ADVOCACY March 1, 2014

How Young is Too Young for Sexual Reassignment Surgery?

“How young is too young for sexual reassignment surgery in clinical, ethical and surgical aspects?”

The WPATH Symposium: Transgender Health from Global Perspective, held on February 14-18, 2013, offered transgender persons, medical practitioners and advocates a number of symposia on medical and surgical researches and advocacy agenda. As an advocate, naturally, I went to listen to the presentation on the advocacy issues. But, man, they are all too familiar. The same were discussed during the last International Conference on AIDS in the Asia and the Pacific (ICAAP). And I am a person who is not keen on listening to discussions over and over again because, on a personal note, we should have started addressing those already. So I took my WPATH Program Booklet and brushed my fingers into the sessions and, viola! I found an interesting topic which I have heard before but nevertheless promised a presentation from a very unfamiliar perspective.

“How young is too young for sexual reassignment surgery in clinical, ethical and surgical aspects?”

As uniformly used in our advocacy, it is the issue of the informed consent. It is the question of the legal age range where adolescents can give their consent for medical procedures.

Dr. Christine Mildrod began her presentation by telling her personal experience where a young person, at the age of 14, asked her to perform a sexual reassignment surgery (SRS). In her words, she said that she was like a “chicken with the head cut off”. She honestly admitted that she did not know what to do. Is it optimum to grant patient’s wishes or withhold them in the name of ethical compliance?

To ease her from this dilemma, she wrote a paper. According to her research, irreversible interventions are not recommended until adolescent has reached the legal age of majority in any given country (referring to Standard of Care V.7). She also cited the research of Mr. Sam Winter, who at that time was sitting beside me at the back of the session room and on the comfort of the fully carpeted floor, about Thai Transgender people taking hormones at a young age and its effects.

As medical practitioners, doctors are bound by the current and existing ethical protocols. She mentioned about the Endocrine Society’s Grading, Recommendations, Assessment, Development and Evaluation (GRADE) System which is used to rate the strength and quality of recommendations. According to the system, the recommendations of lowering down the age of consent are low and the quality of evidence is weak.

Here comes the most interesting part – the discussion on the Informed Consent and the evidence available corroborating it.

Informed Consent is the legal ability of a person to provide legal consent to direct what happens to his or her body. It ensures that the patient is aware of all the potential risks and costs involved in a treatment or procedure. To give consent, he or she must be considered competent to make the voluntary decision.

There are existing principles that govern this issue. She presented three:

The first one is the Rule of Sevens. According to this rule “children under age seven do not have the capacity necessary to make their own decisions; children from seven to fourteen years of age are presumed not to have this capacity until proven otherwise in individual cases, and children over age 14 are presumed to have capacity to make their own decisions and lead their own lives, unless proven otherwise.” By saying “proven otherwise”, I would assume the requisite of a court decision vesting capacity as it is a legal ability to give legal consent.

Then there is United Kingdom’s Gillick Competency. It is part of UK’s jurisprudence stating that a child’s capacity to give consent will depend on his maturity and understanding and the nature of consent required. He must be able to reasonably assess the advantages and disadvantages of the treatment [or procedure] proposed.

Finally, there is the United States’ Mature Minor Doctrine. It says that an unemancipated minor patient has the right choose or reject a health care treatment, sometimes even without the knowledge or agreement of parents, and they should be permitted to do so.

In the end, we were presented with two sets of, not only distinct, but also adversarial ideas clothed in legal, medical and ethical jargons. But who is to decide which among the contesting concepts are applicable? These concepts are recognized landmark decisions written by credible high courts of different countries (at least the later two). If jurisprudence is part of the law as it is the interpretation of the law, does it follow that these concepts be applied as they are construed?

Then again, there is the puzzle of ‘applicability’. One concept may be true and correct, but may not be applicable in a given situation. Vice versa.

It is sometimes beneficial to enunciate these kinds of questions to disturb the tranquility of the advocacy. I believe that when there is conflict, there is progress. In this case, I hold that these conflicting thoughts place us in a progressive way of thinking. There may be debates, arguments and some handsome distractions, but this will lead either to another branch of questioning or to the root cause of the dilemma. As Robert Greene wrote: “Stir up the waters to catch fish.”

This leads me to my next thoughts. These questions may be wrong in whatever form, but I am nevertheless pushing them: Are these principles of Informed Consent applicable to HIV testing of Young Key Affected Populations? Can these principles be used in advocating for lowering down the age of consent for HIV testing? Although the general rule is that these guiding ethics applies only to doctors, are there any exemptions? Into what extent are these ethical doctrines applicable? (My contact details are placed below in the event a reader may intend to violently react, or may want to lecture me for not conducting an extensive research on the matter.)

WPATH manifested the path that I less walk on. From that path, I see many detours and shortcuts, which are inviting depending on my interests. WPATH spotlights that transgender health issues are clearly beyond HIV. These legal and medical doctrines attest to that.

Although it is true that physical health is an immediate element, mental wellbeing is as crucial. I may not be one of the transgender people, but I recognize them.


This article is written by Senior Programme Officer Inad Quinones Rendon