Gender transition isn’t a whim, so why the mistrust?

When it comes to gender transitions, trans patients are often inappropriately held to higher account when compared to people opting for other kinds of medical care. Standards of care are effectively constructed on the assumption that trans patients are less able to provide informed consent. This is a serious problem. Beneath it lies the wider distrust society still has in why people want to transition and in whether they know their own mind.

Typically, the standard for surgeries — from cosmetic plastic surgery to vasectomy, tubal ligation, and abortion — is simply informed consent. A doctor or surgeon talks with the patient and explains what they expect to happen, along with all of the risks and benefits and the relative likelihoods of them happening. This process also involves explaining available alternatives and the risks or benefits of doing nothing. After the patient confirms that they understand all of this, the doctor is said to have received informed consent for the procedure.

A patient is required to be competent to make this decision and if they are unable to understand for some reason – if they are too young for example – another person, such as a parent, may be required to step in.

Double standards

But when it comes to trans healthcare, this isn’t the standard we’re held to. Various centralised healthcare systems like the NHS in the UK require informed consent to proceed but typically also require a diagnosis of Gender Dysphoria (a psychiatric diagnosis listed in DSM-V) before prescribing hormone therapy for trans patients. These systems generally follow the World Professional Association for Transgender Health’s (WPATH) standards of care.

And it’s the gatekeeper model of healthcare in the US, UK and many other jurisdictions, typically involving a psychologist of psychiatrist, that creates an additional barrier.

Although some (private) clinics in the US have finally begun to adopt a model where all that’s required for a patient to begin hormone therapy is their informed consent, genital surgery still requires psychologist or psychiatrist approval. Many surgeons require two letters — as set out in WPATH’s standards — at least one of which must be from a psychologist or psychiatrist with a PhD.

In reality, the requirements for trans patients are even more stringent: in order to be permitted genital surgery – even if the patient elects to pay for it – patients have to demonstrate that they’ve been living in their transitioned gender role for a minimum of a year.

The rationale for this is that procedures such as genital surgery are irreversible and can carry significant social implications - in other words, are considered extreme.

‘Real life’ testing

More explicitly, such policies aim to force patients to experience and adjust to life in their transitioned gender role before providing treatment. The implied rationale, then, is that without living in your transitioned gender role, which may include changing your name or the style of clothes you wear, you can’t really know whether you want the surgery – and therefore can’t really provide informed consent. This “real life test”, as it very recently used to be called, is for the patient’s own good; if someone lived through the proscribed period of time and still wanted surgery, then the gatekeepers could be confident that surgery would be in the patient’s best interest.

This is deeply problematic, though. This isn’t an informed consent model of healthcare, which is the universal model (in western cultures) for everything except healthcare for transgender people.

Consider vasectomy and abortion, two equally irreversible procedures with important social implications that people can obtain just with informed consent, and certainly without any proscribed period of time assigned to the decision (other than time constraints of abortion).

A man can walk into a doctor’s office and request a vasectomy. He won’t be asked to live for another year of simulated sterility to see if he’ll be satisfied with life. Rather, the physician explains the potential benefits and risks, including social implications for infertility, and if the patient expresses a continued desire for the procedure, along with providing informed consent, then the patient receives the procedure.

The same is true for women obtaining an abortion. We don’t force the woman to live a period of time simulating having obtained an abortion (what would that even look like?) to see if she still wants it. And it’s good that we don’t: we respect the autonomy of patients and their rights to make their own decisions about their bodies.

Both procedures are irreversible and carry significant social implications for patients who undergo them. So why are these patients permitted these procedures based on informed consent, but the same privilege isn’t afforded to trans patients?

Just as able

The truth is, trans patients who desire genital surgery don’t come to that decision on a whim. Their decisions are no less well-considered than a woman who seeks an abortion or a man who seeks a vasectomy. If the latter can provide informed consent without a “real life test”, or a forced trial period, or more than one psychological assessment, then trans patients shouldn’t either.

Trans patients are just as able to make informed choices about their bodies – about both hormone therapy and genital surgery. They should be treated just like every other patient.

I don’t mean to characterise trans genital surgery as “elective”. For those who seek it out, it’s medically necessary, and this is widely recognised by medical associations. But it’s worth noting that only a minority of trans people seek out genital surgery. Part of the reason for this is that there are too many barriers to acquiring it if it’s publicly funded, or the high cost of paying for it if done privately. It also requires a high degree of support from friends, colleagues and employers, since surgery can mean you’re unable to work for a minimum of two months.

Changing gender is a life-changing decision. And it isn’t one taken either lightly or based on psychological imbalance. Some people just aren’t the gender they were assigned at birth and making it very difficult or having them “prove it” is more likely to cause more health problems.