Legislation seeking to criminalize or otherwise prevent the provision of gender-affirming care for transgender adolescents is on the rise. This Viewpoint describes these laws and explains why they are harmful and potentially unlawful.
Caring for Transgender YouthTransgender adolescents are those whose gender identity (ie, their psychological sense of their own gender) is incongruent with their sex assigned at birth. 1 According to a 2017 study from the Centers for Disease Control and Prevention, 1.8% of 118 803 surveyed adolescents in the United States identified as transgender. 2 In this same study, approximately 35% of transgender adolescents reported having attempted suicide, highlighting the importance of the mental health concerns affecting this population. 2 Affirmation of an adolescent's transgender identity is associated with favorable mental health outcomes. 1,3,4 Major medical organizations have outlined best practices for supporting transgender adolescents. 1,3,4 These include facilitation of a social transition (ie, taking on the name, pronouns, and other elements of gender expression that match the adolescent's gender identity), consideration of pubertal suppression (ie, gonadotropinreleasing hormone analogues that temporarily and reversibly pause puberty to prevent the development of secondary sex characteristics that often cause psychological distress for transgender youth), and consideration of gender-affirming hormones (ie, medications including estradiol and testosterone that induce physical feminization or masculinization, respectively, that align with the adolescent's gender identity). Although research has not established that these interventions cause infertility, guidelines recommend that adolescents be offered fertility preservation options prior to treatment with gender-affirming hormones, given the theoretical risk that these medications may impair fertility. 1,3,4 Although gender-affirming genital surgery is generally not recommended until adulthood, these guidelines note that some transmasculine adolescents may benefit from masculinizing chest surgery to lessen chest dysphoria. 1,3,4
Shortages of life-saving medical resources caused by COVID-19 have prompted hospitals, healthcare systems, and governmentsto develop crisis standards of care, including 'triage protocols' to potentially ration medical supplies during the public health emergency. At the same time, the pandemic has highlighted and exacerbated racial, ethnic, and socioeconomic health disparities that together constitute a form of structural racism. These disparities pose a critical ethical challenge in developing fair triage systems that will maximize lives saved without perpetuating systemic inequities. Here we review alternatives to 'utilitarian' triage, including first-come first-served, egalitarian, and prioritarian systems of allocating scarce medical resources. We assess the comparative advantages and disadvantages of these allocation schemes. Ultimately, we argue that while triage protocols should not exacerbate disparities, they are not an adequate mechanism for redressing systemic health inequities. Entrenched health disparities must be addressed through broader social change.
This article examines five different Medical-Legal Partnerships (MLPs) associated with Yale Law School in New Haven, Connecticut to illustrate how MLP addresses the social determinants of poor health. These MLPs address varied and distinct health and legal needs of unique patient populations, including: 1) children; 2) immigrants; 3) formerly incarcerated individuals; 4) patients with cancer in palliative care; and 5) veterans. The article charts a research agenda to create the evidence base for quality and evaluation metrics, capacity building, sustainability, and best practices; it also focuses specifically on a research agenda that identifies the value of the lawyers in MLP. Such a focus on the “L” has been lacking and is overdue.
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