocking treatments are usually followed by gender transition treatments, as mentioned.

Medical problems associated with hormone-blocking treatments

First, the drugs used in these hormone blocking therapies have not been authorized for this indication, but for the treatment of precocious puberty, in which they are given to pre-adolescents who want to delay puberty because it occurs prematurely. They are therefore administered for a relatively short period of time and are withdrawn when the individual has reached the maturity needed to begin the changes associated with puberty. Consequently, safety and efficacy data on the use of these treatments for hormonal blockade prior to gender transition are insufficient, and their administration is considered “off-label” because there is no express authorization for their use in this indication.

Second, the side effects are objective and well known: these include effects related to bone mass development and growth (see here), those affecting fertility and the development of sexual organs, and effects on neurological (Hruz PW) and metabolic development.

Ethical problems associated with these treatments

The first ethical difficulty arises from the fact that these hormone blocking treatments are given to children who, unlike in cases of precocious puberty, do not suffer any objective organic disease; instead, what they actually do is to block the normal development of healthy bodies, along with the pathologies previously described. This implies a use that is difficult to justify bioethically, due to lack of safety and efficacy data and a well-established and properly authorized clinical indication (see more).

No less important, however, is the incapacity of minors undergoing these treatments to be able to give consent for the intervention, a requirement in any clinical procedure. Their immaturity and difficulty in properly assessing the consequences and alternatives of the proposed treatments violate due respect for the principle of autonomy, which requires a certain maturity for its exercise that the adolescent in Tanner phase II (beginning of adolescence, in which these treatments are proposed) does not possess. In this respect, a recent article published in the prestigious British Medical Journal covers the case of two British women, one a former patient who had undergone these treatments but has now “detransitioned” and the other the mother of a teenager on the waiting list for treatment. They argue that children are unable to give informed consent to the treatment. The former patient claims the clinic in question did not properly inform or correctly assess the “impulsive” opinion of a teenager who was unable to evaluate the risk/benefit balance of the intervention and, therefore, to duly grant informed consent (see HERE).

A further problem arises in the case of adolescents in whom the introduction of hormone-blocking therapies is not considered as a step prior to gender transition treatments. Instead, what is sought is a “permanent blockade” of the maturity to which adolescence leads, seeking a permanent prepubertal state in order to be considered “non-binary,” that is, neither male nor female. To this end, blocking treatments are applied indefinitely for as long as the affected person does not change his or her mind. In these cases, medical problems may be exacerbated by the duration of the intervention, and it should be bioethically assessed whether or not it is lawful to administer hormonal blockade “indefinitely” to anyone who requests it because of a desire to remain in a state of immaturity in their sexual phenotype.

A paper published in the Journal of Medical Ethics examines this scenario in the case of an adult. The authors argue that considering the term “well-being” as referring not only to the physiological dimension of the individual – the absence of disease – but also to their mental and social dimensions, the request to proceed to hormonal blockade should be addressed in certain cases if the individual so wishes, as he or she perceives that they may be happier if they do not develop the sexual characteristics of their biological sex until the state of maturity. In this way, they could more easily be assigned to a “non-binary” or indeterminate sex. If this “mental well-being” is valued as the fundamental aspect, it would be justified to carry out an intervention that, although it entails undesirable side effects on the physical health of the individual, and possibly also on their mental health in the longer term, could be tolerated to try to make them feel better now about their body image.


“Should this desire prevail over any other consideration, such as the maintenance of bodily integrity, homeostatic balance, abilities, etc.?”


But is it ethically acceptable, in order to cater to a patient’s desire, to subject them to any medical intervention, even it consists of inflicting irreversible damage on them? Should this desire prevail over any other consideration, such as the maintenance of bodily integrity, homeostatic balance, abilities, etc.? What would happen if they later changed their mind and wanted to retrace the path taken and regain their status in the normal maturational state, including their fertility or ability to experience sexual pleasure? How then could the inability to cater to their desire be justified because of the side effects of the treatments applied?

It is true, as mentioned in the article, that personal health or well-being should be regarded as a holistic concept that encompasses all human dimensions, but I disagree radically with its authors in the sense of being able to separate — split — those dimensions, the mental, physical, social and spiritual, seeking to satisfy one of them by harming others. Mental well-being cannot be improved by seeking physical harm, not aimed at curing or correcting a pathology, but precisely at causing it, if it is not in a state of distortion of these dimensions in which the individual is constituted, with which balance — the source of true well-being — is unattainable.

Conclusion

Can the request of someone who wants to block their organic development to remain in a prepubertal — immature — state indefinitely, undergoing untested treatments, with risks and irreversible side effects in many cases, with the sole intention of satisfying a desire, be ethically acceptable?

In this, as in other cases where aggressive interventions are undertaken that are not aimed at correcting disorders or dysfunctions, but rather at inducing them to satisfy the requester’s desire to feel better for seeking to reconcile their body to the image they have of it, the bioethical difficulties are many. A decidedly maleficent intervention on the body can hardly be justified on the grounds that it may be psychologically beneficial. The principle of totality argued by Personalist bioethics allows damage to be inflicted on a part of the body when the intended purpose is thus to save the whole, the life, of the individual. But if neither life nor bodily integrity is threatened, it is hardly justifiable to inflict this damage on the sole grounds of satisfying a desire.

All interventions practiced on healthy people that, in many cases, involve unjustifiable risks with irreversible effects should be carefully evaluated, with the added difficulty that they are practiced on minors unable to give informed consent with the minimum guarantees.

 

Julio Tudela Pharm PhD

Bioethics Observatory – Institue of Life Sciences

Catholic University of Valencia