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Informed Consent: Help or Harm?

There has always been a backlsah to The Harry Benjamin Standards of Care (HBSOC) by the transgender community.  The question that needs to be asked is "Why?"

Many in the trans community see the HBSOC as a barrier to their acquiring their letters of approval/acceptability to move forward to Hormone Replacement Therapy (HRT), cosmetic surgery, or SRS.  This is universal in both the male to female (M2F) and female to male (F2M) transsexual populations.

I think that at this juncture it is critical to establish that the HBSOC are a guideline of treatment protocols established and maintained by The World Professional Association for Transgender Health (WPATH).  The fact that this is a guideline is established at the beginning of the documented standards.  At no time do the HBSOC maintain that any protocol is cast in stone.  These "standards" are pretty much universally accepted but not the only ones.  There are other standards that roughly parallel the HBSOC.  Most surgeons who are at the end of the medical process will usually require compliance with these standards and most often the HBSOC.

The HBSOC are written so as to establish protections for transition; protections for both the patient and the physicians.  This is a fact often lost on both sides of the coin.  There is no question that there is no "test" for transsexualism.  You are transsexual because you say you are.  It is that simple.  The conflict resides in the medical community and the Hippocratic Oath all doctors take to " no harm".  There is no question that medical intervention for transition is permanent (in most cases) and surgical procedures themselves are serious and permanent procedures.  Many in the medical professions see these procedures as a conflict to their oath.

Within both camps we can see people who are well informed, those who are moderately informed and those who are uniformed and operating on "gut feelings."  The transsexual often encounters medical professionals who are uninformed and as a result have to "educate" their doctors about transsexualism and medical processes for care.  The operative word here is care, not treatment.  The reason so many physicians are uninformed is simply that they are not taught about transsexualism in their educations or alternatively are given very little information and at that, often it is out of date or completely incorrect.  It is completely wrong to blame the medical profession for this state of affairs unless you consider that they as a body should be demanding that medical schools get up to date and disseminate the current body of knowledge.  This is becoming increasingly important as more people are coming out and the statistics about the incidence ot transgender in the population are being displaced very quickly.

Simply put, the medical profession at large is not suitably equipped to work with or care for the transgender population.  This of course leads one to ask if the transsexual population is better equipped to demand that the medical profession respond to its needs on demand.  This author completely and totally rejects this concept.  The reasons for this are more simplistic than the arguments above.  The tramspopulation has a vested interest in transition regardless of consequence.  We are driven to transition and see any barrier to that process as interference.  This has led to the Informed Consent "Movement" that demands we tell the medical profession what we want and they must comply.  The problem with this is that we are not trained physicians.  We are well informed but not scientists.  We are allowing our needs to overshadow reason.

The core of these medical barriers are the psychological community who truly do hold the keys to going forward.  Let's examine this dog's breakfast first.

  • The American Psychiatric Association (APA) set the standards for psychiatric treatment based upon their own statistics.  These standards are set out in the Diagnostics and Statistics Manual (DSM)

  • The DSM, while no longer listing Gender as a paraphilia, does list it as a general category under sexual disorders.  Therefore this change is little more than just another brick in the wall.  It still establishes criteria for diagnosis that are unreasonable, ill informed by the standards of current medical knowledge, and a barrier to treatment protocols and availability; from private to publicly funded.

  • The medical professions largely rely on the DSM, not the HBSOC (most have never heard of WPATH) for guidance.

It is therefore correct to ask why?  It still does not justify the demands of Informed Consent.  The solution is obvious, inform the medical and psychiatric communities of the reality of transsexualism.  Easier said than done of course.

Now with that out of the way many pysch docs who do work with our population are often seen as barriers.  Are they really or are they doing their job?

It is critical to understand that first, the doctor wants to establish that there are no psychological impediments to transition.  Many psych conditions are not impediments but others such as schizophrenia or multiple personality disorder are.  Secondly, the p-shrink is obligated to assist the client to be able to make an informed choice. 

This necessarily means removing barriers we have all put up in our lives to protect ourselves from society.  This process begins with addressing the Guilt, Shame and Fear.  Saying and understanding we are trans is one thing, but living openly in public without the Guilt Shame and Fear is another entirely.  Accepting the discrimination we will face in the Real Life Experience (RLE) is not easy.  Overcoming that is the most difficult process in our lives.  It often means the loss of friends and family, jobs and careers, barriers to housing and education, open discrimination by society as well as covert discrimination.  The fact is that until we are "strong enough" to overcome these barriers proceeding to transition could well be a mistake; not by the doctor but by us.  We HAVE to be strong enough to face the aversity.

Of course, there is nothing to stop us from living 24/7 in our correct gender without psych approval.  In fact, it would and does certainly bolster our case to progress.  Even at that, the p-shrink still wants to be assured we are mentally prepared and although the counselling process may be shorter it is still necessary.

This process is NOT an impediment, it is preparation that should continue for a period even after SRS.

Unfortunately, the Informed Consent Movement do not see or consider these arguments.  They see the perceived barriers of counselling and care as being in the way of transition.  In this writer's opinion, this is the dangerous course, not the one most likely to assist the person in transition to make a full and complete transition that is successful in all areas of their life.

These are the reasons Transgender London (and this writer) continue to advocate for the HBSOC protocols as a guideline for both the client and the medical profession but more importantly, for education of the professional communities involved in our transitions.  It is a process that has proven to be safe and with the best interests of the transitioner in mind.

Therefore, this writer sees the Informed Consent Movement as the real barrier.  That barrier is open dialogue between the transgender population and the professional communities.  Inform the professionals through proper education in the medical schools, not demands by our population no matter how well intentioned or educated we are.  Informed Consent should be Mutual Consent.  Cooperation will bring mutual understanding and mutual benefit.



August 7,  2011




This site was last updated 08/07/11