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.

(⁠⁠Link to paper⁠⁠)

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.

(Link to article)

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.

(Link)

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.

(Link)

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.

(Link)

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.

(Link to article)

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.

(Link to article)

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.

(Link to article)

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)