Post op regret and detransition - informed consent and psychotherapy

[Cindy]

I certainly don't want to start and argument, more an intelligent discussion what is your opinion of  'quick' informed consent (basically HRT on demand no questions asked) 'true' informed consent, ( several visits to ensure you understand what you are doing) or extensive psychotherapy so that your problems are aired and discussed fully prior to HRT/surgery?

I come from this issue by comments I have had (not on this site) that quick IC is preferable - even if a number of people suffer or even die from making the wrong decision.

I find that unacceptable, I also BTW find gatekeeping, as generally understood by the community unacceptable. I prefer a model of community based therapy leading to psychiatric informed consent, followed by ongoing community therapy as needed.

Now a given is that everyone involved has to be properly trained and not the fly by night or Bible bashing medical community, but trained sympathetic therapists.

If you have detransitioned or have post op or even post HRT regret how would you like the system changed to a point that would have helped you?

Your thoughts?

[Felix]

I'm not in the category of people whose opinions you are seeking on this, but I think as long as we can find some way to ensure that informed consent is actually informed, it's okay. It wouldn't even be faster than more orthodox paths if we did it right, but it would be more respectful. Some people are clearly harmed by some elements of the standard process and would benefit from a different model.

It seems rare for ftm's to detransition, so again, I know my opinion is flimsy here.

[Beverly]

OK.... in summary

Gatekeeping = wrong.

Quick informed consent = Here is my money, I want to buy that diagnosis.

Proper informed consent = What everyone SHOULD  be going through


Now the rant.....

From what I can see, there are a lot of people who really lack self-belief and who are buying the diagnosis they want and whilst they might have GD many of them have other issues that need to be treated. I think that many "buy" GD as an escape from their current problems because they will be a new person with a new life and all those problems will not follow them. Except they soon find out that transition solves only ONE problem and adds a few more. There are even therapists that will sell you informed consent letters for GRS on the basis of $120 and a phone interview. Somebody challenged me on that a few days ago and I offered to provide a list of such therapists.

Many people seem to regard "proper informed consent" as gatekeeping because somebody is not doing what they want on demand and it seems to be the younger transitioners more than the older ones. Maybe because they are young they lack patience or perhaps they are used to getting what they want. It might even be that the amount of duff information on the internet - you must transition before you are 12 or there is no point - is having an effect.

All I am certain about is that the amount of post-op regret will increase due to people making the wrong decision to have GRS or having massively unreasonable expectations about what GRS brings.

[kira21 ♡♡♡]

In England we do gatekeeping and it's just cruel.

[Beverly]

In England we do gatekeeping and it's just cruel.

On what basis do you say that?

[suzifrommd]

OK, Cindy, you asked.

First, our objectives. What would screening try to achieve. Here's my take:
* Want to make sure anyone with gender dysphoria receives prompt, appropriate care.
* Want to make sure that we're not ruining lives with a medical intervention. Want to prevent suicide or serious mental illness or trauma as a result.
* Want to make sure that ill-informed practitioners (which are, IMO, unavoidable), don't substitute their judgment for those of a competent patient who knows what she needs.
* Want to make sure we don't destroy the physical health of the patient by dispensing medication that damages her.
* Want to make sure transgender patients have the opportunity to be fully educated about all their options.

OK, second, and almost as important, here are things that are NOT our objectives:
* To avoid disappointment. (Disappointment is unavoidable and a human experience from which people can grow).
* To prevent lawsuits (Should not be a consideration in medical treatement).
* To tell patients what is good for them. (IMO, no doctor, no matter how expert, insightful, or experienced can know for sure what's good for a transgender patient).
* To exclude people whose transition might be unsatisfactory (IMO, transition is a RIGHT not a therapy, and is not "by prescription only").

Now here's the answer to your question:

1. There should be a standard set of literature made available to transgender patients. A patient who presents for HRT should be encouraged (but not required) to read it.  It should contain information about the effects and risks of HRT, and also whatever knowledge might help someone successfully transition.
2. The patient should be given the option (but not the requirement) of a psychological screening. It should be explained to the patient what psychological conditions and limitations might prevent them from making a competent decision and give her an opportunity to be screened for them. Upon receiving this information, the patient can decline or accept the screening.
3. Upon receiving the information in 1 & 2, the patient should be given access to HRT on a timetable of her choosing within medical safety guidelines.

What about people who are not mentally competent to make decisions about their care? Well, treat them no differently from ANY OTHER PATIENT who presents with ANY OTHER CONDITION. When any patient is a danger to herself and others, the doctor can make a recommendation for psychiatric care. Doctors do that for anyone they come in contact with who fits that description. But they also provide care that is needed.

Is this the sort of thing you were looking for?

[E-Brennan]

A study on post-op regret based upon how the patient initially obtained a transgender diagnosis would be highly beneficial.  I imagine that those who entered the process via quick informed consent would have a far greater percentage of post-op regrets.

I fall somewhere in the middle on this subject.  From what I've seen, gender issues are so destructive when hidden that by the time someone seeks treatment, they are often also suffering from other issues - depression, stress, suicidal tendencies perhaps, family rejection, crumbling marriages, financial woes etc.  These have to be addressed too, and with quick informed consent there is no attempt to even identify, let alone address, these problems.  Quick informed consent also allows those who are misdiagnosing themselves access to some life-altering treatments, and let's face it, who hasn't misdiagnosed themselves by looking at the internet and talking to equally ill-informed peers?

But on the other end of the spectrum, gatekeeping (which, as I understand it, is where the therapist personally has to "approve" the fact that the patient is suffering from gender issues - i.e. the therapist is no longer objective, but subjective) is equally bad in that it's an archaic roadblock based upon outdated information.  We know far more about gender from a medical perspective than we did when gatekeeping was the norm, and it is unnecessarily cruel.  Imagine having a patient with a broken leg "prove" that he can't walk before being given any treatment whatsoever?  An extreme example, but it conveys the point.

True informed consent is, in my mind, the only way to go.  You're having a professional double check that you're not way outside the diagnostic spectrum, slow the process down a little (because we all get excited and want to get started on the medication as quickly as we can), and encourage a little self-examination to make sure you understand what you're getting into.  There is nothing wrong with having a few sessions with a therapist to make sure you're starting out on the right track.  It's hardly a huge hurdle to overcome in terms of time or cost (and if one can't afford a few hundred bucks for a few sessions of focused therapy, how does one expect to afford the far higher costs of successfully transitioning?)

Of course, I don't advocate for one way into the system either.  There are people I know who have intelligently and thoroughly researched their condition and options, and who would benefit from quick informed consent.  There are others who have bigger problems to worry about that gender, or who have some crazy misconceptions about what transition is, who could use some hardcore gatekeeping.  Most of us, though, seem to fall into the middle where true informed consent is appropriate.

I'm just starting HRT and I'm making sure I'm going to continue visiting my therapist throughout; I want to make sure that I have someone keeping an eye on me so I don't end up in the "regret" column when all is said and done.  I don't want to ever detransition or have any regret - to me, that is a sign that someone (me, the therapist, doctors, whoever) made a mistake.  And as with all medical treatment, mistakes really should be unacceptable.  If one takes transition at a safe and monitored pace, the chance of making a mistake is minimized.

[LordKAT]

I personally think that informed consent must be truly informed. Information presented in written and perhaps visual form and that should be enough for HRT. I do not think multiple visits are needed although I can understand perhaps a second visit which gives a person time to think through all they have been told/shown.

Surgery on the other hand, should require informed consent AND screening for other possible things which could interfere. I see no problem requiring a year of RLE preceding that surgery.

My reasoning is that HRT is less invasive and will often have the person either find it is wrong for them or that is what they needed all along. It is largely reversible without too much hassle if it is the wrong thing.

Surgery is not reversible and has much greater invasive impact. The regret from surgery, if it happens, will be much greater than the regret of HRT.

[kira21 ♡♡♡]

On what basis do you say that?

Well,  it's an opinion,  but they space the appointments you have three months apart.  So in a year you will have 3 or 4 in year.  I spent all of mine talking about the merits of progesterone,  which is funny as they are supposed to be psychiatrists,  not endocrinologists.  They didn't really get to know me at all.  Tbh,  it's nowhere near enough to get to know somebody.  What they were really doing is making people wait it out.  During that time,  which for me was a little over a year (and I was ft way before I had my first gic appointment, had changed my passport gender, name, etc.) but for others I know has been up to 4 years,  you are supposed to present in your desired gender everywhere.  I can't imagine being told that I had to wait four years after presenting in my desired gender before getting hormones. To me that is cruel.  I hear of people having their time 'reset'  for not adhering to their idea of presenting such as not wearing make up or not wearing a skirt. 

People should be allowed hormones as they transition.  2-3 years after does not seem like informed consent,  it seems like gatekeeping. Particularly when you are not putting in any good counselling in that time. It's not 'working through things with you'  it's 'go away and wait it out'  time.

That's why,  but like I said.  It's an opinion. 

[luna nyan]

Cindy,

You've most certainly given a minefield question here.

Firstly, let's define what informed consent is in general medico-legal terms.  I'm going to paraphrase what is generally assumed in a court of law in Australia.

Informed consent is consent given by a person of sound mind and comprehension to undergo medical treatment for a diagnosed condition.

To fulfil these criteria:
1.  The patient needs to be able to understand their condition ie be mentally competent.
2.  A diagnosis of some sort has to be made.
3.  A treatment proposal, with salient outcomes, benefits, disadvantages, and side effects has been discussed and understood.
4.  Alternative treatments have to have been discussed.

For purely physical things - broken bones, cysts, tumours, etc, these criteria are relatively easily fulfilled.   When we start talking about mental health issues, then it becomes somewhat more nebulous.

Going back to transgender treatment, the issue is how to correctly arrive at a diagnosis in timely manner - not every gender identifying individual is definitely truly TG - other issues may be causing the presentation.

Gatekeeping as a means of diagnosis is wrong in my opinion, but neither is the case of handing out scripts willy nilly - there has to be a happy medium in there.

[Beverly]

Well,  it's an opinion,

Indeed. So here is mine. I was fulltime before I went there. In the space of 12 months I had seven appointments, including assessments, endo, followups and surgical opinions and I am talking Charing in my case. I found people willing to listen and help.

I attend a large trans group on a regular basis so each month I touch base with a couple of dozen trans women and the ones who have problems with GICs are the ones who seem to find problems everywhere. Three others had bad experiences with GIC staff in two clinics and they complained and the clinic apologised and assigned other staff.

My experiences are totally unlike that those you (and others) describe. The reason I get annoyed by negative descriptions is because I use to read them and believe them. They convinced me I could not ever transition. In short, they stopped me from transitioning 10 or more years ago. In the end, what I found was people willing to help me as long as I did not go in there and tell them how it was going to be.

There are people out there reading this stuff now. I want them to know that the horror stories that are routinely presented are not true. That other people (me and 2 dozen others) have been helped and UK GICs are not the horrors that people often paint them as. I do not want others to suffer delayed transitions out of fear as I did.

[janetcgtv]

I'm probably going to be asking a very dumb question.

What does Gate keeping mean?

[LordKAT]

Someone other than you holds the keys (decision) on how, when and/or if you can medically transition.

[Shantel]

Informed and really extensive and verifiably well understood consent is an absolute must! Much of the psychotherapy turns out to be really quite predatory intentional gatekeeping for the purpose of using up the hard earned funds of the transitioner which creates more angst than is necessary from what I've observed. One thing missing in this conversation is the fact that at trans group meetings and trans support web sites there is often a lot of mindless group-think BS accompanied by peer pressure and the expectation that everyone will transition completely in the prescribed manner like others have, some are extremely militant and insulting about it as if their own transgendered credibility as a man or a woman is somehow dependent on others joining their ranks. I am dealing with just one such young friend whose name I won't mention who had succumbed to just that mentality and who had gone through the numerous surgeries and was damned close to suicide feeling as if her life had been totally destroyed when we first began to connect and work through it via email and I'm angry about what has happened to that dear child. So I really don't think informed consent is the big elephant in the room here.

[kira21 ♡♡♡]

That's really good to hear that some people are getting more out of the process from the gic.  Unfortunately my experience with the gic (notts) is that they have not identified any councilling groups or anything like that for me.  They have not even mentioned it and I think that should be part of the process. 

I would still really like to talk about issues with a trained professional and I have not been offered the opportunity to do that with the gic and it should be a requirement.

I am not sure if you are blaming the person being treated when you say they find problems everywhere,  but if you are then I,  having spoken to the people I was referring to would not find that very fair,  but I could be misreading what you mean. 

I would not say the 'horror stories'  are not true (unless you think they are all lying - myself included.  I wouldn't really even describe mine as a horror story and if I had to do it again it would not put me off transition, it's just a disappointment and not how it should work. What I think it might be better to say is mixed bag.

[kira21 ♡♡♡]

Someone other than you holds the keys (decision) on how, when and/or if you can medically transition.

And that is their sole purpose,  to decide who gets in. 

[Beverly]

I am not sure if you are blaming the person being treated when you say they find problems everywhere,

Let me give you one example of someone I know. She regards most people as ar*eholes and has a very short temper. She argued with a series of doctors that they should simply give her hormones because she was a grown up. After going through several GPs she rolled up to the GIC argued and rowed with their staff because they would not give her hormones on her first visit. After another two visits of this they chucked her out. Last I saw she was self-medding and blaming doctors and GICs. It was all their fault.

I have known of others who pull stuff like this but most people I know just went to the GICs and talked to them and told their trans story and went on to hormones after the second visit. That is the story for most transwomen I know.

As for chatting and counselling you are better off getting that from your local mental health services. The GICs seem to be concerned with the process of transition.

[BunnyBee]

I think with hormones, informed consent is preferable because the effects are (mostly) reversible, at least for mtf, idk about ftm maybe it's the same.  Many suicides could have been prevented if the victims just would have been able to get on HRT before they gave up on life, it almost happened to me.  HRT, if it gives you psychological relief, can actually let you know pretty much unequivocally that it is the right path for you.  It can also make transition easier, make patients have to deal with fewer indignities, less shame, and can curb violence in some cases.  There are just a lot of substantial positives HRT can potentially provide if you have GID, and comparatively so much less risk.

Surgery, on the other hand, I feel does need some gatekeeping.  Given the success rate now, I don't think it should be any more stringent, and I certainly don't think it should be any less.  Most of the cases of regret I have read about have had either the gatekeepers not doing their jobs very well, or the patient lying about their feelings (sometimes to themselves.)  If the process is followed correctly, the chance of post-surgery regret is slim to none, and that is how we all should want it to remain.

[Declan.]

I personally think that informed consent must be truly informed. Information presented in written and perhaps visual form and that should be enough for HRT. I do not think multiple visits are needed although I can understand perhaps a second visit which gives a person time to think through all they have been told/shown.

Surgery on the other hand, should require informed consent AND screening for other possible things which could interfere. I see no problem requiring a year of RLE preceding that surgery.

My reasoning is that HRT is less invasive and will often have the person either find it is wrong for them or that is what they needed all along. It is largely reversible without too much hassle if it is the wrong thing.

Surgery is not reversible and has much greater invasive impact. The regret from surgery, if it happens, will be much greater than the regret of HRT.

Agreed.

[Dee Marshall]

Cindy, one question because mostly I agree with you. When you say "psychiatric informed consent" are you thinking of a psychiatrist specifically or perhaps a psychologist or other experienced therapist as well? In my area psychiatrists don't do therapy and are quick to reach for the prescription pad. Insurance makes it almost necessary for them. I've only known one who did therapy and I know a lot of psychiatrists.