Drop ‘dehumanizing’ mental health assessments for trans youth wanting body-altering hormone therapy, McGill bioethicist argues
|National Post 22 Apr 2019 at 12:52|
Doctors should stop insisting transgender teens undergo “dehumanizing” psychiatric assessments before granting them body-altering hormones, argues a new paper by a McGill University scholar.
“When I decided that I wanted to take hormones to feminise my body, the last thing I wanted to do was to go in front of a psychologist to justify my decision,” Florence Ashley, a transfeminine bioethicist and masters of law candidate at McGill wrote in the most recent issue of the Journal of Medical Ethics.
Current guidelines recommend trans teens and adults seeking potentially irreversible feminizing or masculinizing hormones first undergo mental health screening — a practice Ashley said devalues trans lives and bodies, reflects a mistrust of trans voices and turns the entire transitioning process into treatment of a psychiatric illness.
Instead, doctors should take the person’s word they are trans, Ashley said, including minors who have the maturity to decide about their own healthcare.
“We generally trust what other people say about their own mental states,” wrote Ashley, a fellow of the McGill Research Group on Health and Law. “If someone says, ‘My arm hurts,’ we typically grant credence to their claims.
“We have this trust in people’s self-reports of their mental states because we hold mental states to be within the purview of people’s epistemic authority — authority over knowledge.”
“If I were to doubt that person’s claim without serious reasons to believe otherwise,” Ashley wrote, “I would be committing an injustice because I would unjustly fail to recognize their authoritative knowledge of their own experience of the world.”
We have this trust in people’s self-reports of their mental states because we hold mental states to be within the purview of people’s epistemic authority — authority over knowledge
The assessment requirements is predicated on the idea that there are “true” trans people, and “false” trans people, Ashley said in an interview with the National Post. “There are people who aren’t fully trans phobic but who have this kind of very visceral suspicions of trans people and are afraid to move away from the medical model.”
“And the illness model is, ‘Well, we have to figure out what this illness is because there is this underlying ‘disease’ we have to cure.” The medical establishment, said Ashley (who prefers the gender-neutral pronoun “they”) has failed to keep up “with our evolving understanding of transitude — the fact of being trans — as part of normal human diversity.”
And while psychotherapy is no longer a condition of treatment, the line between assessments and psychotherapy can be seriously blurry at times, Ashley said, “especially among practitioners who favour lengthier assessments.”
Ashley’s paper comes as wait lists at gender clinics in Canada stretch more than a year, and as experts grapple with how young is too young to prescribe “cross-sex” hormones — estrogens so that a trans girl (a person who was “assigned” male at birth but now lives as a girl) develops a more feminized figure, and testosterone to give a trans boy (female transitioning to male) a more angular jaw, deeper voice and masculine physique.
Ashley socially transitioned months before seeking hormone therapy. A referral letter from a psychologist wasn’t required because the McGill student health clinic didn’t require one.
“Many others are not so lucky — and my own luck ran out when I had to seek two referral letters for genital surgery,” Ashley said.
The assessment for “gender dysphoria” — psychiatry’s term for the distress people can experience when their body doesn’t align with their gender identity — left Ashley feeling “exposed, naked and dehumanized.”
A photo of Florence Ashley, a transfeminine activist and bioethicist at McGill University, who is author of a new paper arguing that trans teens shouldn’t have to undergo psychological assessments before being prescribed body-changing hormones. Photo courtesy of Florence Ashley
In an interview, Ashley said the psychologist asked deeply personal questions about childhood and body image. “It’s always framed as these responses are relevant (when) what you’re really under study for is the validity of your experience.”
Medically transitioning isn’t always about gender “dysphoria,” Ashley said. Gender “euphoria” also leads people to seek out hormone therapy. “Instead of being distressed by my masculine fat distribution, I might simply be overjoyed by the thought of having a feminine fat distribution.” Focusing solely on dysphoria “would miss an essential component of why some trans people want to alter their bodies,” Ashley said.
Cross-sex hormones can cause irreversible physical changes — breast development with estrogen, or a permanent deepening of the voice with testosterone,
However, Ashley said the drugs pose no more risk than other medical interventions for which no psychological assessments are required. Ashley used the “my body, my choice” analogy of abortion.
Although the situations are very different, both are motivated by people’s autonomy and bodily integrity. “The fundamental ethos is that people know what they want regarding their body. Whether they want hormones or whether they want to be pregnant and keep a child to term — they should have the power to bring about the desired situation.”
Ashley said the double standard reflects an “unconscious hostility” towards trans lives and that doctors are positioning themselves as judge and jurors as to who is “really” trans. It’s like requiring someone to validate they are gay.
“For a very long time — and it’s still weirdly a thing that continues to happen today — you’ll have people that say, ‘Oh, I’m not really sure you are trans because you didn’t know you were trans when you were a kid,’ or horrendous stuff like, ‘You don’t wear enough dresses and, therefore, you’re probably not a woman.”
Ashley said doctors should drop the pre-treatment assessments and referral letters and take an informed consent approach instead — allow older trans teens and adults to decide for themselves, once the risks and benefits have been fully explained. And while Ashley’s article doesn’t say where, exactly, the age line should be drawn, the law in most provinces allows mature minors to make decisions about their own care if they can appreciate the “reasonably foreseeable consequences” of their decision.
“The question is much easier when you have parental support,” Ashley said. However, “I personally go on the lower end of things, and I think that, generally, people who have a capacity to provide meaningfully informed consent should be allowed to choose their care.”
The Endocrine Society, an international medical organization, says cross-sex or “gender-affirming” hormones may be administered around age 16, or as young as 13-and-a-half in special circumstances. Some experts worry that, without proper assessments, teens might be started on irreversible hormones they might later regret if their gender dysphoria doesn’t persist.
“We take the use of puberty blockers and/or hormones seriously and all our patients go through rigorous assessments, including a mental health check to ensure they understand the risks and to ensure gender transition is in their best interest,” the gender clinic at B.C. Children’s Hospital said in an email to the Post.
The clinic follows standards of care as set out by the World Professional Association for Transgender Health (WPATH), as do most clinics in Europe and North America caring for transgender and “gender-questioning” children and youth, the hospital said.
Those guidelines recommend assessments by a “trans-competent mental health professional,” the B.C. hospital said, to “independently evaluate the youth’s gender identity and the youth’s ability to consent or assent” to body-changing treatments.
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