By Melani Shahin
In October 2014, Oregon became one of the few states to cover hormone suppressant therapy for transgender minors under Medicaid. The purpose of this treatment is to temporarily suppress puberty in transgender young people via hormone suppressant drugs, such as Lupron. While Oregon’s coverage of puberty blockers for minors under the state Medicaid plan increases the accessibility of this treatment, an interesting ethical question emerges for taxpayers, healthcare providers, and families: can minors truly give informed consent to this kind of medical treatment?
The treatment can be useful for several reasons: first, it is beneficial for minors who eventually want to medically transition because they will not develop the secondary sex characteristics of their assigned gender (such as breasts), which would later need to be altered or removed. Second, because the treatment is non-permanent and its effects are reversible, a minor can decide to end treatment and go through the puberty of their assigned sex, or to continue treatment until they begin to transition using cross-sex hormone therapy.
Though the use of puberty-blockers has been endorsed as a best practice for trans healthcare by the American Academy of Pediatrics, the treatment remains inaccessible to many families and young people because of its high cost. Indeed, Lupron injections can cost $7,500 for three months’ worth of treatment, which would add up to about $30,000 annually.
In order to investigate this modern question of the ethics of minors’ informed consent, it helps to reference an ancient source – the philosophy of Aristotle. In the Nichomachean Ethics, Aristotle argues that being ethical is ultimately bound up in the question of what it means to live a good life; he argues that what makes us ethical is what drives us toward achieving the ultimate end of happiness. In order to pursue this “chief end” of happiness, human beings must also fulfill their natural function, which Aristotle defines as cultivating “[activities] of the soul in accordance with reason [and] … excellence” (1098a4-8; 1098a16-17).
Based on a cursory reading of the Ethics, it might seem that Aristotle would argue that minors are not capable of giving rational consent because they have not had enough time to develop their reason. Indeed, Aristotle argues that the rationality of children is inferior to that of adults, writing, “no one would choose to live the whole of life with the thoughts of a small child” (1174a2-3).
Additionally, he argues, “a person needs to be brought up and habituated in the right way in order to be good, and then live accordingly under a regime of decent behavior” (1180a15-18). Based on this statement, Aristotle might believe that pre-pubescent children who desire hormone treatments simply have not had the time to be properly habituated and develop the adequate reason needed to make an informed decision about their gender identity (of course, this position assumes that gender is something entirely rational or natural, which is a problematic assumption in itself, as theorists like Judith Butler argue). Thus, Aristotle might conclude that it would be counterproductive, and even immoral for the public to subsidize such a treatment. He might suggest instead that the public invest in other forms of “communal supervision” (1180a30) that would allow these young people to be properly “habituated.”
However, upon closer examination, Aristotle’s same arguments about the communal obligation toward developing reason and excellence in young people can be more strongly used to argue that hormone suppressant treatments promote these goals, and therefore should be covered under public health insurance. As I have demonstrated, Aristotle believes that the ethical life is one in which people develop not only their reason, but also their excellences as they pursue happiness.
Indeed, he writes that, “excellence, then, is a kind of intermediacy, in so far as it is effective at hitting upon what is intermediate…excess and deficiency belong to badness, whereas intermediacy belongs to excellence” (1106b27; 1106b33-4). Thus, Aristotle might argue that if hormone suppressants could help trans minors develop an intermediate sense of self and direct them away from excessive dispositions toward depression or other forms of suffering, the community and the government should be especially concerned with cultivating this this kind of development, and should therefore help subsidize the cost of treatment.
Indeed, in an interview with NPR, Dr. Ariel Smits noted the positive effects of hormone suppressant treatment on the mental health of trans minors:
“People with gender dysphoria that did not receive treatment had a much higher rate of hospitalizations or ER visits or doctors visits for depression and anxiety, and they had a pretty significantly high suicide rate. Some studies found about 30 percent’…When people get treatment, she says, those rates drop to a level much closer to that of the general population.”
Furthermore, Aristotle might also argue that because the treatment is non-permanent, and simply delays puberty, using hormone suppressants ultimately allows for minors to make a more rational decision about their gender identity and whether they want to medically transition. This extra time could be beneficial for young trans people because it allows them to live in a body that aligns more closely with their gender identity and does not unintentionally “out” them as trans – i.e. no unwanted facial hair, muscle, or breast development – as they reflect upon their identity and make future medical decisions.
Although Aristotle’s ethical philosophy can be interpreted as indicating that the coverage of hormone suppressants by public insurance is not at odds with concerns about a minor’s ability to give informed consent, several questions about this topic remain: Should a non-permanent, physically reversible treatment even be considered ethically problematic? Is it ethical for the public to subsidize a treatment that has largely unstudied long-term physical effects?
Lastly, is it problematic that a minor must claim to be suffering or in danger of suffering because of their gender identity in order to get treatment from a doctor? By critically thinking about these ethical questions from a variety of philosophical perspectives, we can strive to provide more inclusive, accessible, and comprehensive care for trans people even at their earliest stages of development.
Melani Shahin, FCRH ’18 is a Music and Theology double major.
Aristotle. Nichomachean Ethics. Trans. Christopher Rowe. Oxford: Oxford University Press, 2002. Print.
 Butler, Judith. Gender Trouble. New York: Routledge, 1990. Print.