To promote well-being

An item from the Journal of Medical Ethics:

In this article, we analyse the novel case of Phoenix, a non-binary adult requesting ongoing puberty suppression (OPS) to permanently prevent the development of secondary sex characteristics, as a way of affirming their gender identity. We argue that (1) the aim of OPS is consistent with the proper goals of medicine to promote well-being, and therefore could ethically be offered to non-binary adults in principle; (2) there are additional equity-based reasons to offer OPS to non-binary adults as a group; and (3) the ethical defensibility of facilitating individual requests for OPS from non-binary adults also depends on other relevant considerations, including the balance of potential benefits over harms for that specific patient, and whether the patient’s request is substantially autonomous.

It’s interesting that a technical paper of this kind treats the term “non-binary” as transparent and “medical” – i.e. a straightforward descriptor useful to medical professionals and ethicists.

It later turns out that Phoenix is hypothetical, which reduced my tension a good deal. Having said that…

Phoenix, 18, was assigned female at birth but has identified as gender non-binary (not entirely/exclusively male or female) since age 5.

Wait. Children of 5 don’t know from “identifying as.” When I was 5 I identified as all kinds of people (and probably animals) I saw on tv. This is all adult ideology being insinuated onto children who don’t know wtf the growns are talking about.

Anyway Phoenix hated puberty, especially the start of breasts. I hated that too – I think it’s pretty ordinary and humdrum to hate it. It’s weird. Children of 14 or 12 don’t necessarily love weird things happening to their bodies. But anyway Phoenix hated it so puberty blockers, and then Phoenix wanted to stay on them forever.

Given Phoenix’s severe distress, Phoenix’s paediatrician agreed puberty blockers should be given, but informed Phoenix and their parents he was not prepared to prescribe long-term puberty suppression, as this is riskier than short-term suppression. The paediatrician stated that, when Phoenix turned 16 and had a better sense of their gender identity, they would meet to discuss whether Phoenix wished to discontinue the puberty blockers and (1) revert to their endogenous (female) sex hormones or (2) commence testosterone.

When Phoenix turned 16, they informed their paediatrician that they did not want option (1) or (2). Rather, Phoenix was confident they would identify as non-binary for the rest of their life and wanted to stay on puberty blockers ‘forever’ to ensure their body remained in a ‘genderless’ state. Reluctantly, the paediatrician agreed to extend Phoenix’s time on blockers for another 2 years.

People of 16 are confident about a lot of things that they change their minds about later. More urgently, puberty blockers don’t just make the non-binary person bulge-free in the body, they also block brain development. They make the non-binary person childish, immature, stuck at an early stage.

Phoenix’s doctor refers Phoenix to a psychologist, who confirms that Phoenix continues to have significant distress about their body, similar in degree to that experienced by binary trans patients that the psychologist has seen. Phoenix has regular counselling with the psychologist, who judges that Phoenix’s distress is significant and enduring, and is not a symptom of an underlying psychopathology. The psychologist also reports that she does not see any signs that indicate Phoenix has a fear of growing up.

Phoenix tells the psychologist that they highly value having a body that matches their gender identity. Alternative options, including low-dose testosterone, menstrual suppression and future ‘top’ surgery, are unacceptable to Phoenix because they do not believe these alternatives would accurately reflect their non-binary gender identity.

But what is a “gender identity”? It’s contested that such a thing even exists, that the words even name something real as opposed to a fantasy about the self akin to other fantasies about the self that don’t get adopted into the medical lexicon.

It’s just strange, the mix of formal academic language and assumptions about the reality of “gender identity” and “non-binary identity.” The University of Twitter Philosophy Department.

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