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Title: Ethical Issues Raised by the Treatment of GenderVariant Prepubescent Children

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Ethical Issues Raised by the Treatment of
Gender-Variant Prepubescent Children
by Jack Drescher and Jack Pula


ransgender issues and transgender rights have
become increasingly a matter of media attention and public policy debates. The movement
for transgender civil rights has followed in the wake of
the larger lesbian, gay, and bisexual (LGB) rights movement, and, for the last two decades, trans inclusion has
become a focus of LGBT civil rights organizations. The
movement has had mixed success. For example, in 2013
California passed legislation—now being challenged in
the courts—that “guarantees transgender students access
to interscholastic sports, gym classes, locker rooms and
bathrooms based on their gender identity, irrespective of
their biological sex.”1 By contrast, many states and the
federal government deny civil rights protections and access to care to transgender individuals.
Reflecting changes in psychiatric perspectives, the
diagnosis of “trans-sexualism” first appeared in the
International Statistical Classification of Diseases and
Related Health Problems in 1975 (when the ICD was in
its ninth edition) and shortly thereafter, in 1980, in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM, then in its third edition).2 Since that time, international standards of care have been developed,3 and
today those standards are followed by clinicians across
diverse cultures. In many instances, treatment of older
adolescents and adults is covered by national health care
systems and, in some cases, by private health insurance.
Most recently, the Medicare ban on coverage for gender
reassignment surgery was lifted in 2014.4
In contrast to the relative lack of controversy about
treating adolescents and adults, there is no expert clinical
Jack Drescher and Jack Pula, “Ethical Issues Raised by the Treatment
of Gender-Variant Prepubescent Children,” LGBT Bioethics: Visibility,
Disparities, and Dialogue, special report, Hastings Center Report 44, no. 5
(2014): S17-S22. DOI: 10.1002/hast.365

consensus regarding the treatment of prepubescent children who meet diagnostic criteria for what was referred
to in both DSM-IV-TR and ICD-10 as gender identity
disorder (GID) in children and now in DSM-5 as gender
dysphoria (GD).5 One reason for the differing attitudes
has to do with the pervasive nature of gender dysphoria
in older adolescents and adults: it rarely desists, and so
the treatment of choice is gender or sex reassignment.
On the subject of treating children, however, as the
World Professional Association for Transgender Health
(WPATH)6 notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue
into adulthood, and only 6 to 23 percent of boys and 12
to 27 percent of girls treated in gender clinics showed
persistence of their gender dysphoria into adulthood.
Further, most of the boys’ gender dysphoria desisted, and
in adulthood, they identified as gay rather than as transgender.7
In an effort to clarify best treatment practices for
transgender individuals, a recent American Psychiatric
Association Task Force on the Treatment of Gender
Identity outlined three differing approaches to treating
prepubescent gender dysphoric children. Due to the absence of any randomized controlled treatment outcome
studies of gender dysphoric children, the task force concluded that “the highest level of evidence available for
treatment recommendations for these children can best
be characterized as expert opinion.”8
However, there are sharp disagreements among the acknowledged experts. One of the oldest gender clinics doing research in this area is Toronto’s Centre for Addiction
and Mental Health. There, clinicians work with children
and caregivers to lessen gender dysphoria and decrease
cross-gender behaviors and identification. For example,
natal boys are not permitted to dress in princess outfits
and are discouraged from playing with Barbie dolls. The

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clinic claims its approach decreases the likelihood that GD
will persist into adolescence, leading to adult transsexualism, which, for various reasons, such as social stigma and
a lifetime of medical treatment, is an outcome the clinic
considers undesirable.9
Another long-standing research clinic, the VU
University Medical Center in Amsterdam, makes no direct
efforts to lessen gender dysphoria or gender atypical behaviors. Given that GD diagnosed in childhood usually does
not persist into adolescence and no reliable markers exist
to predict when it will or will not persist, there is no therapeutic target with respect to gender identity outcome, but
the developmental trajectory of gender identity is allowed
to unfold of its own accord. Those in whom it persists are
assisted in transitioning in later adolescence, and those who
desist are assisted in adjusting to their natal gender.10
A more recent entry in this area is the gender clinic affiliated with the University of California, San Francisco,
where a child is supported in socially transitioning to a
cross-gendered role without medical or surgical intervention. As in the other two clinics, only at the onset of puberty are medications administered to suppress development
of unwanted secondary sex characteristics.11 This approach
presumes that an adult transgender outcome is to be expected, that these children can be identified, and that children who transition but then desist can revert to their natal
gender if necessary with no ill effects.12
The State of Empirical Research


esearch on gender dysphoric/gender variant (GD/
GV)13 children and adolescents is still sparse. Some
findings are emerging, however:14

The children and adolescents (collectively referred to
as “minors”) who present for clinical evaluation or
treatment are a heterogeneous group.

For some of these minors, the major issue is crossgender behaviors or identifications; for others, the
gender issues seem to be epiphenomena of psychopathology, exposure to trauma, or attempts to resolve problems such as lacking higher social status
or other benefits they perceive to be associated with
the other gender.

In general, a minor’s notions of gender and gender
identity will vary according to the minor’s age.

Until children master the capacity for operational
thought (between the ages of five and seven), they
tend to conflate gender identity with surface expressions of gender.


The gender dysphoria of the majority of children
with GD/GV does not persist into adolescence, and
when it does not, the children are referred to as “desisters.”

Prospective studies indicate that the majority of
those who desist by or during adolescence grow up
to be gay, not transgender, and that a smaller proportion grow up to be heterosexual.

There is at present no way to predict in which children GD/GV will or will not persist into adolescence or beyond. 15

GD/GV that persists into adolescence is more likely
to persist into adulthood.

GD/GV may be mimicked by gender confusion
that occurs as an epiphenomenon of other problems
(e.g., gender confusion as the result of sexual trauma
or delusions in the context of psychotic disorders).

Much remains unknown, however. In particular, research has yet to show

how either a cisgender identity16 or a transgender
identity develops;

the relative contributions of biology and psychosocial environmental factors in the development of
gender identity, whether cisgender or transgender;

the extent to which gender identity in individuals
with GD/GV does or does not develop along the
same lines as gender identity in cisgender individuals; and

why the gender dysphoria of most children desists
around puberty, while it persists in others into adolescence and adulthood.

Given the absence of strong empirical data regarding the
best GD treatment outcomes in children, each of the three
treatment approaches outlined above raises ethical questions. The rest of this paper does not purport to answer the
questions it presents. Instead, these questions are intended
to stimulate discussion in a wider range of interested parties about the ethical issues with which the experts treating
these children are or should be engaging. Hopefully, such
discussions can serve to improve care for all children and
their families regardless of which gender clinic they choose.
The ethical principles that underlie the questions and
discussions that follow are from The Principles of Medical
September-October 2014/ H A S T I N G S CE NTE R RE P O RT

There is no expert clinical consensus regarding the treatment of
prepubescent children who meet diagnostic criteria
for gender dysphoria.
Ethics: With Annotations Especially Applicable to Psychiatry,17
specifically, section 1.2 and section 5. The first of these
reads, “A psychiatrist should not be a party to any type of
policy that excludes, segregates, or demeans the dignity of
any patient because of ethnic origin, race, sex, creed, age,
socioeconomic status, or sexual orientation” (p. 3). Section
5 states, “A physician shall continue to study, apply, and
advance scientific knowledge, maintain a commitment to
medical education, make relevant information available to
patients, colleagues, and the public, obtain consultation,
and use the talents of other health professionals when indicated” (p. 8).
Clinical Ethics

Is Preventing Transsexualism an Acceptable Clinical
It could be construed, as some in the transgender community maintain, that clinical attempts to prevent transsexualism, no matter how well meaning, are unethical
because they demean the dignity of gender-variant children.18 Although the principles of ethics do not comment
specifically on “gender identity” or “gender expression”
—the usual terms used in laws and position statements
aimed at protecting transgender rights—the rapid cultural
acceptance of gender diversity and psychiatry’s unfortunate
history of trying to “cure” homosexuality raise questions of
whether “prevention of transsexualism” is a benign medical
activity or an attack on an individual’s identity.
This question raises another: is there empirical evidence
that childhood treatment can reduce the rate of persistence
and prevent adult transsexualism in some individuals?
Should Parents Be Told That Adult Transsexualism Is
Kenneth J. Zucker and colleagues note that while many
of the parents with whom they consult do not mind if
their gender-variant children grow up to be gay, they see
having a child who grows up to be transgender as more
problematic.19 It is therefore reasonable to assume that
their clinical approach of representing adult transsexualism
as preventable stems from an effort to satisfy the wishes
of the parents. However, there are presently no controlled
studies that demonstrate that discouraging cross-gender
behavior and interests in childhood does in fact reduce persistence or prevent transsexualism. In addition, there are

no proven, reliable indicators to distinguish children whose
dysphoria will desist from those in whom it will persist.
Since no clinician can accurately predict the future gender
identity of any particular child, shouldn’t we assume that
efforts to discourage cross-gender play and identifications
may be experienced as hurtful and possibly even traumatic,
since, for some children, gender dysphoria will persist into
adolescence and adulthood? If so, is it ethical to offer such
treatment without informing parents of the current state
of the research or of possible harmful side effects (which
may be experienced by desisters as well as persisters)? And
if some children may be harmed, do the benefits outweigh
the risks, and are these risks and benefits sufficiently clear
to parents? Are the harms so unknown or so great that it is
unethical to offer such treatment at all? Mental health professionals should look to other areas of medicine to understand standards for informed consent regarding treatments
whose efficacy and safety are unproven.
Is It Okay to Steer a Child away from a Gender-Variant
In considering whether to support or promote the gender-variant position of a child, parents, family members,
pediatricians, and mental health clinicians should consider
how any action or inaction will affect the child and how it
may result in beneficence (doing what is in the interest of
the child) or maleficence (harm). They also need to consider the ethical principle of autonomy even though children
are not considered autonomous in the eyes of medicine and
the law because they are deemed developmentally immature and unable to fully understand the risks and benefits
of medical decision-making. When it comes to complicated decisions regarding treatments for severe childhood
diseases such as leukemia that have profound impacts on
the child’s immediate emotional and physical well-being,
families and clinicians have constructed creative strategies
to respect the dignity and relative autonomy of the child
who has to bear the pain of difficult treatments.
Since research shows that a relatively low percentage of
children persist and that those who socially transition one
way may need to transition back to their natal gender, a
cautious approach is warranted. Also, given that certain environments (a school, church, or playground, for example)
may be unsafe spaces in which to express gender variance,
protecting a child from overt threats by modifying gender
expression in those settings is a common-sense approach.

SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e


Yet, should caution and modification for safety reasons
rationalize as-yet-unproven efforts to steer a child’s gender identity in a cisgender direction? Given that how any
gender identity develops is an unknown, is it not possible
that opposing a wish to explore cross-gender expression is
harmful to some children? Whether they persist or desist
in their transgender behavior or identity, children may internalize disapproving attitudes toward atypical gender behavior and expression (transphobia), with possible negative
consequences for adult development.20
What are the ethical implications of delaying social
transition for children who persist?
Unlike Zucker et al., Annelou L. de Vries and Peggy
T. Cohen-Kettenis do not discourage cross-gender play,
although they do discourage social transition in prepubescent children because most children with GD will not
remain dysphoric through adolescence. They aim to prevent youths with nonpersisting gender dysphoria from having to make a complex change back to the role of their natal
gender. They cite the qualitative follow-up study in which
several youths indicated how difficult it was for them to
realize that they no longer wanted to live in the role of the
other gender and to make this clear to the people around
However, another ethical question is raised by this approach: Since the clinicians freely admit that they are unable to distinguish persisters from desisters, what are the
risks and benefits of delaying the social transition of persisting children in order to prevent possible psychological
harm to those who will desist? Put another way, are the
children who will grow up to be trans being subjected to
unnecessary stress in order to preserve the well-being of the
majority who will not?22
Further, increasing numbers of young children are making social transitions sanctioned by families before they
even come to a gender clinic. Schools and other community settings are helping children adapt to these changes as
well. That some children may be supported in transition
before they know what their natal sex is or what it means
is a complex issue that deserves further investigation. Does
this complexity increase the burden on medical and childcare systems, as well as families, to fully evaluate and weigh
the factors for and against transition of any child?
What are the ethical implications of permitting early
transition in children who desist?
Diane Ehrensaft makes a case for early social transition
that appears to be based on the belief that those who will
be persisters can be distinguished from other individuals
who present signs of gender dysphoria. She states, “Once
allowed to transition, these children [persisters] typically
relax and the signs of stress, distress, and disruption dissiS20

pate, if not disappear altogether.”23 “Although not a universal phenomenon,” she asserts, “one simple rule of thumb
is that if the assessment is correct, the child shows signs of
getting better; if the assessment was incorrect, the child gets
worse, or at least no better” (346-47).
While Ehrensaft notes correctly that there is little empirical data demonstrating harm in transitioning twice,
there is also no empirical evidence demonstrating that a
prepubescent child who is permitted to socially transition
but then desists can simply and harmlessly transition back
to the natal gender. Given the complexity involved in the
first social transition, should we accept at face value the
claim that transition back to the original gender is entirely
without risks and pitfalls? Furthermore, in the absence of
empirical studies, is permitting early social transition without a verifiable system of distinguishing persisters from desisters an ethically appropriate treatment?
A Work in Progress


bviously, more research is needed to help understand
the biological, cultural, and psychological factors of
gender identity formation, as well as outcomes for those
who persist, desist, transition socially or medically, take
on normative gender (cisgender) identity, or adopt atypical, gender-queer, or nonbinary identities. It would also be
helpful to the affected populations if there were more collaboration and comparison of results between specialized
gender clinics with treatment methods.
As discussed by other authors in this special report, the
Institute of Medicine has commented on the significant
lack of research on the health and mental health needs of
transgender populations.24 However, the ability to conduct
research on transgender individuals in itself raises ethical concerns. In this era of evidence-based medicine, the
demand to produce rigorous research data can hamstring
clinical efforts in the field of transgender medicine. While
clinicians struggle to help patients and families make difficult and often painful decisions in the here and now, they
cannot always wait for research-based conclusions to guide
them. That is not to say that it is impossible to do research
or that it should not be attempted, but that current clinical needs must respect the nuance and subjectivity of gender identity, as well as the ethical standards of beneficence,
nonmaleficence, and autonomy. At this juncture, reasonable informed consent would involve telling parents that
(1) the best treatment approach for these children is a subject of controversy; (2) that there is presently no way to
predict whether their transgender child will desist or persist
into adolescence and adulthood; (3) that it is unclear if an
adult transgender outcome can be prevented; (4) that if
the child is socially transitioned to the experienced gender,
there is a possibility that the child might transition back
September-October 2014/ H A S T I N G S CE NTE R RE P O RT

to the natal gender; and (5) that intervention and nonintervention both may carry risks to the welfare of the child,
requiring that providers and families examine and weigh
predictable risks and benefits in a given situation to the best
of their ability.
With that in mind, we know that the experience of
being a gender-variant child is challenging, possibly characterized by distress and dysphoria, that it can persist or
desist, and that it can open up options for social and later
medical transition that involve serious ethical and practical concerns for clinicians and families. We know that
these children are in our midst now, that their numbers
are increasing at gender clinics and elsewhere, and that
their presence is putting greater pressure on the medical
and mental health systems to create standards and clinical practice, research, and model approaches that adhere
to modern medical ethical standards. As these standards
are created, evaluated, and modified, it will be essential to
continuously reflect on the ethical questions, concerns, and
limitations raised above—and others that may arise in the
future—to best ensure that the medical field is doing its
best to help and not harm gender-variant children, adolescents, and their families.
1. I. Lovett, “California: Rights Guaranteed for Transgender
Students,” New York Times, August 13, 2013, p. A12.
2. Some trans advocates see the medicalization of transgenderism as contributory to this state of affairs (see D. B. Hill et al.,
“Gender Identity Disorders in Childhood and Adolescence: A
Critical Inquiry,” International Journal of Sexual Health 19, no. 1
(2007): 57-74; K. Winters, “Gender Dissonance: Diagnostic Reform
of Gender Identity Disorder for Adults,” Journal of Psychology &
Human Sexuality 17, no. 3/4 (2005): 71-89. Yet, while the gay rights
movement can attribute much of its advancements to the removal
of homosexuality from the DSM in 1973, transgender rights have
progressed, albeit at a slower pace, despite the appearance of gender
diagnoses in both the DSM and the ICD.
3. World Professional Association for Transgender Health,
Standards of Care for the Health of Transsexual, Transgender and
Gender Non-Conforming People, 7th version, 2011, at http://www.
4. A. E. Cha, “Ban Lifted on Medicare Coverage for Sex Change
Surgery,” Washington Post, May 30, 2014, http://www.washingtonpost.com/national/health-science/ban-lifted-on-medicarecoverage-for-sex-change-surgery/2014/05/30/28bcd122-e818-1
5. At the time of this writing, a proposed name change for ICD-11
is “gender incongruence of children.”
6. This was formerly known as the Harry Benjamin International
Gender Dysphoria Association.
7. See World Professional Association for Transgender Health,
“Standards of Care for the Health of Transsexual, Transgender and
Gender Non-Conforming People,” 11.
8. W. Byne et al., “Report of the American Psychiatric Association
Task Force on Treatment of Gender Identity Disorder,” Archives of
Sexual Behavior, 41, no. 4 (2012): 759-96, at 762.
9. K. J. Zucker, “Children with Gender Identity Disorder: Is There
a Best Practice?,” Neuropsychiatrie de l’enfance et de l’adolescence,
56 (2008): 358-64; K. J. Zucker et al, “A Developmental,

Biopsychosocial Model for the Treatment of Children with Gender
Identity Disorder,” Journal of Homosexuality, 59, no. 3 (2012): 36997.
10. A. L. de Vries and P. T. Cohen-Kettenis, “Clinical Management
of Gender Dysphoria in Children and Adolescents: The Dutch
Approach,” Journal of Homosexuality 59, no. 3 (2012): 301-20.
11. All three clinics mentioned here offer puberty suppression
to children when clinically indicated, either to “buy time” in case
they desist after puberty or to prevent development of secondary sex
characteristics in those who persist. However, the approach here acts
under the assumption that they are better able to distinguish desisters
from persisters.
12. D. Ehrensaft, “From Gender Identity Disorder to Gender
Identity Creativity: True Gender Self Child Therapy,” Journal of
Homosexuality 59, no. 3 (2012): 337-56.
13. Further illustrating the controversies, some clinicians (including Ehrensaft) eschew the use of psychiatric diagnoses when evaluating and treating these children. Consequently, the nonmedical term
“gender variance” is an alternative, nonpathologizing way of describing them.
14. Since it often appears that child GD experts talk past each other, Jack Drescher and William Byne invited several of them to publish their clinical approaches in one volume. However, rather than
critique each other, which they often do, the clinicians were asked
to present their own approaches, which would then be discussed by
experts (child psychiatrists, ethicists, attorneys, trans advocates, and
gender scholars) who did not treat GD themselves but who had an
interest in issues related to gender. See J. Drescher and W. Byne,
Treating Transgender Children and Adolescents: An Interdisciplinary
Discussion (New York: Routledge, 2013).
15. In a most recent study, Thomas D. Steensma et al., found a
link between the intensity of GD in childhood and persistence of
GD, as well as a higher probability of persistence among natal girls.
Psychological functioning and the quality of peer relations did not
predict the persistence of childhood GD. Formerly nonsignificant
factors (e.g., age at childhood assessment) and unstudied factors (a
cognitive or affective cross-gender identification and a social role
transition) were associated with the persistence of childhood GD
and varied among natal boys and girls. Steensma et al. concluded,
“Intensity of early GD appears to be an important predictor of persistence of GD. Clinical recommendations for the support of children
with GD may need to be developed independently for natal boys and
for girls, as the presentation of boys and girls with GD is different,
and different factors are predictive for the persistence of GD” (T. D.
Steensma et al., “Factors Associated with Desistence and Persistence
of Childhood Gender Dysphoria: A Quantitative Follow-up Study,”
Journal of the American Academy Child & Adolescent Psychiatry, 52,
no. 6 [2013]: 582-90, at 589).
16. “Cisgender” is used in the transgender community to describe
those who are not transgender.
17. American Psychiatric Association, The Principles of Medical
Ethics: With Annotations Especially Applicable to Psychiatry (Arlington,
VA: APA, 2009). One caveat should be noted: these comments are
made with the understanding that many of the mental health practitioners offering treatment to prepubescent children are not physicians.
18. S. D. Pickstone-Taylor, letter to the editor (“Children with
Gender Nonconformity”), Journal of American Academy Child &
Adolescent Psychiatry 42, no. 3 (2003): 266.
19. K. J. Zucker et al., “A Developmental, Biopsychosocial Model
for the Treatment of Children with Gender Identity Disorder,”
Journal of Homosexuality 59, no. 3 (2012): 369-97; see 391-92.

SPECIAL REP ORT: L G B T B io et h ic s: Visib ilit y, D i s p a ri ti e s , a n d D i a l og u e


20. K. E. Bryant, “The Politics of Pathology and the Making
of Gender Identity Disorder,” PhD diss., University of California,
Santa Barbara, 2007.
21. T. D. Steensma et al., “Desisting and Persisting Gender
Dysphoria after Childhood: A Qualitative Follow-up Study,” Clinical
Child Psychology & Psychiatry 16, no. 4 (2011): 499-516.
22. A similar question can be raised about the treatment of adult
trans individuals. Does the present system of “gate keeping” before
allowing medical and surgical treatment exist for the benefit of those


wishing to transition or to protect those individuals who, after transition, might express regrets?
23. Ehrensaft, “From Gender Identity Disorder to Gender Identity
Creativity: True Gender Self Child Therapy,” 354.
24. Institute of Medicine, Committee on Lesbian, Gay, Bisexual,
and Transgender Health Issues and Research Gaps and Opportunities,
The Health of Lesbian, Gay, Bisexual and Transgender People: Building
a Foundation for Better Understanding (Washington, DC: National
Academies Press, 2011).

September-October 2014/ H A S T I N G S CE NTE R RE P O RT

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