Informed consent for gender-questioning youth seeking gender-affirmative care is a complex issue

Care of gender-dysphoric youth is an issue of current debate. It demands closer attention to the science and also to the gaps in scientific evidence and informed-consent processes.

In their guest editorial for Part 2 of the Gender-affirming care in BC series, Dr Knudson, Dr Metzger, and Ms findlay state that “not all parents are supportive of their transgender youth, and some are even openly malicious.”[1] If parents who support their child’s gender dysphoria but question medicalization are deemed “unsupportive,” distressed youth can become alienated from their families. We must acknowledge established theories of adolescent identity development and the complex etiological pathways to gender dysphoria. It is imprudent to suggest that not supporting medicalization is causing harm when it is entirely possible that the reverse may be true. The best long-term interests of the youth need to be kept in mind, including supporting healthy connections to family.

The failure to mention the weak evidence for medical gender affirmation is of significant concern. Based on systematic reviews of the literature, Sweden, Finland, France, and the UK have concluded that the risks outweigh potential benefits and now tightly regulate medical interventions for youth under 18, in favor of psychological treatments. The interim report of the UK’s Cass Review outlines some of these concerns.[2]

Related articles also fail to address the sharp rise in youth presentations, particularly in adolescent girls.[3] We wonder if research on these cohorts is disregarded as it is a challenge to the gender-affirmation and informed-consent models that are based on the premise that gender is innate and immutable. The increasing numbers of desisters and detransitioners[4] suggests that gender identity is, in fact, mutable. This is especially important given that research has shown that most youth presenting with gender dysphoria who are not socially or medically transitioned realign with their bodies by the end of adolescence, growing up to be gay, lesbian, or bisexual. For example, the largest study to date of boys found an 88% rate of desistance.[5]

Given evidence of the mutability of gender identity, Ms findlay’s informed-consent model is weakened, because we do not know for whom gender identity is immutable (and gender dysphoria persistent).[6] Further, the article avoids discussion of whether youth are capable of consenting to medical treatments that show potential negative impacts on long-term mental and physical health. These treatments are known to cause permanent damage to sex organs and future sexual and reproductive capacity. Someone who has not experienced an orgasm cannot understand what they would be giving up in terms of their sexual functioning. Levine and colleagues[7] provide a good review of the issues regarding informed consent for gender dysphoria.

Clinical practice and informed consent must acknowledge less invasive, nonmedical options such as watchful waiting, treating underlying psychiatric conditions, and exploratory therapy. The affirmation model excludes these treatments, leaving youth open to lifelong morbidity. The potential for harm is significant if we medicalize youth to soothe distress in the moment rather than treat the underlying cause(s). We need more research to help us understand which youths would benefit from a medicalized approach.
—Joanne Sinai, MD, MEd, FRCPC
Victoria
—Leonora Regenstreif, MD, FCFPC, MScCH
Hamilton, ON

Editor’s note: An incorrect version of this letter was published in the September 2022 issue. The following related letters and premise were submitted in response to this version of this letter, and are published in the September issue:

• “A closer look at the evidence for gender-affirming care”
• “Guest editors reply to Drs Sinai, Regenstreif, and Leising”
• “Gender-affirming care for youth—separating evidence from controversy”

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References

1.    Knudson G, findlay b, Metzger D. Guest editorial: Gender-affirming care in British Columbia, Part 2. BCMJ 2022;64:64.

2.    The Cass Review. Independent review of gender identity services for children and young people: Interim report. February 2022. Accessed 28 April 2022. https://cass.independent-review.uk/publications/interim-report.

3.    Littman L. Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria. PLoS One 2018;13:e0202330.

4.    Littman L. Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners. Arch Sex Behav 2021;50:3353-3369.

5.    Singh D, Bradley SJ, Zucker KJ. A follow-up study of boys with gender identity disorder. Front Psychiatry 2021;12:632784.

6.    findlay b. Legal rights of transgender youth seeking medical care. BCMJ 2022;64:65-68.

7.    Levine SB, Abbruzzese E, Mason JW. Reconsidering informed consent for trans-identified children, adolescents, and young adults. J Sex Marital Ther 2022;17:1-22.