Informed Consent FAQs

1. What is informed consent?

The following definition is from the Informed Consent for Access to Trans Health (ICATH) website:

“When a person gives “Informed Consent,” it means that the individual possesses the cognitive ability to make an informed and independent decision about their health care and are choosing to do so without coercion.

The individual understands both the benefits and potential risks of the choice they are making and is able to anticipate how that choice may impact them now and in the future. In other words, the individual has the capacity and all of the information needed to make a completely informed decision.”

2. Is informed consent equivalent to “hormones on demand”?

Informed consent is not the same as “hormones on demand”. “Hormones on demand” implies that anyone who asks for hormones will immediately receive a prescription for them, no matter what. The informed consent model differs from traditional models in that there are no minimum number of visits that must occur, and no routine expectation that clients undergo counselling prior to prescribing.

At the Catherine White Holman Wellness Centre (CWHWC), physicians who have training and experience in providing trans health care carefully assess people requesting hormones. This assessment is completed before a prescription is written.

Each person is assessed on an individual basis to determine their readiness for hormone therapy. Some clients are very knowledgeable about what to expect from hormone therapy, are well aware of the potential risks and are confident in their decision to take hormones. In these cases, if there are no medical or social issues that would need to be addressed, they may receive a prescription within 1 or 2 visits. Other people benefit from multiple visits to become fully educated about hormone therapy and to ensure that the decision to take hormones is right for them. This may also include visits with one of our counsellors. Some medical conditions may need to be addressed prior to safely commencing hormone therapy. There are also times that we may delay hormone therapy due to social factors. For example, a youth residing in a transphobic home where physical changes from hormones may place them at risk for violence or homelessness may need to wait until they are in a safe and supportive living situation. There are some situations where hormone therapy is inappropriate and will not be provided even when requested. Our team will make every effort to provide support and alternative forms of gender affirming care in these situations.

3. Why do we use informed consent at CWHWC?

At the CWHWC we aim to work collaboratively with people who self-identify as trans and gender non-conforming. We strive to provide gender affirming health care that reduces health disparities.

The informed consent model is used at CWHWC primarily because of our strong belief in trans people’s right to self-determination. We do not support the traditional psychiatric model which requires the health care professional to diagnose a psychiatric condition (Gender Identity Disorder) prior to providing gender affirming health care. We believe that trans and gender non-conforming
identities are identities, not pathological conditions. This belief is consistent with the position of the World Professional Association for Transgender Care (WPATH). In 2010 WPATH issued a statement calling for the de-psychopathologization of gender non-conformity.

We are deeply concerned about the health disparities faced by trans and gender non-conforming people. Therefore we offer a model of care that minimizes barriers and involves community members in a way that will hopefully lead to transformative change in the health and well-being of trans communities.

4. What Role Does Counselling Play in the Informed Consent Model Used at
CWHWC?

Our team values the role of mental health professionals in the care of trans and gender non-conforming people. We have a team of mental health counsellors who are available to our clients. These counsellors work on site as part of our inter-disciplinary team. In traditional models of care, mental health counsellors have sometimes been perceived as gate-keepers. In our model, counsellors provide ongoing support and assistance to trans and gender-non-conforming people, to help them cope with, resist, and thrive in a context of profound transphobic oppression. We find that our clients appreciate having counselling made available to them, rather than being expected to participate in counselling in order to receive gender affirming health care.

5. Will getting hormones by an informed consent model rather than a traditional assessment have a negative impact on later access to gender affirming surgery?

Receiving hormones through an informed consent approach should have no bearing on later access to gender affirming surgeries.

The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) recommends criteria that should be met prior to the different types of gender affirming surgeries. In some instances (such as genital surgery) the criteria includes “12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones).” For other surgeries, such as male chest contouring, hormone therapy is explicitly mentioned as not being a pre-requisite. In any case, there is no criteria for surgical assessment that specifies what type of hormone readiness assessment a person needs.

At CWHWC, our physicians have extensive experience making the necessary referrals within the BC medical system for accessing gender-affirming surgeries. We have already had patients who received hormone prescriptions via an informed consent approach receive both approval from the provincially-appointed psychiatric assessors and provincial funding for gender-affirming surgeries.

6. Does informed consent go against the WPATH Standards of Care?

No, the latest version of the Standards of Care (SOC) explicitly discusses the use of the informed consent model and endorses the use of this approach by qualified health professionals.

The main criteria for hormone therapy outlined in the Standards of Care are:

1. Persistent, well-documented gender dysphoria;
2. Capacity to make a fully informed decision and to consent for treatment;
3. Age of majority in a given country;
4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.

In addition, the following paragraphs taken directly from the latest WPATH SOC support the use of an Informed Consent approach to prescribing:

“As in all previous versions of the SOC, the criteria put forth in this document
for hormone therapy and surgical treatments for gender dysphoria are clinical
guidelines; individual health professionals and programs may modify them.

Clinical departures from the SOC 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. This documentation is also valuable for the accumulation of new
data, which can be retrospectively examined to allow for health care – and the
SOC – to evolve.

The SOC articulate standards of care but also acknowledge the role of making
informed choices and the value of harm reduction approaches. In addition, this
version of the SOC recognizes and validates various expressions of gender
that may not necessitate psychological, hormonal, or surgical treatments. Some
patients who present for care will have made significant self-directed progress
towards gender role changes, transition, or other resolutions regarding their
gender identity or gender dysphoria. Other patients will require more intensive
services. Health professionals can use the SOC to help patients consider the full
range of health services open to them, in accordance with their clinical needs
and goals for gender expression.”

Relationship between the Standards of Care and Informed Consent Model
Protocols

A number of community health centers in the United States have developed
protocols for providing hormone therapy based on an approach that has become
known as the Informed Consent Model (Callen Lorde Community Health Center,
2000, 2011; Fenway Community Health Transgender Health Program, 2007;
Tom Waddell Health Center, 2006). These protocols are consistent with the
guidelines presented in the WPATH Standards of Care, Version 7. The SOC are
flexible clinical guidelines; they allow for tailoring of interventions to the needs of
the individual receiving services and for tailoring of protocols to the approach and
setting in which these services are provided (Ehrbar & Gorton, 2010).
Obtaining informed consent for hormone therapy is an important task of providers
to ensure that patients understand the psychological and physical benefits and
risks of hormone therapy, as well as its psychosocial implications. Providers
prescribing the hormones or health professionals recommending the hormones
should have the knowledge and experience to assess gender dysphoria. They
should inform individuals of the particular benefits, limitations, and risks of
hormones, given the patient’s age, previous experience with hormones, and
concurrent physical or mental health concerns.

Screening for and addressing acute or current mental health concerns is
an important part of the informed consent process. This may be done by a
mental health professional or by an appropriately trained prescribing provider
(see section VII of the SOC). The same provider or another appropriately
trained member of the health care team (e.g., a nurse) can address the
psychosocial implications of taking hormones when necessary (e.g., the impact
of masculinization/feminization on how one is perceived and its potential impact
on relationships with family, friends, and coworkers). If indicated, these providers
will make referrals for psychotherapy and for the assessment and treatment of
co-existing mental health concerns such as anxiety or depression.
The difference between the Informed Consent Model and SOC, Version 7 is
that the SOC puts greater emphasis on the important role that mental health
professionals can play in alleviating gender dysphoria and facilitating changes
in gender role and psychosocial adjustment. This may include a comprehensive mental health assessment and psychotherapy, when indicated. In the Informed

Consent Model, the focus is on obtaining informed consent as the threshold
for the initiation of hormone therapy in a multidisciplinary, harm-reduction
environment. Less emphasis is placed on the provision of mental health care
until the patient requests it, unless significant mental health concerns are
identified that would need to be addressed before hormone prescription.”

Glossary

World Professional Association for Transgender Health (WPATH): WPATH is an international, multidisciplinary professional association that promotes evidence based care, education, research, advocacy, public policy and respect in transgender health. The vision of WPATH is to bring together diverse professionals dedicated to developing best practices and supportive policies worldwide that promote health, research, education, respect, dignity, and equality for transsexual, transgender, and gender nonconforming people in all cultural settings.

WPATH Standards of Care: One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus. The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.

References

World Professional Association for Transgender Health: www.wpath.org

WPATH Standards of Care: http://www.wpath.org/documents/SOC%20V7%2003-17-12.pdf

Informed Consent for Access to Trans Health (ICATH): www.icath.org