Informed Consent Is Critical in Healthcare, But Apparently Not to Activist Gender Clinicians
By Nina Silander, PsyD
“If it’s not documented, it didn’t happen” and many other lessons were taught during my graduate education and training to become a clinical psychologist. From collecting comprehensive psychosocial histories and behavioral observations to objective, self-report, and, if possible, collateral data, we pay meticulous attention to detail. But no clinical service occurs without first establishing informed consent. Sometimes pages long, clinicians provide patients with forms to review and sign. These forms outline the nature of services, their anticipated benefits and risks, associated costs, and the limits to confidentiality. Clinicians also typically discuss this information with clients verbally just to make sure the information is understood.
At this point, little surprises me when it comes to developments related to the cultural manifestations of critical and gender theories. However, Eliza Mondegreen’s Unherd article, “The Secret Life of Gender Clinicians” astonished me. She details her observations during several conferences by leading transgender health organizations in the United States, Canada, and Ireland. She notes numerous examples of clinicians determining how to effectively overcome significant informed consent-related obstacles (be it age, acute psychiatric illness, or disability) to move patients forward on the conveyor belt of puberty blockers, cross-sex hormones, and sex “reassignment” surgery. Her observations from attending these conferences were further supported by evidence in the recently leaked WPATH Files. As Mondegreen learned, the provision of information necessary for informed consent is minimized. In one such example:
During the Denver conference, presenters role-played how to secure informed consent for a hysterectomy and phalloplasty in the case of a schizophrenic, borderline autistic, intellectually disabled “demiboy” with a recent psychiatric hospitalisation. At no point do the role-players encounter any real barriers. Instead, they persevere. At first, the patient struggled to understand why a phalloplasty might require multiple surgeries, but then the clinicians “explained everything” and the patient understood. This is called “lean[ing] into the nuance of capacity”.
Moreover, the notion that clinicians are trained professionals with pertinent expertise who rightfully function to an extent as gatekeepers for the purpose of patient protection is wholly rejected.
A bad gender clinician, by contrast, feels an “entitlement to know” why a patient feels the way she does or why she seeks a particular intervention. She clings to a traditional conception of her role as a “gatekeeper” who evaluates and prescribes. She thinks she can “discern a ‘true’ gender identity beyond what is articulated by the patient”. She may believe she can “identify the ‘root cause’ of a transgender identity”, which is seen as pathologising. She may try to leave the door open to desistance — the most common outcome before gender clinicians started interfering with normal development by deploying puberty-blocking drugs…
While perhaps not characteristic of all gender clinicians or clinics, the running over the most basic requisites for clinical services, informed consent, and intentionally hiding this practice from the public as revealed in these accounts, is appalling. Per the WPATH Files, for some clinicians, few conditions are regarded as impediments to giving informed consent:
[A therapist] added that in the last 15 years, she had only declined to write one referral letter, and that was mainly because “the person evaluated was in active psychosis and hallucinated during the assessment session.” “Other than that – nothing – everyone got their assessment letter, insurance approval, and are living (presumably) happily ever after,” said the therapist, who has referred for genital surgery people diagnosed with major depressive disorder, c-PTSD, and who are homeless.
Furthermore, both the WPATH Files and Mondegreen’s firsthand observations reveal “gender-affirming” clinicians’ uncertainty regarding whether other medical procedures actually need a therapist’s approval or disdain that some surgeons require them. I can say that many procedures require psychological evaluations, involving comprehensive assessment and careful conceptualization. And informed consent is a critical component ahead of these interventions. Psychologists, and sometimes other trained clinicians, are often one of several healthcare providers situated to evaluate patients for many medical procedures due to the centrality of psychological well-being on associated risk factors. Suspension of employing one’s own expertise and judgment out of deference to patients’ self-professed needs is clinical malpractice.
Procedures often requiring psychological evaluation include transplant surgeries, pain-related surgeries (e.g., pain pumps and spinal cord stimulator implants, elective amputations), and bariatric surgeries. Occasionally, mental health screenings are also completed ahead of fertility/IVF procedures. To be a candidate for one of these surgeries, typically numerous criteria must be met first. Psychologists evaluate patients closely for any factors that would undermine a successful surgical outcome (e.g., psychiatric symptoms, problematic personality traits, unrealistic surgical expectations, limited insight, underdeveloped coping skills, unhealthy lifestyle habits).
Informed consent is an integral component of these pre-surgical evaluations. While the surgeries themselves entail risks, patients also face considerable post-operative risks, such as acquired injuries (e.g., if bending, lifting, or twisting after a spinal cord stimulator implant) or infections, additional surgery (e.g., debridement or further amputation due to poor wound-care), or even death (e.g., via complications arising from ruptured sutures, dehydration, or prolonged loss of appetite following gastric bypass surgery). The capacity to follow directions from one’s medical team, assuming personal responsibility in one’s healthcare management, and commitment to attend follow-up doctors’ appointments must be ascertained. While many psychologists will not necessarily assert the authority to keep a patient from receiving surgery, they strongly advise against a patient undergoing surgery without first meeting specific conditions, which often entail additional services. Surgeons will also consider the liability of proceeding with surgery for a patient who may experience significant post-operative risk factors.
This may be apparent by now, but to be clear: A person lacking decision-making capacity cannot give informed consent.
Typically, psychologists and psychiatrists evaluate patients for decision-making capacity and often do so in medical settings when cases are sufficiently ambiguous for the attending physicians. The decisions in question can include medical decision-making, the ability to choose a caregiver, appoint a legal guardian or power of attorney, or manage one’s own financial assets. In a legal context, people can be evaluated for their capacity to enter into contracts or defend themselves in a lawsuit, among many other domains. As with informed consent, the capacity to make an informed decision is based on the ability to express a choice, to understand presented information (and recall it), to appreciate (or relate the information to one’s own situation), and to reason (or integrate, analyze, process, and contrast information).
The clinicians Mondegreen observed promoted the notion that comprehension is incidental when obtaining informed consent. This is not only wrong—but unethical. I have worked in a range of inpatient and outpatient healthcare settings, some of which involved conducting capacity evaluations. The process for doing so was careful and informed by patients’ status. For example, psychologists evaluate patients after strokes and head injuries, and many were afflicted by aphasia, an acquired language disorder due to neurological damage. This can entail either expressive aphasia (inability to speak) or receptive aphasia (inability to comprehend), or both. To determine the presence of receptive aphasia, a sequence of asking simple yes/no questions, giving one- and two-step commands, and, as indicated, providing written responses a patient could point to would be administered. If a patient could demonstrate comprehension by responding correctly at a rate notably better than chance, more complex self-report information could be solicited.
The low or utter lack of regard for capacity and ability to consent in the context of “gender-affirmative healthcare” is a total deviation from the standards employed in all other mental health contexts, even for basic services (e.g., consent to participate in group therapy, which requires understanding about its unique limits of confidentiality). I have not even touched upon the ability of minors to give informed consent for “gender-affirmative” interventions. But the WPATH Files reveal that even parents are confused and ill-informed about the procedures their children undergo (e.g., about whether puberty suppression and hormone therapies are “reversible”).
Mondegreen notes that clinicians in this area of healthcare no longer regard these services as merely “gender-affirming care” but rather “medically necessary care.” As such, informed consent is peripheral, even non-essential. After all, plenty of incapacitated patients receive needed medical treatment. But the argument that puberty blockers, hormone therapies, and sex-reassignment surgeries are medically necessary is not substantiated. Apart from it being emotional blackmail when directed at families and healthcare professionals, the claim that these interventions are necessary to prevent suicide, thus necessitating such interventions, is illogical. In any other context, if someone is acutely suicidal, immediate psychiatric treatment for stabilization is the standard operating procedure. If someone is acutely suicidal, the patient would be deemed ineligible for procedures and surgeries like those above, until suicidality has been resolved for a pre-determined length of time. Furthermore, the claim that suicidality remits following “sex-reassignment” surgery is not supported, particularly in light of recent, robust research findings.
Moreover, there is a big difference between the aforementioned surgeries, which are intended to address objective medical issues (e.g., organ failure, obesity, debilitating chronic pain, cancer), and “gender-affirmative” interventions for psychological reasons. In essence, there is no physical defect, condition, or abnormality that will be resolved by the procedure—only the promise that the intervention or surgery will resolve dysphoria by establishing a sense of identity congruence. In the process, the endocrine system is altered with permanent effects, and perfectly functional body parts are permanently altered to the point of being no longer functional or removed altogether.
Perhaps when it comes to informed consent for “gender-affirmative treatment,” it may be so very difficult for patients to provide it because, perhaps, many clinicians cannot adequately explain the information prerequisite for obtaining it. Some do not know, and some apparently choose to ignore, the extent of the risks to ensure that their patients are not fully informed. Mondegreen describes how clinicians are directed to speak about these matters outside of the clinical space:
Presenters also recommended that gender clinicians avoid specifics. Avoid ages (“this care is highly individualised and age-appropriate”). Avoid giving information about the effects of puberty blockers and hormones. Avoid discussing the ins and outs of surgeries. In practice, “holding [the public’s] hands and helping [them] understand” looks more like covering their eyes and telling them whatever they need to hear to feel at ease. “The dinosaurs are scared,” Baker deadpanned.
Perhaps with a more comprehensive assessment of factors that contribute to gender dysphoria and preservation of informed consent, gender dysphoric patients could opt for alternative interventions to resolve their distress. Doing so could allow them to evade the possibility of later regret and the consequences of decisions with permanent effects. How is it compassionate, let alone ethical, for clinicians to mischaracterize detransition due to regret as merely an evolution of one’s gender identity or just a “phase of one’s journey” or simply a matter of the patient “taking active responsibility” when a patient wishes—but is now unable—to produce a biological child?
Regardless of what we believe about transgender identity and affirmative treatments, nothing justifies the skipping over, diluting, or dare I say, concealing the critical information necessary for patients to provide informed consent for any of these medical interventions. Doing so is not, in fact, treating gender dysphoric or trans-identifying patients according to the same privileges and protections that patients receive in any other medical context. Moreover, the multitude of stakes and risks for not doing so are too high.
Photo by siriwan arunsiriwattana on Unsplash