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JSM Sexual Medicine

Improving Access to Care and Consent for Transgender and Gender Diverse Youth in the United States

Mini Review | Open Access

  • 1. Department of Plastic and Reconstructive Surgery, Temple University Medical Center, USA
  • 2. University of Chicago Medicine, Chicago, USA
  • 3. Department of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, USA
  • 4. Rush Medical College, Rush University Medical Center, USA
  • 5. New Health Foundation Worldwide, Evanston, USA
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Corresponding Authors
Alireza Hamidian Jahromi, Department of Plastic and Reconstructive Surgery, University of South Florida, Tampa, Florida, USA
Abstract

Gender-affirming care (GAC) aims to benefit transgender and gender diverse (TGD) youth. GAC includes access to mental health, medical care, and surgical interventions. However, access to GAC and the youth’s ability to consent to GAC is frequently contested. This editorial reviews access to care for TGD youth and discusses perspectives on youth consent for GAC. Pertinent challenges include the ability to provide informed consent within current medical and legal frameworks, mental health and parental concerns, and the long-term effects of GAC. Further research, advocacy, and patient education are warranted to ensure safe access to GAC for TGD youth.

Keywords

• Transgender youth

• Consent

• Access to care

• Adolescent healthcare

• Transgender healthcare

CITATION

Jahromi AH, Reynolds A, Stoehr JR, Whitney N, Ettner R (2023) Improving Access to Care and Consent for Transgender and Gender Diverse Youth in the United States. JSM Sexual Med 7(3): 1116.

INTRODUCTION

The United States is engaged in an ongoing debate regarding access to and consent for gender-affirming care (GAC) for transgender and gender diverse (TGD) youth. TGD individuals, defined as those under 18 years of age, represent a significant portion of the transgender population. The World Professional Association for Transgender Health Standards of Care version 8 (WPATH SOC8) defines “transgender and gender diverse” as gender identities or expressions that differ from the assigned sex at birth, encompassing diverse identities like genderqueer and nonbinary [1,2].

Gender affirming care (GAC) includes mental health, medical, and surgical interventions to address gender dysphoria in TGD individuals. Balancing the rights of TGD youth to make confidential decisions, have reproductive autonomy, and self determine their gender identity with the rights of parents or legal guardians to make therapeutic decisions and ensure treatment safety and efficacy is a complex issue. However, evidence suggests that initiating GAC in youth is safe and provides mental health benefits [3-6]. Currently, most TGD youth in the United States are unable to provide consent for GAC due to age or legal restrictions. This delay in accessing GAC can have profound implications for mental health and long-term health outcomes. This article aims to summarize the current legal standards, explore perspectives on consent for TGD youth, and identify opportunities to improve access to care for TGD youth in the United States.

The Current State of Consent and Access to Gender Affirming Care (GAC) in the United States

In the United States, the age of majority varies across states, ranging from 18 to 21 years old. While minors can receive care for sexually transmitted diseases without parental consent in most states, access to STD prevention and HIV-specific care varies. General healthcare services, including GAC, are available to minors in 12 states, with age restrictions in certain cases. Access to mental health care for minors also varies across states. Consequently, most TGD youth require parental or guardian consent to access GAC. Advocacy efforts may need to focus on expanding minors’ medical care rights or designating GAC as a protected category.

Since 2021, more than 20 predominantly Republican-led states have enacted legislation affecting transgender minors [2]. In 2023 alone, 17 states have implemented bans or significant restrictions on gender-affirming care for underage individuals, including cross-sex hormones and puberty blockers. These laws vary by state, with some imposing penalties on healthcare professionals providing such care and others allowing limited exceptions. Iowa, Mississippi, and Indiana prohibit assistance to minors seeking gender-affirming care, with Mississippi extending the prohibition to all involved, including parents. Mississippi’s law allows legal action against doctors within a 30 year statute of limitations. South Dakota permits continuation of hormone treatment until year-end for minors with pre-existing prescriptions, gradually reducing the dosage. Kentucky’s law restricts care until the end of June. Montana’s forthcoming law targets social transitioning by banning state resources from promoting changes in names, pronouns, or appearances [2] .

Considerations Regarding Consent to Gender Affirming Care (GAC) in Transgender and Gender Diverse Youth

WPATH SOC8 categorizes medical and surgical interventions for adolescents with gender dysphoria into three categories: fully reversible, partially reversible, and irreversible [1]. The first two categories, which include pubertal suppression using gonadotropin-releasing hormone analogs and hormone therapy with estrogen or testosterone, are typically considered for transgender and gender diverse youth. Irreversible interventions, such as genital surgery, are never performed on young individuals, while chest surgery may be considered for emotionally and physically mature older adolescents on a case-by-case basis. Clinicians providing care should carefully consider the individual’s emotional and cognitive development when assessing their capacity to consent to each intervention [3]. While there are well-documented benefits of initiating gender-affirming treatments at an early age [4], it is crucial to acknowledge concerns, such as the ability to consent, mental health concerns, and parental discordance.

Clinicians providing gender-affirming care (GAC) to transgender and gender diverse (TGD) youth must consider their patients’ ability to provide informed consent [7-9]. While the World Professional Association for Transgender Health (WPATH) SOC8 acknowledges the possibility of informed consent from adolescent patients, the American Association of Pediatrics recognizes that only a subset of adolescents possess this capacity [8].

Minors have historically been allowed to consent to care, such as sexually transmitted infection treatment or contraception. Access to GAC could qualify under this exemption, given its sensitive nature and potential similarity in risks to other allowed care. The mature minor doctrine applies to minors who demonstrate capacity to make informed decisions about interventions. This doctrine’s applicability varies by state, but many TGD youth possess the understanding necessary to consent to medical GAC [9-14]. Additionally, the consent practices in medical research involving TGD youth could serve as a model for expanding consent in gender-affirming care [15].

The WPATH SOC8 highlights the importance of involving mental health clinicians in the care of transgender and gender diverse (TGD) youth, including family counseling and psychotherapy [2]. Gender-affirming psychotherapy and counseling are crucial for educating TGD youth about medical and surgical gender-affirming care (GAC), enabling them to understand the associated risks, benefits, and alternatives. Additionally, medical GAC has been associated with improvements in mental health, making it a potential complement to behavioral or psychological GAC [3].

Discordance between parents and TGD youth regarding gender-affirming care (GAC) is a significant challenge. Parental support is crucial for the well-being of TGD youth, as lack of support increases hardships and poor health outcomes [10,11]. When discordance occurs, initial approaches should focus on reconciliation through shared decision-making, mediation, or appointing a third-party guardian. In extreme cases, parental involvement may endanger the safety of TGD youth, leading to homelessness and other risks [12,13].

In the face of restrictive regulations and politicians disregarding medical advice, healthcare providers engaging in gender-affirming care must arm themselves with up-to-date data and advocate for their patients. TGD youth are among the most vulnerable populations, and healthcare professionals have the opportunity to positively impact their health outcomes. Continued research, advocacy, and service to the TGD youth community are essential during these unprecedented times.

REFERENCES

1. Coleman E, Radix AE, Bouman WP, G R Brown, A L C de Vries, M B Deutsch, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022; 23: S1-S259.

2. American Civil Liberties Union. Legislation affecting LGBTQ rights across the country 2021. New York, NY; 2021.

3. Chen D, Abrams M, Clark L, Diane Ehrensaft, Amy C. Tishelman, Yee Ming Chan, et al. Psychosocial Characteristics of Transgender Youth Seeking Gender-Affirming Medical Treatment: Baseline Findings From the Trans Youth Care Study. J Adolesc Health. 2021; 68: 1104 1111.

4. Kidd KM, Thornburgh C, Casey CF, Pamela J Murray. Providing care for transgender and gender diverse youth. Prim Care. 2020; 47: 273 290.

5. Nieder TO, Mayer TK, Hinz S, S Fahrenkrug, L Herrmann, Inga Becker Hebly, et al. Individual treatment progress predicts satisfaction with transition-related care for youth with gender dysphoria: a prospective clinical cohort study. J Sex Med. 2021; 18: 632-645.

6. Turban JL, King D, Kobe J, Sari L Reisner, Alex S Keuroghlian. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One. 2022; 17: e0261039.

7. Kimberly LL, Folkers KM, Friesen P, Darren Sultan, Gwendolyn P Quinn, Alison Bateman-House, et al. Ethical issues in gender-affirming care for youth. Pediatrics. 2018; 142: e20181537.

8. Katz AL, Webb SA, COMMITTEE ON BIOETHICS. Informed consent in decision-making in pediatric practice. Pediatrics. 2016; 138: e20161484.

9. Clark BA, Virani A. This wasn’t a split-second decision: An empirical ethical analysis of transgender youth capacity, rights, and authority to consent to hormone therapy. J Bioeth Inq. 2021; 18: 151-164.

10. McCann E, Donohue G, Brown M. Experiences and perceptions of trans and gender non-binary people regarding their psychosocial support needs: a systematic review of the qualitative research evidence. Int J Environ Res Public Health. 2021; 18: 3403.

11. Simons L, Schrager SM, Clark LF, Marvin Belzer, Johanna Olson. Parental support and mental health among transgender adolescents. J Adolesc Health. 2013; 53: 791-3.

12. Priest M. Transgender children and the right to transition: medical ethics when parents mean well but cause harm. Am J Bioeth. 2019; 19: 45-59.

13. Notini L, McDougall R, Pang KC. Should parental refusal of puberty blocking treatment be overridden? The role of the harm principle. Am J Bioeth. 2019; 19: 69-72.

14. Sims JP, Nolen C. “I Wouldn’t Trust the Parents To ‘Do No Harm’ To a Queer Kid”: Rethinking Parental Permission Requirements for Youth Participation in Social Science Research. J Empir Res Hum Res Ethics. 2021; 16: 35-45.

15. Smith AU, Schwartz SJ. Waivers of parental consent for sexual minority youth. Account Res. 2019; 26: 379-390.

Jahromi AH, Reynolds A, Stoehr JR, Whitney N, Ettner R (2023) Improving Access to Care and Consent for Transgender and Gender Diverse Youth in the United States. JSM Sexual Med 7(3): 1116.

Received : 05 Aug 2023
Accepted : 30 Sep 2023
Published : 30 Sep 2023
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