Puberty blockers and differing ethical perspectives

Puberty blockers and differing ethical perspectives is a short primer on puberty blockers and discussions of ethics.

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The right to health encompasses not just the absence of disease or infirmity but “complete physical, mental and social well being”. It includes access to both timely and appropriate healthcare as well as the underlying social and economic determinants of health, such as conditions of work and adequate food and shelter.

New Zealand Human Rights Commission

The meaning of ‘differing ethical perspectives’ on puberty blocking medications

The ethical issue in question is the right to access appropriate healthcare.

All people, whether they are transgender or not, should be able to access appropriate healthcare. Children also have a right to access appropriate healthcare.

These aren’t just ethical standards, but are the current legal standards in Aotearoa.

One of the frameworks that applies is The Code of Health and Disability Services Consumers’ Rights, which applies to all people getting healthcare. It’s part of the law that says that in healthcare “every consumer has the right to be free from discrimination, coercion, harassment.”

Another ethical framework that applies is also part of NZ law, which is the idea that doctors’ personal ethics and beliefs shouldn’t stop people from being able to get sex and gender related healthcare.

Section 174 of the Health Practitioners Competence Assurance Act is a law that applies to all “reproductive” healthcare, which means healthcare that’s related to the reproductive system. It says that if you want that type of healthcare, but your doctor disagrees due to their beliefs, they can refuse to provide that medical care, but they legally have to tell you about a doctor who will do it.

This applies to things like contraception, sterilisation, and abortion, as well as fertility treatments and other hormonal medication.

This is based on an ethical principle that lets doctors respect their own individual ethical beliefs and not provide sex/gender-related healthcare that they don’t believe in, while still making sure that people who need that healthcare can get it.

People who aren’t transgender also get prescribed puberty blockers. Any move to change these standards for transgender people, and not for people who aren’t transgender, is an anti-transgender move.

This is what has recently happened in the United Kingdom – only gender clinics are no longer allowed to prescribe puberty blockers.

Anti-transgender laws in the United States also specifically target transgender healthcare – sometimes they deliberately say that transgender children (who consent to hormone-related medications) are banned from getting those medications, but intersex children (who may be forced to take hormone-related medications) are not banned.

Cisgender and endosex (non-trans and non-intersex) kids who experience very early puberty (sometimes called ‘Precocious Puberty’) are also not banned.

This is one of the ways that we can tell that the issue isn’t “whether certain medications are ethical.” Instead, the issue is “whether transgender people are allowed to access transgender healthcare or not.”

People who medically need puberty blockers include people who have Precocious Puberty, people whose body has a dangerous reaction to puberty, people who experience extreme psychological distress at going through puberty, and people who experience more than one of these things.

Some people suddenly end up experiencing the “opposite” puberty from the one they expected, because they were born intersex, with innate variations of sex characteristics that mean they don’t develop in the same way as other (endosex) people. They may be prescribed puberty blockers as well.

All of those groups of people might also be transgender, or not, and they should all be able to get medication.

In general, people who need medication are able to go to a doctor, and work with that doctor to figure out what is right for them, or find a different doctor who works with them better. These are part of our basic rights to get healthcare.

Adding extra rules specifically for transgender people, such as bans or extra steps, are about making life harder for transgender people.

Making life harder for one group of people only makes sense in an ethical framework that thinks that those people should have a hard time.

Different and worse treatment is transphobic discrimination

One word for the belief that things should be harder or worse for transgender people is “transphobia.”

You could compare the idea of adding extra rules based on people’s gender, to rules that we used to have in New Zealand that meant people were arrested for “crossdressing.”

This meant that the government and police used to decide which clothes people got to wear based on their sex/gender. This was finally changed in 1966 due to a transgender woman named Carmen Rupe, when it was legally decided that people could wear pants or skirts no matter what sex/gender the government thought they were.

Some of this is discussed in the Te Ara Encyclopedia of New Zealand: https://teara.govt.nz/en/gender-diversity/page-2

You can read more about transphobia and ethical standards that lead to treating transgender people differently here: https://genderminorities.com/2020/11/20/what-is-transphobia/

Who decides for children

In terms of who gets to decide about medical treatment, the Care of Children Act says that parents get to decide what medical treatments a child gets until a child is 16, when children get full rights to control their own medical care. Parents also aren’t allowed to refuse medical treatment for their children if they are deliberately trying to harm that child.

Two frameworks that apply for people who are under 16 are the United Nations Convention on the Rights of the Child, which is international law that New Zealand has agreed to, which says that children should get to make decisions about their own health and lifestyle.

There’s also an international medical legal principle called Gillick Competency, which says that if a child can understand and decide about their own medical treatment, doctors and medical professionals have to respect that decision. This principle also says that rights to make medical decisions aren’t actually a clear line of over-16 vs. under-16.

There are a few ethical frameworks that apply here: One is the idea that parents are meant to take care of their child by making good medical decisions for them, and the other is the idea that children belong to themself. Another is that people get to make their own decisions.

All of these frameworks have some legal weight in New Zealand.

In general, almost all transgender people who use puberty blockers are children who say they understand consent to the treatment, and almost all have the consent of their parents. Doctors are always involved in the decision as well.

Cases where children have not consented to hormonal treatments like puberty blockers are usually only limited to cases of intersex children, or disabled children, where parents and doctors make a decision about that child’s sex/gender without that child understanding or having a say.

Intersex organisations such as Intersex Aotearoa say that intersex children should also be allowed to make choices about their sex/gender related healthcare (https://www.intersexaotearoa.org/all-about-intersex), and disability organisations such as the Disabled People’s Assembly, (https://www.dpa.org.nz/) say the same about disabled children.

Intersex people say that doctors often lie to them about these treatments, instead of trying to help them understand and be able to say “Yes” or “No.”

This is because intersex people are not accepted as normal, so doctors and parents think that they are automatically doing what is best for those children by trying to hide and get rid of those intersex differences.

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