Extended essay To be, or not to be? The role of the unconscious in J Med Ethics: first published as 10.1136/medethics-2021-107397 on 30 July 2021. Downloaded from transgender transitioning: identity, autonomy and well- being Alessandra Lemma,1 Julian Savulescu 2,3,4 1Visiting Professor, ABSTRACT yet gone through puberty are not able to properly Psychoanalysis Unit, University The exponential rise in transgender self- identification understand the ‘lifelong medical, psychological and College London, London, UK 2 emotional implications’ of taking puberty blockers Faculty of Philosophy, invites consideration of what constitutes an ethical University of Oxford, Oxford, UK response to transgender individuals’ claims about how and cross- sex hormones; and second, the experi- 3Biomedical Ethics Research best to promote their well- being. In this paper, we mental nature of puberty blockers specifically, with Group, Murdoch Childrens argue that ’accepting’ a claim to medical transitioning potentially significant unknown side effects and Research Institute, Parkville, 3 in order to promote well- being would be in the person’s little evidence of long-term benefits. In practice, Victoria, Australia 4Melbourne Law School, best interests iff at the point of request the individual this ruling now forbids the prescription of puberty University of Melbourne, is correct in their self- diagnosis as transgender (i.e., suppressants without court order. This particular Melbourne, Victoria, Australia the distress felt to reside in the body does not result ruling is in the process of being challenged by the from another psychological and/or societal problem) GID. A more recent 2021 court order allows for Correspondence to such that the medical interventions they are seeking the prescription as long as there is parental consent. Professor Julian Savulescu, will help them to realise their preferences. If we cannot These medical interventions continue to be provided Faculty of Philosophy, University of Oxford, Oxford OX1 2JD, UK; assume this—and we suggest that we have reasonable in many other countries. Such cases invite consid- julian. savulescu@ philosophy. grounds to question an unqualified acceptance in some eration of what constitutes an ethical response to ox. ac. uk cases—then ’acceptance’ potentially works against best transgender individuals’ consciously stated claims interests. We propose a distinction between ’acceptance’ about how best to promote their well- being. Received 25 March 2021 Given the heterogeneity of transgender identities Accepted 25 June 2021 and respectful, in- depth exploration of an individual’s claims about what promotes their well- being. We and experience,4 it is important to clarify defini- discuss the ethical relevance of the unconscious mind tions and scope. In this paper, we are focusing only to considerations of autonomy and consent in working on binary and non-binary transgender individuals with transgender individuals. An inquisitive stance, we who wish to medically transition (via cross-sex suggest, supports autonomous choice about how to hormones and/or sex reassignment surgery) in realise an embodied form that sustains well- being by order to minimise their distress due to the felt allowing the individual to consider both conscious and incongruence between the natal body (and assigned unconscious factors shaping wishes and values, hence gender at birth) and the body they believe will be choices. congruent with their gender of (self-) identification. http://jme.bmj.com/ For present purposes, we are not concerned with the group more accurately described as ‘gender INTRODUCTION: DEFINITIONS AND AIMS non- conforming’ who often only seek partial or Referrals to gender identity services (GIDs) in the no medical transitioning. However, the group who UK have increased exponentially.1 2 This increase present for medical transitioning will inevitably has exposed the very considerable challenges facing comprise some gender non- conforming people individuals who identify as transgender. It has who see themselves as needing full transitioning. on October 2, 2021 by guest. Protected copyright. also raised concern about how the laudable aims We do not restrict the discussion to a particular age of gender affirmative care may be ushering too group except where specified. We will examine the quickly children and young people into medical extent to which unconscious forces may undermine transitioning leading subsequently to a wish to autonomy and this argument applies both to chil- detransition with all the attendant physical and dren and adults. psychological complications. We argue that ‘accepting’ a claim to medical A recent landmark decision in the UK illustrates transitioning in order to promote well-being this. In the UK, treatment for patients under 18 years would be in the person’s best interests iff at the presenting with gender dysphoria is offered by the point of request the individual is correct in their Gender Identity Development Service provided by self-diagnosis as transgender (i.e., the distress felt © Author(s) (or their the Tavistock Clinic. In December 2020, a former to reside in the body does not result from another employer(s)) 2021. Re- use patient who began taking puberty blockers when psychological and/or societal problem) such that permitted under CC BY. she was 16, before subsequently detransitioning, the medical interventions they are seeking will Published by BMJ. and the parent of a 15- year-old autistic girl who help them to realise their preferences. If we cannot To cite: Lemma A, was on the waiting list for treatment, successfully assume this—and we suggest that we have reason- Savulescu J. J Med Ethics brought a case against the service. The High Court able grounds to question an unqualified acceptance Epub ahead of print: [please ruling deemed that patients under 16 years should in some cases—then ‘acceptance’ potentially works include Day Month Year]. be assumed not to have capacity to consent to such against best interests. This is important because the doi:10.1136/ medethics-2021-107397 interventions. This was for two reasons: first—and treating clinician is also required to make a diagnosis this was the main argument—children who have not of ‘gender dysphoria’, if they operate according to Lemma A, Savulescu J. J Med Ethics 2021;0:1–8. doi:10.1136/medethics-2021-107397 1 Extended essay DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, health narrowly conceived as the absence of disease. As medi- J Med Ethics: first published as 10.1136/medethics-2021-107397 on 30 July 2021. Downloaded from 5th Edition), and so the clinician is required to confirm or vali- cine became increasingly complex, with multiple options with date the patient’s self- diagnosis. Such a clinical formulation must different risk/benefit profiles, it became clear it was necessary to take into account unconscious factors as well as that which is understand patient values to identify the best option. According consciously articulated by the patient. We propose a distinction to the shared decision- making model, patients supplied the between ‘acceptance’ (here used interchangeably with the current values and doctors supplied the facts. However, other models mandate in healthcare for a ‘gender affirming’ approach), and gave greater weight to normative dialogue, that is, dialogue respectful, in- depth exploration of an individual’s claims about about should be done, what is good and right. For example, the what promotes their well- being. We discuss the ethical relevance liberal rationalist model required doctors and patients to engage of the unconscious to considerations of autonomy and consent in normative and value dialogue, as well as exchange of facts, in working with transgender individuals. An inquisitive stance, to identify what would best promote this patient’s well-being in we suggest, supports autonomous choice about how to realise this particular context.9 It is the patient who is privy to their own an embodied form that sustains well- being by allowing the values and to their particular life circumstances, relationships individual to consider both conscious and unconscious factors and position in society. However, sometimes their values conflict shaping wishes and values, hence choices. and sometimes their values should change, for example, a person The relationship between autonomy and best interests (as who autonomously desires to abuse their partner. According to conceived of as well- being) is a complicated and contested one. the liberal rationalist model, doctors and patients are engaged in One of us (JS) conceives of autonomy as constituted by our a joint journey to answer the question: what should the patient rational desires or values.5 This is separate to well-being, which do in this circumstance? can be conceived of either objectively or subjectively. On a purely Productive engagement in a decision-making process can objective conception of well- being (objective list approach),6 only emerge if the clinician is willing to ‘accept’, as a starting well-being and autonomy can come apart. For example, people point, that the transgender individual’s claims have validity, may autonomously desire their own lesser good, for example, if only insofar as they reflect their current best understanding Jehovah’s Witnesses refusing life-saving blood transfusions. of their predicament and their belief that it is the body that Some philosophers include autonomy as one item on an objec- needs to change in order to improve well- being. This point tive list.6 On such an account, what a person strongly autono- may seem self- evident. However, historically, transgender mously desires will be in their interests. Others hold a purely individuals have felt that their claims have been discounted subjective account of well-being which collapses autonomy and outright and that they have been the object of epistemic injus- well-being (interests). tice.10 This has caused distress and added to the significant Fortunately, for this paper, we do not need to resolve this problems and stigma with which transgender individuals have issue. In the case of gender dysphoria, the accuracy of a person’s had to contend.