Standards of Care
The World Professional Association for Transgender Health regularly publishes standards of care in this area. Past and present copies can be obtained from their website http://www.wpath.org.
All reputable practitioners in this area will use these standards.
They essentially require a period of assessment by a suitably qualified and experienced professional, prior to any hormonal reassignment, and a further period, usually called the 'Real Life Experience' prior to any surgical intervention. Second opinions are sought before surgical procedures.
Many professionals work in teams and most can deal with different variations of gender expression and sexual formation. As a consequence, the solution for one person can be vastly different to another's.
The main aim of intervention is to allay feelings variously described as 'Gender Dysphoria' or 'Gender Incongruence', though sometimes this is not present. Then the focus may be on 'significant others' , the social milieu or affirmation of the individual.
The Executive Committee of ANZPATH would like to clarify its position on the Informed Consent Model in relation to accessing hormones to reduce gender dysphoria or address the needs of those with gender incongruence.
There appears to be some confusion around the notion of "informed consent". Within the medical community informed consent is considered a core principle of practice and it is considered standard practice to obtain informed consent prior to any medical intervention. To obtain informed consent the physician must be satisfied that the patient has been given comprehensive information about the proposed treatment. This would include information about the expected effects of the treatment, the possible risks or complications and any alternatives to the proposed treatment. In addition the physician must be satisfied that the patient has the capacity to consent to treatment. In other words, the physician must conduct an assessment of whether the patient has the cognitive ability to make a decision and is free from coercion. This can be a very complex assessment and needs to address the patient’s ability to understand information about treatment; their ability to appreciate how that information applies to their situation; their ability to reason with that information; and their ability to make a choice and express it. In all situations therefore it is important that a physician conducts a comprehensive assessment to ensure that the treatment being prescribed is safe and appropriate. Informed consent therefore is not "treatment on demand".
A number of clinics in the US and Canada have developed protocols in relation to accessing hormones based on an informed consent model. Examples of these clinics include: Tom Waddell Health Centre (San Francisco), Catherine White Holman Wellness Centre (Vancouver), Fenway Community Health Transgender Health Program (Boston) and Howard Brown Health Centre (Chicago). A core feature of all these protocols is that a comprehensive assessment is made prior to prescription of hormones to assess the appropriateness and safety of prescribing hormones for any individual requesting hormones. In some of these protocols (eg Fenway) the assessment must be conducted by a mental health professional. WPATH has reviewed these protocols and states "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."
ANZPATH endorses the view of WPATH that a comprehensive psychosocial assessment (as described in SOC 7) is performed prior to initiating hormones and that this assessment is performed by a suitably qualified and experienced mental health professional as defined in those standards. In Australia such a professional would usually be registered with APHRA.
With the event of telemedicine this should be achievable in most situations in Australia. However if access to a mental health professional is not possible ANZPATH acknowledges that a family or sexual health physician who is suitably qualified and experienced in mental health and transgender health generally could also perform this role.
ANZPATH supports the view that informed consent must be obtained prior to any medical intervention. ANZPATH does not support a treatment model where hormones can be accessed on demand with no consideration of the appropriateness and safety of that treatment.