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Use of the Informed Consent Model in the Provision of Cross-Sex Hormone Therapy: A Survey of the Practices of Selected Clinics
Abstract
Introduction: Some clinics have developed models for the initiation of cross sex hormone therapy (csHT) without an in-depth mental health evaluation and referral. These approaches have also been referred to as the informed consent (IC) model.Aims: (a) Survey practice characteristics of clinics utilizing the IC care model; (b) assess potential legal risks to clinics utilizing the IC care model; and (c) assess for any known cases of regret by patients with respect to csHT.Methods: (a) Convenience sample survey instrument distributed at professional conferences and online and (b) thorough online legal literature search.Results: Responses were obtained from 12 unique U.S. sites. Seventeen known cases of regret were reported across all sites. No cases of malpractice claims or judgments relating to regret about the use of csHT were reported. Only 4 of 12 sites required any contact with a mental health provider prior to initiation of csHT. A minimum number of visits prior to beginning treatment was required by only 5 clinics. The literature review yielded no related legal actions.
... Many clinicians use informed consent models, offering genderaffirming interventions based primarily or solely on the person's informed decision . Informed consent models have been used by some clinics since the early 1980s and were promoted in a 1993 standards of care as an alternative to the WPATH standards of care (Deutsch, 2012;Frye, 1993;Karasic, 2000). Informed consent models have grown in prominence in the last few decades and generated significant scholarly literature Blasdel et al., 2018;Deutsch, 2012;Hale, 2007;Schulz, 2018). ...
... Informed consent models have been used by some clinics since the early 1980s and were promoted in a 1993 standards of care as an alternative to the WPATH standards of care (Deutsch, 2012;Frye, 1993;Karasic, 2000). Informed consent models have grown in prominence in the last few decades and generated significant scholarly literature Blasdel et al., 2018;Deutsch, 2012;Hale, 2007;Schulz, 2018). The rates of retransition or regret reported at informed consent clinics fall within the range reported by clinics that require lengthy gender assessments (Blasdel et al., 2018;Deutsch, 2012;cf. ...
... Informed consent models have grown in prominence in the last few decades and generated significant scholarly literature Blasdel et al., 2018;Deutsch, 2012;Hale, 2007;Schulz, 2018). The rates of retransition or regret reported at informed consent clinics fall within the range reported by clinics that require lengthy gender assessments (Blasdel et al., 2018;Deutsch, 2012;cf. Brik et al., 2020;Bustos et al., 2021;Dhejne et al., 2014;Landén et al., 1998). ...
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.
... and other providers may maintain universal mental health assessor requirements. Existing data on informed consent practices indicate high patient satisfaction and low rates of posttransition regret (Deutsch, 2012;Spanos et al., 2021). Use of mental health assessment and other criteria for access to care were initially based on expert opinion, rather than empirically derived (Meyerowitz, 2002;Walker et al., 1979). ...
... However, insurance companies and surgeons may continue to require mental health assessor letters. Data on the provision of care via informed consent indicate low rates of patient regret and high levels of patient satisfaction (Deutsch, 2012;Spanos et al., 2021). The use of mental health assessment as a gatekeeping measure is contentious and the subject of reported harm from trans individuals (Ashley, 2019a;Brown et al., 2020;Budge & Dickey, 2017;Horton, 2022Horton, , 2023Latham, 2017). ...
... If so, what prevents regret? Is the prevention of regret, the occurrence of which is very low (Bustos et al., 2021;Deutsch, 2012;Wiepjes et al., 2018), overemphasized while reported harms of assessment from trans patients are underemphasized? Previous criteria for access to gender-affirming care, including the central role of mental health assessment, contrasted SOC "ethical care" with unethical practices such as the infamous surgeries of "Tabletop Brown" (Evans & Alexandra, 2020;People v. Brown, 2001). ...
In order to access gender-affirming care, transgender individuals were historically required by international guidelines to undergo mental health provider assessment (Coleman et al., 2012). This requirement for universal mental health provider involvement, initially formulated via professional expert opinion, has not been retained in the most recent World Professional Association for Transgender Health Standards of Care (WPATH SOC 8; Coleman et al., 2022). In the present analysis, I sought to examine the historical and cultural contexts of these expert opinions codified in the first version of the WPATH SOC released in 1979. Foucauldian genealogy and qualitative thematic analysis guided data collection and analysis. Study themes of debate, codification, and change outline the codification of early gender identity research criteria in SOC. These themes examine the historical context of the codification of mental health assessment for access to gender-affirming care. Historical perspectives from trans individuals themselves on assessment criteria are represented in the analysis, including the notable impacts of an individual's race, class, and sexual orientation on attitudes towards assessment practices. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
... However, the emotional experience of regret is not homogeneous but can vary significantly depending on different aspects, such as its duration, its intensity, or the type of situation that causes it: a temporary feeling of ambivalence is not the same as permanent regret, nor is regret following an identity change the same as regret following medical complications 34 . More importantly, regret does not always lead to or is not always present in a detransition since it is possible to find cases of regret without detransition [53][54][55][56][57][58] and of detransition without regret 38,49,53,55,56,[59][60][61][62][63][64][65][66][67][68] . For instance, some detrans individuals have expressed that transitioning was part of their own journey or exploration process and that they could not know beforehand if it was the right decision 38,43,56,67,[69][70][71] . ...
... Reversion/Reversal 54,89,110,[113][114][115] The process by which a person returns to their pre-transition gender identity or gender presentation, either through social, medical, and/or administrative means It may describe: (a) returning to living socially/ legally according to the birth sex; or (b) undergoing birth sex-congruent medical treatment to reverse the physical changes experienced during a gender transition process Disidentification/ Reidentification 43,67 The process by which a person ceases to identify as transgender (disidentification) or reidentifies with their birth sex (reidentification) ...
... Although it is difficult to determine the exact prevalence of people who detransition, overall, the estimates for detransition or regret following hormonal and/or surgical treatments (0-9.8%) 24,[34][35][36][37]48,49,[53][54][55]57,58,66,82,[86][87][88][89][90][91][92][93][94][95]98 are notably lower than those for discontinuation of care/medical treatment (1.9-29.8%) 36,53,55,62,92,[95][96][97][98][99] . ...
Introduction. Gender detransition is the act of stopping or reversing the social, medical, and/or administrative changes achieved during a gender transition process. It is an emerging phenomenon of significant clinical and social interest.
Methods. We systematically searched seven databases between 2010 and 2022, manually traced article references, and consulted specialized books. Quantitative and content analyses were carried out.
Results. We included 138 registers, 37% of which were empirical studies and 38.4% of which were published in 2021. At least eight terms related to detransition were identified, with differences in their definitions. Prevalence estimates differ according to the criteria used, being lower for detransition/regret (0-13.1%) than for discontinuation of care/medical treatment (1.9%-29.8%), and for detransition/ regret after surgery (0-2.4%) than for detransition/ regret after hormonal treatment (0-9.8%). More than 50 psychological, medical, and sociocultural factors influencing the decision to detransition and 16 predictors/associated factors are described. No health or legal guidelines are found. Current debates focus on the nature of gender dysphoria and identity development, the role of professionals in accessing medical treatments, and the impact of detransition on future access to these treatments.
Conclusions. Gender detransition is a complex, heterogeneous, under-researched, and poorly understood reality. A systematic study and approach to the topic is needed to understand its prevalence, implications, and management from a healthcare perspective.
... Although not all TGD individuals desire access to medical interventions for affirming gender embodiment, many do. Data exist on the use of informed consent practices and indicate high patient satisfaction and low risk of post-transition regret (Deutsch, 2012;Spanos et al., 2021). The World Professional Association of Transgender Health (WPATH) began recognizing some care can be provided on an informed consent basis in its SOC, Version 7 (Coleman et al., 2012) and recently removed the universal requirement of a mental health provider assessment in its updated Version 8 (Coleman et al., 2022). ...
... Today, these rigid theories of gender are no longer commonly used. Decades of data indicate rates of posttransition regret are very low (Bustos et al., 2021;Deutsch, 2012;Wiepjes et al., 2018). However, the fundamental bias often remains-that the numbers of trans people should be as few as possible, questioned carefully and at length to be sure they could not have the outcome of being cisgender. ...
... This analysis demonstrates a long history in clinical care that trans identity and embodiment should be either altered or limited to the greatest extent possible. I argue that the portrayal of genderaffirming care continues to be positioned as a method of last resort justified only by narratives of suffering, despite the positive mental health effects of gender-affirming care and decades of data on low rates of post-transition regret (Bustos et al., 2021;Deutsch, 2012;Schulz, 2018;Wiepjes et al., 2018). Community understandings of TGD identity as joyful, fluid, or freedom of expression and embodiment in justifications for access to care continue to be a subjugated discourse (Ashley, 2019a(Ashley, , 2019bTurban & Keuroghlian, 2018). ...
Mental health clinician assessment has historically been required for trans individuals to access gender-affirming medical procedures. This universal requirement that all trans adults undergo an assessment by a mental health provider specifically (vs. a healthcare provider generally) was not retained in the eighth version of the World Professional Association for Transgender Health Standards of Care. Still, insurance companies and surgeons may maintain universal mental health assessor requirements. The practice of mental health provider assessment for access to gender-affirming care was initially established via expert opinion. In the present analysis, I sought to examine the historical and cultural contexts of these expert opinions during the period from the 1960s through the 1980s. Study methods included Foucauldian genealogy and qualitative thematic analysis. Qualitative analysis regarding the creation of criteria for access to gender-affirming care generated three major themes: cure, prevention, and assimilation. Transgender individuals resisted psychological cures of gender variance, and some were able to access gender-affirming procedures they requested via adherence to normative clinician criteria. Clinicians can repair historical harms by becoming aware of ongoing discourse that positions gender-affirming care as a method of “last resort” and by advocating for access to care that respects patient autonomy.
... The Endocrine Society has issued recommendations similar to WPATH in its guidelines [6]. Though widely utilized, experts and advocates have recently scrutinized the WPATH approach as paternalistic, restrictive, and without scientific evidence for benefit [12,[16][17][18][19][20][21]. Although the WPATH standards of care [14] leave room for alternative approaches, the recommendation for an MHP letter prior to hormone initiation is commonly referred to as "the WPATH model" by patients and providers alike. ...
... While some GAH providers adhere to the WPATH recommendation, others do not consistently require mental health evaluation and instead use a process commonly referred to as "informed consent" (henceforth, IC) for GAH [16]. The IC model emerged in the 2000s in an from a small, well-connected pool of providers who prescribe gender-affirming care in the U.S., it is not possible to sufficiently de-identify the data to make it anonymous; nor have we obtained permission from participants when they granted their informed consent to the study. ...
... The contact information is below. attempt to depathologize transgender identity and increase access to gender-affirming care broadly and GAH specifically [12,16,21]. This approach has been loosely defined by the absence of a requirement for an MHP letter, distinguishing it from the WPATH model [16]. ...
Objective
Gender-affirming hormones (GAH)—the use of sex hormones to induce desired secondary sex characteristics in transgender individuals—is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers’ attitudes and base our recommendations on this analysis.
Methods
We conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework—a framework for understanding influences on health professional behavior—to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories.
Results
While some felt a universal requirement for mental health “clearance” was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of “gatekeeping” that limits access to care. Themes we identified included providers’ ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment.
Conclusion
Providers in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.
... Detransitioning refers to a process whereby, after initiating gender transition, an individual discontinues, reverses, or redirects the course of their transition (Exposito-Campos, 2021). Clinicians fear these outcomes when providing trans people with gender-affirming care for myriad reasons, but some concerns evoke questions of professional liability and the ethics of causing harm to patients (Coleman et al., 2012;Deutsch, 2013;Dewey, 2013;Olsson and Moller, 2006;shuster, 2021). ...
... Some medical sciences literature focuses on estimating prevalence of transition regret (Dhejne et al., 2014;Hess et al., 2014;Olsson and Moller, 2006;Bustos et al., 2021). Discrete studies conducted in Germany, the US, Sweden, and the Netherlands show that between 0.3% and 15% of trans people are dissatisfied to some degree with medical transition outcomes (Deutsch, 2013;Dhejne et al., 2014;Johansson et al., 2010;Zavlin et al., 2018). In relation to surgeries specifically, a systematic review and meta-analysis of 27 studies pooling 7928 trans patients found a ~1% "prevalence of regret" after gender-affirming surgery (Bustos et al., 2021). ...
... Ashley and Dominguez (2020) point out that scientific medical knowledge production integral to trans healthcare has historically excluded trans people, which in turn reifies mistaken cisnormative/transnormative assumptions made by clinicians and researchers. Yet, as discussed by participants and corroborated by existing literature, regret is an "exceedingly rare" outcome (Danker et al., 2018, p. 189) even more rarely appearing in a "life ending" form accompanied by malpractice lawsuits expected by some clinicians (Deutsch, 2013;Exposito-Campos, 2021;Korpaisarn and Modzelewski, 2019). Further challenging transnormativity, evidence suggests that many people who detransition do so only temporarily and their trans identities often persist even whilst discontinuing gender transition (or their gender identities may shift dynamically) Turban and Keuroghlian, 2018). ...
When a person openly “regrets” their gender transition or “detransitions” this bolsters within the medical community an impression that transgender and non-binary (trans) people require close scrutiny when seeking hormonal and surgical interventions. Despite the low prevalence of “regretful” patient experiences, and scant empirical research on “detransition”, these rare transition outcomes profoundly organize the gender-affirming medical care enterprise. Informed by the tenets of institutional ethnography, we examined routine gender-affirming care clinical assessment practices in Canada. Between 2017 and 2018, we interviewed 11 clinicians, 2 administrators, and 9 trans patients (total n = 22), and reviewed 14 healthcare documents pertinent to gender-affirming care in Canada. Through our analysis, we uncovered pervasive regret prevention techniques, including requirements that trans patients undergo extensive psychosocial evaluations prior to transitioning. Clinicians leveraged psychiatric diagnoses as a proxy to predict transition regret, and in some cases delayed or denied medical treatments. We identified cases of patient dissatisfaction with surgical results, and a person who detransitioned. These accounts decouple transition regret and detransition, and no participants endorsed stricter clinical assessments. We traced the clinical work of preventing regret to cisnormativity and transnormativity in medicine which together construct regret as “life-ending”, and in turn drives clinicians to apply strategies to mitigate the perceived risk of malpractice legal action when treating trans people, specifically. Yet, attempts to prevent these outcomes contrast with the material healthcare needs of trans people. We conclude that regret and detransitioning are unpredictable and unavoidable clinical phenomena, rarely appearing in “life-ending” forms. Critical research into the experiences of people who detransition is necessary to bolster comprehensive gender-affirming care that recognizes dynamic transition trajectories, and which can address clinicians’ fears of legal action—cisgender anxieties projected onto trans patients who are seeking medical care.
... Providers' fears of transition regret may in part be influenced by societal cisnormativity and stigmatization of trans+ identities, as a large proportion of the general population seems to remain doubtful that trans+ identities are real and see them as being temporary or somehow related to mental illness (Deutsch, 2012;Gould et al., 2024;Levitt & Ippolito, 2014;Whitehead et al., 2012). For some providers of gender-affirming care, fears about patient regret centre around trans+ individuals' needs and are fuelled by concerns that such an experience would lead to other biological, psychological, or social decompensation (e.g., medical risk if reversal is requested, deterioration of a patient's mental health, potential suicide; Westmacott et al., 2024). ...
... A small number of studies have examined the utility of informed consent models in gender-affirming care. In applying this model to gender-affirming hormone initiation across 12 clinics and 1,944 clients, Deutsch (2012) found that 17 cases of regret were reported, and no medical malpractice claims were reported over an average of approximately 3 years of follow-up care. At Fenway Health in Boston, Massachusetts, between 2007 and 2013, Reisner et al. (2015) found that there was widespread use and acceptance of the informed consent approach. ...
Historiquement, une évaluation préopératoire par un professionnel de la santé mentale a été exigée pour que les personnes trans+ puissent accéder aux chirurgies liées à la transition dans la plupart des juridictions canadiennes, malgré le débat actuel sur leur utilité clinique. L’engagement des patients est une étape cruciale pour informer les processus de soins de santé afin qu’ils soient appropriés et culturellement adaptés. Une étude qualitative a donc été menée pour comprendre les expériences des adultes trans+ qui ont subi des évaluations préopératoires de l’état de santé mentale pour des chirurgies liées à la transition et leurs recommandations pour améliorer les processus d’aiguillage. Les participants (N = 21), recrutés par l’intermédiaire d’affiches dans une clinique de santé sexuelle et de médias sociaux, ont participé à quatre groupes de discussion en personne animés par des chercheurs trans+. Les transcriptions ont été analysées à l’aide d’une analyse thématique, qui a permis de dégager deux thèmes principaux. Tout d’abord, en discutant de leurs expériences d’évaluation préopératoire de l’état de santé mentale (thème général 1), les personnes trans+ ont déclaré avoir ressenti de l’incertitude quant à l’objectif de l’évaluation et se sont tournées vers la communauté pour obtenir des conseils sur la manière de « réussir » leur évaluation. Elles ont déclaré s’attendre à devoir mentir sur leur histoire de genre et minimiser leurs symptômes de santé mentale pour pouvoir accéder à la chirurgie. Les participants ont indiqué que leur évaluation ne les avait pas préparés à l’opération, n’avait pas fixé d’attentes postopératoires claires et n’avait pas amélioré la santé mentale et le bien-être postopératoires. Les participants ont mentionné que les évaluations de santé mentale préopératoires avaient tendance à traiter les expériences et les identités trans+ comme des pathologies. Deuxièmement, les participants ont fait part de leurs recommandations en vue d’un changement systémique et procédural (thème général 2). La plupart des participants souhaitaient avoir accès à des chirurgies par l’intermédiaire de leur médecin de famille en utilisant un modèle de consentement éclairé et des pairs mentors pour les aider à s’orienter dans le système de santé. Les répercussions sur la formation, les politiques et la recherche y sont abordées.
... 13 Documentation of the factors mentioned above should come in the form of a referral from the mental health professional (MHP; e.g., clinical psychologist, social worker) who conducted the evaluation, with the caveat that in some cases, a qualified prescribing clinician (termed Informed Consent Model) may perform the assessment. 13,14,16 In 2017, the Endocrine Society published updated clinical practice guidelines, removing the obligation for a MHP to conduct the psychosocial evaluation of TGD individuals requesting GAHT. 15 Instead, they recommend that any knowledgeable clinician with appropriate expertise, regardless of specialty, can perform the assessment. ...
... Additionally, the WPATH SOC Version 8 supports the Informed Consent Model, 23 which differs from the prior approach in that the transgender individual is prioritized as J o u r n a l P r e -p r o o f the decision maker, with the prescribing clinician serving in an advisory role. 13,14,16 The Informed Consent Model places greater weight on the patient's assessment of their preparedness to start GAHT. 27 In all cases, mental healthcare is available based on patient preference and to address relevant mental health concerns rather than as a mandatory prerequisite. ...
Objective:
The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) Version 7 recommended that before initiating gender-affirming hormone therapy (GAHT), patients should seek a psychosocial evaluation from a mental health professional documenting a diagnosis of persistent gender dysphoria. The Endocrine Society published guidelines in 2017 recommending against an obligatory psychosocial evaluation, which was affirmed in the recently published WPATH SOC Version 8 from 2022. Little is known about how endocrinologists ensure appropriate psychosocial assessment for their patients. This study assessed the protocols and characteristics of United States-based adult endocrinology clinics that prescribe GAHT.
Methods:
An anonymous electronic survey sent to members of a professional organization and the "Endocrinologists" Facebook group was responded to by 91 practicing board-certified adult endocrinologists who prescribe GAHT.
Results:
Thirty-one states were represented by the respondents. Overall, 83.1% of GAHT-prescribing endocrinologists reported accepting Medicaid. They reported working in university practices (28.4%), community practices (22.7%), private practices (27.3%), and other practice settings (21.6%). Overall, 42.9% of the respondents reported that their practice required documentation of a psychosocial evaluation from a mental health professional before initiating GAHT.
Conclusion:
Endocrinologists who prescribe GAHT are divided about requiring a baseline psychosocial evaluation before prescribing GAHT. Further work is needed to understand the impact of psychosocial assessment on patient care and facilitate the uptake of new guidelines into clinical practice.
... 18,19 There have been no quantitative studies on consent practices in the United States since WPATH SOC 7 was published. 7 Our study seeks to address this gap, examining the variety of approaches to GAHT initiation utilized by the clinicians who prescribe GAHT, rationale for specific models, trends in clinician setting and training, and differences between minor and adult GAHT. The goal was to acquire exploratory data that could inform future studies and guidelines regarding consent in GAHT. ...
... As there was no validated survey model for this content, question frameworks were derived from a variety of sources, including previous studies about GAHT clinician practices. 7,18,19 Approval was received from the University of Missouri Kansas City institutional review board. After receipt of informed consent to participate, the instrument required respondents to select if they provided GAS and/or GAHT, which created a pathway querying more specific interventions. ...
... The interplay between hormonal changes, surgical interventions, and dermatological outcomes emerges as a significant focal point in understanding the comprehensive postoperative care needed for transgender women [7,8]. Hormonal changes, particularly those associated with hormone replacement therapy (HRT), exert profound effects on the structure and function of the skin [9,10]. Concurrently, surgical techniques such as vaginoplasty and vulvoplasty introduce anatomical alterations, potentially influencing the risk profile for dermatological conditions [3,7]. ...
Introduction The dynamic field of transgender healthcare has had remarkable advancements, notably in the domain of gender-affirming surgeries for transgender women. Within this transformative landscape, emerging research illuminates a compelling narrative regarding the enduring dermatological implications subsequent to such surgical interventions. This comprehensive exploration reveals an increased vulnerability to dermatological conditions, specifically lichen sclerosus (LS), vulvar atrophy, and other cutaneous diseases affecting the vulva and vagina amongst transgender women. The intricate interplay between hormonal alterations, surgical interventions, and the ensuing dermatological outcomes underscores the imperative for a nuanced understanding to facilitate optimal postoperative care for this unique demographic. This review lays the foundation for an in-depth examination of the existing literature, accentuating discernible gaps in knowledge, and delineating the trajectory for future research endeavors.
... Empirical research on adult experiences at these clinics is encouraging. 79 also being legislated in certain jurisdictions, such as in Argentina's Gender Identity Law, 80 which allows selfidentification with no additional requirements. 81 While the informed consent model continues to grow in support in adult trans medicine, as Clark and Viriani note, youth are still required to undergo the diagnostic and pathologizing requirements of older models of care. ...
Political debate regarding trans youth’s access to gender-affirming care (GAC) has pushed many to advocate for GAC by pointing to tragic, pathological outcomes of non-treatment, namely suicide. However, these pathologized arguments are a harmful ethical “shortcut” which should be replaced by a meaningful engagement with the ethics of providing GAC to youth.
... The Companionship Model centers core tenets of relationshipcentered care (Suchman, 2006) and expands on the Informed Consent Model (Deutsch, 2012;Schulz, 2018). The Companionship Model further expands on these two models by emphasizing the clinician's role in collaboratively navigating institutional gatekeeping alongside the client and increasing patients' and clients' access to critical resources for positive medical transition experiences. ...
In October 2022, the World Professional Association for Transgender Health published updated international guidelines (Version 8) regarding Standards of Care for medical interventions for transgender and nonbinary (TNB) people. We encourage providers to use The Companionship Model when they are required to write referral letters for patients and clients. This model includes information regarding obtaining informed consent on the procedures from the client, collaborating with the client in navigating institutional gatekeeping, and utilizing the clinician’s knowledge and resources to increase the client’s access to critical resources. Clinicians are encouraged to use four actions to process gatekeeping with clients: validate (V), ask (A), share (S), and engage (E). The referral letter session includes the clinician validating (V) the client’s assumptions, reactions, and normative mistrust of gatekeeping processes, asking (A) for the client’s reactions to the letter-writing process, sharing (S) the clinician’s critical understanding of the letter-writing session, and engaging (E) the client as a collaborative decision-maker in writing the letter. To illustrate The Companionship Model, we provide two case examples of clients from a community clinic. By using this model, we invite clinicians to shift their typical role from assessor to companion and to navigate gatekeeping with intentionality. We offer specific suggestions for mental health providers to improve their therapeutic relationships and to follow ethical guidelines for decreasing barriers for TNB people to access mental health resources. Finally, we provide sample letters in the cases where a referral letter is required by a clinic or provider.
... During that period, GAHT services were delivered as part of integrated primary care according to the same established standards and guidelines by both Fenway Health and Callen-Lorde. [18][19][20] We compared 12-month STI outcomes in groups who did and did not receive GAHT across 48 months of follow-up. All study procedures were approved by the Fenway Health Institutional Review Board (FWA00000145), which provided single IRB review for this study. ...
Transgender and gender diverse (TGD) adults in the U.S. experience health disparities, including in anogenital sexually transmitted infections (STI). Gender-affirming hormone therapy (GAHT) is known to be medically necessary and improve health. Few studies have assessed the effect of GAHT on STI diagnoses.
To evaluate the effect of GAHT delivered in primary care as an intervention to improve STI outcomes for TGD adults.
LEGACY is a longitudinal, multisite cohort study of adult TGD primary care patients from two federally qualified community health centers in Boston, MA, and New York, NY.
Electronic health record data for eligible adult TGD patients contributed to the LEGACY research data warehouse (RDW). A total of 6330 LEGACY RDW patients were followed from 2016 to 2019, with 2555 patients providing STI testing data.
GAHT exposure was being prescribed hormones, and the clinical outcome was anogenital gonorrhea or chlamydia diagnoses. Log-Poisson generalized estimating equations assessed the effect of prescription GAHT on primary outcomes, adjusting for age, race, ethnicity, gender identity, poverty level, health insurance, clinical site, and cohort years.
The median age was 28 years (IQR = 13); the racial breakdown was 20.4% Black, 8.1% Multiracial, 6.9% Asian/Pacific Islander, 1.8% Other; 62.8% White; 21.3% Hispanic/Latinx; 47.0% were assigned female at birth, and 16.0% identified as nonbinary. 86.3% were prescribed hormones. Among those tested, the percentage of patients with a positive anogenital STI diagnosis ranged annually from 10.0 to 12.5% between 2016 and 2019. GAHT prescription was associated with a significant reduction in the risk of anogenital STI diagnosis (aRR = 0.75; 95% CI = 0.59–0.96) over follow-up.
GAHT delivered in primary care was associated with less STI morbidity in this TGD cohort over follow-up. Patients may benefit from individualized and tailored clinical care alongside GAHT to optimize STI outcomes.
... For example, the last decade has seen an increase in local guidelines for hormone therapy that fall under the rubric of the so-called "Informed Consent Model" (ICM) for GAMC (Gerritse et al., 2021). The ICM emphasizes clients' right to self-determination and minimizes the role of MHPs in assessing eligibility for GAMC (Deutsch, 2012;Schulz, 2018). Concurrently, (a push for) legislation aimed at curbing the provision of GAMC to, especially, TGD youth is on the rise, calling for more rigorous assessments and paternalistic approaches to GAMC (Turban et al., 2021). ...
This qualitative study aimed to map and provide insight into the ethical challenges and norms of adult transgender and gender diverse (TGD) clients in gender-affirming medical care (GAMC). By doing so, we seek to make an empirical and constructive contribution to the dialogue on and moral inquiry into what good decision-making in GAMC should entail. We conducted 10 semi-structured interviews with adult Dutch TGD people who received GAMC. In our thematic analysis, we (1) included both ethical challenges and norms, (2) differentiated between explicit and implicit ethical challenges and norms, and (3) ascertained the specific context in which the latter emerged. We identified the following themes: (1) clients should be in the lead, (2) harm should be prevented, and (3) the decision-making process should be attuned to the individual client. These themes arose in the context of (1) a precarious client-clinician relationship and (2) distinct characteristics of GAMC. Our findings highlight divergent and dynamic decisional challenges and normative views-both within individual clients and among them. We conclude that there is no single ideal model of good decision-making in GAMC and argue that elucidating and jointly deliberating on decisional norms and challenges should be an inherent part of co-constructing good decision-making.
... 20,30 It is important to note, though, that legal action from trans individuals against (M)HPs for care received seems to be rare, including in health centers providing care via informed consent. 31 This of course, could be due to the dependency of clients on the goodwill of the HP for future care, high costs of lawyers, etc. ...
Background
Shared decision making (SDM) is particularly important in transition-related medical interventions (TRMIs) given the nature of treatment and history of gatekeeping in transgender health care. Yet few studies have investigated trans people’s desired decision-making role within TRMI and factors that influence these desires.
Aims
The study investigated trans people’s desired level of decision making during medical transition as well as possible sociodemographic predictors and correlations between decision-making desires and satisfaction with treatment.
Methods
Data were collected from a clinical sample from 3 trans health care centers, as part of the larger ENIGI study. The data consisted of 568 trans individuals (60.2% assigned male at birth) 20 to 82 years of age (mean age = 38.58 years) who took part in the study 4 to 6 years after initial clinical contact. Binary logistic regressions were conducted to determine whether independent variables predicted group membership in decision-making role subgroups while a Spearman rank-order correlation was conducted to determine the relationship between desired decision-making involvement and satisfaction with care.
Outcomes
Main measures were desired decision-making role, satisfaction with treatment, age, education level, country of residence, treatment status, individual treatment progress score (ITPS), gender identity, and sex assigned at birth.
Results
The vast majority of participants wanted to make medical decisions themselves. Age, education level, country of residence, treatment status, gender identity, and sex assigned at birth showed no significant effects in desired level of decision making, while the ITPS neared significance. Satisfaction with treatment was overall very high. For participants assigned male at birth, desire for a more active role in decision making was negatively correlated with satisfaction of labia surgery.
Clinical Implications
A desired decision-making role cannot be predicted based on the trans person’s sociodemographic characteristics. More involvement from health professionals addressing medical information and education obligations may be needed when offering surgical construction of labia to individuals assigned male at birth.
Strengths and Limitations
This study builds on the few existing analyses of desired levels of decision-making role among trans people during transition. It is the first to investigate the role of education level and treatment status/ITPS on the desire of decision-making role. Gender identity and influence of nonbinary identity were not investigated for treatment satisfaction as these items were presented based on sex assigned at birth.
Conclusion
This study highlights that trans people in 3 European trans health care centers during medical transition desire a more active role in decision making. Satisfaction with treatment received was overall very high.
... The ICM has been increasingly practiced worldwide but has not yet been used within NHS services; an oft-cited argument being that ICM will increase transitionrelated 'regret' (de Vries et al., 2021). However, a review of USA clinics which adopted the ICM demonstrated that within twelve clinics, representing a total of 1,944 patients, there were only three cases of 'regret' (0.1%) resulting in reversal of transition-related treatment (Deutsch, 2012). In comparison to this, research into WPATH surgeons' experiences of patient regret of transition-related treatment (Narayan et al., 2021) found that within 18,125 to 27,325 patients, 36 'reversal procedures' were performed (0.2%-0.3%). ...
A gender dysphoria diagnosis is currently required in the UK to access NHS transition-related treatment. However, this approach has been criticised by academics and activists as pathologising, ‘gatekeeping’ transgender identities, and can be viewed by the transgender community as a barrier to necessary medical care. The present research examines transmasculine experiences of gender transition in the UK, focusing on exploring the barriers encountered during identity development and medical transition. Semi-structured interviews were conducted with three individuals, and nine individuals took part in a single focus group. The data were analysed using Interpretative Phenomenological Analysis producing three main themes: ‘Conceptualising Stages of Transition’; ‘NHS Communication and Support’; and ‘Medicalisation, Power and Non-disclosure’. Participants conceptualised access to transition-related treatment as an intrusive and complicated process that negatively impacts identity development. They spoke of barriers such as lack of trans-specific healthcare knowledge, insufficient communication and support from healthcare professionals, and restricted autonomy arising from the pathologisation of trans identities. Results suggest transmasculine individuals may face numerous barriers when trying to access healthcare, and therefore, a move towards the Informed Consent Model could ameliorate many of these barriers and would empower service-users to make informed choices.
... For TGD adults, the informed consent model is the standard of care and existing data for adults suggest low rates of regret. 55 Advocates for an informed consent model for adolescents highlight how requiring a comprehensive biopsychosocial assessment and letter of support is a potential financial and logistic burden, particularly when there are a limited number of mental health providers who are adequately trained in gender affirming care. 56 For some youth, both finding and waiting to establish care with a mental health provider to complete the comprehensive biopsychosocial assessment can substantially delay medical care contributing to health-care inequity for TGD individuals. ...
Transgender and gender diverse (TGD) youth and their families are seeking medical and mental health care at increasing rates. As the number of multidisciplinary pediatric gender programs expands, we consider the history and evidence base for gender affirmative care and highlight existing models of care that can flexibly accommodate the diverse needs of TGD youth and their families. Comprehensive multidisciplinary care includes both medical and mental health providers who work collaboratively with TGD youth and their caregivers to assess gender-related support needs and facilitate access to developmentally appropriate medical and mental health interventions. In addition to direct health-care services, multidisciplinary care for TGD youth and their families extends into community training, education, community outreach, nonmedical programming, and advocacy for TGD youth.
... Although medical providers have been encouraged to use an informed consent or harm reduction model for those utilizing hormones, receiving hormones or other transition-related care often depends on the insurance carrier, the medical practice, and the state of residence (Deutsch, 2012;Dickey & Singh, 2017). There are significant issues within healthcare settings, such as discrimination, unsafe treatment environments, limited access to transgender-specific care, and poor quality of care (Stewart et al., 2017). ...
Transgender individuals have been identified as having greater rates of substance use. Previous research often focused on the intersection of HIV risk and substance use on specific age ranges or on how minority stress and discrimination relate to substance use. Using data from the 2015 United States Transgender Survey, our study is one of the first to explore the relationship among gender identity, age, the role of medical transition, and the use of marijuana within the transgender community. A deeper understanding of the relationship of these variables will benefit the transgender community by allowing for more thorough and accurate assessment protocols for individuals seeking medical transition. Our study used descriptive statistics to examine the intersection of gender identity, age, and use of alcohol, cigarettes, and marijuana. ANOVAs were completed to determine significant impact of gender identity, age, cigarette and alcohol use, and medical transition on the use of marijuana. Significantly, we found that 37% of marijuana use can be predicted by gender identity, age, medical transition, and alcohol and cigarette use. Individuals who experienced any surgical transition reported significantly more marijuana use compared with individuals with no history of surgical transition. Our study highlights the need for more in-depth research about the complicated factors that relate to the impact of transition-related medical care and the intersection of gender identity and age.
... The medicalization of gender identity has contributed to conceptualizing diverse gender identities as potential mental illness (e.g., Whitehead et al., 2012). In the context of historical and cultural doubt about the veracity of transgender identities (e.g., Levitt & Ippolito, 2014), support is lent to the existence of transition regret due to making a "mistake" about one's gender (Deutsch, 2012), which justifies the practice of requiring assessments and "gender role experience" (WPATH, 2012) to determine the authenticity of transgender identities (Bouman et al., 2014). Recent data indicate that regret after gender-affirming surgery is rare. ...
Previous guidelines for gender-affirming health care provided by the World Professional Association of Transgender Health (WPATH) emphasized the need for presurgical assessments; however, the field appears to be moving toward models of care based on informed consent that better support patient autonomy and depathologize gender diversity. The new WPATH guidelines (SOC8) suggest some steps toward informed consent models, while maintaining components of the existing mental health assessment model (Coleman et al., 2022). To date, little research has examined the current practices of health care providers in Canada and the degree to which practices and opinions are consistent with current guidelines. The present research aimed to examine current practices and attitudes of health care providers performing presurgical assessments for gender-affirming surgical procedures. Sixty-four providers participated in an online survey containing multiple response and open-ended questions regarding: decision-making models for surgical referral, referral roles and processes, as well as current and desired changes to assessment guidelines and practices. Results suggest that despite widespread use of WPATH guidelines, procedures for accessing gender-affirming surgeries varied widely by province, and providers who routinely conduct these assessments have different views on their utility. The majority of providers did not believe that presurgical assessments should be mandatory for all surgeries (particularly chest surgeries and hysterectomy/oophorectomy), supported informed consent models, and expressed a desire for better access to mental health services as needed. This research highlights trends in gender-affirming health care and necessary changes in health care delivery that can ensure equitable health care access for transgender people.
... Los roles de género merecen una mención adicional en esta posición de guardianes asumida por lxs psicólogxs. La performance complaciente que a menudo han tenido que desplegar las personas trans en consulta, aparte de ser una ficción que obstaculiza la conexión emocional y la sintonía terapéutica, es una herramienta impuesta de autovigilancia corporal esencialista y binaria, que perpetúa unas ideas de lo masculino y lo femenino como categorías complementarias, mutuamente excluyentes, rígidas e irremediables (Butler, 2004;Deutsch, 2012;Irving, 2008;Missé, 2021). Dicha rigidez prohíbe directamente una autorrevelación de ambas partes implicadas en el proceso terapéutico, y reproduce esquemas de la terapia como espacio de curación, rectificación y normativización. ...
La vigilancia sobre los cuerpos de las personas trans en contextos urbanos es continua. Sin embargo, considero que se pueden construir espacios de resistencia en el medio natural, y que las experiencias al aire libre pueden ayudar a crear resiliencia para superar problemas relacionados con el ser trans que puedan darse en las ciudades. El presente artículo desarrolla la idea de que la naturaleza ofrece un espacio menos generizado para las personas trans, pudiendo escapar de procesos de autovigilancia y sentirnos más libres en nuestra expresión e identidad de género. Asimismo, realizar actividades al aire libre nos empodera a las personas trans en nuestros cuerpos. Partiendo desde las metodologías feministas y queer, y teniendo en cuenta la fluidez y el dinamismo de nuestras experiencias de vida, combiné el uso de la autoetnografía con entrevistas semiestructuradas en profundidad realizadas a cinco personas trans. Posteriormente, estas experiencias se pusieron en conversación con las teorías. La naturaleza fue descrita como un espacio donde se juzga menos, y un lugar donde es posible ser nosotres mismes. También se presentó como un lugar donde escapar de las normatividades de género del contexto urbano que, como argumento, nos está dañando. El aire libre es también un espacio seguro para las personas trans, y desmapear estas contrageografías busca reclamar nuestro espacio en él.
... 9 There is much debate about the ''letter requirement.'' [10][11][12][13][14][15][16][17] While some prescribers require a letter before hormone initiation, an approach known as the ''WPATH model,'' others do not require such a letter. This approach is referred to among both providers and patients as ''informed consent'' 18 and is defined by the lack of requirement for a letter 19 or for formalized mental health evaluation before hormone initiation. ...
... Although some may view their own trans identity or gender dysphoria as a pathological response, they are a minority. There is little basis for doubting clients who believe that their gender identity or gender dysphoria is nonpathological given the rarity of regret and the absence of proven indicators or validated assessment techniques that could accurately predict future regret (Brik et al., 2020;Bustos et al., 2021;Deutsch, 2012;In re: Kelvin, 2017;Lawrence, 2003;Narayan et al., 2021;Pimenoff & Pfäfflin, 2011;Wiepjes et al., 2018). Imposing gender exploration on clients seems manipulative or coercive and incompatible with patient-centered care. ...
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.
... After a test run the term "transgender" was explicitly excluded from the search terms, as the test revealed that "consent models" in relation to this topic had a different meaning and were connected to a different debate (see e.g.Deutsch, 2012). This decision had no discriminatory purpose whatsoever. ...
In the 60+ years that the modern concept of informed consent has been around, researchers in various fields of practice, especially medical ethics, have developed new models to overcome theoretical and practical problems. While (systematic) literature reviews of such models exist within given fields (e.g., genetic screening), this article breaks ground by analyzing academic literature on consent models across fields. Three electronic research databases (Scopus, Google Scholar, and Web of Science) were searched for publications mentioning informed consent models. The titles, abstracts, and if applicable, full publications were screened and coded. The resulting data on fields, models, and themes were then analyzed. We scanned 300 sources from three databases to find 207 uniquely named consent models, and created a network visualization displaying which models occur primarily in one field, and which models overlap between fields. This analysis identifies trends in the consent debate in different fields, as well as common goals of consent models. The most frequently occurring consent models are identified and defined. The analysis contributes toward a cross-disciplinary “consent design toolkit” and highlights that there are more interrelationships between models and fields than are acknowledged in the literature. Where some models are designed to solve distinctively field-specific issues and are specific to biomedical ethics, some may be adaptable and applicable for other fields including engineering and design.
... Healthcare providers and clients are partners in making choices about medical treatment: the provider should inform the client of the risks and benefits and the client should make an informed decision about their healthcare, based on the information provided. [39] This approach respects a client's agency over their own body and is both clinically safe and ethically sound. We uphold the notion of self-determination. ...
We support an affiing approach to managing
the transgender and gender diverse (TGD) client,
centring on the individual’s agency, autonomy
and right to self-determination, as opposed
to practices that pathologise and stigmatise
TGD identity, imposing barriers to accessing
healthcare.
TGD persons have long faced discrimination on
multiple axes, both globally and in South Africa.
Although South Africa enshrines the protection
of human rights in its Constitution, TGD persons
continue to face marginalisation, prejudice
and threats to their safety. Challenges persist
– including homelessness, unemployment,
poor social support, bullying, harassment
and violence – indicating failures of policy
development and practice implementation, and
a disregard for the human rights of persons in
the TGD community.
This guideline has been developed primarily
with the intention of centring and amplifying
voices of TGD persons in order to facilitate
access to healthcare that is sensitive, skilled and
respectful. We recognise that there are signifiant
gaps in the knowledge and skills of healthcare
providers, and a lack of understanding of the
unique experiences faced by TGD persons.
The prevailing sentiment that many healthcare
providers hold around TGD individuals,
informed by ignorance and conditioning within
social and societal structures, are malevolent
towards this community and often include
harmful assumptions and generalisations. We
believe that healthcare providers have an ethical
obligation to interrogate these notions, and we
promote an attitude of respect for diversity that
upholds human rights.
It has been well established that access to
competent and dignifid gender-affiing
healthcare (GAHC) is not only safe, but also
plays a signifiant role in improving measurable
outcomes for TGD clients. It has also been well
established that pathologising approaches
and practices that limit access to care can be
damaging and harmful.
Finally, we recognise that TGD persons have
historically endured being undermined,
condescended to and pitied by the healthcare
system and its providers. We affi a
commitment to upholding a strength-based
perspective that values and respects the
experiences of TGD clients and celebrates
individual identity rather than merely accepting
or tolerating it.
This guideline, which will undoubtedly require
ongoing revision, reflction and refiement
in consultation with TGD communities and
healthcare providers, represents a fist step
made in good faith towards creating a practical
tool founded in robust scientifi evidence,
lodged within a human rights framework, and
is intended to facilitate access to skilled and
sensitive care that will yield tangible benefi to
this unique and important group.
... A study examining barriers to gender transitionrelated healthcare in Massachusetts found that mental health coverage emerged as one of the factors most strongly associated with an inability to access care (42). Previously, a diagnosis of gender dysphoria by a mental health professional was required before approval was granted to cover gender affirming therapy or surgery (43). With new informed consent models, patients are able to access gender-affirming hormones through their primary care clinician without a diagnosis of gender dysphoria, (44) which is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics. ...
Awareness and visibility of transgender individuals have grown exponentially. However, conceptualizing sexual and reproductive health (SRH) as “women's” or “men's” health services further marginalizes transgender and gender-expansive (TGE) youth. Multiple reviews and commentaries have been published on the topic of SRH care for adults under the umbrella term of sexual and gender minorities, all with a call to action for more inclusive care and the need for more clinical research involving TGE individuals, and notably, TGE youth. Results from adult TGE studies are often translated to describe adolescent models. However, models specific to adolescent TGE populations are needed to understand their unique SRH needs. This review will describe the current literature relating to SRH needs of TGE youth and adults, highlighting key areas with significant disparities in need of further research. This comprehensive summary will also provide recommendations for clinicians and researchers with the goal of improving SRH care and obtaining wider representation in both clinical settings and research directed toward TGE youth.
... Informed consent is a legal and ethical basis for most healthcare decisions [23], and the Fenway Institute has advocated for an informed consent model to respect patient autonomy and respect self-determination regarding gender-affirming hormonal treatment and surgery decisions [24,25]. However, evidence suggests the informed consent model is far from universal implementation [26]. Decisions surrounding care are individual and may be challenging when weighing social, financial, and health implications. ...
The Endocrine Nurses Society (ENS) is committed to clinical excellence in the art and science of endocrine nursing throughout the world. ENS recognizes that transgender and gender diverse (TGD) individuals face challenges and inequities that place them in the realm of health disparities. Further, TGD individuals often face substantial barriers to care and have difficulty finding healthcare providers who are knowledgeable about the unique health needs of this patient population. ENS recognizes that endocrine nurses care for young adult and adult TGD individuals. This position statement outlines recommendations for healthcare providers and organizations seeking to embrace a gender-affirming approach to care and increase access to high-quality, comprehensive care for TGD individuals. This Position Statement was accepted by ENS on September 8, 2020 and has been endorsed by the European Society of Endocrinology Nurse Committee, European Society of Paediatric Endocrinology Nurses, Pediatric Endocrine Nursing Society, Endocrine Nurses’ Society of Australasia, and the Federation of International Nurses in Endocrinology.
Background:
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.
Methods:
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.
Results:
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.
Conclusion:
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.
Background
This research concerns improving the National Health Service health services trans adults need. These include the national specialist Gender Identity Clinics that support people making a medical transition. Not all trans people need to make a medical transition, and transition can take many different paths. Waits to be seen by Gender Identity Clinics are, however, several years long, and there may be significant problems of co-ordination between different aspects of transition-related care, and between transition-related care and general health care.
Objectives
The main objectives were to understand:
Which factors make services more or less accessible and acceptable to the variety of trans adults?
How initiatives for providing more person-centred and integrated care can be successfully implemented and further improved?
Design, data sources and participants
An online and paper screening survey was used to gather data on demographics and service use of trans people across the United Kingdom, with 2056 responses. Researchers used survey data to construct five purposive subsamples for individual qualitative interviews, identifying groups of people more likely to experience social exclusion or stigma. There were 65 online interviews. In addition, 23 trans Black people and people of colour attended focus groups.
Six case studies were completed: four on initiatives to improve care and two on experiences of particular trans populations. Fifty-five service provider staff and 45 service users were interviewed.
Results
The following undermine person-centred co-ordinated care and can lead to experiences of harm:
lack of respectful treatment of trans people by general practitioner practices;
inadequate funding of services;
lack of support during waiting;
the extended and challenging nature of Gender Identity Clinic diagnostic assessments, sometimes experienced as adversarial;
breakdowns in collaboration between Gender Identity Clinics and general practitioner practices over hormone therapy;
lack of National Health Service psychological support for trans people.
Case studies indicated ways to improve care, although each has significant unresolved issues:
training in trans health care for general practitioners;
third-sector peer-support workers for trans people who come to National Health Services;
gender services taking a collaborative approach to assessing what people need, clarifying treatment options, benefits and risks;
regional general practitioner-led hormone therapy clinics, bringing trans health care into the mainstream;
psychology services that support trans people rather than assess them.
Limitations
Some contexts of care and experiences of particular groups of trans people were not addressed sufficiently within the scope of the project. While efforts were made to recruit people subject to multiple forms of stigma, there remained gaps in representation.
Conclusions and future work
The findings have significant implications for commissioners and providers of existing National Health Services gender services, including recently established pilot services in primary care. In particular they point to the need for assessments for access to transition care to be more collaborative and culturally aware, implying the value of exploring informed consent models for accessing transition-related care. Further research is needed to investigate how far the findings apply with particular subpopulations.
Study registration
This study is registered as Research Registry, no. 5235.
Funding
This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 17/51/08) and is published in full in Health and Social Care Delivery Research ; Vol. 12, No. 28. See the NIHR Funding and Awards website for further award information.
Transgender and gender-diverse (TGD) patients have unique healthcare needs that have historically been unmet due to a paucity of gender-affirming providers knowledgeable in caring for this marginalized population. As increasing numbers of TGD patients seek transition-related and general healthcare, providers have an opportunity and a responsibility to learn strategies for providing comprehensive, compassionate, and safe care to TGD patients of all ages and needs. This chapter offers an encompassing overview of the medical, surgical, and preventive care tools available to providers interested in delivering gender-affirming care with a special focus on the evolving needs TGD patients experience across their lifespan.
Amidst the misinformation climate about trans people and their health care that dominates policy and social discourse, autonomy‐based rationales for gender‐affirming care for trans and nonbinary youth are being called into question. In this commentary, which responds to “What Is the Aim of Pediatric ‘Gender‐Affirming’ Care?,” by Moti Gorin, we contextualize the virulent ideas circulating in misinformation campaigns that have become weaponized for unprecedented legal interference into standard health care. We conclude that the current legal justifications for upending gender‐affirming care gloss over how this health care field meets conventional evidentiary standards and aligns protocols with most other fields of medicine. Refusal to offer gender‐affirming care is more harmful than centralizing trans and nonbinary people's health autonomy .
This commentary responds to Moti Gorin's article “What Is the Aim of Pediatric ‘Gender‐Affirming’ Care?” We argue that Gorin's case against pediatric gender‐affirming care rests upon numerous false conceptual binaries: female/male, public/private, objective/subjective, and medically necessary/elective. Drawing on feminist bioethics, we show how such dichotomous thinking is both inaccurate and marginalizing of gender minorities .
Introducción. La destransición de género es el acto de detener o revertir los cambios sociales, médicos y/o administrativos con- seguidos durante un proceso de transición de género. Se trata de un fenómeno emergente de gran interés a nivel clínico y social.
Método. Se condujo una búsqueda sistemática en siete bases de datos entre 2010 y 2022, se rastrearon manualmente las referencias de los artículos y se consultaron libros especializados. Se realizó un análisis cuantitativo y de contenido.
Resultados. Se incluyeron 138 registros, 37% correspondientes a estudios empíricos y 38,4% publicados en 2021. Se identifican al menos ocho términos para hacer referencia a la destransición, con diferencias en sus definiciones. La prevalencia difiere en función del criterio utilizado, siendo menor para la destransición/arrepentimiento (0-13,1%) que para la descontinuación de la asistencia/tratamiento médico (1,9%-29,8%), y menor para la destransición/arrepentimiento tras cirugía (0-2,4%) que para la destransición/arrepentimiento tras tratamiento hormonal (0-9,8%). Se describen más de 50 factores psicológicos, médicos y socioculturales que influyen en la decisión de destransicionar, así como 16 factores predictores/asociados a la destransición. No se encuentran guías de abordaje sanitario ni legislativo. Los debates actuales se centran en los interrogantes sobre la naturaleza de la disforia de género y el desarrollo de la identidad, el papel de los profesionales con respecto al acceso a los tratamientos médicos y el impacto de las destransiciones sobre la futura accesibilidad a dichos tratamientos.
Conclusiones. La destransición de género es una realidad compleja, heterogénea, poco estudiada y escasamente comprendida. Se requiere un abordaje y estudio sistemático que permita comprender su prevalencia real, implicaciones y manejo a nivel sanitario.
Résumé
Ces dernières années, la communauté médicale est traversée par les débats sociétaux autour du genre, du sexe, de la procréation et des droits humains. Aussi les questions autour de la prise en charge médicale des enfants et adolescents transgenres viennent elles très régulièrement sur le devant de la scène médiatique suscitant la mobilisation de collègues à l’origine de prise de positions réclamant entre autres l’interdiction de prescrire des traitements hormonaux jusqu’à 25 ans. Nous proposons dans cet article de reprendre point par point les principaux sujets de controverses autour de la prise en charge médicale contemporaine des transidentités de l’enfant et de l’adolescent, à savoir la transition sociale, le blocage pubertaire, les transitions hormonales, et les transitions chirurgicales, et de les mettre en perspective de la situation contemporaine en France. Si la plupart des études cliniques menées depuis plus de 25 ans montrent les impacts positifs des prises en charge médicales des adolescents transgenres sur leur devenir psychologique soulignant l’innocuité relative des traitements, l’accompagnement psychodynamique n’en demeure pas moins essentiel, prenant en compte la singularité de chaque patient au fil des rencontres. Le temps long est parfois requis, parfois contre-indiqué en fonction de chaque situation clinique. Rappelons qu’il n’y a aucune prescription médicamenteuse avant la puberté, et pour les adolescents la durée moyenne entre la première consultation (pour laquelle ils ont attendu souvent un an) et une éventuelle prescription est d’une année. Dans le contexte où la population des enfants et adolescents transgenres est particulièrement vulnérable, ne pas nuire n’est pas systématiquement s’abstenir de prescrire, chaque situation clinique devant être évaluée dans sa singularité avec précaution et discernement. Ces décisions de transition médicale sont discutées et validées si pertinentes, en France depuis 2015, dans le cadre de Réunions de Concertation Pluridisciplinaire. Par-delà les opinions et les débats sociétaux, de réels enjeux éthiques sont à considérer, en particulier autour de la notion de consentement libre et éclairé chez l’enfant et l’adolescent, et les recherches doivent se poursuivre.
Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8.
Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.
Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings.
Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health.
Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.
This book discusses the global prevalence as well as the geographic distribution of HIV-1 and HIV-2 infections and updates on recent shared global initiatives. The demographic trends in HIV in the United States, especially regarding gender, sexuality, race, ethnicity, age, injection-drug use, socioeconomic status, and recent initiatives are reviewed. Special attention is paid to HIV among communities of color, as well as women, children, and adolescences. The role of HIV in men who have sex with men and the transgender community is reviewed in detail. HIV Testing and Counselling lists and describes the various types of HIV testing available. The book also presents an overview of HIV counselling. HIV testing terminology and algorithms are presented to the reader along with descriptive figures. Laboratory markers for HIV are reviewed. The chapter describes who should be tested, as well as pre and post-test counselling elements. A section of the chapter is dedicated to special populations and environments (blood supply screening, prenatal screening, testing settings) Strategies to improve uptake of HIV testing are discussed.
Importance:
Medical education, research, and clinical guidelines are available to support the initiation of gender-affirming care for transgender and nonbinary people. By contrast, little is known about the clinical experiences of those who discontinue or seek to reverse gender-affirming medical or surgical interventions due to a change in gender identity, often referred to as detransition.
Objective:
To examine the physical and mental health experiences of people who initiated medical or surgical detransition to inform clinical practice.
Design, setting, and participants:
Using constructivist grounded theory as a qualitative approach, data were collected in the form of in-depth interviews. Data were analyzed using an inductive 2-stage coding process to categorize and interpret detransition-related health care experiences to inform clinical practice. Between October 2021 and January 2022, individuals living in Canada who were aged 18 years and older with experience of stopping, shifting, or reversing a gender transition were invited to partake in semistructured virtual interviews. Study advertisements were circulated over social media, to clinicians, and within participants' social networks. A purposive sample of 28 participants who discontinued, shifted, or reversed a gender transition were interviewed.
Main outcomes and measures:
In-depth, narrative descriptions of the physical and mental health experiences of people who discontinued or sought to reverse prior gender-affirming medical and/or surgical interventions.
Results:
Among the 28 participants, 18 (64%) were assigned female at birth and 10 (36%) were assigned male at birth; 2 (7%) identified as Jewish and White, 5 (18%) identified as having mixed race and ethnicity (which included Arab, Black, Indigenous, Latinx, and South Asian), and 21 (75%) identified as White. Participants initially sought gender-affirmation at a wide range of ages (15 [56%] were between ages 18 and 24 years). Detransition occurred for various reasons, such as an evolving understanding of gender identity or health concerns. Participants reported divergent perspectives about their past gender-affirming medical or surgical treatments. Some participants felt regrets, but a majority were pleased with the results of gender-affirming medical or surgical treatments. Medical detransition was often experienced as physically and psychologically challenging, yet health care avoidance was common. Participants described experiencing stigma and interacting with clinicians who were unprepared to meet their detransition-related medical needs.
Conclusions and relevance:
This study's results suggest that further research and clinical guidance is required to address the unmet needs of this population who discontinue or seek to reverse prior gender-affirming interventions.
Following the growth in visibility of Transgender and Gender Non-Confirming-identified people (TGNC) in popular culture and media, along with the increase in number of health clinics focusing on working with this population, and the development of a special interest in health professionals in TGNC-related issues, flourishing scientific literature and updated guidelines to help Mental Health Professionals (MHPs) work affirmatively with transgender individuals is pertinent. Despite the increased attention toward TGNC individuals, this population is still faced with political, economic, legal, and medical obstacles affecting their mental health and access to health care. Moreover, MHPs still report having limited training and experience in TGNC-affirmative care. This article aims at providing professionals with the most updated information and research findings to help them develop a more trans-affirmative practice. After defining key terms and providing a definition of TGNC-affirmative health care, this article will focus on summarizing the main documents that inform MHPs working with this population. This article offers research-based guidelines and discusses the major theoretical frameworks professionals are encouraged to incorporate in their work when developing TGNC-affirmative care. Additionally, this article will present the current debate around the diagnoses of Gender Dysphoria (DSM-V) and Gender Incongruence (ICD-11). The controversy between the Medical Model based on the Diagnosis of Gender Dysphoria and the emerging Informed Consent Model will be reviewed.
Purpose:
The World Professional Association for Transgender Health (WPATH) recommends referral by a mental health professional for gender-affirming chest and genital surgeries. However, several transgender health guidelines propose an informed consent model of care to respect patient autonomy. This research aimed to understand, characterize, and asses the quality of information gathered through referral letters for patients consulting for gender-affirming surgeries.
Methods:
A retrospective review of electronic medical records (EMRs), including referral letters from behavioral health (BH) and primary care providers (PCPs), was conducted for patients seeking chest or genital surgery by a single surgeon between 2017 and 2019. Data were abstracted manually and included medical and gender history and documentation of WPATH-recommended surgical criteria.
Results:
A total of 233 patient records, including 171 PCP letters and 231 BH letters, were reviewed. With respect to documentation of surgical criteria, 92% of BH letters documented a diagnosis of gender dysphoria, 63% ability to provide informed consent, and 51% management of BH comorbidities. More than half of individuals with chronic physical health conditions did not have those conditions documented in their referral letters. Similarly, BH letters often failed to document BH diagnoses endorsed by patients. For example, while 80% of patients endorsed a diagnosis of anxiety, more than half did not have it documented in their letters. Overall, greater than half of diagnoses across BH conditions were only documented as present in the EMR.
Conclusion:
Referral letters only variably documented WPATH-recommended surgical criteria and did not reliably document physical and mental health comorbidities. Our research suggests that multidisciplinary pre-surgical assessment may be more useful than referral letters in some settings.
We support an affirming approach to managing the transgender and gender diverse (TGD) client, centering on the individual’s agency, autonomy and right to selfdetermination, as opposed to practices that pathologise and stigmatise transgender identity, imposing barriers to accessing healthcare services. Transgender and gender diverse individuals have long faced discrimination on multiple axes, both globally and in South Africa. Although South Africa enshrines the protection of human rights in its Constitution, TGD individuals continue to face marginalisation, prejudice and threats to their safety. Challenges, including homelessness, unemployment, poor social support, bullying, harassment and violence, persist, indicating failures of policy development, practice implementation and a disregard for the human rights of individuals in the TGD community. This guideline has been developed primarily with the intention of centering and amplifying voices of TGD individuals in order to facilitate access to healthare that is sensitive, skilled and respectful. We recognise that there are significant gaps in the knowledge and skills of healthcare providers, and there is a lack of understanding of the unique experiences faced by TGD persons. The prevailing sentiment that many healthcare providers hold around TGD individuals, informed by ignorance and conditioning within social and societal structures, are malevolent towards this community, and often include harmful assumptions and generalisations. We believe that healthcare providers have an ethical obligation to interrogate these notions, and we promote an attitude of respect for diversity that upholds human rights. It has been well established that access to competent and dignified gender-affirming healthcare (GAHC) is not only safe but also plays a significant role in improving measurable outcomes for TGD clients. It has also been well established that pathologising approaches and practices that limit access to care can be damaging and harmful. Finally, we recognise that TGD individuals have historically endured being undermined, condescended to and pitied by the healthcare system and its providers. We affirm a commitment to upholding a strength-based perspective that values and respects the experiences of TGD clients and celebrates their individual identity rather than merely accepting or tolerating it. This guideline, which no doubt will require ongoing revision, reflection and refinement in consultation with TGD communities and healthcare providers, represents a first step made in good faith towards creating a practical tool founded in robust scientific evidence, lodged within a human rights framework, and is intended to facilitate access to skilled and sensitive care that will yield tangible benefits to this unique and important group.
This paper examines version 6 of the Standards of Care for Gender Identity Disorders (SOC) of the World Professional Association of Transgender Health. The SOC help providers to “understand the parameters within which they may offer assistance to” transgender clients. Flexibility is one of the strengths of the SOC, allowing for customization both at the client and provider level. Treatment models consistent with the SOC range from strict to liberal, with the latter often termed “harm reduction” or less accurately “informed consent” models. Unfortunately, many transgender clients and even some providers do not understand the SOC's flexibility. This misunderstanding occurs despite specific language that the standards are “flexible directions for the treatment of persons with gender identity disorders.” The authors suggest that providers have a responsibility to examine the SOC, determine their own model of care, and communicate this to clients. Providers can use the framework of the SOC to define their practice models. We also suggest areas for improvement in the forthcoming version 7 of the SOC. Our examination is informed by a wide range of practices within the United States of America and internationally that are all consistent with the SOC.
The objective of the study was a follow-up of the treatment outcome of Finnish transsexuals who sought sex reassignment during the period 1970–2002 and a comparison of the results and duration of treatment of compliant and noncompliant patients. Fifteen male-to-female transsexuals and 17 female-to-male transsexuals who had undergone hormone and surgical treatment and legal sex reassignment in Finland completed a questionnaire on psychosocial data and on their experience with the different phases of clinical assessment and treatment. The changes in their vocational functioning and social and psychic adjustment were used as outcome indicators. The results and duration of the treatment of compliant and noncompliant patients were compared.
The patients benefited significantly from treatment. The noncompliant patients achieved equally good results as the compliant ones, and did so in a shorter time. A good treatment outcome could be achieved even when the patient had told the assessing psychiatrist a falsified story of his life and sought hormone therapy, genital surgery, or legal sex reassignment on his own initiative without a recommendation from the psychiatrist. Based on these findings, it is recommended that the doctor-patient relationship be reconsidered and founded on frank cooperation.
Since the 1950s, sexual surgical reassignments have been frequently carried out. As this surgical therapeutic procedure is controversial, it seems important to explore the actual consequences of such an intervention and objectively evaluate its relevance. In this context, we have carried out a review of the literature. After looking at the methodological limitations of follow-up studies, the psychological, sexual, social, and professional futures of the individuals subject to a transsexual operation are presented. Finally, prognostic aspects are considered. In the literature, follow-up studies tend to show that surgical transformations have positive consequences for the subjects. In the majority of cases, transsexuals are very satisfied with their intervention and any difficulties experienced are often temporary and disappear within a year after the surgical transformation. Studies show that there is less than 1% of regrets, and a little more than 1% of suicides among operated subjects. The empirical research does not confirm the opinion that suicide is strongly associated with surgical transformation.