For medical consent to be properly “informed,” patients must understand the treatment in question and its likely impact on their health and life. This requires a comprehensive explanation from a medical professional of the diagnosis and its related uncertainties. It also involves laying out the full range of treatment options – including doing nothing – and the related advantages, disadvantages and achievable outcomes. Even after all this, however, judging whether a patient fully understands can be difficult. Research suggests many patients comprehend or retain very little of the provided information, leaving serious doubt as to whether a patient’s consent is truly informed.
Yet despite such barriers to informed consent among adults, many jurisdictions have begun allowing children to legally consent to a variety of therapies and activities without parental involvement or guidance. In the UK, medical consent can be given at 16 years of age. In Canada, according to the mature minor doctrine, children even younger than this can make serious medical decisions if they are deemed sufficiently mature. In Quebec, for example, medical consent can be given by a child as young as age 14. Eighteen European countries also allow for medical consent by children aged 14 or “according to their maturity” without parental consent. And when the maturity of minors is in doubt or parents disagree between themselves, the courts may decide against either parent’s wishes and “in the best interests of the child.”
With minors being empowered with giving medical consent, parents are not only prevented from participating in such decisions but may not even be informed of the planned medical procedures. The grave problems inherent to this relatively new concept of “consenting minors” are on full display in the case of gender dysphoria.
Gender Roils
Gender dysphoria involves the feeling that one is not at ease in one’s biological body. Claims of this condition have increased tremendously in recent years: according to a 2019 report by Trans Youth CAN!, pediatric cases in Canada rose from just a few in 2004 to over 1,000 in 2016. New gender clinics have opened offering puberty blockers, cross-sex hormones and surgery to address patients’ inner feelings by adapting their bodies to their felt gender identities. All this is known as “gender-affirming treatment” (GAT).
In Canada, following recent amendments to the Criminal Code outlawing what is known as ‘conversion therapy,’ providing any treatment other than GAT is now illegal. ‘Patients are essentially placed in the driver’s seat, prescribing their own treatments,’ Lloyd writes.
GAT usually entails medical and surgical interventions, with psychotherapy only coming as a sideline, if at all. Pre-puberty children presenting with gender dysphoria are usually given puberty blockers to “gain time” and delay their normal biological development so they can later decide whether to move on to cross-sex hormone treatment. Most of them reportedly do so. These hormones are continued for life and can be complemented with surgery to change the outward appearance so as to bring it more in line with the patient’s gender identity.
Given the life-changing consequences involved in a decision to embark on GAT, informed consent should necessarily play a major role. Yet, as Jean Lloyd explains in an essay on Abigail Shrier’s 2020 book Irreversible Damage: The Transgender Craze Seducing Our Daughters, the foundational concept of medical consent has been turned on its head when it comes to GAT.
Rather than explaining the consequences and causes of gender dysphoria to a patient, the only approach offered by GAT practitioners in many Western jurisdictions is unconditional acceptance of the patient’s feelings. In Canada, for example, following recent amendments to the Criminal Code outlawing what is known as “conversion therapy,” providing any treatment other than GAT is now illegal. “Patients are essentially placed in the driver’s seat, prescribing their own treatments,” Lloyd writes. Lloyd quotes a Canadian plastic surgeon who admits that, “For us, the diagnosis is made by the patient, not the doctor.”
Instead of relying on the opinion of medical professionals, people who consider themselves to be gender dysphoric are classified as “clients who are transgender [and entitled] to access hormone treatments and surgical interventions without undergoing mental health evaluation or referral from a mental health specialist.” Subjective self-evaluation is thus accepted as medical truth and it is the doctor who “consents” to a treatment requested by the patient.
Some of the more disturbing anecdotes recounted by Shrier sound almost cult-like: ‘At 18, Julie moved out, began a course of testosterone and abruptly cut off contact with her parents.’
Shrier, a Wall Street Journal columnist, interviewed over 200 people for her book. She warns that gender dysphoria among teenaged girls appears to be a socially contagious, self-diagnosed phenomenon similar to anorexia. Termed “Rapid Onset Gender Dysphoria,” this condition can also affect boys, although the bulk of current research and attention focuses on how girls are pushed towards it through their social environment.
“Fleeing womanhood like a house on fire”: In her 2020 book Irreversible Damage: The Transgender Craze Seducing Our Daughters, author Abigail Shrier charts the worrisome and dramatic rise in gender dysphoria among pubescent girls.
Shrier believes numerous factors may play a role: social media and smartphone use, the media’s image of women, pornography, or trying to escape male attention or abuse. “Many adolescent girls identifying as transgender don’t actually want to become men,” she writes. “They simply want to flee womanhood like a house on fire, their minds fixed on escape, not on any particular destination. They feel alienated from their bodies and the changes brought by puberty: acne, periods and breast development, and uncomfortable attention from men.” Some of the more disturbing anecdotes recounted by Shrier sound almost cult-like: “At 18, Julie moved out, began a course of testosterone and abruptly cut off contact with her parents.”
Maturity Impossible
It is well-established that the prefrontal cortex, the part of the brain that plans and organizes behaviour to achieve goals and inhibits impulses, does not fully develop until age 25. This process of brain maturation, and of maturity in general, is a major reason why parental guidance is vital to informed consent in the context of medical decisions regarding minors, for many of the issues involved in consenting to GAT require clear thinking about long-term goals and desires.
Stephen B. Levine is a retired psychiatrist who was chair of the Harry Benjamin International Gender Dysphoria Association’s Standards of Care committee in 1998. He also served on the American Psychiatric Association DSM-IV Subcommittee on Gender Identity Disorders. In a 2019 article in the Journal of Sex and Marital Therapy, Levine identifies four key questions that should be asked of any patient requesting GAT to determine their appreciation of the long-term risks and consequences:
- What benefits do you expect that the consolidation of this identity, gender transition, hormones, or surgery will provide?
- What do you understand of the social, educational, vocational, and psychological risks of this identity consolidation and gender role transition?
- What do you understand about the common and rare short- and long-term risks of hormone and surgical interventions?
- What have you considered the nature of your life will be in ten to twenty years?
Levine’s third question is crucial. According to authoritative medical research, taking puberty-blocking drugs can affect bone density and lead to weight gain, headaches and even sterility. Cross-sex hormones also entail serious risks. For boys, oral estrogen may place them at elevated risk for cardiovascular disease, thrombosis, weight gain, hypertriglyceridemia, elevated blood pressure, decreased glucose tolerance, gallbladder disease, prolactinoma and breast cancer. Girls taking testosterone may experience low “good” cholesterol and elevated triglycerides, increased homocysteine, hepatotoxicity, polycythemia, increased risk of sleep apnea, insulin resistance and unknown effects on breast, endometrial and ovarian tissues.
Levine concludes that teenagers are unlikely to understand the manifold consequences of GAT or the full implications of transitioning to another gender. He asks whether, for example, they comprehend that “most people in society should be expected to avoid them as love objects.” It is also typical for a transitioned person to have few friends and a small pool of people from which to find a loving partner.
The American Psychological Association (APA) seems to agree. While the APA otherwise supports GAT, its guidelines warn that teenagers’ “intense focus on immediate needs may create challenges in assuring that adolescents are cognitively and emotionally able to make life-altering decisions.” (The full guidelines are here, but require purchase.) These serious concerns about maturity leave informed consent in limbo, especially for minors.
Some in the trans lobby, however, would exclude parents from decisions around gender identity and related treatments. Only adults? Good practices in legal gender recognition for youth, a report by the International Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Youth & Student Organisation (IGLYO), clearly views parental consent as an obstacle. “It is recognised that the requirement for parental consent or the consent of a legal guardian can be restrictive and problematic for minors,” the report states before recommending that “states should take action against parents who are obstructing the free development of a young trans person’s identity in refusing to give parental authorisation when required.”
A Significant British Court Case
A lawsuit heard in the High Court of England and Wales in 2020 illuminates many of the conflicting issues regarding informed consent for GAT. The case was brought by Keira Bell, a transsexual who later regretted her decision to embark on GAT and has since “de-transitioned,” or reversed treatment options to realign her gender identity with her biological sex.
‘[Puberty blocking drugs] prevent the child going through puberty in the normal biological process,’ the judges wrote. ‘This means the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity.’
In her suit, which attracted considerable public attention in the UK, Bell claimed she had not properly given informed consent when she started drug therapy involving puberty blockers at England’s only public clinic for children seeking gender identity treatment, run by the Tavistock and Portman NHS Foundation Trust. Notably, the UK requires parental consent for GAT until age 16. Yet even with that, Bell felt misled and wronged by the health professionals involved in her case.
In their judgement, the three High Court judges expressed concern that very few children coming to Tavistock were refused puberty blocking drugs. Rather, the clinic simply provided information until they deemed the child ready to make an informed decision. This created a problematic situation, as expert witness Sophie Scott, director of University College London’s Institute of Cognitive Neuroscience, noted in testimony:
“Given the risk of puberty blocking treatment, and the fact that these will have irreversible effects, that have life-long consequences, it is my view that even if the risks are well explained, that in the light of the scientific literature, that it is very possible for an adolescent to be unable to fully grasp the implications of puberty-blocking treatment. All the evidence we have suggests that the complex, emotionally charged decisions required to engage with this treatment are not yet acquired as a skill at this age, both in terms of brain maturation and in terms of behaviour.’”
The judges concluded that the clinic’s wide-spread use of puberty blockers interrupted a natural process that children need to pass through before they can fully form their own gender identity. “[Puberty blocking drugs] prevent the child going through puberty in the normal biological process,” the judges wrote. “As a minimum it seems to us that this means that the child is not undergoing the physical and consequential psychological changes which would contribute to the understanding of a person’s identity.”
Additionally, the Court held that puberty blockers were used as a stepping-stone to hormone therapy in the majority of cases. The question raised is whether such medical intervention is warranted at such a young age or whether, having been left to continue through puberty, these children would have resolved their gender dysphoria naturally, as the literature indicates most of them do.
In the most important finding of its ruling, issued in December 2020, the court concluded it would be impossible for a minor under the age of 16 – possibly even under 18 – to properly give informed consent, since they are unable to fully grasp the consequences of their decision. “There is no age-appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years,” the ruling states. “In respect of children aged 14 and 15, we are also very doubtful that a child of this age could understand the long-term risks and consequences of treatment…to give consent.”
As a result of the High Court ruling, the Tavistock clinic was subsequently prevented from handing out puberty-blocking drugs to minors under 16 without a court decision. However, this seemingly sensible ruling was struck down on appeal less than a year later. Rejecting the evidence considered at trial on procedural grounds, the appeal court held that the courts must not take sides in the discussion around the risks and benefits of GAT, instead leaving all of this to professionals and legislators. This ruling denies the general protection that Bell had sought against misleading advice from health professionals. The matter may now make its way to the UK’s highest court.
Developments in Other Jurisdictions
Earlier this year, the responsibility vacated by the UK Appeals Court was taken up in Texas. In February, State Attorney-General Ken Paxton bypassed the normal legislative process and issued a legal opinion declaring that certain GAT therapies should be considered a form of child abuse. Some parents promptly challenged this order in court and the case is currently mired in competing legal procedures.
Texas is not the first state to tackle GAT. Arkansas banned the practice in April 2021, an action that was followed by a federal court decision blocking the state legislation. A trial expected to begin this July may decide the fate of the law. Meanwhile, several other U.S. states are considering similar legislation. Early this year, for example, Florida’s House of Representatives was discussing a bill to make hormone therapy and sex-change surgery performed on children illegal. By last month, 15 states had enacted or were considering similar laws to restrict GAT. This remains a fiercely contested issue across the U.S., where emergency room staff, therapists, and doctors in some states may now report parents to child welfare agencies if they refuse to accept GAT for their children.
In Sweden, the Karolinska Hospital stopped providing GAT in April 2021. The move followed a change in GAT orientation in neighbouring Finland, which now gives priority to psychological intervention rather than medical or surgical treatment. And earlier this year, the Swedish Health Board issued guidance advising against the use of puberty blockers and hormones to treat gender dysphoria in children. The Swedish documentary series The Trans Train, which documented the lives and disappointments of several gender dysphoric patients who had gone through GAT but later came to regret their decisions, may have helped turn the tide in Sweden and Finland. In 12 other European countries, hormone therapy can only be given to adults.
Turning the tide: The widely-watched Swedish television documentary The Trans Train played a major role in shifting public opinion about GAT in Europe; on the show Sametti, a transgender female from Finland (below), explained her regret at having gender treatment.Australia initially adopted a position similar to the UK High Court’s ruling in the Bell case – that court approval is necessary before GAT can be provided to minors. These safeguards were removed by a subsequent ruling, however. And while guidelines developed by the Australian Professional Association for Trans Health call for ignoring parental consent if the children involved are deemed competent, the courts ended this practice in 2020.
In Canada, there is no whiff any political pushback. Quite the opposite. Controversial conversion therapy ban legislation was supported by all parties in Parliament late last year, essentially leaving GAT as the only route available for gender dysphoric Canadians. It is now a criminal offence to treat a patient’s underlying issues with the objective of aligning gender identity with biological sex. A dissenting parent, pastor or psychologist could receive a prison sentence of up to five years for breaking the law. Such a move also greatly weakens the issue of informed consent, since it makes any alternatives illegal.
While Canada’s new law may settle the issue legally – or appear to – it sidesteps the hardships that detransitioners say they suffer as a result of easy access to GAT. As Detrans Canada argued in its brief to a parliamentary committee prior to the passage of the conversion therapy ban, many detransitioners feel they were not sufficiently informed before consenting to their transitioning process, and that medical staff did not always follow best practices and standards of care in approving them for GAT. Some detransitioners in the U.S. feel the same way and have filed malpractice lawsuits which are quietly being settled out of court.
The Trans Bonanza
GAT therapies such as puberty blockers, hormone therapy and surgery are covered by the public health care system in many jurisdictions, including Canada. According to Forbes magazine, the U.S. market for transition services could run as high as US$200 billion, or $150,000 per patient who transitions. This does not include the cost of de-transitioning for those who later regret their decision.
Internationally recognized medical standards for treating gender dysphoria are provided by the World Professional Association for Transgender Health’s (WPATH) Standard of Care document of 2012. It directs practitioners to treat coexisting mental disorders only as part of an overall GAT approach. Patients are to be affirmed in their gender non-conformity, and given puberty blockers. They should also be referred to peer support groups.
These guidelines provide no clear indication that gender dysphoria can be alleviated by other means. Psychotherapy is not required and the treating doctor is never mandated to question a patient’s gender non-conforming feelings. In fact, any treatment that might seek to bring a patient into conformity with their biological gender is declared unethical. This creates a one-way pathway towards gender non-conformity and related medical interventions. That, in turn, creates a rapidly growing demand for pharmaceuticals, such as Lupron, to treat ever-increasing numbers of children presenting with gender dysphoria.
WPATH members who developed these guidelines have been accused of significant conflicts of interest. This includes receiving income based on recommendations included in the guidelines as well as working at clinics or universities that receive funds from advocacy groups, foundations, or pharmaceutical companies that stand to gain from certain treatment paradigms. Some have also received grants from organisations such as transgender advocacy group Tawani Foundation related to research favouring the GAT approach. Of course, such clubby relationships are common throughout academia and science. Of potentially greater concern is that these guidelines were developed without substantive input from scientists and practitioners who may express reservations about GAT or who might advocate psychiatric intervention before commencing pharmaceutical treatments.
The lucrative GAT market has also attracted the attention of Planned Parenthood, the U.S.-based abortion provider. Planned Parenthood has quickly become the nation’s second-largest provider of puberty blockers. Funding for transition treatments, as well as much of the political advocacy required to make such treatments mainstream, has come from many wealthy individuals, including the Pritzker family, George Soros, Martine Rothblatt, Tim Gill, Drummond Pike, Warren and Peter Buffet, Jon Stryker, Mark Bonham and Ric Weiland. Many of these funders stand to gain indirectly from increased sales of puberty blockers and sex-change surgeries arising from their investments in the pharmaceutical industry or health care providers.
A Different Approach
“I’ve learned that there are so many factors that can lead to gender dysphoria that have nothing to do with having been born in the wrong body,” wrote a Canadian parent in the leadup to the federal vote on the conversion therapy ban legislation. “I have learned that feelings of gender dysphoria do not last forever. I have had to navigate this on my own and with extremely little support. I feel that medical professionals, mental health professionals, and policy makers are letting families down.”
Based on testimony from parents, concerned doctors and even the courts, consent by a minor should not be sufficient to make a decision with the momentous physical, psychological, social and even financial consequences of GAT. Yet even parental consent cannot easily substitute for the unknowns of GAT. Consider the less controversial example of a hysterectomy.
Hysterectomies are an irreversible procedure with serious, life-altering implications and possible negative health impacts. Not surprisingly, the medical profession is very careful about recommending this procedure. The Washington, D.C.-based National Women’s Health Network, states that, “It is incredibly unlikely that a doctor will perform a hysterectomy on women ages 18-35, unless it is absolutely necessary to their well-being and no other options will suffice.” Why is a similar level of prudence not applied in cases of children and teenagers contemplating GAT?
The increasing number of detransitioners who came to realize that transitioning to another sex did not resolve their problems suggests that the claimed benefits of GAT have been overstated and the risks and harms suppressed. Yet evidence from interviews with detransitioners confirms that affirmation is often the only therapy available at many clinics. As a 2018 essay in The Atlantic by Jesse Singal observed, “Affirming care has quickly become a professional imperative: Don’t question who your clients are – let them tell you who they are, and accept their identity.” In Canada, this is now imposed by law and is one of the main reasons Detrans Canada was created.
GAT may not even be “necessary” for many patients given that most gender-dysphoric children who do not receive GAT revert to accepting their biological sex once they have moved through puberty. The Appeals Court ruling in the Bell case cited British Endocrine Society statistics that found 85 percent of pre-pubertal children overcome their gender dysphoria by adolescence without medical intervention. This suggests that parents who deny consent for such procedures – where they have such authority – are acting reasonably and in their child’s best interests.
There are other concerns about gender dysphoria beyond the difficulties of proper diagnosis and the phenomenon of social contagion. One is the high proportion of autistic children who present at gender clinics. University of Toronto researchers found that over 20 percent of gender dysphoria patients are on the autism spectrum, a relationship that is poorly understood. Similarly concerning is that Wallace Wong, a psychologist at the Children’s Hospital in Vancouver who runs a “children’s only” gender therapy practice, admits that a large share of the children he sees for gender dysphoria are orphans or foster children. Further, it has been observed that most gender dysphoric boys had an especially close relationship with their mother and a distant, peripheral relationship with their father.
All these examples of unusual or unexpected confounding factors should raise serious questions about the underlying causes of gender dysphoria and how it can best be addressed. And given that most gender dysphoric children resolve their dysphoria by adulthood, how can GAT be the only treatment on offer?
Suicide Prevention?
It is often claimed that providing anything other than affirmation raises the risk of suicide for the youth in question. Parents are thus presented with a Sophie’s Choice of options: “Would you rather have a live daughter or a dead son?” Yet, this may often simply be a tactic to extract parental consent. There is ample evidence of such a ploy on the internet and elsewhere. Psychologist Wong, for example, is on record suggesting his patients claim suicidal tendencies in order to facilitate GAT.
Parental rights bills, as have been tabled in some U.S. jurisdictions, may help bring balance to this sharply polarized field. Even better is the Swedish and Finnish approach which restores science to its central place in this crucial medical question.
A survey of parents with children who have declared their own gender dysphoria found that internet use often spiked prior to their child’s declaration, with 20 percent obtaining advice that how using a “suicide narrative” could help convince their parents to consent to GAT. This makes it difficult to discern how many suicide threats are real and how many are used as a tool to manipulate adults. As Singal wrote in The Atlantic, “The clinicians I interviewed said they rarely encounter situations in which immediate access to hormones is the difference between suicide and survival.”
According to Paul Hruz, a pediatric endocrinologist at St. Louis Children’s Hospital in Missouri, “There’s a very good reason to be concerned about the outcome [of transitioning children] specifically, that some of the largest studies that have been done with the longest follow-up have shown that suicide rates remain markedly elevated after you undergo these affirmation interventions.” Two studies from Sweden and the Netherlands also concluded there was no reduction in suicidal tendencies among post-transition adults. Other research suggests limited mental health benefits of GAT. In fact, there may be aggravating effects. Puberty-blocking drugs such as Lupron could actually increase the risk of suicide.
Overcoming Ideology
An ideologically-driven public discourse about GAT is detracting from a true understanding of what really is going on with gender-dysphoric people. Are they truly born in the wrong body? Is there such a thing as an inner soul or identity – encompassing gender – that is independent of the body we live in? Just a few years ago, most of us would have answered “No.” Very often, other elements are at play.
We must decide if GAT is to be regarded as medical treatment that offers benefits in line with other therapies and prescribed medication. In its Tavistock ruling, the UK High Court expressed serious doubt on this front. “The clinical intervention we are concerned with here is different in kind to other treatments or clinical interventions. In other cases, medical treatment is used to remedy, or alleviate the symptoms of, a diagnosed physical or mental condition, and the effects of that treatment are direct and usually apparent. The position in relation to puberty blockers would not seem to reflect that description.” It is an important point, even if it was superseded by a later higher court ruling.
There are strong reasons to doubt that in any case informed consent can be given by a minor given the realities of the adolescent brain and the confounding factor of reproductive immaturity. Where parental consent can assist by pushing back against wrongheaded medical advice, the vested interests of the pharmaceutical industry or a child’s impulsiveness, this critical safeguard is often removed as a matter of course. In Canada, GAT is now the only option legally available, rendering the very concept of informed consent meaningless since there are no alternatives to consider.
Parental rights bills such as have been tabled in some U.S. jurisdictions may help bring balance to this sharply polarized field. Even better is the Swedish and Finnish approach, which restores science to its central place in this crucial medical question. We must also listen to the detransitioners and grapple with the many studies that place a pro-GAT narrative in serious doubt. There are still many questions left to be answered about what factors contribute to gender dysphoria, whether it persists past puberty, and about the quality of the information accessed by children through social media or directly by GAT advocates. Caution is called for.
Research must be detached from ideological and monetary interests. And laws like Canada’s could be challenged as unconstitutional. Note that Paul McHugh, University Distinguished Service Professor of Psychiatry at the Johns Hopkins University School of Medicine, suggests that GAT is a fad that will eventually fade away in similar fashion to other grievous errors of psychiatry, such as eugenics and frontal lobotomies. As we learn from more international examples, McHugh may well be proven right.
Until then, we must be vigilant to protect our most vulnerable children.
Martin Tampier is a writer, lecturer, concerned parent and part-time political activist. Born in Germany, he has called Canada home since 1999 and currently works as an engineer in Quebec.
Source of main image: Shutterstock.
