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 as a ‘whole person in context’ 2 prior to initiating treatment or care. In this way, they advocate for a process of ‘therapeutic exploration’,4 which includes taking sufficient time to explore Phoenix’s personhood with them so as to support them in achieving an ‘authentic self-discovery’.2 We agree with these authors that 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, D’Angelo,2 Lemma3 and Wren4 describe a comprehensive psychological approach to working with transgender and gender diverse 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 …. (shrink)

We applaud Notini and colleagues for highlighting the clinical and ethical complexities of a case in which a non-binary individual desires indefinite treatment with puberty blockers.1 While we agree discontinuing treatment may cause psychological distress, we believe there are potential physical and neurocognitive harms caused by prolonged treatment that have been underestimated given the limited research conducted to date. Specifically, the impact of permanent pubertal suppression on the brain and decision-making capacity should be considered. In this context, we outline the (...) potential risks of ongoing pubertal suppression on bone and cardiovascular health, sexual and reproductive function, and brain development—all noted in the article but perhaps in an overly simplistic manner.1 First, the authors’ note OPS will almost certainly result in reduced bone density.1 Although we agree the absolute fracture risk is low in studies among older adults, there is less clarity about implications during adolescence and young adulthood when peak bone accrual occurs.2 Further, the authors propose ongoing monitoring with bone density scans, but no clear guidelines for clinicians if bone density becomes critically low—so we ask, at what point would a potential fracture risk outweigh the proposed benefits …. (shrink)

We applaud Notini and colleagues for highlighting the clinical and ethical complexities of a case in which a non-binary individual desires indefinite treatment with puberty blockers. 1 While we agree discontinuing treatment may cause psychological distress, we believe there are potential physical and neurocognitive harms caused by prolonged treatment that have been underestimated given the limited research conducted to date. Specifically, the impact of permanent pubertal suppression on the brain and decision-making capacity should be considered. In this context, we outline (...) the potential risks of ongoing pubertal suppression on bone and cardiovascular health, sexual and reproductive function, and brain development—all noted in the article but perhaps in an overly simplistic manner. 1 First, the authors’ note OPS will almost certainly result in reduced bone density. 1 Although we agree the absolute fracture risk is low in studies among older adults, there is less clarity about... (shrink)

Notini et al 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD young people for whom, all things considered, medical interventions to affirm gender identity promote their well-being. Well-being has become an important conceptual currency in ethical debates and lies at the core of the authors’ analysis of Phoenix’s case. While the authors do not ground their argument in favour of OPS in a specific theory of well-being, welfarist considerations 2 appear to underpin …. (shrink)

Notini _et al_ 1 offer a timely addition in the wake of a significant increase in young people identifying as transgender and gender diverse. The authors focus specifically on the case of 18-year-old Phoenix’s request for ongoing puberty suppression to affirm a non-binary gender identity. A central issue raised by Phoenix’s predicament, and that I suggest we can extend to ethical consideration of requests for other types of medical intervention by binary and non-binary TGD individuals, is whether we should ‘affirm’ (...) the claims made by TGD young people about what promotes their well-being. As a clinician working with TGD young people who have undergone a range of medical interventions to align their bodies with their gender identity, my starting presumption is that it is important to respect what people think will help them: there are some TGD... (shrink)

This paper explores an emerging sub-field of both empirical bioethics and experimental philosophy, which has been called “experimental philosophical bioethics” (bioxphi). As an empirical discipline, bioxphi adopts the methods of experimental moral psychology and cognitive science; it does so to make sense of the eliciting factors and underlying cognitive processes that shape people’s moral judgments, particularly about real-world matters of bioethical concern. Yet, as a normative discipline situated within the broader field of bioethics, it also aims to contribute to substantive (...) ethical questions about what should be done in a given context. What are some of the ways in which this aim has been pursued? In this paper, we employ a case study approach to examine and critically evaluate four strategies from the recent literature by which scholars in bioxphi have leveraged empirical data in the service of normative arguments. (shrink)

"Some patients find it difficult to be in the present because they are stuck in the past; others, by contrast, struggle to remain connected with the past and are suspended in a so-called present that is effectively atemporal, that is out of time”.1 For psychoanalysts, the most profound and ultimately ethical way that we can help individuals, is by helping them know themselves. This involves discovering how they were shaped by their past and how their ongoing self-experience cannot be understood (...) in isolation from its constitutive contexts. Psychoanalysts help patients explore foundational questions such as: ‘Who am I?’ ‘How did I get here?’ ‘How am I implicated in my own suffering?’ ‘How can I grow and flourish and truly engage with my life?’. The answers to these questions emerge from a detailed exploration of the persons lived relational history, their current social and relational context and the political systems within which they are embedded. It is via this expansion of self-awareness that individuals can access agency and true freedom of choice. The clinical approach presented by Notini et al 2 is grounded in a completely different, radically decontextualised understanding of human experience. Their conceptualisation of Phoenix’s gender identity is ahistorical and atemporal: it is indeed ‘out of time’. For these authors, gender identity is assumed to be an immutable core essence, much like Ehrensaft’s3 ‘true gender self….there from birth’. It simply ‘is’. This is a …. (shrink)