So You Want to be a Doctor: A Complex Hypothetical Case Study

As we have emphasized throughout our coursework this semester, the ethical world of medicine is rarely entirely black and white, and if you aspire to be a healthcare professional, it is a virtual certainty that you are going to be faced with these difficult ethical decisions throughout your career. As a preparation for this, it is helpful to be presented with hypothetical scenarios in an attempt to rationally determine the most ethical course of action. Here I will present one such (very) complicated ethical scenario regarding transgender healthcare.

Before I dive into the scenario itself, some background knowledge and physiology are required. Transgender individuals suffer from what is known as gender dysphoria, a conflict between the individual's physical or assigned gender and the gender with which he/she/they identify (Unger, 2016). This dysphoria can lead to severe depression and suicidal ideations, and the suicide attempt rate of transgender individuals is as high as 32-50%, a staggering number (Virupaksha, 2016). For some physiology background, transgender men often undergo hormone replacement therapy through the administration of testosterone. One known side effect of testosterone is erythropoiesis, or the production of red blood cells (Coviello, 2007). This production results in an increased hematocrit level when measured in the laboratory, as there are literally more red blood cells in circulation. If the hematocrit gets too high, this can obviously be a problem, as you can imagine that too many cells will literally make the blood "thick" and blood flow will be restricted as a result. This can cause a myriad of problems if left untreated, so this level is often monitored for patients undergoing hormone replacement therapy with testosterone.

With all of this background, finally the hypothetical scenario: A transgender man with severe gender dysphoria enters your clinic for a follow up appointment with you. He has been on ongoing testosterone therapy and his latest labs reveal that his testosterone and hematocrit levels are above the desired normal range. You explain the results to the patient and at this point he admits to you that he has been using more than the prescribed dose of testosterone. You strongly counsel him against this and state that you wish to lower his testosterone dose to bring the levels back down to the desired range, but he becomes very upset at this point. He states that if he lowers his dose, he will suffer extreme dysphoria which has caused suicidal ideations in the past. He admits to you that he has previously experienced suicidal ideations and feels that there is no way that he can lower the dose and insists that he has tried before. As his provider, you know that increased testosterone and hematocrit levels carry significant health risks, but the severe gender dysphoria carries risks of its own such as severe depression and possibly suicide. From an ethical standpoint and weighing the beneficence, non-maleficence, autonomy, and justice, what do you do as this patient's provider?

References

Unger, Cecile. (2016). Hormone therapy for transgender patients. Translational andrology and urology, 5(6), 877-884.

Virupaksha, H. G., Muralidhar, D., & Ramakrishna, J. (2016). Suicide and Suicidal Behavior among Transgender Persons. Indian journal of psychological medicine, 38(6), 505-509.

Coviello, A. D., Kaplan, B., Lakshman, K. M., Chen, T., Singh, A. B., & Bhasin, S. (2007). Effects of graded doses of testosterone on erythropoiesis in healthy young and older men. The Journal of clinical endocrinology and metabolism, 93(3), 914-9.