A Question of Ethics: Ethics and Pediatric Gender Affirming Care

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Kade Goepferd. Today’s segment, A Question of Ethics recognizes that pediatric clinicians do ethics every day. And our guest host, Dr. Ian Wolfe, director of ethics, offers helpful guidance for pediatric clinicians navigating those everyday ethical issues.

Dr. Ian Wolfe: Welcome to a question of ethics. I’m your host Dr. Ian Wolfe, director of ethics here at Children’s Minnesota, and I’m happy today to welcome as a guest, Dr. Kade Goepferd.

Dr. Kade Goepferd: Thanks for having me.

Dr. Ian Wolfe: Is this the first time the host of Talking Pediatrics has been a guest on another guest host’s podcast?

Dr. Kade Goepferd: It is the second time, in fact. I was on Equity Actions with James Burroughs, but this will be the second time. No, actually the third time I was also on Crack the Case with Bryan Fate. So third time’s a charm though.

Dr. Ian Wolfe: I was hoping I was the first, but I won’t be a trivia question probably at that point, but now I’ll remember that for the trivia question. Well, thank you for being here today and I wanted to have you on to talk about the ethics of gender affirming care. For better or worse, this has become a household term and I think you and I have talked about previously in other forums about the mis and disinformation around this and the politicization that has unfortunately led to it being a household name. And I say unfortunate not because it shouldn’t be a household name, but because of the misunderstanding that a lot of folks have. So I thought it would be beneficial to have you here today so we could talk about what gender affirming care is, and I could talk about how I think of the ethics from what you talked to us about the gender affirming care. So the first question I guess really that I start off with a lot of clinical ethics question is: what is the goal of the medical treatment or the health care treatment? So what is the goal of gender affirming care?

Dr. Kade Goepferd: Well, it’s pretty simple. I am a pediatrician. I’ve been a pediatrician for 20 years, and when I decided to become a pediatrician, the thing that drew me into pediatrics was with the goal of helping kids thrive and making sure that every child has what they need to achieve their optimal health outcomes. And the goal of essential health care for trans and gender diverse kids is just that, it’s to help them thrive. It’s to meet their needs, whatever they are, whether they are social needs, medical needs, a combination of both, to get them to the place where they can be the best version of themselves and the healthiest version of themselves.

Dr. Ian Wolfe: So the terms themselves are always interesting and in ethics we always try to interrogate some of these terms because the idea of affirming care. So we put that together with gender affirming care and it takes on this maybe different conceptual meaning. So what do we mean by gender affirming care?

Dr. Kade Goepferd: I think the term comes from when someone identifies as transgender, their gender identity or sense of themself is different than what other people expect or then might be expected based on their sex assigned at birth. And so to affirm someone in their gender or to provide them with anything that is gender affirming is to say, I see you. I believe you. I know who you are. You’re telling me who you are and I’m going to do whatever I can to make you feel the most comfortable and happy and respected and all of those things. In the context of health care, it gets a little interesting because it’s not like we talk about pulmonary affirming care for asthma treatment. And so it sort of gives it this air of optional or nice to have or sometimes even elective. And really this is essential health care. It is health care that transgender people need to thrive. And we should think of it no differently than any other type of health care or mental health care or support that we provide for young people with any variety of conditions.

Dr. Ian Wolfe: I imagine this didn’t just come out of nowhere. So when we think of treatment in gender affirming, what was the treatment that was done before that or how did we get to this mechanism of deciding that affirming was actually a benefit for children?

Dr. Kade Goepferd: Transgender folks have been around throughout history. You can do a whole course on transgender history. In the medical field really there began to be some medical attention given to transgender folks probably around the fifties and sixties and then really sort of started to become more of a field of medicine with guidelines and some research behind it more in the seventies. And so originally this was largely adults, so transgender adults who were realizing their gender identities more often later in life and seeking care to align their physical bodies with their internal sense of self. As this went on and particularly as our culture and our language sort of caught up to the idea that transgender people exist, we began to see people younger and younger, so in their twenties and then in their adolescent years and sometimes even in their childhood years, find the language to express a transgender identity.

And within the course of that, there was no reason to believe that the same treatments that we offer to transgender adults, to help them live most comfortably as themselves, may extend to young people as well. And so that’s really kind of in the nineties when more research started, started to jump off. What we found is that when we don’t wait, when we affirm young people in developmentally appropriate ways across their life, they do better. They have equal mental health outcomes to their peers. So the stigma and discrimination that so often plagues transgender young people, leading to higher rates of anxiety and depression and suicidality, was diminished by offering support and resources, and in some cases, medical care.

Dr. Ian Wolfe: And it sounds like we know this because the other model didn’t support affirming, it wasn’t necessarily denying that, but it was more of a sort of hands-off do anything.

Dr. Kade Goepferd: Right. We know doing nothing leads to poor outcomes for transgender people. We’ve seen that over time. And we also know that trying to change who someone is or something that is often called conversion therapy, which is really just trauma, is what I’ll call it. Therapy is a little misleading. It’s not actually therapy of any kind, no proven benefit to it. But the concept that through coercion or talk therapy or sometimes painful sort of aversion tactics that you could get someone to change their fundamental sense of self, we know just doesn’t work. So we know that trying to change someone who’s transgender doesn’t work and is in fact harmful. We know that doing nothing leads to worse medical and mental health outcomes compared to peers. And we know that doing something, anything affirming, even using a name and a pronoun that’s affirming, helps young people do better.

Dr. Ian Wolfe: They continue to come out with studies. I know there was even one recently that even just support alone significantly impacts transgender youth compared to peers.

Dr. Kade Goepferd: Yeah, no, absolutely. I mean, people make a big deal about pronouns and that’s kind of become a substitute term for sort of woke or this more enlightened ideology around what I will just call fairness and kindness and respect. But the idea that if you refer to someone in the way that they would like to be referred in the way that they see themselves. So something as simple as using the correct pronouns for someone, the more settings that happens, the better they do. And it’s as simple as using the correct pronouns. It’s as simple as a word, and we know what makes a difference.

Dr. Ian Wolfe: It seems like there’s some parallels here between this idea of affirming versus sort of converting to the intersex society and what happened to that community over decades where they did try to sort of force these children into a particular sex or gender as an infancy without knowing. And we know from several cases and from advocacy from that community that there was significant harms from trying to force a gender identity on to these children. That seems to me, I think an important parallel of why conversion therapy, we know it’s harmful and it’s been used in transgender health, but we know also that they’ve tried it in other conditions as well, and it’s been unsuccessful and in fact, caused more harm than good.

Dr. Kade Goepferd: We could do a whole podcast on the ethics of intersex treatments and how that has impacted children’s health and well-being over the years. I think there’s a couple of key parallels to draw from the intersex community and transgender health. I mean, one of which you just mentioned that we all have an innate sense of who we are. I can’t change who you are anymore than you can change who I am. And even when infants are born with ambiguous either chromosomes or physical characteristics relating to their genitals, if we guess for them, we’re just going to be wrong probably. And so it’s just better to let young people discover that innate sense of who they are, whether they’re intersex or not intersex, whether they’re transgender or not transgender. We just need to let people figure out who they are and we can’t change it as much as we might want to. And the other obvious lesson from the intersex community is that biology is not as black and white as some legislators and politicians would like it to be, that we have beautiful biologic diversity among humanity and among human bodies, and we can’t oversimplify that for our own comfort.

Dr. Ian Wolfe: There’s a number of different appearances of people, but also even the genetic level, there’s different chromosomal types than just what we generally think of as XX or XY. There’s a host of variety there. So this kind of moves us into benefits and burdens. And of course from an ethics perspective, we need to have some good terms and some good history and then look at how do we balance benefits and burdens, which of course is nothing new for pediatrics. And it sounds like there are significant benefits in gender affirming care in general, I think you would say it’s individualized to the patient. And so are there any burdens of social affirmation or social transition that we’d want to think about?

Dr. Kade Goepferd: Yeah, I mean I think the burdens of any transition, whether it’s social or physical transition, is that to be visibly transgender in our society comes with it a lot of stigma and discrimination. Many young people unfortunately still experience rejection from their parents and their families of origin. So I think really the only burden of social transition would be the potential isolation and stigma and discrimination that a young person may face because of that. So even more of an argument for better, more inclusive communities for our young peoples’ schools, health care systems, all of those things.

Dr. Ian Wolfe: And for ethics, we’d want to literally look at, okay, how is a patient themself benefiting? Sometimes we can do medical treatments that have a multitude of benefits to the patient and to the family, but primarily our obligations to the patient. And so how are they benefiting? And for this, it sounds like if you have an incongruence with your gender identity from what it was assigned at birth, social transition benefits you in feeling more your true self and being able to flourish. The burdens then are really the external people’s inability then to really accept that. So there sounds like there’s a high degree of benefit for the individual patient in social transition. And I like to point that out a little bit because as it is an individualized care for each person, is it true that some children maybe don’t progress to medications?

Dr. Kade Goepferd: It’s something that we would really emphasize in the gender health program. And something I say to every new patient and family that I meet, that there’s no one way to be transgender, there’s no one way to be an ethicist. There’s no one way to be a boy. There’s no one way to be a Minnesotan. There’s no one way to be anything. And so we have to look at each individual patient and their family and their culture and their situation and approach what’s going to be best for that individual patient. And they may have things in common with other patients, they may not. But the truth is that being transgender is not about whether you have taken certain medications or have had certain procedures or anything, have a certain haircut, anything like that. You get to claim your own identity, and so whatever is needed for a young person or an adult to feel most like themselves and to get the most significant benefit is what we’re going to aim for. And that is going to be potentially different for each individual person.

Dr. Ian Wolfe: And so within that goal then of what is best for that individual, for some individuals, the first line of treatment is puberty suppression. Correct. And what is the goal or benefit then from a gender affirming care model of puberty suppression for a transgender child?

Dr. Kade Goepferd: Sure. So puberty suppression is something that can be initiated at the time of puberty, which for our clinical listeners I think they’re pretty familiar with. But just in case someone nonclinical is listening, is really around the time of middle school is kind of what I would say for both folks assigned male and female at birth. So sometime in that middle school timeframe, most young people are going to be starting puberty. And for those who are transgender, their body is going to start to change in permanent ways aligned with the hormones that their body is making that may present a significant burden for them down the road, psychological burden and a medical burden quite frankly. And so the benefit to these young people is that we can pause their puberty as they start to go through puberty with a completely reversible medication that has been studied for decades and is often used in kids with precocious or early puberty, exact same medication, until we can get to a time where they are able to participate in a more full way as older adolescents with us in determining what puberty is going to be the best puberty for them.

Dr. Ian Wolfe: So it sounds like it’s a time to pause and really give that adolescent and likely their parents and their clinicians to really help them explore and process their identity. And it’s reversible.

Dr. Kade Goepferd: It’s completely reversible and it’s very safe. I mean, that’s the other thing. There’s a little bit of a hysteria around medications that are sometimes used in essential health care for trans youth. And we have to remember that these medications, especially in the case of puberty suppressing medications have been used for four or five decades in young people with early puberty and at younger ages. So we’re comfortable giving a puberty suppressing medication to a 6-year-old, but somehow it becomes dangerous when we’re giving it to a 12-year-old who’s transgender, which the reality is it’s not. It’s a very safe, well studied medication. The difference is the population. And so we’re actively discriminating against transgender young people.

Dr. Ian Wolfe: So as a pediatrician advises for a child to take ibuprofen for a muscle ache and then advises another child to take ibuprofen for a headache, the safety profile remains the same.

Dr. Kade Goepferd: Exactly.

Dr. Ian Wolfe: Right. So you mentioned precocious puberty, and so I want to, sometimes we compare cases in ethics and I try to think of, okay, I’m a parent of an 8-year-old and I look at my child and it seems like they’re progressing faster than I think is maybe reasonable, and I bring them into a pediatrician and say, I just think my 8-year-old is going through puberty too soon. I just want to stop it for now because worried about what kids might say and things like that, that is a typical case or one of a case that might be.

Dr. Kade Goepferd: Yeah, there are some medical implications for going through puberty too early, but I think your point is that there are also a lot of social implications. So height being one of them, typically people who go through puberty too early are shorter. They will develop secondary sexual characteristics much earlier than their peers. They may get their periods much earlier than their peers, and it is very stigmatizing, but also presents a good deal of psychological distress for a younger child to be developing breasts or getting a period or to go through puberty too early and then spend their lives mismatched in terms of some physical characteristic. In this case, it’s often height relative to their peers. And so we alleviate that distress by pausing their puberty.

Dr. Ian Wolfe: I mean, it’s an interesting comparison for an ethicist, and I know there’s reasons that have a more medical focused goal and of course some of the literature does always talk about precocious puberty having puberty suppression for social distress. And when we think about that idea of how is that child benefiting, to me there’s definitely a significant benefit for a child who is identifying as trans to have their puberty suppressed probably even more so. And what child for precocious puberty, not that they also don’t have reasons as well because there’s a direct benefit to them. And one of the things I think about is because secondary sex characteristics are not reversible. Correct?

Dr. Kade Goepferd: Many of them are not.

Dr. Ian Wolfe: So the idea there then is if we give them time to wait, it’s reversible. But if we don’t do that, there’s irreversible consequences that if their identity as trans does persist and they didn’t get puberty suppression, they’ve now have some significant potential burdens for them.

Dr. Kade Goepferd: For example, once you grow breast tissue and develop breasts, there’s no medication that’s going to change that for you. So if you need to change the physical appearance of your body, that’s going to involve a surgical procedure. If your body makes testosterone and you develop a deep voice, we can’t change that deep voice with any type of medication, so that’s going to involve typically years of voice therapy and sometimes again, a voice box type surgery for someone to feel really comfortable having a voice that’s congruent with their identity.

Dr. Ian Wolfe: And so one of the things we also think about is this idea of uncertainty in balancing these benefits and burdens. So all medical interventions of course come with benefits and burdens that we have to weigh, and also parents are having to weigh them. Patients are having to weigh them, clinicians are having to weigh them. And so of course there are side effects of medications. So the question isn’t, gosh, there’s side effects we shouldn’t do it. The question is, are the side effects proportional to the benefit being achieved? And so one of those things though I think for adolescents that comes up is one of the goals I think obviously is to do what’s best for the child to help them flourish. Part of that I think is how do they become a happy, healthy adult? And that has an impact on what we do in adolescence and how do we think about that in gender affirming care or how do you as a pediatrician in that space think about that?

Dr. Kade Goepferd: Yeah, I mean, again, just kind of going back to the decades of research that we have on the outcomes relating to young people, we know that if they can go through a puberty that is aligned with their identity and we can suppress pubertal changes that are not aligned with their identity, that they will do better. They will have up to a 70% decreased risk of suicidality, they will have less anxiety, depression, immeasurable difference between their peers in fact. They have better rates of staying in school and academic achievement and all of those things. And so we know that the benefit is clear. And the good news for us is that all of the medical treatments, which really there are only a few that we use in essential health care, puberty suppressing medications and pubertal hormones like estrogen and testosterone, are all used in other areas of pediatric and adolescent medicine.

So we know what they do, we know how safe they are, we know potential side effects, and we can counsel patients and families on those potential side effects while at the same time explaining the changes that are associated with them and what is changeable, what’s not reversible, how long they take, things like that. And the ideal for us is that we are making any decisions as a health care team. I think that’s one of the more distressing things that’s happening right now politically, is that there’s an attempt to withdraw the decision-making from the health care team. And so we’re making these decisions, I’m helping inform the decision as a physician, but the parents are helping inform the decision as parents, as people who know they’re a young person really well, and then ideally the young person is helping inform these decisions. And the beauty of using puberty suppressing medications is that it allows us time to let that person’s brain cognitively develop to the point that we know that they are able to more consistently engage in decision making with us, which I know is a big area that you have focused on is medical decision making in adolescence, but we would really like to have this be a joint decision where all of us are giving input.

Dr. Ian Wolfe: The decision making is huge, and I think that’s rightly I think to validate people’s concerns, right? Because I think adolescents making decision makes us uncomfortable. We know that it’s a time of flux and growth and there certainly is identity development going on during that times, and I think as we open up some more exploration of their identity, there’s a good reason to be somewhat worried. Although that speaks really to then good process, which I think you’ve started speaking to a little bit, is that we want to affirm children, but also by providing a space for them to explore, to talk with clinicians, to talk with parents. And so we suspend their puberty sometimes to allow that process to unfold in order to both support and affirm them and while also protecting an aspect of that. And that changes. Every adolescent is different. And of course there are adolescents we know should be involved in decision making because they actually have benefits from being involved in decision making for long-term. They’re able to then learn from those decisions. We also want to respect them as burgeoning moral agents over their own body. And of course we want to protect them from making bad decisions.

And I think it’s always to me, helpful to make a difference between a favorite genre of music phase versus who your core identity is. And I think from an ethicist that makes sense to me, those things are fundamentally different. But you are a pediatrician. How do you think about that?

Dr. Kade Goepferd: There’s something that’s very different about your fundamental sense of identity and who you are, which innately develops very young in childhood, three to four years old, and a preference or like or an interest. So for example, the psychological definition of a phase is something that is nine months or less, sort of a short-lived kind of hyper interest, hyper-focused area. If someone has been consistent in their identity of who they are over years, it is by definition not a phase. Adolescents are often and should be influenced by their peers because that’s a fundamental developmental part of adolescence. They’re supposed to differentiate from family and look to peers for input. Again, something that a young person is doing just because a peer wants them to do it would be sort of a short term decision, a shorter process, something that a young person is affirming for themselves over years, over time across multiple settings, speaks more to an innate sense of who they actually are.

And if I could ask you a question, Ian, I think one thing that I hear come up a lot is we don’t let teenagers make other impulsive decisions. So I’m going to throw at you the tattoo question. So we don’t let teenagers get a tattoo, so why should we let them have a say in their identity and in their health care when it comes to essential health care for trans kids? And I have a whole thing I can say about that relative to brand development and how we make decisions and also that a young person goes into a tattoo shop, it’s just them and the tattoo artist and often an impulsive decision versus when we’re making decisions, it’s over time with parents, with mental health providers, with doctors. So if all of those people were in the tattoo shop, that might draw a comparison. How would you handle that sort of thought about decision-making in adolescence and if they’re capable of participating? 

Dr. Ian Wolfe: That’s a really good question. So there’s not one ethical principle or theory that always wins the day. These things happen in context and intention. And so we do want to respect adolescents have more autonomy over their body as they get older. I often use the example of we might hold down a 2-year-old to give them a vaccine, but we’re not probably going to hold down a 16-year-old to give them a vaccine assuming that they’re capacitated, meaning they can make decisions. And part of that is weighing these sort of benefits and burdens. And so there are some lines in the sands we draw in society. I think one of the ethics arguments of a tattoo is that those are often, as you said, more impulsive. The benefits are pretty significantly low and the burdens of making them wait to 18 are significantly low.

And I suspect there could be cultures in societies that set it different. They set it at 16, right? Drinking ages are different. There are other countries that actually set consent laws lower than 18 where we have a consent at 18. The difference here for me for gender affirming care is we have demonstrated benefits. We know there’s burdens of doing nothing. We do want to provide good process. We have a responsibility to provide benefit, to be a check, to really ensure there’s good treatment to get a good outcome, but it’s not the same. It also because as you say, it’s a fundamental piece of identity, at least I can speak for our gender clinic. People aren’t coming in off the street and checking in and going out with hormones. That’s not happening. So we are providing good process based in evidence with a demonstrated benefit, certainly a demonstrated burden from doing nothing, and especially with puberty suppression, right? Reversibility in that. And so that’s really different to me, the burdens. Then we’re going to say, Nope, we are not going to affirm your identity. We’re not going to give you anything. Maybe we’re going to provide some psychological counseling. But if that gender dysphoria is a big cause of that, we’re then committing a child through adolescence to suffer with significant mental health issues, which will affect their physical health. It will affect their ability to get education. It will affect their social life, which will go on to affect their employment life, all of which will lead to a unhealthier adult who is not thriving. That’s a significant burden. There’s uncertainty, and I think we’ll move into this a little bit area of this certainty around that and how do we know, and this idea of autonomy and when, because think of a child who wants to forego, say a blood transfusion at the age of 14 that will save their life. We probably would say no given the right context because we want to protect them and leave them open to that even if they go and become 18 and they choose to refuse those. But that’s a different benefit burden ratio.

It gets trickier too when there’s say high risk for chemotherapy for cancer treatments. Can a child forgo that? In some cases we say, yeah, they can absolutely make that. In other cases they can’t. Again, getting back to the individualized sense of who they are, sense of what they understand about themselves. If I’m an ethicist coming into a situation where a child wants to forego chemotherapy in some cancer, I’m going to want to verify them. I’m sure the physician will as well to see where they’re at because for some reasons we may not out allow that. But for other reasons, we may. It really depends on the individual child. I think that really speaks to this idea of autonomy, which I want to go to, but I first want to bring up the idea of good process. We worry about, well, what if people change their mind and all these different things, which I don’t think is an invalid worry, but speaking to good process clinics like the Australia Clinic have shown that very few going through that process sort of re-identify was one outcome measure they looked at. But even within that small number who sort of re-identified they did so within this process, and before they’ve got far into the process, I want to validate that concern with folks and say, that’s why we have a good process. And that’s what all the recommendations from all the health organizations say to do.

Dr. Kade Goepferd: I mean, when you look at the most recent standards of care, which came out in 2022 through the World Professional Association for Transgender Health or WPATH is a very clear kind of integrated mental health model, which involves assessment of a young person over a prolonged creative time within the context of their family, their medical health and their mental health.

Dr. Ian Wolfe: And all those sort of things I said about benefits and burdens. And another ethicist I know who has written on this has also said that gender affirming care for children and adolescents is no different in decision making than any other type of medical care that we already undergo. So going through a trial of chemotherapy that’s maybe hard, that’s a similar conversation. Parental discretion with the inclusion of the adolescent in those decisions going forward to figure out what is best for them and their family with the patient at the center. And so if we think then this is no different, right? There’s significantly demonstrated benefits. There are burdens of course, but it’s no different than other types of treatments. And in fact, I would argue that we have significantly more evidence of benefits compared to a lot of different types of treatments. It also falls within, as was noted by a colleague of mine in the consensus statements on pediatric ethics within decision-making that is under parental discretion. And so with that idea that this is seemingly no different ethically than any other decision-making in pediatric health, there’s a significant justice issue that’s kind of come up as we noted, and I was looking through other types of treatments we give hormones for. So Klinefelter my understanding, and this is the ethicist that we can treat some kids with Klinefelter syndrome with testosterone therapy to more affirm their gender identity. And so it begs this justice question of sort of, well, what are the reasons that we wouldn’t offer gender affirming care?

Dr. Kade Goepferd: Unless there was a really significant medical risk or harm based on an underlying condition that a patient had that would be identified by again, their care team. The only reason that care is being denied for young people right now is discrimination, essentially. And so there is a treatment that we know helps young people in all other areas of pediatrics we allow parents the freedom to seek the treatments that they feel are best for their child. And in this one area that has been well studied, has longstanding evidence for its benefit, and we know is associated with good outcomes and low regret, there are attempts to legislatively restrict their access to care.

Dr. Ian Wolfe: And a lot of that legislation, I think is often built off disinformation as I know you and I have both read the Cass Review out of the UK, which not only do they misinterpret the recommendations in that Cass report because the Cass report does not endorse bans and actually endorses expansion, although it is based significantly on bad science and a lot of bad theory and has actually now been debunked in several countries. France being one of those along with Germany, Austria, and Switzerland, who have now all published reviews affirming that this care is beneficial and have debunked essentially the findings of the Cass Review. So a lot of legislation is based on this very narrow and misunderstood reading, the Cass Review, which is essentially based in discrimination

Dr. Kade Goepferd: In the ethical principle of autonomy. For me, a lot of this legislation really speaks other ways in which we have tried to restrict access to people’s bodily autonomy through legislation and health care. And so I would argue that everyone has a right to get the health care that they want and need when they want and need it. But in certain areas of medicine, primarily based on personal belief and/or ignorance, disinformation, misinformation, there is a thought that the government has the right to restrict autonomy for patients who are seeking care. And this is often done, especially in the case of transgender people and transgender youth to a very small, highly stigmatized population, that I think the perception is doesn’t have the power to fight for their own rights.

Dr. Ian Wolfe: And I think it’s important to call out why would we legislate things like that. And so the example, going back to the tattoo, it’d be reasonable for the government to legislate some age requirements in this idea of protecting youth from doing things like that. But there’s also no health interest in these tattoos in a general sense, and that’s different from gender affirming care where there is an actual health interest and benefit. Legislation doesn’t tend to restrict things that actually have a benefit that’s more appropriate to protect patient and parental autonomy and not restrict things when there’s health benefits, but restrict things when maybe there’s no health interest and potential risks such as tattooing. As you mentioned. And I’d be remiss if I didn’t bring up systematic reviews because I think this has become kind of another focal point that has been really misunderstood. And I was actually talking to a pediatric ICU physician about this, and we were talking about systematic reviews and how this kind of got to be this talking point. And he said to me, look, nonclinical folks often lack the understanding to realize what isn’t known. And this is where disinformation gets really dangerous. If most clinical decisions had great evidence and clear systematic reviews, physicians wouldn’t need to come to work and make decisions based on the best synthesis of a combination of the evidence that does exist, if any, the physiologic pharmacologic and the patient specifics. And I think this is particularly true in pediatrics. We do know a lot. We do have evidence, but because there’s not as much research done on pediatrics in general, there’s a lot of medications that we don’t have systematic reviews. And in fact, clinical guidelines are actually developed by consensus recommendations, not necessarily systematic reviews. And so this has kind of been thrown around a lot, but from the ethics perspective, it seems like it doesn’t really amount to much because it’s not the way we often make decisions for a significant amount of health care, both pediatric and adults.

Dr. Kade Goepferd: The other thing that comes to mind for me when we talk about principles of justice is that when we look at essential health care for transgender young people, you’ve referenced this several times, there’s not a problem that exists. The care is good, the care is beneficial, it improves outcomes. Young people are doing well, they’re thriving, they are highly satisfied with their care. There are phenomenally low rates of regret or dissatisfaction compared to any other area of medicine. So there was no problem here. There is a politically generated solution to a problem that doesn’t exist. And I think that’s why it’s really important for those of us who are in ethics and who are in medicine and who are in science to say, wait a second, this is good medical care. It always has been, and there is no problem that we need to solve by restricting it.

Dr. Ian Wolfe: When I’ve looked at this compared to say, other types of treatments that are offered to adolescents, so in 2022, there was around 23,000 appearance altering procedures on youth for cisgender youth with seemingly no sort of process set forward by any recommendations. I know I was part of study working on some, but it seems actually gender affirming care for transgender youth is quite more conservative, actually.

Dr. Kade Goepferd: It is, yeah.

Dr. Ian Wolfe: So I think one final justice thing that I think really is something we talk about in ethics is it gets to this idea of how we think about evidence and some of these systematic reviews and we know there’s really not a lot for a lot of different treatments, and they say things like weak and low, but what those things really mean is more just to undergo shared decision making. But what a lot of this evidence, and we know that there’s a lot of logistical, pragmatic and ethical reasons. We can’t do randomized controlled trials in gender affirming care, but this focus on that sort of perfect piece of evidence from the magic heavens that sort of solidifies this, it doesn’t exist for anything, but it also invalidates some of the lived experience, the clinical experience gained by clinicians and even the experience of parents navigating through this. And so from the ethics perspective, we always really want to include those voices that are affected by these types of care and the policies trying to restrict them. How can we promote those voices or how can folks understand those voices more in seeking with curiosity to learn more about people going through this, people providing this care?

Dr. Kade Goepferd: When they do sort of polling research, what we know is that people who have a relationship with, or a family member who is transgender, they tend to believe more often that gender exists on a spectrum and that they’re not just two genders and they tend to be much more favorable to civil rights for transgender people, including access to public facilities, health care, identification documents, all of those things. And so I think you can’t underestimate lived experience and hearing from people’s experience that’s different than your own. One thing that I think we can start doing is listening to and validating the stories of transgender young people and their parents. When I speak with journalists, I often say, if we look at the data, what we see is that 99% of young people who will go through some gender affirming care procedure, medical treatment of some kind, will have no regret. Of the 1% that do, even less of them actually re-identify. They have regret because they experience what we talked about at the opening of the podcast – stigma, discrimination, isolation within their communities. And if we were to look at the numbers, we would have far less than 1% like 0.2% of true sort of re-identification of folks or regret regarding care. When you look at the way that this type of health care is reported on or talked about, what we would have to do is for every one story of someone who was dissatisfied with their care, we’d have to put right beside it in the same article, 99 stories of kids who are thriving and happy and doing great and not suicidal and have come off of their anxiety and depression medications and are heading to college and are feeling just loved, and like they found community that feels good to them. And these are the kind of stories that I get to experience every day when I’m in clinic with patients and families, and they’re the kind of stories that help me understand that the health care that I’m providing and that the work of advocacy that I’m doing to protect the right to access health care for transgender diverse youth in their families is the right work.

And so I think some amplification of those stories and some balance, some simple understanding that this is not a one-to-one situation. It’s also not opinion versus opinion, it’s opinion versus decades of medical research and fact. There’s biologic fact and science, and then there’s someone’s opinion. And so I think the more that we can really lean into let’s balance the storytelling, let’s call a fact, a fact call, an outcome, an outcome. And when we do that, my patients’ lived experiences and their outcomes and their lives speak for themselves. There isn’t really any question there at all. Kids thriving is why I went into pediatrics, and that’s exactly why I provide health care for transgender and gender diverse young people. And that should be what we all care most about at the end of the day in pediatrics, and I would think in our country.

Dr. Ian Wolfe: All this thinking about the ethics of gender affirming care, it’s actually not novel at all. It’s very ordinary and a part of everyday pediatric ethics and pediatric care. Kade, thank you so much for being here, and thanks for being a Kid Expert here at Children’s Minnesota.

Dr. Kade Goepferd: Yeah, you as well. Thanks for having me.

Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.