1

Gender Affirming Surgeries in Youth: An Ethical and Legal Dilemma

Devin R. Steidler

Department of Nursing, University of Mary

NUR 336 01 – Ethics Law & Policy

Prof. Mary Beth Johnson

November 11, 2022

 2

Abstract

As gender affirming surgeries have become more and more prevalent and advanced in

recent years issues have arisen from both sides of the spectrum on what to do. As states begin to

put forth bans on gender affirming surgeries and therapies, families of trans children have spoken

on the effect of the bans and access to care on their children’s mental health and safety. Risks of

suicide, suicidal ideations, depression and anxiety have all come to the forefront of issues for

transgender youth. We will also take a look at the development of the brain and how it effects

decision making in the youth as well to help come to a solution.

 3

Gender Affirming Surgeries in Youth: An Ethical and Legal Dilemma

With the increasing volatility in the political climate of the United States a few topics

have been brought to the forefront of the battle. One specifically sparked an interest in me due to

its implications in my future occupation as well as its deep seeded ethical and legal

complications. We will discuss the effects of gender affirming surgeries and access to them on

mental health in youth as well as their parents, while also taking a peek at states legal standpoints

and issues involving decision making.

The CDC defines transgender as “an umbrella term for persons whose gender identity or

expression (masculine, feminine, other) is different from their sex (male, female) at birth. Gender

identity refers to one’s internal understanding of one’s own gender, or the gender with which a

person identifies. (Centers for Disease Control and Prevention [CDC], 2022)” Many transgender

peoples choose to undergo surgeries and hormone therapies to change their bodies irreversibly to

the opposite sex, or as close as they can get. Recently there has been a push for these surgeries

and therapies to be started at younger ages, before puberty, to prevent lasting physical signs of

the gender assigned at birth. With that comes pushback on ethical and legal sides bringing in

child emotional status and decision making ethically. Some states go as far as to label

transgender surgeries as child abuse and make it illegal.

Four states throughout the US have made access to gender affirming care illegal,

Alabama, Arkansan, Texas, and Arizona. All of these state laws are new, the oldest dating back

to 2021 in Arkansas while the rest were made in 2022. This emphasizes the possibility of more

states doing the same thing, because of just how new the topic and ethical concerns are. Alabama

implemented a “law that prevents transgender minors from receiving gender affirming care,
 4

including puberty blockers, hormone therapy, and surgical intervention. The bill makes it a

felony for any person to “engage in or cause” a transgender minor to receive any of these

treatments, punishable by up to 10 years in prison or a fine up to $15,000. (Dawson, Kates,

Musumeci 2022)” This law also made it illegal for nurses to withhold information regarding

gender dysphoria from parents as well as also making it illegal for the nurse to encourage such

behavior. In Arkansas, “lawmakers passed legislation prohibiting gender-affirming treatment for

minors, including puberty blockers, hormone therapy, and gender affirming surgery. The law

also prohibits medical providers from making referrals to other providers for minors seeking

these procedures. (Dawson, Kates, Musumeci 2022)” This law also made it illegal for medical

professionals to provide referrals for gender affirming surgeries. Texas classified gender

affirming surgeries as child abuse and made it illegal with a potential consequence of the parents

losing the child. Beyond that it calls for investigation into the parents that supported the child’s

gender dysmorphia. Arizona made it illegal for gender affirming surgeries to be performed but

not hormone therapies or puberty blockers. “In addition, since January 2022, 15 states introduced

a total of 25 bills that would restrict access to gender-affirming care for youth. (Dawson, Kates,

Musumeci 2022)”

Gender affirming care bans effect not only the child but also the parents involved. A

study looked at the effects of gender affirming care bans on youth mental health from the

parent’s perspective involving such things as suicidal ideation, depression, and anxiety in their

children. Out of 85 parental figures, 45 had indicated that these bans would only increase rates of

depression and suicide in transgender youth. One parent stated that the bans were “a death

sentence for Trans youth,” as well as stating she “equates these laws to manslaughter. (Abreu et

al. 2022)” Thirteen parents stated they felt the bans would increase anxiety. Thirty-four parents
 5

voiced concerns about bans decreasing safety for the transgender community overall with

“increasing exposure to anti-transgender sentiment, violence, and discrimination. (Abreu et al.

2022)” With all of these added concerns parents of Trans children face with gender affirming

care bans its clear there’s an increase in added stress and worry that can also effect the parents of

the children.

Suicide is of high concern for transgender youth especially in today’s climate. In a study

focusing on experiences of suicide in transgender youth it was found that almost 30% of

participants had reported at least one suicide attempt. Out of 90 participants 61 had reported

suicidal ideations, and interestingly 5 participants had reported a suicide attempt but no suicidal

ideations, just purely impulsive (Hunt, Morrow, McGuire, 2020). In this study four common

themes were identified among the participants, belongingness, thwarted belongingness,

embodiment, and self-preservation. Belongingness is feeling cared for and part of a group

whereas thwarted belongingness is feelings or rejection and isolation. One can see how the

feelings of belonging and feeling care for can provide encouragement when faced with adversity,

and how feelings of rejection and isolation can lead to an increase in suicidal ideations and

depression. The third one embodiment refers to ones sense of self, and the final theme self-

preservation refers to the participants resilience throughout their experience with suicide and

when discussing it. Embodiment and resilience can also lead to encouragement and help boost

self-esteem while a lack of can do the opposite and increase chances of suicide and depression.

This study shows the scary prevalence of suicidal ideation and suicide among transgender youth

while also showing the importance and effect of personal and interpersonal connections.

There was a study done on executive functioning in 124 transgender youth aged 11-21

years old involving some with autism spectrum disorders (ASD). Overall based on the study
 6

executive functioning problems were common in transgender youth but it was significantly

higher in those with ASD. The study found that a diagnosis of ADS and anxiety had a correlation

to executive functioning problems while depression was of minimal significance. When

compared to the group with gender affirming hormone (GAH) therapy, the group on hormone

therapy showed significantly better executive functioning than that of the group without GAH

therapy. The study points to the increase of stress being a causing factor of anxiety and

depression in transgender youth (Strange et al., 2022).

Some children are so mature and informed they can make their own decisions on the

topics. While this is often encouraged there is no universal line for when one should make their

own medical decisions. While some kids of the same age may be at the same level of decision

making as others, other children may be at higher or lower levels. Age context and development

all play a role in decision making. During development of the brain nothing moves at the same

time or pace. “The amygdala, responsible for emotion processing and input in the reward system,

starts to mature in late childhood and stabilizes at mid- to late adolescence. However, the

prefrontal cortex (PFC) starts to mature in early adolescence and it is not until young adulthood

that this area is mature. (Grootens-Weigers et al., 2017)” Because of this the PFC changes slowly

even into adulthood, while changes to the reward system are made during adolescence. This

inconsistency in development explains the risky decisions often seen by adolescence. Another

factor to include is the fact that decision making is significantly impaired when around peers as

compared to when alone. All this points to reason that youth and adolescence can make their

own healthcare decisions as long as they are competent and rational enough.

While many transgender surgeries have been done, there is an unknown amount that may

feel regret after the surgery. There was a comprehensive study of 27 studies performed on
 7

roughly 8000 transgender participants who received gender affirming surgeries. The study

revealed that less than 1% of participants felt regret after receiving gender affirming surgeries.

Transgender surgeries mean to affirm ones physical appearance with their gender identity and

help tackle gender dysphoria. These surgeries have shown significant increases in the patient’s

self-esteem and body image and satisfaction. It is thought that the number for regret is lower than

theorized due to increases in technology and nursing practice standards of care.

The use of gender affirming surgeries and therapies brings forth an inherent problem,

how can a child legally and safely make their own informed decision on a life changing surgery

at such a young age? In my mind there are 2 ways to go, both leading down paths the other side

doesn’t want to go. 1) Banning transgender surgeries for all under the age of 18 which would

bring an uproar from the transgender community. 2) Legalizing and allowing transgender

surgeries on children under the age of 18. If 1 then a huge uproar from the Trans community

would ignite a nationwide movement in the LGBTQ+ community. If 2 then gender affirming

surgeries will be allowed for patients before puberty and there would be a large uproar from

parents across the country that are against gender affirming surgeries labeling them as child

mutilation. Consequentialism would look at this topic based on the viewpoint of the patient of

the surgery being the good outcome or consequence or causing the greatest amount good or

happiness for people. Kantism would look at this situation from a negative light, like mutilation

of children is evil and should never be done. An ethical principle involved in this would be

autonomy. The right of the patient to make their own decisions. But them the problem becomes

how does one determine if the child is competent enough to make their own decisions. Another

ethical principle used was beneficence, as the need to do good, to help these children who are

struggling with gender dysmorphia become more comfortable in their own bodies. The last one
 8

dealt with would be nonmaleficence, or do no harm. This one really comes to point for those in

the medical field against gender affirming surgeries. Many may feel these surgeries as wrong or

child mutilation.

Really if you ask me, there’s no good way to go about this topic. It doesn’t matter which

direction you move either way you’re stepping on someone’s toes and causing an uproar. Each

step in each direction is a slippery slope. Until there is a concrete line in the sand I suggest nurses

do what they can within their moral beliefs to help the children in any way they can. Personally I

am not for gender affirming surgeries I think it is mostly a mental illness. That doesn’t change

the fact that it is a growing problem across the US and there will be many transgender patients.

Doing the best one can to understand their patient’s situation and try to empathize with them can

go a long way for client care. Understanding the barriers and struggles they have had to cross to

get to this point can provide some powerful insight for nurses and everyone else involved.
 9

References

Centers for Disease Control and Prevention. (2022, September 14). Transgender persons.
Centers for Disease Control and Prevention. Retrieved November 14, 2022, from
https://www.cdc.gov/lgbthealth/transgender.htm#:~:text=Transgender%20is%20an
%20umbrella%20term,with%20which%20a%20person%20identifies.

Dawson, L., Kates, J., & Musumeci, M. B. (2022, June 1). Youth access to gender affirming
care: The federal and state policy landscape. KFF. Retrieved November 14, 2022, from
https://www.kff.org/other/issue-brief/youth-access-to-gender-affirming-care-the-federal-
and-state-policy-landscape/

Abreu, R. L., Sostre, J. P., Gonzalez, K. A., Lockett, G. M., Matsuno, E., & Mosley, D. V.
(2022). Impact of gender-affirming care bans on transgender and gender diverse youth:
Parental figures’ perspective. Journal of Family Psychology : JFP : Journal of the
Division of Family Psychology of the American Psychological Association (Division 43),
36(5), 643–652. https://doi-org.ezproxy.umary.edu/10.1037/fam0000987
Hunt, Q. A., Morrow, Q. J., & McGuire, J. K. (2020). Experiences of Suicide in Transgender
Youth: A Qualitative, Community-Based Study. Archives of Suicide Research, 24, S340–
S355. https://doi-org.ezproxy.umary.edu/10.1080/13811118.2019.1610677

Strang, J. F., Chen, D., Nelson, E., Leibowitz, S. F., Nahata, L., Anthony, L. G., Song, A.,
Grannis, C., Graham, E., Henise, S., Vilain, E., Sadikova, E., Freeman, A., Pugliese, C.,
Khawaja, A., Maisashvili, T., Mancilla, M., & Kenworthy, L. (2022). Transgender Youth
Executive Functioning: Relationships with Anxiety Symptoms, Autism Spectrum
Disorder, and Gender-Affirming Medical Treatment Status. Child Psychiatry & Human
Development, 53(6), 1252–1265. https://doi-org.ezproxy.umary.edu/10.1007/s10578-
021-01195-6
Grootens-Wiegers P, Hein IM, van den Broek JM, de Vries MC. Medical decision-making in
children and adolescents: developmental and neuroscientific aspects. BMC Pediatr. 2017
May 8;17(1):120. doi: 10.1186/s12887-017-0869-x. PMID: 28482854; PMCID:
PMC5422908.
Harris RM, Kolaitis IN, Frader JE. Ethical issues involving fertility preservation for transgender
youth. J Assist Reprod Genet. 2020 Oct;37(10):2453-2462. doi: 10.1007/s10815-020-
01873-9. Epub 2020 Aug 11. PMID: 32780317; PMCID: PMC7550448.

Health care. National Center for Transgender Equality. (2021, October). Retrieved November
15, 2022, from https://transequality.org/know-your-rights/health-care