The last decade has seen a substantial shift regarding psychological and medical approaches to children and adolescents seeking care for gender dysphoria. Gender identity is now recognized as existing along a spectrum rather then as dichotomous male-female categories.1 The number of gender identity clinics in academic pediatric medical centers has increased dramatically over the last decade.2 The nuances around decision-making regarding interventions for children at various ages and stages of development are still controversial. The World Professional Association for Transgender Health standards of care, now in their seventh edition, guide treatment around the world. Still, there are plenty of unknowns that lead clinicians and multidisciplinary teams to individualize their decisions and their approaches to adolescents and families.3 The standards of care and the ways that they are operationalized in the steadily growing number of clinics has raised awareness of 2 fundamental truths: Every person has a gender identity. Gender identity may or may not match a person’s sexual anatomy.

Clinicians who manage children and adolescents with diverse gender identities face questions about the timing of interventions. One big question has to do with choices about surgery in adolescence. The article by Boskey et al4 in this issue describes the creation of a transgender surgery clinic within a children’s hospital. This groundbreaking project will move the field forward and help other centers that care for this group of patients. Boskey et al4 describe some of the complex challenges that they faced in establishing their clinic for transgender surgery.

The establishment of a surgical program for transgender minors raises ethical questions that focus on the risks and benefits of the procedures. There are the risks of the surgery itself. There are also risks that an adolescent will change their mind and regret the decision to undergo an irreversible surgical procedure. There are risks of causing suffering and long-term psychological harms by delaying the procedures. There are benefits of correcting mind-body incongruence earlier in life, thereby giving the adolescent a chance to psychologically feel more whole at a younger age.

Decisions in such cases must necessarily be individualized. For some people, it might be better to wait before undergoing surgery. For others, waiting will be detrimental. Still, individualized treatment decisions are difficult to make fairly and competently in practice. Boskey et al4 acknowledge that the assessments by health professionals that are necessary to individualize decisions have historically been perceived by some as barriers to appropriate and sometimes even life-saving treatment. Health professionals are seen as gatekeepers, approving treatment of some and denying it to others. Such assessments and decisions accentuate the power imbalance that is inherent in the doctor-patient relationship. That power imbalance seems especially problematic when there are well-documented variations in the assessment protocols used by the various gender identity clinics. Some are more permissive, others more restrictive.5 Data from the clinic described by Boskey et al4 and by other clinics doing similar work should describe the complex details regarding individualized decision-making regarding youth who seek surgery and should lead to more consistent standards.

A challenge for everyone working in this field is that there is a lack of good evidence regarding the long-term psychological and physical outcomes for minors who undergo surgical procedures that address gender dysphoria. We lack data on surgical outcomes, psychological outcomes, and the connection between the 2. We lack validated psychological instruments that take into account the dimensionality of gender identity. Studies would need to measure different types of risks: the risk of regretting doing the procedure, the risk of harm from delaying the procedure, and the risk of complications from the procedure. Teenagers want to live normal teenaged lives, to go on dates and have romantic relationships, and to feel comfortable in their own bodies. Doctors and parents want that for them but may also have a more clear-eyed view of the implications of some procedures for future fertility and reproductive decisions. Standards of care reflect expert consensus more than they reflect rigorous outcome data. Furthermore, this is a field in which prospective randomized trials are ethically impossible to do because they would involve denying control patients access to procedures that are now considered standard of care. Additionally, there are many different procedures: chest reconstruction is different from genital reconstruction, and so perhaps decision-making may change depending on the procedure itself.

As long as youth seek gender-affirmative surgical services, and as long as surgeons provide them, the question of where the surgery should take place will always come up. Considering the complexity involved, academic pediatric centers have the multiple layers of perspectives inherent within multidisciplinary teams in place to ensure that all youth, transgender or not, receive the appropriate, compassionate, and ethical care that they deserve for their emotional and physical well-being.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-3053.

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.