Transgender Children and the Right to Transition: Medical Ethics When Parents Mean Well but Cause Harm

Abstract

In this article, I argue that (1) transgender adolescents should have the legal right to access puberty-blocking treatment (PBT) without parental approval, and (2) the state has a role to play in publicizing information about gender dysphoria. Not only are transgender children harmed psychologically and physically via lack of access to PBT, but PBT is the established standard of care. Given that we generally think that parental authority should not go so far as to (1) severally and permanently harm a child and (2) prevent a child from access to standard physical care, then it follows that parental authority should not encompass denying gender-dysphoric children access to PBT. Moreover, transgender children without supportive parents cannot be helped without access to health care clinics and counseling to facilitate the transition. Hence there is an additional duty of the state to help facilitate sharing this information with vulnerable teens.

Keywords:

• gender/sexuality
• disability
• chronic conditions
• and rehabilitation
• mental health
• mental illness
• right to health care

This article is referred to by:

Identification Before Prescription: Necessary Changes for the Support of Transgender Youth

Moving Beyond Mismatch

True Autonomy/False Dichotomies? Genderqueer Kids and the Myth of the Quick Fix

Decision Making and the Long-Term Impact of Puberty Blockade in Transgender Children

Should Parental Refusal of Puberty-Blocking Treatment be Overridden? The Role of the Harm Principle

A Two-Pronged Approach to Minimizing Harms for Transgender Youth: Medical Interventions and Social Interventions

Psychological Maltreatment and Medical Neglect of Transgender Adolescents: The Need for Recognition and Individualized Assessment

Transgender Children, Puberty Blockers, and the Law: Solutions to the Problem of Dissenting Parents

The Social Context of Adolescents’ Right to Transition

The Right to Best Care for Children Does Not Include the Right to Medical Transition

Puberty Blockers Are Necessary, but They Don’t Prevent Homelessness: Caring for Transgender Youth by Supporting Unsupportive Parents

Puberty-Blocking Treatment and the Rights of Bad Candidates

Response to Commentaries on “Transgender Children and the Right to Transition”

Notes

1. One landmark case that comes to mind is Prince vs. Massachusetts, where the court ruled that a child’s welfare can justify overruling parental rights, even parental rights regarding a child being raised according to parental religious beliefs (https://www.law.cornell.edu/supremecourt/text/321/158 ). But what is a child’s welfare? Generally, we have seen this ruling bear out in laws against neglect and abuse, which generally (but not exclusively) override parental authority in cases in which a child faces physical harm.

2. States and counties that have laws prohibiting “conversation therapy” include Pima County, AZ; Westminster, CO; Bay Harbor Islands, FL; Boynton Beach, FL; Delray Beach, FL; El Portal, FL ;Greenacres, FL; Key West, FL; Lake Worth, FL; Miami, FL; Miami Beach, FL; Riviera Beach, FL; Tampa, FL; Wellington, FL; West Palm Beach, FL; Wilton Manors, FL; Athens, OH; Cincinnati, OH; Columbus, OH; Dayton, OH; Toledo, OH; Allentown, PA; Philadelphia, PA; Pittsburgh, PA; and Seattle, WA (see Kids Pay the Price 2017).

3. Every U.S. state now has a law against bullying. Admittedly, the definition of “bullying” varies by district. The extent of the penalty for violating bullying laws also varies. Notwithstanding, the fact that these laws are common speaks to a growing concern for the psychological health of adolescents (“Specific State Laws Against Bullying,” 2017). Another sign that we are taking psychological harm more seriously is the increasing use of psychiatric medication. According to a 2013 report from the Centers for Disease Control and Prevention (CDC), “Approximately 6.0% of U.S. adolescents aged 12–19 reported psychotropic drug use in the past month” (see Jonas et al. 2013). Note that this is in reference to all youth, not just transgender youth. We are taking psychological harm more seriously across the board, and transgender youth deserve special attention in this regard, for they face increased risk of these mental harms.

4. “Gender dysphoria is usually experienced from childhood on, and it is not based on any cultural preference but on a person’s innate sense of self: it is characterized by persistent discomfort and distress about one’s assigned sex or gender” (Brill and Pepper 2008, 200). Similarly, “gender dysphoria refers to discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)” (Coleman et al. 2012).

5. “During the last decade, more children have made a social gender role transition, sometimes as early as 4 or 5 years of age” (De Vries and Cohen-Kettenis 2016). Similarly, “Children as young as age two may show features that could indicate gender dysphoria” (Coleman et al. 2012). See also Brill and Pepper (2008).

6. These examples are taken from the experience of real families. The first can be found in Nutt (2017) and the second in Whittington and Gasbarre (2016).

7. Of course, gender nonconforming behavior does not alone mean that a child is transgender (nor does its absence mean a child is cisgender). Plenty of cisgender children enjoy games and dress that are traditionally considered typical of the opposite gender. Nonetheless, gender nonconforming behavior is often listed as one of the many “signs” that a child might be transgender. For example, in Principles of Transgender Medicine and Surgery, Walter Bockting (professor of medical psychology) and Eli Coleman (professor of family medicine and community health) describe one “vignette” in the early stages of the coming-out process (coming out as transgender) in the following fashion: “His parents expressed concern about Ben’s gender nonconformity. People regularly mistook him for a girl. Ben identified with Dorothy from The Wizard of Oz. At Christmas, he asked for ruby slippers” (Ettner et al. 2016, 140).

8. For information on transgender youth and homelessness, see Burgess (1999), Durso and Gates (2012), Keuroghlian et al. (2014), and Seaton (2017). Seaton and Durso and Gates contain specific information about the risk factors for transgender homelessness.

9. The studies mentioned include Bauer et al. (2015) and Travers et al. (2012). In addition, Olson and colleagues (2016) show that transgender children who do have supportive parents have average levels of depression. In these studies support was measured via surveys where transgender teens described the level of support they received from their parents.

10. Throughout this article, I use the term “they” as a singular gender-neutral pronoun. The term “they” is becoming increasingly used (and advocated) as a singular gender-neutral pronoun, especially among the LGBT (lesbian, gay, bisexual, transgender) community. For instance, see Dembroff and Wodak (2018) and McKenzie and Dembroff (2018).