There is a powerful political movement in this country to prevent transgender minors from accessing gender-affirming care. Twenty-seven Republican-controlled states have banned it, the Supreme Court upheld the laws’ constitutionality, the Justice Department subpoenaed doctors and hospitals for information related to it, and President Trump issued an executive order threatening to withhold funding from hospitals that provide it. Politicians say that they’re protecting minors from harm: for example, Arkansas’s Save Adolescents from Experimentation Act and Montana’s Youth Health Protection Act. But these bans don’t protect children. They harm children in an ideologically driven effort to make them conform to a view of sex and gender that is cultural, not natural. This amounts to paternalistic coercion.
With some exceptions, minors are legally incompetent, so they can’t consent to medical treatment. But ethically, minors should participate in medical decision-making in age-appropriate ways. Ideally, minors would assent to treatment even though they cannot legally consent. Because no one can consent for someone else, parents give permission for their children’s medical treatment. And clinicians make evidence-based judgments about which treatment is in a child’s best interests. This is the gold standard when it comes to pediatric care: when all three parties – the child, the parents, and their clinicians – agree on what should be done.
When this ideal is not achieved, we address it in different ways. Since Meyer v. Nebraska (1923), the Supreme Court has recognized parents’ right to control their children’s education and upbringing. If a child doesn’t want a vaccine but the parents and clinicians think it’s best for them, the child gets immunized. Generally, parents are also allowed to refuse treatment for their child. However, when they refuse treatment that is medically necessary, the state intervenes. So, even when the child and parents agree, sometimes the medical provider’s expert opinion overrides both. For instance, if Jehovah’s Witnesses refuse a life-saving blood transfusion for their child, the state takes custody and permits the treatment. None of these situations captures what’s happening with gender-affirming care. Legal bans apply precisely when the child, the parents, and clinicians all agree, which make them an anomaly in pediatric bioethics.
When a person’s body (or anticipated future body) does not match their gender identity, they often experience psychological distress, known as gender dysphoria. The most effective treatments are counseling and, sometimes, hormonal therapy or surgery. Hormonal treatments typically involve puberty blockers, which delay the onset of puberty by suppressing the production of hormones, and gender-affirming hormone therapies, usually estrogen or testosterone. Puberty blockers tend to be prescribed in early- to mid-puberty, and gender-affirming care is initiated in later adolescence. Surgical treatment typically involves chest reconstruction for transmasculine minors. Genital surgery is almost never performed on minors. Although the number of transgender youth has grown in recent years, only 1.4 percent of adolescents in the US now identify as transgender, and only 2-4 percent of them seeks any kind of medical intervention.
Some medical decisions can wait until a patient turns eighteen, but all the major medical associations, including the American Medical Association, support gender-affirming care as “medically necessary” for at least some transgender youth. Research shows that, when transgender children feel alienated from their own bodies and are repeatedly misgendered by people around them, they have higher rates of depression, anxiety, self-harm, and suicidality. Although targeted counseling can alleviate some of these symptoms, in many cases gender dysphoria can only be effectively treated with both therapy and medical interventions. Studies show that gender-affirming care reduces depression, anxiety, and suicide attempts; improves relationships with parents and peers; and reduces the risks of self-treatment with hormones and silicone obtained from non-medical sources.
Given all these benefits, in situations where everyone involved wants it – the patient, parents, and medical providers – what could possibly justify legal bans on gender-affirming care? Right-wing politicians say that transgender youth will eventually regret it because they’ll be sterile and can’t “nurture their children through breastfeeding.” But this means that the government is putting many adolescents at risk for the sake of a small minority. Only about 7 to 13 percent of those who pursue gender affirmation decide to detransition at some point (so-called “desisters”). And 82.5 percent of that group is motivated by external factors such as pressure from family and transphobic social environments rather than internal factors such as fluctuations in their gender identity. If politicians really cared about trans kids, they’d require more thorough mental health assessments for gender dysphoria, or they’d find ways to protect them from fear and violence, rather than banning treatment that is medically necessary.
By focusing on regrets around reproduction, the state is acting paternalistically, making children align with conservative views on sex and gender. They presume the “biological truth” that there are only two sexes and only two genders, and they expect that people who are assigned female at birth will want to be mothers. The presumption is belied by the facts that some people are born intersex and some people have a deep sense of gender identity that doesn’t conform to the sex they were assigned at birth. And the whole history of feminist critique shows us that gender does not determine people’s basic projects and desires (such as becoming parents).
Even right-wing politicians acknowledge that a binary view of sex is an artificial construct. For example, the Tennessee statute (SB 2696) prohibits gender-affirming care for transgender youth but allows medical treatment for minors “with a medically verifiable genetic disorder of sexual development” (that is, infants and children who are intersex) to correct “external biological sex characteristics that are irresolvably ambiguous.” By recognizing the existence of intersex children, the law itself assumes that there are natural variations in sex (rather than a binary) but characterizes some variations as pathological defects in need of correction. These exceptions for intersex allow medical treatment even when children cannot participate in any way in decision-making. Hormone treatments and puberty blockers are also used, without controversy, for gender-conforming treatment, such as managing early puberty. This shows that these bans are not trying to protect transgender children’s future autonomy but to impose on them (and society as a whole) traditional norms of sex and gender, based on a culturally contingent idea of what is good for them.
Bans on gender affirming care for minors claim to be protecting children, but they actually prevent children from getting the care they need. They ignore the fundamental right of children and their parents to make their own medical decisions. They force a conservative view of sex and gender onto patients that does not stand up to scientific and moral scrutiny.
Matthew C. Altman, PhD and Cynthia D. Coe, PhD are philosophy professors at Central Washington University.