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”. 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.
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). 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-determination in the care they deserve to receive.
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. 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.
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. The ICM views patients as having the capacity to make medical decisions about their own bodies, rather than assuming that medical professionals should be the primary decision makers in healthcare.
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” and respect the patients’ right to accept or reject any medical care recommended.
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. 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-SOC – 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.