The Supreme Courts Trans Health Case Shows Why Patients Should Make the Decisions
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OpinionJanuary 16, 20255 min readThe Supreme Courts Case on Trans Health Shows Why Patients Should Make the DecisionsSupreme Court arguments over trans health care makes plain how badly we need personalized health care in all of medicineBy Meredithe McNamara & Dan Murphy edited by Dan VerganoA transgender rights supporter takes part in a rally outside of the U.S. Supreme Court as the high court hears arguments in a case on transgender health rights on December 04, 2024 in Washington, DC. Kevin Dietsch/Getty ImagesSince 2021 a legal tug-of-war over state bans on health care for transgender youth has wound through U.S. courts. Many judges ruled that bans discriminate against a group of people who should enjoy constitutional protections. Others sustained states claims that such bans protect minors and that trans youth should wait until legal adulthood to be themselves.Now the question before the Supreme Court in U.S. v. Skrmetti is one of sex-based discrimination. Does Tennessees ban on gender-affirming care violate the Constitution because it imposes differential access to hormones and puberty-pausing medications on the basis of sex?In Decembers arguments many of the flawed pseudoscientific justifications for this ban were rehashed, but the justices are tasked with an opinion on the constitutional merits of the case, rather than scientific evidence. Even so, it bears noting that Tennessees law is a bad-faith policy that bans medical care in totality over claims that treatment-supporting research doesnt clear an arbitrary bar set by politicians; especially as they set that bar far above acceptable standards in every other area of medicine.On supporting science journalismIf you're enjoying this article, consider supporting our award-winning journalism by subscribing. By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.With a final decision anticipated this year, SCOTUSs ruling may also address the fundamental question posed by these bans: in what tier of society should a persons medical decisions be madeby patients and their families, or by the state? As health policy veers toward hyperregulation, Americans need an answer.During arguments, Chief Justice John Roberts reflected on his benchs inadequacy in this area: ... my understanding is that the Constitution leaves that question to the peoples representatives rather than to nine people, none of whom is a doctor. Legal scholars recognize his observation as a question about rational basis: a judicial test that courts apply to determine whether a law represents legitimate government interest or encroaches on the peoples constitutional rights. This signals the possibility that SCOTUS may allow the peoples representatives to be the final stop for trans peoples medical decisions.As medical and mental health professionals, we are gravely concerned by the implication that the medical decisions at stake in Skrmetti belong to neither the people nor their providers. We know from experience there is no good proxy for the people when it comes to decisions on their own health. A ruling that assigns medical decision-making power to anyone but the people poses imminent harm to everyone. Lessons from trans health care about the irreplaceable role of the patient could pave the way for a better understanding of whats truly at stake.This siege on trans health care involves so much more than the medications and surgeries subject to bans; what it at risk is a paragon of good health care. Where most medical protocols aim to standardize rather than individualize care, it is remarkable that trans health is scaffolded by guidelines that do both.For example, those guidelines call for a bidirectional transfer of knowledge based on the idea that patients and providers hold nonoverlapping areas of expertise. We provide expert knowledge of medical and mental health care, while the patient provides expert knowledge of their own lived experiences. This is why the guidelines recommend providers and patients begin by taking ample time to get to know each other, then proceed with creating a specific, sensitive care plan.While gender dysphoria is the diagnostic code for that plan, the therapeutic goal is the uplift that comes from authentic self-expression: gender euphoria. Facilitating gender euphoria is associated with psychological resilience and positive health outcomes, but in an openly disparaging social environment, it is painfully difficult to cultivate. Even with constitutional workplace protections, one in five trans people report employment discrimination. They face bathroom bans that make it a felony to empty their bladder in public facilitiesredolent of the separate but equal policies of racial segregation. In addition to this widespread stigma, trans people face violent crime at more than four times the rate of their cisgender peers.We have no treatment for these dignity-shredding realities. Instead we help our patients capture and retain a sense of future orientation, and we celebrate their well-being amidst this storm. One of our patients said it best: Coming out is the hardest thing Ive ever done. But for the first time in my life, I dont want to die. I want to see my own future.It is no surprise to us how measures of continuation of care and satisfaction in trans health consistently land among the highest in medicine. How many people would benefit if this deep fidelity to the bioethical principle of respect for persons was similarly expressed throughout health care? Take obstetrics, for example, where one in five report mistreatment during pregnancy in a health care setting. What if every pregnant persons values, family structures, health profiles, social context, life stories and mental health were revered and respected by a trusted care team? How many more people would feel safer during one of the most vulnerable periods of their lives? When the peoples representatives are permitted to decide against the principle of respect for persons, as SCOTUS has allowed in reproductive health, they lead us further away from the care everyone deserves.Bans do most of their work through intimidation, and harm people from all walks of life. In one instance weve met a teen with a developmental disability who relies on a hormonal treatment to prevent intractable menstrual seizures. She can no longer receive it because its banned for trans youth in her home state, and authorities are combing through prescribing databases. Shes not trans, but her pediatrician cant risk his licensure when thousands of kids rely on him.Weve also met people who dont identify as LGBTQ+ but prefer specialists who offer interventions that foster identity formation and community-building behavior. For many, these staples of queer mental health are a balm for the loneliness epidemic. But practitioners worry that the welcoming pride flags on their websites have become homing beacons for bad actors. Attorneys general in states with bans on gender-affirming care are notorious for abusing their privileges to scour medical records looking for trans people who travel to receive banned care in other states. From a providers perspective, when it comes to the ethical dilemma of being unable to guarantee confidentiality, the safest approach may be to move practice outside the jurisdiction of a state ban.Lawmakers who advance medical bans are neither the people nor their providers. They have no wherewithal to wield the medical authority they have seized. They have no reverence for the fact that the underlying principles of trans health could make everyone healthier. Instead, they have crafted laws that carve out health care from the constitutional right to equal protection under the law. We have watched laws like Tennessees invade the lives of our patients, and we call for accountability now. On behalf of our patients, and especially those who are transgender, we urge SCOTUS to recognize lawmakers medical incompetence and restore the irreplaceable role of the patient in making medical decisions. If they dont, well all be sicker.This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American. The authors' opinions are solely their own and dont represent any organization they are affiliated with.
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