Taking the Long Way Around:

Towards A Depathologized Ethical

Framework of Gender-Affirming
Care for Trans Youth
Navin Kariyawasam and Nanky Rai 1 1

1: UNIVERSITY OF TORONTO, TORONTO, ON, CANADA.

abuse, and to investigate families that enable such

Keywords: Gender
KEYWORD 1, KEYWORD
Affirming 2,Care,
KEYWORD
Trans Youth, 3,
care.3 This spate of legislation is unequivocally harm-
KEYWORD 4, KEYWORD
Pathologization, Informed5 Consent, Medical
ful to trans youth.4 The authors of this paper endorse
Colonialism
fulsome youth access to GAC. Further, these devel-
Abstract untur. Ut hil mo conse modipsam, omni-
opments reveal a more profound drive to maintain
mol enimagnatio
Abstract: Politicaleadebate
dis ipsapiciet
regardingalis
trans
doluyouth’s
Libus
domination through the enforcement of cisheteropa-
inciunttoreic
access gender-affirming
tesciditiunt alitas
care (GAC)
volore,hasnosIhici
pushed
triarchy as an essential feature of settler colonialism.
Estius to
many exera
advocate
coreritforquos
GACmiliquiatus
by pointing unt,
to tragic,
sequis
Regrettably, the mainstream response from trans-
ium faceaquae.
pathological outcomes
Giae porersped
of non-treatment,
quae dolor namely
ma.
supportive clinicians has, for the most part, not cen-
suicide. However, these pathologized arguments
tered on a liberatory approach to the rise in regressive
are a harmful ethical “shortcut” which should be
transphobic policies, but rather reinforces a problem-
replaced by a meaningful engagement with the
atic rhetoric of illness and tragedy rooted in saviour-
ethics of providing GAC to youth.
ism to justify youth access to GAC.5
Advocates, both clinicians and caregivers, have high-

I
lighted the supposed tragic outcomes of denying GAC
n the past year, numerous jurisdictions have
to youth, such as suicidality, self-harm, and depression.
placed significant restrictions on youth access
These treatments are often described as “lifesaving,”
to gender-affirming care (GAC), such as puberty
and their legislative bans are said to “deny life.”6 Clini-
blockade and gender-affirming hormone therapies.
cian responses to bans on care often centre on suicidal-
In the now-overturned Bell v. Tavistock decision, the
ity, and liken gender-affirming care to other lifesaving
High Court in London ruled that “children are highly
treatment such as antibiotics for a bacterial infection.7
unlikely to be able to consent to taking puberty block-
A paper detailing parent and caregiver perspectives on
ers.”1 As of July 2023, twenty U.S. states have passed
the legislation discussed above is provocatively titled,
laws or policy banning gender-affirming care.2 These
“This Could Mean Death for my Child.”8 Clinicians at
restrictions parallel those in the U.K. as broadly based
the Pediatric and Adolescent Gender Clinic at Stanford
in the stance that young people cannot consent to
Children’s Health describe the denial of care as “psy-
GAC. In 2022, Texas Governor Greg Abbott directed
chologically devastating,” and even ethicists seeking to
the Texas Department of Family and Protective Ser-
justify GAC for youth will often point to the miserable
vices to classify the provision of GAC to youth as child
outcomes of treatment omission as a core argument in
Nanky Rai, M.D., M.P.H., is a family physician in To- support of access.9 In a passionate speech to the Iowa
ronto and former 2SLGBTQIA+ Health Theme Lead at the state senate regarding a proposed ban on GAC, State
Temerty Faculty of Medicine at the University of Toronto. Senator Zach Wahls proclaimed “…kids are going to
Navin Kariyawasam, B.Sc. is a fourth-year medical stu- kill themselves because of this law. Iowa children will
dent at the University of Toronto, with a background in
die if this becomes law. That’s what will happen.”10 The
sexual diversity studies and trans health advocacy.
impetus to rescue trans youth from the suffering they

926 journal of law, medicine & ethics

The Journal of Law, Medicine & Ethics, 51 (2023): 926-937. © The Author(s), 2024. Published by Cambridge University Press on behalf of American Society of
Law, Medicine & Ethics. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (http://creativecommons.org/
licenses/by/4.0), which permits unrestricted re-use, distribution and reproduction, provided the original article is properly cited.
DOI: 10.1017/jme.2024.7
https://doi.org/10.1017/jme.2024.7 Published online by Cambridge University Press
 Kariyawasam and Rai

would endure with non-treatment is thus presented as and prisons and on reservations.”15 As part of the logics
the primary ethical justification for such care. of elimination and incarceration, mechanisms of con-
In so doing, clinicians reinforce rather than problem- trol and domination are created through the enforce-
atize the social and political forces aimed at restricting ment of White supremacist and Eurocentric social
the right to autonomy for trans youth. Sahar Sadjadi norms.16 As described by Lugones’ framework of the
identifies this concerning trend, critiquing dominant ‘coloniality of gender,’ the process of colonial settle-
narratives of saviourism and a “looming disaster of ment required the enforcement of normative gender
puberty.”11 Sadjadi argues that this sensationalism is a in order to construct relationships rooted in power and
problematic tactic, not only in that it locates pathol- domination.17 This construction afforded European
ogy within the individual trans child, but also in that colonizers, particularly settlers, a sense of superiority
it obscures a meaningful discussion of the ethics of which justifies the attempted genocide of Indigenous
GAC for youth. Opponents of youth access to GAC peoples and the ongoing invasion, theft, and occupa-
have recognized this rhetorical avoidance, calling it the tion of Indigenous territories.18 Indigenous scholars
“suicide card,” and pointing out the ways in which such Arvin et al. remind us of the political, intellectual, and
rhetoric appears to flee from a meaningful discussion ethical imperative of identifying the ongoing process of

In this paper, we will review critiques of the pathological framework of GAC

provision to youth, drawing upon work both in the clinical setting as well
as by theorists and scholars outside of medicine. We will then briefly review
theoretical and applied depathologized frameworks that more responsibly
engage with and honour the autonomy of trans youth.

of youth autonomy and capacity to make these medical settler colonialism as intertwined with that of cisheter-
decisions.12 opatriarchy, where the enforcement of Euro-Christian
To be sure, the narratives of suicide and pathology frameworks of the gender binary is also used as a tool
used to defend youth access to GAC are well-inten- to delineate ‘legitimate’ citizenship and access to land.19
tioned. They are also often accurate. Youth are likely to The maintenance of settler colonial domination relies
experience worse mental health outcomes as a result on the ongoing imposition of social hierarchies rooted
of restricted access to GAC, and we do not seek to in White supremacy, capitalism, and cisheteropatriar-
deny the realities of such transphobia. However, these chy.20 This allows for the ongoing unjust production of
inherently pathologized arguments are ultimately a the superior (read: socio-bio-psychologically normal)
harmful ethical ‘shortcut’ which should be replaced by therefore deserving settlers who can maintain access
a liberatory praxis of healthcare for trans youth. to occupied lands and resources. While this paper
We argue that the pathologization of gender diversity focuses on the need to dismantle rather than enforce
exists within the framework of settler colonial violence the pathologization of gender variance within clini-
and therefore reinforces rather than challenges the rise cal care, our critique must remain grounded within
in regressive policies attempting to erase the very exis- the broader context in which pathologization is used
tence of gender variance. The amplified and reinforcing as a mechanism of control to maintain settler colonial
nature of patriarchy, heterosexism, and transphobia/ domination.
cisnormativity — aptly defined as cisheteropatriarchy13 In this paper, we will review critiques of the patho-
— cannot be understood outside of the context of colo- logical framework of GAC provision to youth, draw-
nialism, in particular settler colonialism. Patrick Wolfe ing upon work both in the clinical setting as well as
characterizes settler colonialism through the “logic of by theorists and scholars outside of medicine. We will
elimination,” whereby eliminating colonized peoples then briefly review theoretical and applied depatholo-
allows for the theft of Indigenous territories and the gized frameworks that more responsibly engage with
foundation of settler society.14 In addition to the logic and honour the autonomy of trans youth. Our aim is
of elimination, Luana Ross describes colonialism as that clinicians who work with trans youth begin to
a logic of incarceration where Indigenous people are rethink the ways in which they interact with patients
“confined in forts, boarding schools, orphanages, jails and advocate for their access to GAC in the face of

medical-legal partnerships: equity, evaluation, and evolution • winter 2023 927

The Journal of Law, Medicine & Ethics, 51 (2023): 926-937. © 2024 The Author(s)

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 IND EPEND ENT

contemporary attacks on their autonomy. Ultimately, The dominance of the pathologized model is clearly
the authors argue that the pathologization of gen- seen not only in the ethics and advocacy cited above,
der diverse people, including trans youth, is an inte- but also in the diagnostic criteria required for youth
gral aspect of settler colonial assimilation processes. to access GAC in the first place. The definition of gen-
Deconstructing the dominant modes of thinking der dysphoria in the Diagnostic and Statistical Man-
around trans youth and their supposed need for treat- ual of Mental Disorders (DSM) requires a finding of
ment must be understood in the context of a broader “clinically significant distress” for at least six months.28
anti-colonial practice that seeks to name, resist, and Guidelines also continue to recommend a diagnosis of
dismantle settler colonialism, cisheteropatriarchy and dysphoria before GAC is initiated.29 As such, clinicians
white supremacy. expect to see trans youth in distinctly distressful and
pathologized states in order for them to access GAC.
Critiques of the Pathological Framework The most recent World Professional Association for
The justification of youth access to GAC through nar- Transgender Health (WPATH) Standards of Care 8
ratives of tragedy and suicide is undeniably imbri- recommend that youth meet criteria for an ICD-11
cated within a broader positioning of trans bodies diagnosis of gender incongruence, which represents
as inherently sick and in need of correcting by medi- some progress as it does not directly name distress or
cine. Heyes and Latham identify this, arguing that pathology, but still requires a marked and persistent
such medical narratives construct suffering as being incongruence for diagnosis.30 Diagnostic manuals and
constitutive of transness.21 This pathologized eth- clinical guidelines31 also shape the views of policymak-
ics of GAC for youth can be understood through Eve ers and the general public, defining conceptions of
Tuck’s analytical lens of “damage-centred research.”22 normalcy and psychopathology.32
Tuck identifies that while such research is often used Pathological frameworks in the justification of GAC
to leverage reparations or other progressive ends, it for youth, while hegemonic in medicine and even
is ultimately “a pathologizing approach in which the mainstream trans advocacy, ultimately disempower
oppression singularly defines a community.”23 Tuck trans youth and limit their future life options. As such,
draws linkages between damage-centred research and we explore both the individual and institutional level
settler colonialism, where damage-centred research is impacts of a pathologized approach to GAC for trans
instrumentalized to bolster eugenic projects rooted in youth below. Only then, can we better understand the
white supremacy and global capitalism, allowing for ethical imperative to move beyond this approach.
the ongoing domination and exploitation of Indige-
nous peoples and other dispossessed communities. As Impacts of a Pathologized Approach
such, medical institutions’ reliance on damage-cen- Individual-Level Impacts
tered approaches to trans youth continues to reinforce Pathological approaches to the ethics of GAC for
supremacist ideologies based in settler colonialism. youth have a number of harmful effects on the per-
Tuck presents desire-centred research frameworks as son, the most obvious of which is the label of pathol-
a way forward. These frameworks centre the full sub- ogy itself. Such a label is not only inaccurate, in that
jectivity of people involved and are equipped to high- gender diversity is not pathological, but also functions
light structural inequity.24 This will be explored in fur- to attribute any discomfort or distress that trans youth
ther detail in the second part of this paper. may experience as inherent to an illness within them,
In light of the critiques reviewed here, activists have as opposed to the structures of the society in which
been calling for depathologization in trans medicine. they live.33 This is not only problematic in and of
The International Campaign Stop Trans Pathologiza- itself but also, as Horowicz argues, limits therapeutic
tion is a platform that denounces the effects of pathol- approaches, in that diagnostic criteria become indi-
ogization, such as the removal of autonomy for trans vidual symptoms to treat, limiting a holistic approach
patients and the imposition of restrictive and invasive to the youth’s needs.34
evaluations.25 This discussion has grown to include Proponents of the pathological model may defend
trans youth as well, with proponents of depathologi- the current framework in that distress and dysphoria
zation noting higher risks of discrimination, coercive are not posited as inherent to trans identity, but rather
treatment, and binary conceptions of gender under a result of living within a transphobic society. Such an
a pathologized model.26 However, as much of the lit- argument is disingenuous, given the frequent require-
erature cited above indicates, this position is still an ment of distress for access to GAC, especially in the
emerging one, with the dominant position remaining case of youth, whose advocates rely heavily on justifi-
pathological with respect to trans youth.27 cations based in suicide prevention and mental illness.

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The Journal of Law, Medicine & Ethics, 51 (2023): 926-937. © 2024 The Author(s)

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 Kariyawasam and Rai

Indeed, many advocates will simultaneously acknowl- at large. Through the construction of difference as
edge that dysphoria is not constitutive of transness, pathology, the maintenance of a normative gender
yet present the necessity of GAC as based in its role model has been used to regulate and eliminate “devi-
as a treatment for dysphoria.35 Clearly, pathology and ant bodies.” This construction has allowed for the
distress are seen as core to trans identity, as they are preservation and securitization of settler colonial
often the only path to accessing GAC, both ethically nation states and global capitalism, through the elimi-
and clinically. nation of deviance and supremacy of the “normal”
In addition to the pathological label itself, pathol- elite.45 Healthcare professionals, as gatekeepers to
ogization also surreptitiously reifies a binary con- GAC, are positioned as adjudicators of authentic gen-
ception of gender in both medicine and trans youth der, ultimately producing the gender that they ostensi-
themselves. The pathologization of gender variance bly observe and diagnose.46 This is particularly perni-
is historically and discursively based in attempts to cious in the early stages of trans identity development,
preserve a gender binary.36 Such a binary schema of where young people often feel they must choose a path
gender in medicine was deliberately constructed so as so as to access GAC, for which treatment protocols are
to quell fears of a third sex and other such non-binary also highly binarized.47 When clinical practice regard-
bodies.37 Nelson writes: ing gender is formulated in a binary, youth are often
coerced into conformity, in order to be legible to the
That is, society could rest easy with medicine clinicians who dictate their access to care.
pathologizing gender ‘deviance’ and proposing This coercion not only happens at a sociopsycho-
a clinical strategy for explaining and containing logical level, but at a somatic one as well. SAEFTY’s
it: nobody’s genitals were going under the knife report found that youth also felt pressured to follow
unless they had the right kind of illness, and a typical “cookie-cutter” path in their medical transi-
besides, nothing that happened in an operating tion, even when this did not reflect their own transi-
room on any single patient could really challenge tion goals.48 This approach, which always begins with
gender’s ‘fundamental truths’ — e.g., that there puberty blockade and ends with surgery to reflect
are two and only two, that everyone has one or a binary gender, has been identified and problema-
the other, and which one you are is determined tized thoroughly.49 The prevalence of youth seeking
by some deep and immutable fact.38 ‘partial’ treatment (treatment that does not follow a
binary path) is increasing, yet they are often denied
This binary continues to be starkly visible in DSM care because they do not meet the full criteria for
criteria.39 With minimal acknowledgement of non- diagnosis.50 In this way, diagnostic criteria erase the
binary identities, the breadth of diagnostic criteria individual subjectivity and gender constellation of
focus on a desire to be the “other gender.”40 This is trans youth, particularly those who are non-binary.
even more apparent for children, with criteria focused Konnelly identifies this transmedicalist framework as
on masculine and feminine toys and games, “cross- one which pressures non-binary people to push them-
dressing,” and again the desire to be the “other gen- selves into a binary in order to be legible to providers.51
der.”41 The same normative beliefs around trans youth This ideology, for which the medical institution is
are seen in the previous WPATH Standards of Care 7, responsible, even begins to seep into one’s own experi-
whose recommendations continue to influence count- ence of their identity,52 something to which youth are
less guidelines worldwide.42 A qualitative report on especially vulnerable.
trans youth experiences at the Gender Diversity Clinic The binary framework of gender resulting from a
in the Children’s Hospital of Eastern Ontario (CHEO), pathologized and diagnostic model also impacts the
by SAEFTY Ottawa, found that patients were often therapeutic relationship trans youth have with their
uncomfortable with these questions about toys and clinicians. When youth are aware that they must meet
clothing, feeling that “they perpetuated cissexist and certain diagnostic criteria in order to access GAC, they
binary understandings of gender.”43 Similar experi- will often overemphasize the elements of their experi-
ences were reported in New Zealand, where young ence that fit normative medical models: performing
adults felt that readiness assessments were designed a gender that their clinicians will deem legible and
to establish whether they were “trans enough.”44 worthy of treatment.53 This is observed empirically,
Critically, the binary framework of gender in medi- with youth in SAEFTY’s report similarly describing a
cine, rooted in pathology, is not only inaccurate, but pressure to perform stereotypical gender, and at times
plays a critical role in the reproduction of the gen- lying to clinicians so as to access treatment.54
der binary within clinical environments and society

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 IND EPEND ENT

That youth may be required to perform a false gen- it inhabits. Trans theorists have critiqued the medical
der experience to access GAC must primarily be read approach to trans children in that it is formulated to
as a form of medical gender regulation. Dean Spade taxonomize and order gender.60 This is intimately tied
argues that such requirements constitute medi- to a pathological model, where GAC is constructed as
cal governance, designed to regulate trans folks and a remedial treatment to a classified disease.61 Such a
reify normative gender.55 This is, again, used as a dis- construction not only limits the gender possibilities of
cursive tool to retain regulatory and colonial power young trans patients, but also plays a significant role
over bodies labeled as deviant. There are also harm- in a broader system of gender regulation.
ful clinical implications. Trans youth often do benefit The taxonomical and classificatory framework
from therapeutic support in the exploration of their inherent to the pathological model of trans medicine
gender, especially if these supports do not exist else- has been problematized by trans scholars as medical
where. However, the clinicians who care for them and psychiatric colonization.62 This term is impor-
play a dual role of gatekeeper and support. These two tant, in that it identifies the profound imbrication of
roles are in conflict, where youth benefit from genuine pathologization within systems of power that con-
honesty and exploration of their uncertainties, while tinue to label, regulate, and oppress bodies considered
simultaneously aware that they must perform a level deviant. Diagnostic manuals and narratives of the
of normativity and assuredness so as to retain access tragic, inherently ill trans patient position that per-
to care.56 The limits therefore placed on trans youth’s son as a pathological, exotic being, in need of study
ability to disclose to their clinicians are a clear harm to and medical salvation.63 A discursive separation is
their overall care. Furthermore, Ashley calls for us to made between the “us” of medical science and “them”
embrace an “ethics of exploration,” rather than seek- of trans communities who seek GAC. It is upon this
ing to identify and predict a stable gender concept in foundation that narratives of saviourism (intimately
young people.57 This is explored further below. tied to notions of supremacy) can be built. The argu-
The pathological model places further barriers to ment that trans youth need access to GAC to save
access on trans youth. For instance, to satisfy diagnos- them from their eventual suicide and mental illness
tic criteria, youth are often asked deeply invasive ques- plainly cooperates with such a narrative.
tions. They may be questioned on their relationship to The othering of trans youth as a politically distinct
their genitals, the toys they played with as children, “them” is observable in the asymmetric application
or their family dynamics. Young people report feeling of ethical protections to trans youth compared to cis-
uncomfortable with the invasiveness of such inquiry, gender youth. This asymmetry is highlighted by Mil-
expressing that it often feels as though it is to satisfy a rod, addressing the argument that the irreversibility
clinician’s curiosity.58 Yet invasive questions are inher- of GAC makes youth consent to such care impossi-
ent to a model that must locate a pathology within the ble.64 Milrod identifies that similarly irreversible pro-
body in order to justify care. cedures are regularly offered to cisgender youth in a
It is critical to recognize the basis of pathology in variety of settings. A more ludicrous example can be
the patient impacts detailed above. Requiring a path- seen in Pilgrim and Entwistle’s ethical discussion on
ological diagnosis for access to GAC invites the rigid youth capacity to consent to GAC, where a single case
diagnostic criteria that constrain gender to a binary, of necrotizing fasciitis after gender-affirming surgery
restrict treatment protocols, and require performance is cited as a meaningful consideration in the broader
and invasive evaluation. When ethicists and clinicians ethics of such procedures, as though necrotizing fas-
advocate for youth to access GAC on the grounds that ciitis is not an equivalent risk in countless procedures
they will suffer tragic outcomes if left untreated, such performed for young patients.65 Trans youth here
narratives uphold a medical discourse that places are surreptitiously othered as politically and ethi-
trans youth as inherently ill, while evading the true cally distinct from their cisgender peers, furthering
ethical questions at play. a broader regulatory project of labeling and segregat-
ing deviance.
Institutional Impacts Crucially, medicine is deeply involved in this politi-
As stated in the introduction, pathologized narratives cization and disproportionate regulation of trans
of trans folks must be understood contextually within youth. Medicine not only plays a considerable role
a broader system of settler colonialism through “the in trans governance and legal recognition, but also
imposition of the settlers’ gender and sexuality sys- holds almost unilateral control over the determina-
tems of cisheteropatriarchy.”59 The diagnostic model tion of viable and non-viable forms of life.66 Again, it
fixes gender into a stable concept, inherent to the body is pathologization that enables such tight regulation

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 Kariyawasam and Rai

of trans politics, wherein psychiatric dominance and in GAC for trans youth is to remove the diagnosis
gatekeeping to GAC enable a discursive monopoly on entirely: a conclusion already reached by key schol-
legitimate gendered expressions and ways of life.67 ars.75 This is not to disregard the work of innumerable
Critics of pathologization have established a clear trans activists who have used a pathologized frame-
link between pathologizing trans identity and resul- work to achieve recognition from which trans youth
tant desires to treat and prevent such a “medical con- benefit today. As Krieg notes, pathological classifica-
dition.”68 The most dramatic example of this is the tions of trans people were formed in a hostile socio-
continued legitimacy given to the ethics of prevent- political context, where a conception of trans people
ing trans identity in youth altogether, which is often as sick was the most socially palatable means of legiti-
presented as a reasonable ethical debate.69 It is deeply mizing treatment.76 This approach, while flawed, was
concerning that such eugenic principles are given any meant to bring the community genuine benefit, and
credence, even to the point that the WPATH must those who espoused such models should not be vili-
explicitly identify attempts to prevent trans develop- fied. Rather, we must envision the next chapter of clin-
ment as “no longer considered ethical.”70 Here again, ical care for trans youth as moving past and through
the connection to settler colonialism must be reiter- pathologization.
ated. One of the most pernicious weaponizations of A more responsible approach in the ethics of GAC
medicine within colonialist projects is through eugen- for trans youth centres their autonomy and their pre-
ics and the “prevention” of deviance. This allows for rogative to self-determination. However, to rid our-
the maintenance of Eurocentric colonial hierarchical selves of a pathologized framework of youth consent
psychosocial processes that afford settlers control over to GAC leaves us with an important ethical task. Even
peoples, lands, and resources.71 That preventing non- scholars critical of a medicalized and pathological
normative identities and expressions continues to be approach to trans medicine recognize the need for
discussed in earnest represents the ongoing impacts building clinical care that is rooted in bidirectional
of cisheteropatriarchy and White supremacy as key accountability, including informed collaborative
features of colonial ideology that remain embedded decision-making and capacity assessments.77 How do
within medicine. we offer healthcare to trans youth without position-
Beyond such a dramatic instantiation of pathologiz- ing them as sick? How do we evaluate their capacity
ing medical governance, attempts to make the body without erasing their autonomy? If we reject the ethi-
more normative are also clearly visible in GAC for cal shortcut of pathologization, what ethical pathways
trans youth. One of the goals of gender-affirming care exist for providing GAC to youth?
for pubertal youth is described as enabling “a trans-
gender individual to blend into society more easily as Taking the Long Way Around
their affirmed gender.”72 Gill-Peterson problematizes Rethinking Gender-Affirming Care for Trans Youth
arguments used in trans youth medicine that early Developed as an alternative to the standard diag-
transition enables easier passing and a more norma- nostic model, the informed consent model empha-
tive body.73 Such rhetoric posits the value of early tran- sizes patient autonomy and a collaborative approach
sition in its ability to ultimately reduce trans visibility towards care.78 This model removes requirements of
and maintain a visible gender binary. Again, this argu- external evaluations and diagnoses, acknowledging
ment is rooted in pathology, where early intervention that the person is often best positioned to evaluate
enables the treatment of the deviant nature of trans- their benefit from treatment options (with risks and
ness, so as to enable greater assimilation into cisgen- benefits discussed with their healthcare provider).
der society. This is not to invalidate the very legitimate Central to this model are the person’s own experi-
desires that many trans youth may have to ‘pass’ as ences, understanding, and leadership in clinical
normatively gendered people, but rather to problema- decision-making. Rather than having clinicians diag-
tize the broader medico-social society that demands nose a need for treatment, the person seeking GAC is
such presentation. As such, Gill-Peterson calls for us informed of their options and the associated risks, and
to reimagine the clinic entirely, with centrality placed a decision is made collaboratively.
on what trans children say about themselves.74 Leaders in adult trans medicine have embraced
And in light of the plethora of individual and sys- the informed consent model, one of its pioneers
temic harms of pathologization, this reimagined clinic being Fenway Health in Boston, Massachusetts, and
must be completely devoid of a pathological model. increasing uptake is being seen now in hundreds of
The only way to deconstruct the continued medical clinics. Empirical research on adult experiences at
coercion and investment in colonial gender systems these clinics is encouraging.79 Analogous models are

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 IND EPEND ENT

also being legislated in certain jurisdictions, such as in distinction to the implicit prevention of trans identity
Argentina’s Gender Identity Law,80 which allows self- throughout 20th century medicine, by enabling the
identification with no additional requirements.81 want and desire for trans life to develop and flourish.88
While the informed consent model continues to In Ehrensaft’s words, we must “learn to live with gen-
grow in support in adult trans medicine, as Clark and der ambiguity and not pressure our children with our
Viriani note, youth are still required to undergo the own need for gender bedrock.”89
diagnostic and pathologizing requirements of older Critiques of pathology and tragedy as the impetus
models of care.82 In opposition to this, Clark and Viri- for medical care are far from new, and there is a vast
ani advocate in favor of an informed consent model for body of work from which more responsible models
trans youth as well. They present both a deontological can be gleaned, many of which are already in practice.
and consequentialist imperative for an informed con- Developing such models further is out of scope pres-
sent model in GAC for youth, as well as their empirical ently, but there is much to be learned from a review of
research in a youth gender clinic in British Columbia, existing literature. In Tuck’s critique of damage-cen-
Canada.83 They found that youth aged fourteen to tred research, a desire-centred framework is posited
eighteen were able to demonstrate sufficient under- as a possible antidote.90 In Tuck’s words, “desire-based
standing of GAC to provide informed consent, and research frameworks are concerned with understand-
that youth recognized the significance of their deci- ing complexity, contradiction, and the self-deter-
sion, distinguishing it from less consequential deci- mination of lived lives.”91 Desire, in this case, is for-
sions they might make in their regular life. mulated as generative, engaged, and centred on the
Yet, even the informed consent model can be full subjectivity of those involved. Such a framework
applied with a pathologizing lens, with clinicians still flips the script of blame and responsibility and is bet-
perceiving their care as rectifying an illness. Its heavy ter equipped to expose structural inequity. A desire-
reliance on a vague clinical judgement of capacity also centered framework calls for an epistemological shift,
enables inconsistency and bias, which is likely to dis- where the goal is not to “paint everything as peachy,
proportionately affect poor, Indigenous, Black, other as fine, as over” and rather “accounts for the loss and
racialized, and/or disabled youth.84 While a fulsome despair, but also the hope, the visions, the wisdom of
exploration of racial bias in the provision of GAC to lived lives and communities.”92 This depathologizing
trans youth cannot be done justice presently, it is criti- framework resists domination and the creation of the
cal that novel frameworks of care actively engage with subhuman, instead moving us all towards uphold-
the intersectional marginalization of trans youth and ing people’s right to self-determination, which the
account for the ways in which they are likely to face authors believe is a necessary prerequisite for health
multiple axes of oppression when seeking care. and well-being.
Other work highlights the value of dignity in ethical
Celebration, not Cure deliberation regarding GAC in youth.93 Here, GAC is
In addition to an informed consent model, a funda- not seen as a treatment to an inherent illness nor sal-
mental shift in the provision of GAC to trans youth vation from ensuing tragedy, but rather as a means by
may proffer a more fulsome understanding of the role which medicine can support trans youth in accessing
GAC plays in their development. Ashley invites us to dignity and self-actualization. These are meaningful
interrogate the primary assumption in the status quo elements of well-being and represent legitimate goals
debate that youth are cis by default.85 Instead, Ashley of healthcare in their own right. SAEFTY’s report pro-
advocates for an “ethics of exploration” rather than vides examples of what this could look like clinically.
an “ethics of prediction.”86 While gender exploration They suggest evaluating young patients by focusing on
is presently seen as a precondition to GAC, explora- experiences that bring about gender euphoria, com-
tion can in fact be achieved through it. In simplified fort, and joy.94 Such an approach clearly focuses more
terms, this means that we ought not assume that GAC on supporting youth in accessing their well-being,
is meant to affirm a previously determined, stable, rather than diagnosing a pathology of dysphoria.
and static gender, but rather that a fulfilling gender A significant body of literature also suggests for-
can be explored and built through GAC. Similarly, Kai mulating the interface between trans embodiment
Cheng Thom calls on us to let go of the illusion that and medicine as similar to that of disability medicine.
we can be sure of a static and immutable gender and Based on the work of Robert McRuer, Krieg applies the
instead embrace the messy complexity of gender and social model of disability to trans medicine.95 The social
life.87 In this approach, fears of desistence make little model locates trans issues as contextualized within a
sense. Furthermore, such thinking stands in contra- gendered and transphobic society, built in contradis-

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 Kariyawasam and Rai

tinction to a medical model, which locates pathology opatriarchy that remain deeply entrenched within
within the trans body. This model leans heavily on work healthcare institutions.
in crip theory and disability justice, where disability is
also located in an ableist and inaccessible society, rather Conclusion
than the individual.96 Such a model would enable a Implications, Limitations & Future Directions
more responsible ethics of GAC for trans youth, in that Further work must be done to explore the models dis-
they would be seen as having distinct access needs for cussed in this paper, both theoretically and empiri-
which they may seek medical support. cally. The field of GAC, particularly for youth, is new
Using a disability justice lens offers two clear ben- and growing, and the lack of long-term data contin-
efits. The first is that the disadvantages and possible ues to be a hindrance to clinicians and advocates in
distress experienced by trans folks are seen as rooted supporting their patients and communities. More-
in the society in which they live. As such, GAC would over, this paper was unable to address several key
not be seen as correcting a bodily pathology that causes elements of trans medicine. The pathological model

The implications of this paper can expand beyond trans medicine as well.
The ethical quandary presented by youth access to GAC offers a more
expansive enlightenment on status quo frameworks of pediatric consent.

distress, but rather supporting trans youth inhabiting has not only historically been used to ethically jus-
a cisheteropatriarchal world.97 The second benefit is tify GAC, but also to advocate for insurance coverage.
that GAC itself would not be seen as the treatment How alternative models can be instrumentalized for
of an illness. This rejects the common narratives in the same purposes remains to be seen. This is a criti-
contemporary ethics for this field of care, which rely cal limitation of the present work, as financial access
on the justification of treating a tragic illness, instead to GAC is not only imperative but also affects trans
identifying unique access needs that trans youth have. youth made most vulnerable through capitalism and
This not only removes a stigmatizing and restrictive classism. Yet, while this was not explicitly explored in
pathological label, but also fosters a more collaborative our work, much of the shift from the need to treat an
approach to GAC in trans youth, where their unique illness to the responsibility to empower a choice can
access needs are considered, rather than a “cookie- be applied to funding as well. More fundamentally, the
cutter” treatment path being foisted upon them. authors support a critical interrogation of insurance
The use of a disability justice model is not without coverage as the model of economics in healthcare in
criticism, with legitimate concerns expressed about and of itself.
the continued reliance on a form of diagnosis, whether With regard to pediatric ethics, many ethical ques-
a disability or pathology.98 The approach will have to tions remain, such as approaches to dissenting par-
be carefully built, but there is certainly much to be ents, fertility preservation, and supportive discontinu-
learned from disability justice. ation of GAC. The present paper also failed to address
Critically, the models presented above should not the vital intersections between trans medicine, race,
be understood as mutually exclusive. In moving past and racism. While we address the central role of set-
pathologized ethical frameworks of GAC in youth, a tler colonialism in the creation of gender as pathol-
simplistic and definitive approach, while tempting, is ogy, we have not directly addressed the multiple axes
unlikely to suffice. Lessons from desire-centred frame- of marginalization and unique access needs facing
works, informed consent models, and disability justice Two Spirit Indigenous youth, as well as trans youth of
ought to be used in confluence, so as to foster the most colour, particularly Black trans youth. Further work
supportive, inclusive, and responsible ethics of care must be done to understand these nuanced interac-
with trans youth. Through this work we can not only tions and best support youth in these situations.99
support trans youth in embodying self-determination Other intersectional approaches, such as in GAC for
but can also begin the process of undermining settler disabled youth, require analysis as well, especially
colonial structures and practices rooted in cisheter- due to the frequent removal of autonomy for these
communities.

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 IND EPEND ENT

The implications of this paper can expand beyond the ethical shortcut of pointing to tragedy and illness
trans medicine as well. The ethical quandary pre- in order to justify such care, especially in the face of
sented by youth access to GAC offers a more expansive the unconscionable legislative attacks on trans youth
enlightenment on status quo frameworks of pediatric we have seen in the past years. Yet, the continued
consent. There exists a considerable body of ethical lit- attempts to remove trans youth autonomy and invali-
erature critiquing dominant approaches to minors in date their personhood make a depathologized ethical
healthcare in that they severely underestimate youth approach all the more imperative. We must learn to

This paper reviews extensive critique of the traditional approaches to

GAC provision for trans youth. A framework that justifies such care
by pathologizing trans youth and lamenting the tragic outcomes of non-
treatment, such as suicide and mental illness, is found to be rooted in
cisheteropatriarchy, a central feature of settler colonialism. The landslide
of legislation attacking the autonomy of trans youth is a continuation of an
ongoing process of colonial attempts to control and oppress “deviance,”
in service of white cisheteropatriarchal supremacy.

capacity to consent.100 As Alderson notes, adults are “embrace discomfort [and] appreciate ethical com-
typically presumed competent unless they show dis- plexity.”102 Diagnostic frameworks of evaluating youth
cernable signs of incompetence; the inverse is true access to GAC participate in the ongoing medical colo-
for minors.101 In rethinking their approach to trans nization of gender deviance, leading to the erasure of
patients, we ask clinicians to consider expanding this non-binary genders, the requirement of false gender
reformulation to their adolescent practice as a whole. performance, and invasive evaluations that ultimately
Questions of competence, desistence, and rationality form a barrier to access. The cumulative impact of
are not uncommon in pediatrics, and the frameworks these patient-level consequences results in ongoing
reviewed in this paper may be helpful in many clinical settler colonial exploitation and expropriation.
scenarios. Rather than taking this problematic ethical short-
cut, we implore clinician advocates to take the long
Summary way around. This fundamental switch in the practice
This paper reviews extensive critique of the tradi- of GAC, which challenges rather than reinforces cis-
tional approaches to GAC provision for trans youth. heteropatriarchy, leads to improved access to anti-
A framework that justifies such care by pathologiz- oppressive healthcare, with the potential to uplift
ing trans youth and lamenting the tragic outcomes rather than undermine broader anti-colonial move-
of non-treatment, such as suicide and mental illness, ments towards liberation. We must do the uncomfort-
is found to be rooted in cisheteropatriarchy, a central able work of rethinking GAC for trans youth, as well
feature of settler colonialism. The landslide of legisla- as trans medicine more broadly. Only through this dis-
tion attacking the autonomy of trans youth is a con- comfort can a truly liberatory framework of GAC for
tinuation of an ongoing process of colonial attempts trans youth be achieved.
to control and oppress “deviance,” in service of white
cisheteropatriarchal supremacy. We have also begun Acknowledgements
a cursory exploration of possible ways forward in the We would like to thank SAEFTY Ottawa (particularly Ollie and
Sam) for their invaluable contributions, both through their excep-
provision of GAC, drawing from Tuck’s desire-centred tional report as well as their input on this project. We would
research, Ashley’s ethics of exploration, applications also like to thank the many people who inspired, supported, and
of the informed consent model, and work in disability reviewed this work, including Nat Rambold, Sarah Millman, Eric
Zhao, and Melissa Giblon.
justice.
Building a responsible ethical approach to GAC for
Note
trans youth is a daunting and delicate task. It is no The authors have no conflicts to disclose.
surprise that well-meaning advocates have relied on

934 journal of law, medicine & ethics

The Journal of Law, Medicine & Ethics, 51 (2023): 926-937. © 2024 The Author(s)

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 Kariyawasam and Rai

13. The term cisheteropatriarchy is complex and multifaceted. For

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https://doi.org/10.1017/jme.2024.7 Published online by Cambridge University Press