Let’s talk about transgender youth: Ethical implications of navigating–or avoiding–controversial and polarizing issues and why dialogue matters

How many of us have ever felt a sense of dread around engaging in conversations about certain topics–even with colleagues, friends, and family, people we otherwise respect and trust–because we worry about the potential fallout if we don’t have all the information, know that we hold differing opinions, or have a general fear of hurting feelings or saying the wrong thing? Increasingly, this feeling pervades our culture. And this phenomenon is not just about political divides (left vs. right, conservative vs. liberal, Democrat vs. Republican); it is about the growing difficulty of engaging in meaningful dialogue about vital topics within our own field.

In this article, we introduce the first of a series of articles about “hot topic” issues, those polarizing topics that are relevant to practicing psychologists and that tend to be avoided out of discomfort or fear, and we explore them from an ethical framework. The ethical implications are two-fold: (1) the specific ethical considerations of each topic (which is intrinsically connected to why these issues are so difficult and important), and (2) the broad ethical implications of navigating–or avoiding–hard conversations around topics relevant to the practice of psychology. Our hope is to inspire productive dialogue and to provide useful recommendations for how to effectively approach these conversations, in recognition that good outcomes depend on curious, collaborative, and respectful dialogue.

Hot Topic: Working with Transgender Children and Adolescents

A recent Pew Research Center poll highlights the complexity of Americans’ views on transgender issues (Parker, 2022). In 2022, 38% of adult Americans said that a person’s gender can be different from their sex at birth, while 60% said that gender is determined by sex at birth. Compared to 5 years earlier, where 44% and 54% reported these views, respectively, the data suggest that a rising share of Americans believe a person’s gender is determined by their sex at birth. When asked about the pace of change in issues related to people who are transgender or nonbinary, 43% of Americans say that changes are happening too quickly, 26% say not quickly enough, and 28% say the pace is about right. Generally, older adults view the change as too quick and younger adults as not quick enough. Roughly equal numbers of Americans say that their knowledge of science has influenced their views, whether they believe that gender is determined by or can be different from sex at birth.

In 2022, the World Professional Association for Transgender Health (WPATH) published the eighth edition of the Standards of Care (SOC-8), a collection of recommendations based on the best available science and expert professional consensus in transgender health (Coleman et al., 2022). One significant change from the previous iteration was the addition of a chapter specifically about adolescents, due to the exponential increase in referral rates and the unique developmental considerations for this cohort, particularly in relation to medical interventions (Coleman et al., 2022). The SOC-8 guidelines for both children and adolescents share the following key features: highlighting the importance of professional expertise, interprofessional collaboration, comprehensive biopsychosocial assessment, and informed consent and assent (including reviewing the risks and benefits of interventions); facilitating open and respectful exploration without favoring one particular identity; prohibiting conversion therapy; and involving parents and caregivers throughout the process (Coleman et al., 2022).

Furthermore, WPATH guidelines state that health care professionals should only recommend medical or surgical treatments to adolescent patients when seven specific requirements are met. Specifically, the young person must (1) meet diagnostic criteria for gender incongruence per ICD-11; (2) have experiences that are marked and sustained over time; (3) demonstrate emotional and cognitive maturity to provide informed consent/assent; (4) address mental health concerns that may interfere with diagnostic clarity, capacity to consent, and medical treatments; (5) have been informed of reproductive effects; (6) have reached Tanner stage 2 (i.e., has started puberty) for pubertal suppression; and (7) have had at least 12 months of gender-affirming hormone therapy prior to gender-related surgical procedures (Coleman et al., 2022).

Two factors are working hand-in-hand to heighten the controversy around transgender youth: the rapid increase in access to and pursuit of pediatric gender-related medical treatments and the lack of data about long-term outcomes with this population. In 2018, Chen and colleagues wrote:

As pediatric psychologists trained in evidence-based care, we have been challenged to identify best practices in the absence of substantive research evidence. ‘Doing nothing’ is not a neutral decision, as research suggests that nearly half of transgender youth experience suicidal ideation and nearly a quarter have made an attempt, with suicide attempts significantly associated with lower body esteem (Grossman & D'Augelli, 2007). Guidelines for clinical care have been established based on the collective expertise of clinicians working with TGNC [transgender and gender-nonconforming youth] youth and are rapidly evolving, outpacing outcomes research in this vulnerable population. (p. 74)

Gender-affirming interventions, which include social affirmation, puberty blockers, cross-sex hormone therapy, surgeries, and legal affirmation, exist on a spectrum from reversible to irreversible (Rafferty, 2018). These processes are intertwined with developmental stages, which can broadly be broken down into three cohorts: prepubescent children, peripubertal youth, and pubertal adolescents. Given the limitations of the current evidence base and the complex and evolving nature of gender diversity, we face a number of questions that directly tie into ethical decision-making. Chen et al. (2018) outlined treatment options, the state of the science, and ongoing controversies for these three cohorts. The following questions are adapted from their comprehensive review:

• How stable is gender identity in prepubertal children? What is the effect of social transition on gender identity development? What is the relative harm of encouraging social transition (e.g., the child feeling “boxed in” or inadvertently reinforcing the gender binary)?
• What is the role of endogenous puberty in gender identity consolidation? What short- and long-term impact does the interruption of puberty have on critical and sensitive windows of cognitive, social, and physical development (e.g., bone mineral density and fertility)? How does puberty suppression interact with gender-related surgical outcomes?
• What might be the limits and possibilities of treatment with genderqueer and non-binary youth? In what ways are late-identifying transgender youth distinct from transgender youth with a history of gender dysphoria in earlier childhood? How appropriate are medical interventions for youth with co-occurring mental health or developmental disorders?
• How much decisional capacity does a young person have to make decisions about partially or fully irreversible treatments?

Ethical Considerations: How Ethics Intersect with Ongoing Controversies

In line with the Five-Step Ethical Decision-Making Model (Knapp et al., 2017), the first step to approaching and resolving ethical dilemmas is to identify relevant principles or codes from the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA], 2017).

The guiding principle of beneficence and nonmaleficence is paramount. At the core of these questions is the careful consideration of potential harm and benefits of pursuing a specific course of action, whether that is intervening or not intervening. Although the goal is to support young people to thrive in all aspects of health and well-being across the lifespan, the current gaps in our knowledge, both at a general level and in terms of individual differences, mean that it is often not clear what course of action will best achieve that aim. On the extreme ends of the spectrum, one risk is providing insufficient intervention, which could contribute to significant mental health challenges, including depression, anxiety, low self-esteem, isolation, self-harm, or even suicide. Another risk is intervening in ways that prove to be more harmful than anticipated. Examples of long-term risks include loss of fertility, bone health, and sexual functioning; the need for future medical treatments to alter or reverse previous surgical outcomes due to evolving gender identity; or chronic pain and lifelong medical care (Chen et al., 2018; Rafferty, 2018).

Ethical codes related to boundaries of competence (2.01), avoiding harm (3.04), cooperation with other professionals (3.09), and informed consent (3.10) are especially pertinent to working with gender-diverse youth (APA, 2017). Ethical care of youth who are considering gender transitioning relies on sufficient levels of expertise for diagnostics and treatment planning and delivery, taking reasonable steps to avoid harm, collaboration with other professionals on the care team, and ensuring that the young person and their parent or caregiver have been provided with enough information to make informed decisions.

Psychologists hold unique duties and responsibilities when it comes to caring for young people, particularly vulnerable populations such as transgender and gender-diverse children and adolescents and their families. Whether through delivering therapy and assessment services, creating organizational and public policy, conducting and disseminating research, or instructing and training future generations of psychologists, young people and their families rely on professionals for guidance and support in answering tough questions using the best tools and knowledge available. How can we collectively learn, dialogue, and best serve these clients when these issues can also become entangled with our own and others’ lack of knowledge/competence, personal beliefs, political stances, or spiritual beliefs? Is it possible to uphold the ethical principles of beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity if we cannot engage in thoughtful, respectful, and open-minded dialogue? What happens to our ability to operate within boundaries of competence, to maintain competence, and to base our work on sound scientific evidence and professional knowledge if our field becomes caught in the mire of fear, judgment, and even polarization?

Below is a sample of questions that are relevant to ethical practice of serving transgender and gender-diverse youth and that may be a starting point for dialogue:

• How do we responsibly translate research findings to clinical application? In other words, how do we evaluate the evidence base in a balanced, objective way to give us an accurate degree of confidence in interpreting the data when working with individual youth?
• How do we approach work with families who have cultural, religious, or family values and beliefs that do not align with gender transition interventions?
• How do we best understand and support youth who go on to detransition later in life?
• How do we create space for vital research on topics such as detransitioning and the potential impact of social media and peer influence on gender identity?
• How do we respond in situations where we discover that other professionals are likely providing care outside the bounds of ethics (e.g., taking steps that are in clear conflict with WPATH guidelines)?

Moving Forward: Suggestions for Dialogues About Hot Topics

Israel (2020) has researched and practiced having difficult conversations for decades, and her ideas are an important tool to add to our toolbox. In Israel’s 2020 book Beyond Your Bubble: How to Connect Across the Political Divide; Skills and Strategies for Conversations that Work, she presents practical strategies for engaging in dialogue, which she defines as “being able to understand ideas and the people who hold them–and being able to make a connection with these people,” a concept that is distinct from diatribe, discourse, and debate (p. 30). She succinctly captures this process in a flowchart that begins with the simple question, “Do you want to have a conversation with someone who holds views different from your own?” From there, the pathway towards meaningful dialogue involves listening skills (e.g., allow uninterrupted speaking, reflect, use “I” statements, ask open-ended questions), perspective taking (e.g., be curious and nonjudgmental, assume the other person has positive intentions, and try to advocate for their position), and dealing with distressing feelings that come up (e.g., remember your motivations, pause, and, of course, breathe). While Israel’s work is not specific to mental health, any difficult conversation shares similar challenges and solutions. If we can be clear about our motivation for engaging in a conversation, assume good intentions, listen, and take others’ perspectives, we can find common ground and work together to make progress in service of our shared goals, which in this case is to help youth thrive.

Made of soap and water, bubbles are beautiful and fun and magical, but they are also fragile. The bubbles we create from political insulation are similarly unsustainable. If we cannot survive outside of our bubbles; if we cannot tolerate listening to our friends and families and neighbors; if we cannot see beyond our own perspectives; if we view our fellow citizens as enemies, how can we sustain our relationships, our communities, our country? (Israel, 2020, p. 15)

 
References

American Psychological Association. (2017). Ethical principles of psychologists and code of
conduct. http://www.apa.org/ethics/code/

Chen, D., Edwards-Leeper, L., Stancin, T., & Tishelman, A. (2018). Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions. Clinical Practice in Pediatric Psychology, 6(1), 73–83. https://doi.org/10.1037/cpp0000229

Coleman, E., Radix, A. E., Bouman, W. P., Brown, G. R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Hancock, A. B., Johnson, T. W., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F. L., Monstrey, S. J., Motmans, J., Nahata, L., Nieder, T. O., Reisner, S. L., … Winter, S. (2022). Standards of care for the health of transgender and gender diverse people (Version 8). International Journal of Transgender Health, 23(Suppl 1), S1–S259. https://doi.org/10.1080/26895269.2022.2100644

Israel, T. (2020). Beyond your bubble: How to connect across the political divide; Skills and strategies for conversations that work. American Psychological Association.

Knapp, S. J., VandeCreek, L. D., & Fingerhut, R. (2017). Practical ethics for psychologists: A positive approach (3rd ed.). American Psychological Association. https://doi.org/10.1037/0000036-000

Parker, K. (2022, June 28). Americans’ complex views on gender identity and transgender issues. Pew Research Center’s Social & Demographic Trends Project. https://www.pewresearch.org/social-trends/2022/06/28/americans-complex-views-on-gender-identity-and-transgender-issues/

Rafferty, J. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics, 142(4), e20182162–. https://doi.org/10.1542/peds.2018-2162