Informed Consent…and Thoughtful Consideration

NOTE: The opinions expressed here are only the writer’s, Nancy Quay, LMSW.  They are not meant to reflect any official statement from the University of Michigan Health System (UMHS) or the UMHS Comprehensive Gender Services Program (CGSP).

Informed Consent for Medical/Surgical Treatment

The Informed Consent model of care, growing in popularity and availability in the transgender health world, is based upon a common assumption that individuals can be—in fact, should be—responsible for their own healthcare decisions.  It is a medical model that grew throughout the 20th century, in part caused by legal action taken by patients against physicians.

An excellent article on informed consent was written by Hana Osman in 2001 and I encourage you to read it.  It is critical that we understand the history as we embrace change within the practice of transgender healthcare.

Informed consent for transgender patients is currently in practice in many places, and is being debated in others.  There are many arguments in favor of gender-variant people having access to the medical and surgical care that will bring them into congruence and enhance their lives.  The recent and appropriate shift from ‘Gender Identity Disorder’ (placing the problem within the patient) to ‘Gender Dysphoria’ (placing the problem within society) is an indication that the field of transgender healthcare is a rapidly evolving landscape.  Personally, I applaud many of the changes and also the larger conversation about the importance of serving the needs of our transgender citizens.

So where is my hesitation?

Addressing the Binary

The issue of binary genders is often brought up in discussions of gender variance.  Having only the choices of male/female, masculine/feminine, and boy/girl is restrictive, and robs many people of the freedom to live more fluidly.

But here’s what catches my attention—in the 16 years I’ve worked as a social worker and psychotherapist with transgender people, while many of my clients have commented on the restrictions of binary gender, those same people have moved from one end of the spectrum to the other.  That is, people assigned male at birth have become women; people assigned female at birth have become men.

See the problem?  It is still a binary designation, they’ve just moved from one side to the other, most usually with the help of medicine and/or surgery.

Do we live in a binary world?  Absolutely.  Gender is seen that way but there are other dichotomies as well—adult/child, teacher/student, therapist/client, doctor/patient, Republican/Democrat, and many more. 

The REAL Binary

However, I believe the real binary category is between SELF and OTHER…that these designations are the foundation of all other binary categories.  For example, the designation between ‘self’ and ‘other’ is the basis for many of the wars fought around the globe.

You are you.  I am me.  To you, I am the other.  To me, you are the other.

And therein is my personal issue with the model of informed consent for gender transitions.

There is No Vacuum

No one, NO ONE, transitions in a completely ‘other’ free environment, even transgender people who have no family, no close friends, no employer, etc.

We live in society.  We are surrounded by ‘others’ all the time.

All of us have ‘others’ in our lives.  It might be the person who walks his dog by our house and knows our dog, even if he doesn’t technically know us.  If we transition and change in looks or behavior, he will notice.  It might be the mail carrier, who notices our name change.  Perhaps it’s the grocery clerk who notes a change in our appearance and maybe even a change in what we buy to eat.

Does it matter?  Maybe, maybe not.

But the trouble with the informed consent model is that the question—does it matter? — is never asked.

What is asked?  Well, here are a few: are these medications safe for me?  Can I tolerate any side effects?  Do I understand the risks?  Am I prepared to take the medications on a regular basis?  Am I taking full responsibility for the effects of these medications on my body?

Too many people, daunted by the prospect of explaining their gender concerns to others, feel that medical and/or surgical transition will force acceptance.  That is, if one doesn’t want to hear dad’s disappointment, mom’s fear, or sister’s distress, just don’t tell them until after breasts develop, or voice deepens.  It will still be a battle, but the outcome will be pre-ordained, all of the good, but also all of the bad.

Informed consent allows this to happen.

Without a chance to talk to a professional—someone with no vested interest in one’s answers who has heard hundreds of stories from transitioning people—what about the other questions?

For instance: am I prepared emotionally for the change in my appearance? Am I prepared socially for how that might change my status in the world? Am I prepared for negative reactions to the changes, which may affect my job security, my social life, or my emotional and physical safety?

These are crucial questions.  A transitioning person who has limited or no opportunity to explore the full ramifications of their physical and emotional changes with a caring and supportive professional is at risk for negative outcomes.  And I don’t believe that is anyone’s goal.

Thoughtful Consideration

The informed consent model, with all of its strengths and weaknesses, is here already.  If it isn’t in your neighborhood, it will be soon, and in many, many ways transgender people will benefit from it if they are within the care of knowledgeable and compassionate medical providers.

But I encourage everyone—providers, patients, caring ‘others’—to thoughtfully consider all the ramifications of gender transition, not only for the person experiencing it but for society at large.

If we are to offer this service to our transgender citizens, we must also offer everyone else a chance to learn and grow about gender variance in a non-judgmental environment.

It won’t be achieved by forcing ‘others’ to accept the new ‘self’.   And it won’t be achieved by implying that gender transition is trivial, or doesn’t matter.

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