Taking the Long Way Around: Towards A Depathologized Ethical Framework of Gender-Affirming Care for Trans Youth

A scoping review of the ethical issues in gender-affirming care for transgender and gender-diverse individuals

BACKGROUND

Globally, there is a notable increase in recognising the health needs of transgender and gender-diverse individuals. As a result, gender-affirming care services are evolving and expanding in many parts of the world, and this has provoked increased debate on various aspects of the interventions that comprise such care. Resolution of these debates depends on addressing important ethical issues. This scoping review aims to identify the key ethical issues and arguments regarding gender-affirming care across various medical interventions.

METHODS

We searched Embase, PubMed and SCOPUS to identify peer-reviewed publications that could meet some eligibility criteria such as publications presenting an ethical issue, argument, or principle related to gender-affirming care for transgender and gender-diverse individuals and having been published from 2012 to 2023. We applied Arksey and O'Malley's scoping review framework. The text of included publications was analysed inductively.

RESULTS

Eighty-two publications were identified for inclusion. Sixty-two publications (76%) were published in or after 2019, and 20 (24%) between 2012 and 2018. Five aspects of gender-affirming care that draw ethical analysis or debates were identified: decision-making process, guideline and model of care, deletion of health data, funding, and fertility preservation and services. Ethical issues and arguments were identified within each aspect of care. The arguments are organised according to the four principles of biomedical ethics: autonomy, beneficence, non-maleficence and justice.

CONCLUSION

This scoping review captures the key ethical issues in various aspects of gender-affirming care. There were substantial differences in the depth to which each aspect of gender-affirming care was discussed, with ethical issues in decision-making processes receiving the most attention, and deletion of health data given the least attention. This review also characterises the dominant ethical arguments and underlying principles used to justify positions on the issues. Within each ethical issue, the four principles of biomedical ethics featured commonly, but were applied very differently and accorded unequal weighting. Additionally, in some discussions, arguments supporting medical interventions were given more attention; in others, the rationales opposing medical interventions were dominant. Perhaps unsurprisingly, there was limited resolution and increasing disagreement. Important constraints in the methodologies of argumentation used to support or oppose aspects of gender-affirming care were also identified.

Beyond inclusion politics: A critical discourse analysis of sex and gender in medical education

INTRODUCTION

Medical training refers frequently to sex and gender, yet these terms are often used vaguely and interchangeably with little critical engagement. We aimed to better understand the key discourses around sex and gender in medical training.

METHODS

All verbal and written instances of gendered/sexed language, occurring in lectures, slides and provided written materials, within 1 year of preclerkship medical education at a single institution in Canada were recorded autoethnographically by a medical student. We analysed these instances using critical discourse analysis informed by anticolonial, feminist and queer theoretical perspectives, particularly contrasting the concepts of governmentality and ungovernability to better understand how sex and gender are deployed in medical training.

RESULTS

Despite the proliferation of ostensibly queer- and trans-positive content in medical curricula, sex and gender were frequently communicated inconsistently and imprecisely. In addition to, and perhaps as a result of, this inconsistent use, we uncovered three key discourses of (1) gender policing, (2) misogyny and (3) gender legibility. Collectively, these discourses can illustrate how medical education governs and reinforces gender norms.

DISCUSSION

The repetitive and everyday use of ill-defined and uncritical gendered and sexed language can be seen to discursively uphold systems of cisheteropatriarchy and transphobia within medicine. Trans and intersex bodies cannot be considered addendums to be tacked on to a foundation of cisnormative and inaccurate teaching in medical education. Institutional attempts to improve curricula must go beyond the addition of new modules, which can be undermined by otherwise cisheteropatriarchal understandings of sex and gender.

Steering into the Curves: Using Diagnosis to Support the Dignity and Autonomy of Trans Youth

This response to Kariyawasam and Rai affirms their critique of the pathologization of trans youth but forecasts a foreseeable negative outcome of their proposed elimination of diagnosis as a prerequisite to gender-affirming care (GAC) - the risk of removing GAC entirely from the medical sphere and compromising the wellbeing of those transgender individuals for whom GAC is deeply affirming. We suggest an ethical framework of GAC that expands past a focus on autonomy to incorporate a principle of respect for persons that affirms the dignity and diversity of trans youth - recognizing the need to facilitate both medical assistance and social change.