Enlightened consent – going beyond the minimum

By Lena Van Hale, Manager – Magenta WA and Secretary – Living Proud Inc

The HealthPathways WA Transgender Health and Gender Diversity HealthPathway is now LIVE.

As a long time trans activist and peer supporter, I’ve watched with delight as informed consent models have surged in popularity within gender affirming care (GAC). When I transitioned, very few of us accessed care at all, and those that did required expert knowledge from our peers. I became “informed” before I ever saw a clinician. Meeting with a trans friend, I learned how she handled herself, and what preoccupied her. I became an expert through a type of field research, because non-experts were guaranteed to fail the assessments required to access GAC.

It is undoubtedly positive that trans patients no longer need to have an encyclopaedic knowledge of gender to access GAC, however it leaves us with big shoes to fill if we are to replace those older methods of information transfer. Now that our models have improved, we must be flexible enough to BOTH adequately educate patients, while also not delaying urgent care for others.

If we are to go beyond our minimum requirements for good care, for a person just questioning their gender, “minimum informed” might simply be knowing that people with gender incongruence exist. Knowing we exist is one thing, knowing our forms and labels is another, and knowing how to work out if any of these forms fit you is another entirely.

Questioning “does my internal gender feel different to my external?” vs “would I feel more comfortable with a different external gender?”, each may return strong feelings for a patient. It is important for a trans person to understand that each of these are valid trans experiences, even if their answers contradict. Other valuable questions include “can I picture myself growing old as this gender?”, “can you imagine other people in your life perceiving you as another gender?”, and “if you had a button that could change your external and/or internal gender instantly, would you press it?”

When acting on gender incongruence, the “minimum informed” is knowing that Hormone replacement therapy (HRT) exists, understanding its side effects, its intended effects and expected time frames, and its reversibility. For most patients this is a tiny piece of their puzzle. Acting on it may mean social transition. It may include dealing with other health issues. Understanding what you can and can’t change about yourself starts before hormones and goes far beyond them.

For most people, this includes a long process of picking apart which aspects of the self are a cultural gendered expectation, and which parts may be innate or instinctual. Developing a healthy internal narrative of sex and gender is an important part of living a happy life, even for cisgender people. A trans person who internalises negative gendered stereotypes may attribute these to themselves (from all genders too), and may even intentionally engage in problematic behaviour, having internalised this as a natural part of living as their chosen gender. As an educator I often find it important to push back on this. I often joke that just because my gender is valid, doesn’t mean my gender is relevant.

While we may currently lack the perfect informed consent checklist, we need not overcomplicate it. We don’t have to quiz patients on gender theory for them to feel safe explaining both what they want and what they think is possible to get from transition. A questioning patient’s needs differ from a confident patient who already questioned for years, but each may require urgent care. If a patient has an insecurity or stereotype so extreme it may continue to negatively impact them after transition, we should be able to identify that and even challenge it without requiring assessment by a full multi-disciplinary team.

All patients should know they can change their mind and should not be judged for it, but they should also know that regret is extremely rare. Not all trans people medically transition, and some choose to take lower doses of hormones or only take them temporarily for some small changes. Clinicians and patients must also understand that some people regret not accessing HRT sooner, not pursuing a stronger regime, or not transitioning faster or slower.

A transparent, collaborative informed consent process is a massive improvement on older models of GAC, positioning patient and clinician as allies rather than adversary and gatekeeper. Foster a collaborative environment, gather a good understanding of their personalised goals for transition, aim to reach a mutual agreement to where you each think they are well informed, create a shared agreement for you both to sign, and document it.

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