Doctors, stop asking your trans patients for referral letters before giving them hormones

By Florence Ashley.

A few days ago, I sent off an email to someone I know at my university’s student health clinic to inquire about their ability to prescribe hormone replacement therapy (HRT) to trans students. A friend of mine had recently contacted me for recommendations of providers, but I knew that most of the physicians who practiced the informed consent model—which doesn’t require a letter of referral from a mental health professional—had close to a year-long wait-list at the shortest.

Years ago, I was lucky enough to obtain an appointment within a few weeks at the university’s clinic. Luckily for me, one of the physicians there was one of the handful of practitioners of the informed consent model in the city. When he left the clinic, I was told that the clinic was taking steps to ensure that they would continue to offer HRT on an informed consent basis. Currently, I was told, only one of their physicians initiates HRT and this physician isn’t taking new patients except through drop-in hours.

Access to HRT is a staple of trans healthcare. For those who wish to take hormones—not every trans person does—access has a positive impact on wellbeing. This impact can be cashed out in terms of lower rates of anxiety, depression, and suicidality, but there is more to it than pleasure minus pain. There is an intangible element in accessing transition-related care, an element that relates to bodily autonomy and self-actualisation.

I remember reading a comic strip about tattoos: “Sometimes my body feels like a rented house and that I shouldn’t settle in because soon I’ll be moving out again. But when I get a tattoo, it feels like I’m painting the walls. And when I look at them, I’m reminded that this is more than a rental. I own this body and its walls are mine and I’ll paint them however I want.”

Accessing HRT as a trans person means finally being able to make your body into a home. Even if you may never feel at home in the world—easy lives aren’t always the best lives—at least you can feel more at home in your body, in yourself.

It makes you feel a special kind of way, a special kind of hell, to hear that after deciding to initiate HRT, you must prove your gender dysphoria to the satisfaction of a mental health professional prior to obtaining a prescription. Cisgender people get to have gendered bodies they feel at home in without having to partake in such a patronizing performance. Why shouldn’t we?

When I wrote “Gatekeeping Hormone Replacement Therapy for Transgender Patients is Dehumanising”, which is now available in the Journal of Medical Ethics, I wanted to highlight the feeling of dehumanization that frequently washes over trans people when we are forced to undergo mental health assessment to access care. By highlighting the dehumanising nature of the process, I wanted to set aside traditional bioethics principles in favour of how the process is experienced by trans people.

Although it has become ubiquitous in trans health literature and among specialised healthcare providers, it is still difficult to find physicians ready to prescribe HRT on an informed consent basis, even in large metropolitan areas such as Montreal, where I currently live. I hope that explaining how gatekeeping is not only unethical but dehumanizing my article will motivate physicians to adopt the informed consent model. In the meantime, I’m not sure what to tell my friend.

Paper title: Gatekeeping hormone replacement therapy for transgender patients is dehumanising

Author(s): Florence Ashley

Affiliations: LL.M. Candidate, McGill University Faculty of Law; Fellow of the Research Group on Health and Law

Competing interests: None.

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Twitter: @ButNotTheCity

Facebook: @ButNotTheCity

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