You may also like
Coming Out to Children as a Transgender Parent
31 August, 2021
No More Gatekeepers
31 August, 2021
Transgender in Transition
31 August, 2021
We hear a lot about “Informed Consent,” but what is it and what does it really mean?
To start, Informed Consent means that a person who is engaging in a contract for a medical procedure or a clinical intervention. Here is a good definition from
https://www.ncbi.nlm.nih.gov/books/NBK430827/:
Written by Dr. Carol Clark.
“Informed consent is the process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention. The patient must be competent to make a voluntary decision about whether to undergo the procedure or intervention. Informed consent is both an ethical and legal obligation of medical practitioners in the US and originates from the patient’s right to direct what happens to their body. Implicit in providing informed consent is an assessment of the patient’s understanding, rendering an actual recommendation, and documentation of the process. The Joint Commission requires documentation of all the elements of informed consent “in a form, progress notes or elsewhere in the record.” The following are the required elements for documentation of the informed consent discussion: (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient’s understanding of elements 1 through 4.
It is the obligation of the provider to make it clear that the patient is participating in the decision-making process and avoid making the patient feel forced to agree to with the provider. The provider must make a recommendation and provide their reasoning for said recommendation.”
In the field of gender identity and diagnosis of gender dysphoria, informed consent has become a focal point of discussion for transitioning people, therapists, medical practitioners, and those people making decisions about how it is applied to a person seeking hormone therapy or surgery related to their gender.
How this became an issue is due to the many incarnations of the World Professional Association for Transgender Health (WPATH) Standards of Care (SoC). The intention of the SoC has always been to assist transitioning people – that is, people whose gender identity does not match their biological sex or gender assigned at birth – to bring their bodies into harmony with their identified gender through hormone therapy and/or surgeries. In the early versions of the SoC, there were rigorous recommendations as to need for mental health counseling, presenting in the identified gender, and being on hormone therapy prior to surgery – all of these with prescribed lengths of time. Mental health providers (therapists and psychologists) would follow the SoC without regard to the actual needs of the transitioning person (client). Doctors would also try to adhere to these standards in very narrow ways. For some transitioning people, this was fine, but for many it was not.
The main problem was that everyone was in a different place in their transition. A person in their 60s who has spent their life knowing that their assigned gender was not who they were but not even knowing of the possibility of transition until the internet made its appearance is in a very different place than someone in their 20s who has been able to do their own research and connect with other trans people.
Another problem over the years has been with therapists (sometimes endocrinologists and surgeons and even family doctors) who think they know more than they do about gender dysphoria and transition. It is said that a little knowledge is a dangerous thing and that is very true when it comes to gender transition. Some of the horror stories include those of therapists who rushed transition, therapists who delayed transition, and doctors who did not specialize with trans people but thought they could prescribe hormones or even do surgeries without the necessary knowledge and skill.
Over the years, the SoC have relaxed to the point where the 7th edition recommended that a person’s transition be individualized as they work with their therapist. There were no recommendations as to the order of transition steps or timeframes in which to complete them. The SoC also went so far as to state that a physician or surgeon could proceed using only an “Informed Consent” model, meaning that a recommendation from a therapist could be bypassed altogether.
So, what’s wrong with that, you may ask? People go on hormone therapy and get body-altering surgeries every day without the need of a therapist saying it’s ok. Certainly, trans people have been chafing for years under what is perceived as “gatekeeping” by therapists. Why can’t a transitioning person go over informed consent for hormones or surgery and then do it? Well, I’ll tell you.
I’ve been working with trans people for 30 years, since just before the internet really took off. For the first year or so, I was learning the basics, and unlike a lot of therapists who learned by charging clients for sessions during which the client felt like they were paying to teach the therapist, I learned by attending support groups and listening, by taking trans people to lunch and hearing their stories, and by talking with experts like Dr. Marilyn Volker. I attended educational panels and read the SoC.
When I began seeing trans people in counseling, I learned that they can have very different needs. Some needed help coming out to family and friends. Some had substance abuse problems. Some were struggling with employment and the very real fears of losing their jobs. Some had religious conflicts. Some had been abused in childhood and others more recently. And some people just needed their letter of recommendation.
For everyone, I began by reframing the term “gatekeeper.” I could tell that a lot of people were trying to say what they thought I needed to hear to write their letters, but of course that was apparent immediately and so we discussed the nature of our relationship. I always begin from the perspective of wanting to help the client get where they want to go, but more, I want them to be happy and healthy both when they get there and in their lives moving forward. Sometimes, for all of us, not just trans people, we get so focused on a single goal that we don’t pay attention to anything else. Have you ever heard the phrase “Be careful what you wish for, you just may get it?” This is where informed consent becomes more than just knowing the physical effects of hormone therapy or surgery.
Over the years, I found that a significant part of my job was to correct the misinformation that people would get from the internet or other trans people in support groups. Online groups and information can be wonderful, but it is largely unregulated. Anyone can say anything and they often do. For a gender dysphoric person who is struggling with how to make changes to every aspect of their lives, including their bodies, much of that information can feel intimidating, overwhelming, and even bullying, as in “Do it the way I did it,” or “My way is the right way,” or even “Therapy is a waste of time and money. You don’t need it.” My job, as I have always seen it, is to get the client’s history and then together develop a transition plan that is completely individualized. Well before the 7th edition of the SoC, I was doing this. I was not adhering to artificial timeframes for therapy and, in fact, I was doing very little “therapy.” I was evaluating each client’s readiness for hormone therapy or surgery based on how realistic their expectations were. Where there was a lack of knowledge or misinformation, I focused on presenting realistic information based on my years of experience and what science was available.
“Informed Consent” means something different with a mental health provider than it does with a medical provider. The 4 elements listed in the beginning of this article are applicable for the latter. Informed Consent from the therapy perspective relates to the client being fully aware and realistic in their expectations of life during and post-transition.
For example, a client might come to me wanting a letter for feminizing hormone therapy, but they are living with their parents and working in male presentation. They tell me that they don’t feel comfortable “coming out” to either parents or employers until they have been on hormones for several months and feel like they can “pass.” Their expectation is that parents and employer will fully accept them as female at that time. This is not realistic.
To begin with, people don’t like being blindsided and they get resentful and angry and hurt. The coming out process usually goes far more smoothly when a trans person comes out prior to starting any changes. It’s not that they need permission or need to delay, it is simply a respectful way of bringing important people into the decision-making and allowing them to be part of the process. This can also contribute to helping others in the system, both family and work, to be more accepting of the transition.
Another consideration is that once a person begins hormone therapy, they give off a new scent and their body begins to change in ways that is only noticeable by others’ limbic systems. This is what happens when several females reside together and begin to menstruate at the same time each month. Our limbic systems operate on an unconscious level, but they are always reading the environment as part of our survival. In the most primitive way, we are motivated by sex and danger to keep both our individual selves and our species alive. The limbic system therefore reads a multitude of gender cues of which our conscious brains are unaware. When the limbic system cannot identify something, such as another person’s gender, and has no context in which to relate to it, then it interprets the signals as possibly being dangerous and that makes us anxious or angry or scared. So, if the transitioning person begins hormone therapy without telling the people closest to them, then those people will pick up mixed cues and become anxious without knowing why.
Finally, regarding “passing,” many transitioning people are used to seeing themselves in the mirror with the body and face of the person they don’t want to be and that does not change no matter how long they are on hormones or how many surgeries they have. Not everyone, but certainly those with a strong preoccupation about passing. What happens, then, is that they continue to see what they have always seen and will never feel confident enough to fully transition and live their lives. Therapy can help with this. After all, our looks are what they are and few of us would ever leave the house if we became fixated on looking a particular way before venturing out. It’s like an anorexic person looking in the mirror and seeing themselves as fat.
This is just one example of what I might need to cover during the evaluation process. It is very dependent on each individual’s situation. After reviewing and educating, however, I will write the letter. My only concern is that the trans person has a plan to address the potential issues I bring to their attention. In the above example, if this person tells me their backup plan if they get kicked out of their house or lose their job, then we’re good. Informed Consent means that they are informed about the issues – risks and benefits – that they have a plan and a backup plan, and have the capacity to consent. If a person is in active addiction or has a mental illness, then that needs to be addressed before they are able to give Informed Consent. These don’t preclude transition, they need to be considered.
In the end, what I want is what the client wants – to live a happy, healthy life feeling comfortable in their body. That is what Informed Consent is all about.