What is Informed Consent?

The traditional way of handling Hormone Replacement Therapy (HRT) for transgender patients is to obtain a letter of recommendation from a therapist. This can take anywhere from one visit to one year or even more of regular therapy sessions, which, as you can imagine, can be both cost-prohibitive and too time-consuming for a community that faces inordinate rates of homelessness, unemployment, and lack of adequate insurance and transportation access.

The traditional way of handling Hormone Replacement Therapy (HRT) for transgender patients is to obtain a letter of recommendation from a therapist. This can take anywhere from one visit to one year or even more of regular therapy sessions, which, as you can imagine, can be both cost-prohibitive and too time-consuming for a community that faces inordinate rates of homelessness, unemployment, and lack of adequate insurance and transportation access.

Moreover, there is no firm standard for therapists to go by, and therapists themselves can be subject to their own social biases. For example, some may not recognize gender nonconformity, and may expect their patients to perform heteronormative ideals of their identified gender.

Informed Consent removes that extra barrier from the equation. In an informed consent clinic, patients still do the appropriate labwork and are informed of the risks and benefits of beginning HRT. Mental health concerns are even addressed, and if the doctor feels like a patient should probably see a therapist to rule out other concerns, they can make that call.

The process is exactly identical to the traditional approach, except that the doctor doesn’t require a letter from a third party saying that you’re trans in order to discuss treatment options. You know, the way they treat literally everything else, including mental health issues.

University of California, San Francisco (UCSF) Transgender Care and Treatment Guidelines note that “most medications used in gender affirming hormone therapy are commonly used substances with which most prescribers are already familiar due to their use in the management of menopause, contraception, hirsutism, male pattern baldness, prostatism, or abnormal uterine bleeding.”

HRT for transition manegement isn’t even that outside the box. The fact is, family practice doctors are all very familiar with hormones. They treat hormone imbalances regularly, and at the end of the day, non-HRT trans people are just regular people who suffer from hormone imbalances.

A study in the Journal of Humanistic Psychology looked into various informed consent clinics and saw no significant regret rate and no known malpractice suits related to transgender management. According to the report, “the Informed Consent Model of transgender care shows promise in not only alleviating barriers to accessing treatment, but also for allowing a narrative of transgender experience to emerge outside of the distress narrative that is at the core of the diagnostic model. Not only might this contribute to the depathologization of gender variance in the psychological and medical fields, but it may also help us shift toward a larger culture of equal rights and protection for individuals with nonnormative gender identities and expressions.”

The Harms of Gatekeeping

Not only can the therapist approval approach be prohibitively expensive for many transgender and gender nonconforming people, but the performative nature that some therapists require can be quite untherapeutic for a community that’s already struggling with having to prove their identity to their family, friends, and coworkers.

There are psychologists, for instance, who do not recognize transbians (lesbian trans women) as valid, and may even view them as “autogynephilic”, a term coined by sexologist Ray Blanchard to refer to “a man’s paraphilic tendency to be sexually aroused by the thought or image of himself as a woman.” And, of course, since Blanchard only offered two choices for his transgender typology – “homosexual transsexuals”, which referred to trans women who were attracted to men (which actually would be straight trans women) and so-called “autogynephilic transsexuals”, which I guess refers to all of us who aren’t solely attracted to men.

As you can imagine, this cisheteronormative narrative can put transbians (especially butch trans ladies) and gay trans men (especially effeminate gay trans men) at a disadvantage when it comes to proving their transness to a psychologist. Especially in a city like ours where most therapists are some brand of Christian family counselors.

And let’s not forget that gender is a broad spectrum that many providers are simply refusing to recognize. This doesn’t just put Gender Nonconforming people and nonbinary people at a disadvantage. But also people of different ethnicities and cultures that Western society has largely erased. For instance, two-spirit in some indigenous cultures, hijra in India, and various others all over the world. Every culture has their own way of viewing and experiencing gender.

Unfortunately, the expansion of Western colonization has erased many of these expressions. For example, European settlers in the Americas denounced indigenous traditions and gender expressions as “savage”. The British takeover of India resulted in hijra identities – which were once revered in their society – being outlawed. Religious missions in African regions have resulted in the deaths of gay and gender variant people there. Between Western military influence and evangelical missions all over the world, we’ve brutally erased much of the diversity that once thrived.

Point being, gatekeeping isn’t just an obstacle for some people. For some, it’s contributing to violence against themselves and their entire cultures.

Who’s Deciding These Rules Anyway?

The World Professional Association for Transgender Health (WPATH) Standards of Care has historically required therapist confirmation “independent of the patient’s verbal claim”, as their verbal claims are “possibly unreliable or invalid sources of information.” This was honestly pretty ironic considering that Dr. Harry Benjamin, the founder of WPATH (then called the Harry Benjamin International Gender Dysphoria Association), went directly against psychologists’ recommendations in order to treat transgender people.

The WPATH has since lightened its stance, and in the most recent edition (Standards of Care, Version 7) published in 2011, they wrote that informed consent model protocols “are consistent with the guidelines presented in the WPATH Standards of Care, Version 7. The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided.” (p. 35).

It’s a start, I guess.

Meanwhile, the World Health Organization (WHO) has declassified gender dysphoria as a mental disorder altogether. In their most recent edition of the International Classification of Diseases (ICD-11) published in 2019, WHO reclassified “Gender Identity Disorder”, which was previously in the section on Mental Disorders, to “Gender Incongruence”, which is now in the section on Sexual Health.

Reproductive health expert for WHO, Dr. Lale Say reports that, “it was taken out from mental health disorders because we had a better understanding that this was not actually a mental health condition, and leaving it there was causing stigma.”

In time, Gender Dysphoria will fall off of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as well. After all, homosexuality was classified as a mental disorder until the second edition of the DSM published in 1973. It’s often not the dysphoria itself that causes mental stress – it’s the social stigma attached to it.

There’s Gotta Be a Better Way!

I’m not suggesting that we give out hormones willy-nilly. I’m not even suggesting that we not see therapists ever. I’ve been seeing my therapist for years and he’s been great for me. Honestly, everyone should have a therapist! I sincerely hope that we get universal healthcare someday and that it includes mental health services like regular therapy visits.

I simply don’t feel that we need to make a therapist letter a prerequisite of hormone therapy. And I feel like removing that barrier will help us to actually be more honest and open with our therapists. I’ll be honest, I wasn’t completely truthful with my therapist until after he wrote my letter. I worried that maybe he wouldn’t think I was valid as a transbian who honestly kind of dislikes makeup. But with that barrier out of the way, I can truly be myself with him!

I’ve heard similar reports from gender nonconforming and nonbinary trans people who wished to begin microdosing hormones, but adapted their experiences into a hetero-loving binary-toting friendly package to appease their therapists.

Gatekeeping doesn’t make us safer. It only removes access to care and causes us to feel less trusting and less supported by those we might otherwise benefit from the most. Because unfortunately, gatekeeping only creates yet another power dynamic that we’re on the wrong end of.

Related: Addressing the Detransition Myth

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References:

University of California San Francisco. “UCSF Transgender Care & Treatment Guidelines”. https://transcare.ucsf.edu/guidelines/initiating-hormone-therapy

Schulz, Sarah L. “The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria”. Journal of Humanistic Psychology. https://journals.sagepub.com/doi/full/10.1177/0022167817745217

Blanchard, R (October 1989). “The concept of autogynephilia and the typology of male gender dysphoria”. The Journal of Nervous and Mental Disease. 177 (10): 616-623. https://journals.lww.com/jonmd/pages/articleviewer.aspx?year=1989&issue=10000&article=00004&type=abstract

Harry Benjamin International Gender Dysphoria Association, Inc. The standards of care for gender identity disorders. Published February 12, 1979:4-5.Google Scholar

World Professional Association for Transgender Health. ” Standards of Care for the Health of Transsexual, Transgender, and GenderNonconforming People”. Version 7. https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf

World Health Organization. “International Classification of Diseases” Version 11. https://www.who.int/classifications/icd/en/

Say, Lale, PhD. “WHO: Revision of ICD-11 (gender incongruence/transgender) – questions and answers (Q&A)”. Jun 18, 2018. https://www.youtube.com/watch?v=kyCgz0z05Ik&feature=youtu.be