Advancing adolescent capacity to consent to transgender-related health care in Colombia and the USA

Abstract

Many sexual and reproductive health care services, including gender reassignment treatment, facilitate reproductive autonomy and self-determination of gender identity. Individuals who are unable to refuse or consent to these services on their own behalf, such as adolescents, are at risk of violations of their rights to privacy and self-determination. This paper explores the issue of adolescent capacity to consent to transgender-related health care in Colombia and the United States (USA), focusing on the two countries' struggles to balance the rights of adolescents to make autonomous and confidential decisions with the rights of their parents. Unfortunately, many countries, including Colombia and the USA, have been slow to develop jurisprudence and legislation that explicitly protect transgender adolescents' capacity to consent to gender assignment treatment. Courts in Colombia, however, have developed jurisprudence that restricts parents' ability to make medical decisions on behalf of their infant intersex children, which lays a strong normative foundation for advancing adolescent capacity to consent to transgender-related health care. It is a strategy that may prove effective in other countries in the Americas, even those with different frameworks for adolescent medical decision-making capacity, such as the USA.

Résumé

Beaucoup de services de soins de santé sexuelle et génésique, y compris le traitement pour changer de sexe, facilitent l'autonomie génésique et l'autodétermination de l'identité sexuelle. Les individus incapables de refuser ou d'accepter ces services, comme les adolescents, risquent des violations de leur droit à la confidentialité et à l'autodétermination. L'article examine la question de la capacité des adolescents à donner leur consentement à des soins de santé liés à la transsexualité en Colombie et aux États-Unis d'Amérique, en se centrant sur la lutte des deux pays pour équilibrer les droits des adolescents à prendre des décisions autonomes et confidentielles avec les droits de leurs parents. Malheureusement, beaucoup de pays, notamment ces deux-là, ont tardé à définir une jurisprudence et une législation qui protègent explicitement la capacité des adolescents transsexuels à consentir au traitement de changement de sexe. Les tribunaux en Colombie ont néanmoins développé une jurisprudence qui restreint la capacité des parents à prendre des décisions médicales au nom de leur nourrisson intersexuel, ce qui constitue un solide fondement normatif pour faire progresser la capacité des adolescents à accepter des soins de santé liés à la transsexualité. C'est une stratégie qui peut se révéler efficace dans d'autres pays aux Amériques, même s'ils disposent de cadres différents pour la capacité de décision médicale des adolescents, comme les États-Unis.

Resumen

Muchos servicios de salud sexual y reproductiva, incluido el tratamiento de reasignación de sexo, facilitan la autonomía reproductiva y autodeterminación de identidad de género. Las personas que no pueden negarse o dar su consentimiento para recibir estos servicios, tales como adolescentes, corren el riesgo de sufrir violaciones de sus derechos a la privacidad y autodeterminación. En este artículo se explora el asunto de la capacidad de los adolescentes para consentir en recibir servicios de salud para personas transgénero en Colombia y Estados Unidos (EE. UU.), con un enfoque en la lucha de los dos países por sopesar los derechos de los adolescentes de tomar decisiones autónomas y confidenciales y los derechos de sus padres. Desgraciadamente, muchos países, incluidos Colombia y EE. UU., se han demorado en formular jurisprudencia y legislación que proteja explícitamente la capacidad de adolescentes transgénero para consentir en recibir tratamiento de asignación de sexo. Sin embargo, las cortes de Colombia han creado jurisprudencia que limita la capacidad de los padres para tomar decisiones médicas en nombre de sus bebés intersexuales, lo cual sienta una sólida base normativa para promover la capacidad de los adolescentes para consentir en recibir servicios de salud para personas transgénero. Es una estrategia que podría resultar eficaz en otros países en las Américas, incluso aquellos con diferentes marcos para la capacidad de toma de decisiones médicas en la adolescencia, tales como EE. UU.

Key Words:

• adolescents and young people
• law and policy
• sexual rights
• intersex issues
• transgender issues
• agency and decision-making capacity
• Colombia, USA

Notes

* An adolescent is a person between the ages of 10 and 19 years.¹ A child is a person below the age of 18 years, unless under the law applicable to the child, majority is attained earlier.² A minor is a person who has not yet reached the legal age of majority. While this paper focuses on adolescent capacity, many of the laws and the jurisprudence discussed here address all minors and do not distinguish between adolescents and younger children. Where appropriate, the term “minors” will be used instead of “adolescents”.

* In this case, the father of a 16-year-old Jehovah's witness requested that the Colombia Constitutional Court order a clinic to perform a blood transfusion on his son, despite the fact that the young man refused to consent to the procedure. Without the blood transfusion, which was a necessary part of the young man's cancer treatment, it was likely that he would die.¹⁴

† “Minors may freely and autonomously testify, recognize children born out of wedlock and receive support, give their children up for adoption, enter into certain contracts. However, they still need parental authorization for other activities, including marriage, being adopted and entering into an employment contract.” ¹⁴

* In countries where the prescription of puberty-delaying hormones to pre-adolescent transgender children has been introduced, namely the Netherlands, USA and Australia, the practice remains controversial.²⁶

* “At common law recognition of the gradually increasing capacity of minors was called the Rule of Sevens: under the age of seven, a presumption of no capacity; from seven until fourteen a rebuttable presumption of no capacity; and from fourteen to twenty-one a rebuttable presumption of capacity.” ³⁰

† The Supreme Court has upheld state laws requiring parental involvement in a minor's decision to have an abortion, so long as they include an “alternative”, such as a judicial bypass procedure, which waives the consent or notification requirement for those adolescent young women who cannot involve their parents. “To benefit from the judicial bypass mechanism, a young woman must appear before a judge and prove either that she is mature enough to decide whether to have an abortion or, that despite her immaturity, an abortion would be in her best interests.” ³¹

** “For example, the minor might reasonably fear that their parent might prevent them from transitioning through violence, strict surveillance such as preventing the minor from leaving the house, and even forced institutionalization.” ²⁹

* Managing or treating an intersex condition or sexual development disorder may involve a range of surgical procedures (e.g. to alter appearance, allow voiding of urine, allow standing urination, allow for future menstrual flow, allow for future sexual intercourse, or support gender identity development) and non-surgical interventions (e.g. sex-hormone therapy or psychological counselling), depending on the specific condition diagnosed.^34,35 Optimal care for children with these disorders, as a result, requires an experienced multidisciplinary team comprised of a range of paediatric sub-specialists (e.g. endocrinology, urology/surgery, psychology/psychiatry, gynaecology, social work, nursing and bioethics).³⁵

* Colombia ratified the UN Convention on the Rights of the Child on January 28, 1991. The USA, however, has yet to do so.⁴⁸