Drop 'dehumanizing' mental health assessments for trans youth wanting body-altering hormone therapy, McGill bioethicist argues

QuoteActivist Florence Ashley argues trans youth and adults wanting to modify their bodies shouldn't be forced to undergo mental health assessments first

https://nationalpost.com/news/drop-dehumanizing-mental-health-assessments-for-trans-youth-wanting-body-altering-hormone-therapy-mcgill-bioethicist-argues

Sharon Kirkey

April 22, 2019
3:49 PM EDT

Its how we do it in NY, through something called informed consent.  While the clinic might make you have 1 session with a therapist on site its just a formality rather then a "thou shalt not pass".  The goal of the session is usually just to make sure you are positive about it as it is a major life alteration.

And from my experience made transition both viable and as simple as could possibly be. The hardest part of transition though is dealing with how life might treat you and the people around you.  I think its important to verify that it is indeed an informed decision.

Actually, I don't agree with some Ashley statements. Seriously, we should trust people to diagnose their mental health? Why do we need psychiatrists then? It would be disasterous. They spending years studying mental health and mind diseases. Let people do their work, they must at least check if you really have some conditions which drive you into opposite gender behavior and provide you with alternatives. Otherwise, please, unleash all Napoleons and give them armies, they definitely need to conquere the Europe right now.

Right now I'm waiting for my own psychiatrist diagnose my mental health, because, you know, I wanna be healthy Alice, not crazy one.

The article is basically complaining about the WPATH guidelines, even though WPATH includes informed consent protocols. I think the author, and indeed many in our community, need to update their knowledge about how we receive treatment.

There's nothing dehumanising about signing a paper that says "I understand what this medicine does." 

QuoteThe article is basically complaining about the WPATH guidelines, even though WPATH includes informed consent protocols. I think the author, and indeed many in our community, need to update their knowledge about how we receive treatment.

QuoteActually, I don't agree with some Ashley statements. Seriously, we should trust people to diagnose their mental health? Why do we need psychiatrists then? It would be disasterous.

My understanding from reading here and elsewhere is that people, even adults, are denied informed consent, because their doctors haven't accepted current WPATH protocols.  This article talks about older teens and adults being allowed to make their own choice, provided they're aware of the consequences.

I got my HRT through informed consent.  I told my doctor, who referred me to an endocrinologist.  At my age, should I be required to talk to a psychologist or psychiatrist to do something I've wanted to do for many years?  Prior to the protocol changes here, 3 years ago, I would have had to.  I would suggest even castration should be available on informed consent.  As it is, with the current protocol, I have to be on hormones for a year and then get 2 evaluations, though those evaluations do not require a psychologist or psychiatrist.  It could be a medical doctor, nurse or social worker.

Hi, Alice

Quote from: Alice V on May 03, 2019, 04:40:25 AM
Actually, I don't agree with some Ashley statements. Seriously, we should trust people to diagnose their mental health? Why do we need psychiatrists then?

I agree with you, Alice.
To quote from the article:

QuoteIf someone says, 'My arm hurts,' we typically grant credence to their claims.

This is true. However, if someone tells a doctor "I have a hairline fracture in my ulna" I believe taking an x-ray is justified.

QuoteThe assessment requirements is [sic] predicated on the idea that there are "true" trans people, and "false" trans people, Ashley said in an interview with the National Post.

Hmm. I believe there are also people who get fixated on things they've heard about. When I started reading medicine as a child, I felt alarmed that many of the symptoms described in the textbooks seemed to fit me. Again, had I gone to the doctor to say I've got, say, leprosy, I would certainly hope that he'd have made sure I really had it before writing a prescription.

QuoteAnd the illness model is, 'Well, we have to figure out what this illness is because there is this underlying 'disease' we have to cure.

As I understand it, some illness/disorder has to be diagnosed for insurance to cover a procedure. Since Ashley appears to be talking about Canada, I assume the costs are covered by some form of national health insurance. Of course it is true that when one pays for the surgery and/or hormone therapy on one's own, informed consent may well suffice. However, even so I would hope that some assessment is made before commencing.

I'm afraid to quote the next paragraph, as I believe that including too much text of the article constitutes a terms of service violation, but to me its discussion of pubertal changes is the crux of the article.

I went through puberty. I was looking at old photographs today, and they made me hurt. I completely agree that arresting my development before the changes occurred would have spared me immense pain.

I do believe that immediate intervention in the form of blockers to every child on the brink of puberty who asks for an assessment will overall cause less harm than allowing those who do transition to undergo pubertal changes. In fact, this is a point I myself strongly stressed when discussing the matter with my referring psychiatrist. I do not, however, believe that immediately prescribing hormones on demand without any assessment is the right thing to do.

In the article Ashley also mentions "gender euphoria" as motivation for seeking hormone treatment. In this case, judging from the article, the seeker is not unhappy with one's body, but just feels overjoyed at the thought of having female fat distribution. I really don't see how this relates to the subject of transsexual children. To me, if a child is overall healthy, happy and well balanced, it would seem that the risks would outweigh the merits. (I can't but think of a situation where steroids are prescribed to a boy who "feels overjoyed" at the thought of having huge muscles.)

Overall, though, I get the feeling that the article may perhaps be exaggerating or reorganizing Ashley's comments. The end part seems to indicate that what she wants is an informed consent approach for older teens and patients. What I find very interesting that the only mention of blockers in the article is in a comment by the gender clinic at B.C. Children's Hospital. I would certainly hope that their use would be a logical first step in any treatment plan for children—and believe that Ashley would also be aware of it. I'd be rather surprised if she hadn't mentioned them at all in her paper or during the interview.

Quote from: Alice V on May 03, 2019, 04:40:25 AMRight now I'm waiting for my own psychiatrist diagnose my mental health, because, you know, I wanna be healthy Alice, not crazy one.

So am I. In adults, whose pubertal changes have already taken place, the situation is not as urgent. After recently (to my great surprise) suddenly finding myself eligible for non-private treatment, I myself am quite resigned to waiting. I don't like to, but do understand that the purpose of the assessment procedure is to ensure that a few loud regretters will not emerge to endanger public funding for those who desperately need the treatment.

There are other things about the assessment procedure that I do find extremely frustrating—but discussing them on an open forum would reveal too much personal information. I only hope that these aspects will eventually be addressed so others will not need to go through what I will...

Anyway, I've known what I feel since an extremely early age, and expect the process, once it starts, to go smoothly. I also expect it to be interesting.

Our minds are fragile things. There might be dozen reasons to consider ourselves to be TG, and doctors at least should check if we alright. Now I wanna say one thing that probably nobody will like but I believe in that. For medicine there is normal and not normal. And just biologically we aren't normal and we wanna put our healthy bodies under the risk of dozens sequelas. I don't blame doctors for reasonable doubts about our psychics. I believe that though free HRT for anyone could be convenient it also quite dangerous and sometimes it might not be solution for problem.

As for teens, call me agist, but they actually don't know life and have no idea of what do they want and how to reach it. At least, in mother Russia, but I suspect it something worldwide. Dammit, even adults might be lost. And you suggesting them to decide their fate without any investigation?

Hi, Alice

I believe you wrote in response to my post, right?
If so, I once again agree with you. I believe at least some assessment should be made even if treatment is offered under informed consent.

Where children are concerned, I think assessment is even more important. However, especially masculinization can be quite rapid, and even be almost complete by the time assessment is done. This is why I believe blockers should be used to buy time for the patient. If the child decides not to transition, very little is lost. In the opposite case they can prevent much suffering.

One other thing to consider, as I understand it you will quickly discover if HRT is for you or not.  If someone tries it and stops before the physical changes happen, is there a problem?  Is a therapist really necessary then?

BTW, When I got my prescription, I couldn't wait to get home and start my HRT and the first thing I do, when I get up in the morning, is take my pills.  I just don't want to wait any longer than necessary.  I guess HRT is appropriate for me, as I'm so happy to be on it!

@zirconia , I answered to everyone

QuoteOne other thing to consider, as I understand it you will quickly discover if HRT is for you or not.  If someone tries it and stops before the physical changes happen, is there a problem?  Is a therapist really necessary then?

When you drastically changing chemistry of your body there always might be a problems (though not neccessary). They may be immediate or long-termed.

QuoteBTW, When I got my prescription, I couldn't wait to get home and start my HRT and the first thing I do, when I get up in the morning, is take my pills.  I just don't want to wait any longer than necessary.  I guess HRT is appropriate for me, as I'm so happy to be on it!

I do not know how you can get your prescription. For me it means "visit dozen specialists, be questioned by them, bring them blood test and hell know what else, then receive approval to start HRT (if your health is good for that) from endo and diagnosis F64.0 from counsil of those specialists which allow you to get prescription". I found it annoying a bit but quite acceptable, because I will know that I'm not mentally ill and my wish to change my body isn't dictated by some conditions, and I will probably survive HRT if I will do it correctly.

QuoteI do not know how you can get your prescription.

I got mine on informed consent.  I told my doctor I wanted feminizing hormones and was referred to an endocrinologist, who prescribed it.  This has only been possible in Ontario, where I live, for a bit over 3 years.  Prior to that it was necessary to go to a therapist.  In fact, you had to live a year with RLE, before you could even get hormones and the program you had to go through was more of an obstacle course, than a program to help trans people

Obviously we have different circumstances
...and points of view.

I believe informed consent or refuse should be used after diagnostics to ensure that patient understand all risks of treatment plan or risks of refusing treatment at all. You, I guess, believe, that informed consent should be used to let people diagnose themselves on their (and society) own risk. I assume that WPATH thinks that way too. And though I suppose it is good for natural selection, I don't agree with that For me, our condition is out of normal, therefore we should let professionals to do their work to understand how fix it.

M y informed consent appointment, with the endo, was about a half hour, with us discussing why I thought I was trans, my plans and also health issues.  I had also first raised the issue with my own doctor about 2 years earlier.

Forgive me my scepticism. Endo might check if you physically healthy enough for that. That's okay, and that's main function of this specialist. Talking about "why" and plans is just a friendly conversation unless your endo have in pocket psychiatry diploma.

And about your doctor... Which speciality your doc have? I have friends-doctors too. Two x-ray specialists, one anestesiologist, one surgeon. Now we can have some terminology issues. In my vocabulary, therapist is doc who diagnose physical diseases, psychiatrist is one who diagnose mental ones, and psychologist is one who isn't doc at all and just took some lessons about psychology, that kind of specialists forbidden from making diagnosis. And in my opinion, only second one can decide if you don't have any conditions which makes you behave as opposite gender and you just trans.

My doctor is just a regular family doctor.  However, I see her regularly, get blood tests for my physicals etc.  She would also get the results from any specialists I'd seen.  As for friends, I do have a psychologist friend I've known for over 20 years, who is happy for me to get HRT.  She came right out and said she'd known I wanted it for years, even though I had never mentioned it to her previously.  I've never been to her or any other psychologist in a professional manner, but the first time we met, I was fully cross-dressed and we were at a "Fetish Night", so she knows about this side of me.  In other issues, in recent months, I have had blood tests, ultrasound, X-rays and CT scan and been seen by an internist and urologist.  So, I think my health has been fairly well examined.

I still don't like absence of professional examination from psychiatrist, but I assume 20-years friendship with one may be considered such examination. Then I agree, your diagnosis might be quite accurate.
So remind me why we don't need that?

I don't understand your obsession with this.  This is current WPATH protocol, which has been developed by the various professionals.  Then it was allowed by the governments in many areas, including Ontario, on top of which it is done with professional care, in my case my GP and the endo I was sent to.  Why do you think you know more than all those?  What are your qualifications in this matter?

Umm, rational thinking?
Because, again, there is conditions or mental diseases that cause opposite gender behavior and urge for gender correction, that must be excluded before letting one starting transition. For some reasons, I don't care about WPATH authority and it's protocols, and I care less about governments. We started from my opinion about Ashley's statements which suggest to let people diagnose themselves instead of letting professional psychiatrists do their work. Sure it would be convenient for those who really have transsexualism, but it might turn disasterous for those who haven't.

It isn't obsession. It is you who trying to prove me something, and I attentively listen and answer.

QuoteFor some reasons, I don't care about WPATH authority and it's protocols, and I care less about governments.

Oh, I see.  You're the expert and everyone else is wrong.

Great.

In Sweden we don't have informed consent. We need to see a whole team of specialists and then get the RIGHT diagnose to get treatment. You have to wait atleast a year to see the first doc. Then it takes 6 months to years before they determine if you are transgender or something else.

Before I started seeing the team I was waiting and waiting for my turn. I wished we would also have informed consent here. But now I'm not as sure. I think it was valuble to see the psychologist and the psychotherapist to turn and twist myself inside out and yet after that still feel as a man. That made me more sure about this is my path. This is the right decision.


Tony