Gender assessments are traditionally required before accessing gender-affirming interventions such as hormone therapy and transition-related surgeries. Gender assessments are presented as a way of preventing regret experienced by some people who reidentify with the gender they were assigned at birth after medically transitioning. This article reviews the theoretical and empirical foundations of commonly used methods and predictors for assessing trans patients’ gender identity and/or dysphoria as a condition of eligibility for gender-affirming interventions. We find that the DSM-5 diagnosis, taking gender history, standardized questionnaires, and regret correlates rely on stereotyping, arbitrary, and unproven considerations and, as a result, do not offer reliable ways of predicting future regret over-and-above self-reported gender identity and embodiment goals. This finding is corroborated by empirical data suggesting that individuals who circumvent gender assessments or pursue care under an informed consent model do not present heightened rates of regret. The article concludes that there is no evidence that gender assessments can reliably predict or prevent regret better than self-reported gender identity and embodiment goals. This conclusion provides additional support for informed consent models of care, which deemphasize gender assessments in favor of supporting patient decision making.
We conducted a systematic review describing conversion practices prevalence estimates internationally and exploring heterogeneity across country and socially relevant subgroups. We identified fourteen articles that reported prevalence estimates among SGM populations, and two articles that reported prevalence estimates from studies of mental health practitioners. Prevalence estimates among SGM samples ranged 2%-34% (median: 8.5). Prevalence estimates were greater in studies conducted in the US (median: 13%), compared to Canada (median: 7%), and greater among transgender (median: 12%), compared to cisgender (median: 4%) subsamples. Prevalence estimates were greatest among people assigned male at birth, whether transgender (median: 10%) or cisgender (median: 8%), as compared to people assigned female at birth (medians: 5% among transgender participants, 3% among cisgender participants). Further differences were observed by race (medians: 8% among Indigenous and other racial minorities, 5% among white groups) but not by sexual orientation. Conversion practices remain prevalent, despite denouncements from professional bodies. Social inequities in conversion practices prevalence signal the need for targeted efforts to protect transgender, Indigenous and racial minority, and assigned-male-at-birth subgroups.
Keywords: conversion practices; sexual orientation; gender identity
This article analyses the legacy of Marsha P. Johnson as a heroine through the notion of labour, emphasising how heroine narratives are both a product of labour as well as a form of labour. After offering a short account of Marsha P. Johnson’s role in the Stonewall riots and STAR, we explore the development of trans communities’ ability to create, sustain and disseminate heroine narratives, emphasising Tourmaline’s pivotal archival role in establishing Johnson’s legacy. Then, we elucidate the role of heroine narratives in creating and sustaining a collective identity. We argue that community attachment to Marsha P. Johnson reclaims the place of trans communities in LGBTQ+ history but is often done in a manner that obscures the whiteness of mainstream trans advocacy. We suggest that the recent increase in interest towards the life-sustaining labour of STAR House reflects the evolution of trans collective identity in the post-visibility era.
By attending to how people speak about their gender, we can find diverse answers to the question of what it is like to have a gender identity. To some, it is little more than having a body whereas others may report it as more attitudinal or dispositional—seemingly contradictory views. In this paper, I seek to reconcile these disparate answers by developing a theory of how individual gender identity comes about. In the simplest possible terms, I propose that gender identity is how we make sense of our gender subjectivity, the totality of our gendered experiences of ourselves. Gender identity is constituted by gender subjectivity, but this constitutive relationship is underdetermined. While gender subjectivity may narrow the range of inhabitable gender identities, it is always compatible with more than one. To arrive at a gender identity, we arrange gender subjectivity like building materials. My theory helps us understand how different people offer seemingly incompatible accounts of their gender identity without questioning their authenticity or validity. They simply arrange similar building materials differently.
Despite multiple rigorous observational studies documenting the association between positive mental health outcomes and access to puberty blockers, hormone therapy, and transition-related surgeries among adolescents, some jurisdictions have banned or are attempting to ban gender-affirming medical interventions for minors due to an absence of randomized-controlled trials (RCTs) proving their mental health benefits. This article critically reviews whether RCTs are methodologically appropriate for studying the association between adolescent gender-affirming care and mental health outcomes. The scientific value of RCTs is severely impeded when studying the impact of gender-affirming care on the mental health of trans adolescent. Gender-affirming interventions have physiologically evident effects and are highly desired by participants, giving rise to concerns over adherence, drop-out, response bias, and generalizability. Complementary and well-designed observational studies can instead be used to ground reliable recommendations for clinical practice and policymaking in adolescent trans healthcare, without the need for RCTs. The lack of RCTs on the mental health impacts of gender-affirming care for trans adolescents does not entail that gender-affirming interventions are based on insufficient evidence. Given the methodological limitations of RCTs, complementary and well-designed observational studies offer more reliable scientific evidence than RCTs and should be considered of sufficient quality to guide clinical practice and policymaking.
Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around “gender exploratory therapy” as a proposed alternative. Whereas gender-affirmative approaches follow the client’s lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths’ trans identities or gender dysphoria. Few detailed descriptions of the approach’s parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.
Sexual orientation and gender identity and expression change efforts (SOGIECE) aim to deny or suppress nonheterosexual and transgender identities. SOGIECE, including “conversion practices,” are controversial and remain prevalent despite contemporary legislative bans and denouncement of these harmful practices from numerous health profession organizations. Recent work has questioned the validity of epidemiological studies associating SOGIECE with suicidal thoughts and suicide attempts. This perspective article addresses such critiques, arguing that the balance of available evidence indicates SOGIECE contribute to suicidality, while proposing methods to better account for structural context and the multitude of factors that may explain both SOGIECE attendance and suicidality.
Existing research on gender minority stress theory largely presumes that transgender identity is a categorically immutable characteristic often tied to a unidirectional gender transition, neglecting to consider individuals whose gender identity/expression and embodiment desires change over time. Applying constructivist grounded theory, this article empirically develops the concept of detransphobia from the distal and proximal gender minority stressors, stigma, and discrimination experienced by individuals who shifted or reversed their gender transition. Participants’ experiences of multiple gender transitions, and their embodiment following detransition, rendered them vulnerable to unique gender minority stressors for inhabiting an unintelligible category—detrans. Detransphobia was found to be rooted in cisnormativity and transnormativity, together with socio-politically-located anti-transgender stereotypes related to the process and the outcomes of detransitioning. Detransphobia compounds gender minority stressors and social exclusion in those who shift or reject their past transgender identity through the process of detransition.
L’expression « Rapid-Onset Gender Dysphoria » (ROGD) a été conçue en 2018 pour décrire une prétendue épidémie d’adolescent·es faisant leur coming-out trans « sans crier gare » sous l’effet d’une contagion sociale facilitée par des problèmes de santé mentale. Ce terme reflète une tentative délibérée d’arsenaliser un discours en apparence scientifique pour rejeter l’accumulation de preuves du bénéfice de la transition. Cet article propose une présentation de la théorie de la ROGD et de son histoire, présente une critique détaillée des affirmations théoriques et empiriques liées à cette théorie, en éclairant plusieurs inquiétudes structurelles vis-à-vis du discours sur la ROGD. Il établit que des affirmations liées aux discours sur la ROGD, notamment à propos du déclin de la santé mentale et des rapports familiaux après le coming-out, s’expliquent mieux par le fait que l’étude-phare concernant la ROGD a recruté ses participant·es sur des sites web transantagonistes émergeant sur fond de plus grande acceptation sociale des personnes trans, et de leur plus grande visibilité. La théorie de la ROGD peut mieux être comprise en tant que tentative de se constituer une respectabilité en employant un langage d’apparence scientifique pour contourner la recherche existante, qui démontre l’importance de l’affirmation de genre.
Transgender conversion practices involve attempts to alter, discourage, or suppress a person’s gender identity and/or desired gender presentation, including by delaying or preventing gender transition. Proponents of the practices have argued that they should be allowed until proven to be harmful. Drawing on the notion of expressive equality, I argue that conversion practices are prima facie unethical because they do not fulfill a legitimate clinical purpose and conflict with the self-understanding of trans communities.
Keywords: conversion practices; transgender; ethics; burden of justification; equality
In recent years, the suggestion that over 80% of trans and gender creative children will grow up cisgender has been strongly criticized in the academic literature. Although concerns over the methodology of these studies, known as desistance research, has shed considerable doubt regarding the validity of the reported number, less attention has been paid to the relevance of desistance research to the choice of clinical model of care. This article analyzes desistance research and concludes that the body of research is not relevant when deciding between models of care. Three arguments undermining the relevance of desistance research are presented. Drawing on a variety of concerns, the article highlights that “desistance” does not provide reasons against prepubertal social transition or peripubertal medical transition, that transition for “desisters” is not comparably harmful to delays for trans youth, and that the wait-and-see and corrective models of care are harmful to youth who will grow up cis. The assumed relevance of desistance research to trans youth care is therefore misconceived. Thinking critically about the relation-ship between research observations and clinical models of care is essential to progress in trans health care.
Keywords: transgender youth; gender dysphoria; desistance; medical transition; social transition
The study examines the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice, using constructivist grounded theory as a qualitative approach. Participants included 28 adults living in Canada who had experiences of stopping, shifting, or reversing a gender transition. Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.
In this article, I argue that adolescent medical transition is ethical by analogizing it to abortion and birth control. The interventions are similar insofar as they intervene on healthy physiological states by reason of the person’s fundamental self-conception and desired life, and their effectiveness is defined by their ability to achieve patients’ embodiment goals. Since the evidence of mental health benefits is comparable between adolescent medical transition, abortion, and birth control, disallowing transition-related interventions would betray an unacceptable double standard. While great enough risks can override autonomy over fundamental aspects of personal identity, I demonstrate that the available scientific evidence does not corroborate the view that adolescent medical transition is dangerous. Consequently, adolescent medical transition should be recognized as ethical and remain available.
Social Transition 2022. Trans Bodies, Trans Selves, 2nd ed., Oxford University Press, pp. 185–214 (VoR) [with Avy A. Skolnik]
From clothes to haircuts, piercings to names, society genders human beings in a multitude of ways, beyond the physiological. For many transgender people, transition involves actively intervening on these traits. This chapter explores how trans people devise their social transition and what it may involve, including names, pronouns and gender labels, clothing, make-up, hair, packers, stand-to-pee devices, breast forms, binders, tucks, gaffs, hip and butt padding, voice training, piercings, tattoos, demeanor, and choice of spaces. The chapter also includes some reflections on navigating gender norms, responding to misgendering or deadnaming, and how social transition can make people feel.
Keywords: transgender; social transition; gender norms; society
Currently, no word exists in our vocabulary for the broad category which includes being trans and being cis. To address this gap, I propose the adoption of a new term: gender modality. Gender modality refers to how a person’s gender identity stands in relation to their gender assigned at birth. It is an open-ended category which includes being trans and being cis and welcomes the elaboration of further terms which speak to the diverse experiences people may have of the relationship between their gender identity and gender assigned at birth.
Keywords: transgender; terminology; aspects of gender
The aim of this study was to describe the prevalence of SOGIE conversion efforts, including their sociodemographic correlates, among LGBTQI2+ persons. Using community-based sampling, we assessed SOGIE conversion attempts and involvement in conversion services of 3,261 LGBTQI2+ persons aged 18 years and older in Quebec, Canada. A quarter of respondents experienced SOGIE conversion attempts, and fewer than 5% were involved in conversion services. Over half of those who were involved in SOGIE conversion services consented to them, but the services’ goals were made clear and explicit to only 55% and 30% of those who engaged in SO and GIE conversion, respectively. The results also suggest that family plays a key role in SOGIE conversion attempts and services utilization, and that indigenous, intersex, transgender, non-binary, and asexual persons, people of colour, as well as individuals whose sexual orientation is not monosexual (i.e., bisexual, pansexual) were more likely to have been exposed to conversion attempts and involved in conversion services.
Keywords: conversion practices; sexual orientation; gender identity
Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients’ capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient’s identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth’s authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves.
Keywords: transgender youth; informed consent; capacity to consent; law; medical transition
Conversion therapy continues to occur in both regulated and unrelated settings in Canada. Health care providers, patients, parents, policy-makers and politicians need improved clarity on the nature of conversion therapy. The defining feature of conversion therapy and analogous practices (e.g., intersex surgeries, denial of gender-affirming medical care) is an ideology that favours heterosexual and cisgender identities and behaviours over all others. Canada’s medical regulators should act to augment any federal legislation, by making it clear that they will take prompt disciplinary action against members who cause harm through engaging in or supporting conversion therapy interventions.
The language of law creates the transgender subject by fabricating a legal conception of sex or gender which, for a long time, excluded trans people. Using Québec law as a case study, the article analyzes the law’s narratives of gender to highlight two conceptual phases. Through these two models – the medical and minoritizing models – Québec law first chronicles the existence of trans people as a transitional and liminal moment between two binary states of being, while the minority model sees transitude as an exceptional reality that is defined by its opposition to the dominant social framework. The two abovementioned visions follow each other historically and reveal the evolution of trans legal subjecthood. Despite recent progress, more remains to be done in order to truly include trans people as usual subjects of law.
Keywords: sex; gender; legal subjecthood; transgender; law and society; critical analysis; equality
The notion of gender dysphoria is central to transgender health care but is inconsistently used in the clinical literature. Clinicians who work in transgender health must understand the difference between the diagnosis of Gender Dysphoria as defined and described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and the notion of this term as used to assess eligibility for transition-related interventions such as hormone-replacement therapy and surgery. Unnecessary diagnoses due to the belief that a diagnosis is clinically required to access transition-related care can contribute to stigma and discrimination toward trans individuals.
Keywords: transgender; access to health care; ethics of diagnosis; pathologization; gender dysphoria
When a person openly “regrets” their gender transition or “detransitions” this bolsters within the medical community an impression that transgender and non-binary (trans) people require close scrutiny when seeking hormonal and surgical interventions. Despite the low prevalence of “regretful” patient experiences, and scant empirical research on “detransition”, these rare transition outcomes profoundly organize the gender-affirming medical care enterprise. Informed by the tenets of institutional ethnography, we examined routine gender-affirming care clinical assessment practices in Canada. Between 2017 and 2018, we interviewed 11 clinicians, 2 administrators, and 9 trans patients (total n = 22), and reviewed 14 healthcare documents pertinent to gender-affirming care in Canada. Through our analysis, we uncovered pervasive regret prevention techniques, including requirements that trans patients undergo extensive psychosocial evaluations prior to transitioning. Clinicians leveraged psychiatric diagnoses as a proxy to predict transition regret, and in some cases delayed or denied medical treatments. We identified cases of patient dissatisfaction with surgical results, and a person who detransitioned. These accounts decouple transition regret and detransition, and no participants endorsed stricter clinical assessments. We traced the clinical work of preventing regret to cisnormativity and transnormativity in medicine which together construct regret as “life-ending”, and in turn drives clinicians to apply strategies to mitigate the perceived risk of malpractice legal action when treating trans people, specifically. Yet, attempts to prevent these outcomes contrast with the material healthcare needs of trans people. We conclude that regret and detransitioning are unpredictable and unavoidable clinical phenomena, rarely appearing in “life-ending” forms. Critical research into the experiences of people who detransition is necessary to bolster comprehensive gender-affirming care that recognizes dynamic transition trajectories, and which can address clinicians’ fears of legal action—cisgender anxieties projected onto trans patients who are seeking medical care.
Keywords: transgender; regret; bioethics; medical decisionmaking; detransition
There are over 1 million transgender people living in the United States, and 33% report negative experiences with a healthcare provider, many of which are connected to data representation in electronic health records (EHRs). We present recommendations and common pitfalls involving sex- and gender-related data collection in EHRs. Our recommendations leverage the needs of patients, medical providers, and researchers to optimize both individual patient experiences and the efficacy and reproducibility of EHR population-based studies. We also briefly discuss adequate additions to the EHR considering name and pronoun usage. We add the disclaimer that these questions are more complex than commonly assumed. We conclude that collaborations between local transgender and gender-diverse persons and medical providers as well as open inclusion of transgender and gender-diverse individuals on terminology and standards boards is crucial to shifting the paradigm in transgender and gender-diverse health.
Keywords: transgender; gender information; management; healthcare; health records
Simpson’s paradox refers to cases when trends found in the data disappear or inverse when groups are aggregated. Because reported data are used to guide policymaking, understanding and being able to identify instances of Simpson’s paradox are crucial to LGBTQ+ policy. This article offers a theoretical introduction to Simpson’s paradox before looking to a recent LGBT poverty study as an example of the paradox and of its dangers in the context of LGBTQ+ policy. The study found that the aggregate of cisgender bisexual women was much poorer than other cisgender LGB groups and comparable in poverty levels to trans respondents, but the pattern was largely absent from age-disaggregated data—the aggregate pattern emerged from the comparatively young age of cisgender bisexual women in the study. Some thoughts are offered on how researchers can best mitigate the impact of Simpson’s paradox on policymaking as well as on how data users should engage with statistics to avoid distortions in the decision-making process.
Keywords: LGBTQ+ policymaking; Simpson’s paradox; statistics; age; sexual orientation; gender
A recent paper by Teresa Baron and Geoffrey Dierckxsens (2021) argues that puberty blockers and hormone therapy should be disallowed before adulthood on prudential and consent-related grounds. This response contends that their argument fails because it is predicated on unsupported premises and misinterpretations of the available evidence. There is no evidence that a large proportion of pubertal and postpubertal youths later discontinue medical transition. Meaningful assent is a viable and commonly accepted alternative to meaningful consent in paediatric bioethics. And finally, the primary purpose of transition-related interventions is to actualise youths’ gendered self-image, not treat an underlying mental illness.
Keywords: transgender youth; informed consent; bioethics; medical transition; gender-affirmative care
Jurisdictions increasingly recognize ‘X’ as a legal gender marker alongside ‘M’ and ‘F’, offering an alternative to those whose gender identity falls outside or in excess of the man/woman dichotomy. This chapter explores the justifications and limitations of ‘X’ as a gender marker, arguing that it does not place non-binary people on an equal footing to men and women since it serves as a single, catch-all option for a wide range of non-binary identities. The chapter the explores the possibility of expanding the availability of gender markers to reflect the full diversity of non-binary people but suggests that it would be rejected as absurd due to the ongoing role of gender markers in preserving cisnormativity. It concludes that abandoning gender markers may be the only fully inclusive option. For gender liberation to come within reach, we must imagine a future without gender markers.
Using the ‘Informed Consent Model’ (ICM), clinicians prescribing hormone therapy to trans patients do not require a letter from mental health professionals attesting to their gender identity and/or gender dysphoria. Despite their prevalence and history in North America, ICMs remain poorly understood by medical professionals and are often treated as a monolithic concept. This article surveys the differences between ICMs along a continuum ranging from Strong ICMs to Weak ICMs to No-Letter Models.
Keywords: transgender; medical transition; informed consent; hormone replacement therapy
Dans cet article, j’applique le droit de la responsabilité et de la déontologie professionnelle aux approches thérapeutiques vis-à-vis des jeunes trans et créatif·ve·s dans le genre. J’explique que sous ces régimes légaux, l’approche correctrice (qui vise à prévenir les identités trans) sont fort à penser illégales alors que l’approche de l’attente vigilante (qui vise à délayer la transition sociale et/ou médicale) se rapproche de plus en plus de l’illégalité puisqu’elle est fondée sur des raisonnements cissexistes. Seule l’approche trans-affirmative respecte tant l’esprit que la lettre du droit de la santé.
Keywords: enfants trans; approches cliniques; droit de la santé; déontologie professionnelle
Trans reparative therapy is an umbrella term for sustained efforts that seek to discourage behaviors associated with a gender other than the one assigned at birth and/or promote gender identities that are aligned with the person’s gender assigned at birth. It is predicated on the view that being transgender or markedly gender nonconforming is pathological and that transitioning should be avoided if at all possible. Reparative therapies are known by many names: conversion therapy, reparative practices, the corrective approach, the psychotherapeutic approach, and the pathology response approach. Different terms highlight different aspects and subtypes of reparative therapy. This entry addresses the practices’ current social context, the differences and similarities between reparative therapy targeting sexual orientation versus gender identity, the defining features of contemporary approaches, the practices’ harmfulness and unethicality, and the legal regulation of reparative therapy.
Gender information management is becoming an area of increased concern and tension in recent years due to the parallel rise of trans visibility and the increase of government surveillance. With this Article, I aim to provide a structured and principled analytical framework for managing gender information in a manner that is responsive to different institutional contexts. Part I sketches the ethical considerations and principles which guide my recommendations. Whereas ethical considerations are the values which underlie my recommendations—the why—the proposed principles provide us with conceptual tools to bridge the why, when, and how of gender information management. Part II explores four different contexts in which gender information should be gathered and recorded and makes recommendations specific to each of those contexts. These four contexts are: administrative records, special programs, aggregate assessment, and research. Part III sketches how and what—when justified under the recommendations—gender information should be requested, recorded, and recounted.
The names of cases in in rem actions—an action directly over a thing rather than against a person—are frequently humorous. Just look at South Dakota v. Fifteen Impounded Cats! However, there are distinct differences in the volume of humorous styles of cause between the United States and Canada. After confirming that the Unites States indeed has funnier in rem styles of cause than Canada, this paper seeks to understand the reason behind this discrepancy. Unexpectedly, the answer revealed itself to be neither the United States’ greater police powers nor remnants of British haughtiness in Canada…
Keywords: funny case names; in rem actions; humorous law; civil forfeiture
How to account for participants’ psychological and emotional exhaustion with research has been under‐explored in the research ethics literature. Research fatigue, as it is known, has significant impacts on patients’ well‐being and their ongoing and future participation in studies. From the perspective of researchers and researched communities, research fatigue also creates selection bias and opportunity costs, negatively impacting the collective scientific enterprise. Institutional Review Boards should systematically consider research fatigue during the research approval process and strive to mitigate it.
Keywords: research fatigue; over-researched communities; research ethics; ethics approval; IRB; REB
Trans health is an irreducibly political area of medicine. Clinicians must become aware of that politicization and actively engage with trans communities in humble, attentive and supportive ways, using their power to better trans lives across the board. Such an approach has fourfold benefits: 1) it positions trans communities as knowers and subjects in their own healthcare; 2) it fosters a strong therapeutic relationship; 3) it grants access to otherwise inaccessible information; and 4) it responds to social and political determinants of health. After reviewing these benefits, we discuss what fruitful engagement with trans communities would look like.
Keywords: transgender, gender dysphoria, community medicine, primary care, family medicine, politics
Le langage du droit crée le sujet transgenre en tissant une conception légale du sexe ou genre, une conception qui a longtemps exclut les personnes trans. L’autaire propose d’analyser le langage du genre en droit québécois pour en faire ressortir deux phases conceptuelles. À travers ces deux modèles – l’un médical et l’un minoritaire – le droit québécois relate l’existence des personnes trans en premier lieu comme un moment essentiellement transitoire et liminal entre deux états d’être binaires, alors que le modèle minoritaire y voit plutôt une réalité d’exception, se définissant par son opposition au cadre social majoritaire. Ces deux visions s’enchaînent historiquement et révèlent l’évolution récente de la conception négative des personnes trans comme minorité qui ressort des avancées législatives récentes en droit québécois. L’autaire conclut que, malgré les avancées, il reste plus à faire pour réellement inclure les personnes trans comme sujets habituels de droit.
Mots clés: genre, transgenre, approches critiques, droit à l’égalité, sexe, sujet de droit
The defence of voluntary intoxication, which has been back in the news as a result of the recent decision of the Ontario Court of Appeal in R v Sullivan, is frequently decried as antifeminist. Pursuant to the defence, defendants who acted while intoxicated to the point of automatism or severe psychosis may be acquitted. This article seeks to complicate feminist perspectives on the voluntary intoxication defence, showing that the issue of voluntary intoxication is far more nuanced than some suggest. After summarizing the state of the law of the voluntary intoxication defence and reviewing its prevalence in the jurisprudence, this article critically reflects on the voluntary intoxication defence and highlights how its removal contributes to the criminalization of mental illness and weakens crucial criminal law standards used to protect the most vulnerable — both problems from a feminist standpoint. The article concludes that a feminist analysis of the voluntary intoxication defence requires more nuanced policy discussions than those that have prevailed in the public sphere.
Keywords: voluntary intoxication defence; automatism; criminalization of mental illness; principles of fundamental justice; carceralism; feminism
In recent years, opponents of the gender-affirmative approach to trans youth have argued that it bears homophobic roots and may be tantamount to conversion therapy. This argument is mistaken. In this article, I first argue that there is no evidence that social and/or medical transition is motivated by homophobia. Contrary to the critique’s tacit premise, many if not most trans people are LGBQ following transition. Furthermore, despite social progress in the last decade, transphobia remains more common than homophobia. Second, the gender-affirmative approach is fundamentally dissimilar to conversion therapy, unlike clinical approaches that oppose affirmation and seek to prevent transition. The comparison to conversion therapy relies on a superficial understanding of sexual orientation, such that a change of label (e.g. straight, bisexual, gay, lesbian) is equivalent to a change of sexual orientation even without changes to the targets of sexual attraction. By contextualizing conversion therapy in relation to trans youth care, I show that, on the contrary, conversion therapy has long focused on preventing transgender youth from growing up trans.
The term ‘rapid-onset gender dysphoria’ (ROGD) was coined in 2016 to describe an alleged epidemic of youth coming out as trans ‘out of the blue’ due to social contagion and mental illness. The term reflects a deliberate attempt to weaponise scientific-sounding language to dismiss mounting empirical evidence of the benefits of transition. This article offers an introduction to the theory of ROGD and its history, presents a detailed critique of the empirical and theoretical claims associated with the theory, and highlights structural concerns with the ROGD discourse. The article argues that claims associated with ROGD, including assertions of declining mental health and degrading familial relationships following coming out, are best explained by the leading ROGD study’s recruitment of parents from transantagonistic websites against a background of growing visibility and social acceptance of trans people. ROGD theory is best understood as an attempt to circumvent existing research demonstrating the importance of gender affirmation, relying on scientific-sounding language to achieve respectability.
Keywords: rapid-onset gender dysphoria; social contagion; trans youth; gender affirmation
In this article, the author argues that our current medical practices with regard to obtaining informed consent are inadequate. They do not require the systematic disclosure of information which is necessary to prepare for the surgery and what it comes with, but which would not impact the decision to undergo surgery. The article analyzes the two primary processes for obtaining informed consent, namely with and without a referral from a mental health professional, and sketches how both processes fall short of disclosing all relevant information. The author draws on personal experience and community knowledge to argue for an expansion of the notion of informed consent which is better adapted to the needs of patients who are preparing for the surgical process. They highlight how surgeons and mental health professionals are poorly situated to learn and transmit all actionable information and take note of the various barriers patients face in attempting to independently access this information. They then foreground the importance of community knowledge and interdisciplinary collaboration as central devices to meet the legal burden born by professionals tasked with obtaining informed consent and facilitating the informed consent process, as well as to improve the well-being of trans individuals who seek transition-related surgeries.
Keywords: transgender; informed consent; law; duty to disclose; surgery
Dans cet article, je commence en proposant un résumé des techniques existantes de français neutre. Ensuite, j'évalue les avantages et inconvénients de diverses approches. Enfin, je propose une nouvelle approche systématique au français neutre basée sur les travaux d'Alpheratz, auxquels j'ajoute mes propres modifications.
In this article, I begin by summarising the extant techniques of gender-neutral French. Then, I evaluate the advantages and disadvantages of various approaches. Finally, I propose a new systematic approach to gender-neutral French based on the work of Alpheratz, complemented by my own alterations.
Mots-clés: français neutre; language; grammaire; personnes non-binaires Keywords: gender-neutral French; language; grammar; non-binary people
In this letter to the editor, I comment on the controversy surrounding the disruption of Kevin Hsu's talk at the Society for the Scientific Study of Sexuality Conference. Responding to J. Michael Bailey and Bruce Rind who accuse critics of being ideologically-motivated, I highlight how the science/ideology dichotomy they present is a false one, and that science always retains a normative, value-infused element. Hsu and Bailey's support of the theory of autogynephilia is not pure science, but equally ideological. In light of science's ideological elements, I tentatively propose the notion of epistemic violence as a means of choosing between competing interpretations in scientific research involving marginalised populations.
In a previous article, I argued that assessment requirements for transgender hormone replacement therapy (HRT) are unethical and dehumanising. A recent response published by the Journal of Medical Ethics criticises this proposal. In this reply, I advance that their response misunderstood core parts of my argument and fails to provide independent support for assessment requirements. Though transition-related care may have similarities with cosmetic surgeries, this does not suffice to establish a need for assessments, and nor do the high rates of depression and anxiety justify assessments, especially given the protective role HRT plays towards mental well-being.
In a recent commentary published in The American Journal of Bioethics, Michael Laidlaw, Michelle Cretella, and G. Kevin Donovan argue that the watchful waiting is the leading clinical approach and that it disallows puberty blockers prior to 16 years old. In this response, I show that they misrepresent the literature. The leading approach is the gender-affirmative model, not watchful waiting, and the watchful waiting allows youth to take puberty blockers when they begin puberty.
Keywords: transgender youth; puberty blockers; watchful waiting; the Dutch approach
Gender identity clinics have reported unexplained shifts in assigned sex ratios in recent years. Recent attempts at explaining these shifts have often presumed that they reflect a shift in assigned sex ratios in the underlying transgender and gender diverse population. This letter to the editor challenges the assumption, highlighting that the disparity in size between gender identity clinic populations and trans and gender diverse communities makes it more likely that the shift in assigned sex ratios is attributable to a change in referral patterns due to sociocultural factors.
Keywords: gender identity clinics; sex ratios; demographics
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 mental health professional prior to prescription. Drawing on personal and communal experience, the author argues that assessment and referral requirements are dehumanising and unethical, foregrounding the way in which these requirements evidence a mistrust of trans people, suppress the diversity of their experiences, as sustains 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 to transgender care.
Youth explore their genders—both theirs and others’. Exploration is not only a vessel of discovery and understanding, but also of creation. Centring the notion of gender exploration, this article inquires into the ethical issues surrounding care for transgender youth. Arguing that exploration is best seen not as a precondition to transition-related care but as a process which can operate through transitioning, the article concludes that the gender-affirmative approach to trans youth care best fosters youth’s capacity for healthy exploration. Unbounded social transition and ready access to puberty blockers ought to be treated as the default option, and support should be offered to parents who may have difficulty accepting their youth.
Keywords: bioethics; transgender youth; social transition; medical transition; gender-affirmative care
In her article, Maura Priest argues in favour of legislation which would enshrine trans youth’s right to access puberty blockers without parental approval. In so arguing, she acknowledges the unlikelihood that such laws would be passed without a requirement that parents be notified. In this peer commentary, I argue that the proposed legislation should include measures for publicly-funded education and counselling of parents of trans youth. Although access to puberty blockers is necessary, it can also precipitate conflict within families, especially if notification is required. Given the disastrous impact of parental rejection and youth homelessness, any measures seeking to promote access to puberty blockers must be accompanied by harm-reduction measures targeting parents of trans youth who have difficulty accepting their child’s gender identity and transition. These measures can take many forms. Both supervised parent support groups and narrative ethics-inspired counselling should be considered as primary means of addressing parental hostility and rejection of their trans child.
Keywords:bioethics;policy; transgender youth; medical transition; puberty blockers
If I don’t tell you that I was assigned male at birth, as a transgender person, can I go to jail for sexual assault by fraud? In some jurisdictions like England or Israel, the answer is: yes. Previous arguments against this criminalisation have focused on the realness of trans people’s genders: since trans men are men and trans women are women, it is not misleading for them to present as they do. Highlighting the limitations of this position, which doesn’t fully account for the messiness of gendered experiences, the author puts forward an argument against the criminalisation of (trans)gender history non-disclosure rooted in privacy. Gender identity is a private matter and people should not be forced to figure it out or communicate it to others to have an intimate life. Mobilised in this context, privacy can be understood as a refusal of the state’s authority to order our gendered lives. The author argues that this mobilisation is compatible with leftist critiques of privacy. Finally, the author considers whether (trans)gender history non-disclosure is a criminal offence in Canada and concludes that it is not.
Keywords:criminal law; sexual fraud; privacy; discrimination; non-disclosure; human rights
In a recent article, Dubov & Frankel argue that facial feminization surgery should be deemed medically necessary insofar as it helps transgender people “pass” as cisgender, which is required for their wellbeing and ability to function. This peer commentary problematises their argument by pointing out how it constrains our understanding of trans embodiment to narratives of gender dysphoria, to the exclusion of narratives about gender euphoria and creative transfiguration, as well as by calling into question the value of facial feminization surgery for those who will never be able to pass as cis. With consideration to the diversity of trans experiences of the body and the variety of reasons why trans people desire facial feminization surgery, we invite policymakers to move away from justifications of insurance coverage that rely on the putative mutual exclusivity of medically necessary care and cosmetic care, arguing that aesthetic experiences of the self can be sufficiently ethically important to justify insurance coverage on their own. Under this theoretical frame, we can create space for insurance coverage while also resisting the gatekeeping that comes with medicalization.
Keywords: bioethics; insurance coverage; medical transition; transgender embodiment; facial feminization surgery
In a Letter to the Editor, “Gender Transitioning before Puberty?”, Steensma and Cohen-Kettenis (2011) cautioned against prepubertal gender transition by referring to two children assigned female at birth who, they say, had “transitioned when they were in elementary school” and subsequently struggled with returning to “their original gender role.” This letter to the editor criticises their argument, highlighting that it fails to account for the fact that the two youth had not socially transitioned in the usual sense of the term, and arguing that preventing youth from being gender non-conforming would be ethically questionable.
Keywords: bioethics; transgender youth; social transition; the Dutch approach; gender-affirmative care
The question of judicial protection of trans people has come to the fore in recent years, culminating in Bill C-16 which added gender identity and gender expression to the federal anti-discrimination and hate crime laws. In this article, the author contests the notion that anti-discrimination and hate crime laws are effective in mitigating anti-trans harassment, discrimination, and violence. Suggesting that the model of anti-trans acts which underlies anti-discrimination and hate crime laws is erroneous, the author argues that the law’s impact on trans well-being will be modest and that a careful analysis of anti-trans attitudes enables us to identify a number of more effective governmental avenues toward trans emancipation.
Keywords: criminal law; human rights; anti-discrimination law; hate crime laws; critical trans politics
Dans cet article, l’autaire explore la question de savoir si une obligation légale de respecter les pronoms et accords neutres existe en contexte scolaire francophone au Québec. Ille débute par un survol du contexte vécu par les personnes non-binaires francophones ainsi que de leurs besoins par rapport au respect des pronoms et accords neutres. Ensuite, ille analyse l’état actuel du droit relativement au harcèlement et à la discrimination envers les personnes trans en contexte scolaire et évalue la plausibilité qu’une obligation de respecter les pronoms et accords neutres soit retenue par les tribunaux québécois. Enfin, à la lumière des limites du droit, ille propose une approche stratégique concernant le respect des pronoms et accords neutres qui met l’accent sur le développement de politiques institutionnelles s’appuyant sur le droit.
Mots-clés: droits de la personne; droit à l'égalité; personnes non-binaires; pronoms; français