What is are the ethical issues/dilemma presented in the story? If more than one, which one would take priority? What are the facts that support the decision making process related to the chosen ethical dilemma, including objective and subjective facts, who are the moral agents, what values impact decision making for each moral agent, what are some external forces (social, legal, community, religion, scientific evidence based treatments etc).

lReflection Paper #2 Write a short paper reflecting on the following questions related to the case study below. You may need to bring in additional resources to effectively address the case study:1. What is are the ethical issues/dilemma presented in the story? If more than one, which one would take priority? What are the facts that support the decision making process related to the chosen ethical dilemma, including objective and subjective facts, who are the moral agents, what values impact decision making for each moral agent, what are some external forces (social, legal, community, religion, scientific evidence based treatments etc).2. What ethical principles and theories apply to this situation? Define and then give specific examples of how the principles/theory apply to the case and how these may aid in ethical decision making by the moral agents.3. As a healthcare provider, how might you address the ethical issue? What are some of the possible solutions to the ethical issue?4. What is your personal reflection related to the ethical issues?Remember to use APA format including double spacing, citing your sources of information with intext citations and include a reference list ). Please do not submit in .pages formatBelow is a case study for this discussion.Children represent a small number of individuals with gender dysphoria and in only 10-20% of the children, gender dysphoria will continue to manifest in adolescence [5]. However, psychological therapy and support are highly recommended; while such services are now far more widely available, they are still insufficient to provide for complete wellbeing of these patients. Inadequate management of children with persistent gender dysphoria can lead to isolation, feeling of self-hatred, and suicidal ideas and attempts. Also, “passing through the wrong puberty” can have serious consequences for these individuals. Viable treatment options vary from fully reversible treatment, such as puberty-suppressing gonadotropin-releasing hormone analogues (GnRH) to partly reversible treatment, gonadal steroid treatment, as well as irreversible treatment, such as surgical removal of genitalia and reconstruction of new ones according to the desired gender. Surgery includes bilateral mastectomy with chest reconstruction, hysterectomy with oophorectomy followed by either metoidioplasty or phalloplasty for trans-male individuals, and bilateral orchiectomy with penectomy followed by vulvoplasty and vaginoplasty in trans-female individuals [6].Pubertal suppression is implemented using GnRH analogues at Tanner 2 or 3 stage of puberty. Hypothalamus produces GnRH at low levels in prepubertal children. Levels become cyclical during puberty, leading to the production of luteinizing hormone (LH) and follicle stimulating hormone (FSH) by the anterior pituitary. LH and FSH stimulate ovaries and testicles to produce sex hormones, estrogen and testosterone, which are responsible for stimulating the growth of genitalia. Also, they lead to the development of breasts, voice deepening, menstrual cycle, and so forth, which transgender youth can find particularly tough to handle [7].There are only a few reports related to the use of GnRH analogues in transgender youth. De Vries et al. were the first to introduce the concept and research on the use of puberty blockers for treatment of transgender youth. The main idea behind the suppression of endogenous puberty was to decrease distress by preventing the development of “noncongruent” secondary sexual characteristics. This would give young individuals more time to get accustomed to their situation and to better explore their gender. In the examined group, all of 70 eligible candidates showed improved mental health and general functioning. Authors concluded that the treatment was fully reversible, which was one of its main advantages [8]. Despite the positive outcomes in puberty suppression, many experts still have concerns and resist the implementation of this treatment in their regular practice. Viner et al. proposed that GnRH therapy can be physically damaging for teenagers and can lead to unfavorable psychological consequences [9]. Olson-Kennedy et al. also recognized these dilemmas, stating that available data on puberty suppression was limited and many questions remained unanswered [10]. One of the main reasons against this treatment is that going through puberty may help the individual to become congruent with their biological sex, meaning that their GD would not persist into adolescence. Results from Steensma et al. showed that majority of children developed homosexual orientation after completion of the GnRH treatment [11]. As for potential consequences, Hembree recently reported no long-term consequences in follow-up studies of GnRH treatment [12].Finally, the decision about implementing GnRH treatment is very difficult and cannot be made without ethical dilemmas. Both opponents and advocates of pubertal suppression are guided by the same ethical principles, beneficence, nonmaleficence, and autonomy, but have different views on where these principles lead. A unique and clear overview is necessary, and, to this day, it has not yet been elaborated. Considering that GnRH treatment is relatively new and controversial, additional qualitative research and empirical studies are necessary for appropriate bioethical definitions.Bizic, M., Jeftovic, M, & Pusica, S. (2018). Gender dysphoria: Bioethical aspects of medical treatment. BioMed Research International 2018

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