Ethics of Pediatric Gender-Affirming Care: A Case Study Comparison

Objective:This article aims to explore ethical tensions in pediatric gender-affirming care and illustrate how these tensions arise in the clinical setting.Method:This article utilizes two de-identified cases of transgender youth-Emma and Jayden-as a framework for discussing ethical principles in pediatric gender-affirming care. Case summaries detail the medical history of these two patients, their familial context, and their encounters with healthcare providers. Subsequently, the ethics of both cases are synthesized. As represented in this work, these cases do not constitute Institutional Review Board-regulated human subjects research.Results:Emma's parents want to forgo pubertal suppression and pursue hormone therapy, effectively skipping a step in the gender-affirming care standard for youth presenting in early puberty. Jayden's parents, on the other hand, are skeptical of their son's identity and resistant to pursuing treatment. Both cases reflect disparate health goals between youth and parents and offer insight into the ethical tensions of gender-affirming care for pediatric patients.Conclusions:Key ethical discussions center on the standard of care, treatment reversibility, and pediatric decision-making. Jayden's parents resist the standard of care for pediatric transgender patients. In contrast, Emma's parents seek an acceleration of the staged progression recommended in the standard-of-care guidelines. The degree of reversibility of the treatment option in question influences the deliberation of these cases because it is the provider's ethical obligation to preserve the future rights and autonomy of pediatric patients. Finally, while capacity in children is not presumed, providers should actively involve pediatric patients in treatment decisions that are increasingly subjective.Implications for Impact Statement The standard of care, treatment reversibility, and pediatric decision-making are three important considerations in the ethical provision of gender-affirming care for pediatric patients. Clinicians and decision-makers, including parents, ought to weigh the impact of each consideration on patient autonomy. Although the autonomy of pediatric patients is necessarily limited, steps should be taken to safeguard these patients' future decision-making capacity and align with their healthcare goals and values to the fullest extent possible.