AMA Journal of Ethics^®

Abstract

Some people want to modify their bodies through hormonal and surgical treatments in order to resolve gender dysphoria, the distress they experience when their bodies do not align with their gender identity. The World Professional Association for Transgender Health (WPATH) offers guidelines to clinicians regarding treatment of people wanting to modify their bodies for this reason. Prior to these modifications, WPATH advises that mental health screening is needed and that psychotherapy is recommended though not a requirement. In fact, these advisories allow clinicians some freedom in applying the standards to specific cases. Although some variation from the WPATH Standards of Care can be clinically acceptable, informed consent remains an essential component of clinical encounters involving body modifications.

Case

Among her patients, Dr. Leonard, a family medicine practitioner, has developed a reputation as a physician especially welcoming to lesbian, gay, bisexual, transgender, and queer (LGBTQ) patients. Over the years, Dr. Leonard has noticed—with much happiness—that her LGBTQ patients are coming out at younger ages and embracing identities that span an increasingly diverse spectrum of gender and sexuality—an indication, she thinks, that important social and cultural progress has been made.

Today, Dr. Leonard’s nineteen-year-old patient, Tyler, is coming to see her. Tyler was female-sex assigned at birth; however, four years ago, Tyler came out to friends and family as a transgender male. In recent visits, Tyler has begun discussing with Dr. Leonard the possibility of pursuing medical assistance with gender transitioning, including gender-transitioning hormone therapy and gender reassignment surgery, which might involve “top” surgery—breast removal, in this case—or “lower” (also called gender affirmation, gender confirmation, or genital reassignment) surgery, a procedure to change genitalia. On his last visit, Dr. Leonard sent Tyler home with some readings relevant to the next steps of his transition to try to help him decide whether and when—if ever—to pursue gender transitioning with medical interventions.

“Dr. Leonard, I read what you gave me about the next steps of possible treatments, and I wanted to ask you about something,” Tyler said during his appointment. “While I do want to begin transitioning with top surgery, I read that I’ll have to get clearance from a mental health counselor first. But I don’t think my transition should require mental health counseling or approval.”

Dr. Leonard conceded that current guidelines from the World Professional Association for Transgender Health do recommend that patients receive at least an assessment and one documented referral for gender-transitioning surgery from a mental health professional before undergoing a procedure. She suggested to Tyler that he might view mental health counseling as a way to learn about and prepare for the potentially long lasting and irreversible effects of surgical body modification.

Tyler was still resistant. “Dr. Leonard, I don’t think I should have to prove to someone that I am who I am. Who else has to do that?” Tyler added that he had seen counselors in the past—for instance, to help him cope with his parents’ divorce. When it came to gender identity, however, he explained, “It’s the one thing about me I struggle with least. I’m really being pressed to do the counseling to make others comfortable with my decision, so it bothers me that this is pitched as being ‘for my own good.’”

Dr. Leonard had never been prompted to question the process of mental health assessment and counseling for transgender patients in the past. And while her medical judgment still sided with the idea that patients probably benefit from mental health counseling for gender-transitioning HRT or surgery, she also sympathized with Tyler. Dr. Leonard wondered if, in some cases, it could be harmful to ask a patient for identity affirmation through such institutionalized, formal channels. She wondered what to do next.

Commentary

Many people look to hormonal and surgical interventions to bring their bodies into alignment with idealized images they have of themselves as men and women. Men do this, for example, by having chin implants, breast tissue reduction, liposuction, and other body-shaping interventions. Women do this, for example, by having breast augmentation, breast lift, liposuction, and tummy-tucks, among other body-shaping interventions. Some men and women also reshape their genitals; men remove or restore foreskins, and women reduce or enlarge labia, for example. They do so, again, to conform their bodies to idealized gendered images they have of themselves.

Despite having female- or male-typical bodies, some people experience a male or female gender identity, respectively. Some of these people regret—if not suffer from—the ways in which their bodies do not conform to their gender identity, and some consequently look to clinical interventions to achieve an idealized body appearance, insofar as possible. The American Psychiatric Association (APA) advises physicians to treat the “dysphoria” (the distress) of people, rather than trying to treat the cross-sex identity itself [1]. Body modification through clinical interventions can help reduce the distress of wanting—but not having—physical traits that align with one’s gender identity. In what follows, I will respond to the case above by focusing on which requirements, if any, should be observed in the clinical provision of hormonal and surgical treatments that modify people’s bodies in the name of gender expression.

Should Mental Health Screening and Psychotherapy be Necessary before Body Modifications?

In this case, Tyler seeks body modifications to express a male identity, but he disputes any requirement that he get “clearance” from a mental health professional as a condition of access to those modifications. The World Professional Association for Transgender Health (WPATH) [2] does maintain that a mental health assessment “is needed” [3] for people wanting to modify their bodies for reasons of gender expression. That group also recommends—but does not require—psychotherapy as a prerequisite for body modifications [2]. (In some jurisdictions, evaluation by a health care professional is necessary to change one’s sex identity, as recorded by the state [4].)

But what rationale is behind WPATH’s recommendations? One possible reason, as articulated by Dr. Leonard in the case, is that body modifications are “irreversible,” involving as they do excision of genitalia, construction of genitalia, and hormone treatment to shape secondary sex characteristics. WPATH itself uses the language of irreversibility in describing some interventions [5] and the outcome of some physical changes [6]. In the face of this irreversibility, and the scale of the changes involved, is it not just prudent to ensure insofar as possible that Tyler is committed to the interventions he is asking for? And would psychological assessment and counseling not help offer some assurance that the interventions, their consequences, and their potential risks and benefits have been carefully considered?

Tyler doesn’t see it this way, however. He is confident of his decision and skeptical about clinicians serving as gatekeepers to body modification. A skeptic might press Tyler’s point even further: Aren’t the required assessment and recommended counseling for gender-affirming body modification paternalistic? If so, whose views are supposed to be endorsed by such paternalism, anyway? Why should a clinical authority have to “sign off” on an adult’s proposed body changes, except perhaps because society retains some interest in policing those changes, perhaps to secure the comfort found by some in a neat and tidy gender binary world of only hes and shes? After all, a skeptic might say, equivalent assessment and counseling are not required for men and women who wish to alter their bodies to conform to the gender norms of their given sex, even though many of those modifications are equally irreversible. There seems to be a troubling double standard at play here.

Against this skepticism, psychological assessment and therapy can be defended as important in clarifying the motives for body modification and the nature of its effects. Dr. Leonard might draw upon some of the following ideas to engage Tyler and show the benefit of assessment and therapy, despite apparent overtones of paternalism. These processes can, for example, clarify what is most important to Tyler: entering into a particular gender role, modifying relationships, having specific body traits, or something else. These processes can also help identify capacities and traits that could facilitate someone’s success in a gender transition. Counseling can also help explore some of the foreseeable physical and psychological effects of gender role change, residual effects of stigma attached to gender transition, and the implications of gender transition for family dynamics and workplace status, among other things. In short, psychological assessment and counseling can be instruments of success in gender transition rather than impediments to the exercise of choice. Still, a skeptic might respond that assessment and counseling are not equally valuable or necessary to all people. If so, these processes should be optional, not obligatory.

This skeptic might even challenge the idea that body modifications are irreversible. In a sense, hormone treatment is reversible at will because someone can simply stop it at any time for any reason. Not all hormones’ effects would vanish, but some would diminish over time. As for surgical interventions, breast restoration might also be possible to a degree, although it would probably involve significant additional interventions, procedures, or prosthetics. Options for penis reconstruction and even transplantation are becoming more promising for people looking to restore that body part [7]. Analogously, any constructed penis or scrotum could also be removed, and certain labial and vaginal reshaping can be carried out. These examples suggest that surgical body modifications are not irreversible in an absolute sense, even if a complete return to the status quo ante cannot be guaranteed. Even so, that degree of reversibility might be acceptable to some people who come to regret decisions to modify their bodies. In any case, no amount of prior assessment and counseling ahead of body modifications for gender expression will protect all people from all regrets over body modifications.

In the face of this skepticism about WPATH’s required assessment and highly recommended counseling, it is worth noting that WPATH itself says that its standards are flexible:

Clinical departures from the SOC [standards of care] may come about because of a patient’s unique anatomic, social, or psychological situation; an experienced health professional’s evolving method of handling a common situation; a research protocol; lack of resources in various parts of the world; or the need for specific harm-reduction strategies. These departures should be recognized as such, explained to the patient, and documented through informed consent for quality patient care and legal protection [8].

As a matter of professional ethics, then, a clinician might accommodate some people who want to bypass certain steps—such as psychotherapy—in the process of body modification, but important cautions apply to ensure the psychological and moral integrity of those decisions.

Informed Consent for Gender-Affirming Body Modifications

As a matter of moral integrity in clinical encounters informed consent must be obtained for body modifications for gender expression, as it must be for any clinical intervention. Physicians must take steps to ensure that their patients understand the nature of the interventions (i.e., exactly what will be done), their consequences (i.e., foreseeable effects), the risks and benefits of the interventions (including their reversibility or not), and alternatives to the hormonal or surgical interventions (such as means of gender expression involving modifications of behavior, roles, and ways of relating to others).

It may be that future generations of transgender people will come to decisions about body modifications with more information and perhaps less uncertainty than people at present. WPATH offers a variety of recommendations for the care of gender-nonconforming children and adults, and some of these will be exposed to health care professionals early on in their lives; that exposure may help them consolidate their interests in modifying their bodies while still relatively young. For example, clinicians now routinely treat certain minors to suppress the onset of puberty and, later in adolescence, to initiate treatments to shape the body in desired ways [9-11]. In some instances, clinicians have even surgically modified the bodies of minors, although most professional groups recommend delay until a child reaches the age of 18 [12]. When caring for people with this kind of medical history, clinicians might depart from WPATH’s recommended standards of care, depending on an individual patient’s needs for mental health assessment and psychotherapy. Even so, someone’s prior history of mental health assessment and psychotherapy offers little justification for any waiver of informed consent when it comes to body modifications for gender expression.