It's Not Just About Trust

One of my news feeds dropped the following article this morning:  "Gender Transition isn't a Whim, so Why the Mistrust?".

After reading through it, the article is more or less the standard "I know I need this surgery, so why can't I get it on demand?" argument.

To a certain extent, I am sympathetic to this.  People who are transsexual usually know from an incredibly early age that they are, and what they need.  This is beyond question in my mind.

The notion of informed consent is pervasive in Western Medicine, and in general terms it works fairly well.  But, informed consent is a point solution to a specific problem.  Informed consent does tackle the understanding of what the effects of a specific form of medical intervention are.  Usually in terms of physiological issues, potential complications and so on.

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.

It took me a few minutes to figure out what bugs me about this claim.  The issue is not merely that it is a case of "informed consent" for Gender Reassignment Surgery (GRS), but rather that gender transition is a complex process that encompasses a wide range of actions and treatments.

Any one step of transition requires a degree of informed consent.  For example, starting cross-sex hormone treatment requires that the doctor and patient have a clear, coherent discussion of the effects of hormones - both short and long term, as well as possible side effects.  However, taking hormones is merely a facilitating step in the process of transitioning across genders.  One step of many that a patient is ultimately undertaking.

Gender transition is not one step.  Hormones and GRS are the tangible markers that most people can grasp.  What is much harder to understand is the long term process of social transition.  For some, it is an easy, almost seamless process, for others it can be much more difficult to make the adaptations they desire.

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.

 I can appreciate the perception that there is a "gatekeeper" mentality in some areas.  Let's face it, your average GP or Endocrinologist simply doesn't have a lot of training in dealing with cross-gender patients, and as a result may feel profoundly uncomfortable providing treatment without the input of a psychologist who specializes in such matters.

Western Medicine has become very "siloed" in the last fifty years or so.  Most GPs don't have the tools to make specialized diagnosis and refer patients to specialists all the time.  Specialists are often so focused in their own domain that they really do not feel comfortable making assessments outside of that domain.

To some extent this can be addressed by training, but it doesn't necessarily resolve the ethical and practice guidelines considerations that all of these professionals are bound by.  It would be very nice indeed if there was more uniformity in this regard, but there isn't.  Even more unfortunate is that in some localities, physicians have been known to turn trans patients away on the basis of personal beliefs on the matter rather than practical medical guidance.

Is it "gatekeeping" for a GP to say that they want an assessment from a psychologist before providing hormone therapy?  If we are talking about a situation where the psychologist is trying to make the availability of the referral letter contingent on a long term therapeutic relationship, one might be a little bit concerned.

However, the WPATH SOC v7 addresses this quite explicitly:

The SOC do not recommend a minimum number of psychotherapy sessions prior to hormone therapy or surgery. The reasons for this are multifaceted (Lev, 2009). First, a minimum number of sessions tends to be construed as a hurdle, which discourages the genuine opportunity for personal growth. Second, mental health professionals can offer important support to clients throughout all phases of exploration of gender identity, gender expression, and possible transition – not just prior to any possible medical interventions. Third, clients differ in their abilities to attain similar goals in a specified time period.  

Further, the SOC sets out fairly clearly the basic criteria for GRS referral:

Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients: 

1.  Persistent, well documented gender dysphoria; 

2.  Capacity to make a fully informed decision and to consent for treatment; 

3.  Age of majority in a given country; 

4.  If significant medical or mental health concerns are present, they must be well controlled; 

5.  12 continuous months of hormone therapy as appropriate to the patient’s gender goals (un- less the patient has a medical contraindication or is otherwise unable or unwilling to take hormones). 

6.  12 continuous months of living in a gender role that is congruent with their gender identity;
Although not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional. 

Rationale for a preoperative, 12-month experience of living in an identity-congruent gender role: 

The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery. As noted in section VII, the social aspects of changing one’s gender role are usually challenging – often more so than the physical aspects. Changing gender role can have profound personal and social consequences, and the decision to do so should include an awareness of what the familial, interpersonal, educational, vocational, economic, and legal challenges are likely to be, so that people can function successfully in their gender role. Support from a qualified mental health professional and from peers can be invaluable in ensuring a successful gender role adaptation (Bockting, 2008). 

The duration of 12 months allows for a range of different life experiences and events that may occur throughout the year (e.g., family events, holidays, vacations, season-specific work or school experiences). During this time, patients should present consistently, on a day-to-day basis and across all settings of life, in their desired gender role. This includes coming out to partners, family, friends, and community members (e.g., at school, work, other settings). 

Health professionals should clearly document a patient’s experience in the gender role in the medical chart, including the start date of living full time for those who are preparing for genital surgery. In some situations, if needed, health professionals may request verification that this criterion has been fulfilled: They may communicate with individuals who have related to the patient in an identity-congruent gender role, or request documentation of a legal name and/or gender marker change, if applicable. *Emphasis Added

Ms. McKinnon goes on to critique these requirements as follows:

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.

Here is where I beg to differ with Ms. McKinnon's assessment of the situation.  She seems to have conflated GRS with gender transition.  The two are NOT the same thing, although they are closely related to each other.  The claim being made is fundamentally that as long as the patient is able to give "informed consent" to GRS, they should be able to have access to it.

Superficially, this seems almost reasonable.  However, there are two enormous "buts" that must be discussed here.

First, unlike every other surgical procedure out there, GRS unequivocally changes the patient's status in many different aspects of their life, not merely in the relative privacy of our bedrooms.  As part of a broader picture of gender transition, it also affects the patient's social context and status, friendships, workplace and goodness knows what else.  Informed consent for GRS has to account for these realities somehow.

Second, we know that there are those who attempt to gain access to GRS who either are unsuitable candidates, or have not yet adapted to their chosen gender role in society.  Whether we are talking about characters like Walt Heyer (how he ever got approval for GRS is beyond me, but that was the early 1980s, a different era), or the person who early in their journey decides that they desperately need surgery *now* (I've seen it, and I personally have talked more than one such person out of their tree - at least half of them backed away from transition after that, and I respect them for having the strength and wisdom to recognize when to step away from the precipice)

One of the things that makes gender transition quite different from other conditions that doctors deal with is that it lacks clear diagnostic criteria that they can examine objectively.  In fact, there are no physiological symptoms that they can examine directly.  Is it unreasonable that the surgeons insist upon an objective third party assessment?

We also cannot ignore the political dimension of those who choose GRS and then discover that they made an awful mistake.  People like Mr. Heyer run around spouting a pack of lies a mile deep about about GRS, and ultimately make it more difficult for the rest of the trans* community to access the treatment they need.  This cannot be ignored, nor can we ignore the consequences for both transsexuals seeking treatment as well as the practitioners that they rely on.

But to argue that this contravenes the notion of "informed consent" is to assume that "informed consent" is a one way street.  It is not.  Informed Consent merely means that the practitioner has discussed with you the treatment that is proposed and its consequences.  In general, it starts from the presupposition that the practitioner has performed sufficient diagnostic assessment to be confident that this treatment will address the diagnosed condition, something which few surgeons will feel that they have the appropriate diagnostic skills for in the case of GRS.

What has changed is that although a psychologist's assessment is needed for a surgery referral, there is no explicit requirement for a long term therapeutic relationship.  (This didn't really exist in the previous SOC, but the current SOC is much clearer about it)

In short, Ms. McKinnon's position is based in large part on a misunderstanding of the nature of the WPATH SOC, and even more troublingly a failure to understand the ethical issues that a surgeon faces in providing GRS.  She tries to draw analogies with other "on demand" surgical options, but fails to acknowledge the unique aspects of gender transition in general.  No other medical process has such a profound impact on the life of the patient.

To proceed with caution has merits for both practitioners and patients in the long run.  A vasectomy can be reversed, a woman who has an abortion has the opportunity to become pregnant again.  gender transition is a process that is far more broad in its impact than just the patient.  Their social context changes, the people around the patient are very directly impacted, and so on.  "Undoing" all of that is difficult to say the least - at least as difficult as transition itself, and then there is the physical impossibility of "undoing" GRS.  To look at one part of the process - surgery - apart from all of the other aspects involved is incredibly short-sighted.

It may be frustrating, but a successful gender transition really does require many experts to contribute their expertise.  I would love to argue in favour of more open access, but the potential for serious harm to happen to someone whose motives for transition are unclear or they are ill-prepared for it is far greater than the implications of having a few cross checks in the system.  The world needs fewer Walt Heyers, not more.

No, Transition Does Not Absolve You Of Your Past

I'm sure that the far right is going to use this story in the war currently being conducted on transgender rights in both Canada and the United States.  

Transgender Defense: 'Donna' Says 'Doug' Is the Spokane Serial Killer

In fact, LifeSite has already picked up on the story:

Transsexual accused of serial killing: I didn’t kill those women because I’m a new person

According to the ABC News story, Donna Perry is trying to claim that she cannot be held accountable for murders that she committed prior to undergoing gender reassignment surgery.

When detectives interviewed Perry and asked why the murders had stopped, she replied, "Douglas didn't stop, Donna stopped it," according to the affidavit. 

... 

The accused's reported defense that it was not Donna Perry but Douglas Perry who killed the women is headline-grabbing, but not necessarily a true reflection of how transgender people view their nonconforming identity, according to mental health experts.

I have enormous problems with this as any kind of defence in a court, and I would hope that her lawyers would advise against it as well.  Simply put, although it is hardly uncommon for transsexuals to talk about their pre-transition lives in a somewhat dissociated manner, transition does not produce a "whole new person".  More realistically, one is the sum of their experiences before and after transition.  Transition is an opportunity for enormous personal growth, but it hardly absolves one of what happened before transition.

"For some people, it's a metaphor: 'I was a different person before I came out,'" said Dr. Jack Drescher, a New York City psychiatrist who sat on the work group on sexual and gender identity disorders contained in the DSM-5 -- the latest edition of the Diagnostic and Statistical Manual. 

"It's a certain way that they use the metaphor when transitioning for those who were very unhappy before and now are happy," he said. "But it's different when a person makes a claim that somehow they have no linkage to the person they used to be –- that would be more of a disturbed presentation." 

Having what is now called gender dysphoria in the DSM-5, does not necessarily mean that a person has impaired judgement, which is often a legal defense, according to Drescher. 

"It's wrong to generalize from this person's life – it's not typical of the transgender experience," said Drescher, who does not know Perry and is not connected to the case. 

Dr. Drescher makes some very clear points, and his second statement is in fact what I thought when I first read the article.  If Ms. Perry in fact thinks of "Doug" as a distinct entity quite separate from herself today, there could well be a much more serious psychological issue over and above Gender Dysphoria.

Regardless, I would very surprised if any court would accept core of the argument that is being made by Ms. Perry.  At its core, it implies that because she underwent gender transition that she cannot be held accountable for criminal acts which occurred before transition.

My concern is twofold.

First, I do not believe that Gender Dysphoria should be seen as sufficiently debilitating to result in a "not criminally responsible" finding.  It is a serious condition, to be sure, but I would find it extremely difficult to swallow the notion that someone who is transsexual is not capable of understanding the difference between right and wrong in making their day to day decisions.

Second, such a finding would effectively undo any equality rights gains that have been made in the last thirty years.  While I have no doubt that the writers at LifeSite News would be positively ecstatic with such an outcome, the consequences for the real lives of a lot of people would be devastating.

Most likely, I expect Ms. Perry will find that she is found guilty of murder, and locked away for the remainder of her life for actions done long before she transitioned.

More From The "I Regret GRS" Club

Another pseudo-anonymous letter allegedly from a transsexual who regrets having GRS has been posted on Walt Heyer's blog.

Why do I say "pseudo-anonymous"?  Because, frankly, I'm not at all sure that Heyer hasn't written it himself - there are some significant overlaps with aspects of Heyer's own story which I have critiqued in detail already.  I am not at all convinced that we aren't looking at a sock puppet.

However, even if it is a 'sock puppet', it is worth taking a closer look at what is said - in part because it attempts to critique the latest edition of the WPATH Standards of Care.

I have tragically come to realize my story is fairly typical of most MtF persons. I was molested by my "trusting" grandfather at age 3, father was killed at age 5 and while my mother remarried; you could essentially say I grew up without a "father figure" or role model.

There are a couple of things here that set off alarm bells for me.  First is the "I was sexually molested" line, and the attempt to link it to "most MtF" transsexuals.  The religious right wing, aided and abetted by people like Heyer love to try and associate transsexuality with some kind of flawed upbringing - in particular sexual abuse or the absence of an appropriate father figure - both are common tropes, with no basis in evidence.  Yes, a percentage of transsexuals were sexually abused as children, but so are a percentage of non-transsexuals.  Any attempt to declare a causal link here is sloppy reasoning or wishful hypothesizing.

By my late thirties, this feeling of a "feminine core" continued. It led me to purchase online and experiment with Estrogen and an Anti-Androgen. My body slowly started to feminize. I dieted and exercised feverishly and got my body down to an acceptable female weight. I felt great; this must be who I am?

I remarried again in my early forties to a wonderful woman. Yet, the programming in my mind was so scrambled by then that it was difficult to differentiate between reality and fantasy. By the time I started seeing a gender therapist and a surgeon they were as convinced as I was that I was female.

Since I was already on estrogen, the endocrinologist felt morally/ethically obligated to continue that same protocol and at least monitor it and prescribe it legally. I received my first letter for surgery after a year and the second after two years. My childhood issues were jotted down by the therapists almost as if a side note. (A very common failure in approving surgery.) At no time did I tell my family, consider my career or even consider talking to the love of my life of my plans. This "sickness" and it is a sickness, consumes and takes over your life! You will lie to everyone around you as you continue to lie to yourself to get it done.

Thought number one here:  The person seems to have started by self-medicating - taking hormones apparently without the supervision of a doctor or even a psychologist.  I've seen this line before - almost always from people who attempted transition that shouldn't have in the first place.

The second point here is that the person does not appear to have engaged with a therapist until they had walked a long ways along the physical transition path.  This is consistent with Heyer's own biography, in which he clearly did not engage with a therapist on any consistent basis.  It has long been my opinion that there is nothing wrong with regularly being in contact with a therapist during gender transition.  While it is not essential to transitioning successfully, an objective cross-check cannot hurt.

The author does not tell us how long he engaged with therapists to gain the letters for surgery, and ethically, the therapist is only obliged to do an assessment.  Unresolved issues related to past abuse are ultimately up to the patient to decide if they are willing to pursue and resolve them prior to having surgery.

Lastly, and perhaps most importantly, the author clearly could not be living full time at the point where they acquired the letters for surgery.  Not only were they not working in their chosen gender, but even their spouse was not aware of their plans.  Given the dramatic effects of hormones, I am somewhat puzzled how this could possibly be, unless communication in the relationship had broken down to the point that the couple were keeping separate rooms.  I find this particular aspect of the story far too close to Heyer's own story.

The recently published WPATH Version VII has simply allowed the medical community to open the "floodgates" for this very tragedy to unfold. To get on cross gender hormones and then have surgery has become almost as simple as going to the convenience store for a pack of gum. If the client wants it, give it to them. "Real Life Test"? Maybe, maybe not, depending on your circumstances, occupation, etc. It is a billion dollar industry that thrives on your illness.

The most recent edition of the SOC does not make it "easier" to get access to hormones - an assessment and referral letter is still needed.  Whether or not all doctors who see transsexual patients implement this requirement is another matter entirely.

A careful reading of the current SOC is pretty clear, and there is a lot of clinical flexibility in the system.  Given the incredible diversity of gender variant people that are being identified, and the fact that they all have somewhat different needs, this is not surprising.  Again, for someone considering transition, it is more important than ever to engage with a treatment team that includes experienced professionals who understand the subtleties and shades of grey appropriately.

Get help. Don't mutilate your body. The psychiatrist, psychologists, and surgeons will enjoy a wonderful life. You, however, could end up with a tortured life, ending up penniless, possibly unemployed, without family or friends and maybe even homeless. And that's if you haven't tried or committed suicide by then! All so you can become the girl you "think" you are inside and wanted to be! People, God or whatever you believe in made you in the correct gender. It is encoded in your very DNA. If you think differently, get real help; but, DON"T CHANGE IT.

Gender is not just physical sex;  even if all aspects of it are somehow encoded in our DNA, such a perspective is a gross oversimplification.  It is well known that genes are expressed differently in each individual.  The biochemical system that is the human body is not absolute and deterministic in nature or function.

Lastly, the implicit notion that transsexuals are somehow lying to themselves has been tested and disproven repeatedly.  Even the DSM IV test clearly established the difference between delusion and the transsexual's experience.  A story like this is, to me, a cautionary tale - one that tells us all that when undertaking something as subtle and complex as gender transition, that there is much to be said for being cautious in how you approach the subject.   If you find yourself having to lie, or cover things up, then you better get to a place where those lies are no longer necessary and see if you can live with yourself openly.

PFOX - Your Source for Lies and Distortion

This time, PFOX has opened its yap about the bogeyman of having taxpayer-funded gender surgery available in the United States:

if the proposed federal health insurance will cover sex-change surgeries, hormone treatment, etc. for Gender Identity Disorder as opposed to therapy.

This is one of those typical lies that we see from the "pray away the gay" crowd. The key phrase is "as opposed to". This leaves it open to the reader to understand that Gender Surgery would somehow be available apart from appropriate psychological counselling.

If PFOX was even marginally honest with their readers, they would have acknowledged that the WPATH Standards of Care are entirely based on access to surgery only with a psychologist or psychiatrist's recommendation.

In fact, section X of the SOC is quite unambiguous about the triad of treatments required for "profound GID":

In persons diagnosed with transsexualism or profound GID, sex reassignment surgery, along with hormone therapy and real-life experience, is a treatment that has proven to be effective. Such a therapeutic regimen, when prescribed or recommended by qualified practitioners, is medically indicated and medically necessary.

As an aside, Gender Reassignment Surgery is probably the only medical procedure in the world that requires the patient to prove to not one, but two professionals besides the surgeon that they are in fact in complete control of their faculties.

But, then again, it's not like I haven't caught PFOX with their proverbial pants down before, either.

p.s. PFOX links to a very heart-breaking story of an "Ex-Transgender". I don't want to dismiss his narrative as invalid, for it is not. However, he is exactly the kind of patient that the SOC is designed to weed out before they get to surgery. The long term literature is clear - those few who need GRS benefit from it.