Boston Children’s Hospital establishes a framework for gender-affirming surgeries on minors

Zinnia JonesThroughout the past decade, there’s been no shortage of popular alarmism surrounding the spectre of “children being given sex changes” – a misconception borne of either incidental or deliberately cultivated ignorance about what transition entails at various ages, suggesting the image of five-year-olds being given irreversible surgeries. In response to this, trans people and allies point out for the thousandth time that young transgender children undergo social transitions consisting of nothing more than changes of names, attire, and presentation, only those adolescents whose gender dysphoria persists past the onset of puberty are given puberty blockers that pause development without producing any permanent changes, and only legal adults aged 18 or older are able to access any irreversible gender-affirming surgeries such as vaginoplasty or chest surgery.

And this reply is largely accurate – just not entirely.

The reality is slightly more complex than that absolute age threshold. While the overwhelming majority of gender-affirming surgeries are performed on trans people who have reached legal adulthood, operations on transgender minors in late adolescence are not unheard of. Milrod & Karasic (2017) interviewed several vaginoplasty surgeons in the United States who had performed surgery on trans girls under age 18, one as young as 15. These surgeons broadly emphasized the importance of judgment on a case-by-case basis in evaluating an individual patient’s suitability and readiness for surgery, and their overall maturity and understanding of the process. Additionally, Olson-Kennedy, Warus, & Okonta (2018) reported on the clinical features of transgender men and boys who had undergone or not undergone male chest reconstruction surgery, with at least one participant receiving this surgery at the age of 13 and 49% of those who’d had surgery having received it when under the age of 18.

So: Irreversible gender-affirming surgeries are sometimes performed on trans people who have not yet reached legal adulthood, and this has largely been at the individual discretion and judgment of medical providers and a decision made on a case-by-case basis. As Olson-Kennedy et al. note: “Professional guidelines lack clarity regarding referring minors (defined as people younger than 18 years) for chest surgery because there are no data documenting the effect of chest surgery on minors.”

A recent publication by clinicians at the Boston Children’s Hospital takes a different approach, seeking to develop an ethical and policy framework for medical decision-making and provision of surgical care to transgender minors, many of whom already receive other gender-affirming care at the hospital’s Gender Management Service clinic (Boskey et al., 2019). In their paper, the authors seek to account for the many concerns that factor into a hospital offering gender-affirming surgeries to pediatric patients – given the fevered controversy surrounding even the mistaken perception that children are commonly receiving transition surgeries, to call this a minefield would be an understatement. The authors nevertheless argue that the benefits of providing these effective treatments necessitate navigating these difficult questions and developing a process by which transgender minors can receive gender-affirming surgeries when appropriate.

In this case, the authors elected to take a decidedly conservative approach to prerequisites for minors to obtain these surgeries, requiring the consent of both parents but remaining open to the possibility of developing procedures for appealing this:

There was substantial discussion among the ethics team, hospital counsel, and center providers as to whether the consent of both parents must be required for minor patients to undergo gender-affirming surgery. Although consent from both parents, alongside assent from the minor, is the standard for care in the hospital’s GeMS program, many transgender youth have complicated family situations. This may make acquiring 2-parent consent to perform surgery on an adolescent unfeasible or impossible, particularly when 1 parent is no longer involved in the minor’s life. Eventually, the center decided on a policy incorporating the standard of 2-parent consent but with the intention to develop formal procedures allowing for appeal in cases in which such a requirement appears to interfere unduly with the informed choices of minors and raises the possibility of significant harm.

They further sought to determine “an appropriate age range for patients to be able to access each type of gender-affirming surgical procedure”, and concluding that male chest reconstruction or breast augmentation could be performed at age 15 in certain appropriate cases:

After weighing the guidelines and feedback from stakeholders, the center decided to deviate from the SOC and set 15 as a minimum age for undergoing a chest reconstruction or breast augmentation, with surgery at age 15 only being appropriate for those individuals who have had a strong and consistent gender identity and, in rare cases, those who are significantly limited in life activities by the presence of their breasts. Because the risk of desistence of a transgender identity declines sharply after puberty, the center thought that this allowed for a reasonable balance of recognizing the possible risk of a premature decision with respecting patients’ current needs and preferences.

Finally, without specifying a lower limit, the authors conclude that provided a patient exhibits an understanding of the procedure’s fertility impact and required postsurgical care and is capable of making an informed decision, vaginoplasty can be performed on trans girls under age 18. However, this comes with particular legal concerns due to state law:

The center staff eventually came to the conclusion that it is appropriate to offer vaginoplasties to certain individuals before the age of majority so that they can safely embark on their adult lives. However, to address legal concerns related to performing vaginoplasties in Massachusetts minors, it was necessary to institute a policy requiring such patients to either have undergone fertility preservation or to seek out a court order granting permission for surgery. To date, the only family to which this option has been offered has decided to pursue the court order.

Overall, these guidelines and policies represent a preliminary and cautious attempt at defining a medical pathway for transgender minors to access gender-affirming surgery in the context of a dedicated gender clinic. Regardless of whether the requirements are seen as overly onerous or not strict enough, this is significant as an initial step toward formally allowing this vulnerable population to access necessary care that was previously unavailable to them.

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About Zinnia Jones

My work focuses on insights to be found across transgender sociology, public health, psychiatry, history of medicine, cognitive science, the social processes of science, transgender feminism, and human rights, taking an analytic approach that intersects these many perspectives and is guided by the lived experiences of transgender people. I live in Orlando with my family, and work mainly in technical writing.
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