In this article, we analyse the novel case of Phoenix, a non-binary adult requesting ongoing puberty suppression to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity. We argue that the aim of OPS is consistent with the proper goals of medicine to promote well-being, and therefore could ethically be offered to non-binary adults in principle; there are additional equity-based reasons to offer OPS to non-binary adults as a group; and the ethical defensibility (...) of facilitating individual requests for OPS from non-binary adults also depends on other relevant considerations, including the balance of potential benefits over harms for that specific patient, and whether the patient’s request is substantially autonomous. Although the broadly principlist ethical approach we take can be used to analyse other cases of non-binary adults requesting OPS apart from the case we evaluate, we highlight that the outcome will necessarily depend on the individual’s context and values. However, such clinical provision of OPS should ideally be within the context of a properly designed research study with long-term follow-up and open publication of results. (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)

Notini et al 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD young people for whom, all things considered, medical interventions to affirm gender identity promote their well-being. Well-being has become an important conceptual currency in ethical debates and lies at the core of the authors’ analysis of Phoenix’s case. While the authors do not ground their argument in favour of OPS in a specific theory of well-being, welfarist considerations 2 appear to underpin …. (shrink)

Notini _et al_ 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD... (shrink)

"Some patients find it difficult to be in the present because they are stuck in the past; others, by contrast, struggle to remain connected with the past and are suspended in a so-called present that is effectively atemporal, that is out of time”.1 For psychoanalysts, the most profound and ultimately ethical way that we can help individuals, is by helping them know themselves. This involves discovering how they were shaped by their past and how their ongoing self-experience cannot be understood (...) in isolation from its constitutive contexts. Psychoanalysts help patients explore foundational questions such as: ‘Who am I?’ ‘How did I get here?’ ‘How am I implicated in my own suffering?’ ‘How can I grow and flourish and truly engage with my life?’. The answers to these questions emerge from a detailed exploration of the persons lived relational history, their current social and relational context and the political systems within which they are embedded. It is via this expansion of self-awareness that individuals can access agency and true freedom of choice. The clinical approach presented by Notini et al 2 is grounded in a completely different, radically decontextualised understanding of human experience. Their conceptualisation of Phoenix’s gender identity is ahistorical and atemporal: it is indeed ‘out of time’. For these authors, gender identity is assumed to be an immutable core essence, much like Ehrensaft’s3 ‘true gender self….there from birth’. It simply ‘is’. This is a …. (shrink)

Although informed consent models for prescribing hormone replacement therapy are becoming increasingly prevalent, many physicians continue to require an assessment and referral letter from a mental health professional prior to prescription. Drawing on personal and communal experience, the author argues that assessment and referral requirements are dehumanising and unethical, foregrounding the ways in which these requirements evidence a mistrust of trans people, suppress the diversity of their experiences and sustain an unjustified double standard in contrast to other forms of clinical (...) care. Physicians should abandon this unethical requirement in favour of an informed consent approach to transgender care. (shrink)