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After Juan Carlos made the decision to leave, everything happened quickly. One day She called me to say that her flight already had a date. She asked me if I could please go to the airport with her because her parents did not speak to her.

She told me that she was going to live in Italy and that while all his papers were legalized she would work as a waiter. She said that she was afraid to start over but that it was the least of it when she could live the way she wanted.

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Months had passed since Juan Carlos started his process with HIV. I had seen how psychological therapy has helped him and one day He called me and said: " Paula! I am ready for the next step, I want to live a life being myself". I heard him happy and invited him to a coffee to explain to me what was happening.

At the coffee he arrived with a big smile on his face then he started telling me what will be his next step.

JC: "Paula I am ready for the next step. I have been working that hard with my psychologist and now I am ready to accept and share I am Transgender. I was born as a man but all my life I have felt myself as a woman. I am ready to express myself in the way I like to be "

P: I am really happy to hear about your decision. I know it would be a difficult way but anything you need I am here"

JC: Tomorrow I will talk with my parents, I hope they understand. I know it would be difficult for them but I can not continue hiding myself.

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Pediatric ethics can be difficult and I remember one of those difficult moments when you faced it. One day with Juan Carlos at the hospital, a child arrived in a life-threatening situation. He had been in a car accident, he had lost a lot of blood and his leg was destroyed (It would not be viable to make a reconstruction). His situation was difficult, his vital signs were low, and he was losing too much blood because of his destroyed leg. The surgeon examined the patient's leg and he said it will be impossible to repair it. The best next step at that moment was to amputate his leg and continue blood transfusions. Juan Carlos ran to see the parents but he just found the patient's grandmother. She explained the parents were on a cruise and they didn't have a way of communicating. I got there and started informing the child situation, after all, I explained that we will need to amputate his leg that's why we need his parent's consent.  When I realized there were not there I understood we will have to do it without informed consent because it was a life-threatening situation.

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After the notice, I saw how Juan Carlos went through different stages in his process of accepting this new.

Next day after the notice Juan Carlos came to my consult telling me he could not have HIV.

- JC: "Everything is a mistake, this hospital doesn't have good laboratories"
- P: I understand it is difficult to process this notice, this hospital lab's results are reliable but we can repeat the exams here and in another place if you want to be sure about the results.
-JC: Yes, please repeat the exams and I will also do them in another place

Something I identified in this process is that you as a doctor can not fight with your patient telling him that the results are reliable, if the patient needs to repeat them and that would help him to accept the notice, let's do it.

When the results arrived I repeat the process of telling Juan Carlos that the results confirmed he has HIV. He was very angry that he crushed the plastic bottle of water. I tried to calm him but he just shut me up and start telling: "I am very angry with Mario because he put me in this situation. I am a stupid to had sex with a man. God punished me even though I always followed his words"

After telling me this, he just left the room very angry, he told me he will call me soon.

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Telling someone bad news is always a challenge for a doctor and it was for me when I had to do it with Juan Carlos. He told me he was afraid of having HIV. I told him that we could make him a panel for STI and also I will have to ask him some things about his sexual life everything would be confidential. He told me: "I do not want to answer questions, I am going to tell you why I am interested in these lab tests."

He told me, eight months ago he had gone to the pride parade in another department of Nicaragua where no one knows him. He told me he tried to pass unnoticed and he achieved it.  After the parade, a guy called Mario invited him to a party. Juan Carlos accepted and spent a nice moment with Mario. After the party, they both were a little drunk and Mario invited Juan Carlos to his house. They had sexual relations but the problem was they didn't use protection. The next morning Juan Carlos was confused because of the new experience and he told Mario his story making him promise not no tell anyone about him. Mario asked him for his phone number but Juan Carlos did not give it because he could not continue meeting Mario because of his secret.

He told me he spent a lot of days worried about having sexual relations without protection but he did not make any test because Mario seemed healthy. The problem was that yesterday Juan Carlos found a message from Mario on Facebook. The message said this: Sorry for contacting you even though you asked me not to do it. I recently made my ITS labs and I am sorry to tell you that I got a positive result for HIV. I did all the confirmatory labs and I got a positive result too. It is not easy to contact you by Facebook to tell you this, but I did this to advise you to do the lab test, and if you have a positive result start as soon as possible your treatment.

Juan Carlos told me he was really afraid and regretful because he had continued having sexual relations with his girlfriend and he was afraid of affecting her.

I thanked Juan Carlos to have the confidence for telling me that, and I explained the following:

"  I am sorry you are in this difficult situation and I understand this new can make you feel afraid. I am going to be honest with you:  Because you had sexual relations without protection there is the possibility you got HIV, but we need to make the respective labs. Because of the time after this risk relation, the results we get will be reliable. Once we have the results we could talk about the next steps "

Juan Carlos told me he was really afraid because he thought no one will love him with that STI and a positive result will mean talking with his girlfriend about this and telling her to also perform the labs.

I immediately performed Juan Carlos the HIV test with all the confidentiality protocols and we just had to wait one day to have the results. I told him to come back the next day to give him the results.

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STOP ! Jehovah's witnesses do not accept blood

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STOP ! Jehovah's witnesses do not accept blood

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I was working in the emergency room when a 12-year-old child arrived brought by his neighbors. He had fallen from a considerable distance and he had an open fracture in his right leg. Neighbors told me they had seen the child lose a lot of blood and even though they tried to stop the bleeding with pressure, it continued. When I examined the patient I identified he was with Tachypnea, tachycardia, decreased blood pressure, decreased peripheral pulses, and slow capillary refill, also he was cold, sweaty, and with an altered state of consciousness. I immediately called the traumatologist to help me stop the bleeding. I identified the child was close to a hypovolemic shock so we immediately need to restore his blood volume. I knew he will need a blood transfusion quickly. I asked for his parents, but there was no family close to give me consent for the procedures. Neighborhoods explained to me that child's parents were fishermen so they had gone to the coast and there was no way to contact them.  The child's family had not a good economic situation so his parents used to leave him alone because, at his short age, he knew how to manage alone. Because I could not find his family and I was just thinking about saving his life I was going to start the blood transfusion when Juan Carlos stopped me saying:

- JC: " What are you doing? This child and his family are part of my group of Jehovah's Witnesses. Did you know we do not accept blood transfusions?

- PP: His parents nor other familiar are here for consent. He is just a child and not an autonomous person, I am just trying to save his life.

- JC: I am telling you, this child is Jehovans Witness if you do a blood transfusion you will be in serious problems for not respecting our religion.

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Neighbors who brought the child confirmed what juan carlos said and I was so scared for my next step. In this way and quickly I started analyzing my etic dilemma, thinking about the 6 steps as follows.

1. Identify the moral problem

In this case, the moral problem is about giving the child a  treatment that is not accepted in his family religion. The problem here is the child is not autonomous and I don't have any consent because his parents are absent but at least 5 people are telling me not to do it because they know this family's beliefs.

The final decision will be in his parent's hands but they are not here. Otherhand there are two perspectives of seeing the problem.
- In my perspective even though I respect religion believes,  I do not have their parent's order for not doing it, and because I must give the child's best interest treatment I could make a blood transfusion.
- The other perspective is the one of the neighbors, Juan Carlos and maybe his parents (we dont know certaintely ).They believe it is not correct to do that because of his religion believes and they are accusing me of not respecting autonomy.

2. Gather relevant information

- Condition and prognosis: He is in a critical state and he has a bad prognosis (hypovolemic shock) if we do not do the blood transfusion. If we give him the treatment he will certainly live.
- Desition Maker: Because the child is not autonomous, his parents will be the decision makers but they are not here.
- Beliefs, values, and desires: Jehovah's Witnesses do not accept blood transfusions and in this case, because of the parent's absence we don't know their desires about their son's health.
Time frame: I don't have too much time to decide because it is an emergency and the patient will be in a hypovolemic shock soon. I do not have enough time to wait for his parents, to return.
- Laws: It would be against laws not to respect patient autonomy. In this case, I don't have parents' order to not give this treatment so in theory I am not violating laws. I will be against the law if I don't try to save this child just because some people are sure that his family will not accept the treatment.

3. Identify the available options and their likely consequences

There are two possible next steps in this case.
-  Not give the child treatment: If I take this option my patient probably will die because of a hypovolemic shock. When their parents come back they could accuse me of not saving him because of neighbors' comments.
- Give the child the treatment: If I take this option my patient will survive. When their parents come back they could accuse me of not respecting their religious beliefs. I will be able to defend myself because they were absent.

4. Identify and evaluate arguments for and against the available options

PROS OF GIVING THE TREATMENT:
- Save a child's life
- Accomplish my duty as a doctor
- Accomplish principles of beneficence, nonmaleficence, and justice (because it is an emergency)
- Give the parents his child alive

CONS OF GIVING THE TREATMENT:
- Parents could accuse me of not respecting their religious beliefs

PROS OF NOT GIVING THE TREATMENT:
-  Parents will not accuse me of not respecting their religious beliefs

CONS OF NOT GIVING THE TREATMENT:
- The child probably will die
- I will go against beneficence, nonmaleficence, and justice principles.
- Parents could accuse me of letting their son die.

*autonomy principle will not be directly affected because his parents are absent

5. Choose a course of action and deffend it

At the end, I decided to make the blood transfusion. Juan Carlos was really angry with me and even the principal member of Jehovah's Witnesses came and told me I will have problems for not respecting their religion. Even though a lot of people were against my decision I kindly told them I was prepared for everything I will have to explain to his parents later.

6. Carry out the chosen action and asses it

So in the end the blood transfusion was made and my patient stabilized. I just had to wait for his parents to return to manage the consequences.

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Juan Carlos and I worked in the same hospital, he was a nurse and I was a doctor. There was one day when we both have a case that challenged our ethical principles as health personnel. We had a patient called Cristina Contreras, she was a 55 years old mother of two girls 15 and 13 years old. She had assisted because of the popular 3 P:  polyuria, polydipsia, and weight loss. Juan Carlos recognized her as a member of the salon and when I examined her I immediately recognized that could be Diabetes so I send her the necessary exams. When she came back with the results we confirmed her diagnosis. At the first moment, she was really sad and scared. I tried to calm her and give her time to accept the notice. After this, she told me more about her habits and family and we started talking about the treatment steps. She lived with her husband and her two girls. Her family did not have the best economic situation but with her new work things were better. She was a waitress in a popular restaurant in Nicaragua, and because of this, her habits had worsened. She used to have bread, cheese, and coffee for breakfast and dinner, and for lunch whatever had been cooked in her work. She also told me that she loved coca cola so she drank it all day.  After analyzing her case and redirected her to nutrition I told her we were going to start with lifestyle changes and metformin as treatment. I chose her treatment thinking about beneficence: Give the patient the best option for treatment thinking about all her life aspects because she would be able to take the pill and also because she promised to start changing her habits.

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Two weeks later Cristina came back to me for control, we take her glucose levels and there were not better. Her glucose were at the limit when we can think about insulin as an option in the treatment. I talk to her and ask her about her lifestyle changes but he told me she was busy to think about eating well or doing exercise. She accused me of giving her the wrong treatment because her symptoms and her glucose levels did not get better. I told her that the treatment would work if she understand she is the only one responsible for her health condition. She told me that a friend told her insulin was the right treatment and she asked me to give her that treatment. I told her that thinking about Beneficence and Nonmaleficence, that treatment would not be the correct one. I explained to her that beneficence told me to give her the best treatment for all her life aspects. Thinking she did not have enough time for more complex treatments, the pill, and little lifestyle changes would be the best option. On the other hand, nonmaleficence makes me not give her a treatment that will cause more harm than benefit, and as we know insulin is a complex treatment that requires patient commitment because could cause hypoglycemia. Following the autonomy principle, I did the positive duty of explaining in detail all the benefits and risks of both treatments. In the end, she decided on insulin. I disagreed with that option but I could not make anything more because she had her autonomy. I gave her all the indications for her insulin treatment and explained to her the red flags of hypoglycemia to know when to go to the emergency.

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Juan Carlos was going to be 30 years old soon and he had not married anyone yet. After his parent's bad reaction to his sexual identity, the situation was ignored and Juan Carlos wanted to solve his problem. He thought that if he start dating a girl and act as "man" does, he will forget everything about being transgender. In this way, he started dating Karen. She was a member of Jehovan's Witnesses. They started dating and one month later, he asked Karen to be her girlfriend. Juan Carlos's parents were really happy and thought his idea of being transgender was just a confusing moment.

One year after, Karen told him:

" We will be 30 soon and I want to know if one day you will ask me to marry you?. I have clear life objectives and didn't want to spend time with someone who doesn't want the same."

The dilemma for Juan Carlos started there because he could ignore his sexual identity but it was not as easy when this involves other people and his entire life. Even though he loved Karen, he will live a lie if he say yes.

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The moment Juan Carlos had this problem he quickly called me and I helped him to analyze the options. The problem was about lying to Karen and offering her something he doesn't want for his life.

The first option was to continue lying and tell her he would like to build a life together, and the second option was to tell her the truth about his sexual identity and admit his life objectives are not the same.

Our analysis summarizes as this

The first option implies lying to people, in this case, Karen, her family, his family, and even himself. At first see, it seems easy to say this option is the wrong one but Juan Carlos lived a hell the months after telling his parents about his sexual identity. His parents told him they were disappointed, her mother didn't stop crying and in the future, his religion will deny him, and his purpose of being as his father will end. Since he started dating Karen everything goes well, his parents were affectionate again and he continues going to Jehovah's Witnesses salon. Furthermore, he knows Karen is happy with him, and they could have a good future. The bad part of this decision is the big lie he will have to maintain for the rest of their lives. How could he marry someone knowing he does not love her in that way?
How could they have children with her? He knows that taking this option also implied his happiness, life is not bad with this lie, but he will never be the real Juan Carlos.

The second option is say the true even thoug this will hurt a lot of people: Karen, his family and members of Jehovah's Witnesses. In this case Karen will get harm after knowing she was living a lie. Juan Carlos parents will be disapointed, maybe they will ask him to leave home, and all the Jehovah's Witnesses will use him as example of what biblie says its wrong. The good part of this desition is he could experinece life in the way he really wants, and he will also respect himself.

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Juan Carlos was born in Nicaragua in 1996. Her parents Verónica and Julian had met in a community of Jehovah's Witnesses when they both have 14 years old and after too many preachings together they fell in love and got married. They bought a house in a safe neighborhood and their jobs allowed them to have a medium economic position. Years later, Julian became the major brother of the congregation and Verónica got pregnant. When they knew their baby was going to be a boy, they felt really happy. Both imagined their boy becoming the successor of his father, an example of preacher and a good son.

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Juan Carlos grew up in a lovely family, playing soccer with his father each weekend and helping his mother at home. At school he showed being an excellent student and all her classmates wanted to be their friend. He always went to Jehovans witness saloon with his parents to listen to his fathers sermons and all sundays he assited to the biblie studies. Until 15 all his live semmed good but one day he had a thougt that started a hell . One day when he was recolecting family clothes to wash them, he saw her mothers dresses. He started thinking how beautiful that dress was, without thinking he ran to his room, locked the door and he put on the dress. He could not stop watching himself at the mirror and the worst part was when he wish being a women. Since that moment he stop being that happy guy and most people saw how his light turned off.

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The day Juan Carlos's results were ready I was waiting for him to come. For giving him the results I used SPIKE.

Setting
I prepared the place where I will receive Juan Carlos. I made sure it was a private place, without distractions and noises. I saw first the results and they were positive results so I know I will have to choose the best word to give him this news. I prepared tissues and I closed my laptop to focus on this situation.

After everything was ready, I asked Juan Carlos to enter and take a sit. I asked him how everything was going and if he want me to call someone to accompany him. He answered he wanted to be alone.

Perception
I knew because the last appointment he was really afraid because the meaning of a positive result. He was worried also because he could trasmitted this STI to his girlfriend. The conversation goes like this:

- How do you feel today? Did you remember what we talked the last appointment?
- Hello Paula, the truth is that I am afraid and yesterday I could not sleep. I read a lot about HIV on the internet and everything says I will die slowly because this is the worst illness. Do you have my results?
- I understand you have read a lot of things on the internet, I could explain some of them after if you want it because some sources are good and, others not at all. On the other hand, yes I have your results.

Invitation
- Okay Juan Carlos here I have your results. Would you like me now to give you the results?  and would you like me to explain it in detail or not?
- Yes Paula please give me the results and in easy words tell me what will happen to me

Knowledge.
- Okay Juan Carlos, I am sorry to tell you this: The results were positive for HIV. In this case, because we were not in a window period and we made a highly specific test the results are reliable, even though we will repeat the test.  This is a virus that affects your immune system and does not allow it to do its work well.
the - I read on the internet it does not have a cure. I am going to die?
- It is true it does not have a cure because it is a virus, but it has an effective treatment.
-  I can not believe this.

Emotion
Juan Carlos started crying and I offered him tissues. I told I understood it was not easy to hear that. I told him if he wanted me to give him a moment alone or if he wanted me to call someone. He answer no but asked me for a hug and I gave it to him.

Strategy and Summary
After a moment he calmed down and say " I have to accept I have AIDS ". I saw him destroyed so I asked him if he wanted to talk about the next steps. He told me he just wanted to know if he was going to have a good or bad prognosis.  I told him this virus has a treatment that will give him a good life quality and prognosis. I also tell him HIV is not the same as death or AIDS and that I could explain it.

- Okay Paula, there is a solution it is all I need to hear now. I wanted a moment to process this news. It is okay if I come tomorrow to talk with you in more detail about the next step in AIDS?

- That would be okay. Please call me if you need something. I know this is difficult but tomorrow we will continue talking about this, I will also would like to talk with you about the difference between AIDS and VIH.

- Thanks Paula, tomorrow will be a better day with a new mindset to face this. See you tomorrow.

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The day her flight left, I went with her. She was carrying only one suitcase and I was surprised how her life and dreams can fit into something so small.

I was very nostalgic to say goodbye and I remembered everything we lived together. Before boarding time we decided to have a coffee at the airport. She told me that she was sad that her parents didn't say goodbye, when suddenly her phone rang. It was her mother telling her that she loved her no matter how she was. Her mother said her father soon would also be ready to talk to her. When the call finished she told me now she was ready to leave.

The time to leave arrived, I hugged her and watched her walk towards her new beginning. I would like this story to end here but the father of his ex-girlfriend, someone who hated the LGBTQ + community, shot him in the head. And that was how Juan Carlo's life ended in a single second.

Days have passed since this event and I still cannot believe the violent and hateful manner in which Juan Carlos died.

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The moment the grandmother heard that, she immediately said a big NO. She started yelling " You will not amputate his leg, I do not give my consent". I tried to calm the grandmother and explain to her that because we could not contact the legal guardians of the child in this life-threatening situation we will have to do what we need to save him without legal consent. She hit me and start saying "You can not do that". She threatened me saying " I will denounce all the hospital and especially you ". Juan Carlos stayed there with the grandmother trying to calm her. I communicated this situation to the medical team and they started the amputation surgery. After the surgery and with the treatment the child got stable, when he woke up he was really scared so we called a psychologist to help him until their parents arrive. Finally, the parents answered the phone and they were coming back. Juan Carlos and I were scared because it was the first time we proceeded without the presence and consent of the legal guardians.

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One day after, I was having a relaxed day in emergency service. I was attending to a mother who came with her soon. Both of them had been waiting 3 hours to be attended. His son had flu and I was starting to examine him when someone told me an incounsicius patient had arrived. The mother take my arm and angrily told me she waited for 3 hours because I was the only doctor in the emergency service. I asked Juan Carlos to talk with the mother and I left. Juan Carlos told her that because of the Justice principle I had to attend to the ones who first need medical attention, in this case, an emergency of an unconscious woman. The angry woman left the hospital.

When I arrived, I saw Cristina on the bed. Cristina was unconscious. A work partner brought her to the hospital when Cristina Faintined. I immediately recognized she was in a hypoglycemic state. We treated her and she recovered. After that moment Cristina returned to Metformina and start doing lifestyle changes and nowadyas her glucose levels are controlled.

Cristina was a patient who challenged my ethical principles, cause all my patients had accepted my recommendations, and Cristina was the first one who chose another option.

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One week after Juan Carlos fit of rage he came back to my consult. He was no more angry but sad. He was more calmed and he told me

JC: "I have spend bad days but now I am trying to live with this notice. I am considering trying therapy and I am also interested in starting treatment for HIV. The next step after this appointment is talking with my girlfriend, I want to advise her to go to a doctor. I know maybe she will end up with me, but anyway, I was living a lie. Maybe is an opportunity to start living my reality as a transexual person. Ironically, VIH forced me to stop lying to myself and others. Above all, I hate have hurt Karen in this way, maybe she has HIV because of me"

I identify Juan Carlos was dealing/negotiating with his diagnosis because of the amount of ideas he had. We started to review the next steps in his process. We talked about the treatment, the prognosis, the control exams, and the dates. After the talk, he was more calmed because he understood with the correct following he would manage the situation. He also understood HIV does not mean AIDS or dying, and that relieved him. After being sure that the information I shared and the agreements for their treatment and follow-up have been made clear I gave him information about support groups and psychologists.

After Juan Carlos left the room I was happy because I saw he was starting to face this new.

The worst moment came that night when Juan Carlos called me at 9 pm. He was crying and breathing quickly, I identified he was having a panic attack. He told me:

" I just told Karen everything. She was very disappointed and cried a lot. As I expected, she ended up with me. I did not give him details of how it happened, enough with the issue of HIV, and the problem of my sexuality I am not ready to share it yet. I hurt her too much, how can I continue living with this? I know that HIV will not kill me, but today I just want to stop feeling. Please come over because I'm starting to have ideas of ending my life"

I went to Juan Carlos quickly to give him support and we talked for hours. After he calmed down, I told him that we should seek psychological help immediately. He agreed so I immediately took him to a mental health expert.

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After our coffee meeting, Juan Carlos talked with his parents about his process. He told them that he was Transgender and what that means. He explained to them that for many years he tried to ignore it but now he wanted to live in the way he identified himself.  Their parents were really angry, his mother didn't stop crying and his father told him to leave home.

Juan Carlos rented a department and started discovering himself as a transgender person. He started wearing "women's clothes" and asking close people to treat him with the pronoun SHE.

At the beginning of this process, she was confident about her decisions and even though most people don't respect his identity, he trusted in the process.

Now her spotify was always playing "BORN THIS WAY" and I was really happy to see how empowered she was

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The rumor about my decision spread among all the Jehovah's Witnesses and even Juan Carlos was angry with me. Two days later, parents arrived. They were really scared when they came to the hospital. I explained to them the way his son arrived and all the treatments we did. I told them that because they were not here I had to take quick decisions. I told him that neighbors told me they were Jehovah's Witnesses and that they do not accept blood transfusions. I continued talking when their parents just gave me a big hug and told me "Thanks for saving my son's life. We are Jehovah's Witnesses, but now we understood maybe we could not follow this rule of not blood transfusion, more when it saved our son.

Days after someone told me this family was rejected by Jehovans witnesses because of accepting blood transfusion.

This day I learned a lot of things:

1. Believe in your decisions and manage the consequences.
2. The fact that your patient belongs to a religion does not definitively guide your steps in the treatment, you must wait for your patient's decision and respect their autonomy. In this case, the family, despite belonging to this religious group, preferred a decision that went against their beliefs because it was about the life of their son.

Juan Carlos was angry for two more days and then he started talking again with me. He told me he realized how beliefs could change when it affects someone important to us.

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After analyzing all the options with Juan Carlos I told him about the two Philosophical currents I had learned in my clinical ethics class.

I told him:

There are two ways to affront this situation. The first one is like Kant's deontology and the second one is like utilitarianism.

Kant would talk about categorical imperatives and in this way lying is always wrong and no matter the situation or the effects of the action. If you think like Kan you will choose the second option: Tell the truth even if this will harm Karen and your parents. In my opinion, this is the hardest option and maybe it could destroy your life, but it could open you a door for freedom.

On the other hand, if you follow utilitarianism you must look for the benefit of the greatest number of people. In this case, you should choose the first option because you will not harm all the important people in your life. Utilitarianism says you must decide as a disinterested spectator and in this case, you must not think about your happiness at the moment of the decision. In my opinion, acting as a disinterested spectator in this situation is not good for you because if you continue with this lie, you will never be happy.

After one day, Juan Carlos told m he had taken a decision. He told me: "It does not matter my happiness if I harm my family and Karen. I will do what is best for the greatest number of people and I will find a way of being happy with that. Karen is a lovely woman and I know I will give her a good life.

I could not believe what I was hearing and I tried to convince him to think like Kant, but he told me: Sorry Paula, for me the important part is the consequences of my decision.  This world is already bad, How to tell the truth will make me happy?

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When he tried on her mother’s dress Juan Carlo's life changed. He looked for information about his desire of being a woman. Finally, he understood transgender people and recognized himself as this. The first thing he did after he realized being transgender was searching in the bible about other ways of love and he got scared because the answer was clear: Women with men. He asked himself what happen with all the other ways of loving and he felt he was disappointing god and his family. With time his parents started being worried cause his son will be 30 soon and he had not married anyone yet.

The moment Juan Carlos and I met, he had 27 years old and I had traveled to Nicaragua to visit my cousin Andres. I saw him crying in the park and I decided to try to comfort him. He told me, that he confronted the situation and told her parents. They were very disappointed and they tell him he will not go to Jeovan's witness anymore. I comforted him and we became good friends, nowadays he had a difficult relationship with his parents and step by step is trying to accept himself.

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At the end of the appointment, I saw him afraid. He asked me if he had to tell her girlfriend about this. I said "Yes".  Telling her this would help her to go to the doctor and start the diagnosis process soon,  because if not maybe she could have it but not start the treatment at the time. I asked him if he wanted me to call someone but he just left the room telling me He will try telling her girlfriend and he will be in contact with me

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When the parents arrived at the hospital they started to tell everyone, the mother came to me and told me they have been started the legal process to denounce us. After, we invited them to talk in one room of the hospital, at the beginning they did not want to talk but we convinced them. We organized a little meeting with all the doctors who had participated in this case. Everyone started to explain what doctors have to do in a life treating situation and the absence of legal guardians. We explained to them that without the amputation there was a high probability of shock or infection that could end with the patient's death. I also told them " I understand that this will be a challenge, but we as doctors will help you to go through the process, he will have the option of a prosthesis and psychological care ". After all the meeting they understood how everything happened. They told us "Thanks for saving his live, sorry for all the problem, now we understood"

That day I understood how important is to take a decision and defend it until the end. In this special case, the legal guardians were absent,  but we always have to choose to save lives!

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After Juan Carlos started his process of dealing with his sexual identity she started facing how hard that would be.

Her parents were really angry, they didn't talk to her and all her family gave him back, it was as if she never existed for them. Besides, the rumor ran fastly and one day Karen's father called him saying. "So now you are a girl? You will never be a woman, you are just an afraid man who did not mature. You as people of the LGBTI+ community are not part of god´s creation, you just sin and hurt my daughter. But do not worry, soon you will have your consequence"

On the other hand, his community of Jehovah's Witnesses let her know that she was no longer welcome at the meetings through a signed letter. The letter contained her father's signature and the wishes that he "find God and reform"

She could bear that people do not want to call her by the pronoun "she", that many people have turned their backs on her, and even, that they observed her in the street when she put on heels but there was a drop that spilled the glass. One day she was walking on the street on heels when a man put his foot to make her fall. On the floor he kicked her and tell her "fight as man". Lucky a policeman was close and stop the situation. She called me crying and saying

JC: Tomorrow something worse could happen. I need to run away from here, start over. Paula I'm leaving here, I'm going to Europe, and I'll start over, I'll make myself known as HER and I'll have a new name. Juan Carlos is everything that I am not anymore”

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After a few days, Juan Carlos told me that going to the psychologist had helped him a lot and that he was even ready to go to a support group. He wanted to know more stories and learn how they coped with HIV.

Moths later in his control appointments I saw him better. Without a doubt, I admire the process that Juan Carlos had, despite difficult days the sun came out again for him. He told me all his family was confused about his break up with Karen and make him a lot of questions. He told me he is not ready to face his sexual identity problem yet but he knows this process will give him the courage. I told him: one step at a time you will do it great.

At the end of this happening, I understood that as doctors we don't have to think just about how to give bad notices but also try to follow our patient's process of accepting the bad news

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Goodbye Juan Carlos, thanks for everything you taught me.

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Goodbye Juan Carlos, thanks for everything you taught me.

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Thank you Juan Carlos for making this time in Nicaragua unforgettable. Here are 7 lessons you taught me.

1. Sometimes our desire to avoid hurting others can be above our happiness and we must avoid putting ourselves in that situation. I can't forget the time it felt like a trolley dilemma when she had to decide between telling the truth about her gender identity or lie . On that occasion, she decided to be unloyal to herself in order to avoid harming her parents and her girlfriend. What happened after that, made me understand that many of our decisions are like a trolley dilemma. She sacrificed herself for the good of the majority, as the theory of Principalism would say. What I learned from that occasion is that many times we cannot seek other people's happiness if we don't seek our own in the first place. In this way, following utilitarianism or Kantianism strictly is complicated.

2. Because we worked together in the healthcare system, I cannot forget the time a case challenged our principles of medical ethics. Never before we have observed how a patient refused the best treatment option and preferred the risky option. I remember that the patient had diabetes in its early stage and instead of the recommended treatment for this stage she preferred to use insulin. I felt angry but Juan Carlos reminded me two things: Firsrt,  that doctors should not be paternalistic, and second, that that patients are autonomous. The patient fell into a hypoglycemic coma and went to the emergency room. That day I understood that the job of doctors is to allow the patient to make an autonomous decision with all the necessary knowledge. The final decision and its consequences are part of the patient, our duty is to help to create an informed decision but not act in a vertical relationship.

3. There was another moment in which, together, we learned to make decisions using principalism. A child who belonged to Jehovah's Witnesses arrived at the emergency room, his parents were not there to give consent for a blood transfusion and many people who knew him were interfering with the treatment. Together with Juan Carlos we analyze the 6 steps to make a decision. (Identify the moral problem , Gather relevant information , Identify the available options and their likely consequences , Identify and evaluate arguments for and against the available options , Choose a course of action and deffend it , Carry out the chosen action and asses it) . That day I learned how important it is to deffend the decisions you make to the end and deal with whatever comes next. When the parents arrived, they thanked the medical team for having performed the blood transfusion because that saved their son. Also I learned  that the fact that your patient belongs to a religion does not definitively guide your steps in the treatment, you must wait for your patient's decision and respect their autonomy. In this case, the family, despite belonging to this religious group, preferred a decision that went against their beliefs because it was about the life of their son.

4. On the other hand, with Juan Carlos I learned how to communicate difficult news to patients. When Juan Carlos was diagnosed with HIV, applying SPIKE (Setting, Perception, Invitation, Knowledge, Emotion, and Summarize) made a big difference in the process of dealing with these hard times. Juan Carlos reminded me that patients are not diseases, they are people, they have families, a history and different circumstances. Learning the correct way to approach to your patient is the goal when we have to communicate bad news.

5. Next lesson Juan Carlos taught me was that as doctors we don't have to think just about how to give bad notices but also try to follow our patient's process of accepting the bad news. It is not jsut about communicate but also look and recommend what could helpt that person. In this case I recommended Juan Carlos, support groups and psychological help. Also is important to be there to answer your patients questions.

6. One of the last lessons we learned together was in the field of pediatric ethics. When we had to communicate the difficult decision to amputate the leg of a child who had suffered irreparable damage due to a traffic accident. That day I understood that legal guardians of children cannot always make the best decision due to the emotional involvement. Because of this, it is important that as doctors we try to give a correct explanation about the patient's situation and the treatment alternatives. Being the legal guardian of a child in a life or death situation is not easy, so we must try to guide parents towards the best decision.

7. Finally, the biggest lesson that Juan Carlos left me is that we must live in the way we want. I was a witness of Juan Carlos process of discovering here identity and in the last month together I was happy to see that she was proud to be who she was and to identify herself as a transgender person. Born this way played all the time on her spotify and the decision she made to start from zero elsewhere, showed me that we can always choose a new path. Juan Carlos showed me the reality of the LGBTQ+ community and showed me the struggle they have. Next year I will go out to PRIDE and I will shout for him and for all the people who deserve to live without violence or discrimination.

It hurts me that a hate crime has ended the plans that Juan Carlos had for her future, however I know that she left having recognized and accepted herself as she was.

A big hug to heaven Juan Carlos I will always remember you.