From Gatekeeping to Truly Informed Consent: The Mental Health Provider’s Role
by Sand Chang, PhD
Gatekeeping
Trans and gender nonconforming patients who desire and seek gender-affirming medical interventions are typically required to meet with a mental health provider who can assess appropriateness and readiness for care. This is based on the guidelines set forth by the World Professional Association for Transgender Health (WPATH) Standards of Care Version 7 (SOC7), which was published in 2011.
Although the SOC7 made a significant departure from previous versions of the SOC in that it no longer requires psychotherapy prior to approval for transition-related or gender-affirming medical interventions, it still places the mental health provider in a gatekeeping role. This is often referred to as a “gender assessment” and often involves a detailed gender history.
I want to underscore that the term “gender assessment” is problematic, as trans people know why we/they are, and no mental health professional can act as the expert and determine whether someone is truly trans, or a woman, or a man, or nonbinary, etc. In addition, the practice of obtaining a thorough gender history perpetuates a singular, binary, medicalized narrative of what it means to be trans and, thus, who and who does not merit medical care.
Gender assessments often include questions that are irrelevant to obtaining truly informed consent. For example, the kinds of toys a person played with as a child does not make someone any more or less of a man or woman and certainly does not speak to whether someone understands the risks and benefits of the care they seek. Another example is the extent to which a person endorses having “gender dysphoria” (which is a diagnosis that is required in order to make the case for medical necessity of requested services). Someone who reports having milder gender dysphoria (or no dysphoria at all) is not necessarily a less appropriate candidate for care than someone who reports severe dysphoria.
I use this example not to minimize the kind of pain and suffering that dysphoria causes, but to make the case that patients should not be set up to compete with each other based on who is more convincing at communicating their distress. In addition, a person’s gender story and awareness are not without context, including cultural and familial norms and the level of safety in exploring, expressing, or acknowledging (even to oneself) a gender that differed from expectations.
I want to shift the conversation to talk about how mental health providers can be helpful in supporting trans patients through the process of seeking and receiving gender-affirming medical care. As a health care system, we need to move away from gatekeeping based on gender narratives and toward a more client-centered, collaborative approach that focuses on informed consent.
Informed Consent
Truly informed consent goes beyond skimming and signing a piece of paper or having a rushed conversation with a physician/surgeon. Trans patients deserve accurate information that can help them understand what they are choosing and why.
Though there is often information and collective wisdom shared in trans communities, including online forums, not all information is up-to-date or relevant to the person’s medical system or provider team. Mental health providers can support patients in exploring risks and benefits, including the emotional aspects of medical decision-making, as well as help patients in the process of navigating medical systems. Here are some examples:
1. Goal setting
Providers may help their patients identify and name their specific goals – because we want to move away from assuming that all patients have the same goals when seeking similar medical interventions – and explore what a medical intervention may mean for them in the context of their lives. Clear conversations about hopes, expectations, and desired benefits, as well as concerns, questions, and perceived risks, may serve to prevent medical errors.
For example, there are a number of ways that providers can support informed consent for a transmasculine person considering a hysterectomy. There may be many reasons why that person may be interested in this particular surgery, including: dysphoria related to having certain organs that do not feel in line with the person’s gender identity, cessation of menses, wanting to reduce hormone dosage, or prevention of health problems.
About a decade ago, trans people and medical providers believed that people taking testosterone had to have a hysterectomy within five years in order to prevent the development of ovarian cancer. This information is no longer considered valid, but many patients (and providers) do not know this. Upon learning this information, they can still move forward with choosing this surgery, but they can also opt not to if there is no other reason why they are considering it.
Other examples include low dose hormones, opting out of surgeries, or exploring alternatives forms of surgery.
2. Psychosocial factors around surgery
It is important that patients get accurate information about what surgery preparation and recovery entail. That can help with elements of planning, such as securing a stable place to recover, enlisting adequate physical and emotional support, negotiating time off with employers, financial planning, dealing with insurance, and health changes that have to be made to support a positive outcome. The mental health provider can also involve caregivers or partners who also need to go through a process of informed consent (e.g., making a clear agreement to take time off work to drive the patient to surgery or help with wound care).
3. Navigating medical systems
Providers may assist in helping patients know what to ask in medical visits, and how to advocate for their needs. Patients often do not know what information they need, or they may feel intimidated when meeting with surgeons. Mental health providers can support patients in feeling more prepared and empowered in these interactions.
4. Related health needs or desires
Some patients need support in navigating questions about preserving reproductive function and how that may be affected by medical interventions.Others would benefit from support in understanding how certain medications may affect longer term health, such as the ways that sex hormones (whether endogenous or exogenous/prescribed) protect bone health.
In addition, there is a high prevalence of mental health symptoms in trans populations that is impossible to separate from gender dysphoria, anti-trans discrimination, trauma, and health disparities. Trans patients deserve respectful, competent care from providers who understand the cultural context of these concerns, do not use them to disqualify patients from care, and seek to link patients to the resources that can better support their wellness through accessing medical services.
5. Emotional resilience and coping skills
Patients have a wide range of emotional or mental health needs. Some people feel adequately resourced, while others feel they could benefit from having a provider help them identify or build a set of coping skills (that would be available to them while receiving medical interventions).
The process of seeking gender-affirming medical interventions can be stressful, whether it be directly related to the intervention itself or simply based on having to interact with medical systems and providers that systematically discriminate against trans people. Mental health providers can provide an outlet and a space for patients to build and maintain stability and resilience.
Patient Education Programs
In the transgender health system that I work in, our interdisciplinary team has designed pre-surgical patient education programs for different surgeries to address so many of these factors.
Patients deserve to know what they were choosing, what to know about preparation and recovery, and how to take care of mental health and emotional needs. This has been especially important for patients who are obtaining services that have only been covered by health insurance plans for a few years and for which there is not a great deal of accessible, reliable information.
For instance, patients considering phalloplasty will need information about the hair removal involved from the skin graft donor site, scarring, possible complications, the need for physical therapy for the donor site, the varied number of surgeries (and recovery periods), how different options may affect sexual function, having urethral lengthening or a vaginectomy then raises the necessity of having a hysterectomy, the high risk of complications, and related reproductive options/implications. Patients who attend these classes often benefit from hearing a panel of patients who have had the same surgery and can share their experience firsthand.
I am under no illusion that gatekeeping practices around gender identity are going anywhere soon. But those of us who believe in the affirmative model of care can employ a harm reduction approach and seek to provide services that are actually relevant and useful to our patients.
The philosophy behind most of the training and education of medical and mental health professionals that I do is based on the value of giving people the information they need to make their own choices about their bodies. Patients really appreciate the opportunity to learn and feel like partners in their own health care experiences, and in my opinion that’s always the goal—a more patient-centered, collaborative model of care.
About Sand Chang
Sand Chang, PhD (they/them/their) is a Chinese American genderqueer-identified psychologist, educator, and trainer. They currently work for NCAL Kaiser Permanente in designing clinical and cultural competence education programs for transgender health and maintain a private practice in Oakland, CA specializing in trauma and EMDR, eating disorders, addictions, relationships, and healing work with marginalized communities, particularly people affected by the intersections of racism, homophobia, and transphobia. In their private practice, Sand runs consultation groups for mental health providers working with trans clients. Sand served on the Task Force that authored the 2015 APA Guidelines for Psychological Practice with Transgender and Gender Nonconforming Clients and is the past Chair of the APA Committee on Sexual Orientation and Gender Diversity (CSOGD). Outside of their professional work, Sand is a dancer, avid foodie, punster, and pug enthusiast.
Questions for Sand? Tweet @drsandchang or comment.
About Patients & Providers
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genderqueer.me 
How have you come to find this sort of “patient-centered” and collaborative model of care to be received by coworkers who may not be as experienced with trans patients?
Responses tend to vary. I’ve found that providers who approach the work with some degree of humility and openness are able to hear why it is so important for trans patients’ autonomy and dignity to be respected. However, there are many providers who are trained in a very hierarchical model which assumes that the provider always knows best and the patient is not capable of making the best decisions for themselves. For providers who are very inexperienced, their own anxieties or biases can result in greater fear-based gatekeeping.
Do you find it difficult in professional settings as a HCP who is also trans to try and explain or argue why the gatekeeper model is incorrect to professional peers? I’ve been struggling with this as someone who falls into both of these categories myself.
Yes, absolutely! When people don’t have a framework for understanding cultural identities, oppression and privilege, or intersectional dynamics, this message can be very confusing and counter to providers’ medical or mental health training. One challenge that I’ve witnessed and experienced again and again is that when trans providers advocate for patient-centered care, they are cast as activists/advocates and no longer considered professionals/providers. Many people I’ve talked to who have been in the role of both trans community member and health care professional have talked about the great deal of emotional labor and diplomacy that goes into the work so as not to end up in burnout.