The legal position regarding the best interests of the child in gender reassignment decisions in South Africa

Abstract

Although the recent concepts ‘gender dysphoria’ (according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, 2022) and ‘gender incongruence’ (as defined in the World Health Organization’s 2022 International Classification of Diseases, ICD-11) may seem to refer to recent phenomena, research has shown that gender diversity has affected individuals since the earliest times. Recent years have seen a rapid increase in the number of adolescents and children diagnosed with gender dysphoria. The prevalence of gender dysphoria is also reflected in growing public attention and fierce debates regarding gender reassignment procedures. Despite opposition to the procedures, an increased acceptance of gender diversity in some parts of the world has been noted, accompanied by the emergence of adolescent gender affirming health care and the establishment of gender responsive health services. Not all adolescents affected by gender dysphoria are able to express their gender incongruence from an early stage, often leading to feelings of social alienation, anxiety and depression. Past medical practices, as this thesis shows, have created unintended barriers to care for genderdiverse adolescents. Adolescents and children were initially not incorporated in clinical practice guidelines and standards of care issued by the World Professional Association for Transgender Health (WPATH), an international body that sets the standards of care for transgender medicine. In recent years, WPATH has recommended medical interventions for adolescents and children with gender incongruence. This is because delaying or minimising such medical interventions may prolong the manifestation of gender dysphoria in adolescents and children. Early intervention has been found to have a positive effect on the psychological well-being and social functioning of these children, as well as establishing an external physical appearance more closely aligned with their gender identity. Despite the recommendation of early medical intervention, the optimal age of introducing genderaffirming therapies remains a contested issue in this sensitive field of medicine and law. The thesis identifies several legal challenges obstructing adolescents’ access to gender affirming health care in South Africa. Drawing on a comparative legal overview of both proactive and restrictive approaches regarding the provision of gender affirming care in Australia, the United Kingdom, New Zealand, Canada and Denmark, the thesis postulates that the current South African legal framework governing gender affirming health care fails to meet the bests interests of children and adolescents suffering from gender dysphoria. In order to address this, the thesis first explores, through the lens of the best interests of children, different perspectives regarding children and adolescents’ informed consent to gender affirming health care. Secondly, the thesis concludes with sound recommendations informed by the legal comparative analysis, which provides a firm foundation for the consideration of children and adolescents’ access to gender affirming health care. This foundation will promote ongoing civil discourse and deliberative dialogue toward better shared decisionmaking in adolescent gender affirming health care and beyond. In the final instance, the thesis demonstrates how access to gender affirming health care services must be grounded in a human rights discourse, strengthened by the application of the yardstick of the best interests of the child.

Dikgopolotaba tsa moraorao e leng ‘masisapelo a tliswang ke bong ba tlhaho le bong bo fapaneng le bong ba motho ba boitsebiso’ (ho ya ka 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders, 2022) le ‘bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso’ (jwalo ka ha ho hlaloswa ke World Health Organisation’s 2022 International Classification of Diseases, ICD-11) eka di bua ka diketsahalo tsa matsatsing a jwale, feela diphuputso di bontsha ha phapano ya bong e le tlhobaboroko ho batho ho tloha sethathong. Sesosa sa bokudi, e leng masisapelo a tliswang ke bong ba tlhaho le bong bo fapaneng ba motho ba boitsebiso, se atile ka sekgahla dilemong tsa jwale dipalong tsa bana le batjha. Ketsahalo ena e hlalositsweng ka hodimo e iponahatsa ka tsela eo setjhaba se tsepamisitseng maikutlo le dingangisano tse matla mabapi le oporeishene tse fetolang bong. Ho hlokometswe ho eketseha ha mafatshe a amohelang bong bo fapaneng, mme ho tsamaya mmoho le ho ropoha ha ditshebeletso tsa bophelo tse tshehetsang batjha le ho thehwa hwa ditshebeletso tsa bophelo tse arabelang bong ba motho, le ha ba bang ba le kgahlanong le tsona. Ha se batjha bohle ba anngwang ke masisapelo a tliswang ke bong ba tlhaho le bong bo fapaneng ba motho ba boitsebiso, ba kgonang ho hlalosa bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso ba sa le banyane, mme sena se lebisa ho maikutlo a ho kgetholleha setjhabeng, ngongoreho le kgatello ya maikutlo. Ditlwaelo tsa bophelo tsa kgale, jwalo ka ha thesese ena e bontsha, di bakile dithibella tsa tlhokomelo tseo e seng tsa ka boomo ho hlokomeleng batjha ba bong bo fapaneng. Ho tloha sethatong, batjha le bana ba ne ba sa kenyelletswa ditataisong tsa ditshebeletso tsa bongaka le boemong ba tlhokomelo bo nehelanweng ke World Professional Association for Transgender Health (WPATH), e leng mokgatlo wa matjhabatjhaba o thehang boemo ba tlhokomelo bitsong la meriana ho ba fetolang bong. WPATH e kgothalleditse bonamodi ba bongaka bitsong la batjha le bana ba nang le bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso dilemong tsa jwale. Lebaka ke hore tiehiso kapa ho nyenyefatsa ha bonamodi bona ba bongaka bo ka atolosa boiponahatso ba bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso ho batjha le bana. Ho ile ha fumaneha hore bonamodi bo nakong bo na le ditlamorao tse ntle maemong a bana bana a kelello le tshebetsong ya phedisano, le hona ho thehweng ha tjhebeho e kantle ya sebopeho sa mmele e tshwanang le bong ba bona ba boitsebiso. Ntle le dikgothalletso tsa bonamodi ba bongaka bo etswang nako e sa le teng, dilemo tse dumellesehang tsa ho kenya tshebetsong theraphi e tshehetsang bong e ntse e le taba e lwanelwang maemong ana lekaleng la bongaka le molao. Thesese e hlwaya dikgwehlo tse mmalwa tse thibellang batjha ho fumana tlhokomelo ya bophelo e netefatsang bong Aforika Borwa. Thesese e sisinya hore motheo wa semolao wa Aforika Borwa wa jwale o laolang tlhokomelo ya bophelo e netefatsang bong e hloleha ho ananela dikgahlehelo tse bohlokwa tsa bana le batjha ba nang le bong ba tlhaho bo sa dumellaneng le bong ba motho ba boitsebiso, ka ho bapisa tjhebeho tsa Australia, United Kingdom, New Zealand, Canada le Denmark, tsa semolao tsa katamelo e nang le dipehelo le e se nang dipehelo sepheong sa tshebeletso e netefatsang bong. Ho phenyekolleng sena, thesese e lekotse dikgahlehelo le tumello e nang le tsebo ya tshebeletso ya bophelo e netefatsang bong ba bana le batjha pele, Bobeding, thesese e phethela ka dikgothalletso tse tsepameng ho manollo le papiso ya semolao eo e leng motheo wa tshekatsheko ho ananelweng hwa bana le batjha ho fihlelleng ditshebeletso tsa bophelo. Motheo ona o tla kgothalletsa dipuisano setjhabeng le dingangisano tsa maikemisetso tse tswellang pele e le ho nka diqeto tse kopanetsweng ditabeng tsa ditshebeletso tsa bophelo tse netefatsang bong ba batjha ho ya ho ile. Qetellong, thesese e bontsha hore ho fihlella ditshebeletso tsa bophelo tse netefatsang bong di tshwanetse ho thehwa dipuisanong tsa ditokelo tsa botho mme di tshehetswe ka ho sebedisa dikgahlehelo tse bohlokwa tsa ngwana.

Nakuba kunezimvo ezahlukene ngenxa yengcindezi yokwehluka kwemizwa nobulili (njengokwethula kwesishicilelo sesi-5 Somqulu Wamanani Okuxilongwa Kwezifo Zengqondo sezi-2022) kanye nempicabadala ngobulili (njengokuchaza Kwenhlangano Yezempilo Yomhlaba ohlelweni lwesifo lomhlaba onyakeni wezi-2022, i-ICD-11) okubukeka kuqondiswe esimweni sakamuva socwaningo esiveza ukuthi ukwehluka kobulili sekubalimaze kanjani abantu ngabodwana kulesi sikhathi. Kule minyaka esanda kudlula kube nokunyuka okukhulu kubantwana abasemabangeni okukhula abaxilongwe batholakala bekule mpicabadala yobulili. Ukukhula kwale mpicabadala ibonakala emiphakathini nasezingxoxweni ezivutha uphondo mayelana nobulili nengqubo ehambisana nabo. Noma kukhona ukungaboni ngasolinye kulezi zingqubo, ukukhula kwabemukelayo ukwehluka kwabantu ngezinhlobo zokuzikhethela ubulili kuyaqapheleka emhlabeni jikelele, kuhambisana nokuvumbuka kwabantu abaqinisekisa nanezempilo ezeseka ukwamukelwa kwezinhlobo zobulili ezahlukene emkhakheni wezempilo. Akubona bonke abantwana abasebangeni lokukhula abathintekayo kule mpicabadala yobulili, abanye basheshe babonakale besebancane ukuthi bayiluphi uhlobo lobulili, nokuthi imizwa yabo ingakuluphi uhlangothi, noma bazibona bengena ngaphansi kwamaphi amaqembu emphakathini, okumbandakanya ukukhathazeka nokucindezeleka. Ezokwelapha zesikhathi esidlule nemiqulu yocwaningo esibhalilwe isiveze imingcele edinga ukuqashelwa ngokwehluka kwezinhlobo zobulili kubantwana abasebangeni lokukhula. Abantwana abasebangeni lokukhula nabantwana nje bonke bebengafakiwe ezinhlelweni zokwelapha ezinemihlahlandlela nezimiso zokunakekela ezikhishwe Inhlangano Yezemikhakha Yomhlaba Yokuguqulwa Kobulili Yezempilo (i-WPATH), lena inhlangano yomhlaba ebeka izimiso zokunakekeleka nezokwelashwa kokuguqulwa kobulili. Eminyakeni esanda kudlula i-WPATH ilethe iziphakamiso zokungenelela kwezokwelasha kubantwana abasebangeni lokukhula nabantwana basebancane abanobulili obunesidingo sokuqondiswa. Lokhu kunonembe lokuhamba ngonyawo lonwabu noma ukuba mbalwa kwamathuba okwelashwa okwenza impicabadala yobulili iqhubekele phambili kubantwana abasebangeni lokukhula nasebantwaneni abasebancane. Ukungenelela kusesemabangeni aphansi okukhula kutholakale kunomphumela omuhle ekwelekeleleni umqondo nobuyena umntwana, nokwamukeleka kwakhe emphakathini kanjalo nokwakhekha kwezicubu zomzimba ezihambelana nobulili abuncamelayo nazizwa eyiyona umntwana. Ngaphandle kwezincomo zokungenelela kwabezokwelapha umntwana esemncane, kunebanga umntwana okufanele uma esefike kulona akwazi ukuzibona emukeleka ebulilini obuthize ngokwenziwa kwezinhlelo ezelekelelayo okugcine kuwudaba olusabhungwa futhi olubucayi emikhakheni yezomthetho neyezempilo. Lo mqulu wocwaningo uhlonze izinselelo ezimbalwa zezomthetho ezigqashula izibopho zokufinyelela kubantwana abasebangeni lokukhula abadinga ukwelekelelwa ukuze baqiniseke ubulili babo ngokwezempilo eNingizimu Afrikha. Ukuhogela imikhondo ekuqhathanisweni kwesendlalelo somthetho nalokho kokubili, ukulungiselela kusenesikhathi nezimiso ezinqabayo mayelana nokuhlelelwa kokuqinisekisa ubulili ngokuqaphela e- Australia, eNgilandi, e-New Zealand, e- Canada naseDenmark, lo mqulu wocwaningo unikeza imibandela yezivumelwano zokuthi ezomthetho zaseNingizimu Afrikha zibe nesisekelo esilawula ukuqinisekisa kobulili ngokwezokwelashwa nokunakekela okuhambisana nezifiso zabantwana abasebangeni lokukhula abanenselelo yale mpicabadala yobulili. Ukuze kuzanywe isixazululo, lo mqulu wocwaningo uqala ngokuhlola usebenzisa izinjulakuhlola ezihambisana nezifiso zabasemabangeni okukhula, ubheka nezimvume nokwelashwa nokunakekelwa. Okunye lo mqulu wocwaningo uphetha ngokwethula iziphakamiso eziya emkhakheni wezomthetho oqhathanisa ukuhlaziya okuyikona okunikeza isisekelo esinzulu ngokulandelwa kwendlela yokufinyelela kubantwana abasebangeni lokukhula ukufinyelela ekwelashweni okumayelana nokuqinisekisa kobulili nokwelashwa. Lesi sisekelo sizophumelelisa izingxoxo ezinohlonze nemibono eqhubezela phambili ukwabelana ngezimvo nokuthatha izinqumo ngabantwana abasemabangeni okukhula ukufinyelela ekwelashweni okumayelana nokuqinisekisa ubulili, ukwelashwa nokuqhubekela phambili. Ngasekuphethweni lo mqulu wethula ukuthi kungafinyelelwa kanjani ekwelashweni okumayelana nokuqinisekiswa kobulili nokwelashwa okuhambisana nezinsizakusebenza okumele zesekwe ngamalungelo abantu, kuqiniswe nangokwethulwa kwenkombandlela ebeka izidingo zabantwana phambili.