Adolescents’ ability to make their own decisions regarding GRS in medical contexts. - An ethical normative argumentative analysis

Fanny Holmberg

Human Rights - SGMRE16H Bachelor Thesis - 15 Credits Spring Semester 2019 Supervisor: Anders Melin

Abstract The aim of this research is to highlight the ethical debate concerning children, more specifi- cally adolescents, with gender dysphoria. In Sweden, one has to be 18 years old in order to receive a Gender Reassignment Surgery (GRS) and that becomes problematic when adoles- cents desire a sex-change rapidly due to the strong discomfort of gender dysphoria. With support from Respect for Autonomy in accordance with the feminist perspective of Rela- tional Autonomy, this article conducts a positive and normative argumentation that adoles- cents between the ages of 10 to 18 should have the right to make decisions themselves in re- gard to their autonomy if they have the ability to self-determinate. The main conclusions of this argumentative analysis are that if an adolescent is autonomous, which is determined in accordance with Respect for Autonomy and Relational Autonomy, she should have the ability to decide herself if she wants to go through with a GRS. Additionally, the subject would ben- efit from more recognition and medical attention.

Keywords: Children’s autonomy, Gender reassignment, Genital autonomy, Sex change, Children’s Rights, Gender dysphoria, and Mental health.

Wordcount: 12229 words.

1

TABLE OF CONTENT

ABSTRACT 1

1. Introduction 3 1.1. Aim 3 1.2. Research standpoint 4 1.3. Relevance to Human Rights 5 1.4. Delimitations 6 1.5 Previous Research 7 1.5.1 Children’s Autonomy 7 1.5.2 Gender Reassignment 8

2. Background 10 2.1. Trans Person/Transsexual 10 2.2. Gender Dysphoria 11 2.3. Gender Reassignment Surgery (GRS) 11 3.4. Puberty 15

3. Theory 16 3.1. Respect for Autonomy 16 3.2. Relational Autonomy 17

4. Method 18 4.1. Chapter Outline 19 4.2. Material 19

5. Argumentation 20 5.1. Research standpoints 21 5.2. Counter-arguments 22 5.2.1.Social Distance and Same-Gender Friendship 23 5.2.2. Puberty 23 5.2.3. Falling In Love and Experiencing Sexual Attraction 24 5.2.4. Confusion 26 5.2.5. Infertility as a result of GRS 31

6. Conclusion 33 6. Bibliography 35

2 1. Introduction The research topic of this thesis is the children’s right to autonomy in the case of gender reas- signment. According to Swedish law, one has to apply to The juridical Council of the Na- tional Board of Health and Welfare, (Socialstyrelsens rättsliga råd) in order to go through with gender reassignment surgery from here on referred to as GRS. However, in order to be able to even apply for a GRS, one has to be over the age of 18, be a citizen of Sweden and has to have received a certificate from a doctor that specializes within the field. This certifi- cate can be received when the person affected has gone through an investigation on gender dysphoria (Fpes.se. 2019). This study aims to suggest that this Swedish legislation ethically conflicts with the presumed ability to self-determination within children with gender dyspho- ria. The debate involves questions in regards to ethics, namely what is ethically right to do and this research will apply a positive argumentation on the debate. One can locate an ongo- ing debate within this field, and just recently the subject has become more spoken about in Sweden, which is my country of origin. The subject has further gained media attention, and openly Swedish trans persons have started to enter the public sphere where they discuss eve- rything in regards to transgenderism. The debate portrays two sides of opinions, one in favor and one against, and this research will present both sides of the debate in order to conclude the standpoint of the thesis wishes to display.

1.1. Aim The purpose of this thesis is to highlight the ethical debate in regards to adolescents with gen- der dysphoria and their presumed right to self-determination. The already conducted research within this specific area is predominantly done by authors from the United States, with few exceptions. However, in Sweden, there is a mainstream view that human rights are substan- tial for all and that Sweden is a country where one can be whomever one wants. In many cases this is valid; however, one could claim that this particular field is not as developed. For that reason, there is significant importance in researching cases where this mainstream view is inadequate.

The gap that this research investigates is children’s autonomy and gender reassignment as it is a study that aims at ethically debating the adolescent’s autonomy and, in this context, linked with the right to undergo a GRS is conflicting with Swedish legislation. Since children

3 with gender dysphoria fall within this gap, they are in some form forgotten and excluded from society. Due to the exclusion, one can regard the targeted groups as marginalized. Therefore, this thesis also becomes a study of marginalized people since this research aims for a targeted group. This aspect will provide this study with valuable knowledge on how rights-based politics and policies should be formulated to be able to deal with diversity. Moreover, this research touches on the subject of inclusion since children with gender dys- phoria in many cases are excluded from the society in which they live.

1.2. Research standpoints Since this research is of a normative kind, there will be no research question. Instead, this re- search will present two normative standpoints that narrate the primary argument provided by the author. Moreover, this research will present and explain counterarguments that goes against this article’s standpoints. In this presentation, found in the analysis, each counter-ar- gument is broken down into dimensions where weaknesses of those arguments are high- lighted. Further, there will be sections which consist of arguments in favor of the standpoints apparent within this article. This studies normative standpoints are as followed;

- Adolescents (10-18 years) should have the right to determine themselves if they want to proceed with a GRS since they have the right to autonomy, which grants them their right to bodily integrity. If this is not guaranteed, one violates the child's right to au- tonomy.

- One should take this decision with great caution due to the risk of regretting the tran- sition. With caution, meaning that each case should be evaluated and investigated as a single case where the persons active in the process has to take into consideration each background.

These comments are relevant within this field of research which can be located within the presentation of previous research. However, the contribution that this research will aim for will be to add the theoretical framework of Respect for Autonomy in addition to the feminist perspective of Relational Autonomy, which is explained under the Theory chapter. Hopefully, a new theoretical framework and perspective will act as navigation in the debate so that it goes in accordance with human rights and this studies normative standpoints. Further, one

4 could declare that it is an essential process in order to open up for discussion and thereby, add the subject in the sphere of social debates.

The reason as to why there has been a limitation on the age range to 10-18 years is grounded in studies in regards to adolescent stages. The adolescent stage is between the ages of 10 to 21 and throughout that time range, an adolescent spends 8 years of being able to take legal decisions themselves (Upreti & Shamara, 2018: 401). For this reason, it became natural to limit the age range to 10-18 years since that is the time when the adolescent lacks the author- ity to decide themselves. During this period of time, there are various developmental transi- tions from childhood to adulthood, involving cognitive, personality, physical and social de- velopmental changes (Ibid). Maturity is an important concept within the adolescent stage and should, therefore, be taken into large consideration when measuring the adolescent progress of each individual (Ibid).

Further, the reason as to why this study is limited to Sweden only is because the ethical de- bate that this study aims to highlight has risen rather quickly during the recent years in Swe- den, which make the subject highly relevant and up to date to the Swedish society. Other countries might also have this type of ethical debate; however, the research would then be too extensive and less in-depth.

1.3. Relevance to Human Rights The connection to human rights in this normative argumentation is embedded in the perspec- tive of children, more specifically adolescents, and their ability to act upon their self-determi- nation. The Children's Rights Convention, (CRC) adds a possible framework of how one could go about in this ethical debate and can be used as a guideline to all the questions that the debate entails. Further, since this debate is of an ethical nature, the focus will not be one the legal aspect of the CRC, but rather above that on a more conceptual ground. In order to disconnect the concept of autonomy to the legal perspective, this research will take support from Debra L. Delaet who adds another concept to the debate, namely Genital Autonomy. This concept aims to apply the whole concept of autonomy to the sphere of Human Rights (DeLaet, 2012). The concept will be further explained under the heading 1.5.1. Children’s Autonomy. The normative argumentation that will be added onto this research will focus on

5 how one can go about to ensure the best interest of the individual affected, given that one ac- cepts this debate as an ethical debate within the sphere of Human Rights.

1.4. Delimitations The delimitation that one can locate within this research is the limited access to the target group, which leads to a restriction in gathering the primary data. However, the method cho- sen within this research does not require primary data since it performs a literature review and analysis of the already conducted research. For this reason, the material will consist of secondary data exclusively.

Additionally, I will add an age limitation between 10-18 years since that is stated to be the time during the adolescent stages where the individual lacks the authority to take own deci- sions legally (Upreti & Shamara, 2018, 401). Moreover, one could possibly make a compari- son with another country such as the United Kingdom; however, that is not the aim of the re- search, and therefore, this research will not use a comparative method. Once again, one has to understand the reason as to why there has been a limitation added on the focus, namely Swe- den. The reason in particular lies within the fact that Sweden is my country of origin and thereby the country that I identify myself as belonging to. This type of subject, which is a sensitive subject, is such an essential part of the development of Sweden and I want to be in- volved in the process. Further, the study would be too extensive for me as an author to con- duct if I were to include, let say, Europe. However, that can be a possible way of continuing this study later in life.

1.5 Previous Research Since the research field touches upon many concepts, the previous research will be divided into sub-chapters, where each subchapter act as one of the theoretical concepts that this thesis is built upon. Additionally, this research will use previous research to motivate the aim and reason behind this study.

1.5.1 Children’s Autonomy When searching for articles that have made research on children’s autonomy, the main focus was on the child’s right to bodily integrity, and within this searching field, two relevant arti- cles were chosen, namely The Right to Bodily Integrity and Genital Autonomy, Children’s

6 Rights, and Competing Rights Claims in International Human Rights Law. A.M Viens has conducted research called The Right to Bodily Integrity wherein the author highlights that children ought to have to their bodily integrity. Further, the author claims that since this right has such importance, it needs to be protected with the same adequate protection as applied to adults (Viens, 2014). Similar to Viens, Debra L. DeLaet focuses on the whole concept of au- tonomy and connects it to the concept of Human Rights by giving the concept another word- ing, namely Genital Autonomy. Consequently, the concept, according to the author, becomes a fundamental human right with that terminology since it is a concept that belongs to all peo- ple, including children. Although this article emphasizes the importance of genital autonomy, the author has a negative attitude towards children having the right to reassign their gender whenever they want (DeLaet, 2012).

Both of the articles cited above place great emphasis on the process of creating an ethical de- bate within this particular topic, which is one of the aims of this research. Further, both of the authors explain the importance of allowing children to decide over their own bodies by ap- plying new concepts on the social sphere, therein the concept of Genital autonomy. These concepts are a way of applying the debate onto other more discussed debates, in order for this subject, in particular, to be more noticed and reviewed.

1.5.2 Gender Reassignment

The second theoretical concept that is highly important within this area of research is Gender Reassignment, and therein the concept of Gender Dysphoria. Lindqvist and his co-authors place great emphasis on Gender Dysphoria when conducting their research. The main focus of their research is to measure the quality of life of individuals that suffer from Gender Dys- phoria and thereby wish to go through with a GRS (Lindqvist et al., 2016). Further, the au- thor’s main focus of going through with their research is to place emphasis on the fact that the quality of life (QoL) is lower with transgender women compared to the general popula- tion, which indicates that there is a need to appropriate care and treatment within cases of this kind (Lindqvist et al., 2016: 226). Similar to Lindqvist and his co-authors, Simona Rodat re- searches the aftermath of proceeding with a GRS and how that influences the degrees of power of people involved (Rodat, 2018). The conclusive focus within this article is that there are different sides to being a person with gender dysphoria. On one side, the discomfort of being in a body that does not correspond with the persons' mental gender and the concerns

7 that comes with the process of hiding these contradictions towards other people may prove to be an obstacle to smooth professional development amongst the persons affected. On the other hand, a person who continually strives to become proper or accepted in order to adjust to the social norms, expectations, and demands can become rather strong-willed and pre- served, which can concretize as an accomplishment or success itself (Rodat, 2018: 127).

Moreover, in Gender affirmation surgery and the younger patient, it is presented that the core of their research consists of an argument that treatment of adolescents with gender dysphoria would ideally prevent secondary sex characteristics and in addition to this, make life and their experienced gender identify more comfortable and achievable in the future. To strengthen their primary focus, it is stated that gender identity, in the majority of cases, is shown to be the same as it was during their time as adolescents (Monstrey et al., 2018: 2) Similar to Mon- strey et-al, Steensma and Cohen-Kettenis have conducted research which also focuses on gender reassignment and age, more specifically before puberty. However, there is a more negative view of providing prepubescent children with GRS. The authors claim that the chances of regretting the decisions, because gender dysphoria will disappear, are high and therefore it is advisable to maintain the age limit of 18 years old (Steensma et al., 2010). In addition to the above stated, Brendan S. Abel has conducted research in which the author aims her focus on hormone treatments before puberty and argue in advance for such treat- ments. The author further supports her research by presenting other researchers in which they have detailed statistics of the benefits in regards to behavioral, emotional, and psychological functioning in adolescents with gender dysphoria (Abel, 2014: 23). In the article Effects of Gender Reassignment on Quality of Life and Mental Health in People with Gender Dysphoria, the authors argue that the outcome of being denied GRS is a phe- nomenon of varying degrees of discrimination and traumatization. This is argued to be due to the fact that their desired gender expression is not in line with the normative values of the so- ciety (Özata Yildizhan et al., 2017: 2). Thus, the authors claim that adolescents should have the right to proceed with a GRS if they wish.

Under this subchapter, the authors all have one purpose, and that is to investigate the lives of trans persons, both the ones that have received a GRS and the ones that have not gone through with the surgery. Some focus on the process that leads up to the surgery, including the available treatments, how that process can be improved, and other focuses on the after-

8 math and outcome of having gender dysphoria during the adolescence. Even though the re- sults and conclusions within each of these researches are different, the authors all want to place the subject in the social debate. Some of the authors have a negative view of the debate, mostly generated by the risks that come with a GRS and some have a positive view, which mostly is generated by the right to bodily integrity. Either way, they all have one aim that is similar to one another and that is the need to draw attention to adolescents who have gender dysphoria and their process of receiving a GRS. This aim goes hand in hand with the second aim of this article, namely adding the debate onto a social agenda where it gets the recogni- tion that the debate deserves. The goal is to make this subject more discussed in open and so- cial contexts because if we do, improvement is possible - improvement in such a way that the situations that occur within this field can be adapted to each person's best interest, thus im- prove the QoL of adolescents affected. Lastly, there is research conducted by Drescher, J & Byne. W (2012), which reads up on what we know about the subject and what we do not know and need to investigate more about. This article will take great support from the lastly mentioned article since it provides a summary of scientific facts that should be used to gener- ate and discuss this subject.

2. Background In order to fully understand this research, one has to be sure about what some of this article’s concepts are described to be academically and thereby the choice of emphasizing them be- came natural, in order to get the aim and focus right and precise. Additionally, some pro- cesses or treatments need to be explained in order for the reader to fully understand the pur- pose of this research, and therefore they are stated under this heading.

2.1. Trans Person/Transsexual

An individual who identifies themselves as a trans person is a person who goes against the norms of society in regards to gender, or gender identity, about the expected gender that the person affected has been assigned during birth. The assigned sex and the desired sex are not the same (Transammans, 2019)1. Transsexual is a person who has a wish to go through with

1 Translated by the author

9 gender confirming treatments from the attendance or change their gender in their passport (Ibid).

Moreover, continuing to the mental health of trans persons. The year 2015, the Public Health Agency of Sweden conducted research which indicated that 36 % of all transpersons had con- sidered taking suicide within the last years. On the contrary, it was only 6 % of the population in general who had considered taking suicide. The highest rates of this 36 % were adoles- cents, namely individuals within the ages of 15-19 (Folkhälsomyndigheten, 2015). Some of the possible reasons as to why the rates are so high can be the intense feelings that gender dysphoria brings, body-related shame or difficulties during the process of gender-confirming treatments (Williams, 2017).

2.2. Gender Dysphoria

Gender dysphoria means a noticeable difference between the gender that an individual ex- pressed and experienced himself/ herself to be and the gender that others would assign to him/her. This difference must be present for at least six months in order for it to be stated as Gender dysphoria (Mesh.kib.ki.se, 2019). Adolescents with gender dysphoria often experi- ence puberty as very mentally strenuous which in many cases leads to depression, anxiety or social isolation. One should not mistake gender dysphoria as sexual orientation, and there is no apparent connection between the two; thus adolescents with gender dysphoria can be straight, gay or bisexual (Socialstyrelsen, 2015: 7)2.

2.3. Gender Reassignment Surgery (GRS)

The term Gender Reassignment Surgery will be used frequently throughout this research, and I, therefore, believe that it is essential to understand what the surgery entails. Additionally, there will be a paragraph where puberty-blocking or hormonal treatments are described and mentioned briefly.

2 Translated by the author

10 Surgical operations in regards to changing the genital appearance are constructed to remove the gonads. In the case of vaginoplasty, the testicles are removed, and in the case of vaginec- tomy, the uterus is removed. There are different methods that one can choose when transi- tioning and the following presentation will consist of bullet points in order to make this presentation as easy to follow as possible (Transformering, 2018)3. Firstly, the presentation which describes the transition of the female sex to the male sex.

● Metaplastic: a penis is made by the clitoris, which will grow if one uses hormonal treatment, where the erectile tissue is uncovered and thereby becomes longer. By this, the glans is created, and the urethra is extended with the help of a mucous membrane that is collected from the mural of the vagina and then led through the newly created glans. The person in question can get an erection, which is a process that makes the mucous membrane fill with blood during arousal. The scrotum is made from the ex- ternal labia, or one can have them done from silicon (Ibid).

● Phalloplasty: A penis is created with the help of skin collected from either the under- arm, stomach or thigh. A noticeable scar will be a side effect of this method. The mu- cous membrane, in this case; the clitoris is usually embedded in the penis. The urethra is extended with the help of the mucous membrane that is collected by the mural of the vagina and then led through the newly created glans. The person in question can not get an erection; however, this can be fixed with an erection implant in the shape of a bendable stick (Ibid).

The majority of trans persons who have gone from the female sex to the male sex can have an orgasm by stimulating the clitoris, which now is a part of the penis.

When conducting these kinds of surgeries, some possible risks can complicate the recovery. Fistulas, which are a type of hole that emerges between organs or the skin, are one of the side effects of the surgery. Further, the urethra could be to tight which would lead the person af- fected feeling pain when urinating. However, these complications can all be fixed quite simply. Another outcome that can be accounted for as negative is the possibility of steriliza-

3 Translated by the author

11 tion. Since in some of the operations, such as vaginoplasty and vaginectomy, the gender gon- ads are removed which makes the person affected unable to reproduce. However, if gametes, sperm or egg, have been saved before proceeding with the surgery, there is a possibility of reproduction in the future. The saving of gametes can be a part of the gender-confirming treatment (Ibid).

Continuing with the procedure of transiting from the male sex to the female sex. Firstly a hysterectomy, a surgery where the uterus is removed, and a salpingo-oophorectomy, removal of ovaries and fallopian tubes, can be done. This procedure will block the production of estro- gen within the body and thereby, the person affected will have to take hormones throughout their whole life in order for the body to be well. A part of the persons who take testosterone can experience discomfort in their uterus which can lead to a hysterectomy being needed. In this case, the person only needs a medical indication which states that surgery is needed for other reasons than gender dysphoria. Secondly, a vagina is created, and this procedure is di- vided into two parts (Ibid).

● Penile inversion: the penis becomes a vagina; parts of the glans become the clitoris, and the skin of the person affected is used to create the labia. The division is applied here, where one surgery focus on the making of the vagina and the second part fo- cuses on the clitoris and labia. Some additional surgeries might be needed, such as standard corrections of the part removed from the erectile tissue or dilating the open- ing of the vagina (Ibid).

● If the person affected is requesting a vagina with depth, the surgery is slightly differ- ent. In this case, the vagina is made out of the person’s skin which has been collected by different parts of the body. The reason as to why one might need this type of sur- gery can be due to the fact that the person affected has been taking GnRH analogs, Gonadotropin-Releasing Hormone which is a puberty blocker, which pauses the growing of sex. The outcome of this can be that the sex does not have enough skin it- self to be transitioned into a vagina. However, the surgeons place great emphasis on satisfying the individual and take significant consideration to the patient. The side ef- fect of this type of surgery is that the person affected has to train the vagina with a stick in order to maintain the depth. This process has to be executed one to two hours

12 each day, and after there has been a full recovery, this stick can be replaced with vagi- nal sexual intercourse. Scarring can also be visible when the vagina is shaved, though the grade of the scarring depends on the individual and her or his ability to recover (Ibid).

Additionally, there are a few complications or possible risks with the surgeries. One can ex- perience that the urethra is to tight which results in pain while peeing, and fistulas can be de- veloped. Both of these risks can be remediated rather quickly. During arousal, the erectile tis- sue that is still there can be swollen which will cause discomfort when having vaginal sexual intercourse. The most common correction here is to remove a part of the erectile tissue. Lastly, sometimes the vagina does not get the depth or width as the person affected requested, though this can be fixed through additional surgery (Ibid). Lubrication, the process of the vagina becoming wet during arousal, can occur; however, it is always recommended to use some lubricant since the created vagina is more sensitive. The person affected has recovered fully from the surgeries, an orgasm is possible precisely in the same way as females born with the female sex (Ibid).

GRS is, for obvious reasons, a prominent and substantial surgery where significant decisions are being made, and therefore, it is crucial to let an investigation take place. This investiga- tion usually takes up to one year, and sometimes efforts can be made during the investigation. The process involves psychiatrists, therapists, and counselors and in some cases a medic who specializes in the subject of hormones. Before actually going through the GRS, treatments in regards to the secondary sex characteristics can be made, such as breast implants or penile implants. Additionally, the person affected can begin with hormonal treatments, sessions with speech therapists or hair removal treatments in order to transition to the desired gender (So- cialstyrelsen, 2015:8)4.

Hormonal treatments are just what they appoint to be, namely treatments that supply the hor- mone of the other sex. In other words, testosterone to females in order to deepen their voice, increase the natural hair growth, decrease the breast tissue, cancel the menstruation, increase the size of the clitoris as well as the muscle growth in relation to the amount of body fat.

4 Translated by the author

13 Males who strive to be females get supplies of estrogen which leads to increased breast tis- sue, the function of getting an erection decreased, the size of testicles and the production of sperm also both decreases. Additionally, the skin gets softer, and the growing of facial hair decreases as well as the rest of the human hair. Lastly, body fat increases in relation to mus- cle mass. The physical changes can be noticeable throughout two years; however, the treat- ments with hormones have to be taken continuously during the person’s whole life (Ibid).

Puberty blocking medications, GnRH analogs, are medicine in a synthetic form of the human body’s GnRH hormone. They work, if taken regularly, by suppressing the secretion of two hormones that stimulate the testes to produce testosterone and the ovaries to produce estra- diol, namely luteinizing hormone and follicle-stimulating hormone. Testosterone and estra- diol are the hormones that trigger the changes that occur during puberty. It can be taken by monthly injections or through small implants that are placed under the skin. The GnRH ana- logs prevent additional changes in both primary and secondary sex characteristics (Kuper, 2014). Research suggests that when there is a reliable and consistent physical dysphoria pre- sent, delaying or denial of GnRH is linked to higher rates of depression, anxiety, eating disor- ders and suicidality. Further, it is stated that “In addition, it is more difficult to align the body with one’s affirmed gender once physical changes in secondary sex characteristics occur, es- pecially for male-bodied individuals” (Kuper, 2014: 8).

2.4. Puberty

Puberty is a stage that we all go through where changes involving body structures, body func- tions, and physical appearance appear. The differences between the sexes can be divided into two characteristics, namely primary and secondary. Primary sex characteristics include egg production in female-bodied individuals and sperm production in male-bodied individuals. The reason as to why they are referred to as primary is because they are linked to sexual re- production. The changes that puberty does to the primary characteristics are that women's egg fully mature and males start to produce sperm. Secondary sex characteristics include fat dis- tribution, muscle mass, breast tissue, voice, body hair, height, and body frame. During pu- berty, these characteristics change and additionally cognitive development, changes in the brain such as problem-solving or planning, also occur during this time. Meanwhile, adoles-

14 cents can experience increased sexual attraction where sexuality and dating become more in- teresting. The timing of puberty varies across individuals and is driven by changes in hor- mone production; thus the changes have no timeline (Kuper, 2014).

3. Theory

3.1. Respect for Autonomy This thesis will take support from the base idea of respect to autonomy within modern medi- cal ethics, where the Respect for Autonomy, from now on mentioned as RfA, will be used as a theoretical framework in order to navigate the debate in a way that goes in hand with HR. In other words, RfA will support the positive argumentation for adolescents’ right to self-de- termination. However, in order to understand the theoretical framework that will be applied to the concept of Autonomy, it is necessary to understand what the concept involves. Auton- omy is a concept that has a lot of different meanings depending on what context you apply it to. The context and meaning that this research will apply to will be as following; Autono- mous agents are persons who are able to self-govern, thus governing oneself. What is an agent then? An agent is an individual who acts, and in order to act, one must initiate one’s ac- tions. For that to be possible, one has to exercise one’s power, and since no one has the power to act except the agent herself, she alone is entitled to exercise this power, if she is entitled to act. What one can draw from this is that if someone is an agent, one has the ability to describe oneself, therein all the commitments, judgments, and decisions regarding her actions, as au- thoritative (Buss & Westlund, 2018).

RfA is an important moral principle that applies moral limits through constraining actions. The principle can also limited in the sense that it limits the actions in scope and weight, meaning that we must not overextend or overweight the respect for autonomy (Childress, 1990: 12). Additionally, the principle focuses on one aspect of personhood alone and that is the ability to self-determination. In order to have the ability to self-determination, one must have a moral life, which is generated through three components. The individual needs to be competent, informed and act voluntarily, or in other words, make their own decisions. If you

15 have all these components, meaning that you have a moral life, you are regarded as autono- mous and thereby have the ability to self-determination (Ibid: 13). That ability must be re- spected according to this principle. The ideal of autonomy, presented above, must be distin- guished from the condition for autonomous choice and that is the framework that this princi- ple will apply to the concept of autonomy. Immanuel Kant, a historical philosopher, chose to exclude children from this principle because he regarded them as nonautonomous (Ibid: 15). However, this thesis aims towards the principle that the self-determination of adolescents in the medical context should be taken into serious consideration, given that the distinction be- tween adolescents and grownups is not sharp. Therefore, this thesis aims to land in the pre- sumption in favor of self-determination within the adolescent years. Because this thesis aims towards that specific principle, there is a need to support this theoretical framework with an additional perspective that focuses on when a person should be regarded as autonomous.

3.2. Relational Autonomy

An additional perspective that will strengthen the theoretical framework of this thesis is the feminist perspective of the concept of autonomy. This concept is often phrased as Relational Autonomy since feminist theory understands autonomy as an ability to self-government, which is precisely what this research argues for. In order to eliminate any confusion, it will be specified what the perspective of relational theory this research will take support from, namely the procedural and causal. The procedural and causal relational autonomy perspec- tives suggest that one achieves autonomy when the agent, the person in question, has the ca- pacity to undergo an internal intellectual process which includes a reflection on her motiva- tions, beliefs, and values. Additionally, some focus will be placed on the effects of external relational factors on the agents’ autonomy, rather than the internal relational factors (Stoljar, 2018). This is simply due to the fact that causal accounts only investigates the effects of ex- ternal factors and thereby, the choice of directing the focus towards those becomes natural. When talking about external relational factors on the agents’ autonomy, it can be highlighted that in principle, the affected agents can be fully intact, although there are oppressive social conditions such as norms, and thereby become fully autonomous (Stoljar, 2018).

This debate that one can locate within the sphere of transgenderism can be seen as an ethical debate since there is an ethical dilemma involved in this situation, namely; What is ethically

16 right to do?, is it ethically right to deny an adolescent a GRS? and is it ethically right to grant an adolescent a GRS? Ethics are connected to moral and each person has a different view on morals, because of everything from culture to age (Oxford Dictionaries | English, 2019). This difference is then projected onto the situations which make this debate rather sen- sitive since there is no right or wrong answer to the questions that arise. Instead, the positions towards this situation are determined by various ways of understanding the conditions, which might be accounted for as ethical or unethical, and then taking a stand in the debate. Because it is an ethical debate, the theoretical framework, and the additional perspective applied will have importance in guiding the reader in what the ethics of this article are. The reason as to why this specific theoretical framework and additional perspective is chosen to be applied is because it contributes to an understanding of the circumstances. It applies a new lens that one can use to look upon the whole situation. With this them as a premise, one can get a greater understanding of the rationality behind the arguments that this research will pronounce since they are justified and reasoned through this specific theory.

The emphasis that this research will focus on, within the concept of autonomy, is the notion of bodily integrity. Within A.M Viens article The Right to Bodily Integrity, the main focus is directed on the argument that children’s autonomy, their bodily integrity, is significant, and therefore needs to be provided with the same adequate protection as adults (Viens, 2014). To further explain the focus that will compose this research, I will replace the notion of bodily integrity to a concept that is not very known as of now, namely the wording Genital Auto- nomy. This announced wording from Debra L. DeLaet tries to connect the whole concept of autonomy to human rights by applying the notion of the wording Genital Autonomy. Conse- quently, the notion, according to the author, becomes a fundamental human right with that terminology since it is a notion that belongs to all people, including children (De.Laet, 2012).

4. Method The method applied to this research is of a normative argumentative kind. The core idea within the method, in epistemological terms, is that the arguments aim at the achievement of knowledge (Siegel and Biro 1997: 278). In other words, one can say that a normative argu- mentative analysis is a description of argumentation as a practice with fundamental correct- ness conditions. Within this method, three normative concepts spring from the very practice of arguing, namely justification, rationality, and reasonableness. These three would generate

17 an argument that there are good reasons for, meaning that there is an ethical argument for it, which would itself justify the proper and reasonable arguments and additionally make the claims rational. In this way, things do not inherit any of these concepts themselves; however, when added together, an ethical argumentation becomes possible (Bermejo-Luque, 2016).

This argumentation aims to provide research that counts as an attempt of supporting the nor- mative standpoints of this study. Further, the method requires a process of justification through adducing reasons that show that the normative standpoints are well-supported and rational. As follows, a presentation of a brief description will be provided, where it is illus- trated how this is to go about;

4.1. Chapter Outline

Firstly, starting with declaring and describing this article’s position, which can be found un- der the heading 1.2. Research Standpoint. Secondly, this research will provide the reader with a brief overview of previous research, which will bring you an oversight of the debate, in or- der words, what has been done within this research field. This can be located under the head- ing 1.5. Previous Research. The next step will be found under heading 2. Background where the facts and primary concepts that are important to know within this field are announced. After that, there will be a theory chapter, namely 3. Theory, where the theoretical framework and the feminist perspective of autonomy is presented. The method chapter is located under heading 4. Method, where the method and material is presented. Lastly, a presentation of the counterarguments that are most relevant to this subject is presented and answered with facts provided under heading 2. One can locate all this under heading 5. Argumentation.

4.2. Material The data that will be the base for this research will mainly be secondary sources, predomi- nantly in terms of already conducted research within the relevant field. This data will be used to highlight the two different sides of the debate, but also to strengthen the article’s view on the case. Therefore, most of this thesis will consist of an argumentative analysis of the de- bate, which will enhance the credibility and viability of the text since the contrasting argu- ments are collected through a literature search of scientific articles that have been peer-re- viewed. In addition to the literature search, this research will take support from pages that are

18 published by different organizations that work in advance for transgenderism and GRS in Sweden and direct their full attention on trans persons and transsexuality. The reason for this is that there will be a need to identify certain principles, laws or regulations that are applied in Sweden and therefore this research will make use of official documents so that there can be no subjectivity in the process of explaining those.

The choice of only using secondary sources within this article lies on the base of the fact that this research is a normative argumentative analysis and thereby does not need to have any primary sources. The reason as to why this article has conducted a study mainly based on sec- ondary sources lies within the aim that this research has. However, there is no belief that this will lower the credibility or validity of this research since the literature used is chosen with high accuracy and, as beforehand mentioned, is peer-reviewed. I feel entirely confident in my sources and believe that they are the most accurate ones to apply to the research that I am conducting.

5. Argumentation

This section of the research will consist of two main parts, namely the thesis standpoints and the counterarguments. In the first part, the thesis standpoints will provide you with a brief re- cap of what this research actually argues for. The second part will be a presentation of coun- terarguments where each sub-chapter consists of each common counter-argument. Under each counterargument, there will be sections where the weaknesses of every argument are de- scribed, and additionally, a section where it is presented why this thesis argues against them.

5.1. Research standpoints

In order for the reader to understand what the counter-arguments argue against, one has to re- member why this study was conducted in the first place. This study aims to present a positive argumentation where the presumption is in favor of adolescents being able to self-determine themselves and are thereby autonomous. This autonomy is in need of respect in the medical context, which generates this thesis main point; Every adolescent between the ages of 10 to 18 should have the right to decide themselves if they want to go through with a GRS. Addi-

19 tionally, it is important to notice that this study argues that the process that the decision inher- its should be extensive and well evaluated in accordance with persons who are specialized within this subject. The person affected, and his or her relatives should be well informed of the risks that come with the procedure and the chance of regretting the decision. Additionally, each case should be handled as a new and original case where every person, including the background and history of the person, should be taken into consideration.

Continuing with the addition of RfA as a theoretical framework, which proposes that in the medical context, each individual who has a moral life, meaning being competent, informed and act voluntarily, is autonomous. It is necessary to protect that autonomy and thereby should the individuals that are autonomous have the ability to self-determination (Childress, 1990: 12). The complexity with this framework is that it separates children from the principle of RfA. However; since the aim of this thesis is to involve children in the decision-making process in the medical context, support will be taken from empirical material as well as the perspective of Relational Autonomy. In accordance with the above stated, the goal is to high- light that the distinction between adolescents and adults is delicate. Relational Autonomy provides this argumentation with a perspective that it is not the age that decides when an indi- vidual becomes autonomous, but rather the capacity to undergo an internal intellectual pro- cess. This process includes a reflection on her motivations, beliefs, and values and when the individual is is fully intact with these, she becomes fully autonomous (Stoljar, 2018).

To further support the argument that the distinction between adolescents and adults is deli- cate, there will be an application of empirical material. There are challenges to this proposi- tion that are important to acknowledge (Hein et al., 2015: 2). Firstly, one should not impose complex medical decisions on a child who is not capable of making them and secondly, one should not exclude the children that are capable of taking part in the decision-making. The capacity to make decisions is generated by the individual’s abilities and the competence to make autonomous medical decisions (Ibid). Naturally, this is a hard and complicated line since each individual is different. With the assistance of a reliable and structured tool called The MacCAT-CR, one can measure competence in children. This tool is a semistructured in- terview format developed by Appelbaum and Grisso (2001) that measures decision-making from four aspects, namely the understanding, appreciation, reasoning, and expressing a choice. The MacCAT-CR counts' scores which determine the competence of the child. Stud- ies through this tool showed that children of 11.2 years and above generally appear to be

20 competent and thereby can make autonomous medical decisions (Ibid). Children of 9.6 and younger are not generally competent, however; children between 9.6 and 11.2 years appears to be in a transition period. During this period, they develop important capacities but the ma- turity within each child differs (Ibid). From an ethical perspective, one could suggest that the understanding of competence needs to be developed and that the tool should be expanded to generate not only the four criteria but also the emotions of the individual.

5.2. Counter-arguments

Under this heading, there will be a presentation of the counterarguments that this article will focus on. Further, there will be arguments based on the facts provided in this study that will question and argue against the counter-argument. In order to make this argumentative analy- sis as easy and comprehensible as possible to follow, there will be under-headings in which each under-heading present one common argument. The following three headings will por- tray three general comments that are rather common within the debate of GRS and adoles- cents. In order to make the arguments as easy to follow as possible, the authors have divided persons with gender dysphoria into two groups, namely persisters and desisters. Persisters are the one who goes through with the transition and desisters are the ones who have not gone through a transition (Steensma et al., 2010: 500).

5.2.1.Social Distance and Same-Gender Friendship

● The first part is connected to the social environment, where it is argued that changing environment is essential and can eliminate the social distance between gender. With social distance, it is referred to as the differences that are applied to genders; thus boys should act in one way and girls in another way. Between the ages of 10 to 13, the elimination of this social distance could lessen the discomfort that persons with gender dysphoria might experience and children would thereby enjoy same-gender friendship more. In other words, the feelings of gender dysphoria have, amongst other factors, a connection to social distance (Steensma et alt., 2010: 512).

Just because one might enjoy same-gender friendship more through this alleged social dis- tance between gender, does not automatically bring out the feelings of gender dysphoria or confusion regarding their gender identification, neither does that imply that the feelings one

21 person feels can be dissolved through that. One can agree that the social distance between gender can be problematic in cases where children have a hard time to identify themselves, whether it comes to, for example, gender or sexuality. However, that does not mean that if we eliminate this distance, all persons with gender dysphoria will stop feeling the way they do. From the aspect of RfA, the social distance and the enjoyment of same-gendered friendship can not be connected to the ability of self-determination. If a person is autonomous and is fully intact with her on motivations, beliefs, and values, she is able to determine herself if she has gender dysphoria or not. Regardless of the gender of her friends or the social distance she might experience, she is her own autonomous person who has the ability to decide for herself.

5.2.2. Puberty

● When puberty hits you and the feminization or masculinization process starts one can determine whether the discomfort is related to gender (Steensma et alt., 2010: 512).

For the persons who go through puberty early, around the age of 10-15, the denial of GRS be- comes unsettled, however, for the persons who go through puberty later, 15-18 year, will not be as affected as the ones going through puberty earlier. This outcome is a consequence of the age limit being 18 years old and if the person affected just then have gone through pu- berty, the proceeding of the surgery, puberty-blocking treatments, or hormonal treatments will be more effective since the body has not already gone through the process of the changes that puberty brings. After all, the feminization or masculinization starts when puberty hit, and before that, the differences between the two sexes are not that evident (Kuper, 2014). In these types of ethically constraining situations, the theoretical framework of RfA in accordance with the Relational Autonomy could contribute with guidance. If one withdrew the focus on puberty and added it to the abilities to self-determination and capacity to undergo internal in- tellectual processes, each individual's personal reference would matter.

5.2.3. Falling In Love and Experiencing Sexual Attraction

● The experience of falling in love and experiencing sexual attraction. The persisters who are attracted to same- (natal) sex partners indicate the awareness of sexual attrac- tions acted as a confirmation of their gender dysphoria, simply because they naturally viewed themselves as heterosexual. For the desisters, the experience of falling in love

22 acted as a wake-up call where the person affected suddenly questioned their cross- gender identification, regardless of sexual orientation. Within this aspect, the claim is that the feeling of having a cross-gender identify could be connected to underlying motives, rather than overt behavior, such as imposing gender roles. With underlying motives, it is referred to childhood traumas that might have affected the individual in such a way that he or she experiences the feelings that come with gender dysphoria. Additionally, the is a claim that the desisters imply that their desire for a sex change was more related to the opportunity to fulfill the favored gender role and less related to an actual aversion against their body per se (Steensma et al., 2010: 513).

The notion that one can get from these comments as a whole is that there is a need to locate the alleged problem and find out the reason behind it by investigating underlying factors of why a person feels this bodily discomfort that later generates gender dysphoria. However, al- ready here one could intervene, simply because there is no ground to the statement and thereby no belief that having gender dysphoria can be triggered by something that happened during childhood. Neither is it believed that there is a reason as to why people feel this way and as a result of this, adolescents would more likely benefit from taking their own decisions in regards to the feelings that come with gender dysphoria. That is to say, if they have the ability to self-determination and can reflect upon their motivations, beliefs, and values. Simply because no other but themselves know what they need and feel at that exact moment. This argument can be supported by statements that one can locate in Drescher, J. & Byne, W (2012) article where it stated that we have yet to learn the causes of gender dysphoria in mi- nors. In other words, the article presents facts such as the following; there are no known causes of why a person has gender dysphoria. Additionally, written under “what we have yet to learn” it says and I quote:

“The relative contributions of biological and psychosocial environmental factors in the devel- opment of gender identity, whether cisgender or transgender” (Drescher, J. & Byne, W., 2012: 503)

With this in mind, the comments presented above lose their meaning. In other words, the comments completely lack logic, almost in the same way as saying that people get cancer be- cause they overeat chocolate does, which also makes no sense whatsoever. Instead, one

23 should realize that the human mind is impressive and that there is no template for how the brain should work.

The argument that one proportion of all affected might be confused as to who they are and tries to become the more beneficial gender has an interesting perspective to it, and I do be- lieve that there is some truth to it. Adolescents do, for obvious reasons such as puberty, go through stages where there is significant confusion in regards to their body, gender, and sexu- ality. Furthermore, the desire to become the more powerful sex, namely a man, is understand- able which itself says a lot about the construction of today's society. However, they would not be targeted as belonging to the group of adolescents with gender dysphoria by the psychi- atrist and doctors involved in the process of identifying gender dysphoria (Socialstyrelsen, 2015)5. Gender dysphoria is a severe state of mind where one noticeably experiences a differ- ence between the gender that one experiences oneself and the gender that others would assign to that person (Mesh.kib.ki.se, 2019). This cannot be identified with teenage confusion, which I believe is a process that everyone goes through sometimes during their lives. Instead, there should be a sharp distinction between these groups, and it is when this distinction fails or becomes blurry that things can be problematic. Additionally, there is a lack of understand- ing of why the authors investigate sexuality as a possible factor of cross-gender identifica- tion. To feel that her biological sex does not correspond with her social sex has nothing to do with a person’s sexual orientation (Socialstyrelsen, 2015: 7)6. Just because one might be in- terested in the same sex does not mean that you inherit a higher risk of getting gender dys- phoria. This fact holds significant knowledge, which most likely will change many people’s perspectives and understanding in this debate.

5.2.4. Confusion

● A common argument within this debate is that the decision is generated from confu- sion rather than an actual desire for a sex change. Gender dysphoria may be mimicked by gender confusion that occurs as an epiphenomenon of other problems, such as sex- ual trauma. For this reason, one should want until a legal age in order to minimize the risk of regretting the transition (Drescher, J. & Byne, W., 2012).

5 Translated by the author 6 Ibid

24 This argument is reasonably valid in the sense that yes, the periods where the individual tran- sitions from being a child to an adolescent are confusing and can in some cases be understood or mistaken as gender dysphoria. If one then adds a trauma, such as sexual trauma, to that al- ready consisting of confusion, one can understand that the whole process becomes even harder to sort out. However; trauma such as sexual trauma can occur whenever throughout your whole life and if one adopted this to the argument, gender confusion could also take place whenever throughout life. In that case, a legal age would not solve the problem, since it can happen to anyone during every stage of their life.

The transition from being a child to an adolescent to an adult is an essential point of the pro- cess of getting access to the surgery since there is such a great risk of regretting the transition. However, it can be argued that each individual is different and there can not be a pre-decided frame added onto every single person. Each individual who is autonomous, which is gener- ated by the ability to self-determination and the capacity to undergo internal intellectual pro- cesses, should be given the opportunity to decide herself what she wants to do with her body and integrity and this does, for obvious reasons, entail that the decision of a GRS has to be looked at in the same way. The process of identifying gender dysphoria and then coming to a conclusion, where the best interest of the person affected is in the center, should be the start- ing point. The perspective of Relational Autonomy and the theoretical framework of RfA, de- scribed under heading 3. Theory, could be applied here. They assert that each individual, in- cluding adolescents, who have the ability to self-determination should be able to exercise it, which is precisely what is deprived of the person affected when she is denied a GRS (Stoljar, 2018). Together with the denial of a GRS, internalized oppression appears which leads to op- pressive social conditions, such as harmful norms. These norms can project hate to the person affected, whose life might decline rapidly in quality and thereby, the person affected might experience mental health issues as a consequence (Stoljar, 2018). If the society could normal- ize the whole phenomenon of transsexuality and trans persons, there would be no, or less, in- ternalized oppression and thereby the oppressive social conditions, such as norms, would be more accepting and including. Hopefully, this would guide the society to obtain an increased acceptance towards this field, which then later would lead to a decreased number of suicides or mental health issues among the persons affected.

● In general, a minor’s notion of gender and their gender identity will vary during their lives. This variation promotes that the ones proceeding with a GRS might regret the

25 transition and thereby, the decision cannot be made until the person affected is 18 years old or older (Drescher, J. & Byne, W., 2012).

This is a frequent critic of this debate and therefore one of the essential points to discuss. When looking at the debate that goes on in the public sphere, this is the main ground of re- sistance. For this reason, the discussion will be divided into two parts, where the first part fo- cuses on the knowledge aspect of the debate and the second part focuses on the life aspect of the debate. Starting with the first part, namely the chance of regretting the transition, one could conclude that the base within this argument is the risk. The possible risk of regretting the surgery is mentioned quite frequently during this debate, and this is because there is an argument that various things trigger the risk of regretting the transition. Some of those things are sexuality, puberty, gender confusion or childhood trauma (Drescher, J. & Byne, W., 2012).

Firstly, sexuality; the authors of these arguments imply that the sexuality of the person af- fected could determine if the gender dysphoria will proceed or not. Secondly, puberty; the au- thors of these arguments imply that the persons with gender dysphoria often discover them- selves and their sexual and personal identity during that process. Thirdly, gender confusion; the feeling that comes with gender confusion can mimic the feeling that comes with gender dysphoria. Lastly, childhood trauma; the author implies that childhood trauma can trigger feelings that are similar to gender dysphoria and thereby it is just a matter of confusion rather than a need for a transition (Drescher, J. & Byne, W., 2012).

All these risks listed above are argued to be the reason as to why the age limit of GRS should be 18 years old. With that information alone, one could see the rationality of the arguments; however, when other essential facts are brought into the discussion, these arguments lose their rationality quite quickly. There are no empirical studies that ensure that an 18 years old individual has a greater ability to self-determination than a 13-year-old. Neither is there any empirical study done on the difference between adolescents and adults. As stated throughout this article, puberty can not be connected to a certain age and sexual orientation is not con- nected to transgenderism. If these four later mentioned points where to be stated as scientific facts then yes, those counter-arguments would make sense. However, that is not the case; on the contrary, there is no evidence that sexual orientation has anything to do with transgender-

26 ism, even if the case where that the vast majority of trans persons were bisexual or heterosex- ual. What is meant by this is that the sexual orientation does not correspond with transgender- ism. Moreover, puberty hits individuals during different stages in life and does not mean the same to all of those individuals. Some might change tremendously, and some might not even notice that large of a difference. The ability to self-determine and thereby, being autonomous is not granted by age but rather by the abilities the individual has and the capacity to undergo internal intellectual processes.

If one reflects the counter-argument, that means that puberty determines whether or not a per- son has gender dysphoria. Then, when looking at the possible treatments where puberty- blocking is one of the most successful ways of treating gender dysphoria, it would already be too late for the person affected. The main argument here is that one should generate individu- als' capacity to undergo an internal intellectual process which includes a reflection on her mo- tivations, beliefs, and values and the ability to self-determination in order to make out if the person affected is autonomous and mature enough to make the decision regarding GRS her- self. Further, there will always be a risk with taking such a crucial life decision, and that goes for all big life decisions, everything from divorce to abortion. The risk of regretting the tran- sition is a topic that needs to be more highlighted and openly spoken about. This is because if the topic is brought up into discussion, it gets more highlighted and thereby engages more people. By eliminating the stigmatization around the discussion of transsexuality and transpersons, more knowledge would be broadcasted, and that would improve and make the steps up to a GRS more available and attainable. The individuals affected should be provided with knowledge of what the surgery is and the risks with the surgery but also with knowledge regarding transsexualism.

Another aspect to this is the strong and demanding culture within transgenderism that is a subject mentioned by various public trans persons, one example of this is a video published by a Swedish national tv program provided by TV4 on Youtube (Nyhetsmorgon, TV4, 2018)7. In this video, Abbey, a trans person, describes this in such a way that it is almost a requirement to undergo a GRS in order to even account oneself as trans persons. Further Ab- bey says that the pressure almost leads to an unwanted surgery, however; in the presence of family support, Abbey repented and is today happy with being just Abbey (Nyhetsmorgon,

7 Translated by the author

27 TV4, 2018 - translated by the author). This culture applies an incorrect definition to the con- cept of trans persons and that is something that needs to be recognized. The definition only states that a trans person goes against the norms of society in regards to gender (Transam- mans, 2019)8. There is no mention that one has to undergo the surgery, but rather that the person do not follow the typical norm. This pressure that the transgender culture applies to people can in many cases become problematic and lead to decisions that might not be thought through, which causes a greater risk of regrets. On the other hand of this situation, one does not need to go through with a GRS in order to be accounted as transsexual and that is a state- ment that needs to be established for the person affected before looking upon the alternative treatments. It should be okay to have a penis and still be accounted for as a girl, both socially and juridically, and the other way around.

This pressure that comes with the strong culture of transgenderism can rise to various things and one could argue that love is one of the reasons as to why this pressure might even exist. People want to assist others with gender dysphoria so bad and the only commonly known way to eliminate this gender dysphoria is through surgery. One could further argue that this action lies within human nature because, in situations where there is no right answer, we look for a solution. This act is not prompted by hate, rather the contrary, this is a way of friends and family attempting to help the affected person in the only way they know and can. In other words, one can say that this strong and demanding culture is built on a lack of knowledge both on the subject on transgenderism, but also on the potential treatments and measures that the person affected can receive. The main point to highlight here is that it is okay to be an own person, whether that includes a penis or a vagina. The biological gender does not define who you are nor how you should look. There is neither a template on what a trans person is or should do, in the same way as there is no template on what a male or female is or should do. Norms can be beneficial when used in the right way, for example, norms in regards to moral behaviors. One acts in a way because of the moral norm, e.g. say thank you. However, they can likewise be extremely harmful and dangerous, and this situation and the suicide numbers amongst adolescents with gender dysphoria are clear examples of this.

8 Translated by the author

28 Every decision comes with a risk and the decision of receiving a GRS is no different. How- ever; if the risks start to dominate the decisions, one would never have the ambition to pro- gress or thrive after a goal. The world would most likely standstill if the individual were to act by the risks that come with changes. Most assuredly, the person affected needs to be fully in phase with the possibility of regretting the transition, just as much as the person needs to be aware of the possible complications or risks with the surgeries. However, to be 100% sure of anything can be difficult and might be a reason for the decision of transiting to be post- poned. However, what if it is not? Take a look at the numbers of trans persons who have had suicidal thoughts during the later years. What if this decision could save a life? Of course, this will always be an ethical dilemma where there is no right answer. However, with the the- oretical framework in accordance with the feminist perspective that is suggested in this study as a core idea, one can get some guidance in regard to the ethical aspect of this debate.

If one should generalize this to the most extreme, it is a question of either losing the person or having the person regretting the transition and one would likely choose the latter one. To say this is not the same as minimizing the fact that the person regretting the transition must be draining both mentally and physically. However, if it were between that or losing the person in question, the decision would be crystal clear. The person regretting the transition would most likely be offered sessions with therapists and so on, and additionally there are a large number of ways to mimic the required sex, such as dildos or filled bras.

5.2.5. Infertility as a result of GRS ● The factor of infertility, which is stated to be a fact when conceiving a GRS since there is a process in this surgery where the gender gonads are removed, is a standard topic within this debate (Wibowo et al., 2016). The factor of infertility can in many aspects be a trigger and thereby lay the ground of objection towards the surgery.

Since infertility is a factual consequence, there is no denial within this aspect. However; a permanent solution has been developed to minimize the effect that infertility might have on the persons affected. This solution is a process, as mentioned under heading 4. background, of retracting the gametes before doing the vaginoplasty or vaginectomy in order to preserve

29 them. The sperm or eggs are then added in a freezer where they are stored until the person af- fected choices to use them (Transformering, 2018)9. The biological aspect of reproduction for a female, thus giving birth, can not be fulfilled if the person has received a GRS since there has been a transition of gender. However, the person affected might not have the desire to give birth since that individual nowadays identifies oneself as, in this case, a male.

Another way of approaching the infertility question is to look at the aspect that the persons affected might feel grief for not being able to have their biological children. Not the least, in- fertility can be hard to handle and grasp for the person affected for obvious reasons, such as a desire to become a parent. To this aspect, there is no solution since, as of today, a person who has transitioned from a female to a male can not give birth himself. However; his eggs that were collected before the transition can be used, for example with the help of a surrogacy mother. For a female who has transitioned from a male, the perspective of giving birth is also, right now at least, impossible and there is no solution to this yet. However, with the develop- ment of technology, I would dare to say that one should be hopeful. The solution presented above can from the development of technology and therefore, there is no assurance that the latter situation can not be fixed.

This type of development shows that society does flourish and the recognition of this devel- opment is filled with so much happiness and satisfaction. Just the thought alone that we get to live during a time where the world progresses into an acceptable and beautiful sphere where everybody is their own person is so amazing. This joyful development is also significant to highlight, likewise as it is significant to highlight the not so bright side of the debate. One can quickly lose oneself in hate or despite and that is the part that can become the most toxic, which might even result in suicide. Instead, one should look at the progress where solutions as beforehand mentioned are found to make the person affected the happiest that one can be. Theoretically speaking, the Respect for Autonomy and the Relational Autonomy goes in ac- cordance with the development in such a way that the development can be seen as a conse- quence of them. If no one adapted to the concept of RfA, no one would work towards change within this particular debate. The respect of autonomy places individuals in a mindset where

9 Translated by the author

30 the person is generated by abilities rather than gender. The same goes for Relational Auton- omy, who generates persons by their capacities and not by their gender or the norm system that comes with gender.

6. Conclusion Throughout this process of researching the selected field, one could declare that the debate includes much more than only opinions. There are strong feelings embedded within each ar- gument and that itself makes this process very mentally draining, even for me as an unaf- fected individual. There is so much affection involved in these situations, but that does also go for antipathy. All feelings combined are remarkably powerful, and that makes the subject very delicate, even for us who are considered to be unaffected. One could say that it is be- cause of this reason that the subject is such a stigmatized and isolated subject, which makes it even more important to highlight and discuss.

In order to come to any kind of conclusion, the following paragraph will consist of a brief re- cap of the counter-arguments. All counter-arguments were collected from different debates that are present within this specific area of research. All comments and arguments are general and common and thereby the ones that were most relevant to the discussion. Roughly, one can divide them into three subgroups. From these counter-arguments or comments, there have been conclusions drawn in accordance with arguments against the counter-arguments provided by the author in unity with facts, theoretical framework and feminist perspective, and thereby needs to be emphasized within this article.

The first subgroup is in regards to puberty and the changes that come with that process, namely social distance, and same-gender friendship, falling in love and experiencing sexual attraction. The second subgroup investigates the possibility of regretting the decisions, the pressure, and the possible confusion. The last subgroup highlights the fact of infertility, and together all of the subgroups highlight the so-called resisting comments and arguments of this debate. Since this debate is of an ethical nature, there are no right answers. The only thing one can do is to, with the help of personal morals and theories, take a stand within the debate. What this article tries to do is to apply the debate to a sphere where it is discussion from a positive argumentation where the presumption is that the majority of adolescents have the

31 ability to self-determination and have the capacity to undergo an intellectual internal process. Certainly, there are adolescents who are not able to do all that, but the belief is that age can not decide that. It is the abilities and capacities that determine whether a person is autono- mous and mature enough to take decisions in regards to her own autonomy in the medical context. Not the guardians nor the doctors, only herself.

Moving on to the paragraph where the pressure of transgender culture is mentioned. Amongst other things, the pressure of having to go through with a GRS even though the person af- fected might not even desire to do so is presented here. This pressure acts in a way that makes the person affected feels obligated to go through with the surgery because otherwise, he or she is not a real trans person. The GRS is not a solution, but rather a helping mechanism to become one true self if the person affected desires a change of sex, which not all trans per- sons do. This difference is essential and needs to be more highlighted and spoken about. It is interesting to observe that at the same time as this debate is secluded, a large number of peo- ple still take part in it and that includes people who are not directly affected or connected to the debate. This observation lead me to the question; Why do people feel the need to include themselves in lives that are not theirs to live? Is this because the topic can be regarded as stigmatized or forbidden and therefore becomes more interesting? The answer will remain unknown, but what one does know is that there is a need for change within this particular topic. A change that will benefit the ones that are affected or connected to this ethical debate.

To finish this article, there is a need to remind you what the comments that this article argues for is, namely that every individual between the ages of 10 to 18 should have the right to go through an individual investigation where the concept of gender dysphoria can be assured. After this investigation is made and evaluated by specialists within the subject, the person af- fected should be granted the right to undergo the surgery or get access to the available treat- ments. In accordance with these processes, the person affected and the relatives should be no- tified with every possible risk that the transition might include. In accordance with these comments, the autonomy and maturity of the individual can be generated by their ability to self-determination and their capacity to undergo an internal intellectual process where the in- dividual's motivations, values, and beliefs are included. In other words, one could say that this research is made to grant children their human rights in the same way that we all enjoy our human rights every day.

32

33 6. Bibliography

Abel, B. S. (2014). Hormone Treatment of Children and Adolescents with Gender Dyspho- ria: An Ethical Analysis. LGBT Bioethics: Visibility, Disparities, and Dialogue, special re- port, Hastings Center Report 44, no. 5: S23-S27. [Accessed 12 March 2019]

Appelbaum PS. and Grisso T. (2001). The MacArthur Competence Assessment Tool for Clin- ical Research (MacCAT-CR). Sarasota, FL: Professional Resource Press.

Bermejo-Luque, Lilian. (2016). "What should a normative theory of argumentation look like?" OSSA Conference Archive. 122.

Buss, S. and Westlund, A. (2018). Personal Autonomy (Stanford Encyclopedia of Philoso- phy). [online] Plato.stanford.edu. https://plato.stanford.edu/entries/personal-autonomy/ [Ac- cessed 3 May 2019].

Childress, J. (1990). The Place of Autonomy in Bioethics. The Hastings Center Report, 20(1), 12-17. doi:10.2307/3562967

DeLaet, D. L. (2012). Genital Autonomy, Children’s Rights, and Competing Rights Claims in International Human Rights Law. The International Journal of Children's Rights 20, 4, 554- 583, brill https://doi-org.proxy.mau.se/10.1163/15718182-55680007. [Accessed 12 March 2019]

Drescher, J. & Byne, W. (2012). Gender Dysphoric /Gender Variant (GD/GV) Children and Adolescents: Summarizing What We Know and What We Have Yet to Learn. Journal of Ho- mosexuality, 59:3, 501-510, DOI: 10.1080/00918369.2012.653317

Folkhälsomyndigheten. (2015). Hälsan och hälsans bestämningsfaktorer för transpersoner. En rapport om hälsoläget bland transpersoner i Sverige. Solna: Folkhälsomyndigheten

Fpes.se. (2019). Transition | FPES. https://fpes.se/om-transtransition/#.XKHmohMzbVo [Accessed 1 Apr. 2019].

34 Hein, I.M., De Vries, M.C., Troost, P.W., Meynen, G., Van Goudoever, J.B. and Lindauer, R.J.L. (2015). Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children’s competence to consent to clinical research. BMC Medical Ethics, vol. 16, pp. 1–7, 2015. [Accessed 1 July. 2019].

Kuper, L.E. (2014). Puberty Blocking Medications: Clinical Research Review IMPACT LGBT Health and Development Program

Lindqvist, E.K., Sigurjonsson, H., Möllermark, C., Rinder, J., Farnebo, F, and Lundgren, T. C. (2016). Quality of life improves early after gender reassignment surgery in transgender women. European Journal of Plastic Surgery, 2017, 40 (3):223-226. https://doi- org.proxy.mau.se/10.1007/s00238-016-1252-0 [Accessed 14 Mar. 2019].

Nyhetsmorgon TV4 (2018) Abbey has repented - there will be no surgery: “I got so affected off-”. Available at: https://www.youtube.com/watch?v=TubnFvMkPrs [Accessed 1 May 2019].

Mesh.kib.ki.se. (2019). Könsdysfori | Svensk MeSH. https://mesh.kib.ki.se/term/D000068116/gender-dysphoria [Accessed 1 Mar. 2019].

Monstrey SJ, Claes K, De Cuypere G. (2018). Gender affirmation surgery and the younger patient. Pediatr Med 2018;1:3. [Accessed 14 March 2019]

Ohchr.org. (2019). OHCHR | Convention on the Rights of the Child. https://www.ohchr.org/en/professionalinterest/pages/crc.aspx [Accessed 4 Mar. 2019].

Oxford Dictionaries | English. (2019). ethical | Definition of ethical in English by Oxford Dictionaries. Available at: https://en.oxforddictionaries.com/definition/ethical [Accessed 21 May 2019].

Rodat, S. (2018). The Impact Of Gender Reassignment On The Professional Career Path And Power Relations. Social Sciences and Education Research Review, 2018, Vol 5, Iss 1: 110-

35 129 http://sserr.ro/wp-content/uploads/2018/08/SSERR_2018_5_1.pdf [Accessed 4 Mar. 2019].

Siegel, H. and J. Biro (1997). Epistemic normativity, argumentation, and fallacies. Argumen- tation 11, 277-292.

Socialstyrelsen. (2015). Till dig med könsdysfori. http://www.socialstyrelsen.se/publika- tioner2015/2015-6-1 [Accessed 16 April. 2019].

Steensma, T.D., Biemond, R., De Boer, F. and Cohen-Kettenis, P.T. (2010). Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry, 16(4):499-516. DOI: 10.1177/1359104510378303 [Accessed 14 March 2019]

Stoljar, N. (2018). Feminist Perspectives on Autonomy (Stanford Encyclopedia of Philoso- phy). [online] Plato.stanford.edu. https://plato.stanford.edu/entries/feminism-autonomy/ [Accessed 3 May 2019].

Transammans. (2019). Om trans och cis. https://www.transammans.se/trans/om-trans [Ac- cessed 16 April. 2019].

Transformering.se. (2018). Underlivskirurgi | Transformering.se. http://www.transformer- ing.se/vardhalsa/transvard/underlivskirurgi [Accessed 23 Apr. 2019].

Upreti, R. and Sharma, S. (2018) ‘A study on social maturity of adolescents across their fam- ily type’, Indian Journal of Health & Wellbeing, 9(3), pp. 401–403. https://search-ebscohost- com.proxy.mau.se/login.aspx?direct=true&db=afh&AN=129285043&lang=sv&site=eds-live [Accessed 5 August 2019].

Viens, A. (2014). The Right to Bodily Integrity. London: Routledge, https://doi.org/10.4324/9781315237367. [Accessed 12 March 2019]

36 Wibowo, E., Johnson, T. and Wassersug, R. (2016). Infertility, impotence, and emasculation - psychosocial contexts for abandoning reproduction. Asian Journal of Andrology, 18(3), p.403.

Williams, A. (2017). “EV1490: Risk factors for suicide in the transgender community”, Eu- ropean Psychiatry, 41, Supplement, p. S894, ScienceDirect, EBSCOhost, viewed 22 Septem- ber 2017

Özata Yildizhan, B., Yildizhan, E., Yüksel, S., Avayu, M. and Noyan, H. Effects of gender reassignment on quality of life and mental health in people with gender dysphoria. Turk Psikiyatri Dergisi, vol. 29, no. 1, p. 10p. [Accessed 14 Mar. 2019].

37