THE DOCTOR WON'T SEE YOU NOW: RIGHTS OF TRANSGENDER ADOLESCENTS TO SEX REASSIGNMENT TREATMENT SONJA SHIELD* I. INTRODUCTION .................................................................................................... 362 H . DEFINITIO NS ........................................................................................................ 365 III. THE HARMS SUFFERED BY TRANSGENDER ADOLESCENTS CREATE A NEED FOR EARLY TRANSITION .................................................... 367 A. DISCRIMINATION AND HARASSMENT FACED BY TRANSGENDER YOUTH .............. 367 1. School-based violence and harassment............................................................. 368 2. Discriminationby parents and thefoster care system ....................................... 372 3. Homelessness, poverty, and criminalization...................................................... 375 B. PHYSICAL AND MENTAL EFFECTS OF DELAYED TRANSITION ............................... 378 1. Puberty and physical changes ........................................................................... 378 2. M ental health issues ........................................................................................... 382 IV. MEDICAL AND PSYCHIATRIC RESPONSES TO TRANSGENDER PEOPLE ........................................................................................ 385 A. GENDER IDENTITY DISORDER TREATMENT ........................................................... 386 B. FEARS OF POST-TREATMENT REGRET .................................................................... 388 C. THE HARRY BENJAMIN TREATMENT PROTOCOL ................................................... 390 D. HEALTH LAW STANDARDS OF CARE: AN ALTERNATIVE TO HBIGDA ................. 392 V. INFORMED CONSENT LAW .............................................................................. 393 A . G EN ERA L R ULE ..................................................................................................... 393 B. EXCEPTIONS TO INFORMED CONSENT LAW THAT ALLOW MINORS TO CONSENT TO O W N CARE ....................................................................................... 398 VI. TRANSGENDER ADOLESCENTS SHOULD HAVE THE RIGHT TO CONSENT TO THEIR OWN TRANS-RELATED HEALTH CARE ............. 401 A. OUTCOME STUDIES OF SEX REASSIGNMENT SHOW POSITIVE RESULTS ................ 401 B. MANY ADOLESCENTS HAVE THE CAPACITY TO CONSENT .................................... 401 C. REQUIRING A SURROGATE DECISIONMAKER FURTHERS No STATE INTERESTS ..... 406 1. Supporting a parental role................................................................................. 407 2. Supporting informed decision making ............................................................... 409 J.D., New York University School of Law, 2005; M.S.W., New York University School of Social Work, 2004. The author wishes to thank Liz Loeb, Carrie Davis, Ray Carannante, Paisley Currah, Z. Gabriel Arkles, Dean Spade, Zabrina Aleguire, Sarah From, Nicole Avallone, Ady Ben-Israel, and the many others who gave me feedback and thoughtful suggestions. Thanks to Hannah Gladstein and the N. Y. U. Review of Law & Social Change for shepherding this Article through the editorial process. And of course, to my family, for everything. 361 Reprinted with the Permission of New York University School of Law N.YU. REVIEW OF LAW& SOCIAL CHANGE [Vol. 31:361 3. Protectingagainst adverse effects ofprocedure................................................ 410 D. THE NATURE OF THE DECISION MAKES CASE-BY-CASE EVALUATIONS OF MATURITY N ECESSARY ......................................................................................... 411 VII. ADVOCACY STRATEGIES FOR EXPANDING MINORS' ACCESS TO TRANSGENDER-RELATED MEDICAL CARE ............................................. 412 A. ADVOCACY WITH HEALTH CARE PROFESSIONALS ................................................ 412 B. ADVOCATING UNDER THE EXCEPTIONS TO INFORMED CONSENT LAW .................. 414 1. The m ature m inor exception .............................................................................. 414 2. The em ancipation exception .............................................................................. 419 3. The em ergency exception ................................................................................... 422 4. Exceptionsfor mental health treatment............................................................. 423 C. USE OF COURT-ORDERED MEDICAL TREATMENT TO OVERRIDE PARENTA L V ETO ........................................................................................................ 424 D . LEGISLATIVE SOLUTIONS ...................................................................................... 427 1. Codify the mature minor exception .................................................................... 428 2. Create specific exceptionsfor transgenderyouth .............................................. 430 3. Expand the role of surrogate decision-makers .................................................. 431 VIII. CONCLUSION ................................................................................................... 433 1. INTRODUCTION Transgender adolescents' who seek sex reassignment treatment are caught in a dangerous holding pattern. Their gender identity exposes them to significant bias and discrimination at home, at school, and on the street, often to devastating effect.2 Yet many who are mature, capable of giving informed consent, and have full understanding of their gender identity are prevented from medically transi- tioning to the gender with which they identify until they reach eighteen, the legal age of consent. The dangers that transgender youth face during their adolescent years are numerous, scarring, and often have permanent repercussions. Many are kicked out of their homes by their parents and then are placed in foster care or become homeless. 3 Due to discrimination based on their gender nonconformity, many find it difficult to obtain legal employment or housing, and become trapped in a cycle of poverty, homelessness, and criminalization. 4 In addition, the physical changes wrought by puberty are not easily reversed, so an individual barred from sex reassignment procedures until after puberty will forever see the mark of this 1. In this Article I use the term transgender to refer to individuals whose gender identity differs from the physical sex they were assigned at birth. See generally discussion infra Part II. 2. See discussion infra Part III.A. 3. See discussion infra Part III.A.2-3. 4. See id. Reprinted with the Permission of New York University School of Law 2007) THE DOCTOR WON'T SEE YOU NOW delay on his or her body. 5 Despite these significant harms, and the fact that many adolescents have the maturity to make the decision to seek sex reassign- ment treatment, most transgender adolescents must bide their time until they turn eighteen and are transformed into legal adults. They are prevented from actual- izing their identities and must defer age-appropriate development until later in life, making explorations of intimate relationships and avocation difficult, if not impossible, in the interim. As a general rule, minors below the age of consent may not authorize their own medical care.6 The law presumes that parents will act in the best interest of their minor children, so that parents' decisions about whether a transgender ado- lescent will receive sex reassignment treatment can effectively act as "an abso- lute, and possibly arbitrary, veto" 7 over the adolescent's identity and physical self-determination until the adolescent turns eighteen. This situation is highly problematic. First, parents may refuse to consent to their child receiving transgender-related treatment, acting out of bias and ignorance rather than their child's genuine need and best interests. Second, there is a high incidence of lesbian, gay, bisexual, and transgender (LGBT) 8 youth in foster care, so trans- gender youth are highly likely to fall under the guardianship of the State.9 The State is not always knowledgeable enough or sufficiently free of bias to be able to adequately act in the best interests of transgender youth in its care. There are, however, several potential remedies. Professional medical treat- ment protocols already define the circumstances in which adolescents may re- ceive sex reassignment procedures. 10 Medical professionals should provide transgender adolescents with treatment to the fullest extent permissible under these protocols.'1 In addition, where parents or guardians will not consent, com- petent transgender adolescents should be allowed to consent to their own medi- cal care. The law already provides that adolescents below the age of majority 12 may consent to their own medical care in certain analogous circumstances. Advocates should make use of the legal doctrines underlying this body of law, particularly the mature minor13 and emancipated minor 14 doctrines, to assist adolescents in gaining access to necessary health treatment. Legislatures should 5. See discussion infra Part IlI.B.1. 6. See discussion infra Part V.A. 7. Bellotti v. Baird (Bellotti I), 443 U.S. 622, 643 (1979) (recognizing exception to general requirement of parental consent for minors' medical decisions) (citing Planned Parenthood of Cent. Mo. v. Danforth, 428 U.S. 52, 72 (1976)). The parallels between abortion and access to health care for transgender youth will be discussed further infra Parts VI.C. 1, VI.D. 8. See discussion of terminology infra Part II. 9. See infra