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Youth should decide: the principle of subsidiarity in paediatric transgender healthcare
  1. Florence Ashley
  1. Faculty of Law and Joint Centre for Bioethics, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Florence Ashley, Faculty of Law, University of Toronto, Toronto, ON M5S 2C5, Canada; f.ashley{at}


Drawing on the principle of subsidiarity, this article develops a framework for allocating medical decision-making authority in the absence of capacity to consent and argues that decisional authority in paediatric transgender healthcare should generally lie in the patient. Regardless of patients’ capacity, there is usually nobody better positioned to make medical decisions that go to the heart of a patient’s identity than the patients themselves. Under the principle of subsidiarity, decisional authority should only be held by a higher level decision-maker, such as parents or judges, if lower level decision-makers are incapable of satisfactorily addressing the issue even with support and the higher level decision-maker is better positioned to satisfactorily address the issue than all lower level decision-makers. Because gender uniquely pertains to personal identity and self-realisation, parents and judges are rarely better positioned to make complex medical decisions. Instead of taking away trans youth’s authority over their healthcare decisions, we should focus on supporting their ability to take the best possible decision for themselves.

  • gender identity
  • informed consent
  • decision making

Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

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Data availability statement

Data sharing not applicable as no data sets generated and/or analysed for this study.

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  • Contributors FA is the sole author and acts as guarantor of the content.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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