New Generations, New Genders
Eli Silver, ND
Transgender Adolescents and Informed Consent
Adolescents today are experiencing more flexibility and diversity in gender expression than in any previous generation. With this comes a growing need for ethical access to gender-affirming interventions such as androgen blockers, surgeries, and hormone replacement therapy.
Hormonal transition is often the earliest intervention in a young transgender or gender non-binary person’s life and can make huge improvements in both quality of life and measurable health outcomes. For many practitioners this presents a seemingly complicated ethical question: how can we judge an adolescent’s readiness to begin hormonal transition?
In this article we look at the unique health needs of transgender and gender non-binary adolescents, historic methods for determining readiness for gender transition, and the emerging philosophy of informed consent.
The Value of Supporting Gender Expression
Transgender and non-binary youth are at significantly higher risk for stress, familial or social rejection, and situational depression. According to the 2012 Youth Report by the Human Rights Committee,1 40% of gender-expansive youth surveyed (one-third of whom identified as “transgender” and two-thirds of whom identified as “other”) reported rejection or exclusion by their peers; 42% reported that they were frequently subject to homophobic or transphobic slurs; and only 9% reported that their communities were accepting of their gender identity. In that same study, only 4% of gender-expansive youth reported being “very happy,” as compared to 24% of their straight, cisgendered peers.1
These statistics represent a broad experience of social rejection and isolation that has significant health consequences: transgender youth are twice as likely to report drug and alcohol use as compared to their cisgendered peers,1 and lifetime risk of suicide attempt for transgender and non-binary individuals is a shocking 41%, compared with 1.6% for the general population.2
Children and adolescents who are allowed to live and express themselves according to the gender with which they identify have better outcomes, as reflected by a wide range of mental and physical health markers. Several studies have shown that, when allowed to live according to their experienced gender and given access to gender-affirming therapies, transgender and non-binary youth experience well-being and other mental health outcomes that are equal to or often better than their general-population peers.3 In addition, access to supportive adults such as family, community members, and healthcare providers significantly impacts the mental and physical health outcomes of transgender youth.
Despite this, many practitioners, due to their own lack of education or unconscious gender values, often fear that gender-affirming therapies for children and adolescents will somehow harm them. Due to this, they may place unnecessary roadblocks in the way of gender-affirming care, or refuse to offer care altogether.
Past Standards of Care for Transgender Individuals
Since the 1970s, many of our standards of care (SOC) for transgender and gender non-conforming individuals have been set by the World Professional Association for Transgender Health (WPATH). Past iterations of the WPATH’s Standards of Care required that both an assessment by a mental health professional and a diagnosis of gender dysphoria be in place before an individual was allowed to access the medications needed for gender transition.4 While the 2012 revision of WPATH’s SOC no longer makes this a requirement, 6-12 months of psychiatric care is still strongly recommended before a diagnosis of gender dysphoria is made and “the letter” is given to an individual to access gender-affirming therapies.5
The label “disorder” for what many would argue is a natural aspect of sexual and gender diversity is, in itself, often alienating and upsetting for transgender and non-binary individuals. Compounded by the reality of having to have one’s gender identity defined not by oneself but by a mental health provider, and the considerable time and cost of procuring such an assessment, this aspect of WPATH’s SOC has often been both emotionally degrading and prohibitive. For transgender and gender non-binary youth who are in areas where a trans-competent therapist is not available, WPATH’s SOC can be an absolute barrier to care.
With mental health providers acting as gatekeepers to care for transgender youth, many of these youth are unable to access hormones at an appropriate age. This can lead to delays in initiation of hormone therapy and the accompanying secondary sexual characteristics acquired in late adolescence, or it can encourage unsafe methods of hormone access, such as sharing hormones between friends or purchasing hormones illegally without a prescription or medical oversight. In addition, this carrot-on-a-stick scenario often fosters feelings of resentment or mistrust on the part of transgender youth seeking gender-affirming therapies, which can impact their long-term choices regarding medical professionals.6
Informed Consent: A New Model for Transgender Care
Ostensibly, the WPATH’s SOC assessment recommendations are in place to ensure that individuals don’t undergo therapies that can cause permanent alterations in their gender presentation without careful consideration. However, they don’t take into account that, while many people develop consciousness of their trans identity in late adolescence or adulthood, a significant percentage of individuals seeking gender-affirming therapies began to have an awareness of their gender variance in early childhood. By the time they seek these therapies, many youths have been carefully considering and researching gender transition for several years.
The most recent edition of the WPATH’s SOC, published in 2012,5 while still strongly recommending the need for a mental health diagnosis, does acknowledge the shift in mentality toward an informed consent model. Other leaders in transgender medicine and care, such as Fenway Health and the University of California San Francisco’s Center for Excellence in Transgender Medicine, have abandoned the notion of mental health evaluation altogether and wholly embraced informed consent as the model of choice for proceeding with gender-affirming therapies for both adolescents and adults.7
The informed consent model offers an alternative to the pathologization of transgender identities and paternalistic outlook on trans care and instead encourages practitioners to focus on patient education and open communication regarding the risks and benefits of hormonal gender transition.
In the context of pediatric care for transgender and gender non-binary patients, informed consent is invariably complicated by patient age and ability to understand therapies and their potential benefits and risks. While 18 is the age of consent in most states, many transgender youth who have parental support elect to begin their hormone therapy earlier: a transgender youth with family support may begin gender-affirming hormone therapy as young as 13 years old, though more commonly this will be initiated between age 16 and 18.8 In a scenario like this, it’s usually a pediatrician or care provider who will facilitate honest and transparent education of trans youth and their families.
In order to foster informed consent, practitioners take a front-seat role in honest discussion of hormones and hormone-blockers with youths and their families. It is the practitioner’s role to make sure that both the patient and their care providers understand the potential risks of denial of gender-affirming therapies, as much as they understand the risks of the therapies themselves. This requires the practitioner to truly step into the role of docere – the doctor as teacher – and to prepare adolescents and their families to determine their readiness for treatment. Once all parties understand the relevant risks and benefits of hormone therapy, the decision of whether or not to initiate treatment should lie with the individual and their families.
Our Roles as Practitioners & Allies
The structure and philosophy of naturopathic medicine offers us a unique opportunity to form relationships with our patients and their families. Within this framework we have a capacity to educate and evaluate our patients’ readiness to initiate gender-affirming interventions. While an ICD-10 diagnosis of gender dysphoria (F64) is often an important step in the process of obtaining insurance coverage for lab work, gender-affirming surgeries, and medications, the first and most important step for most trans youth and their families is initiation of care with a doctor who is willing to uphold their natural right to identify and define their own gender experience.
We have the opportunity to perform an incredible service for these children and adolescents, simply by giving them the information they need to make the best choices possible for themselves and their lives. While this may challenge some practitioners to re-evaluate their understanding of gender or their unconscious gender values, the informed consent model represents a critical respect for patient autonomy, including that of gender-expansive adolescents and youth.
- Baum J, Brill S, Brown J, et al. Supporting and Caring for Our Gender-Expansive Youth: Lessons from the Human Rights Campaign’s Youth Survey. 2012. Available at: http://assets.hrc.org//files/assets/resources/Gender-expansive-youth-report-final.pdf?_ga=2.57874860.763766954.1498499986-622149860.1497899458. Accessed April 28, 2017.
- Grant JM, Mottet LA, Tanis J. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. 2011. The National Gay and Lesbian Task Force and the National Center for Transgender Equality. Available at: http://www.thetaskforce.org/static_html/downloads/reports/reports/ntds_full.pdf. Accessed June 6, 2016.
- de Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704.
- The Standards of Care. Historical Compilation of Versions 1-6; 2005. World Professional Association for Transgender Health. WPATH Web site. http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351. Accessed August 8, 2016.
- Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th version; 2012. World Professional Association for Transgender Health. WPATH Web site. https://s3.amazonaws.com/amo_hub_content/Association140/files/Standards%20of%20Care%20V7%20-%202011%20WPATH%20(2)(1).pdf. Accessed August 8, 2016.
- Cavanaugh T, Hopwood R, Lambert C. Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients. AMA J Ethics. 2016;18(11):1147-1155.
- Deutsch MB. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People. 2nd ed. June 17, 2016. Available at: http://transhealth.ucsf.edu/protocols. Accessed November 18, 2016.
- Metzger DL. Endocrine Therapy for Transgender Youth. 2010. [Powerpoint presentation] British Columbia Children’s Hospital and the University of British Columbia. Available at: http://www.cpath.ca/wp-content/uploads/2010/06/EndoTransYouth.pdf. Accessed January 2, 2016.
Eli Silver, ND, is a trans-identified graduate of the National College of Natural Medicine in Portland, OR. In addition to running a busy private practice in the Detroit, MI, area, Dr Silver is an HRT education counselor and medical advocate to transgender and gender non-binary children, youth, and adults with Transcend the Binary, a Detroit-based advocacy and resource organization. Dr Silver is a dedicated proponent of advancements of the medical rights and access for queer and trans families and individuals.