It's Time for Gender Affirming Healthcare to Operate Using an Informed Consent Model

Grey Weinstein (he/they/xe)

“Can you believe this shit?” I griped to my roommates, flopping down dramatically on our couch. “It’s like, I have to fucking renew my license to be transgender.”

    “Can you believe this shit?” I griped to my roommates, flopping down dramatically on our couch. “It’s like, I have to fucking renew my license to be transgender.” I waved my hands with a flourish, unsure exactly what I was trying to communicate besides the extent of my frustration. “It’s like, ‘Oh, I gotta pass the transsexuality exam again, otherwise how will the doctors know that I’m a real transsexual?’” I’d spent the past year trying to acquire gender affirming surgery– top surgery, a double incision mastectomy to be exact. Before I could even schedule a consultation, I needed to pass a psychological examination administered by a mental health professional. This examination was intended to ensure that I was an acceptable candidate for the surgery; in other words, that I was really transgender, that I wouldn’t change my mind or regret the procedure later. (Read: That I wouldn’t sue the plastic surgeon on the basis of post-transition regret.) After seeing a therapist to get this diagnosis of gender dysphoria, I sent a letter with my official diagnosis to the surgeon’s office. Seven months later, the day of my consultation arrived, and the doctor told me that he wouldn’t have availability for the actual surgery for another two years. This means a lot of things for me, but one of those things is that my gender dysphoria diagnosis would expire. Hence my disgruntled and not particularly eloquent complaint that I would have to go through the psych eval process yet again to “renew my license to be transgender.”

    Surgery is a big decision, and scary to some, and it makes a lot of sense that talking it through with a therapist would benefit many people. But the requirement that trans people get a letter (sometimes multiple letters) stating a formal gender dysphoria diagnosis prior to accessing gender affirming care is, in a word, bullshit. It’s a lot of other words too– pathologizing, stigmatizing, gatekeeping– and to really understand why would require a deep dive into the history of gender affirming healthcare. Whole books can be (and have been) written on this topic, but here is a brief and extremely opinionated history of “mental health letter” requirements in American transition-related healthcare, intended for the curious layperson.

    Gender affirming healthcare really got big in the United States around the 1950s, after endocrinologist Harry Benjamin brought over techniques used by sexologist and trans health pioneer Magnus Hirschfeld from Germany. In my opinion, the figures of Hirschfeld and Benjamin are very complicated, inspiring in some ways and deeply problematic in others. For the purposes of this story, however, let’s just keep in mind that these are both cisgender white men with a huge amount of control over trans healthcare. From its inception, gender affirming care (which consisted of both exogenous hormones and surgery) was not something doctors gave to anyone who asked. Instead, they appointed themselves the arbiters over which individuals deserved to medically transition. Initially, this decision was left up to individual doctors. 

    Doctors at this time were mainly concerned with their ability to use these (at the time brand new, cutting edge) medical technologies to create cis-passing, heterosexual bodies. This meant that they were mainly evaluating potential patients based on their perception of these patients’ future abilities to “pass” as cisgender following transition. In other words, doctors wanted trans women to appear traditionally feminine and for trans men to appear traditionally masculine; they also only wanted to grant medical transition to trans women who were attracted to men, and trans men who were attracted to women. You can probably see where this is going– all across the country, what few doctors offered gender affirming treatment only granted it to the individuals they deemed most sexually attractive. (Much of the medical literature from this time period focuses mainly on trans women, because doctors were most fascinated, excited, and repulsed in turn by the group they could most easily fetishize– transmisogyny strikes again.) Doctors handing out estrogen only to the trans ladies who gave them boners is horrifying for a lot of reasons, not least because it is so degrading and dehumanizing to the patients themselves. But of course, what is considered “passing” and sexually attractive by Western beauty standards is rooted in white supremacist understandings of beauty and femininity/masculinity. Using such inherently racist standards as a measuring stick for who gets to transition inevitably led to trans people of color’s systemic exclusion from access to care. (Class and socioeconomic status also play a role in who is considered attractive and passing, but more frequently working class trans people couldn’t even afford gender affirming care in the first place, at least not through a doctor.) 

    Around the 1960s, trans-related medicine began to be studied in universities. This led to the creation of university-funded “gender clinics” across the country, which offered gender affirming care to patients. (Although it is a topic for another article, I’d be remiss not to at least mention that these clinics also tended to focus on performing wildly unethical and morally abhorrent invasive surgeries on intersex infants.) Around this time– and into the 1970s, when gender clinics increasingly became privatized– doctors began outsourcing the task of determining who deserved gender affirming care to the mental health industry. This was widely a move to protect doctors themselves, not their patients; the medical establishment still regarded trans healthcare as fringe and immoral, and there was intense fear of being sued among doctors who provided it. Unfortunately, therapists did not tend to have a kinder view towards trans people. Their tests of who was a “true transsexual” also centered around patients' heterosexuality and often passibility. They added other elements as well– a “true transsexual” was someone who consistently showed signs of nonconformity with their gender assigned at birth starting in childhood, and was always repulsed by his or her own genitals. (Yes, “his or her;” there was no room for nonbinary identity in this conception of transness.) Therapists would determine whether a patient was “authentically” transgender, and those who were approved were granted access to treatment.

    The requirement that trans patients get a letter from a therapist formally diagnosing them was codified by the Harry Benjamin International Gender Dysphoria Association (HBIGDA), founded in 1979. HBIGDA rebranded itself as the World Professional Association for Transgender Health (WPATH) in 2007, and the WPATH Standards of Care are widely used by practitioners of trans healthcare today. Let me repeat that, for those in the back: The organization that today requires all trans patients to get a gender dysphoria diagnosis prior to accessing care is the same organization which mandated trans people be subjected to humiliating, degrading evaluations in the 1970s. The parameters of what a gender dysphoria diagnosis entails are contained in the diagnostic criteria established by the Diagnostic and Statistical Manual of Mental Disorders (DSM). Previously called “gender identity disorder,” gender dysphoria is listed in the DSM-5 as “incongruence between the gender assigned at birth and the experienced/expressed gender.”

    The history of the “mental health letter” requirement (in other words, the psychological evaluation requirement, or the gender dysphoria diagnosis requirement) reveals some of the more obvious ways that such restrictions cause harm. Forcing trans patients to be evaluated by a mental health professional prior to accessing care puts many patients into contact with transphobic therapists, who ask invasive, dehumanizing questions about our sex lives or our experiences of abuse and trauma. The basis of these questions– and the fact that they are still so widely seen as acceptable to ask– is derived from a history of doctors only permitting attractive and “passing” people to transition. The requirement rests on the foundational assumption that some people seeking medical transition are not “truly” or “authentically” transgender, but are mere “deceivers,” “cross-dressers,” or “confused homosexuals.” Additionally, in order to prove the “legitimacy” of one’s transness, one must see a mental health professional, which inevitably comes with fees. Thus, “mental health letter” requirements maintain a financial barrier to medical transition which forms an additional obstacle to poor and working-class trans folks. 

    Furthermore, “mental health letter” requirements are ridiculously pathologizing. On its face, it should be clear that if transness is not a mental illness or a psychological disorder (and reader, I certainly hope you would agree with this statement), it has little business being in the DSM. Even dressing up the diagnosis in the language of “gender dysphoria” (as in the change from “gender identity disorder” to “gender dysphoria” in 2013), requiring a diagnosis from a mental health professional firmly places transness in the realm of the pathological. In doing so, the medical establishment reaffirms that cisness and gender conformity are the norm, and that any deviation from this norm is unnatural and ought to be at the very least subject to scrutiny if not outright horror. 

    Taking a look at the diagnostic criteria listed in the DSM-5, additional problems arise; it is clear that the medical community’s definition of gender dysphoria reifies the conservative gender binary. The DSM continually describes gender dysphoria as the desire to be the “other gender,” and gives examples of gender dysphoria in children such as a child assigned male at birth presenting “a strong preference for cross-dressing or simulating female attire” or “ a strong avoidance of rough-and-tumble play.” Let’s take a moment to really interrogate the implications of these criteria: gender dysphoria is the desire to be the “other gender,” so of course there are only two genders, male and female, and those are directly oppositional to each other. The examples provided of transfemininity in children might as well come out and say, “Being a girl means wearing dresses, being a boy means wrestling.” 

    It’s certainly true that many trans people have these experiences in childhood, wherein they are drawn to the roles and norms associated with the so-called “opposite sex,” and there’s nothing wrong with that. But enshrining this sort of gender nonconformity in diagnostic criteria reinforces stereotypical, conservative understandings of gender while simultaneously reinforcing the gender binary. It frames medical transition as a project of bringing gender nonconforming people back into line with the traditional and binary understanding of gender. (Your child who was perceived as a little boy wearing a dress was a problem in that she was expressing herself in a way that varies from conventional masculinity; now she is legible as a woman to the rest of society so the problem is fixed.) People who express gender nonconformity as children absolutely deserve to transition– scholars don’t make this argument in an attempt to prove that trans people are somehow problematically “conforming to traditional gender norms” through the process of medical transition. Rather, it is an argument that all trans people, regardless of whether they exhibit certain “symptoms” of this “disorder,” deserve to transition. That includes people who won’t pass as cis, who don’t fit within the binary, and/or who will continue to be gender nonconforming their whole lives (butch trans women, feminine trans men, etc). And of course, the stereotypical understandings of gender which the DSM enforces are also racialized; thus, as in the views of doctors in the 1950s, the DSM-5’s definition of gender dysphoria continues to reify white supremacist understandings of gender.

    Finally, here is what in my mind is the biggest and most fundamental outrage of the “mental health letter” requirement: It places authority over access to medical transition in the hands of a largely cisgender professional class, removing agency over our own bodies from trans patients. The idea that a therapist is better suited to determine what my gender is than I am is ridiculous and frankly insulting. I’ve lived as my gender for my whole life, embodying it in different ways as my understanding of it shifts and changes and matures. In the best case scenario, the mental health professional who diagnoses a trans patient and writes them a letter does so in a single session, in which case it is absurd to think that they could evaluate this person’s gender in such a short period more accurately than the patient themself. At worst, the therapist requires additional weeks or months of therapy, in which case the trans patient finds their medical transition continually delayed, often to the detriment of their mental health. (And even in this worst case scenario, the therapist still would not have greater insight into their client’s gender than their transgender client themself.) I was incredibly privileged to have access to a competent therapist who wrote me a letter without asking invasive questions or stringing me along for months; not everyone is so lucky.

    Instead of these gatekeeping requirements, trans healthcare ought to operate on an informed consent model. Under informed consent, patients are informed of the effects of a specific medical intervention and, if they consent to it, are granted access to that care. Informed consent is increasingly being utilized for access to hormone replacement therapy (HRT). In fact, the WPATH Standards of Care 8 (the most recent version of WPATH’s SOC, released in 2022 but not yet widely adopted) advocates a kind of informed consent for HRT by no longer requiring “mental health letters” for its prescription. Although a culture of fear mongering around trans care and its perceived “irreversibility” has so far prevented surgeons from adopting informed consent (think, “We can’t let our innocent young (white) daughters mutilate their bodies!”), I hope to see progress on this in the future. Given that requirements for official diagnosis are so inextricably linked to racism, misogyny, classism, and transphobia, it is long past time to ditch them. Trans patients know ourselves best, and we deserve to exercise autonomy over our bodies.