Is it depression? Perhaps, and yet. How do I fight a despair that seems so reasonable? A few years ago, my mother asked for my wishes for the new year. I told her candidly of my wish not to get stabbed. Neo-Nazis armed with knives had been hanging around queer bars in Montreal. Usually optimistic to a fault, I saw on my mother’s face a nod of resigned agreement. My answer to her had been half-considered, not quite in jest yet not quite earnest. In truth, only with her response did I feel the full weight of my fears. Little has changed since; as I write, far-right rags have had a few good weeks of running articles targeting me for saying something about how gendering animals normalizes bioessentialism. Their comments, an ode to my inhumanity. I should stop reading them, but I have a perverse fascination with others’ revulsion. Maybe if I acquaint myself with their contempt, it can no longer take me by surprise. But worry not — for every person who wishes me dead, two will put pronouns in their email signature. Biweekly declarations of empty support as I read the morning news of yet another frantic attempt to excise trans lives from society.

Hearken unto me, fellow creatures. We, trans communities, are not the only ones targeted — far from it. Society is imploding. Witness the dismantling of the welfare state and the semblance of any social net. The ruthless exploitation of land and workers, the brutalities freely dispensed to those Black and Indigenous people who dare exist before the eye of a militaristic police. Over the horizon, if you squint a bit, you can see the downfall of civil and human rights at the hands of demagogues and populists. And if that was not enough, our little grassy ship through space is on fire. A climate crisis, approaching with unshaken determination. Choose your poison; there is no happy ending.

Once, I had hoped that my dearest communism would arrive in time to save us from despondency. Alas, I fear the demise of capitalism will not come to pass. Overcoming greed, endless consumption, and so-called merit; abolishing poverty and inequality — pipe dreams from more naïve days of mine. The promise of revolution is not one I see in the future. Not in time to save humanity from the climate apocalypse. Only barely have we sacrificed our comforts to survive a pandemic. Survive… at least seven million did not. How foolish would it be to think ourselves capable of collecting our forces and beating back planetary warming, so affectively distant it is, against the prodigious authority of capital, forever hungering for its own expansion.

Those who resist with a voice loud enough that power takes notice will be met with violence unbecoming. Among the greatest threats to racial capitalism was the Black Power Movement. And so was Fred Hampton assassinated by agents of the state as his girlfriend lay in bed next to him. Some fifty-two years ago, his death — revolutionary movements no longer pose a threat. The brutalities of the police against those who protest its violence are for its own amusement and delight. The police is now militarized, and the military equipped with hi-tech toys of mass destruction. Never has the disparity been greater between the soldiers of capital and the people. If there was ever a time for revolutionary movements to succeed, it lies in the past.

In truth, conspicuous violence rarely needs be resorted to. Capitalism has perfected the ability to quash threats to its sovereignty. The tools of ideology turn the pressure valves, let off just enough steam for the pipe not to explode. Leaders and elites at the margins can be assimilated and brought into the fold, dead or alive. Their revolutionary thought, if they have any, can be sterilized and turned into a marketing strategy. If all else fails, give them a professorship. In 1917, Vladimir Lenin wrote about how great revolutionaries were made ‘hip’ among the liberal elite:

After their death, attempts are made to convert them into harmless icons, to canonize them, so to say, and to hallow their names to a certain extent for the ‘consolation’ of the oppressed classes and with the object of duping the latter, while at the same time robbing the revolutionary theory of its substance, blunting its revolutionary edge and vulgarizing it.

There is nothing worse for a movement than its co-optation by capital. Capitalism has had some hundred years since to polish its ideological stratagems. Their sophistication is without rival. Martin Luther King Jr. has become an idol of white liberals. Seamlessly, quotes from Malcolm X are deployed to criticize radical Black voices. The legacies of Marsha P. Johnson and Sylvia Rivera are turned into soundbites before our eyes, to be used by reformist trans movements and their middle-class ex-military leaders. Today, even Justin Trudeau is an intersectional feminist — taking a knee at a Black Lives Matter event and tweeting his sorrow at the mass graves of Indigenous children just before signing off on another pipeline or appealing a court ruling that requires his government to finance healthcare and education for Indigenous youth. Oh and of course, how mightily unconcerned does he seem about the lack of clean drinking water on reserves. But don’t worry — he gets it.

Radicalism has become little more than a spectacle. A brand, a marketing strategy, an aesthetic. Like punk when I was young; all it took was a spiky belt and an album with the parental advisory tag — no matter that this little frenchie kid could not understand any of the lyrics. Radicalism is no longer a matter of feeling, compassion, or commitment, but one of appearances. I do not mean to deny the profound affect that underlies the unyielding pledge of many leftists. But you cannot organize a revolution if you do not know which of your comrades will remain at your side past the first sign of strife. With hashtags and Pepsi ads, we have been disarmed. O hope, how I wish you could still be mine to bear.

Every so often, I wake up crying from a dream of pregnancy. Crying, because I will never experience a burgeon of life taking form by my stomach, growing in the nook between my ribs and pelvis. I would be stunning with a baby bump. But on this wretched earth, my prayers are being reshaped, torn into gratitude. Never will I be the cause of another’s existence. Perhaps it is a blessing, so beset am I already with worries for the younglings in my life. Death sounds peaceful — a thought I caught myself thinking a few days ago, for the first time in a decade.

How do you live in a world that can never be repaired? How do you resist when you are too exhausted to dream of a future? Far too often have I daydreamed of giving up, of fleeing to the forest, to live in a small cabin of pine and cypress hidden in the depths of a valley. In flowing dresses and crowns of flower wreaths, there to dance barefoot on the twigs and needles with my girlfriend, in between gathering berries and logging wood. An impotent dream, I must concede. Between boredom, guilt, and the early onset of osteoporosis should I dare renounce pharmaceuticals, I wouldn’t last long. Outside, November — I prefer the city.

Not long ago, I began to play with an idea in my head. What if I conceived of activism as a palliative endeavor, rather than one guided by a utopic end? In palliative care, living past illness is no longer the goal. Something of a ritual, and much of a prayer. Its goal is to ease pains, like a balm after the sun; to cultivate comfort and love among the suffering. How do you help in a world of fire? What do you do when you run out of water? Cuddle and fuck. Aren’t the flames pretty? Let them set the mood. Suck dick. Eat pussy. Build a bookcase. Write a poem for the friend you’re crushing on. Kiss your lover under a rain that pours like nails from heaven; leave your damp clothes on the floor and shower with your bodies held together for warmth like mousebirds. Love one another — because the world sure fucking won’t. Palliative activism is a joyful or, at least, content pessimism. Maybe even an optimistic fatalism. Or fatalistic optimism — I don’t know what words mean anymore. If we are doomed to suffer, maybe we can ensure that there will be love among the suffering.

An outgrowth of my hopelessness, in palliative activism I would give up my hopes for revolution and justice, replacing them with comfort in the now-and-then. Like revolutionary struggle, its progenitor, palliative demands change — yet its demands are not in the hopes of crafting one day a just future but to reduce the pain and injustices that so many carry unto the end of days. If you are still capable of hope, then hope — I envy you. But I must figure out how to go on when weariness cuts you bare. No, I don’t want to give up on systemic change, nor turn away from justice — I want to hold and cradle them in my arms, warm them, hold them close to my heart — but I know this won’t do anymore. Not without faith. But perhaps I can hold onto them if I approach with a mind toward harm reduction rather than a teleological attitude that besets me with unkindness.

To reduce suffering and hold each other in kindness and care is still an activism. Giving up cannot be palliative; nor can liberalism. We do not diminish misery — at least not well — by helping only those most privileged among us. Even if the revolution never comes, liberal reformism cannot be squared with the materialism of palliative activism. A wish for life, not formalities, not rights for the rich marginals. And besides, you and I both know that there is no fun in kissing up to the powers that be. Their asses aren’t that soft. Pleasure lies in the fight. May the bridges we burn offer warmth and comfort — we must imagine Sisyphus happy.

What would I do differently if this decade were my last? My eyes set on revolution, I have often found anger in my bones and the kindness disappeared from my voice. Too often have I sought to be right rather than kind. Too often have I lacked kindness toward myself, wallowing in the infinite guilt of… perhaps I could have done more. More, and perhaps we could have had our revolution.

Wishing revolution has erected a barrier against my enjoyment of the world that remains. Feu Lauren Berlant called these hindering desires ‘cruel optimism.’ Cruel optimism appears when the object of your desire — say, communism — becomes an obstacle to your happiness and flourishing. Cruel is the optimism that seeks happiness yet inhibits it.

My palliative activism is a bittersweet response to the cruel optimism of revolution. It cultivates the ephemeral bubbles of love and community. It invites us to surrender to the love and care we can foster. It holds space for being wrong, for being flawed, for redemption. I have been unforgiving of imperfection, though negligible its harms can sometimes be, for want of revolution. But the revolution is not at stake; I am no longer able to dream of perfection. How about we cut ourselves and each other some slack? How about we refuse to let idealism get in the way of our present needs, present loves, present communities? We are not disposable.

Palliative activism begins where grief turns to wisdom, and wisdom to care. It carves its roots in the (post-)erotic entanglements of anarchic love, surges from those abandoned moments where we dare care for the wounded bird within ourselves. Because refusing the banality of cruelty, refusing to be worn bare, refusing to do violence unto each other — these may damn well be the closest we will come to revolution.

Maybe I am too far gone to hope anymore. But, for solace, there may still be hope.

This essay is an excerpt from Gender/Fucking: The Pleasures and Politics of Living in a Gendered Body (CLASH 2024). Florence Ashley (they/them) is an Assistant Professor at the University of Alberta Faculty of Law and John Dossetor Health Ethics Centre.

Transgender people face many formal barriers to gender-affirming care, sometimes known as ‘gatekeeping’. Gender-affirming care refers to a wide range of medical interventions that patients pursue to affirm, actualize, and/or embody their sense of gender. Common forms of gender-affirming care include transition-related surgeries, hormone therapy, puberty blockers, and hair removal. Healthcare providers often refuse to offer gender-affirming care to trans patients without an assessment of the person’s gender identity or dysphoria. Adolescents may moreover need to show that they have experienced gender dysphoria for several years before receiving care and may be denied care until they satisfy a strict age requirement. In this paper, I sketch out the basic form of my argument that patients have a presumptive right to gender-affirming care based on the principle of gender self-determination. By presumptive, I mean that there is a presumption that patients have such a right but that the presumption can be rebutted by showing that encroachments are adequately justified under the standards described later in this article. Presumptive rights can be contrasted with absolute rights, which cannot be rebutted or derogated from.

Being transgender is a matter of diversity, not pathology.1 When providers create barriers to gender-affirming care, they are impairing their patients’ ability to live out their sense of gender. People should be able to determine their lived gender without the interference of doctors. Given the psychological and social importance of gender, it may be suggested that healthcare providers recognize a presumptive right to gender-affirming care and strive to remove barriers to care that cannot be justified.

A presumptive right to gender-affirming care is an important part of redressing gaps in access. Not every trans person wishes to pursue gender-affirming interventions — it is a deeply personal choice — but many do. In Canada, 73% of trans people want to or have pursued some form of gender-affirming care and another 16% is unsure.2 Yet, only 26% of trans people have received all desired gender-affirming care.2 Barriers to care erected by clinicians are one of the reasons for the large gap between desire for gender-affirming care and access to gender-affirming care.

The aim of this paper is not to present a definitive argument for gender self-determination as a medical right — it would be impossible given the available space — but to foster reflection among healthcare providers on how they may be knowingly or unknowingly creating barriers to gender-affirming care. For interested readers, I have addressed some common concerns with a right to gender-affirming care in a previous article.3 My hope is that, by reflecting on their attitudes and practices, healthcare providers will help reduce the stark gap in access to gender-affirming care.

Medical Autonomy and Everyday Autonomy

At the heart of medical ethics lies the principle of autonomy, according to which patients must be free to act “in accordance with a self-chosen plan.”4 Autonomy is the reason why patients have a right to refuse care, and it underpins healthcare providers’ duty to properly inform patients so that they can decide whether to accept a proposed treatment or not. Medical autonomy is, however, asymmetrical. While patients have the right to refuse an intervention, medical autonomy does not typically afford them the right to demand a specific intervention from their doctor.4 Nor does medical autonomy generally prevent providers from imposing discretionary restrictions and conditions on access to care. Gender-affirming care can be considered along similar lines as abortion, which is also desired for its own sake and often framed as a right.3

Gender-affirming care, however, does not only implicate medical autonomy. It implicates autonomy over everyday life — thereby engaging the principle of gender self-determination. A person’s gender is one of the most powerful determinants of the shape of their life. Gender influences how others refer to you, what facilities you use, who you date, which peers you have, how others treat you, and which social norms are applied to you. It is also implicated in the body, with primary and secondary sexual characteristics playing a central role in social and sexual intercourse. Bodily features influence whether others perceive you as male, female, or non-binary, as trans or cis. Having certain body parts also shapes your ability to do many things such as use urinals or have penetrative sex — the latter of which is recognized as significant in the treatment of erectile dysfunction. If you do not feel like your body reflects your sense of gender, you may experience persistent discomfort in everyday life and struggle to flourish in your social or romantic life. Feeling misperceived may also cause you to withdraw from meaningful relationships and can be a source of significant distress.

Gatekeeping gender-affirming care curtails everyday liberty, dictating critical aspects of trans individuals’ social, interpersonal, and embodied life. The impact of gatekeeping gender-affirming care extends far beyond the medical realm, permeating the deepest reaches and crevices of trans people’s lives. Access to gender-affirming care determines whether and how you get to live as yourself, every day of your life. For most, a life in another gender would be a radically different existence.

The Principle of Gender Self-Determination

Recognizing the impact of gender-affirming care on everyday autonomy brings us to the principle of gender self-determination. Gender self-determination means that individuals have a right to define, express, and embody their gender identity as they see fit. Gender self-determination is one of the cornerstones of the Yogyakarta Principles. The Principles are an international legal document that sets out human rights recommendations regarding sexual orientation and gender identity.5 They were developed in 2006 by leading human rights experts at an meeting held in Yogyakarta, Indonesia. While the Principles do not use the term “gender self-determination,” it is the golden thread that binds the document. According to the document:

Each person’s self-defined … gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom. … No one shall be subjected to pressure to conceal, suppress or deny their … gender identity.

I would suggest that the principle of gender self-determination can be derived from many long-recognized rights. Given the expressive facets of gender, the right to free speech offers a compelling foundation for gender self-determination.6 The principle could also be justified based on equality rights since cisgender or non-trans people typically have a body that aligns with their sense of gender and since lack of access to gender-affirming care facilitates social discrimination.3 The right to privacy, the right to identity, the right to dignity, and the right to live and act with integrity may also offer support the principle of gender self-determination.7,8 As explained by Loukēs G. Loukaidēs, later of the European Court of Human Rights: “For [someone] to be able to function freely, in the full sense of the term, [they] must have the possibility of self-definition and self-determination: the right to be [oneself].”9 Gender self-determination is implicitly and explicitly recognized by multiple international actors, including the European Court of Human Rights, the Inter-American Court of Human Rights, and the United Nations Independent Expert on Sexual Orientation and Gender Identity.10–12

Gender Self-Determination as a Medical Right

The principle of gender self-determination alters the ethical obligations of healthcare providers. Given the impact of gender-affirming care on people’s ability to express, embody, and live out their gender in everyday life, trans people have a presumptive right to gender-affirming care. Trans patients are, in this sense, in a special situation that expands the traditional scope of medical autonomy. This reasoning is perhaps best expressed in the decision of the European Court of Human Rights in Van Kück v Germany, which explained that “the burden placed on a person to prove the medical necessity of treatment, including irreversible surgery, in the field of one of the most intimate private-life matters, appears disproportionate.”10

Medical care often constrains everyday liberty; that is not the sole province of gender-affirming care. But there are differences of kind and degree where gender-affirming care is concerned. Conventional approaches of diagnosis and treatment have little place in gender-affirming care, as being trans is a matter of diversity rather than pathology.1,8,13 Gender-affirming care is a way for the person to shape themselves from a gendered perspective, not a means of treating an underlying pathology. Once we understand trans existence in terms of diversity rather than pathology, we can begin to rethink gender self-determination as a medical right.

Justifying Barriers to Gender-Affirming Healthcare

Given the presumptive right to gender-affirming care, healthcare providers should avoid creating unjustified and unnecessary barriers to accessing transition-related medical interventions.14 The presumption in favour of access to gender-affirming care can be outweighed by other considerations. Barriers to gender-affirming care are, however, infringements that must be retrieved from the jaws of immorality by greater goods. Because trans people have a presumptive right to gender-affirming care, the burden of justifying barriers to care lies on the healthcare providers who erect them. Whether a barrier is sufficiently justified cannot be reduced to an algorithm. It requires the careful exercise of personal judgment and collaborative discussion. These discussions must include trans scholars, communities, and patients.

A barrier to gender-affirming care would be justified if there was clear and compelling evidence that it prevents harms of sufficiently great magnitude and quantity that they unambiguously outweigh the barriers’ negative impacts on gender self-determination and wellbeing. Clear evidence reports ethically relevant outcomes (e.g., quality of life), can be generalized to the relevant clinical population, and cannot reasonably be interpreted differently.

Compelling evidence is derived by robust scientific methodologies that are suited to the research question and, considered as a whole, establish the existence of disproportionate harm. The harm that barriers seek to prevent must be sufficiently serious to outweigh individuals’ autonomy in defining the most fundamental aspects of their personal identity. From the perspective of non-maleficence, impairing one’s ability to live out their sense of gender is itself harmful. Unfortunately, healthcare providers have historically failed to recognize the psychological and social harm of denying gender self-determination. When evaluating whether a barrier is justified, providers should give considerable weight to its impact on autonomy, with the understanding that autonomy includes the right to make bad decisions for oneself. The freedom to make only good decisions would be meaningless.

The threshold I propose for justifying barriers to gender-affirming care — clear and compelling evidence that the barrier’s benefits outweigh its negative impacts — does not seem to be satisfied for at least three common barriers to gender-affirming care. These questionable barriers involve (1) the requirement of gender assessments, (2) the requirement of several years of gender incongruence for adolescents, and (3) rigid age requirements.

Gender Assessments

The traditional requirement of assessing gender identity and/or gender dysphoria is based on expert consensus and there is “no scientific evidence of the benefit of these requirements.”15 No clear and compelling evidence shows that assessments are effective in predicting and preventing regret, or that they are necessary and proportionate.16 Diagnostic requirements were developed to legitimate gender-affirming care in the eyes of the public, avoid legal liability, and restrict access as much as possible.17 These requirements reflected providers’ pathologizing understanding of trans communities as well as suspicion towards them, with the original standards of care — published in 1979 — encouraging providers to assess gender identity and gender dysphoria “independent of the patient’s verbal claim” and referring to patients as “possibly unreliable or invalid sources of information.”18 Assessments are viewed negatively by many trans individuals, and can cause distress due to increased delays and mistrust in patients’ fundamental self-understanding.19 Standardized questionnaires and freeform evaluations often reflect stereotyped, narrow, and inaccurate understandings of trans communities.20 No reliable predictor of regret has been identified in the literature.16 There is no test for being trans. On the contrary, some studies have suggested that assessments do not improve outcomes.21,22 Clinics that de-emphasize or renounce assessments do not report higher rates of regret or lawsuits.21 De-emphasizing or renouncing assessments has become prevalent in North America and no evidence of negative outcomes has yet to emerge.

Duration of Gender Incongruence for Adolescents

The requirement that adolescents experience “several years of persistent gender diversity/incongruence” prior to initiating hormone therapy or surgery is also on uncertain footing. The requirement is not grounded in evidence that immediate access to gender-affirming interventions, without waiting several years, is associated with regret or negative mental health outcomes.23 Nor is it backed by evidence that being older correlates with better mental health outcomes. Instead, its proponents justify it based on precautionary reasoning, pointing to the fact that some youths elect not to pursue transition-related interventions and claiming that low regret rates are only applicable to youths who “demonstrated sustained gender incongruence and gender-related needs over time.”23 The empirical claim is misleading given that studies demonstrating positive outcomes often do not specify the length of identification prior to the intervention and come from a wide range of clinical context, including some that deliberately aim to reduce delays and barriers to care.24,25 Critically, there is no clear and compelling evidence that the requirement is necessary. No available data suggests that faster access to gender-affirming care would lead to worse outcomes. Given this dearth of supporting evidence, providers may instead prefer to focus on supporting adolescents’ decision-making process.

Age Requirements for Physical Interventions

Another barrier to gender-affirming care takes the form of rigid age requirements for puberty blockers, hormone therapy, and surgeries. Age requirements vary across providers and guidelines but are typically 12 or Tanner II for puberty blockers, 14 or 16 for hormone therapy, 15, 16 or 18 for chest surgeries, and 17 or 18 for genital surgeries. These age thresholds are not based on empirical evidence, but are rather linked to assumptions about youths’ cognitive and emotional maturation.26 Concerns over maturity and capacity to consent are legitimate, but are not adequately captured by strict age requirements. Rigid age requirements act as barriers for youths who are younger but equally as mature, disciplined, and supported as some older patients. Moreover, these types age requirements betray an all-or-nothing understanding of autonomy that belies its gradual development and heterogeneity across the population.27 The developing autonomy of youth is recognized in Canadian law under the mature minor doctrine. In the words of the Convention on the Rights of the Child, youths’ views must be “given due weight in accordance with the age and maturity of the child.” No clear evidence suggests that acceding to youths’ reasoned requests for gender-affirming care would be harmful, especially in contexts where the intervention is hormonal or where the patient has sufficient discipline and support to follow post-operative care. From the foregoing, it is unclear whether rigid age requirements can meet their burden of justification.

Conclusion

Gender is an immensely impactful facet of who we are, one that should not be determined by healthcare providers. In this paper, I have suggested that providers of gender-affirming care may have an ethical duty to respect the gender self-determination of patients, and accordingly bear the burden of justifying the barriers they erect on access to gender-affirming care. Being trans is a matter of diversity, not pathology. By avoiding unnecessary and unjustifiable barriers to care, providers can acknowledge the role of gender-affirming care in one’s ability to live out their sense of gender and demonstrate respect for the dignity of trans patients. My aim is not to chastise providers but invite greater reflection. Ours is a painful history, one that we must take care not to reproduce. Going forward, I hope that providers working with trans communities will carefully examine their practices to ascertain whether they are justified by clear and compelling evidence. Practices that fail to meet this threshold of justification should be abandoned.

References

1. American Psychological Association. Resolution on Gender Identity Change Efforts. American Psychological Association https://www.apa.org/about/policy/resolution-gender-identity-change-efforts.pdf (2021).

2. Trans PULSE Canada. Report — Health and health care access for trans and non-binary people in Canada. https://transpulsecanada.ca/results/report-1/ (2020).

3. Ashley, F. Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health. Kennedy Institute of Ethics Journal 32, 127–171 (2022).

4. Beauchamp, T. L. & Childress, J. F. Principles of Biomedical Ethics. (Oxford University Press, New York, 2019).

5. The Yogyakarta Principles: Principles on the Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity. (2007).

6. Wingate, P. R. Trans Bodies, Trans Speech. Minnesota Journal of Law & Inequality 41, 331–361 (2023).

7. Lau, H. Gender Recognition as a Human Right. in The Cambridge Handbook of New Human Rights: Recognition, Novelty, Rhetoric (eds. von Arnauld, A., von der Decken, K. & Susi, M.) 191 (Cambridge University Press, 2020). doi:10.1017/9781108676106.

8. Ashley, F. Gatekeeping Hormone Replacement Therapy for Transgender Patients is Dehumanising. Journal of Medical Ethics 45, 480–482 (2019).

9. Loukaidēs, L. G. Essays on the Developing Law of Human Rights. (M. Nijhoff Publishers, Dordrecht, 1995).

10. Van Kück v. Germany, no 35968/97, European Court of Human Rights (2003).

11. Advisory Opinion on Gender Identity, Equality, and Non-Discrimination of Same-Sex Couples, OC-24/17, Inter-American Court of Human Rights (2017).

12. Madrigal-Borloz, V. Protection against violence and discrimination based on sexual orientation and gender identity. (2018).

13. Coleman, E. et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism 13, 165–232 (2012).

14. Beischel, W. J., Gauvin, S. E. M. & van Anders, S. M. “A little shiny gender breakthrough”: Community understandings of gender euphoria. International Journal of Transgender Health 1–21 (2021) doi:10.1080/26895269.2021.1915223.

15. Bouman, W. P. et al. Yes and yes again: are standards of care which require two referrals for genital reconstructive surgery ethical? Sexual and Relationship Therapy 29, 377–389 (2014).

16. Ashley, F., Parsa, N., kus, til & MacKinnon, K. Do gender assessments prevent regret in transgender healthcare? A narrative review. Psychology of Sexual Orientation and Gender Diversity (in press).

17. Marrow, E. “I hope that as our selection becomes more accurate, the number … will be very few”: The creation of assessment criteria for gender-affirming care, 1960s–1980s. Psychology of Sexual Orientation and Gender Diversity (2023) doi:10.1037/sgd0000633.

18. Berger, J. C. et al. Standards of Care: The Hormonal and Surgical Sex Reassignment of Gender Dysphoric Persons. (University of Texas Medical Branch, Galveston, 1979).

19. Horton, C. “It felt like they were trying to destabilise us”: Parent assessment in UK children’s gender services. International Journal of Transgender Health (2021).

20. Galupo, M. P. & Pulice-Farrow, L. Subjective Ratings of Gender Dysphoria Scales by Transgender Individuals. Archives of Sexual Behavior 49, 479–488 (2020).

21. Deutsch, M. B. Use of the Informed Consent Model in the Provision of Cross-Sex Hormone Therapy: A Survey of the Practices of Selected Clinics. International Journal of Transgenderism 13, 140–146 (2012).

22. Pimenoff, V. & Pfäfflin, F. Transsexualism: Treatment Outcome of Compliant and Noncompliant Patients. International Journal of Transgenderism 13, 37–44 (2011).

23. Coleman, E. et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health 23, S1–S259 (2022).

24. Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M. & Clark, L. F. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr 172, 431 (2018).

25. Kuper, L. E., Stewart, S., Preston, S., Lau, M. & Lopez, X. Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy. Pediatrics 145, e20193006 (2020).

26. Milrod, X. How Young Is Too Young: Ethical Concerns in Genital Surgery of the Transgender MTF Adolescent. The Journal of Sexual Medicine 11, 338–346 (2014).

27. Clark, B. A. & Virani, A. This Wasn’t a Split-Second Decision”: An Empirical Ethical Analysis of Transgender Youth Capacity, Rights, and Authority to Consent to Hormone Therapy. Journal of Bioethical Inquiry (2021) doi:10.1007/s11673–020–10086–9.

While the vote to remove O’Toole was private, Conservative sources report that it stemmed in significant part from his role in banning conversion practices by unanimous consent. According to the CBC, politician Garnett Genuis “spearhead[ed] the coup because he was in Latvia when [the caucus] gave unanimous consent to make conversion therapy illegal.”

Conversion practices are a discredited family of interventions that seek to change, prevent, or discourage someone’s sexual orientation, gender identity, and gender expression. They are predicated on the view that being cisgender and heterosexual is preferable, and that being lesbian, gay, bisexual, or transgender is undesirable and should be prevented. The practices are opposed by virtually every reputable professional association on account that they are ineffective, reinforce homophobia and transphobia, and cause tremendous harm to those exposed to them. They are harmful regardless of age, apparent consent, type of practitioner, and whether they target sexual orientation or gender identity and expression.

There are good reasons to think that the decision to unanimously support Bill C-4 was not motivated by goodwill for LGBTQ+ communities. According to the National Post, Conservatives “fast-tracked conversion therapy bill to avoid a fight they would surely lose.” Although Erin O’Toole called himself “a long-time ally of the community,” many in his caucus clearly feel differently. And I would personally doubt O’Toole’s self-ascribed allyship.

Yet even that strategic and cynical decision was too much for the Conservative Party to handle. Less than two months after Bill C-4 received Royal Assent, O’Toole’s leadership was challenged, and he was kicked to the curb. The mere appearance of being LGBTQ+ friendly, however superficial, seems to revolt a large portion of its base.

Lest there be doubt about the direction the party is taking, the person elected as interim leader — Candice Bergen — voted against banning conversion practices in June 2021. Just a few years ago, she described herself as pro-life, defended far-right politician Derek Sloan, and was photographed wearing a “Make American Great Again” hat. The slogan, associated with disgraced former U.S. president Donald Trump, is widely understood as a symbol of racism, white supremacy, sexism, and transphobia.

I am no fan of Erin O’Toole. But his ouster and replacement by Candice Bergen as an interim leader heralds the party’s intolerance. As much as it has tried to depict itself as inclusive and changed, the Conservative Party’s leadership crisis reveals its undying homophobia and transphobia. In an era of growing polarization, this should make everyone worried. LGBTQ+ people deserve safety and equality, like everyone else.

Florence Ashley, BCL/JD, LLM (Bioeth) is a doctoral candidate at the University of Toronto Faculty of Law and Joint Centre for Bioethics. A leading expert on conversion practices, their book Banning Transgender Conversion Practices: A Legal and Policy Analysis will be published by UBC Press in April 2022.

Je vous écris pour partager mon désarroi face à la décision hâtive de votre département de sanctionner Ciel Ash Paré pour des propos dits inappropriés. Vous n’êtes pas sans savoir que la liberté d’expression est protégée par l’article 3 de la Charte québécoise des droits et libertés de la personne. Bien que cette liberté ne soit pas sans limite, le simple caractère inapproprié ou offensant d’un propos ne saurait justifier sa violation. Cette liberté est d’autant plus large en dehors des activités universitaires, dont dans les médias sociaux. Est-ce que votre université place en probation les élèves qui ont des propos racistes, transphobes, et sexistes sur les médias sociaux? Non. Punir les personnes qui répliquent, certes de façon enflammée, à des propos jugés discriminatoires tout en tolérant ces propos revient à punir les gens pour leur marginalisation et leur envoyer le message qu’elles ne sont pas bienvenues.

Ciel Ash Paré est une personne ouvertement non-binaire. Le contenu de ses cours et les interventions de ses pair·e·s sont fréquemment cissexistes, voire transantagonistes. De plus, Ciel Ash Paré se fait souvent mégenrer par l’université et ce malgré l’obligation légale qu’a celle-ci de respecter l’identité de genre des élèves et d’offrir un environnement éducatif sain pour les groupes marginalisés. Sa probation existe parce que Ciel Ash Paré a ouvertement contesté des propos cissexistes dans le cadre de ses cours, l’université et son corps enseignant ayant manqué à leur obligation de garantir un environnement respectueux et non-discriminatoire pour les personnes trans. La contravention à la mise en probation découle d’une situation similaire : Ciel Ash Paré contestait des propos cissexistes et transangatonistes, propos qui l’affectent personnellement et contribuent à la toxicité de l’environnement universitaire pour les étudiant·e·s trans en travail social. Une des rares personnes ouvertement non-binaires en travail social, ses répliques ont été rapportées à l’université, j’en doute par certaines des personnes qui étaient en accord avec les propos cissexistes et transantagonistes. Les personnes ayant tenu ces propos n’ont pas, à ma connaissance, été réprimandés ou punis pour ceux-ci. Au final, la situation est celle-ci : le transantagonisme en travail social et à l’Université de Montréal demeure impuni alors qu’une des seules personnes ouvertement non-binaires du programme est punie pour avoir utilisé le mauvais ton en répliquant.

Cet état de fait n’est malheureusement pas inhabituel. Le concept de « tone policing » se réfère justement à cette tendance à discipliner comment les groupes marginalisés répondent à leur propre oppression, soumettant la justice sociale à une norme de civilité qui protège le status quo et blâme les personnes marginalisées pour les émotions qu’engendrent les préjugés et l’oppression. N’en déplaise à l’université, le choix de comment contester les préjugés et l’oppression est au cœur de la liberté d’expression. La liberté d’expression, valeur fondamentale de la société québécoise, garantit aux personnes marginalisées le droit de manifester leur désaccord de façon « inappropriée » et « offensante ». Rien dans les propos d’Ciel Ash Paré ne dépasse les limites de ce qui est acceptable dans une société libre et démocratique, ou dans une université qui tient la liberté d’expression à cœur.

La sanction imposée à Ciel Ash Paré est d’autant plus insultante dans le contexte politique actuel. Il y a à peine quelques mois, la province du Québec a fortement opposé les sanctions envers les professeur·e·s qui utilisent des termes offensants et, plus particulièrement, le mot en ’n’. On nous a dit que cette liberté académique était nécessaire à la mission universitaire ainsi qu’à la lutte contre l’oppression des minorités visées par ces termes. Aujourd’hui, l’École de travail social de l’Université de Montréal nous dit que, finalement, la liberté académique n’est pas si importante que ça — certainement pas assez pour protéger les étudiant·e·s marginalisé·e·s qui défendent leur communauté contre des propos insensibles et discriminatoires.

Non seulement votre sanction viole-t-elle la liberté d’expression d’Ciel Ash Paré et communique aux communautés trans que l’Université de Montréal n’a que faire de la justice sociale et de l’égalité, mais elle est disproportionnée. Les propos d’Ciel Ash Paré ne sont certainement pas graves. Or, votre sanction déroutera son cours d’étude. La précarité socioéconomique des personnes trans et non-binaires est bien établie, ainsi que leur marginalisation académique. Dans ce contexte, votre sanction remet en question sa capacité même de réussir et terminer le programme. C’est une sanction odieuse qui ne démontre aucun sens de proportionnalité avec la supposée offense.

Tant que vous ne pouvez garantir un environnement sans cissexisme et transphobie, punir les personnes trans qui contestent leur marginalisation ne sera autre chose que discriminatoire. Le fait que le ton soit jugé « déplacé » ne change en rien ce simple fait. Votre décision contribue directement à la marginalisation du corps étudiant trans et non-binaire de l’Université de Montréal. Je vous implore de revenir sur celle-ci.

I have a million thoughts to share on Bell v. Tavistock, the decision from the UK High Court which stated that by-and-large youths 13 or under must ask courts if they want puberty blockers, and that most youths aged 14–15 will also need to ask courts to allow them to take blockers. The decision will be appealed by the Tavistock. Let me write down some of these thoughts.

First, the Court confuses consent to puberty blockers and consent to hormone therapy. Though the latter often follows, it is independently consented to at a later time. Full knowledge of the latter shouldn’t be required.

Second is the related confusion of the Court as to the purpose of puberty blockers. Puberty blockers serve at least three purposes: (1) alleviate gender dysphoria, (2) prevent bodily changes that would have to be reversed, and (3) gives time. It isn’t one or the other — if blockers weren’t about giving more time to the youth (a goal I disagree with), then we would just prescribe hormone therapy directly and skip over blockers. After all, waiting until 16 for hormones significantly delays puberty compared to peers!

Third, the Court considers extensively the question of puberty blockers’ reversibility and ability to fully appreciate its consequences, but does not consider how endogenous puberty is non-consensual for the youth, and equally hard to fully appreciate. This is a feature of the law of informed consent, but it is a deeply cisnormative feature that privileges what society considers natural development regardless of youths’ actual autonomy. Given this, it’s not surprising that the Court speaks of blockers ‘promoting persistence’ as though it’s a negative thing, as though there is something wrong with being trans. There, they selectively cite from the DSM-5 (and only perfunctorily acknowledge critiques) but fail to mention that the WPATH Standards of Care specifically state that being transgender is part of normal human variation. And I would add: healthy.

Fourth, the Court inadequately handles the question of scientific uncertainty, privileging speculative unknowns over the known reality of these youths. They do so by asking for incontrovertible evidence of positive mental health impacts. Notwithstanding the fact that various forms of evidence of blockers’ positive impacts exist, this fundamentally misconstrues blockers as a treatment akin to anti-depressive medication, rather than one related to personal autonomy and self-actualization as with birth control. Asking for that sort of statistical evidence clashes with the Gillick test for birth control, which asked for no such evidence. The only place where ‘effectiveness’ on mental health is referenced is when the parents won’t be informed. In that case, birth control can be prescribed confidentially if the person’s mental health is likely to suffer without it. Note how the standard is not only individual, but the threshold is merely ‘likely to’. That threshold is met under current evidence on puberty blockers.

The Court gets around engaging with that thorny precedential difference by folding the question of blockers’ impact on mental health into the question of capacity to consent. Yet, it’s unclear how that’s relevant. Youth are coming in asking for puberty blockers because they see bodily changes during endogenous puberty as being in some sense contrary to their bodily self-image, which is related to their gender identity. They want their body to reflect how they understand their own gender. That’s the primary experience, and blockers’ effectiveness is best understood in terms of whether they actually do block endogenous pubertal development. Mental health effectiveness is important but secondary. This apparently understanding of gender dysphoria as a typical mental illness akin to depression, treated by drugs with unclear effects, and requiring careful differential diagnosis underlies much of the Court’s surprise at data not collated by GIDS. If we understand puberty blockers as an option for individualized bodily self-actualization among a population that’s part of normal human variance, then it’s no longer surprising that clinic-wide statistics weren’t gathered: it’s not relevant to the individualized process.

Fifth, I’m concerned that the Tavistock gave up too much. Its evidentiary showing may have been weak, but I’m particularly puzzled by the concession that parents couldn’t offer surrogate consent. Why not? Of course, puberty blockers shouldn’t be offered contrary to the child’s well-considered request. However, if the child falls just shy of the bar of full capacity to consent, why isn’t their informed assent sufficient to let parents offer surrogate consent? Let us remember that if parents aren’t allowed to offer surrogate consent, it becomes a question for courts to decide whether the treatment is granted. It’s unclear to me why it’s better to have courts make that decision rather than specialized clinicians. If parents consent, youths meaningfully assent, and clinicians believed that it’s in this particular youth’s best interest, why should the decision have to go before courts? They’re not well-equiped, let alone better equipped, to make that decision. All it will do is unduly burden families and the court system. This very approach was rightfully rejected in Australia in Re Kelvin, but UK courts are driving backwards. The Tavistock’s approach in this respect seems overly conservative, leading to an ill-advised concession.

Sixth, the decision is unduly dismissive of teenagers’ psychological capacity — a problem that has long been noted in child studies. It’s true that 12 year-olds aren’t fully mature. But neither are many 30 year-olds! And if the law’s understanding is that a 16 year old is fully mature no matter how complex the decision might be, then it’s questionable that a 12 year old will be too immature to give consent to puberty blockers. While the decision is certainly not simple, it’s not at all out of the ordinary and is arguably simpler than consent to such things as cancer care and other decisions that involve the contemplation of death.

Youth understand far more than we give them credit for at 12 years old. If you’re having trouble imagining what level of psychological maturity that involves, there are interviews with Jazz Jennings at 11. You’ll see that she’s articulate and nuanced in her words. Does someone have perfect understanding and capacity at 12? No. Neither at 16 or 30, for that matter. Perfect understanding and capacity are impossible to ever achieve. But if the threshold is such that all 16 year-olds have capacity by default, regardless of relative maturity and the complexity of the decision, then 12–15 year-olds should generally be able to consent to blockers. They’re teenagers, not infants.

Seventh and last, contrary to what the Court asserts, the fact that the treatment goes to the heart of an individual’s identity INCREASES rather than UNDERMINES capacity to consent. Why? Because the heart of a individual’s identity is far more within their realm of intimate understanding than other decisions. This is where I circle back to the fact that the Court inappropriately treats puberty blockers as if they were antidepressants. They’re not, because they’re about gender identity. Gender identity, frequently lying at the heart of an individual’s identity and sense of self, is something we have particular epistemic authority over. As a result, the youths are better positioned to give consent, not less!

Critical thoughts on Bell v. Tavistock was originally published in Empowered Trans Woman on Medium, where people are continuing the conversation by highlighting and responding to this story.

Les auteurs mentionnent qu’interdire les thérapies de conversion préviendrait l’approche la moins invasive, qu’ils appellent la « psychothérapie exploratoire ». Or, c’est faux. Cette approche, mieux connue sous le nom d’attente vigilante, n’entre pas sous le joug des projets de loi puisque cette approche ne vise pas à changer l’identité de genre de l’enfant. Cette approche vise plutôt à prendre plus de temps avant de permettre la transition de genre sociale et médicale. Rappelons qu’aucune démarche médicale n’est envisagée avant la puberté. S’il est vrai que les thérapies de conversion sont aussi hostiles à la transition, ce qui les distingue est la tentative de changer le genre des jeunes trans. Tout au long du 20e siècle, de nombreux moyens ont été tentés pour influencer l’identité et l’expression de genre des jeunes enfants, tous plus infructueux les uns que les autres et souvent avec des conséquences désastreuses. Pensons à la jeune Leelah Alcorn qui décéda par suicide après avoir été soumise à des thérapies de conversion pour changer son identité de genre. Le préjudice causé par les thérapies de conversion liées au genre est clair. Une récente étude par des chercheurs de Harvard publiée dans JAMA Psychiatry, un des plus prestigieux journaux de psychiatrie, a démontré que tenter de changer l’identité de genre des jeunes trans augmenterait de près de trois fois leur taux de suicidalité. Lorsque l’enfant a moins de 10 ans, on parle plutôt d’une augmentation de 4 fois.

Même si l’approche d’attente vigilante sans tentative de conversion ne soit pas visée par la loi, il vaut la peine de mentionner que celle-ci soulève de nombreux problèmes quant au bien-être des jeunes. En affirmant que l’attente vigilante est moins invasive, les auteurs élisent la détresse bien réelle de jeunes demandant des interventions hormonales. De nombreuses études confirment que ces interventions ont d’importants effets positifs sur la santé mentale tant chez les adolescents que les adultes, alors que la transition sociale est associée à des avantages similaires. Sur le plan de la transition médicale, on parle d’une réduction d’idéations suicidaires de l’ordre de 60 à 70%. Dans une population dont le taux de tentatives de suicide par année est de 21% pour un taux cumulatif de 40%, ces interventions sont plus que nécessaires.

Avec de telles données, on ne se surprend pas que les experts se rangent derrière l’approche affirmative, approche qui permet l’exploration identitaire ainsi que les interventions médicales aux jeunes trans les désirant (ce qui n’est pas le cas de tous). L’approche affirmative est promue par l’American Academy of Pediatrics, le groupe spécialisé en santé trans de la Pediatric Endocrine Society, et les standards de soins du Royal Children’s Hospital et de la Australian Professional Association for Trans Health (ce dernier document fut endossé par la prestigieuse revue The Lancet). Dans tous les cas, le même mot d’ordre ressort du consensus scientifique : « Suivre l’enfant. »

Pour promouvoir l’attente vigilante contre toute science, Nadia El-Mabrouk et ses coauteurs citent le mythe voulant que 80% des jeunes trans se réconcilient avec leur genre assigné à la naissance lors de l’adolescence. Or, non seulement ce nombre a-t-il été réfuté par la littérature scientifique, mais il n’est pas pertinent : toutes les dites ‘réconciliations’ étaient prépubères alors qu’aucune intervention médicale n’est offerte avant la puberté.

Ultimement, les thérapies de conversion visant l’identité de genre sont dangereuses et contraires à la science. C’est pourquoi la Société canadienne de psychologie, l’Association des psychiatres du Canada, l’Ordre des travailleurs sociaux et thérapeutes conjugaux et familiaux du Québec, l’Ordre professionnel des sexologues du Québec et tant d’autres organisations professionnelles s’y opposent. Les projets de loi 70 et C-6 ne font que viser des pratiques dangereuses qui sont contraires à la dignité et à l’égalité des personnes trans. Ces pratiques sont contraires à la science et au bien-être des personnes trans. Elles méritent d’être interdites.

______________________________

Florence Ashley, LLM (Bioéth), Doctorante en droit et bioéthique à l’Université de Toronto

Olivier Ferlatte, PhD, Professeur adjoint, École de santé publique de l’Université de Montréal

Annie Pullen Sansfaçon, PhD, Professeure titulaire, École de travail social de l’Université de Montréal et Chaire de recherche du Canada sur les enfants transgenres et leurs familles

Françoise Susset, D Ps, Psychologue clinicienne et psychothérapeute conjugale et familiale et Ancienne présidente de l’Association professionnelle canadienne pour la santé transgenre (CPATH)

It was with great pleasure that I received an invitation to compile a compendium of those passages which, hidden in the pages of my scholarly writing, some may consider humorous. I offer them with little more commentary, letting myself note only that I hoped for them to lighten the stern atmosphere that pervades the cold halls of academe. May they bring you some of the joy I had writing them.

“Qui est-ille ? Le respect langagier des élèves non-binaires, aux limites du droit”, (2017) 63(2) Service social 35–50:

“Don’t Be So Hateful: The Insufficiency of Anti-Discrimination and Hate Crime Laws in Improving Trans Wellbeing”, (2018) 68:1 University of Toronto Law Journal 1–36:

“Genderfucking Non-Disclosure: Sexual Fraud, Transgender Bodies, and Messy Identities”, (2018) 41:2 Dalhousie Law Journal 339–77:

“Thinking an Ethics of Gender Exploration: Against Delaying Transition for Transgender and Gender Creative Youth”, (2019) 24:2 Clinical Child Psychology and Psychiatry 223–36:

“Science Has Always Been Ideological, You Just Don’t See It” (2019) 48:6 Archives of Sexual Behavior 1655–57:

“The Misuse of Gender Dysphoria: Toward Greater Conceptual Clarity in Transgender Health” (2021) 16:6 Perspectives on Psychological Science 1159–64:

“Surgical Informed Consent and Recognizing a Perioperative Duty to Disclose in Transgender Health Care” (2020) 13:1 McGill Journal of Law and Health 73–116:

“A Critical Commentary on ‘Rapid-Onset Gender Dysphoria’” (2020) 68:4 The Sociological Review 779–799:

“Recommendations for institutional and governmental management of gender information” (2021) 44:4 NYU Review of Law & Social Change 489–528:

“Nuancing Feminist Perspectives on the Voluntary Intoxication Defence” Manitoba Law Journal (forthcoming):

“The Constitutive In/Visibility of the Trans Legal Subject: A Case Study” (2021) 28:1 UCLA Women’s Law Journal 423–57:

“Accounting for Research Fatigue in Research Ethics” (2020) 35:3 Bioethics 270–76:

“‘X’ Why? Gender Markers and Non-Binary Transgender People”​ in Trans Rights and Wrongs: A Comparative Study of Legal Reform Concerning Trans Persons (Springer, 2021) at 33–48:

Banning Transgender Conversion Practices: A Legal and Policy Analysis (Vancouver: UBC Press, 2022)

“Interrogating Gender-Exploratory Therapy” (2022) Perspectives on Psychological Science:

“Transporting the Burden of Justification: The Unethicality of Transgender Conversion Practices” (2022) 50:3 Journal of Law, Medicine & Ethics​ 425–42:

“Reflecting on the Rhetoric of Adoption in Trans Youth Care” (2023) 2:3–4 Bulletin of Applied Transgender Studies 249–75:

“Do Trans/Humanists Dream of Electric Tits” in Neal Baer (ed), The Promise and Peril of CRISPR (Johns Hopkins University Press, 2024), 139–50:

“Genderfucking as a Critical Legal Methodology” (2024) 69:2 McGill Law Journal 177–211:

Before responding to his claims, I wish to yet again remind him that Bill C-16 did not in fact make using the wrong pronouns illegal. Rather, repeated and/or intentional misgendering could already constitute harassment pursuant to human rights and employment law prior to Bill C-16, which only concerns a few areas under federal jurisdictions such as banking and air travel. His repeated assertion that Bill C-16 created this offence, despite being corrected, borders on bad faith.

Jordan Peterson claims that, according to C-16, identity “is something solely determined by the individual in question (whatever that identity might be).” This is plainly false. C-16 doesn’t claim that, say, someone can simply will themselves into being a scholar on gender or a high school teacher. To be a scholar on gender, you need to produce scholarship relating to gender — such as peer-reviewed articles, something Jordan Peterson has yet to do despite his public interventions on the topic. To be a high school teacher, you need to be generally employed at one.

Personal identity is negotiated and emerges out of the complex contributions of ourselves and society. Some aspects of personal identity are largely determined by others’ recognition. Being a scholar and being a high school teacher are two such examples.

Other aspects, like gender identity, are not. Gender identity is part of our self-concept and has long been understood as something internal to the person. The expression “gender identity” was ostensibly coined by psychiatrists Robert Stoller and Ralph Greenson around 1963 to talk about trans people. In 1964, Stoller explained that “[g]ender identity is the sense of knowing to which sex one belongs, that is, the awareness ‘I am a male’ or ‘I am a female’,” distinguishing it from the recognition of oneself as masculine or feminine.

While it is true that personal identity is not solely self-determined, gender identity is. It is inherent in the concept ever since it was coined by mental health professionals. This is not to say, however, that gender identity appears out of the void and that social factors cannot play into this self-determination. It would be difficult to identify with men or women if we do not have a sense of those social categories. In this sense, gender identity is always constituted in conversation with our social world.

Building on the mistaken suggestion that gender identity cannot solely be self-determined, Peterson claims that trans people refuse to engage in identity negotiation. This is false on multiple levels.

Like everyone else, most trans people alter their behaviour and external appearances in response to gender norms corresponding to their gender identity. Trans men, like cis men, rarely wear dresses. This is not because they think wearing dresses would make them women, but because they recognise that the injunction on men not to wear dresses applies to them and that they would face disapproval if they wore dresses. Others, of course, happily and intently ignore this gender norm. Either way, however, their everyday choices occur in relation and with awareness of social norms. Though gender identity itself may not be negotiable, trans people constantly navigate social norms when translating their identity into material choices.

By asking others to respect their gender identity, trans people are also engaging in identity negotiations. Firm stances are not incompatible with negotiation, especially when disrespect can have serious mental health consequences. Furthermore, trans people constantly make compromises. Gender-neutral French is very difficult, and so I accept that people use feminine grammatical gender for me. We also rarely highlight every instance in which others use the wrong pronouns, recognising that accidental and occasional slip ups happen to everyone — also a compromise.

Peterson also complains that non-binary identities, which are neither completely male nor female, fail to provide us with “any real social role or direction”. This misrepresents non-binary lives. Saying what non-binary isn’t already says something important about social role: it is neither a male social role nor a female one. However, Peterson’s critique also shows a lack of creativity. It is true that non-binary people are refusing to slot themselves into one of those two social roles, but it is also because they’re making their own path for themselves. They are creating a new social role, a new direction. Unless we wish society to remain static, we should welcome this kind of social creativity. It expands everyone’s world.

Jordan Peterson shows his hand when he claims that the notion of gender identity “poses a further and unacceptably dangerous threat to the stability of the nuclear family, which consists, at minimum, of a dyad, male and female, coming together primarily for the purposes of raising children in what appears to be the minimal viable social unit.” I, for one, won’t contradict this. I have no attachment whatsoever with the nuclear family and believe that it is only valuable for those who choose it. Peterson’s exhortation that families be composed of a man and a woman does little more than show his homophobic tendencies. Same-sex families, single-parent families, polyamorous families, and childless families are no less valuable. Familial arrangements have no value beyond the happiness it brings to those in it. If the nuclear family suits you, all the power to you. If it doesn’t, don’t force yourself in it.

In the end, Jordan Peterson’s opposition to the notion of gender identity seems to take root in his fetishization of the nuclear family. For those of us who recognise a plurality of happy romantic and familial arrangements, his position reeks of conservatism. It is best left in the past, where it belongs. While there is value in recognising the existence of men and women, especially given the continued existence of sexism, there is no value in rejecting or obscuring the existence of trans and non-binary people.

The National Post has declined to publish this response.

As recently as this year, she said: “Puberty, then, does not have to be imagined as an inevitable natural disaster ravaging the child’s body and body-brain integrity from within, to be averted at any cost.” Of course, puberty need not be a disaster for gender creative kids — not all of them want to transition — but her criticism of puberty blockers and of the view of gender identity as internally constituted seems at best irresponsible and at worst intentionally feeding into anti-trans sentiment. (I personally lean towards the former.) We’re far from even touching upon best practices such as critically reflecting on her role as a cis anthropologist working on trans youth.

Unsurprisingly, perhaps, her work has been cited favourably by anti-trans and conservative outlets.

Conservative outlet Mercatornet reads: “Medical professionals such as Sahar Sadjadi, a physician and anthropologist, have expressed concerns regarding the growing use of puberty suppression treatments in children diagnosed with gender dysphoria.”

Another fan-favourite anti-trans outlet, 4thWaveNow cites her 2013 paper to drum up fears around puberty blockers and infertility.

When confronted about her uptake by anti-trans movements during the hiring process, she refused to answer, saying she didn’t want to talk about politics. Considering how irreducibly political trans youth care is, this worries me.

Also worrisome is her apparent disconnect from the world of trans advocacy and healthcare. Her work is ethnographic in nature yet doesn’t extensively engage with the rich literatures and knowledges produced by trans scholars and community organisations. Trans scholars are confined to “by the by, these people talk about this topic” notes and paragraph endings, in her latest article. I am told she also deflected when pressed on that point. Her acknowledgements sections are also noticeably short on trans people. Her apparent disconnect from trans and trans healthcare communities is also apparent from the anecdotal survey of Facebook mutuals. Whereas I tend to have ~50 mutuals with most people active in trans health and even 15 with people who have been repeatedly accused of engaging in conversion therapy and are considered persona non grata in many trans health circles, I only share a single mutual with her. Though none of this is determinative, it speaks to a pattern: how are we expecting someone to conduct high quality research on trans issues without meaningful connections to trans and trans health communities?

I highly question the wisdom of hiring someone, at the peak of political opposition to trans youth, who is cisgender, and who seems to be divested of meaningful connections with the studied community, critical of crucial care for transgender youth, and uninterested in accounting for the deeply political nature of her work.

What message is the hiring committee sending, especially when all the points I made were raised during the hiring process? Surely they could have found someone whose work wasn’t so fraught with risks, whose work was going to be deeply rooted in the communities being studied. (This needs not necessarily be trans youth: the department sorely needs rooted scholarship by academics of colour, especially Black and Indigenous ones.)

Why this choice?

(Par Florence Ashley, juriste et bioéthicienne spécialisée en santé trans.)

J’ai lu le reportage d’Émilie Dubreuil sur la détransition, publié par Radio-Canada, avec attention et scepticisme. J’avais été interviewée pour celui-ci et avait donc une certaine idée à quoi m’attendre. Je m’attendais à ce qu’il y ait plusieurs points à rectifier. Les voici.

Phénomène de mode

En 1975, Ethel Groffier écrivait dans la Revue de Droit de l’Université de Sherbrooke:

Des médecins ont même émis l’hypothèse que le transsexualisme serait, en quelque sorte, le résultat d’une mode et que le nombre croissant de cas serait provoqué par la publicité entourant les théories chirurgicales nouvelles.

Plus de 44 ans après, peu a changé. Encore, on voit l’augmentation du nombre de personnes trans attribuée à un phénomène de contagion sociale. Encore, cette supposée contagion est accusée de prendre comme proie les personnes ayant des problèmes de santé mentale et des traumatismes. Un demi-siècle de pareil au même.

L’article d’Émilie Dubreuil se fonde sur l’étude de Lisa Littman, appuyée par la Dre Susan Bradley, pour offrir la thèse de la contagion sociale. Selon cette thèse, être trans est populaire et offre une échappatoire aux jeunes en proie à des problèmes de santé mentale ou qui ne veulent pas accepter leur homosexualité.

Susan Bradley est présentée comme sommité mondiale et nous dit : « Personne ne peut m’accuser de transphobie quand même. » L’affirmation est assez ironique, puisque les travaux de Susan Bradley sont taxés de transphobie depuis plus d’une vingtaine d’année. En 2003, le très respecté Simon Pickstone-Taylor a écrit que l’approche de la Dre Bradley était « fâcheusement proche des thérapies réparatrices pour homosexuels. » Le but explicite de son approche clinique était de « prévenir la transsexualité adulte » en demandant notamment aux parents de ne pas laisser leurs enfants adopter les jouets et vêtements de leur choix, mais plutôt de les habiller et leur offrir des jouets correspondants aux stéréotypes de genres. La critique des travaux de Bradley à la clinique de CAMH s’est sommée par sa fermeture suite au Projet de loi 77 prohibant les thérapies réparatrices.

Les travaux de Lisa Littman ne sont pas moins controversés. En 2017, j’ai co-écrit un texte critiquant la notion de « rapid-onset gender dysphoria » qui a été endossé par plusieurs sommités dans le domaine. La validité scientifique de l’étude a été fortement critiquée à cause de ses divers choix méthodologiques très douteux, et l’interprétation même des données tentent d’attribuer un phénomène pathologique à des données qui s’expliquent facilement par les tensions parent-enfant observées. Les lacunes de l’étude ont forcé sa republication avec corrections et excuses. La version actuelle souligne que celle-ci n’étaye pas l’existence du phénomène, mais ne fait qu’émettre une hypothèse à valider.

Être trans n’est pas particulièrement populaire. Les personnes trans vivent plus d’hostilité, de harcèlement, de discrimination, et de violences que les personnes non-trans ou gaies. Alors que 34% des jeunes gais ou bisexuels rapportent de l’hostilité parentale face à leur identité, le taux est de 64% chez les jeunes trans. La thèse de l’homosexualité réprimée n’est pas plus plausible, puisque seulement 15% des personnes trans sont hétérosexuelles (par rapport à leur identité de genre). La plupart sont bisexuelles : comment échapper à la bisexualité en transitionnant?

Ampleur de phénomène

Les personnes qui détransitionnent sont importantes, et leurs expériences doivent être pris en compte. Toutefois, comme pour toute intervention clinique, il faut contextualiser la détransition et le regret. Les soins de transition répondent à un besoin réel. Comme pour toute intervention, un certain taux de regret est inévitable et acceptable dans la mesure où l’intervention crée plus de bien que de mal dans l’ensemble.

Les données récentes sont souvent offertes sous forme de taux de détransition ou retransition. Par exemple, une personne qui cesse un traitement hormonal entrepris sera comptée comme ayant détransitionné ou retransitionné. Cette donnée n’est pas la plus pertinente au niveau éthique. Certaines personnes entreprennent des traitements en sachant vouloir arrêter éventuellement lorsque leurs buts personnels seront atteints. D’autres cesseront le traitement pour des raisons externes comme la présence de transphobie parentale. D’autres cesseront après avoir réalisé que cette intervention ne les sied pas, mais tout en étant reconnaissants d’avoir pu essayer. Les docteurs Jack Turban et Alex Keuroghlian ont soulevé cette dernière situation dans un article publié dans le Journal of the American Academy of Child & Adolescent Psychiatry. Dans une étude non-scientifique sur les réseaux sociaux, 62.9% rapportent avoir détransitionné pour des raisons politiques ou idéologiques, suggérant que la réduction de la transphobie et des discours opposant les personnes trans aux droit des femmes cis pourrait aussi réduire les taux de détransition.

Chez les personnes ayant entrepris des chirurgies génitales entre 1972 et 2015 en Suède, le taux de regret se situait entre 0.3% et 0.6%. D’autres études, plus vieilles, identifient le taux de regret entre 0% et 6%. Dans une autre étude, 6% des personnes ayant entrepris des chirurgies génitales avait des regrets occasionnels, et aucune n’avait de regrets constants.

Les données les plus récentes ont été présentées dans les conférences scientifiques et ne sont pas encore publiées. Une étude à la clinique nationale du Royaume-Uni a rapporté un taux de détransition de 0.99%. À la clinique de Callen-Lorde à New York, 2.3% des jeunes ont cessé les thérapies hormonales, mais aucun regret n’était présent.

La détransition est et a toujours été un phénomène réel, mais doit être contextualisé. Les taux de regret rapportés sont bas en comparaison aux interventions médicales et chirurgicales non-liées à la transition. Si ces regrets sont importants à prendre en considération, les délais de traitement le sont aussi. Selon l’étude TransPULSE en Ontario, l’accès aux soins de transition désirés est associé à une réduction annuelle de 62% des idéations suicidaires, et 69% des tentatives de suicide. Il faut donc se demander quelles pratiques cliniques prennent le mieux en considération tant les besoins des personnes trans que les besoins des personnes qui détransitionnent.

Détransition versus transition : un faux dilemme

« Si on permet la transition plus facilement, c’est qu’on augmente les risques de détransition. » C’est logique, non? Mais non, c’est trompeur. Ce n’est pas vrai. Pour comprendre pourquoi, il faut se pencher deux aspects cruciaux des dynamiques cliniques : notre faible capacité à distinguer qui détransitionnera, et l’incitation à l’honnêteté.

Walt Heyer est un conservateur américain connu pour son opposition aux soins trans. Celui-ci a transitionné dans les années 80, mais après 8 ans a décidé de re-transitionner et de se réidentifier comme homme. Dans les années 80, les protocoles étaient très lourds. Il fallait se faire suivre par des psychiatres pendant des années et des années avant de pouvoir transitionner, et toute personne qui ne correspondait pas à la vision de la « vraie personnes trans » de l’époque se faisait exclure. Malgré cette approche, Walt Heyer a pu transitionner.

Comme je l’ai récemment expliqué dans un article du Clinical Child Psychology and Psychiatry, la certitude clinique n’est pas de ce monde. Aucun marqueur ne garantit que la personne ne détransitionnera pas. L’identité personnelle est dynamique et évolue à son propre rythme. Ajouter des barrières à la transition retarde celle-ci, mais fait très peu pour réduire les taux de détransition et peu importe notre approche clinique, il y en aura toujours. Les indicateurs cliniques utilisés ne font qu’exclure des personnes qui ne détransitionneraient pas, et sont rarement en forte corrélation avec la re-transition ou regret futur. Ce sont, la majeure partie du temps, des stéréotypes de genre imposés par les psychologues. Pour ne donner qu’un exemple, une sexologue a récemment douté de l’identité de genre d’une amie parce que celle-ci ne portait pas de robes.

Quand on augmente le nombre de sessions nécessaires pour accéder aux soins pour mieux évaluer si la personne est réellement trans, on ne fait qu’encourager le mensonge et le repli défensif. Si je sais qu’on retardera mon accès aux hormones si je parle de mes incertitudes, de mes doutes, de mes craintes, je n’aurai pas le goût d’en parler. Je passerai ceux-ci sous silence dans l’espoir de plus rapidement accéder aux soins désirés.

Ce que l’approche de consentement éclairé fait, ce n’est pas seulement donner un accès plus rapide à la transition. C’est aussi créer une atmosphère dans laquelle on se sent à l’aise de parler de nos incertitudes, doutes, et craintes. C’est une atmosphère qui permet et même encourage l’exploration honnête, tant envers les professionnels de la santé qu’envers soi. Pour les personnes qui détransitionnent, cet espace sans jugement aide à réaliser plus rapidement que la transition n’est pas pour eux.

Aucune approche clinique ne garantit l’absence de détransition. Néanmoins, nous avons de bonnes raisons de penser que l’approche de consentement éclairé est mieux adaptée aux besoins des personnes qui détransitionnent que les approches diagnostiques lourdes. Le bien-être des personnes trans et des personnes qui détransitionnent ne sont pas en opposition. Les deux sont bien servies par l’approche par consentement éclairé.

Publié sur Urbania le 15 mai 2019.