Testosterone Therapy For Transgender Men

Testosterone Therapy For Transgender Men

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Testosterone Therapy For Transgender Men

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Testosterone Therapy For Transgender Men

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The balance between the requirement, benefits and risks of hormone replacement therapy has been a matter of debate for past few decades. This is debate mainly arise from the interplay of the conflicting legal, ethical and professional codes of conduct. The following essay aims to analyse the ethical and legal factors that come into play while handling hormone replacement therapy and especially when the concerned patient is a minor. At the end, the essay will provide a personal reflection from the perspective of a student doctor regarding what are best possible approach that can be undertaken on the basis of the case study.
Case summary
Mr. X is a 14-year-old biological female, identifying as male, who came in to a GP practice to discuss the possibility of starting testosterone therapy. Mr. X was currently being administered puberty blockers but wished to commence with testosterone therapy. His mother accompanied him and she was not in support of starting testosterone therapy. Mr. X’s mother believed that he should wait a “a few more years” before making the decision.
Mr. X had history of depression and anxiety. He attends counselling once per week. There was no other relevant medical history of note.
The GP advised Mr. X and his mother that while he was on puberty blockers there was no rush and that he should consider this decision carefully. The GP also referred him to a psychologist and endocrinologist. Mr. X seemed reluctantly accept this plan, however, made it clear that it would be his preference to start testosterone therapy as soon as possible.
This case raised the ethical issue of administering hormone therapy to minors who are under the age of 16. Since usually the consent of the caregiver is required but Mr. X’s mother is unwilling to consent.
List of relevant concepts
The lists of relevant ethical concepts that must be taken into consideration include autonomy, beneficence. The professional codes of conduct that must be taken into consideration include duty of care, social responsibility, confidentiality, quality of life and respect to the dignity and choice of the individual. The legal concepts or facts that must be referred while handling this case include statutory obligations of medical practitioners and guidelines of the gender reassignment surgery as proposed by Ministry of Health, New Zealand. Finally the professional concepts that gains significance in this case are integrity, self-care, doctor-patient relationship, cultural competence.
Understanding of the relevant ethical and professional concepts in relation to the clinical situation
Autonomy: In medical practice, the concept of autonomy is defined as the right of competent adults in order to participate in the decision making process and informed consent in their own medical care. The principal mainly underlines the requirement of seeking consent of the concerned patient before the initiation of any investigation or treatment [1]. However, in this case study, Mr. X is a minor, as he is 14 years and hence the right to participate in the decision making process is completely opted over the shoulders of his care giver that is his mother. According to reports, if a patient is a child or minor he or she is not completely autonomous in participating in the medical decision making process. It is the duty of the physicians to seek help from his or her care givers on a way towards final decision making and at the same time give patient (if adolescence) an opportunity to take part in the process [2]. Thus in this case it will be duty of the physician to listen to the decision of Mr. X but the final mode of action will solely be based on the consent of his mother.
Beneficence: The ethical principal of beneficence is defined as an act of mercy, charity of kindness which has a strong connotation of doing good for others.  Beneficence actions in medical practice are required to be undertaken in order to prevent harms to the patience [2]. Testosterone replacement therapy over Mr. X who is minor is against the ethical principle of beneficence as it is associated with potential harm. The testosterone replacement therapy is associated with complications like cardiac anomalies, thrombophlebitis, hepatomegaly and acne. Moreover, testosterone replacement therapy is also found to create emotional changes. For the case study, it is evident that Mr. X suffers from depression and anxiety and this he attends counselling once per week. The application of Testosterone therapy might interfere with his anxiety level and thereby heightening his mental health complications [3]. Another ethical aspect that comes into consideration along with beneficence is non-malfeasance. Non- malfeasance promotes not causing harm [3]. However, preventing the provision for hormone transplant of Mr. X just under the consent of his mother is unfair as it is ultimately causing harm to Mr. X. Nurturing a soul of one gender and sharing a body of another gender creates immense emotional distress which might further increase his emotional anxiety and depression. So in order to secure non-malfeasance, the GP must interact with Mr. X know his actual concerns and make him understand why taking hormone replacement therapy at his age is not legally and biologically permissible.  
Relevant professional guidelines in relation to patient
Duty of care: Ethical aspect of duty of care is the obligation to avoid acts which could be reasonable foreseen to harm other people. In this case, it will be the duty of the doctor to provide adequate time to the patient and their carer to think about the requirement of the sex change as it is a permanent process. In this case study, the GP has exactly done that.
Social responsibility: The social responsibility of the healthcare professional also aligns with the duty of care [4]. Apart from this, it will be social responsibility of the doctors to make the mother of Mr. X to understand that if her child is suffering from gender dysphoria then it will wise to allow her child to go through the process of sex change. On the same time it will be the social duty of the doctors to counsel Mr. X about how he is feeling or why he wants to go through sex change. Moreover, the social responsibility of the healthcare professionals also entails discussing the consequences and the side effects of initiating testosterone therapy and why execution of the same is detrimental for minors.
Quality of life (QoL): It is the role of the healthcare professionals to uplift the QoL of the patients. In order to abide by the same, the GP in the concerned case has referred Mr. X to a psychologist and endocrinologist. This will help in the understanding of his mental and physical condition towards the process of hormone replacement therapy. However, staying on puberty blocker also hampers the quality of life as it increases emotional distress among the peers of the same age group. When he will see that his friends is attaining puberty and contrary he is not then it will hamper his QoL. Thus GP must also consider this aspects in order to increase his QoL.
Respect to the dignity and choice of the individual: It is also the professional role of the healthcare professional to respect the dignity and the choice of the individual who is undergoing the therapy [4].  Here the GP has respect the dignity and choice of Mr. X but since he is a minor, the GP has dependent on the onus of his mother and has asked her to take the decision. Thus the act of GP is in sync with professional code of conduct.
Legal aspects of the case study
Ministry of Health New Zealand in the domain of Gender Reassignment Surgery states that individuals who are over 18 years old are only eligible for the hormone replacement therapy. Thus autonomy of Mr. X cannot be taken into consideration as he is only 14 years old. Moreover, proper counselling by a mental health psychiatrist as proposed by the concerned GP will help in the identification of the underlying mental health issues and subsequently this data will be helpful in framing possible steps in the hormone replacement therapy.
Informed consent
Informed consent has ethical, legal and administrative perspective in healthcare. From ethical perspective, informed consent signified seeking respect to patient’s autonomy via ensuring that the process of treatment is directed towards his or her chosen path. However, the patient must be guided with pros and cons of each path by the doctor in order to take informed decision [2]. In case of Mr. X, the ethical obligation of informed consent is, the consent must be taken from his mother as he is a minor. The legal aspect of informed consent mainly deals with the generation of the awareness about the complications of the medical interventions associated and its expected outcomes [2]. In this case, GP have assured Mr. X and his mother that staying on puberty blockers will help them to think about the final decision. However, the GP did not take initiatives to inform them about the possible complications associated with testosterone replacement therapy. Administrative informed consent deals with compliance of the system rule and regulation and thus is beyond the scope of the case study as no final decision has been taken. I will also abide by the rules of Ministry of Health New Zealand in the domain of Gender Reassignment Surgery.
A justified decision about what to do
The first step that the GP must do is to identity that whether Mr. X is suffering from gender identity disorder (GID) and subsequently suggesting for further check up to analyse his phenotypic and genotypic backup of sex chromosomes. Proper knowledge about his mental and physical condition will help to uplift Mr. X QoL and at the same time will help him to get an actual scenario of his gender consequences. The concerned GP has exactly done the same as he has referred Mr. X to a psychologist and an endocrinologist. In the domain of ethical consideration the GP has abided by the ethical principal of beneficence that will not cause him any harm via unwanted hormonal therapy. However, it would also be wise if the GP had informed both Mr. X and mother all the consequences of testosterone therapy and this will help them to participate in the informed decision making process. It would be best that the GP keeping the ethical principle of beneficence ahead of autonomy as Mr. X being minor, the entire right of autonomy will anyhow opted over his mother. Furthermore, it is also the duty of the GP to take into consideration of the ethical principle of non-malfeasance. Non-malfeasance signifies not harming or causing less harm to the service user in order to reach an optimal beneficial outcome [2].  In order to satisfy the ethical principle of non-malfeasance, the GP must educate Mr. X the consequences of puberty blockers and withdrawing the same under the permission of Mr. X mother. This is because, giving puberty blocker might hamper the normal upbringing of Mr. X while causing emotional distress among his peers. Overall it can be said that not giving testosterone therapy to minor Mr. X is a wise decision.

Faden RR, Kass NE, Goodman SN, Pronovost P, Tunis S, Beauchamp TL. An ethics framework for a learning health care system: a departure from traditional research ethics and clinical ethics. Hastings Center Report. 2013 Jan;43(s1):S16-27.
Rogers W, Braunack-Mayer A. General practice ethics: Inter-professional responsibilities. Australian family physician. 2015 Jul;44(7):519.
Irwig MS. Testosterone therapy for transgender men. The Lancet Diabetes & Endocrinology. 2017 Apr 1;5(4):301-11.
Nursing Council of New Zealand. Code of Conduct for Nurses. 2017. Access date: 18th Retrieved from: https://www.nursingcouncil.org.nz/Nurses/Code-of-Conduct

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