The assessment of gender dysphoria left me feeling exposed, naked, and dehumanised. Although the assessment process is alone a difficult experience, it is only made worse by the apparent conflation of gender dysphoria under the WPATH Standards of Care and Gender Dysphoria as a psychiatric diagnosis defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)."

Florence Ashley, transfeminine Jurist and Bioethicist

History

The ICM was developed by community health centres in response to the WPATH-SOC model characterized by psychosocial assessments. Despite their juxtaposition, the WPATH-SOC does not preclude obtaining patient informed consent, nor does the ICM advocate neglecting clinician judgment or providing surgeries or “hormones on demand”.6 According to WPATH, using an ICM is not necessarily in tension with the WPATH-SOC as these are “flexible clinical guidelines” suggested to reflect clients’ individual needs.7

The evolution of gender-affirming care at community health centres reflects the larger societal changes and assumptions about trans people. Rather than viewing trans as pathology (trans as a mental health condition) we are observing a movement toward a strengths-based depathologization of human gender diversity (trans as a normative human condition).8 The adaptation of patient-centred, gender affirming medicine for trans people represents a unique opportunity to meet the underserved needs of trans patients, emphasizing their autonomy and self-determination9 in the care they deserve to receive.

Key Principles

Patient-centred care

Patient-centred care is defined by patient inclusion in medical decision-making based on individual need and value, rather than being passive recipients of health professionals’ decisions.10 The ICM recommends that clinicians assist clients in making educated decisions by openly discussing all risks and benefits of medical interventions, possible side effects, alternative treatments, and decide collaboratively the best course of action.11

Autonomy and Self-determination

All patients have the right to autonomy and self-determination in medical decisions related to their health and bodies, and should be given the opportunity to make free and informed choices.12 The ICM views patients as having the capacity to make medical decisions about their own bodies,13 rather than assuming that medical professionals should be the primary decision makers in healthcare.14

Informed consent procedures include informing patients about the “known risks of pharmaceutical drugs, medical procedures, and tests [...] to support patients' rights of, and capability for, autonomy”15 and respect the patients’ right to accept or reject any medical care recommended.16

Protocol workarounds

Protocols have limits, and if applied uncritically, protocols in gender-affirming medicine such as the WPATH-SOC and the DSM-5 gender dysphoria diagnostic criteria can impose harms, such as conveying there are always universal responses in clinical practice.17 While a diagnosis of gender dysphoria makes access to gender-affirming medical care possible for patients, paradoxically, this diagnosis pathologizes trans identities. Shuster (2016) has found that trans people’s complex, and often fluid, gender identities are fundamentally incompatible with standardized medicine like that of the WPATH-SOC.

In a previous study of clinicians who work with trans patients, Shuster (2016) also found that clinicians “bend the rules” or “loosely interpret” the WPATH-SOC18 – recognizing when these protocols do not work well. Experienced clinicians recognize when these protocols fail trans people, and when they create problems for patient autonomy, self-determination, and in applying patient-centred care.

Footnotes
  1. Chang SC, Singh AA, Dickey LM. (2018). A Clinician’s Guide to Gender-Affirming Care: Working with Transgender & Gender-Nonconforming Clients. Oakland, California: Context Press. ↩︎
  2. Barry, M.J., & Edgman-Levitan, S. (2012). Shared decision making – The pinnacle of patient-centred care. New England Journal of Medicine 366(9), 780. ↩︎
  3. Reisner, S. L., Bradford, J., Hopwood, R., Gonzalez, A., Makadon, H., Todisco, D… & Mayer, K. (2015). Comprehensive transgender healthcare: The gender affirming clinical and public health model of fenway health. Journal of Urban Health 92(3), 585,587. DOI:10.1007/s11524-015-9947-2. ↩︎
  4. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, G., DeCuypere, J… & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism 13(4), 188. ↩︎
  5. Ashley, F. (2019). Gatekeeping hormone replacement therapy for transgender patients is dehumanising. Journal of Medical Ethics. DOI: 10.1136/medethics-2018-105293. ↩︎
  6. Cavanaugh, T., Hopwood, R., & Lambert, C. (2016). Informed consent in the medical care of transgender and gender-noncomforming patients. AMA Journal of Ethics 18(11), 1150. ↩︎
  7. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, G., DeCuypere, J… & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism 13(4), 165-232. ↩︎
  8. Bockting, W. (2009). Are gender identity disorders mental disorders? Recommendations for revisions of the world professional association for transgender health’s standards of care. International Journal of Transgenderism 11, 53-62. ↩︎
  9. Reisner, S. L., Bradford, J., Hopwood, R., Gonzalez, A., Makadon, H., Todisco, D… & Mayer, K. (2015). Comprehensive transgender healthcare: The gender affirming clinical and public health model of fenway health. Journal of Urban Health 92(3), 584-592. DOI:10.1007/s11524-015-9947-2. ↩︎
  10. Diamond-Brown, L. (2018). “It can be challenging, it can be scary, it can be gratifying”: Obstetricians’ narratives of negotiating patient choice, clinical experience, and standards of care in decision-making. Social Science & Medicine 205, 48-54. ↩︎
  11. Porch, M., Stukalin, R., & Weisbrod, H. (2014). Complex cases in community mental health: Stories from the castro and the tenderloin. Journal of Gay & Lesbian Mental Health 18, 393-411. DOI: 10.1080/19359705.2014.938582. ↩︎
  12. Shuster, S.M. (2019). Performing informed consent in transgender medicine. Social Science & Medicine 226, 191. ↩︎
  13. Tomson, A. (2018). Gender-affirming care in the context of medical ethics – gatekeeping v. informed consent. South African Journal of Bioethics and Law 11(1), 24-28. ↩︎
  14. Reisner, S. L., Bradford, J., Hopwood, R., Gonzalez, A., Makadon, H., Todisco, D… & Mayer, K. (2015). Comprehensive transgender healthcare: The gender affirming clinical and public health model of fenway health. Journal of Urban Health 92(3), 585,587. DOI:10.1007/s11524-015-9947-2. ↩︎
  15. Shuster, S.M. (2019). Performing informed consent in transgender medicine. Social Science & Medicine 226, 191. ↩︎
  16. Tomson, A. (2018). Gender-affirming care in the context of medical ethics – gatekeeping v. informed consent. South African Journal of Bioethics and Law 11(1), 24-28. Access: http://www.sajbl.org.za/index.php/sajbl/article/view/571 ↩︎
  17. Berg, M. (1997). Problems and promises of the protocol. Social Science and Medicine 44(8), 1081-1088. ↩︎
  18. Shuster, S.M. (2016). Uncertain expertise and the limitations of clinical guidelines in transgender healthcare. Journal of Health and Social Behavior 57(3), 319-332. ↩︎