Abstract
Introduction
During the last decade, the age of youths presenting for gender confirmation has steadily
fallen. Transgender adolescents are being treated with gonadotropin‐releasing hormone
analogues and subsequently cross‐sex hormones at early or midpuberty, with genital
surgery as the presumed final step in treatment for female‐affirmed (male‐to‐female)
individuals. Despite the minimum age of 18 as eligibility to undergo irreversible
procedures, anecdotal reports show that vaginoplasties of female‐affirmed patients
under 18 have been performed by surgeons, thereby contravening the World Professional
Association for Transgender Health Standards of Care.
Aim
The purpose of this article is (i) to provide a review of salient factors regarding
genital surgery in transgender adolescents; (ii) to review various ethical protocols
for determining maturity in gender dysphoric individuals under 18; and (iii) to present
a new systematic set of ethical principles largely derived from the surgical management
of youths with disorders of sex development and adapted to the needs of transitioning
adolescents.
Methods
A literature review of the topic was performed. Ethical guidelines derived from applied
treatment protocols of children with disorders of sex development were written.
Main Outcome Measure
Progressing from the current state of ethical standards and clinical assumptions,
a new development of ethical guidelines for genital surgery in the female‐affirmed
transgender adolescent was created.
Results
There were no controlled studies of vaginoplasties performed on female‐affirmed adolescents
under 18 years of age. A new set of ethical guidelines was created in order to support
treatment professionals in their decision making process.
Conclusions
Professionals across disciplines treating female‐affirmed adolescents can utilize
the proposed ethical guidelines to facilitate decision making on a case‐by‐case basis
in order to protect both patients and practitioners. These guidelines may also be
used in support of more open discussions and disclosures of surgical results that
could further the advancement of treatment in this emerging population. Milrod C. How young is too young: Ethical concerns in genital surgery of the transgender
MTF adolescent. J Sex Med 2014;11:338–346.
Key words
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