The messy question of medical consent for young patients in Canada.
“I went into this court case with the hopes of saving my daughter from making an irreversible medical mistake,” John* says. “The potential is very high that she could change her mind down the road.”
John, a Calvin College graduate who brought the story to Christian Courier, is the father of a 14-year-old diagnosed with gender dysphoria: feeling that one’s emotional identity is opposite of one’s biological sex. A provincial court in B.C. is currently in session to determine if his child is capable of choosing to receive hormone treatment to transition from female to male, and if John, who does not consent, has the legal right to deny this treatment.
The teen’s mother, Emily, supports the hormone therapy, which is already approved by a local health care team – leaving the family at a seeming impasse. John and Emily are separated and share joint custody of their child. The B.C. Children’s Hospital is attempting to enforce the B.C. Infant’s Act, which states “a minor . . . may give an effective consent to healthcare if [their] provider, first is satisfied that [they] understand the nature, consequences, benefits and risks of the proposed treatment, and, second, concludes that the treatment is in [their] best interests.” But B.C. courts ordered a temporary injunction for the hormone treatment in February.
The Vancouver Sun says the teen’s lawyer is pursuing “a court declaration that the treatments go ahead,” as, according to the lawyer, “it [is] a potentially ‘life and death’ situation” due to the teen’s risk for suicide. John has since filed for another injunction with the Supreme Court of B.C.
The legal cases have sparked a debate surrounding the medical age of consent in Canada. According to the Canadian Pediatric Society, “there is no universally accepted, legally defined age for medical consent” (cps.ca), leaving individual cases open to interpretation. As a letter addressed to John from the B.C. Children’s hospital states, “Although the child’s parents may serve the crucial role of friend and advisor with respect to a healthcare decision, the parent cannot veto [a minor’s] decision.”
‘ETHICAL AND LEGAL TANGLE’
Determining the teen’s best interests is resulting in “a messy ethical and legal tangle, where a number of deeply interested parties – all with competing points of view on this issue […] – are at odds over how to proceed” (Jan. 18, 2019, National Post).
The American Psychiatric Association says that gender dysphoria “causes clinically significant distress or impairment in . . . functioning.” But “before any physical interventions are considered for adolescents [diagnosed with gender dysphoria],” the World Professional Association for Transgender Health suggests that “extensive exploration of psychological, family and social issues should be undertaken.” An adolescent should not move to another stage of treatment until they and their parents have been given time “to assimilate fully to the effects of earlier interventions.” WPATH also states that refusing “timely” medical intervention for gender dysphoria “is not a neutral option for adolescents.”
Medical treatment for adolescents diagnosed with gender dysphoria is a “newer development,” according to B.C. Children’s Hospital Consent Form, “and the long-term effects are not fully known.” The Caring for Transgender Adolescents in B.C.: Suggested Guidelines states that post-puberty, gender identity is “fixed” in most individuals. As “psychological treatments are not particularly successful in changing gender identity once . . . consolidated, changing the body to match the identity is often the treatment of choice for very gender dysphoric adults.” However, “the outcome for children with gender concerns is far more variable than for adults . . . It is extremely important to take into account that children and adolescents are in a rapidly changing developmental process.” B.C. Children’s Hospital’s informed consent form lists possible long-term considerations and risks of testosterone therapy.
“Quick and temporary fixes like testosterone injections and hormone blockers are not the solutions,” John said in an interview with CC. “Long term solutions that involve love and inclusion are the solution to her wellbeing.”
Both parents long for a happy and healthy child but their perspectives on how to accomplish that are polarized. In a Christianity Today article (June 2018), Rachel Gilson states, “It would be naïve to assume there is agreement on what seeking the well-being of transgender people means. Desiring to care for this community does not prevent people from reaching very different conclusions about what that care should look like.” In the National Post, Emily said: “I didn’t quite understand transgenderism myself . . . But having gone through the experience I’ve gone through with my son I fully believe that, yes, it is very possible that transgenderism does exist and there are people wandering around feeling excruciatingly uncomfortable in their own skin . . . If this is what alleviates my child experiencing this dysphoria, I’d rather move forward . . . If it happens to have side effects down the road, we’re OK to handle that – at least our child would still be alive” (Jan. 18, 2019). John says, “If she still feels that nothing will make her happy when she is an adult, then she can make her own path. At least I haven’t eliminated her options. I’m simply leaving bread crumbs so that she can find her way back if she ever chooses that.”
SHARED DECISION MAKING
If there is serious conflict in medical care decision making, the Canadian Pediatric Society recommends that “if circumstances permit, the proposed intervention should be delayed while an attempt at a resolution is made.” Involvement with “spiritual care, social work and bioethics,” they add, brings “value to the decision-making process to ensure that the needs of all participants are met.” Working collectively whenever possible supports the best possible outcomes, states CPS: “A family-centred, shared decision-making model best respects and supports the emerging capacity of the pediatric patient as well as parental authority and the knowledge and expertise of Health Care Practitioners,” as messy as the process might be.
*Names, currently under a publication ban, have been changed.