https://orcid.org/0000-0003-1944-4122
Introduction
Trans healthcare has seen some positive changes over the past two decades, moving from the pathologisation of difference as ‘disorder’, to approaches that recognize and embrace the diversity, dignity and value of trans lives. In a short time, we have also seen a shift from widespread clinical control and gate-keeping to the growing adoption of affirmative approaches to trans healthcare, which are predicated on respecting trans and gender-diverse peoples’ rights to safe and respectful healthcare. Whilst these evolutions are welcome and important, progress is inconsistent and uneven, and subject to legislative and political rollback. Progress is particularly patchy and fragile in healthcare services for trans, gender-diverse, and gender non-conforming children, with children defined here as encompassing all non-adults under the ages of 18 (United Nations, Citation1989). In multiple countries affirmative healthcare is under attack, with children’s trans healthcare services bearing the brunt of attacks on rights-based practice. There are many locations where trans healthcare services for children fail to uphold trans children’s rights, with approaches in children’s services not keeping up with the improvements that are more widely being seen in adult trans healthcare.
In this editorial we first call attention to the importance of child-rights informed policy and practice in trans healthcare. We outline critical pillars of rights-respecting healthcare for trans, gender-diverse, and gender non-conforming children. We highlight the importance of embedding rights within service delivery, discussing the need for child participation in healthcare design, evaluation and accountability. In the second section of this editorial we articulate and call attention to a sector-wide ethical duty of care to children, building a sector where child rights violations are no longer tolerated. We highlight the responsibilities of all trans healthcare stakeholders and professionals, including those in adult trans healthcare, in ensuring a sector-wide shift to ethical and rights-respecting practice. Trans children in particular require greater allyship from professionals working in trans health, including those in adult healthcare, helping to ensure that as the wider field evolves and improves, children are not left behind.
Child rights in trans healthcare
Ethical approaches to working with or providing services to children have an obligation to recognize and uphold child rights. Child rights are enshrined in international human rights frameworks including the United Nations Convention on the Rights of the Child (UNCRC). The UNCRC protects the rights of children in every country in the world apart from the USA (the sole country to have failed to ratify it). The UNCRC recognizes each child as a rights holder, with rights articulated across 54 articles that cover all aspects of a child’s life (United Nations, Citation1989). The UNCRC rights that are particularly relevant to trans children include the right to identity (article 8), the right to protection from violence and abuse (article 19), the right to life, survival and development (article 6), the right to health (article 24), and the right not to be discriminated against in accessing all other rights (article 2). Child rights may also be explicitly guaranteed in domestic law, as seen to differing degrees in countries including Belgium, Norway, Spain, Iceland, South Africa (Lundy et al., Citation2013), and more recently in Scotland (United Nations Convention on the Rights of the Child (Incorporation) (Scotland) Bill, Citation2022).
Within the UNCRC trans, gender-diverse, and gender non-conforming children have a right to equitable healthcare. This right to health must be upheld through addressing entrenched barriers to healthcare equality. This editorial articulates critical pillars that can enable and sustain rights-respecting practice in children’s trans healthcare. These pillars are presented in terms of institutional responsibilities for children’s rights below, summarized in Box A. These same pillars are revisited in terms of children’s healthcare rights at the end of the article in Box B. These pillars of rights-respecting practice are designed to enhance healthcare well-being and justice for all users of children’s trans healthcare services, whether or not a given child identifies as trans, and regardless of social and/or medical transition pathways. The centering of children’s rights within healthcare services, benefits both trans children and those children who are exploring their identity.
Box A: Institutional responsibilities for children’s rights in trans healthcare services.
Rights-based healthcare services and institutions need to:
Protect children from anti-trans prejudice, including from healthcare professionals
Proactively carry out depathologisation of health services, reforming healthcare policy and practice to undo a long legacy of problematizing trans, gender-diverse, and gender non-conforming children’s lives
Uphold a commitment to self-determination, repudiating approaches built on conversion, suppression or control of children’s identities
Respect bodily autonomy
Enable children’s power and influence in medical decision-making, supporting and enhancing evolving capacity, within approaches based on informed consent, or informed assent.
Tackle cisnormativity and transnormativity in trans healthcare, recognizing diverse identities and pathways as equally valid, with an equal right to healthcare
Protect children from anti-trans bias in assessments of healthcare evidence or risk, and in medical policy and practice
Protect children from abuse, violence, and the harms of gender minority stress, including in schools and at home.
Build safe and affirming communities to help protect children from trans-hostile environments, including through healthcare interventions in political, legislative or media discourse and policy.
Protection from prejudice is vital for reducing healthcare inequalities. Anti-trans prejudice, including amongst healthcare staff and healthcare leadership, is a significant driver of healthcare inequalities, with trans people harmed by the impacts of prejudice or ignorance in healthcare (Sundus et al., Citation2021). Healthcare leaders have a responsibility to recognize healthcare prejudice, including amongst healthcare professionals, taking steps to protect trans, gender-diverse, and gender non-conforming children from prejudice or ignorance. Prejudice can be ingrained at a systemic and institutional level, for example in services where being trans is regarded as a ‘bad outcome’ (Horton, Citation2024). Prejudice can be addressed through enhanced training and education, as well as through clear policy commitments to a child’s right to trans positive and respectful healthcare provision. Anti-trans prejudice needs to be recognized, with targeted action to protect trans children from its influence across healthcare policy, procurement, management and delivery.
Trans depathologisation is another critical priority to protect children’s healthcare rights. Pathologisation is recognized as a driver of healthcare inequalities, influencing healthcare approaches wherein trans identities are devalued and problematized (Horton, Citation2022a; Pearce, Citation2018; Suess Schwend et al., Citation2018). Trans identity is not in itself a form of illness, and a growing body of literature indicates that trans children with access to appropriate care and support do not have higher rates of psychopathology than the general population (Olson et al., Citation2016). Treating trans identities as a pathology or problem adds to healthcare inequalities, escalating and reproducing shame, perpetuating and reinforcing society prejudice, and justifying clinical coercion and institutional violence (Horton, Citation2022b, Citation2024; World Health Organisation, Citation2020). Healthcare providers and leaders have a responsibility to ensure children’s healthcare is depathologised in line with World Health Organization’s International Classification of Disease Version 11 (ICD-11), which stipulates the importance of trans healthcare being delivered without treating trans-ness as a pathology or problem (World Health Organisation, Citation2021). This depathologisation effort needs to be proactive, resourced and comprehensive, recognizing both the legacy of pathologisation in current trans healthcare approaches, and institutional responsibilities to upholding children’s right to healthcare that is free from pathologisation (Adams et al., Citation2017).
Health inequalities are also connected to past and present practices of clinical control over trans people’s lives, bodies and identities. Across trans healthcare there is widespread recognition of the importance of self-determination and bodily autonomy (Allen et al., Citation2024). These principles are arguably even more important in trans, gender-diverse, and gender non-conforming children’s healthcare, recognizing the harms of approaches that seek to convert, deny or suppress children’s identities, or healthcare services that operate through coercion and control over children’s lives, bodies and healthcare options.
In adult healthcare there has been a significant shift toward services based on informed consent (Cavanaugh et al., Citation2016). In children’s healthcare (outside of trans-specific services), informed consent and informed assent are recognized as vital components of rights-based healthcare (Lansdown et al., Citation2016; Modi et al., Citation2014; World Health Organization, Citation2021). The World Health Organization recognizes the importance of recognizing child decision-making rights in healthcare, with healthcare providers playing an important role in building and enhancing evolving capacity (World Health Organization, Citation2021). Within trans healthcare services for children, informed consent approaches need to recognize children’s right to healthcare decision making considering their evolving capacity (as with e.g. Gillick competency in England and Wales), with healthcare professionals taking steps to support and enhance decision-specific capacity. Where children are not considered competent, they need to be supported to make decisions with their informed assent. Trans children are particularly vulnerable to coercion, barriers to transition, and denial of healthcare, with healthcare decisions (including decisions made on behalf of a child to prevent access to healthcare, or decisions to keep a child in extended assessment) made by families, healthcare providers or legislators in direct opposition to a child’s assent. Approaches based on informed consent and informed assent are therefore even more important in trans children’s healthcare, recognizing the steep power differentials between parent/carers and adult healthcare gatekeepers and child healthcare service users (Cavanaugh et al., Citation2016).
Ethical healthcare services need to tackle cisnormativity (assuming everyone is or should be cis). This can include avoiding double standards between healthcare offered to trans or cis children, ensuring trans lives are valued as highly as cis lives, and being vigilant to policies or practices that implicitly or explicitly regard transness as a bad outcome (Horton, Citation2024). Services also need to tackle transnormativity (assuming there is one acceptable way to be trans, gender-diverse, or gender non-conforming), avoiding clinical policy or practice that validates a normative description of being trans or enforces a normative route to social or medical transition (Clark, Citation2021). Cisnormativity and transnormativity can both negatively impact on children’s experiences in healthcare services, limiting and constraining possible outcomes in terms of personal identity and treatment pathways.
Ethical services also need to tackle anti-trans bias. Conscious and subconscious bias is known to impact on the design, delivery and management of children’s trans healthcare services, with double standards in the appraisal of evidence (Giordano & Holm, Citation2020; Horton, Citation2024). Clark et al. (Citation2020, p. 176) have highlighted the need to “recognize how anti-trans bias may impact the perceived magnitude of risk regarding gender health-care interventions”.
Ethical healthcare services also need to protect children from abuse, supporting trans children’s safety, mental health, happiness and well-being. Trans, gender-diverse, and gender non-conforming children have a right to healthcare provision that is safe, respectful and supportive, avoiding abusive and intrusive approaches (Horton, Citation2022b). As part of this, children need to be protected from the violence and gender minority stress that they can experience in homes, schools and communities that are non-affirming or unsafe (Veale et al., Citation2017). Healthcare services must adopt a holistic approach to health and wellbeing, including efforts to ensure schools are trans-positive, safe and affirming, and that trans children have safe and affirming homes (Katz-Wise et al., Citation2018). Targeted interventions can build parent and carer understanding and support for their child, while also protecting children from harmful ‘reparative’ or ‘conversion’ approaches and familial abuse (Riggs & Bartholomaeus, Citation2018).
As part of the principal of justice for ethical clinical practice, a healthcare provider’s duty of care extends beyond the clinic, with responsibilities to help build safe and affirming communities for the trans, gender-diverse, and gender non-conforming children under their care (Clark et al., Citation2020). This responsibility calls for healthcare providers to do more to challenge local, national or global policy and discourse that creates a hostile climate for trans children (Ashley & Domínguez, Citation2021). Trans children in particular are significantly impacted by the wider political, legislative and media climate, experiencing significant harm in environments where trans people are at risk of violence, persecution and abuse. Healthcare providers and services have a unique opportunity and responsibility to use their positions of trust and authority to advocate for children’s safety, especially where medicalised misinformation or a legacy of trans pathologisation is driving harmful and abusive legislation or policy.
Embedding child rights and trans ethics in clinical practice
There are many positive examples of healthcare practitioners recognizing the importance of a rights-based approach to working with trans children, including in primary healthcare (Well BN, Citation2024), social work (Redcay et al., Citation2019), pediatrics and education (RCPCH, Citation2024). Practitioners and institutions without a clear commitment to trans children’s rights need to take steps toward this. A commitment to children’s rights is a necessary but insufficient component of rights-respecting practice. Rights-respecting approaches need to be built into trans healthcare systems, institutions, policies and practices. Healthcare institutions can undertake child rights focused reviews of existing policy and practice, seeking to understand and reduce areas of potential child rights violations.
Healthcare services must learn from and embed best practices in trans healthcare ethics (Allen et al., Citation2024; Ashley, Citation2023). Lessons can also be drawn from existing scholarship on trans research ethics (Adams et al., Citation2017; Bauer et al., Citation2019; Vincent, Citation2018). Wider trans research ethics has highlighted the importance of working in partnership with trans communities (Adams et al., Citation2017), taking responsibility for the wider impacts of policies or practices on trans communities (Bauer et al., Citation2019), recognizing decision-maker positionality and power differentials vis-à-vis participants or service users (Bauer et al., Citation2019), being accountable to trans communities, and centering trans priorities and perspectives (Marshall et al., Citation2022).
Partnership and accountability is a vital part of children’s healthcare rights under UNCRC article 12. Children have a right to participate in decisions that affect their lives, having their views listened to, and utilized to reform healthcare policy and practice. In healthcare the UNCRC Committee have emphasized children’s right to participate in the “development of health policy and services” (United Nations, Citation2009, 98), noting children’s views “should be sought on all aspects of health provision, including what services are needed, (and) how and where they are best provided” (United Nations, Citation2009, p. 104). Trans healthcare providers have a duty to take action on the basis of trans, gender-diverse, and gender non-conforming children’s perspectives and priorities, ensuring children have power and influence over the design, operation and evaluation of their healthcare services.
Children’s trans healthcare services therefore need to center the perspectives and priorities of children and young people, informed by the healthcare outcomes that matter to children (Chong et al., Citation2021; Sitas et al., Citation2023). This team of authors from across multiple countries and nations (England, Scotland, Wales, Australia, New Zealand, Canada) is engaged in a new research project focused on understanding the trans healthcare measures that matter most to trans children and young adults. The project is taking place in partnership with existing clinical services, to ensure identified child and youth priorities are embedded into culturally competent service design, delivery and evaluation.
All healthcare service users have an equal right to have their views taken seriously in shaping the design and delivery of their healthcare services. Efforts are needed to ensure children’s trans healthcare services are engaged with, respectful to, and accountable to all trans, gender diverse and gender non-conforming children, especially those who are multiply marginalized. Non-binary children are at risk of being disadvantaged in healthcare services, with effort needed to uphold non-binary children’s rights (Chew et al., Citation2020; Clark et al., Citation2018). Neurodivergent trans children are at particular risk of experiencing healthcare rights violations or barriers to having their views heard and listened to in shaping policy and practice, and healthcare services need to recognize their responsibilities to such children and young people (Glaves & Kolman, Citation2023). Other groups of trans, gender-diverse, and gender non-conforming children who may be vulnerable to losing out on their rights to participation in the design and evaluation of healthcare services include children with unsupportive parents (Clark et al., Citation2020; Riggs & Bartholomaeus, Citation2018), children in care (Winter, Citation2006), refugee or migrant children, children from marginalized racial, religious or ethnic communities, Indigenous children and children of color, and disabled children (Baril et al., Citation2020). Healthcare systems and services must significantly enhance their efforts to proactively articulate, champion and protect the rights of all children, especially those facing multiple intersecting axes of oppression.
Younger children are also at risk of being overlooked in the design or evaluation of trans healthcare services. Pre-adolescent trans children are particularly at risk of being medicalised, coerced and controlled by healthcare services that problematize trans childhood (Horton, Citation2024). When considering the healthcare needs of younger children, healthcare services may benefit from co-operation with supportive parents and carers. Collaboration with parents and carers needs to recognize the risk of parental prejudice or cis/transnormativity, or the potential for parental misunderstanding of trans children’s experiences (Riggs & Bartholomaeus, Citation2018). Action is needed to ensure service collaboration with families is held accountable to younger children’s priorities, with proactive action to ensure younger children’s views are heard and centered.
A sector-wide duty of care to trans children
Trans children are disproportionately likely to experience rights violations in trans healthcare services for a range of reasons. Rights violations can occur actively by design, through clinical approaches shaped by pathologisation and anti-trans prejudice (Horton, Citation2024). Rights violations can be sustained passively, in services that incrementally adapt or repeat historic approaches without questioning or addressing the legacy of harmful policy and practice that is particular to trans children’s healthcare (Winters, Citation2022). This can happen for example in services that force trans children through extended and intrusive assessments, without inspecting the history of pathologisation and prejudice that informed past presumptions of clinical necessity. Rights violations can be sustained through subconscious cisnormativity, transnormativity or anti-trans bias (Pearce, Citation2018). They can also be engineered, through social climates and legislation hostile to trans existence (Abreu et al., Citation2022). A prejudice-driven rhetoric of child protection or safeguarding can ironically be weaponised to undermine child rights in a sector like trans healthcare, for example where unsupportive parents advocate for child rights violations and conversive practices. Rights violations are also more likely to persist in children’s trans healthcare due to power differentials between adults and children. Trans children are disadvantaged compared to trans adults in their ability to mobilize and collectively demand healthcare rights at an institutional, sectoral and national level, especially when already overwhelmed with a fight for rights, dignity and survival at family, school and community level (Amery, Citation2023; Hawkesworth, Citation2023).
In a context of historic, contemporary and likely future rights violations, greater efforts are needed to protect and defend the rights of trans children. This responsibility lies particularly with stakeholders in trans healthcare, including and perhaps especially professionals in adult trans healthcare. Healthcare professionals working in trans health need to consider their responsibilities to trans children, becoming active allies in articulating, establishing and holding the whole sector accountable to an ethical duty of care.
Healthcare professionals working in trans health need to step up, building a sector where child rights violations are no longer passively tolerated. This responsibility cuts across diverse arenas, in healthcare policy and practice, research, media, legislation, academic journals and conferences. In all these spheres healthcare professionals working in trans health, especially in adult services, can do more to call out child rights violations, centering trans children’s healthcare rights. Allies can add their voice in challenging pathologising rhetoric and centering the rights of child service users. Allies, particularly those with professional credentials, can make vital interventions in institutional or legislative consultations on trans healthcare policy and practice. Allies can and should do more to highlight and challenge abusive and rights-violating clinical practice.
Positive examples of stakeholders standing up for trans children’s healthcare rights can be found. The Welsh Children’s Commissioner, Rocío Cifuentes, recently called out the likely child rights violations in the National Health Service’s (NHS England) proposed approach to trans children’s healthcare. She described the NHS draft service specification as “highly concerning and…contrary to children’s human rights” (Children’s Commissioner for Wales, Citation2023, p. 42). She also critiqued proposed NHS restrictions on social transition, and plans to make healthcare access contingent on mandatory research participation, describing these requirements as “highly concerning”, at odds with a child’s right to “free and informed consent” (Children’s Commissioner for Wales, Citation2023, p. 42).
As healthcare practitioners and researchers, we recognize the significant challenges inherent in a shift to rights-based practice, especially in children’s trans healthcare. The forces invested in upholding the status quo are strong, notwithstanding the forces fighting for shifts in an even more regressive and harmful direction. A coalition for child rights must therefore be proactive, coordinated, strategic and assertive in testifying to the necessity of child rights-respecting practice. Progressive clinical stakeholders in children’s trans healthcare services will face extensive challenges to enacting reform, and need the support, backing and advocacy of clinical peers, especially those in adult healthcare. They will also need the support, ambition and accountability mechanisms of civil society, of groups working with trans, gender-diverse, and gender non-conforming children, of affirming families, and of children themselves, collectively using whatever power and influence is available to call for and demand healthcare that is respectful of child rights.
Conclusion and recommendations
We are at a critical moment for children’s trans healthcare services, with growing barriers and threats to rights-respecting practice. All actors within trans healthcare need to recognize and uphold a duty of care to children, with explicit and proactive commitments to children’s rights. In several countries and institutions forces opposed to trans rights are being successful in defending and expanding healthcare rights violations, starting with trans children. Trans-positive stakeholders in civil society, politics, communities, the media, and especially in healthcare services, need to more assertively articulate and defend trans children’s rights. This effort needs to be prioritized and resourced within healthcare institutions, with investment in identifying and tackling rights violations, being accountable to children and upholding child rights in service design, delivery and evaluation.
This editorial concludes by revisiting the critical pillars of rights-respecting practice. Earlier in this article (in Box A) rights were presented from a perspective of institutional and professional responsibilities toward trans, gender-diverse, and gender non-conforming children. Here we revisit and restate those same rights from the perspective of rights that are due to and can be claimed by children (Box B). This reframing of rights is vital as rights operate in both directions. Upholding child rights is a responsibility and duty of rights-bearers, in particular those with institutional and professional power and responsibilities (Box A). Rights can also be loudly and confidently demanded by trans, gender-diverse, and gender non-conforming children (Box B). Advocates for children’s rights can work both to hold institutions and professionals accountable, and to help children to understand, articulate and demand their rights. Trans-positive stakeholders, whether in civil society, politics, community, and especially those in healthcare services, need to be much more active, coordinated and effective in building a sector and society where trans children’s rights are secured.
Box B : Children’s rights in trans healthcare.
We recognize trans, gender-diverse, and gender non-conforming children’s rights to:
Safe and respectful healthcare, free from anti-trans prejudice.
Healthcare services where trans, gender-diverse, and gender non-conforming lives are welcomed and celebrated, not pathologized or problematized
Self-determination, in a healthcare system where trans children’s identities are recognized and respected
Bodily autonomy, in systems where children are protected from institutionalized control over their bodies.
An informed consent (or informed assent) approach to healthcare, where children have supported and evolving power and autonomy over their own healthcare.
Healthcare wherein diverse lives and healthcare pathways are recognized and respected
Healthcare unaffected by anti-trans bias
Safe and affirming homes and schools, where children are not exposed to violence, trauma and gender minority stress.
A safe and affirming wider political, legislative and media climate, where trans children can grow up in confidence and security.
Centre for Diversity, Research Policy and Practice, Oxford Brookes University, UK
[email protected]
Ruth Pearce*
School of Education, Glasgow University, UK
*Center for Applied Transgender Studies, Chicago, USA
Jaimie Veale
Trans Health Research Lab, School of Psychology, University of Waikato, Hamilton, New Zealand
T. C. Oakes-Monger
The Trans Learning Partnership, Spectra, UK
Ken C. Pang
Department of Adolescent Medicine, The Royal Children’s Hospital, Parkville, Australia; Clinical Sciences Theme, Murdoch Children’s Research Institute, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Melbourne, Australia [email protected]
Annie Pullen Sansfaçon
School of Social Work, University of Montreal, Montreal, Quebec, Canada; Canada Research Chair on Partnership Research and Empowerment of Vulnerable Youth, University of Montreal, Montreal, Quebec, Canada
Sophie Quinney
Cardiff and Vale University Health Board, Welsh Gender Service, NHS Wales, UK
Disclosure statement
No potential conflict of interest was reported by the authors.
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References
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