Trans Health, Live from the 2018 WPATH Conference:

Ethics and Suicidality in Transgender Health

I am so fortunate to have had the privilege of attending a second WPATH Biannual Symposium this year in Buenos Aires. I am grateful for my level of education (4th year medical student) and the privilege I have as a white middle class cisgendered woman to travel safely and use my financial aid and family support to travel internationally.

I spent the first half of the conference in ethics sessions. The new Standards of Care 8 will have a chapter on ethics and education by/for transgender people and their providers; thus, there was considerable collaborative discussion on this topic. Many of the people involved in the dialogue and creation of this new chapter are not trans, nor are they ethicists. Careful consideration must be employed to recognize the power, privilege and influence when making these delicate ethical considerations.

The first consideration that was called for in the Global Education Initiative seminar was to suspend judgement, as ones first considerations are usually biased. Furthermore, reaching an ethical decision will likely require compromise. Pithy topics like informed consent, surgery, civil rights and medical rights were approached within a westernized conceptual framework of nonmaleficience, beneficence, autonomy and justice. I was disappointed, personally, that morality/morals were also brought into the conversation as combining ethics and morals always shifts to a JudeoChristian framework which is inherently misogynist/paternalistic and racist. Aspirational ethics were briefly mentioned but not followed up on – those beyond the moral frameworks.

AnneLou  L.C de Vries, a Dutch child psychiatrist whom I have been idolizing for years, and Dr Ehrensaft, a UCSF Director of Pediatric Mental Health gave a structured and functional mini-session on the ethics and tensions in Child/Adolescent Care as it relates to gender. Dr. Ehrensaft reframed the basic biomedical ethical principles as:

For children, the tensions between nonmalefience, child autonomy and parental anxiety were elucidated; for adults, beneficence, group harm and justice were key ethical issues.

Dr. de Vries offered a method of deliberating a case, facilitated by an ethicist, to formulate the ethical dilemma, create a consensus, and make an action plan for difficult cases. This is what the Dutch model uses to make decisions.

By identifying each person involved’s values, it makes complex decision making more straightforward. This eases the predicament of the pain of doing something vs the pain of doing nothing as providers.

The sessions left more questions than answers, and this arena will certainly be a hot topic to keep abreast of for future policy challenges. When the room was opened to questions, these were some of the ethical questions left unanswered:

• Moving through space as a trans person – restrooms/change rooms / justice/ fairness/ equality
• Workplace equality – access/financial freedom/ accommodating vs hiring practices
• Crossdressing – as a crime, as authentic
• Access to vs adequate training as providers – certification vs gatekeeping
• BMI/surgery access/autonomy/do no harm/ individual rights
• The ethics of bad evidence / risk factors not compounded for in studies/ false evidence
• Why does gender medicine require specific ethical debate?

Some new (to me) statistics were also offered at this conference:

• There are roughly 25 million transgender people worldwide (2016)
• 0.53% of the US population is transgender
• In the US transgender folx suffer 15% unemployment or higher (USTS 2015)
• <5% of transgender research is on transgender employment and discrimination in the workplace

I attended a sobering “Finding Order in Chaos” presentation on suicidality published by Dalhousie that looked at all transgender research on suicide done in English between 1997 – 2017 that had more than 5 people and included those over 18yo. The minority stress model was clearly evidenced and all People of Color including First Nations people were more likely to have attempted or completed suicide. Furthermore, higher incomes and education levels created safety, and directly correlated with a decreased likelihood for suicide attempt and completion.

Nonsuicidal self injury was explored by another researcher in this presentation, which represents “an important condition for future study” as per the DSM5. Transmasculine and nonbinary folks were found to be more at risk for these behaviors. Again, lower income, higher stress and higher gender presentation incongruence were risk factors. Self harming behaviours with negative affect were found in 63% of the longitudinal cohort, and self harm was perceived over and over again as a mechanism/ behavior engaged in circumstances where people felt it was necessary to hide the true self and repress identity development.

Clearly the environment, ability to walk through the world safely and have resources to build a life/career are important determinants for wellness. More research is needed to bring funding and resources to the trans and nonbinary communities and promote justice and employment security. The developing ethical framework of this medicine serves to create and reflect the basic human rights that trans people in all countries are still being denied. The ongoing struggle to secure basic respect for transgender and nonbinary children’s rights to even exist in so-called first world countries like Canada and the US illustrate the importance of this work.

Part two of this review will focus on primary care sessions and the most up to date research I encountered in Argentina WPATH 2018.