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This essay describes an instrumental advocate’s development, engagement, and accomplishments intransgenderhealth at the intersection of law and medicine. Reflecting on the evolution of insurance policy reforms in conjunction with the need to increase the availability of clinicians who can understand and respectfully treattransgender patients, the author demonstrates how visibility, tenacity, and ingenuity can create far-reaching change.

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The sheer gamut of issues impactingtransgenderhealth equity may seem overwhelming. This article seeks to introduce readers to the breadth of topics addressed in this symposium edition, exemplifying thattransgenderhealth equity is a global issue that demands an interdisciplinary approach.

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The lack of access to gender-affirming surgery represents a significant unmethealth care need within thetransgender community, frequently resulting in depression and self-destructive behavior. While sometransgender people may have access to gender reassignment surgery, an overwhelming majority cannot afford facial feminization surgery. The former may be covered as a “medical necessity,” but FFS is considered “cosmetic” and excluded from insurance coverage. This demarcation between “necessity” and “cosmetic” intransgenderhealth care based on specific (...) body parts is in direct opposition to the scientific community’s understanding of gender dysphoria and professional guidelines fortransgenderhealth. GRS affects one’s ability to function in an intimate relationship, while FFS has the same impact on social interactions an, therefore may have a far greater implication for one’s quality of life. FFS is a cost-effective intervention that needs to be covered by insurance policies. The benefits of such coverage far exceed the insignificant costs. (shrink)

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In this manuscript, “Intersectional Structural Stigma, Community Priorities, and Opportunities forTransgenderHealth Equity,” Poteat and Simmons outline the legal and policy barriers that impede efforts to end the HIV epidemic amongtransgender people in the South. They present qualitative and quantitative data from a community engaged research study conducted withtransgender adults and other key stakeholders as well as finding from an analysis of policies impactingtransgender people in both states. Violence prevention and decriminalization (...) are highlighted as key policy initiatives that would advancehealth equity fortransgender people. (shrink)

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Background:Transgenderhealth care is a subject of much debate among clinicians, political commentators, and policy-makers. While the World Professional Association ofTransgenderHealth (WPATH) Standards of Care (SOC) establish clinical standards, these standards contain implied ethics but lack explicit focused discussion of ethical considerations in providing care. An ethics chapter in the SOC would enhance clinical guidelines. Aims: We aim to provide a valuable guide for healthcare professionals, and anyone interested in the ethical aspects of (...) clinical support for gender diverse andtransgender people of all ages. Recognizing that the WPATH is a global association, we address broad challenges. We offer a reflection on general ethical principles, providing conceptual tools for healthcare providers, patients, and families to navigate the specific challenges they might encounter intransgenderhealth care, in line with WPATH’s worldwide mission and scope. Method: This article employs a descriptive analysis, and our framework of reference is the four principles of biomedical ethics: respect for autonomy, beneficence, nonmaleficence, and justice. Results: The article presents a discussion on the four ethical principles as applied totransgenderhealth care. We address issues such as respect for patient autonomy in decision-making, the role of beneficence and nonmaleficence in clinical interventions, and the importance of justice in equitable treatment and access to care. Some of the ethical concerns we address in this article pertain to the current sociopolitical climate, where there has been increasing legal interference, internationally, fortransgender and nonbinary people, particularly youth, seeking medical care. Discussion: We highlight the interplay between ethical principles and clinical practice, underscoring the need for ethical guidance in addressing the diverse challenges faced by healthcare providers and patients intransgenderhealth care. We advocate for continuous refinement of ethical thinking to ensure thattransgenderhealth care is not only medically effective but also ethically sound. (shrink)

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McLeod focuses her book on what she calls "typical refusals in reproductive healthcare." She defines this at several points, describing these as primarily refusals that "target services that are standard and that the objectors believe will result in the death of a human being that has the moral or religious status of a person ". Abortion is one procedure that is commonly targeted by "typical refusals." McLeod notes that clinicians engaging in such refusals may refuse not only the procedure itself (...) but also to make a referral for a procedure because they find this kind of indirect complicity to still be a violation of conscience. This... (shrink)

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As secular culture exerts pressure on Catholichealth care to conform to its standards, there is need for a clear response to those who claim that the body is not constitutive of the person but can be manipulated to suit a subjective view of the self. Patients who suffer from gender dysphoria deserve our compassionate support, but "therapies" that carry out or encourage the destruction of one's natal sexuality are contrary to the Christian tradition and to the teachings of (...) the Catholic Church. This book provides the arguments, evidence, and practical advice needed for Catholichealth care to resist this ideology and courageously affirm the biological reality of the person. Through careful analysis, narrative case studies, and policy language,Transgender Issues in CatholicHealth Care critiques current interventions for gender dysphoria and provides practical guidance for professionals and institutions committed to providing whole-person care. -- Provided by publisher. (shrink)

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This article aims to analyze the current literature on the social capital oftransgender and gender diverse(TGD) people, given their fragility in social andhealth terms. The paper followed the guidelines developed by Tricco, Langlois, and Straus. The results of this paper reveal significant gaps in the literature relating to the social capital of TGD people and highlight how the various types of shared capital are for sexualhealth to be considered in future research ontransgender (...)health. This is the first article that analyzes in detail the relationship between social capital and TGD individuals. To date, there is no other scientific evidence in the literature in this regard. The paucity of scholarly evidence available for paper limits our ability to make conclusive statements about social capital of TGD people. Small sample sizes in the included studies warrant caution when deriving generalized conclusions about social capital. (shrink)

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BackgroundDuring adolescence, bullying often has a sexual content. Involvement in bullying as a bully, victim or both has been associated with a range of negativehealth outcomes.Transgender youth appear to face elevated rates of bullying in comparison to their mainstream peers. However, the involvement oftransgender youth as perpetrators of bullying remains unclear in the recent literature.ObjectiveThe aim of this study was to compare involvement in bullying betweentransgender and mainstream youth and among middle and (...) late adolescents in a general population sample.MethodsOur study included 139,829 students in total, divided between a comprehensive school and an upper secondary education sample. Associations between gender identity and involvement in bullying were first studied using cross-tabulations with chi-square statistics. Logistic regression was used to study multivariate associations. Gender identity was used as the independent variable, with cisgender as the reference category. Subjection to and perpetration of bullying were entered each in turn as the dependent variable. Demographic factors, family characteristics, internalizing symptoms, externalizing behaviors, and involvement in bullying in the other role were added as confounding factors. Odds ratios with 95% confidence intervals are given. The limit for statistical significance was set at p< 0.001.ResultsBoth experiences of being bullied and perpetrating bullying were more commonly reported bytransgender youth than by cisgender youth. Amongtransgender youth, all involvement in bullying was more commonly reported by non-binary youth than those identifying with the opposite sex. Logistic regression revealed that non-binary identity was most strongly associated with involvement in bullying, followed by opposite sex identity and cisgender identity.Transgender identities were also more strongly associated with perpetration of bullying than subjection to bullying.ConclusionTransgender identity, especially non-binary identity, is associated with both being bullied and perpetrating bullying even when a range of variables including internal stress and involvement in bullying in the opposite role are taken into account. This suggests that bullying during adolescence may serve as a mechanism of maintaining heteronormativity. (shrink)

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The idea oftransgender identity is less perceived as a mental illness but as a sexualhealth condition in many parts of the Western world, while it is seen as an anomaly in most parts of Africa.Transgender identity is a gender expression that differs from the naturally assigned sex. The widely accepted reason behindtransgender is unsatisfactory feelings toward assigned sex by the individual. This work sets out to exploretransgender identity and family life (...) in Africa. Several works have explored the concept but with less emphasis on family life as it relates to the African setting. Furthermore, this work sets out to demonstrate some implications oftransgender identity in an ideal African family. In this work, we shall argue that oncetransgender identity is normalized in Africa, it will be a threat to family life. The arguments to be used are historical, analytical, descriptive as well as evaluative. (shrink)

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Background:Transgender individuals experience discrimination, stigmatization, and unethical and insensitive attitudes in healthcare settings. Therefore, healthcare professionals must be knowledgeable about the ways to deliver ethical and culturally competent care. Ethical considerations: No formal ethical approval was required. Aim: To synthesize the literature and identify gaps about approaches to the provision of ethical and culturally competent care totransgender populations. Design: A Scoping Review Literature Search: Literature was searched within CINAHL, Science Direct, PubMed, Google Scholar, EMBASE, and Scopus (...) databases using indexed keywords such as “transgender,” “gender non-conforming,” “ethically sensitive care,” and “culturally sensitive care.” In total, 30 articles, which includedtransgender patients and their families and nurses, doctors, andhealth professionals who provided care totransgender patients, were selected for review. Data were extracted and synthesized using tabular and narrative summaries and thematic synthesis. Findings: Of 30 articles, 23 were discussion papers, 5 research articles, and 1 each case study and an integrative review. This indicates an apparent dearth of literature about ethical and culturally sensitive care oftransgender individuals. The review identified that healthcare professionals should educate themselves about sensitive issues, become more self-aware, puttransgender individual in charge during care interactions, and adhere to the principles of advocacy, confidentiality, autonomy, respect, and disclosure. Conclusions: The review identified broad approaches for the provision of ethical and culturally competent care. The identified approaches could be used as the baseline, and further research is warranted to develop and assess organizational and individual-level approaches. (shrink)

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For a variety of reasons, it's difficult to determine, with any accuracy, the number of trans and gender nonbinary folks living in the United States.1 Data are difficult to obtain since neither the U.S. Census Bureau nor the Centers for Disease Control and Prevention survey people's gender identity. But even if they did, responses would likely be unreliable. Many members of these two groups are hesitant to answer such questions for fear of their safety, resulting discrimination, or because they disagree (...) on the definition of what it means to betransgender. It's also difficult to obtain accurate numbers on these groups since most medical forms still rely on a two-sex system of... (shrink)

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This paper draws on findings from qualitative interviews with queer and trans patients and with physicians providing care to queer and trans patients in Halifax, Nova Scotia, Canada, to explore how routine practices ofhealth care can perpetuate or challenge the marginalization of queers. One of the most common “measures” of improved cultural competence inhealth care practice is self-reported increases in confidence and comfort, though it seems unlikely that an increase in physician comfort levels with queer and (...) trans patients will necessarily mean betterhealth care for queers. More attention to current felt discomfort in patient–provider encounters is required. Policies and practices that avoid discomfort at all costs are not always helpful for care, and experiences of shared discomfort in queerhealth contexts are not always harmful. (shrink)

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Health-care providers frequently face clinical ethical dilemmas when working withtransgender youth who require hormone therapy but lack parental support for this intervention. Through semi-structured interviews and grounded theory analysis, we explored ethical and clinical decision-making processes ofhealth-care providers, as well as thehealth care experiences of trans youth with family discordance. We analyzed responses in relation to North American bioethics principles, best interests standard, and the harm principle, exploring issues of autonomy, evidence, and anti-trans (...) bias. We propose an ethically acceptable clinical approach termed parallel process hormone therapy initiation to address the needs oftransgender youth with complex family situations. (shrink)

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Increasingly,transgender minors are seeking medical care such as puberty-suppressing or gender-affirming hormone therapies. Yet, whether these interventions should be performed at all is highly controversial. Some healthcare practitioners oppose irreversible interventions, considering it their duty to protect children from harm. Others view minors, like adults, astransgender individuals who must be protected from discrimination. The underlying ethical question is presented as a problem of priority. Is it primarily relevant that minors are involved? Or should decision makers focus (...) on the fact that they treattransgender individuals? The paper explores the relevance for medical practice. We provide results of an interview study with German healthcare professionals. We discuss the general question whether prioritization among different group memberships of the same person is ethically defensible. We conclude that priority conflicts between group memberships of the same person can be deceptive and should be addressed by an intersectional approach. Eventually, we discuss practical implications. (shrink)

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BackgroundWhile fertility preservation is recommended practice for paediatric oncology patients, it is increasingly being considered fortransgender children and young people in paediatric care. This raises ethical issues for clinicians, particularly around consent and shared decision-making in this new area of healthcare.MethodsA systematic review of normative literature was conducted across four databases in June 2020 to capture ethical considerations related to fertility counselling and preservation in paediatrictransgender healthcare. The text of included publications was analysed inductively, guided by (...) the Qualitative Analysis Guide of Leuven.ResultsTwenty-four publications were identified for inclusion. Four key ethical considerations emerged from this literature: access to fertility preservation, conscientious objection, decision-making capacity of children and young people, and shared decision-making.ConclusionIn the identified literature, there is consensus thattransgender children and young people should not be refused access to fertility preservation services solely due to their gender identity, and that clinicians with conscientious objections to fertility preservation for this group have an obligation to refer on to willing providers. Factors that create ethical complexity in this area of paediatric care include the child’s age, mentalhealth, and parents’ views. (shrink)

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Manytransgender people need specific medical services to affirm their gender. Gender-affirminghealth care services may include mentalhealth support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services amongtransgender people, which hinders the ability of insurance regulators,health plans, and otherhealth care organizations to plan and budget for thehealth care needs of this population and to ensure thattransgender people can (...) access medically necessary gender-affirming care. This study used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services. (shrink)

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This paper describes the significance of key empirical findings from the recent and landmark study Caring and Aging with Pride: The NationalHealth, Aging and Sexuality Study (with Karen I. Fredriksen‐Goldsen as the principal investigator), on lesbian, gay, bisexual, andtransgender aging andhealth disparities. We will illustrate these findings with select quotations from study participants and show how nonconscious bias (i.e., activation of negative stereotypes outside conscious awareness) in the clinical encounter andhealth care setting (...) can threaten shared decision‐making and perpetuatehealth disparities among LGBT older adults. We recognize that clinical ethicists are not immune from nonconscious bias but maintain that they are well situated to recognize bias and resulting injustice by virtue of their training. Further, we discuss how clinical ethicists can influence the organization's ethical culture and environment to improve the quality and acceptability ofhealth care for LGBT older adults. (shrink)

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This article examines the barriers to qualityhealth care fortransgender, nonbinary, and gender-expansive people (TGE) who become pregnant and give birth, identifying three central themes that emerge from the literature. These insights suggest that significant reform will be necessary to ensure access to safe, appropriate, gender-affirming care for childbearing TGE people. After illustrating the need for systemic changes that untether rigid gender norms from the provision of perinatal care, the article proposes that the Midwives Model of Care (...) offers a set of values and clinical practices that are well-suited to meet the needs of many TGE patients during pregnancy and childbirth and which should be incorporated into the healthcare system more broadly. (shrink)

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Thetransgender experience predicts that the gender affirming pathway is undertaken. The gender affirmation process is not mandatory, and the process is not the same for all people. Affirmation of gender is a social determinant oftransgender and gender diverse (TGD)health, but which also has a multidimensional structure: social, legal, psychological, and medical. At this point, however, it is necessary to understand the type of pathway that TGD people can undertake in Italy, so the purpose of (...) this paper is to make the articulation of the pathway known and explicit, trying to detect the sociological aspects and the impacts that the various components of the gender affirming pathway require. The gender affirming pathway in Italy is characterized by many critical issues: it is focused on the affirmation of medical, legal, and psychological dimensions; however, the affirmation of social gender is also important to promote their integration into society, theirhealth and general well-being. In conclusion, it is necessary to develop and implement research and concrete impacts of social gender affirmation, the potential of which is to reduce inequalities, in general, andhealth, which negatively impact the Italian TGD individuals. (shrink)

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Transgender inclusion within policy is critical yet often missing. We propose a policy tool to assesses human rights, access to resources and opportunities, language, and implications fortransgender and nonbinary individuals. Acknowledging trans communities as standard policy practice can serve as an essential practice to shift dialogue and norms.

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Over the past decades, great strides have been made to professionalize and increase access totransgender medicine. As the evidence base grows and conceptualizations regarding gender dysphoria/gender incongruence evolve, so too do ideas regarding what constitutes good treatment and decision-making intransgender healthcare. Against this background, differing care models arose, including the ‘Standards of Care’ and the so-called ‘Informed Consent Model’. In these care models, ethical notions and principles such as ‘decision-making’ and ‘autonomy’ are often referred to, but (...) left unsubstantiated. This not only transpires into the consultation room where stakeholders are confronted with many different ethical challenges in decision-making, but also hampers a more explicit discussion of what good decision-making intransgender medicine should be comprised of. The aim of this paper is to make explicit the conceptual and normative assumptions regarding decision-making and client autonomy underpinning the ‘Standards of Care’ and ‘Informed Consent Model’ currently used intransgender care. Furthermore, we illustrate how this elucidation aids in better understanding stakeholders’ ethical challenges related to decision-making. Our ethical analysis lays bare how distinct normative ambiguities in both care models influence decision-making in practice and how foregrounding one normative model for decision-making is no moral panacea. We suggest that the first steps towards good decision-making in gender-affirming medical care are the acknowledgement of its inherent normative and moral dimensions and a shared, dialogical approach towards the decision-making process. (shrink)

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Although informed consent models for prescribing hormone replacement therapy are becoming increasingly prevalent, many physicians continue to require an assessment and referral letter from a mentalhealth professional prior to prescription. Drawing on personal and communal experience, the author argues that assessment and referral requirements are dehumanising and unethical, foregrounding the ways in which these requirements evidence a mistrust of trans people, suppress the diversity of their experiences and sustain an unjustified double standard in contrast to other forms of (...) clinical care. Physicians should abandon this unethical requirement in favour of an informed consent approach totransgender care. (shrink)

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Journals have been described as “duty bearers” of upholding fundamental ethical principles that are essential for maintaining the ethical integrity of newly generated and disseminated knowledge. To play our part, we evaluated diversity and inclusion in the leadership and management of global and internationalhealth journals. We developed Journal Diversity Index (JDI) to measure three parameters of diversity and representation (gender, geographic, socioeconomic status). Relevant information regarding editorial board members of systematically screened journals was sequentially extracted and job titles (...) were categorized into five editorial roles. Chi-squared test was utilized to study associations between gender and geographic distribution of editors along with the Medline indexing of the journal and its impact factor. Out of 43 journals included, 62.7% were published from two high-income countries. Women comprised 44% of the total editors. Among all the editorial board members, we did not find any information suggesting the representation of non-binary andtransgender individuals. Furthermore, 68.2% of editors were based in high-income countries with 67.3% of the editors belonging to the Global North. This disparity in geographic region and socioeconomic level was observed across all five editorial roles. Among all women editors, more than 70% worked in non-Medline and non-impact factor journals. Only two journals scored “excellent” on JDI. Despite the continuous evolution of the definition of globalhealth ethics, marginalized individuals, and their perspectives remain underrepresented in this field. Thus, we call for swift action regarding the decentralization and redistribution of global and internationalhealth journal editorial boards. (shrink)

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The purpose of this paper is to utilize virtue ethics as the appropriate paradigm by which to improvehealth care delivery totransgender individuals.Health disparities fortransgender individuals occur external to the medical environment as well as internal to the medical profession. A commitment to virtue ethics should be undertaken to improve the care totransgender individuals. In this manuscript I call on virtue ethics to address the intersectionality of such environmental structures for the (...) promotion of the good of the patient as per the telos of medicine by Edmund Pellegrino, consistent with the eudaimonia of Aristotle’s Nicomachean Ethics. Virtue ethics is the appropriate paradigm for which bioethics can address the framework that poses barriers to access tohealth care and maintenance ofhealth through a lack of competent, knowledgeable and compassionate providers for thetransgender population. Further, I pose that ascribing to improving the care to the individualtransgender patient involves a call to action to overcome social ecological spheres of influence that are affecting thehealth of the individual and thereby the population of thetransgender individuals as a whole. Through virtue ethics, the virtuous physician improves thehealth of thetransgender individual and the character of themselves and the profession of medicine. (shrink)

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As a research team focused on vulnerable youth, we increasingly need to find ways to acknowledge non‐binary genders inhealth research. Youth have become more vocal about expanding notions of gender beyond traditional categories of boy/man and girl/woman. Integrating non‐binary identities into established research processes is a complex undertaking in a culture that often assumes gender is a binary variable. In this article, we present the challenges at every stage of the research process and questions we have asked ourselves (...) to consider non‐binary genders in our work. As researchers, how do we interrogate the assumptions that have made non‐binary lives invisible? What challenges arise when attempting to transform research practices to incorporate non‐binary genders? Why is it crucial that researchers consider these questions at each step of the research process? We draw on our own research experiences to highlight points of tensions and possibilities for change. Improving access to inclusivehealth‐care for non‐binary people, and non‐binary youth in particular, is part of creating a more equitable healthcare system. We argue that increased and improved access to inclusivehealth‐care can be supported by research that acknowledges and includes people of all genders. (shrink)

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For individuals pursuing medically assisted gender transition, gender-affirming surgical treatments, such as oophorectomy (removal of the ovaries) and orchiectomy (removal of the testicles), cause sterility, and gender-affirming hormone treatment with medications (i.e., testosterone and estrogen) may negatively impact infertility. The major United States (US) medical associations already endorse fertility preservation (FP) through cryopreservation (i.e., “freezing” egg and sperm) fortransgender individuals. Despite these endorsements from the relevant medical societies, medical insurance coverage for FP remains very limited in the US. (...) Given the high out-of-pocket costs for FP services, fertility preservation remains financially out of reach for manytransgender individuals who may desire it. We present an ethical justification for universal FP coverage for alltransgender and gender diverse (TGD) individuals who request this option during medically assisted gender transition. First, we argue that gender-affirming medical care is analogous to other medical interventions and treatment regimens that compromise fertility, such as cancer care, and that both types of interventions need to be afforded the same medical benefits and assistance in pursuing fertility goals. Second, we argue that the lack of FP fortransgender individuals contributes to the ongoing and profound transphobia and anti-trans bias that has been exacerbated in the past several years across the healthcare landscape in the United States. We argue that the provision of FP coverage fortransgender individuals is necessary for clinicians and third-party payers to state their unequivocal support for TGD patients and their healthcare needs. (shrink)

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Alternatives to convenience sampling (CS) are needed for HIV/STI surveillance of most-at-risk populations in Latin America. We compared CS, time space sampling (TSS), and respondent driven sampling (RDS) for recruitment of men who have sex with men (MSM) andtransgender women (TW) in Lima, Peru. During concurrent 60-day periods from June-August, 2011, we recruited MSM/TW for epidemiologic surveillance using CS, TSS, and RDS. A total of 748 participants were recruited through CS, 233 through TSS, and 127 through RDS. The (...) TSS sample included the largest proportion of TW (30.7 %) and the lowest percentage of subjects who had previously participated in HIV/STI research (14.9 %). The prevalence of newly diagnosed HIV infection, according to participants' self-reported previous HIV diagnosis, was highest among TSS recruits (17.9 %) compared with RDS (12.6 %) and CS (10.2 %). TSS identified diverse populations of MSM/TW with higher prevalences of HIV/STIs not accessed by other methods. (shrink)

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Despite a recent wave in global recognition of the rights oftransgender and gender-diverse populations, referred to in this text by the umbrella label of trans*, international law continues to presume a cisgender binary definition of gender — dismissing the lived realities of trans* individuals throughout the world. This gap in international legal recognition and protection has fundamental implications forhealth, where trans* persons have been and continue to be subjected to widespread discrimination inhealth care, longstanding (...) neglect ofhealth needs, and significant violations of bodily autonomy. (shrink)

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Background Decision-making competence is a complex concept in the care fortransgender and gender diverse adolescents, since this type of care concerns one’s developing gender identity and involves treatment options that often lack international consensus. Even despite competence assessments, moral challenges arise in the decision-making process. Here, traditional forms of clinical ethics support such as moral case deliberation might not fit as these do not provide thematic guidance. This study therefore aimed to develop a practice-oriented ethics support tool to (...) assist care providers when dealing with moral challenges around decision-making competence intransgender adolescent care. Methods The study followed a participatory design to develop a tool in close collaboration with care providers; they had a say in all phases of development and dissemination. Firstly, nine care providers were interviewed about experienced moral challenges and needs for ethics support. Based on this, the structure and content of the tool was constructed and discussed in two focus group meetings, after which four care providers tested the tool and additional feedback was collected from the team and an advisory board. The final tool was presented to all Dutch care providers intransgender adolescent care. Results Care providers expressed a need for guidance in defining and assessing decision-making competence. Main moral challenges concerned discussing fertility options with young clients, dealing with co-occurring mentalhealth difficulties and the decision-making role of parents. The final tool, named the Competence Consultant, is an interactive pdf containing four parts: (1) Clarify information; (2) Identify doubts and moral questions; (3) Guidance for conversations and (4) Overview and Conclusions. Discussion Developing an ethics support tool in a controversial care setting is highly relevant as it aims to help individual care providers in defining, discussing and dealing with their moral challenges in actual practice. The ‘Competence Consultant’ fortransgender care providers contributes to their moral sensitivity and moral competence. It is an example of the development of innovative and integrative forms of thematic ethics support. (shrink)

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As a population, people who self‐identify as lesbian, gay, bisexual, ortransgender face significant risks tohealth and difficulty in obtaining medical and behavioralhealth care, relative to the general public. These issues are especially challenging in safety‐nethealth care institutions, which serve a range of vulnerable populations with limited access, limited options, and significanthealth disparities. Safety‐net hospitals, particularly public hospitals with fewer resources than academic medical centers and other nonprofit hospitals that also serve (...) as safety nets, are under immense financial pressures. However, with the introduction in 2011 of standards for LGBT inclusion by The Joint Commission, showing progress on LGBThealth care has become a compliance issue for hospitals. And because thehealth care community itself has contributed to LGBThealth disparities through prejudice, disrespect, or inadequate knowledge that have made it difficult for LGB and especially T people to seek care or to obtain the care they need, there is a moral case for allocating scarce resources to this population: we owe them some investment in righting wrongs that thehealth care system itself has produced.So, where to begin in the typical safety‐net hospital or clinic? Beyond staff training, which is essential and for which good models now exist, what does justice demand from a service‐utilization perspective? Given the range ofhealth care services that an LGBT person in the safety net may need or want, how should we set priorities? And what can't we promise to do for this member of our community? (shrink)

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Withinhealth care systems, negative perceptions of lesbian, gay, bisexual, andtransgender persons have often translated into denial of services, denial of visitation rights to same‐sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the uniquehealth care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient's valued relationships because of, for example, a (...) narrow definition of “spouse,” “parent,” or “family.” Bureaucratic exclusion has taken a particularly prominent form in the U.S. military. Until its repeal and termination in 2011, the “Don't Ask, Don't Tell” policy had for eighteen years barred openly gay men and lesbians from serving in the military. Among the effects of DADT is a dearth of information about the number and needs of LGBT service members who transition to the VeteransHealth Administration forhealth care at the end of their military service. The long‐standing social stigma against LGBT persons, the silence mandated by DADT, and the often unrecognized bias built into the fabric of bureaucratic systems make the task of creating a welcoming culture in the VHA urgent and challenging.The VHA has accepted a commitment to that task. Its Strategic Plan for fiscal years 2013 through 2018 stipulates that “[v]eterans will receive timely, high quality, personalized, safe, effective and equitablehealth care irrespective of geography, gender, race, age, culture or sexual orientation.” To achieve this goal, the VHA undertook a number of coordinated initiatives to create an environment and culture that is informed, welcoming, positive, and empowering for the LGBT veterans and families whom the agency serves. (shrink)

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Amidst the misinformation climate about trans people and theirhealth care that dominates policy and social discourse, autonomy‐based rationales for gender‐affirming care for trans and nonbinary youth are being called into question. In this commentary, which responds to “What Is the Aim of Pediatric ‘Gender‐Affirming’ Care?,” by Moti Gorin, we contextualize the virulent ideas circulating in misinformation campaigns that have become weaponized for unprecedented legal interference into standardhealth care. We conclude that the current legal justifications for upending (...) gender‐affirming care gloss over how thishealth care field meets conventional evidentiary standards and aligns protocols with most other fields of medicine. Refusal to offer gender‐affirming care is more harmful than centralizing trans and nonbinary people'shealth autonomy. (shrink)

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Recently, debate over whetherhealth care providers should have a protected right to conscientiously refuse to offer legalhealth care services—such as abortion, elective sterilization, aid in dying, or treatments fortransgender patients—has grown exponentially. I advance a modified compromise view that bases respect for claims of conscientious refusal to provide specifichealth care services on a publicly defensible rationale. This view requireshealth care providers who refuse such services to disclose their availability by other (...) providers, as well as to arrange for referrals or facilitate transfers of care. This requirement raises the question of whether providers are being forced to be complicit in the provision of services they deem to be morally objectionable. I conclude by showing how this modified compromise view answers the most significant objections mounted by critics of the right to conscientious refusal and safeguards providers from having to offer services that most directly threaten their moral integrity. (shrink)

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In lieu of an abstract, here is a brief excerpt of the content:Feminist Studies 41, no. 3. © 2015 by Feminist Studies, Inc. 623 Jaye Cee Whitehead, Kath Bassett, Leia Franchini, and Michael Iacolucci “The Proof Is in the Pudding”: How MentalHealth Practitioners View the Power of “Sex Hormones” in the Process of Transition In the United States today, popular discourse touts the power of “sex hormones” and hormone receptors in the brain to chemically produce gender expressions (manifested (...) in physical sex traits, behaviors, and attitudes) and identities (a sense of self as feminine or masculine). These accounts range from common assumptions that Western ideals of femininity (such as empathy understanding, cooperative orientation, nurturing behavior) and masculinity (rational/spatial understanding, competitive orientation, violent behavior) are produced by corresponding sex hormones, to studies that reduce complex gender identities and macrosocial economic phenomena to presocial, binary, hormonal processes.1 For sociologists, accounts that reduce complex identities to internal hormonal reactions are problematic for two primary reasons: first, they are inaccurate because they fail to examine how hormonal reactions are embedded in a complex cultural process of meaning and interpretation; second, they operate as bioreductive ideologies that obscure the social power inherent to the process of gender identity construction. In what follows, we extend both of these insights by examining mentalhealth 1. For an example of a hybrid popular-scientific account of the power of sex hormones to destabilize economic structures, see Jon Coates and Joe Herbert, “Endogenous Steroids and Financial Risk Taking on a London Trading Floor,” Proceedings of the National Academy of Sciences 105, no. 16 (April 2008): 6167–72. 624 Whitehead, Bassett, Franchini, and Iacolucci practitioners’ divergent interpretations of the power of sex hormones in the process of gender transition.2 In doing so, we examine the cultural power of sex hormones in crafting gender identities without reproducing reductionist interpretations of trans embodiment. Perhaps what is most perplexing about the way we speak of sex hormones is that we know it is inaccurate to describe these hormones as sexed; scientists have acknowledged since the 1930s that they are neither sex specific in their function, nor in terms of their location in male or female bodies.3 In her extensive historicization of sex hormones, Anne Fausto-Sterling concludes that it is more accurate to call androgen- and estrogen-based hormones, “steroid hormones” as they have functions that are not confined to corresponding sexed bodies. In fact she urges scientists to “break out of the sex hormone straightjacket” and to look at steroids as just one of a number of components that are important to the creation of sex and gender, including environment and experience.4 Scholars also point to an inextricable link between the chemical operation of hormones and the social process of constructing meaning, both at the level of social interaction and macrocultural constructions of sex categories and gender ideologies.5 While brain organization/activation theory attributes sex and gender differences to hormonal interactions within the developing brain, Fausto-Sterling questions the distinction between activation and organization by pointing out how “the brain can respond to hormonal stimuli with anatomical changes…hormonal systems, after all, respond exquisitely to experience, be it in the form of nutrition, stress, or sexual activity (to name but a few possibilities ).”6 Drawing from Elizabeth Grosz, Fausto-Sterling argues that the power of hormones is best understood according to the model of the 2. “Gender transition” is a controversial phrase, as it implies that transgendered individuals who receive hormone therapy are changing identities. We are only using it for lack of clear alternative phrasing, not because we believe body modifications change gender identities. 3. See Anne Fausto-Sterling, Sexing the Body: Gender Politics and the Construction of Sexuality (New York: Basic Books, 2000); Rebecca Jordan-Young, Brainstorm: The Flaws in the Science of Sex Differences (Cambridge, MA: Harvard University Press, 2010); and Nelly Oudshoorn, Beyond the Natural Body: An Archeology of Sex Hormones (New York: Routledge, 1994). 4. Fausto-Sterling, Sexing the Body, 193–94. 5. Fausto-Sterling, Sexing the Body. 6. Ibid., 232. Whitehead, Bassett, Franchini, and Iacolucci 625 Möbius strip, wherein internal components of the self are always connected to and continuous with outer components such as culture and environment.7 In other... (shrink)

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In lieu of an abstract, here is a brief excerpt of the content:Reviewed by:Abortion to Abolition: ReproductiveHealth and Justice in Canada by Martha PaynterRebecca Simmons (bio)Abortion to Abolition: ReproductiveHealth and Justice in Canada by Martha Paynter Winnipeg, MB: Fernwood Publishing, 2022Martha Paynter's Abortion to Abolition: ReproductiveHealth and Justice in Canada is a bold, ambitious work that seeks to not only catalog Canada's meandering and often backtracking path toward reproductive justice, but to act as a (...) manifesto for Paynter's own ideas and goals for reproductive justice. The book takes the form of an anthology of stories, divided into chapters, that are grouped according to a certain right; for example, the right to bodily autonomy. This format effectively guides the reader from abortion to abolition. Paynter adroitly starts the book with white feminist favorites such as bodily autonomy and not having children. Then she logically progresses to more radical ideas such as parenting in prison and the total abolition of prisons. The stories in this book are accompanied by warm, colorful illustrations by Julia Hunt. These drawings help the reader visualize the person behind the story and the very real life that was affected by reproductive law and/or social norms. Paynter holds a PhD in nursing, and it is from this background that she writes, seeking to educate nurses and other healthcare professionals alongside a broader readership garnered through her clear, approachable writing style.Chapter 1 introduces the reader to many of the book's key themes by considering the right and need to have bodily autonomy, and the multiple ways this manifests itself in ordinary (and less-ordinary) life. Paynter considers the disparate stories of five women, all fighting in some way for bodily autonomy. The stories cover events of gender-based gun violence, sexual assault,transgender rights in prison, the legalization of sex work, police violence, and institutional racism. Each story recounted by Paynter catalogs tragedies and injustices with blunt and brutal honesty—perhaps to an unnecessary extent. Every horrific fact is laid bare for the readers as they uncover the intricacies of gender-based, imperialist, and racist violence. Paynter has chosen these stories to display the multitude of ways in which people—especially Black, Indigenous, people of color (BIPOC) and minoritized genders—can be willfully wronged by the state and [End Page 209] the criminal justice system, such that the reader must begin to confront the fact that these structures don't seem to exist to benefit or protect the most marginalized in society.Chapter 2 approaches the right not to have children through a number of stories related to contraception, abortion, and family planning. Paynter sketches some of the key points in Canada's journey toward the decriminalization of abortion, from paradoxical trailblazers, such as Dr. Emily Stowe in the 1800s, to the viral memefied content of art protestor iamkarats. While the unequivocal legality of abortion in Canada suggests incredible progressiveness and support for women's rights, Paynter paints a more complex picture through her chosen narratives. Crucially, the inequitable geographical access to abortion, in particular, throughout the huge landmass of Canada suggests that the right to not have children in Canada is not universal. Moreover, Paynter suggests that access is also bounded by financial constraints, finite public funding, and the limited availability of inclusive clinics that prioritize healthcare for LGBTQ2S+ people.Chapter 3 considers the topic of having children; in particular, the right to reproductive technologies and freedom from forced sterilization. Paynter quickly makes clear that while many white feminists might see having and not having children as diametrically opposed, they are two equally essential parts of reproductive justice. Paynter draws attention to the Sexual Sterilization Act of 1928 that was only overturned in 1972. She describes it as part of the "genocidal colonial project" (84), a collection of laws and policies aimed at fulfilling eugenicist, neoimperial ideals of increasing production of the white "race" and promoting the genocide of Indigenous peoples. Furthermore, Paynter argues that evidence of forced sterilization of Indigenous peoples, and other physical violence and neglect, persists to the present day and must be stopped and reparations made for previous harms. Paynter then considers the complex, often-debated case of commercialized surrogacy, which she defines... (shrink)

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Recent conceptual developments in psychiatric diagnosis have the potential for catastrophic results, particularly for Christians in the mentalhealth field, but also for all persons who have a vested interest in the identification and treatment of mental disorder. I explore these theoretical developments by focusing on the manner in which dysphoria has been situated in the dominant contemporary system of psychiatric nosology, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. I target for discussion, primarily, two specific consequences (...) of dysphoria’s new place in contemporary psychiatry, namely, the explicit depathologizing of Pedophilia and the introduction of “Gender Dysphoria” as a new diagnostic category. Although Pedophilia and Gender Dysphoria share the characteristic of not being designated as mental disorders by the American Psychiatric Association (APA), they interestingly differ insofar as a sufficient degree of dysphoria is believed to have the ability to transform Pedophilia from a “condition” to a psychiatric disorder (namely, “Pedophilic Disorder”), while no amount of dysphoria, it is believed, is capable of transforming the diagnosis of Gender Dysphoria into an explicit psychiatric disorder. I trace some of the likely motivations for the APA’s having made these changes, discuss some of these changes’ untoward theoretical and practical consequences, and attempt to forge a coherent path to a more general theory of psychopathology. (shrink)

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As the saying goes, “The road to hell is paved with good intentions.” And in the recent burst of clinical attention being paid to the needs of lesbian, gay, bisexual, andtransgender patients, good intentions abound. But while this long‐overdue interest in LGBThealth care aims to highlight important gaps and bring into relief serious issues inhealth care delivery for LGBT persons, such work can inadvertently reinforce both the marginalization of sexual minorities and the cultural norms (...) related to sexuality, gender identity, and the conventional family. To ensure that positive outcomes for LGBT patients are inextricably paired with those noble intentions, we advocate for a new, queer bioethics—a methodology of scholastic, bioethical, and critical scrutiny that not only addresses the needs of LGBT persons inhealth care settings but also considers the perspectives, histories, and feelings of such parties. (shrink)

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Vulnerability is a broad concept widely addressed in recent scholarly literature. Lesbian, gay, bisexual, andtransgender people are among the vulnerable populations with significant disadvantages related tohealth and the social determinants ofhealth. Medical ethics discourse tackles vulnerability from philosophical and political perspectives. LGBT people experience several disadvantages from both perspectives. This article aims to justify the right tohealth for LGBT people and their particular claims regarding healthcare because they belong to a vulnerable group. (...) Rawls’ theory of justice and Norman Daniels’ normal functioning approach will be discussed in this context. Despite the fact that the right tohealth can be justified by Daniels’ normal functioning approach, there is still a theoretical gap in justifying the right tohealth for particular vulnerable populations such as LGBT peopleand discussing society’s duty to compensate for these disadvantages. In search of solid theoretical grounds for the justification of the right tohealth for LGBT people, the present author takes the opportunity to utilize Daniels’ flexible definition of normal functioning to show that normal functioning not only varies by age but also by different states of human existence, including sexual orientation and gender identity, and to propose replacing the life span approach with normal states of human existence. (shrink)

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On the heels of the groundbreaking Obergefell v. Hodges ruling legalizing same-sex marriage in the United States, the lesbian, gay, bisexual, andtransgender movement for marriage equality has received unprecedented coverage. Few people, however, have heard of the marriage equality movement for people with disabilities. In order to understand the lack of coalition between the two movements, as well as the invisibility of the PWD marriage equality movement, I provide a conceptual analysis of both marriage movement discourses. Drawing on (...) Cathy Cohen's work on secondary marginalization in the black community, I argue that both LGBT folks and PWD actively obscure the most needy, most dependent, and most queer members of their respective communities to gain sympathy and support from a independent, heteronormative majority. However, bringing the two movements into dialogue can help us rethink intimate relationships, marriage, and who counts as a citizen worthy of rights. (shrink)

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In the last several years, queer and trans people have grown in prominence in our public discussions of policy, education,health care, and other spaces of social life. Politicians,health care practitioners, and average citizens are increasingly aware of our existence and the particular challenges we present, albeit this awareness is often not well-intentioned or informed. Indeed, according to the 2015 U.S.Transgender Survey, trans people, in particular, specifically avoid accessing neededhealth care due to either (...) fearing negative interactions withhealth care providers or being unable to affordhealth care, and those who do manage to... (shrink)

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Background: The therapeutic itinerary is not limited to the identification and availability ofhealth services offered, but relates to the different individual searches and sociocultural and economic possibilities of each patient. In this study, we discuss the therapeutic itinerary of transsexual people seeking healthcare, from the user’s perspective. Objective: The aim of this study was to discuss the therapeutic itinerary of transsexual people seeking healthcare, from the user’s perspective. Design and participants: Individual interviews were performed with 10 transsexuals at (...) the Trans Space of a University Hospital of Pernambuco, using the Universal Declaration of Human Rights as the theoretical reference and the Bardin’s thematic content analysis as the reference methodological framework. Ethical considerations: This study was approved by the Human Research Ethics Committee at the Federal University of Pernambuco under protocol no. 91284218.5.0000.5208. Findings: The comprehensive care for transsexual people was evidenced through four categories analyzed: low demand of transsexuals inhealth services; use of social name inhealth services; care permeated by prejudiced and discriminatory attitudes; andhealth system and professionals who are not able to meettransgenderhealth issues. Discussion: Transsexual people are stigmatized and experience prejudice in their dailyhealth, in a way they do not enjoy fundamental rights, as if they had fewer rights, or infringe the principle of universality of access tohealth. Thus, for effective and comprehensive care, thehealth team must keep up to date on the public policies existing in the healthcare of transsexual people and reconstruct what they understand by gender. Conclusion: Knowledge about the therapeutic itinerary oftransgender people may support evaluation processes ofhealth service networks to ensure the access to and reorganization of these services. Understanding this dynamic allows fostering discussions about the structure ofhealth services at all care levels for the care of this population. (shrink)

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I am pleased to introduce this Symposium Edition of The Journal of Law, Medicine & Ethics, which covers a wide variety of issues central totransgenderhealth equity, including Dr. Jamison Green’s recent history of the impact ofhealth policy ontransgender communities, Dr. M. Killian Kinney, Ms. Taylor Pearson, and Prof. Julie Ralston Aoki’stransgender equity tool for legal policy analysis, and Prof. Elizabeth Kukura’s analysis of issues facingtransgender, non-binary, and gender expansive (...) people during pregnancy and childbirth. (shrink)

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Transgender people have among the highest rates of suicide attempts of any group in society, driven strongly by the perception that they do not belong in the sex of their physical body. Gender reassignment surgery is a procedure that can change thetransgender person’s physical body to accord with their gender identity. The procedure raises important ethical and distributive justice concerns, given the controversy of whether it is a cosmetic or medical procedure and the economic costs associated with (...) performing the procedure. This paper argues that there is a strong case for funding GRS as a matter of clinical necessity and justice. This paper will be divided in four key sections: First, the state oftransgenderhealth will be outlined, including the role of GRS and common objections to it. Second, a number of common objections to GRS will be analysed at the outset and shown to be unconvincing. Third, a constructive argument will be advanced, arguing that publicly funded GRS is clinically necessary, cost-effective, and demanded by principles of justice. Fourth, the paper will briefly discuss moralistic biases and why we demand a higher burden of justification for funding GRS compared with other analogous procedures. (shrink)

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The International Covenant on Economic, Social and Cultural Rights was signed by Turkey in 2000 and has been in force since September 23rd, 2003. For this reason, the Covenant is considered as act of parliament in our domestic law, and unlike the general procedure of application of the law, it can not be alleged to contradict the Constitution (According to Article 90 of the Turkish Constitution). The article 12 of the Covenant defines the right tohealth and its content. (...) In the article 12 of the Covenant, in its General Comment No. 14 published in 2000, the right to the highest attainable standard ofhealth was interpreted and commented upon. This document contains a detailed description of the right tohealth, its content, and its obligations to State parties. Although this Comment of the Covenant is not binding, it is a document to which the State parties refer when taking measures related tohealth services. Every publication and comment on the right tohealth was based on the General Comment 14 of the Covenant. The Article 12 was reinterpreted by the Covenant on May 2nd, 2016 in the context of rights to sexual and reproductivehealth. İit has been emphasized that legal, procedural, practical and social barriers limit the access of individuals to full range sexual and reproductivehealth services. It has also been pointed out that accessibility of sexual and reproductivehealth services is a distant target for women and girls. Moreover, it has been stated that discrimination that increases exclusion in legislation and practice limits lesbian, gay, bisexual,transgender and intersex (LGBTI) individuals and disabled people'senjoyment of sexual and reproductivehealth rights. For this reason, it is stated that although commenting on the rights of sexualhealth and reproductivehealth is included in 14 comments, it is important to make an interpretation about them. This comment is an interpretation of a binding Convention. Therefore; It is a document that will provide guidance on measures to be taken by States Parties in respect of their rights to sexualhealth and reproductivehealth. At the same time, obstacles to discrimination in medical practice bring important approaches in terms of respect for autonomy and respect for private life. In our article, information about the content of the ESKHK's interpretation and possible reflections of this content in the field of medical law and ethics will be given. (shrink)

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The World Professional Association forTransgenderHealth’s Standards of Care, now in its seventh edition, is a frequently cited, internationally recognized, evidence-based document that details a comprehensive framework for gender-related care of trans people. However, the WPATH SOC still relies heavily in some cases on gatekeeping practices, dubbed “triadic therapy,” or a process where a trans patient is encouraged to seek out psychotherapy, and hormone therapy, and only then be able to engage in surgical options for transitioning. I (...) use G. Alan Marlatt’s harm reduction framework to argue that the triadic process creates its own set of harms that trans people have to contend with, especially insofar as it focuses on resolving gender dysphoria in a demanding, moralizing, and top-down way as opposed to enriching trans lives by reducing harms that prevent us from flourishing. Using Marlatt’s criterion that harm reduction ought to be bottom-up, low threshold, and not moralizing, I develop a list of suggestions for what ought to be centrally considered in treating trans patients. (shrink)

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In the context oftransgenderhealth, most people are not comfortable with allowing a twelve‐year‐old child with gender dysphoria to elect to undergo gender reassignment surgery. The likelihood is too high that the child would be unable to fully comprehend the scope of a decision that carries significant, permanent consequences, particularly because the decision to surgically change gender is based upon a conception of gender that can fluctuate during adolescent years. Conversely, however, most people would not contend that (...) this fluidity is reason to wholly deny certain medical care such as hormonal treatments totransgender youth, a demographic with extremely high rates of violent behavior, self‐harm, and suicide. This paper will explore ethical considerations to this emerging debate of what therapeutic options should be offered totransgender children and adolescents.Pediatric endocrinologists have been treating gender dysphoric adolescents with puberty‐suppressing drugs and, to a lesser extent, with cross‐sex hormone therapies for more than twenty years. Clinicians and thought leaders have mentioned ethical components of this emerging practice in the few cohort studies and clinical review articles about the subject. However, ethics have generally been a secondary consideration in the medical academic literature. In this paper, I will provide a brief overview of the practice, summarize the current research on hormone treatment fortransgender minors, and provide an ethical analysis of the practice. (shrink)

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