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We thank the commentators for their thoughtful responses to our article.1 Due to space constraints, we will confine our discussion to just three key issues.
The first issue relates to the central ethical conundrum for clinicians working with young people like Phoenix: namely, how to respect, value and defer to a person’s own account of their identity and what is needed for their well-being, while staying open to the possibility that such an account may reflect a work in progress. This conundrum thus relates both to what will be beneficial for that person and what constitutes respecting their autonomy, and clinicians must dwell on these questions when deciding what forms of medical intervention to offer.
D’Angelo,2 Lemma3 and Wren4 highlight the importance of considering Phoenix (or, indeed, any person pursuing gender-affirming interventions) as a ‘whole person in context’ (p5)2 prior to initiating treatment or care. In this way, they advocate for a process of ‘therapeutic exploration’ (p1),4 which includes taking sufficient time to explore Phoenix’s personhood with them so as to support them in achieving an ‘authentic self-discovery’ (p5).2 We agree with these authors that identity (including gender identity) development is a complex, life-long process that is influenced by biological, psychosocial and relational aspects, all of which may contribute to an individual’s desire to pursue gender-affirming interventions. To explore the various factors—both conscious and unconscious—that might be motivating Phoenix’s decision to pursue ongoing puberty suppression (OPS), D’Angelo,2 Lemma3 and Wren4 describe a comprehensive psychological approach to working with transgender (trans) and gender diverse (TGD) individuals and propose questions to guide such discussions. Consistent with this approach, we stipulated that Phoenix had undergone regular psychological counselling and that the psychologist had judged that ‘Phoenix’s distress is significant and enduring…not a symptom …
Twitter @briandavidearp, @juliansavulescu
Contributors LN is the main author of this article, wrote the first draft, revised subsequent drafts based on feedback received from coauthors and prepared and submitted the manuscript for publication. All coauthors (BDE, LG, JS, MT and KCP) commented on the paper and made revisions. All authors contributed substantially to the content and arguments of the paper, and have approved the final version of this response.
Funding JS was supported by the Wellcome Trust (WT203132/Z/16/Z and WT104848/Z/14/Z). LN is the recipient of an Early Career Researcher Grant awarded by the University of Melbourne (project title: ‘The ethics of ongoing puberty suppression for gender non-binary youth’).
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
↵Wren also highlights the importance of sex hormones for brain maturation, functioning and behavior, raising concerns about the potential cognitive effects of ongoing puberty suppression, and echoes our call for more research in this area.4
↵As evidenced by Phoenix’s breast bud development.
↵Acknowledging the lack of methodologically rigorous data regarding the impact of puberty suppression on cognitive development.
↵This is a key lesson learned from other contexts, such as the surgical assignment of sex in intersex conditions.