When writing this, I had just finished reading Scott O. Lilienfeld’s piece titled “How can skepticism do better?“, in which he notes that:

The great Swiss developmental psychologist Jean Piaget got a number of details wrong; for example, he almost surely underestimated children’s cognitive capacities in many domains. Nevertheless, Piaget imparted a crucial insight that has stood the test of time: Psychologically, children are not miniature adults (Lourenço and Machado 1996). They conceptualize the world in markedly, perhaps qualitatively, different ways than we do.

The fact that children are not “miniature adults” introduces what seems to be one of the main obstacles to knowing what’s right in these cases: it is difficult to respect the personal autonomy of a child because it’s so difficult to know what an authentic choice is.

This is not only because of the obvious issues of age, maturity and when informed consent is possible, but also because these factors are being assessed against a backdrop of a complex and emotive conversation.

As (I think) Nick Cohen put it in one of his articles, social norms and orthodoxy shift, and today’s mainstream can be tomorrow’s heresy. For example, a feminist might at one time have unproblematically signed up to the idea of two genders, while today that same position might have you shunned and abused with descriptors like “TERF” (Trans-Exclusionary Radical Feminist).

Another example of the overheated conversation here – as usual, worst on social media – is found in the label “transtrender“, where this means that you’re faking being trans because you think it’s cool to be trans. But what if you are trans, but simply find yourself surrounded by judgmental asshats who think you’re faking?

I raise these examples to make the simple point that factors like these (and of course all the more obvious ones like gender dysphoria itself) mean that the conversation can be muddy, and that decisions made by the child, the parents, and even the medical staff could be unduly influenced by current conventions, rather than only the good of the child.

So here’s the first ethical problem for me: your experience of distress is going to be strongly influenced by what your environmental conditions consider normal. If gender dysphoria is considered to be an independent identity of its own, then it’s plausible that the perceived need for treatment would weaken, as you’d be subject to relatively less stigmatisation and prejudice than in a world where dysphoria was not recognised.

Furthermore, many children with gender dysphoria lose their dysphoria as they age into adulthood. Environments in which dysphoria is recognised, and not considered problematic by default, would likely generate less of a pressure to intervene medically and thus avoid a number of false positives and unnecessary treatment.

So that’s the first issue: it’s difficult to know whether intervention is required, and to what extent.

The second issue is informed consent: it’s well-established that our brain development regarding skills like calculation of risk isn’t yet complete until the early 20s. Making any permanent changes – for example in gender reassignment surgery – would usually seem ill-advised in the case of children (especially given that the dysphoria can ease as the child ages).

But on the other hand, denying a child or an adolescent autonomy (by refusing hormone suppression treatment, for example) could well lead to worse outcomes down the line, and the same could be true of surgery also.

These negative outcomes could include not only the predictable social stressors (family relationships, feelings of being denied choice), but crucially, an ever-increasing disjunct between the way you feel and the way you look, as the body matures in the “wrong” way. The problem, though, is that I don’t think there’s a one-size-fits-all policy solution here. Just as with other fraught medical issues like assisted dying, it’s going to take some work to get this right (or, as right as we can get it).

As a starting point, I’d say that individual assessments, with an objective panel of experts, and extensive counselling of the child and parents would need to be undertaken to establish whether hormone treatment should be used or not.

The problem is of course that prevailing cultural norms and theoretical perspectives on what gender is (etc.) are going to influence this, as noted above – so you’re going to find different attitudes to treatment, and therefore different levels of suffering, both across cultures and across time (as societies evolve or devolve, or simply change).

I’d want to set an even higher bar for surgery, which should in general (I’m sure there will be justified exceptions) be reserved as the outcome of a choice made by a legal adult (although this doesn’t necessarily mean mature in the brain sense mentioned above, it’s nevertheless the point at which people are legally allowed to make choices – whether good or bad).

I don’t think that anyone can claim to reliably know the gender of someone who is 5, never mind 2. So, surgery should in general be motivated by health concerns above all else, for example in the case of this Australian 5 year-old girl, whose surgery has been approved in part because the male gonads she has might result in tumours later on in her life.

In conclusion: we need to make our best efforts to determine what the child’s informed preferences are, and that requires an awareness of the fact that this conversation is deeply influenced by current norms, especially regarding whether there’s a problem needing medical intervention at all.

If a considered judgment is made that something needs to be done, intervention should be as minimal as possible to alleviate the current distress, and surgery rather than hormones would typically be ill-advised, bearing in mind that the situation can change after puberty in any case.

(P.S.: The day after I emailed a version of the above to my friend, I heard Dr Eve talking to Eusebius McKaiser on Cape Talk and Radio702 about exactly these issues. The podcast of their conversation is available on 702’s website.)