This article considers the claim that gender diverse minors and their families should not be able to consent to hormonal treatment for gender dysphoria. The claim refers particularly to hormonal treatment with so-called ‘blockers’, analogues that suspend temporarily pubertal development. We discuss particularly four reasons why consent may be deemed invalid in these cases: the decision is too complex; the decision-makers are too emotionally involved; the decision-makers are on a ‘conveyor belt’; the possibility of detransitioning. We examine each of these (...) reasons and we show that none of these stand up to scrutiny, and that some are based on a misunderstanding of the nature and purposes of this stage of treatment and of the circumstances in which it is usually prescribed. Moreover, accepting these claims at face value could have serious negative implications, not just for gender diverse youth, but for many other minors and families and in a much broader range of healthcare settings. (shrink)

The principles that usually direct ethical decision making are not easily or straightforwardly applicable to the care and treatment of anorexia nervosa, particularly the care and treatment of severe and enduring anorexia nervosa, where the sufferer seems to be recalcitrant to treatment and where the condition has become life-threatening.There are exceptional circumstances that characterize this puzzling and still scarcely understood condition; I suggest that these exceptional circumstances provide moral reasons for partial derogation from the usual principles of ethical decision making.In (...) what follows I argue... (shrink)

Understanding Eating Disorders is an original contribution to the field of healthcare ethics. It develops a new theory concerning the moral basis of eating disorders, and places such disorders for the first time at the centre of philosophical discourse. The book explores the relationship that people have with food and their own body by looking at genetics and neuro-physiology, sociology and family studies, clinical psychology and psychiatry, and frames abnormal eating at the extreme of a spectrum of normal behaviours, directed (...) by moral values. Giordano argues that abnormal eating is not a psycho-pathological phenomenon, but the coherent implementation of ordinary moral values with a long tradition in Western culture. The book also contains a detailed analysis of UK legislation, accompanied by a timely critique of the law on treatment of mental disorders in general and of eating disorders in particular. (shrink)

A large part of the debate around the right to refuse life-prolonging treatment of anorexia nervosa sufferers centers on the issue of competence. Whether or not the anorexic should be allowed to refuse life-saving treatment does not depend solely or primarily on competence. It also depends on whether the anorexic’s suffering is bearable or tractable, and on the degree of involvement of the family in the therapeutic process. Anorexics could be competent to refuse lifesaving treatment (Giordano 2008). However, the anorexic’s (...) refusal of life-saving treatment should not be respected purely because it is a competent decision. In fact, anorexia has two characteristics that weaken the strength of the principle .. (shrink)

Anorexia nervosa is currently classed as a mental disorder. It is considered as a puzzling condition, scarcely understood and recalcitrant to treatment. This paper reviews the main hypotheses relating to the aetiology of anorexia nervosa. In particular, it focuses on family and sociological studies of anorexia. By reflecting on the hypotheses provided within these domains, and on the questions that these studies leave unanswered, this paper suggests that anorexic behaviour is understandable and rational, if seen in light of ordinary moral (...) values. (shrink)

A demographic revolution is taking place in Europe and worldwide. According to World Health Organization estimates, the number of people aged 60 and over is growing faster than any other age group. This change in the population structure affects disease patterns and is deemed to cause an increase in the demands on healthcare systems. This raises concerns about the ethics of healthcare delivery . What criteria should direct healthcare distribution? Is it right to meet the demands of an ageing population, (...) to the detriment of the younger strata of population? a. (shrink)

Simona Giordano presents the first full philosophical study of ethical issues in the treatment of anorexia and bulimia nervosa. Beginning with a comprehensive analysis of these conditions and an exploration of their complex causes, she then proceeds to address legal and ethical dilemmas such as a patient's refusal of life-saving treatment. Illustrated with many case-studies, Understanding Eating Disorders is an essential tool for anyone working with sufferers of these much misunderstood conditions, and for all those ethicists, lawyers, and medical practitioners (...) engaged with the widely relevant issues they raise. (shrink)

Both clinical literature and biographical accounts suggest that many transgender individuals experience shame or have experienced shame at some point in their life for reasons related to their gender identity. In clinical psychology, at least until the 1960s, shame has not received much attention; focus was on guilt and shame was regarded mainly as a ‘by-product’ of guilt. From the 1960s shame has been identified as an emotion not necessarily related to guilt and with unique features, and has been studied (...) in connection with a number of situations, such as domestic abuse, trauma, illness, and sexual orientation. However shame has been studied less in connection with gender variance. Shame has however intrigued philosophers, writers and artists for a very long time. Yet, the importance of the contribution of various disciplines to the understanding of the experience of shame in vulnerable individuals has been overlooked. This paper attempts to explore the meaning of shame for transgender individuals, by making reference not only to clinical studies, but also to artworks and literary novels. Franz Kafka, named “the poet of shame” is particularly salient to the analysis of shame, and some of his works will enable us to shed light on the complexities of the experience of shame in transgender individuals which may defy clinical observation. (shrink)

A demographic revolution is taking place in Europe and worldwide. According to World Health Organization estimates, the number of people aged 60 and over is growing faster than any other age group. This change in the population structure affects disease patterns and is deemed to cause an increase in the demands on healthcare systems. This raises concerns about the ethics of healthcare delivery. What criteria should direct healthcare distribution? Is it right to meet the demands of an ageing population, to (...) the detriment of the younger strata of population? a. (shrink)

The importance of humanities in the medical curriculum is increasingly recognized. For example, in the United Kingdom, The General Medical Council, which is an independent body established under the Medical Act 1858 and responsible, among other things, for fostering good medical practice and promoting high standards of medical education, in its publication Tomorrow’s Doctors, encouraged inclusion of humanities in the medical curriculum. Literature, arts, poetry, and philosophy are thought to foster the doctors’ ability to “communicate with patients, to penetrate more (...) deeply into the patient’s wider narrative, and to seek more diverse ways of promoting well being and reducing the impact of illness or disability.”. (shrink)

Imposing artificial feeding on people with anorexia nervosa may be unethical. This seems to be Heather Draper's suggestion in her article, ‘Anorexia Nervosa and Respecting a Refusal of Life‐Prolonging Therapy: A Limited Justification.’ Although this is an important point, I shall show that the arguments supporting this point are flawed. Draper should have made a brave claim: she should have claimed that people with anorexia nervosa, who competently decide not to be artificially fed, should be respected because everybody is entitled (...) to exercise their autonomy, not only ‘in the middle’ of their life, but also at the end of it, or when their own life is at stake, because autonomy also extends to the most difficult moments of our life, and, ultimately, ‘stretches [.*T*.*T*.] far out into the distance’ at the end of it. I explain why Draper should have made the brave claim, and why she has not made it. I conclude that a defence of people's entitlement to competently refuse artificial feeding cannot rest upon the arguments developed by Draper. Whether or not we should respect competent refusal of artificial feeding depends on the normative strength that we are ready to ascribe to the principle of autonomy, to the moral relevance that we ascribe to the circumstances in which a person's autonomy is exercised, and, perhaps, eventually, on our sense of compassion. (shrink)

Gender Identity Disorder is classified as a mental illness and included in the DSM-IV and ICD-10. It will also be included in the DSM-V. The psychiatric diagnosis, in spite of some apparent advantages, has significant psychological and social adverse implications. This paper discusses some of the main epistemological reasons to consider gender variance as a mental disorder. It will also evaluate whether reasons of other kinds may justify the inclusion of gender variance amongst mental illnesses.

Studies suggest that the majority of gender diverse children (up to 84%) revert to the gender congruent with the sex assigned at birth when they reach puberty. These children are now known in the literature as ‘desisters’. Those who continue in the path of gender transition are known as ‘persisters’. Based on the high desistence rates, some advise being cautious in allowing young children to present in their affirmed gender. The worry is that social transition may make it difficult for (...) children to de-transition and thus increase the odds of later unnecessary medical transition. If this is true, allowing social transition may result in an outright violation of one of the most fundamental moral imperatives that doctors have: first do no harm. This paper suggests that this is not the case. Studies on desistence should inform clinical decisions but not in the way summarised here. There is no evidence that social transition per se leads to unnecessary medical transition; so should a child persist, those who have enabled social transition should not be held responsible for unnecessary bodily harm. Social transition should be viewed as a tool to find out what is the right trajectory for the particular child. Desistence is one possible outcome. A clinician or parent who has supported social transition for a child who later desists will have not violated, but acted in respect of the moral principle of non-maleficence, if the choice made appeared likely to minimise the child’s overall suffering and to maximise overall the child’s welfare at the time it was made. (shrink)

In this paper, we present the case of a couple who refused to disclose the sex of their child to others, and some of the responses that this case prompted in the international media. We outline the ethical issues that this case raises, and we place it into the more general context of parental preferences regarding the gender (development) of their children and of the impact on children of parental choices in the matter. Based on current knowledge of gender identity (...) development, we identify some of the potential pitfalls of such a course of action and we briefly present some alternative strategies that could be implemented in order to ensure more freedom of gender formation in children. (shrink)

In this issue of the Hastings Center Report, Tony Hope, Jacinta Tan, Anne Stewart, and Ray Fitzpatrick, reporting on twenty-nine interviews they conducted with women with so-called anorexia nervosa, note that the participants recurrently raised issues of authenticity. The paper reflects on the way their behaviors, experiences, and choices can be considered authentic , or inauthentic . The authors also pose a question about the normative implications of their analysis—if some choices are inauthentic, then is it ethical to override them? (...) For example, they suggest that “showing respect” for the sufferer “does not necessarily mean simply acceding to the person’s .. (shrink)

Simona Giordano investigates the moral concerns raised by current clinical options available for transgender and gender diverse children and adolescents. From the time young children express gender incongruent preferences and attitudes, up to the time in which older adolescents might apply for medical or surgical treatment, moral questions are likely to be asked: should children be enabled to express themselves freely inside and outside the domestic environment? What are the implications of the choices that parents might make early on? How (...) should clinicians respond to distress around sexual anatomy? Is it ethical to suspend pubertal development? What level of evidence should we seek for medications to be used in paediatric care? What are the risks and benefits of various forms of hormonal treatment? Is it ethical to defer surgical interventions till adulthood? Giordano provides a detailed ethical analysis of these and many other questions that are likely to arise at various stages of a person's life and proposes a moral formula to answer these questions, as well as others, that are likely to arise in a fast-changing landscape. Children and Gender combines a detailed ethical analysis with an accurate clinical description of gender development and available clinical pathways. (shrink)

The book offers an accessible account of EDs and closely examines the concept of addiction, Drawing on a wide range of medical, psychological, physiological, sociological and philosophical sources, the book examines the benefits and risks of exercise for the ED population, explores the links between EDs and other abuses of the body in the sports environment and addresses the issue of athletes with disordered eating behaviour. Importantly, the book also surveys current legislation and professional codes of conduct that guide the (...) work of fitness professionals and clinicians in this area and I presents a clear and thorough set of case histories and action points to help professionals better understand, and care for, their clients with EDs. --. (shrink)

Atypical gender identity organisation (AGIO) is a serious medical condition in which the phenotypical appearance is experienced as alien by the person affected. AGIO is source of great distressDistress, and obtaining medical treatment is for many a life-or-death matter. Many of those who cannot receive treatment are at high risk of suicide. AGIO is not only a problem of personal health, but also a public problem, because sufferers are often exposed to discrimination, abuse and violence, and each act of discrimination, (...) abuse and violence is a public issue. Thinking about AGIO represents a great challenge for us all. It involves rethinking about gender identity in a more comprehensive way, inclusive of phenomena that go beyond the classic gender divide ‘male–female’, and thinking of ways of ensuring all citizens, whatever their gender identityInternational guidelines for treatment of gender identity disorder, a secure and peaceful place in society. I explain what AGIO is, how it manifests itself, and provide a brief history of AGIO. I offer an overview of risks and benefits of available treatments. I analyse the ethico-legal issues that surround AGIO. In particular, ethics of interfering with natural development, competenceMinors, competencein minorsCompetence in minors, validity of informed consentConsent, role of the family, moral and legal responsibilityResponsibility of professionals for omission of treatment and ageismAgeism. I conclude that medical treatment should be offered, even to minors just after the onset of puberty, if the child has a profound and persisting AGIO, if she/he is competent to make a judgement on the matter, and if treatment is likely to enhance his/her quality of life. Deferring treatment till adulthood is not a morally neutral option, and it is indeed unethical, if the child is likely to be harmed by pubertal development. (shrink)

This paper investigates legal and moral justificationsof coerced treatment for psychiatric patients who aredetained on the grounds that they may harm others.While the general issues concerning compulsorytreatment and detention have been widely canvassed, ithas seldom, if ever, been noticed that the moralreasons that we may have to detain a person whoappears to be dangerous to others are different fromthe moral reasons we may have to treat him or her. For example, it has not been noticed that compulsorydetention and compulsory treatment (...) are supported bytwo different moral principles, namely the Principleof Harm and the Principle of Beneficence, and,therefore, that the arguments which support compulsorydetention do not also support compulsorytreatment. The conceptual confusion between legitimacyof compulsory detention and legitimacy of compulsorytreatment is exacerbated by the ambiguous wordingutilised in S 3 of the UK Mental Health Act, whichimplies that treatment may be necessary for theprotection of others. Failure to pay attention to these distinctions has led to tragic consequences, in terms of violations of individual autonomy and in terms of public safety. (shrink)

A short story of an assassin and a sleeping old Fisherman: Before I explain the rationale of this anecdote, let me begin my response by saying how grateful I am to Bratton and Tomasini for engaging with me over such a thorny and unpleasant topic. Many of us have either suffered eating disorders, or have a relative or a friend who has had an eating disorder, or who has died with anorexia. I still remember giving a talk on anorexia nervosa, (...) several years ago, and at the end of the talk one senior academic was very shaken and nearly in tears. He had lost his sister with anorexia. For many of us, eating disorders are an extremely sensitive issue, and for this very reason, I feel particularly indebted when .. (shrink)

Eating Disorders, particularly anorexia and bulimia, are of immense contemporary importance and interest. News stories depicting the tragic effects of eating disorders command wide attention. Almost everybody in society has been touched by eating disorders in one way or another, and contemporary obsession with body image and diet fuels fascination with this problem. It is unclear why people develop eating disorders. Clinical and sociological studies have provided important information relating to the relational systems in which eating disorders are mainly found. (...) This paper shows that their explanations are not conclusive and points out that the reasons why people develop eating disorders should not be found in the dysfunctional interactions occurring in both familial and social systems, but in the moral beliefs that underlie these interactions. Eating disorders are impossible to understand or explain, unless they are viewed in the light of these beliefs. A moral logic, that is a way of thinking of interpersonal relations in moral terms, gives shape to and justifies the clinical condition, and finds consistent expression in abnormal eating behaviour. The analysis offered here is not mainstream either in philosophy (eating disorders are in fact seldom the subject of philosophical investigation) or in clinical psychology (the methods of philosophical analysis are in fact seldom utilised in clinical psychology). However, this paper offers a important contribution to the understanding of such a dramatic and widespread condition, bringing to light the deepest reasons, which are moral in nature, that contribute to the explanation of this complex phenomenon. (shrink)

Gender Identity Disorder (GID) is regarded as a mental illness and included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It will also appear in the DSM-V, due to be published in 2013. The classification of GID as a mental illness is contentious. But what would happen to sufferers if it were removed from the diagnostic manuals? Would people lose their entitlement to funded medical care, or to reimbursement under insurance schemes? On what basis should medical treatment for (...) GID be provided? What are the moral arguments for and against funded or reimbursed medical care for GID? This paper starts out with a fiction: GID is removed from the diagnostic manuals. Then the paper splits in two, as in happened in the Howitt’s 1998 film Sliding Doors . The two scenarios run parallel. In one, it is argued that GID is on a par with other body modifications, such as cosmetic and racial surgery, and that, for ethical reasons, treatment for GID should be privately negotiated by applicants and professionals and privately paid for. In the other scenario, it is argued that the comparison between GID and other body modifications is misleading. Whether or not medical treatment should be funded or reimbursed is independent of whether GID is on a par with other forms of body dissatisfaction. (shrink)