F Ashley et al, “Gatekeeping gender-affirming care is detrimental to detrans people” (2025)International Journal of Transgender Health
Abstract: Gender assessments are often required to access gender-affirming medical interventions. These assessments are typically defended as a way of preventing regret, offering a compromise between the interests of trans and detrans people. Whether they do is integral to ongoing debates about models of care in transgender health. Building on previous work demonstrating the inefficacy of gender assessments, this article explores the impact of gender assessments and argues that they are detrimental to detrans people. Assessments appear to be detrimental to detrans people because they disincentivize honesty and authenticity, inhibit gender exploration, increase shame and anger associated with detransition, foster transnormativity, hinder the development of a strong therapeutic alliance, and diminish the quality of informational disclosure. Given the detrimental consequences of gender assessments, clinicians should reconsider gatekeeping practices in favor of supporting patient decision-making and offering better care to people who detransition.
Florence Ashley, "Genderfucking as a critical legal methodology" (2024) 69:2 McGill Law Journal 177
Abstract: In this essay, I theorize genderfucking as a critical legal methodology. Genderfucking is defined by its focus on the needs and experiences of those who ‘fuck’ with gender, resisting attempts at gender governance through laws, policies, and practices. Adopting a politics of messiness, genderfucking is critical of recognition and calls into question the state’s legitimacy in defining and policing gender categories. Genderfucking offers a rich and fertile approach for analyzing a social, political, and legal world indelibly marked by regimes of gender and, in so doing, steps on the path towards gender liberation.
Florence Ashley, "Parental Rights Over Transgender Youth—Furthering a Pressing and Substantial Objective?" (2024) 62(1) Alberta Law Review 87–119
Abstract: Parental rights are increasingly being invoked to oppose the growing inclusion of trans youth in education. Recently, some provinces have proposed or adopted laws and policies predicated on the belief that parents have a right to be informed of their child’s choice of name and pronouns at schools and that trans youth should not be allowed to change the names and pronouns they use at school without parental consent, which I term “blanket veto and disclosure laws.” In this article, I explore whether blanket veto and disclosure laws can be justified under two dominant conceptions of parental rights — parental authority and parental entitlement. Using the framework provided by section 1 of the Canadian Charter of Rights and Freedoms, I argue that blanket disclosure and veto laws cannot be justified under either conception of parental rights. Conceived as protection of parental authority, blanket veto and disclosure laws are unjustified because they are not rationally or narrowly tailored to their objective. Conceived as protection of parental entitlement, the laws are unjustified because their objective is inconsistent with the values of a free and democratic society. Regardless of the conception of parental rights we adopt, blanket veto and disclosure laws are constitutionally and politically deficient.
F Ashley. “Gender self-determination as a medical right.” (2024) CMAJ, 196, E833–35 Abstract: In this article, I argue that the principle of gender self-determination grants trans people have a presumptive right to gender-affirming care, and that physicians should accordingly rethink barriers to gender-affirming care. By considering gender self-determination as a presumptive right, physicians are more likely to avoid unnecessary barriers to care. This presumption can be rebutted by showing that encroachments are adequately justified by clear and compelling evidence. Many common barriers to gender-affirming care—such as rigid age requirements and the requirement that adolescents prove several years of gender incongruence—do not satisfy this threshold.
F Ashley. "Do Trans/Humanists Dream of Electric Tits? CRISPR and Transgender Bioethics" in Neal Baer (ed), Reshaping Human Nature: The Promise and Peril of CRISPR (Johns Hopkins University Press, 2024)
Abstract: This chapter explores on the possibilities and risks of CRISPR gene editing for trans lives, discussing its potential use in conversion practices and medical transition before offering some reflections on the ethics of hype. For those who believe in a ‘trans gene’, CRISPR risks being used as a form of high-tech conversion practices to ‘correct’ trans existence. Regardless of its effectiveness in that regard, the spectre of CRISPR highlights lacunas in ethical discussions around conversion practices. CRISPR could more positively be used as a form of high-tech medical transition, helping trans people customize transition-related interventions and better achieve their embodiment goals. However, this prospect is also fraught due to the prevalence of cisnormativity within the medical profession. Rather than loosening gender norms, CRISPR could reinforce them by excluding trans people who do not want to blend in with cisnormative society. CRISPR is hyped. It lets us imagine possibilities that can sustain life as much as destroy it. Given these risks, bioethical engagement with CRISPR should begin by discussing the ethics of hype. Caught in the daydreams of CRISPR’s endless possibilities, let us not forget to fight for a better world. (Link to paper)
F Ashley, S Brightly-Brown, GN Rider,. Beyond the trans/cis binary: Introducing new terms will enrich gender research. Nature, 630, 293–95
Abstract: Human experiences are inevitably richer than the categories we carve out for them. But finding the right concepts and language to describe their diversity is an essential part of the scientific endeavour. The term ‘gender modality’ could enable researchers to broaden their horizons. Gender modality refers to how a person’s gender identity relates to the gender they were assigned at birth. Scientists should expand the gamut of gender modalities included in questionnaires given to participants, to capture a broader range of experiences. Researchers can also use gender modality to refine how they phrase questions or discuss results. Lastly, researchers can use gender modality to think more meticulously about what it is that they are really trying to capture in their study. Researching gender should begin with critically engaging with current language and concepts. Thoughtfulness, flexibility, curiosity and empathy are what science needs.
Link to paper: https://www.nature.com/articles/d41586-024-01719-9
Florence Ashley, “Reflecting on the Rhetoric of Adoption in Trans Youth Care” (2023) 2 Bulletin of Applied Transgender Studies 249–75
Abstract: Adoption is increasingly being discussed as an alternative to procreation for trans youth given the impact of gender-affirming medical care on fertility. In this article, I caution against idyllic views of adoption and offer a critical perspective on the social, political, and ethical dimensions of adoption. After reviewing adoption’s relationship to sexism, racism, imperialism, and cisheteronormativity, I sketch an alternative view of adoption as a complex and multi-valenced form of care in an unjust world.
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Florence Ashley, Neeki Parsa, til kus, & Kinnon R MacKinnon, “Do gender assessments prevent regret in transgender healthcare? A narrative review” (2023) Psychology of Sexual Orientation and Gender Diversity
Abstract: Gender assessments are traditionally required before accessing gender-affirming interventions such as hormone therapy and transition-related surgeries. Gender assessments are presented as a way of preventing regret experienced by some people who reidentify with the gender they were assigned at birth after medically transitioning. This article reviews the theoretical and empirical foundations of commonly used methods and predictors for assessing trans patients’ gender identity and/or dysphoria as a condition of eligibility for gender-affirming interventions. We find that the DSM-5 diagnosis, taking gender history, standardized questionnaires, and regret correlates rely on stereotyping, arbitrary, and unproven considerations and, as a result, do not offer reliable ways of predicting future regret over-and-above self-reported gender identity and embodiment goals. This finding is corroborated by empirical data suggesting that individuals who circumvent gender assessments or pursue care under an informed consent model do not present heightened rates of regret. The article concludes that there is no evidence that gender assessments can reliably predict or prevent regret better than self-reported gender identity and embodiment goals. This conclusion provides additional support for informed consent models of care, which deemphasize gender assessments in favor of supporting patient decision making.
Link: https://psycnet.apa.org/fulltext/2024-16010-001.html
Florence Ashley & Sam Sanchinel, “The Saint of Christopher Street: Marsha P. Johnson and the Social Life of a Heroine” (2023) 134 Feminist Review 39–55
Abstract: This article analyses the legacy of Marsha P. Johnson as a heroine through the notion of labour, emphasising how heroine narratives are both a product of labour as well as a form of labour. After offering a short account of Marsha P. Johnson’s role in the Stonewall riots and STAR, we explore the development of trans communities’ ability to create, sustain and disseminate heroine narratives, emphasising Tourmaline’s pivotal archival role in establishing Johnson’s legacy. Then, we elucidate the role of heroine narratives in creating and sustaining a collective identity. We argue that community attachment to Marsha P. Johnson reclaims the place of trans communities in LGBTQ+ history but is often done in a manner that obscures the whiteness of mainstream trans advocacy. We suggest that the recent increase in interest towards the life-sustaining labour of STAR House reflects the evolution of trans collective identity in the post-visibility era.
Florence Ashley, “What Is It like to Have a Gender Identity?” (2023) MIND
Abstract: By attending to how people speak about their gender, we can find diverse answers to the question of what it is like to have a gender identity. To some, it is little more than having a body whereas others may report it as more attitudinal or dispositional—seemingly contradictory views. In this paper, I seek to reconcile these disparate answers by developing a theory of how individual gender identity comes about. In the simplest possible terms, I propose that gender identity is how we make sense of our gender subjectivity, the totality of our gendered experiences of ourselves. Gender identity is constituted by gender subjectivity, but this constitutive relationship is underdetermined. While gender subjectivity may narrow the range of inhabitable gender identities, it is always compatible with more than one. To arrive at a gender identity, we arrange gender subjectivity like building materials. My theory helps us understand how different people offer seemingly incompatible accounts of their gender identity without questioning their authenticity or validity. They simply arrange similar building materials differently.
Florence Ashley, Diana M. Tordoff, Johanna Olson-Kennedy, & Arjee J. Restar, “Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare” (2023) International Journal of Transgender Health
Abstract: Despite multiple rigorous observational studies documenting the association between positive mental health outcomes and access to puberty blockers, hormone therapy, and transition-related surgeries among adolescents, some jurisdictions have banned or are attempting to ban gender-affirming medical interventions for minors due to an absence of randomized-controlled trials (RCTs) proving their mental health benefits. This article critically reviews whether RCTs are methodologically appropriate for studying the association between adolescent gender-affirming care and mental health outcomes. The scientific value of RCTs is severely impeded when studying the impact of gender-affirming care on the mental health of trans adolescent. Gender-affirming interventions have physiologically evident effects and are highly desired by participants, giving rise to concerns over adherence, drop-out, response bias, and generalizability. Complementary and well-designed observational studies can instead be used to ground reliable recommendations for clinical practice and policymaking in adolescent trans healthcare, without the need for RCTs. The lack of RCTs on the mental health impacts of gender-affirming care for trans adolescents does not entail that gender-affirming interventions are based on insufficient evidence. Given the methodological limitations of RCTs, complementary and well-designed observational studies offer more reliable scientific evidence than RCTs and should be considered of sufficient quality to guide clinical practice and policymaking.
Florence Ashley, “Transporting the Burden of Justification: The Unethicality of Transgender Conversion Practices” (2022) 50:3 Journal of Law, Medicine & Ethics 425–42
Abstract: Transgender conversion practices involve attempts to alter, discourage, or suppress a person’s gender identity and/or desired gender presentation, including by delaying or preventing gender transition. Proponents of the practices have argued that they should be allowed until proven to be harmful. Drawing on the notion of expressive equality, I argue that conversion practices are prima facie unethical because they do not fulfill a legitimate clinical purpose and conflict with the self-understanding of trans communities.
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Florence Ashley, “Interrogating Gender-Exploratory Therapy” (2022) Perspectives on Psychological Science
Abstract: Opposition to gender-affirmative approaches to care for transgender youths by some clinicians has recently begun to consolidate around “gender exploratory therapy” as a proposed alternative. Whereas gender-affirmative approaches follow the client’s lead when it comes to gender, gender-exploratory therapy discourages gender affirmation in favor of exploring through talk therapy the potential pathological roots of youths’ trans identities or gender dysphoria. Few detailed descriptions of the approach’s parameters have been offered. In this article, I invite clinicians to reflect on gender-exploratory therapy through a series of questions. The questions are followed by an exploration of the strong conceptual and narrative similarities between gender-exploratory therapy and conversion practices. Finally, the ethical dimensions of gender-exploratory therapy are discussed from the lenses of therapeutic neutrality, patient-centered care, loving attention, and therapeutic alliance, suggesting that the approach may be unethical.
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Florence Ashley, “Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health” (2022) 32:2 Kennedy Institute of Ethics Journal, 127–71
Abstract: In this article, I argue that adolescent medical transition is ethical by analogizing it to abortion and birth control. The interventions are similar insofar as they intervene on healthy physiological states by reason of the person's fundamental self-conception and desired life, and their effectiveness is defined by their ability to achieve patients' embodiment goals. Since the evidence of mental health benefits is comparable between adolescent medical transition, abortion, and birth control, disallowing transition-related interventions would betray an unacceptable double standard. While great enough risks can override autonomy over fundamental aspects of personal identity, I demonstrate that the available scientific evidence does not corroborate the view that adolescent medical transition is dangerous. Consequently, adolescent medical transition should be recognized as ethical and remain available.
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Florence Ashley, “‘Trans’ Is My Gender Modality: A Modest Terminological Proposal” in Trans Bodies, Trans Selves, 2nd ed. (Oxford: Oxford University Press, 2022) at 22
Abstract: Currently, no word exists in our vocabulary for the broad category which includes being trans and being cis. To address this gap, I propose the adoption of a new term: gender modality. Gender modality refers to how a person’s gender identity stands in relation to their gender assigned at birth. It is an open-ended category which includes being trans and being cis and welcomes the elaboration of further terms which speak to the diverse experiences people may have of the relationship between their gender identity and gender assigned at birth.
Florence Ashley, “Youth should decide: the principle of subsidiarity in paediatric transgender healthcare” (2022) Journal of Medical Ethics (online first)
Abstract: 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.
Florence Ashley, “The Constitutive In/Visibility of the Trans Legal Subject: A Case Study” (2021) 28:1 UCLA Women’s Law Journal 423–57
Abstract: The language of law creates the transgender subject by fabricating a legal conception of sex or gender which, for a long time, excluded trans people. Using Québec law as a case study, the article analyzes the law’s narratives of gender to highlight two conceptual phases. Through these two models – the medical and minoritizing models – Québec law first chronicles the existence of trans people as a transitional and liminal moment between two binary states of being, while the minority model sees transitude as an exceptional reality that is defined by its opposition to the dominant social framework. The two abovementioned visions follow each other historically and reveal the evolution of trans legal subjecthood. Despite recent progress, more remains to be done in order to truly include trans people as usual subjects of law.
Florence Ashley. “The Clinical Irrelevance of ‘Desistance’ Research for Transgender and Gender Creative Youth” (2021) Psychology of Sexual Orientation and Gender Diversity
Abstract: In recent years, the suggestion that over 80% of trans and gender creative children will grow up cisgender has been strongly criticized in the academic literature. Although concerns over the methodology of these studies, known as desistance research, has shed considerable doubt regarding the validity of the reported number, less attention has been paid to the relevance of desistance research to the choice of clinical model of care. This article analyzes desistance research and concludes that the body of research is not relevant when deciding between models of care. Three arguments undermining the relevance of desistance research are presented. Drawing on a variety of concerns, the article highlights that “desistance” does not provide reasons against prepubertal social transition or peripubertal medical transition, that transition for “desisters” is not comparably harmful to delays for trans youth, and that the wait-and-see and corrective models of care are harmful to youth who will grow up cis. The assumed relevance of desistance research to trans youth care is therefore misconceived. Thinking critically about the relationship between research observations and clinical models of care is essential to progress in trans health care.
Florence Ashley, “‘X’ Why? Gender Markers and Non-Binary Transgender People” in Isabel C. Jaramillo Sierra and Laura Carlson (eds.), Trans Rights and Wrongs: A Comparative Study of Legal Reform Concerning Trans Persons, Ius Comparatum - Global Studies in Comparative Law Series, Springer, 33–48
Jurisdictions increasingly recognize ‘X’ as a legal gender marker alongside ‘M’ and ‘F’, offering an alternative to those whose gender identity falls outside or in excess of the man/woman dichotomy. This chapter explores the justifications and limitations of ‘X’ as a gender marker, arguing that it does not place non-binary people on an equal footing to men and women since it serves as a single, catch-all option for a wide range of non-binary identities. The chapter the explores the possibility of expanding the availability of gender markers to reflect the full diversity of non-binary people but suggests that it would be rejected as absurd due to the ongoing role of gender markers in preserving cisnormativity. It concludes that abandoning gender markers may be the only fully inclusive option. For gender liberation to come within reach, we must imagine a future without gender markers.
(Link to paper)
Florence Ashley, Colton M St. Amand, G Nic Rider, “The Continuum of Informed Consent Models in Transgender Health” (2021) Family Practice
Using the ‘Informed Consent Model’ (ICM), clinicians prescribing hormone therapy to trans patients do not require a letter from mental health professionals attesting to their gender identity and/or gender dysphoria. Despite their prevalence and history in North America, ICMs remain poorly understood by medical professionals and are often treated as a monolithic concept. This article surveys the differences between ICMs along a continuum ranging from Strong ICMs to Weak ICMs to No-Letter Models.