Gatekeeping vs Good Process: Ethical Decision Making in Gender Affirming Medical Interventions

Abstract: Medical gatekeeping can be ethically problematic and unjust where it only seems to exist in order to hold power over another’s bodily knowledge. Gatekeeping is a common practice in many medical spaces both in organized national health systems and in US healthcare. It also exists to both provide fair process, such as in transplant, and in terms of responsible health utilization such as access to expensive specialized treatments. The tension between unjust gatekeeping and justified good process is ever present in adolescent health, particularly where it involves decisions that elicits discomfort around the adolescent’s current and future identity. This discomfort is inconsistently focused on certain populations. Many find no issue with halting “early” puberty for children to protect them from social distress yet many of those same people are uncomfortable temporarily halting puberty to prevent distress from a child experiencing gender dysphoria.
This inconsistent discomfort has led to valid criticisms of medical gatekeeping. We agree with many criticisms of gatekeeping for adults seeking access to gender affirming medical treatments (GAMT), we argue that for pediatric GAMT, gatekeeping should be conceptualized as providing good ethical process. In this article we will discuss some of the criticisms to gatekeeping. We will present an ethical justification for gatekeeping, or rather what we would call “good process,” in pediatric GAMT. We will present what we mean by good process. We will then present the ethical justification for this process and argue that legal restrictions and involvement in this space are not necessary and unethical.

Keywords: Gender affirming care, Adolescent, decision making