Psychiatric ethical issues of transgender people

Introduction

At present, assistance to transgender people in the Russian Federation is considered to be difficult due to the lack of clear legal provisions regarding the gender reassignment procedure; therefore, universal human ethical provisions and professional (psychiatric) ethical principles come to the fore and are of decisive importance. The requirements for the provision of medical care and the expectations of society in the modern world require the use of universal ethical principles, on the basis of which moral standards of behavior for a doctor of any specialty are developed [1][2].

With regard to transgender patients, medical specialists, including psychiatrists and clinical psychologists, are often not ready to accept (and, accordingly, use) ethical principles during treatment, since the latter are complex and ambiguous in relation to application to such patients or clients (the latter – in the absence of formal mental disorders).

What ethical issues are currently observed in the provision of care to transgender patients? This study considers the main ethical problems from the point of view of the basic, “classical” ethical principles of bioethics described more than 40 years ago by Beauchamp and Childress [2].

First of all, it should be noted that in the modern world, it is not only widely discussed, but the opinion is already accepted that “transsexuals, transgender or gender nonconforming people cannot be considered sick”, “expression of gender identity that does not correspond to sex at birth is common and culturally diverse and should not be viewed as pathological or inherently negative” [3]. In this regard, the question arises as to whether transgender identity should be considered a nosological unit and displayed in diagnostic and statistical manuals. Some experts propose not to consider transgender identity as a mental illness and exclude it from the ICD and DSM [1][4], which will put an end to the permissive role of a psychiatrist in matters of gender reassignment [1]. This opinion is substantiated by the fact that in order to allow a psychiatrist to give permission for endocrinological and surgical intervention, a transgender patient needs in one way or another to “pretend to be mentally ill”, to broadcast the corresponding transgender signs and complaints, although in fact the subject may feel his/her experiences differently and could describe it in words that do not meet the expectations of the psychiatrist [1][5].

Other experts, on the contrary, claim that the removal of transgender identity from diagnostic headings threatens to turn assistance to transsexuals into something “similar to the model of assistance in cosmetic surgery” [1].

The World Psychiatric Association considers sexual orientation to be innate and determined by biological, psychological, and social factors, and that psychiatrists have a social responsibility and should advocate for overcoming social inequalities in relation to each individual, including inequalities that extend to gender identity and sexual orientation [3].

Despite the regrettable tradition of stigmatization and discrimination, decades have passed before modern medicine abandoned the understanding of same-sex orientation and behavior as a pathology and the World Health Organization accepted same-sex orientation as a variant of the norm of human sexual orientation. The authors hope that this will also happen to transgender people¹.

Today, the United Nations Human Rights Council pays great attention to the rights of lesbian, gay, bisexual and transgender people (LGBT), and in the two main diagnostic and classification systems (ICD-10 and DSM-5), same-sex orientation, attraction, and behavior are not considered pathological as there is a significant amount of research showing that sexual behavior and sexual variability depend on multiple factors¹. In addition, it has been convincingly demonstrated that there are higher than expected rates of mental disorders among LGBT people, but once their rights and equality are recognized, these rates begin to decline¹, which once again raises the question of excluding the diagnosis of transgender identity from the diagnostic headings.

Ethical principles in the provision of mental health care to transgender people

In the Russian Federation, there is currently an unresolved ethical conflict: in many psychiatric institutions, “prohibitive tactics” prevail which allow psychiatrists to issue permission for gender reassignment only to “true” transsexuals, and open dissatisfaction is expressed with the exclusion of the diagnosis of transsexualism from the list of mental illnesses and its return into the modified national classification [4][6][7][8]; in a large number of clinics, there is an absolutely opposite liberal attitude toward the issuance of formal legal permits for gender reassignment to almost all who apply for this problem.

The authors of this study consider extremes as unacceptable ones, although it should be mentioned that the prohibitive tactics, despite their aggressiveness, still imply the possibility of a subsequent correction in case of the patient's erroneous opinion; in cases of liberal tactics, consequences can sometimes arise that will be difficult to correct due to irreversible changes in the body, as well as possible irreversible consequences for harm to the mental health of the patient. The latter statement is not absolute, as modern society is increasingly accepting the possibility of repeated transgender transitions and repeated surgeries due to the achievements of modern medicine.

Attention should be also drawn to the opinion of foreign authors, which is reflected in the standards of medical care for transgender people [3] and fully coincides with the position of bioethics: decisions of transgender patients regarding medical interventions should always be “first of all, the decisions of the clients” [1][3], and mental health professionals (including psychiatrists) “should be there to guide clients and help them make informed decisions and be fully prepared” for appropriate [gender transition] interventions [1][9].

The principle of patient autonomy being the beginning and basis of bioethics implies the patient's freedom of choice and, accordingly, the patient's responsibility for his/her choice [2]. The choice will be autonomous if the patient acts in accordance with his/her own intentions and plan, understands his/her actions, and makes his/her choice without external influences [2].

This principle means that a doctor cannot have unconditional and exclusive competence in determining the patient's welfare [1][2]. However, with regard to transgender patients, the opposite situation is observed: it is the psychiatrist who determines whether endocrinological therapy and surgical intervention are necessary for a transgender patient. The patient's opinion remains on the sidelines; the patient in this case loses his/her autonomy and freedom of choice [1][9].

The principle of autonomy implies not only recognition, but above all respect for the autonomy of the patient [1][2] – respect by the psychiatrist for the choice of the patient, no matter how this choice differs from the doctor's position; it is the choice of the patient that should determine the further actions of the psychiatrist [1][9].

Respect for the autonomy of the patient is based on Kant's philosophy that each person is an unconditional value and is able to determine his/her own destiny: “Each person is an end in itself and in no case should be considered as a means for the implementation of any tasks, even if they were tasks of the common good”, “The good of an individual is not just proportionate, but even more significant than the good of all mankind” [2].

The principle of respect for autonomy is very often violated when treating transgender patients as the psychiatrist might show a carefully hidden, but tangible attitude toward the transgender patients even being without mental disorders as to the patients with an abnormal, not completely full-fledged personality (similar to the attitude in case of homosexual orientation) and a priori mentally ill, unable to independently make the right choice and independently determine their fate, which affects the resolution of the issue of gender reassignment.

In addition, at present, in order to have gender reassignment surgery, a transgender patient must undergo the full range of psychological and mental examinations, accept the classification of mental disorders, accept that his/her experiences are a mental disorder, i.e., practically recognize him/herself as mentally ill [1][9]. Can a consultation with a psychiatrist and “labeling as the mentally ill person” [1][9] be ethical with regard to a transgender client in this perspective? Will this be respect for the patient’s autonomy?

However, the question also arises of whether, from the point of view of morality and philosophy, it is normative, subject to the recognition of any inconsistency as a norm, to provide the patient with a decision on what to do with his/her gender without taking into account the opinion of the psychiatrist [1]. Another question concerns the appointment algorithm and selection criteria – to whom, when, and how to perform medical services for gender reassignment. Given the decision to be made solely by the patient, would the mechanism of gender dysphoria treatment be not similar to medical interventions in cosmetic surgery, or similar to vasectomy and tubal ligation, where each client decides which procedure and when to perform [1]?

Since the main ethical principles of providing medical care are “nonmaleficence, beneficence, justice and respect for the autonomy of the patient” [1], consultation by a psychiatrist in order to resolve the issue of gender reassignment and elevating transgender people to the rank of mentally ill [9] deprives the latter of autonomy and, consequently, free will in decision-making and grossly violates the moral and ethical principles of medical care. At the same time, the patient, having received a psychiatrist's refusal to issue a “permissive certificate”, does not receive any psychological support in this difficult, sometimes catastrophic situation for him/her, which is an acute ethical problem that has not yet been resolved today.

The very algorithm for providing care to transgender patients is currently categorically violating the patient's ability to make decisions independently, even if the patient is mentally healthy or has a borderline mental disorder parallel to transgender – gender reassignment is impossible without the permission of a psychiatrist.

Most bioethicists consider that the decision on hormone therapy and surgery should be made jointly by patients and their doctors (including psychiatrists) based on the most thorough consultations and strict procedures for signing informed consent, i.e., professional medical assistance should be used in matters of gender reassignment decisions in the same way as it is applied to any other interventions desired by the patient, thus striving for equality between people with different sexes and transgender people who seek medical help [1, 9]. This approach, according to the authors of this study, most fully corresponds to the ethical criterion of the patient's autonomy, the right to freedom of choice and responsibility for it.

In the Russian psychiatric community today, there are two polar points of view of practicing psychiatrists involved in helping people with gender dysphoria: on the one hand, some psychiatrists insist on the complete depathologization of transgenderism, including transsexualism [10], on the other hand, another part of psychiatrists insists on the fact that the very desire to reassign sex is a manifestation of psychopathology (“abnormality”)² [4][6][10], and believes that only with “true transsexualism” according to Benjamin and Bukhanovsky [11][12] there are direct indications for gender reassignment as the only way to rehabilitate people with a congenital general organism anomaly (which was previously designated as a psychiatric diagnosis of “transsexualism”).

In fact, one is witnessing a clash of two ethical positions in psychiatry: the first is associated with the right of individual freedom in the modern world, the right of freedom to make any decisions regarding changes in one's appearance, sexual orientation, gender, and even voluntary departure from life (either in the form of a true suicide, or in the form of suicide through euthanasia); the opposite ethical point of view refers to the responsibility of society, the state, and medicine (in particular, clinical psychiatry and psychiatrists) for the fate of people who want to radically change their appearance, sexual orientation, and gender identity.

At present, considering the predominance of conservative moral and ethical attitudes in Russia, it seems unlikely that legislative provisions will be adopted regarding, for example, the permission of euthanasia or completely free, uncontrolled medicine, in particular psychiatry, addressing the issue of gender reassignment or, moreover, the introduction of “multi-sex orientation” up to the denial of sex in general.

The authors of this study admit that it is necessary to rely, first of all, on the interests of the patient, and the truth lies in the middle between these points of view: a compromise solution is needed that rejects both absolute permissiveness and absolute medicalized control by psychiatry.

According to the authors of this study, neither legally nor ethically adequate solution to the problems in the psychiatry-transgender dilemma is possible today; it is necessary to search for and adopt a compromise “intermediate” solution, which also takes into account the patient's opinion, the right to autonomy, independence in making a decision about reassigning sex, and including the patient's responsibility for the choice.

The following algorithm is proposed: people seeking to reassign their gender should be consulted by psychiatrists, psychologists, and sexologists to obtain an opinion on the state of their mental health in the following triad: “mentally healthy”, “there are any borderline mental disorders”, or “psychological disorders of the psychotic level are revealed”.

In the first case, the participation of a psychiatrist is further excluded and the decision to reassign gender is the patient's complete prerogative. In the third case, psychiatrists should block the patient's decision to reassign gender until the patient leaves the psychotic state (which implies procedural incapacity) and returns (or does not return) to considering the issue of his/her transgender transition, if the patient's request for gender reassignment will be still valid by then. In this case, in relation to patients with transgender identity combined with a severe mental disorder of a psychotic level, the principle of autonomy cannot be applied, since patients are actually incompetent and cannot make decisions autonomously. The refusal of the psychiatrist to reassign gender in this case will be a means of protecting the patient from possible harm that he/she can do to him/herself, and this refusal will be justified in this situation by the principle of beneficence.

The main ethical problem, according to the authors of the study, concerns the second case, which includes the most common contingent – patients with borderline mental disorders. The essence of the problem lies in the fact that the patient has a conflict about the decision to reassign gender not only with the micro- and macrosocial environment but also with the psychiatric service, which prevents the implementation of the patient’s desire to reassign gender. In this case, the authors, based on the interests of the patient and legal positions, propose to transfer the resolution of the issue of gender reassignment to the competence of the court, providing the latter with the results of specific psychological, psychiatric, and sexological examinations [13]. However, the authors acknowledge that it is currently difficult for the court to consider these contentious cases due to the fact that there are no competitive examinations in the country, and, accordingly, it is extremely difficult to make a court decision without competing independent expert opinions; also, the problem seems to be hardly solvable due to the extremely low professional training in relation to the transgender problem on the part of psychiatrists and clinical psychologists who would conduct such examinations, as well as in connection with the practice of complete lack of knowledge of judges in relation to transgender issues, which again requires obtaining compulsory additional education by lawyers at the stages of undergraduate studies.

The principle of nonmaleficence implies that the actions of a psychiatrist should not harm the patient through failure to provide assistance, malicious intent or negligence, thoughtless, unskilled actions [1][2], immorality, even if they entail something positive. With regard to transgender patients, a complex ethical problem arises when a psychiatrist, based on his/her worldview and moral ideas, considers gender reassignment to be immoral, wrong, contradicting, for example, religious foundations, and classifies transgender identity as something “wrong”, thereby blocking help to transgender patients.

On the one hand, according to this principle, the perceived risk of any medical intervention should not be a means to a good end [1]; therefore, one of the most difficult ethical problems is as follows: if in cases of transgender identity combined with nonpsychotic disorders, permission is given for endocrinological and surgical intervention, irreversible somatic consequences in the patient are subsequently not excluded, which can be extremely significant when reconsidering the decision to reassign sex and in the case of the impossibility for the patient to fully return his/her biological somatic status. On the other hand, if the patient gets a refusal for gender reassignment, there is a risk that the patient with transgender identity will attempt to independently change his/her somatic status (hormone administration, self-injury), which is likely to cause harm. The question of which of the listed options will cause more harm is considered to be extremely controversial.

At present, in the majority of countries, including the most democratized ones and the ones with the most liberal laws such as the United States, it is impossible to obtain a permit for weapons without the so-called formal psychiatric control over the state of mental health [14] (the fact that this control cannot prevent people with subtle mental disorders from obtaining weapons, about which these people themselves, for obvious reasons, do not report to specialists, should be put aside). The answer to the question of why it is not recommended to give permission for the purchase and use of weapons, if necessary, to people with mental disabilities, is clear: in certain situations, these people can be dangerous to others and dangerous to themselves. Moreover, it is clear to everyone that the latter is much less of a concern for modern society – the “right to commit suicide” is the choice of the individual [15]. How dangerous, by analogy, is an uncontrolled transgender transition without psychiatric control? First of all, hormonal (and especially surgical) intervention can lead to irreversible consequences strongly deteriorating health; second, the fact (which is so disliked by the supporters of complete liberalization) that there are cases of not only social decompensation but also suicides of people who have experienced transgender transition without prior typification of their mental state, should be mentioned [16][17].

 Hence, consultations with a psychiatrist, and in some cases an examination of a patient by clinical psychologists, are necessary for all people who have declared their desire for a transgender transition, both from an ethical point of view and from a legal one (the same as the need to study the mental state of people who are called up for military service or who want to acquire weapons does not cause any doubts). The main goal in this case is to identify severe mental illnesses at an initial or progressed stage, which, from the point of view of a formal examination, will imply the patient’s procedural incapacity and, accordingly, the inability to make a decision on gender reassignment. However, the major problem concerns not this very small percentage of patients, but other patients who are referred to a numerous continuum of people from formally healthy ones with certain psychological or sexual characteristics to patients with a wide range of various mental disorders (personality anomalies, sexual addictions, and various forms of affective and schizotypal disorders). When these disorders are identified, the task of psychiatrists should be to offer treatment for identified mental illnesses, especially in cases where they significantly affect the desire to reassign gender and biological sex (i.e., change passport data and social status or get hormonal and surgical treatment). When these patients refuse psychiatric treatment, a complex conflict arises due to the fact that in terms of law, such patients can make independent decisions regarding almost all aspects of their lives, including gender reassignment issues. The opinion of psychiatrists protesting against the free decision-making of such “mentally unhealthy people” is justified by the fact that the transgender mindset is always the result of some kind of mental disorder and will automatically disappear after the “successful treatment” of the identified mental illness. Therefore, given this position, it is logical to refuse to issue “permission” for gender reassignment to transgender people, behind which there is a “high moral personal responsibility” for the fate of a patient who has even minor mental disorders, as well as an unspoken, but clearly present fear of responsibility for the fact that in the future, both society and the patient can make claims that not everything possible was done to prevent the patient’s “ill-conceived” decision induced by “a mental disorder”, which can sometimes lead to irreversible consequences for the somatic, and in some cases for mental health.

 However, a formal refusal to issue a certificate for gender reassignment, which is required in Russia if the patient does not accept the identified mental disorder, does not want treatment, will not lead to a comfortable existence for the patient, and the latter will seek a solution to his/her issue in one way or another, either in his/her own country or by emigrating to other countries (by analogy with the period 20–30 years ago, when people with a homosexual orientation left the country to resolve the social conflict and get the possibility of a free and more comfortable life for them). Would this refusal be ethical in this case? Will it ease the suffering of the patient? After all, the ultimate ethical task of medical activity is not only to diagnose, confirm, and offer treatment for a pathology or illness, but, above all, to alleviate the suffering of the patient and improve the quality of life in all possible ways, not only physically but also psychologically, mentally, and morally. Therefore, in such a case, a refusal to provide medical care that does not resolve the patient's problem, from an ethical point of view, will be detrimental.

Also, in accordance with the principle of nonmaleficence, performing an action that may lead to negative consequences requires strong reasons, namely, the good should significantly outweigh the risks or losses [1]. With regard to transgender patients, this is the most important ethical problem: the main objections to resolving the issue of gender reassignment are based on the benefit of resolving the main psychological (more often psycho-psychopathological) conflict, which, according to psychiatrists, does not outweigh the risk of somatic irreversible consequences, but may not be shared by the patient and increase his/her distress [1][9], ruminations, worsen the course of his/her mental disorder (which is observed in combination with transgender identity or may occur as a reaction to the situation) [17].

Despite the irreversible consequences after gender reassignment procedures, the loss of reproductive abilities, research data show that regrets after gender reassignment are quite rare [17][18], but existing standards still focus solely on the risks that are considered “as an excuse” for violating the patient’s right to make autonomous and independent decisions. These experts believe that clients who wish to undergo gender reassignment procedures should undergo only psychotherapeutic sessions that strengthen their gender identity, help and strengthen the patients in their decision [1].

The issue of competence is of great ethical importance. Is it ethical or not when transgender issues are resolved by specialists with minimal knowledge in this area? In this case, the requirement of ethics not to go beyond the boundaries of one's specialty, remaining on the solid ground of scientific knowledge and experience, is impossible to achieve. Herewith, the question arises of the quality of the clinical and psychological assistance provided to transgender patients, since in this case, as a rule, very thorough hours-long clinical-phenomenological, clinical-psychopathological, pathopsychological, and sometimes paraclinical examinations by specialists with a high educational qualification dealing with problems of clinical psychiatry, sexology and sexopathology, as well as clinical (medical) psychology are required. In addition, it is important to make a final decision on the permission to reassign the patient's gender by a council of listed specialists, especially in unclear, controversial, and conflict cases, and not by one professional, regardless of his/her rank and position.

The principle of beneficence

The principle of beneficence is based on the fact that the person being helped is in danger or under threat of serious harm, for the likely prevention of which the psychiatrist can perform certain actions [2].

According to the principle of beneficence, the actions of a psychiatrist should not lead to risks for the patient. In any case, the psychiatrist's prohibitive actions regarding gender reassignment can be interpreted as a danger to the patient and imply a significant risk of suicide, as well as an increase in the patient's distress, aggravation of his/her feelings and mental disorder. However, permissive actions of a psychiatrist can be also considered serious (in some cases irreparable) harm to the somatic health of transgender patients.

For a patient with a transgender identity combined with mental pathology, a real help will be a “health certificate” allowing gender reassignment. In severe mental illness, the actions of the psychiatrist for preventing the threat and damage to the patient will be an unconditional refusal to reassign gender and appropriate treatment of the patient. In borderline mental disorders combined with transgender identity and upon the patient’s refusal to get treatment, the psychiatrist cannot perform real actions to prevent danger or damage to the patient due to existing legal provisions, and also because they will be quite controversial from the standpoint of the ethical principle of beneficence and autonomy. The principle of beneficence states that the benefit that a person receives as a result of the actions of a psychiatrist should outweigh the harm, and the actions performed by the psychiatrist should pose minimal risk and be aimed at ensuring the benefit of the patient, which, even if full recovery is not implied, should at least alleviate the patient’s suffering [2]. In matters of transgender identity, there is an ethical problem of the comparability of the possible hypothetical damage and risk to the patient's health as a result of endocrinological and surgical treatment with a more likely and much more often observed significant improvement in the quality of life of patients after gender reassignment. Who should determine whether gender reassignment is a benefit for a transgender patient – a psychiatrist or a patient [1]? In Russia, medical paternalism dominates, when the doctor relies on his/her own judgments in resolving the issue of the patient's needs, not assuming that they may differ from the patient's judgments regarding this issue. Regarding the issue of gender reassignment, the situation is similar: the value system of a psychiatrist and his/her ideas about the benefit for a transgender patient may categorically diverge from the values of the patient and the patient’s opinion about his/her own benefit.

It should be noted that the principle of beneficence may come into sharp conflict with the principle of benefit for society: for the stability of social life in the conservative society of modern Russia, a liberal attitude toward an increase in the number of people with a non-traditional gender is categorically not welcomed. A conservative-protective society always adheres to the ethical concept of utilitarianism, in which the criterion for evaluating human actions is utility, and the only goal of moral activity is to achieve the greatest amount of happiness for the greatest number of people [19]. The emergence of an increasing number of transgender people, and even those with psychiatric disorders, is categorically unacceptable for society in light of this concept. Psychiatry is aimed at performing a dual function – protecting the interests of the patient and protecting the interests of society [20]. The inconsistency of this function follows from the possible discrepancy between personal and public interests in relation to transgender identity, since the interests of transgender patients are contrary to public interests; at the same time, society damages the interests of transgender patients. What should be the central position? Individual-personal or cultural tradition and society? The ethics of utilitarianism, according to which the criterion for evaluating human actions is utility, and the only goal of moral activity is to achieve the greatest amount of happiness for the greatest number of people, or deontological ethics, according to which the basis of moral life is duty, the fulfillment of which is associated with an internal command (morality is beyond any expediency and does not serve to satisfy human needs)?⁸ The authors of this study consider that rampant reformatism (“everything is allowed if it does not affect the interests of other people”) and archaic conservatism (“everything new is pathological”) are equally unacceptable in ethical terms and the legal field for solving the problem of transgender identity in the present historical “transitional” period of the contemporary “postmodern” civilization (especially in the modern Russian Federation) and a compromise should be reached, as well as the notorious “golden mean” should be found.

Conclusion

Any assistance to any patients with any diseases, disorders, and even without them in the modern world is provided from the standpoint of bioethics [2]. Transgender patients are the most vulnerable category seeking medical help from psychiatrists; often their problems are stigmatized and misunderstood even by experts. It is this category of patients, like no other, that should be provided with medical care strictly based on ethical principles solely for the benefit of patients. However, the use of an ethical approach when treating transgender patients at the present time and in the present situation still leaves more questions than answers.