Gender dysphoria is a persistent distress about one’s assigned gender. Referrals regarding gender dysphoria have recently greatly increased, often of a form that is rapid in onset. The sex ratio ha...

Ethical concerns have been raised about routine practice in paediatric gender clinics. We discuss informed consent and the risk of iatrogenesis in the prescribing of gonadotropin-releasing hormone...

Volume 19, Issue 6, June 2019, Page W3-W4.

Gender dysphoria is a clinically significant incongruence between expressed gender and assigned gender, with rapidly growing prevalence among children. The UK High Court recently conducted a judicial review regarding the service provision at a youth-focussed gender identity clinic in Tavistock. The high court adjudged it ‘highly unlikely’ that under-13s, and ‘doubtful’ that 14–15 years old, can be competent to consent to puberty blocker therapy for GD. They based their reasoning on the limited evidence regarding efficacy, the likelihood of progressing (...) to cross-sex hormone therapy and the ‘life-changing consequences’ of puberty blockers. In this article, I offer two concurrent arguments to dispute their reasoning. First, I argue that minors can be competent to consent to puberty blockers for GD, because the decision to undergo puberty blocker therapy is no more complex or far-reaching than other medical decisions that we accept a child should be able to make. Second, I argue that—irrespective of competence—such legal restriction for all children fundamentally contradicts the central ethical tenet of child healthcare: best interests. For these two reasons, the high court should not restrict access to puberty blockers for competent GD children. (shrink)

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient’s well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause (...) dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria. (shrink)

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)

Volume 19, Issue 6, June 2019, Page W3-W4.

The original “Dutch Protocol”—the treatment model comprised of puberty blockers, cross‐sex hormones, and surgery—was intended to improve the mental and physical health of pediatric patients experiencing distress over their sexed bodies. Consequently, both researchers and clinicians have couched eligibility for treatment and measures of treatment efficacy in terms of the interventions’ effects on outcomes such as gender dysphoria, depression, anxiety, and suicide. However, recent systematic reviews have concluded that the scientific evidence supporting these interventions is uncertain, leading to (...) significant international differences in what treatments are offered to youth. Against this backdrop, a different argumentative approach has emerged in support of gender‐affirming care. This approach appeals not to reductions in patient morbidity or mortality but to patient autonomy, where medical intervention is pursued as a means to the satisfaction of a patient's “embodiment goals.” In this article, I raise objections to autonomy‐based justifications for pediatric gender‐affirming care, concluding that these arguments misunderstand the place of autonomy in clinical decision‐making and, consequently, put patients at risk of medical harm. (shrink)

Increasingly, transgender minors are seeking medical care such as puberty-suppressing or gender-affirming hormone therapies. Yet, whether these interventions should be performed at all is highly controversial. Some healthcare practitioners oppose irreversible interventions, considering it their duty to protect children from harm. Others view minors, like adults, as transgender individuals who must be protected from discrimination. The underlying ethical question is presented as a problem of priority. Is it primarily relevant that minors are involved? Or should decision makers focus on (...) the fact that they treat transgender individuals? The paper explores the relevance for medical practice. We provide results of an interview study with German healthcare professionals. We discuss the general question whether prioritization among different group memberships of the same person is ethically defensible. We conclude that priority conflicts between group memberships of the same person can be deceptive and should be addressed by an intersectional approach. Eventually, we discuss practical implications. (shrink)

We applaud Notini and colleagues for highlighting the clinical and ethical complexities of a case in which a non-binary individual desires indefinite treatment with puberty blockers.1 While we agree discontinuing treatment may cause psychological distress, we believe there are potential physical and neurocognitive harms caused by prolonged treatment that have been underestimated given the limited research conducted to date. Specifically, the impact of permanent pubertal suppression on the brain and decision-making capacity should be considered. In this context, we (...) outline the potential risks of ongoing pubertal suppression on bone and cardiovascular health, sexual and reproductive function, and brain development—all noted in the article but perhaps in an overly simplistic manner.1 First, the authors’ note OPS will almost certainly result in reduced bone density.1 Although we agree the absolute fracture risk is low in studies among older adults, there is less clarity about implications during adolescence and young adulthood when peak bone accrual occurs.2 Further, the authors propose ongoing monitoring with bone density scans, but no clear guidelines for clinicians if bone density becomes critically low—so we ask, at what point would a potential fracture risk outweigh the proposed benefits …. (shrink)

We applaud Notini and colleagues for highlighting the clinical and ethical complexities of a case in which a non-binary individual desires indefinite treatment with puberty blockers. 1 While we agree discontinuing treatment may cause psychological distress, we believe there are potential physical and neurocognitive harms caused by prolonged treatment that have been underestimated given the limited research conducted to date. Specifically, the impact of permanent pubertal suppression on the brain and decision-making capacity should be considered. In this context, (...) we outline the potential risks of ongoing pubertal suppression on bone and cardiovascular health, sexual and reproductive function, and brain development—all noted in the article but perhaps in an overly simplistic manner. 1 First, the authors’ note OPS will almost certainly result in reduced bone density. 1 Although we agree the absolute fracture risk is low in studies among older adults, there is less clarity about... (shrink)

A recent paper by Teresa Baron and Geoffrey Dierckxsens argues that puberty blockers and hormone therapy should be disallowed before adulthood on prudential and consent-related grounds. This response contends that their argument fails because it is predicated on unsupported premises and misinterpretations of the available evidence. There is no evidence that a large proportion of pubertal and postpubertal youths later discontinue medical transition. Meaningful assent is a viable and commonly accepted alternative to meaningful consent in paediatric bioethics. And (...) finally, the primary purpose of transition-related interventions is to actualise youths’ gendered self-image, not treat an underlying mental illness. (shrink)

Lord Scarman’s judgment about when someone under the age of 16 years should have the right to make their own medical decisions emphasised the decision-making abilities of the particular child. He said: > …the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves a sufficient understanding and intelligence to enable him or her to understand fully what is proposed.1 That created a duty on (...) healthcare practitioners to assess whether a particular minor has decision-making abilities at a degree that would enable them to understand the decision to a high extent, sufficient hopefully that they would ‘own’ the decision. In December of 2020, the High Court considered whether young people with gender dysphoria and seeking access to puberty blocking therapy, were likely to pass Scarman’s mature minor test and cast doubt on their ability to fully understand that decision, thereby making it less likely that a healthcare practitioner would decide they are a mature minor for that therapy. The High Court said: > It is highly unlikely that a child aged 13 or under would be competent to give consent to the administration of puberty blockers. It is doubtful that a child …. (shrink)

In previous Ethics briefings 1 we have highlighted the developments in the case of Bell & Another v the Tavistock and Portman NHS Foundation Trust. The case concerned a judicial review of the practice of prescribing puberty blocking treatment to children and young people at the Gender Identity Development Service managed by the Tavistock and Portman NHS Foundation Trust. The Court of Appeal in its judgement2 found the Trust’s practices to be lawful, and overturned previous guidance given by the (...) High Court which had contradicted the 'Gillick principle' regarding whether a child or young person could consent to medical treatment, without the consent of its parent. Despite this legal success, concerns over the GIDS continued. In September, NHS England commissioned an independent and wide-ranging review of gender identity services for children and young people led by Dr Hilary Cass, past president of the Royal College of Paediatrics and Child Health. Dr Cass’s Interim review, published in March,3 has resulted in a decision by NHS England to close the GIDS at the Trust by Spring 2023, and replace it with regional centres at existing children’s hospitals offering more 'holistic care' with ’strong links to mental health services’. It is proposed that regional centres will be established at Great Ormond Street Hospital, and Alder Hey Children’s NHS Foundation Trust. Dr Cass was critical of the clinic’s failure to collect sufficient data on the impact of puberty blockers in under-16s. …. (shrink)

In this issue's lead article, "Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health," Florence Ashley argues that insofar as we accept that abortion and birth control can be ethical interventions for adolescents, so, by analogy, should we treat interventions such as puberty blockers that aid in gender transition as ethical. None of these interventions treat illness or pathology, but rather they operate on healthy bodies, not in order to cure, but in order to help patients live (...) in line with their fundamental self-conception and to realize their embodied goals. Parenting, pregnancy, and gender all go to the heart of our embodied identities and sense of self, they point out. Moreover, Ashley... (shrink)

Volume 26, Issue 3, September 2020, Page 195-196.

Blocker argues that the literary problem of absurdity is basically a metaphysical problem of being, focusing on the metaphysical distinction of being as essence and being as existence. This book compares philosophical prose with the fiction writing of four major absurdist writers—Camus, Sartre, Ionesco, and Beckett.

The usual strawsonian account of referring won't do for fictional entities. The problem is that we still don't have a sufficiently clear notion of ordinary referring, And the root of this problem is that referring is still perceived in terms of a paradigm relation of a description to an existing thing. But that relation is preceded by the more fundamental relation of thought to an object of thought, Whether real or imaginary. The conclusion reached is that fictional reference is an (...) institutionalized partial use of ordinary referring, Parasitic on it though leading a legitimate life of its own. (shrink)

An overview of Japanese philosophy from the seventh century to the present.

This book brings philosophical aesthetics into a broader cultural interest in the fine arts and draws together the classics of the history of aesthetics, the mid-twentieth century or "Analytic" aesthetics, and late-twentieth century or "Continental" post-structuralist "theory.".

A defense of the embattled concept of aesthetic distance is achieved by reinstating a prominent feature of distance ignored in the current controversy. Distance is not the only supposed psychological posturing discussed by bullough, But also the space which is necessary to art between the art medium and the world represented therein. Examples from painting, Film and absurdist literature are discussed in terms of the historical tension between medium "opacity" and "transparency" in order to show how total transparency is avoided (...) to create the space between the art medium and reality, Without which art can neither "say" anything nor even exist. (shrink)