You may have heard of the “informed consent” model for delivering gender-affirming hormone therapy (GAHT). It’s the model we use here at Plume, and an important cornerstone of delivering gender-affirming care. But what exactly is “informed consent,” and why is it so important? In this blog, we’ll break down the informed consent model, how it differs from other models of care, and what it means for you in practice.
Before we dive into the meaning of “informed consent,” let’s talk about the historical model of delivering hormone therapy for gender-affirming care. Previously, in what is sometimes called the “standard model” of care, medical providers would require a letter of assessment and support from a mental health professional before prescribing hormones to trans individuals. In other words, you couldn’t consent to getting hormones by yourself – a mental health provider had to “okay” the hormone prescription. This process could drag on for 2-3 years for some folks. This is a different model than consent for almost all other medical treatments. For example, you don’t need a mental health provider’s permission to get a flu shot, diabetes treatment, or to get your appendix removed.
There’s a lot of history behind why this was the model of care previously used – too much to fully dive into in this blog. But briefly, the old model was based on two ideas: 1) the medical ethics principle of “do no harm;” and 2) the assumption that mental health providers were best equipped to assess gender identity, gender dysphoria, and availability and need for support ((Cavanaugh, T., Hopwood, R., Lambert, C. AMA J Ethics. 2016;18(11):1147-1155. doi: 10.1001/journalofethics.2016.18.11.sect1-1611. Available at: https://journalofethics.ama-assn.org/article/informed-consent-medical-care-transgender-and-gender-nonconforming-patients/2016-11 )). In essence, medical providers relied on this mandatory “second opinion” from a mental health provider because they often did not (and still do not) have sufficient experience providing GAHT due to a lack of training and education around gender-affirming care.
But there’s more to this history than just a basic knowledge gap. This requirement of a letter is also rooted in stigma, misunderstanding of the trans experience, and ultimately a reluctance to give trans people autonomy over their bodies to decide what is best for them.
Trans folk pushed back against this stigma, and in 2012 the World Progessional Association of Transgender Health released new standards of care that supported the use of the informed consent model for providers with experience in gender-affirming care. ((WPATH Standards of Care for the Health of Transsexual, Transgender and Gender-Nonconforming People. Version 7. https://www.wpath.org/media/cms/Documents/SOC%20v7/Standards%20of%20Care_V7%20Full%20Book_English.pdf)) By not requiring people to find (and pay for!) a mental health provider to provide a letter of support, the informed consent model helps to reduce structural barriers that prevent our community from accessing needed medical care.
So what exactly is “informed consent”? In general, informed consent means that a person is able to understand the risks, benefits, alternatives, unknowns, and limitations of a given treatment. In the gender-affirming care setting, this means that medical providers who feel comfortable making an assessment and diagnosis of gender dysphoria are able to start GAHT without a prior assessment by a mental health provider ((Deutsch, M. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People: Initiating hormone therapy. (June 17, 2016.) Available at: https://transcare.ucsf.edu/guidelines/initiating-hormone-therapy)). It should be noted that one does not have to have gender dysphoria to be trans or gender non-conforming, but for many folks with gender dysphoria, hormones can be very helpful in reducing gender dysphoria and can often be lifesaving. The informed consent model has already been used by many major LGBTQ health clinics across the country for years, including Fenway Health, Planned Parenthood, and Howard Brown Health to name just a few. But, unfortunately, there are still many providers in the US who require a letter from a therapist before starting GAHT.
At Plume, using the informed consent model means that you can get your hormone prescription after an initial visit with one of our medical providers. We don’t require you to have another visit with a mental health care provider to get a letter validating what you’ve already told us. You and your medical provider will work together to develop an individual treatment plan to best meet your goals.
It’s also worth noting that practicing informed consent does not mean we don’t recognize the importance of having mental health support. Mental health support is incredibly important, but we recognize that this support might come in the form of a therapist, your friends, a primary care provider, a psychiatrist, online communities, family, and many other combinations of folks from your life. If you do see a mental health professional, the informed consent model can help to foster a more trusting and open relationship, as you are free to focus on your mental health without worrying about needing to say the “right” things to get a letter of support (Cavanaugh et al., 2016).
At its core, the informed consent model centers your autonomy and empowers you to make decisions about your body, whether it’s hormones or the type of mental health support you find best for you. Here at Plume, your provider will be there to facilitate a discussion about the risks and benefits of treatment options, but at the end of the day, we recognize that you are the one best positioned to judge if a given medical intervention is right for you.
