Assessments and gender dysphoria

How assessments benefit clients and removing them undermines ethical care

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In a recently published paper in the International Journal of Transgender Health (a free copy of the full article is available at the author’s website), authors Ashley et al. make a bold claim. They write that gender assessments shouldn’t occur before starting gender affirming medical treatments because assessments do more harm than good. The authors argue that gender assessments are a form of gatekeeping where all of the power resides with the doctor and none with the patient; the problem with assessments as they see it, is that the patient must convince the doctor that they are ‘truly trans’ which means they are less likely to be honest about doubts and misgivings, negating the theory that assessments allow for gender exploration.

The authors also argue that assessments do little to prevent detransition regret. Rather than trying to prevent detransition, the authors claim that assessments should focus instead on normalizing detransition as part of what they call a gender journey. They make the case for allowing hormone prescriptions as part of gender exploration, essentially arguing that any attempt to slow the medicalization process down thwarts the patient’s embodiment goals.

The authors barely mention the risks of using hormones in an exploratory way — some testosterone-induced changes, for example, are permanent (e.g. dropped voice, hair redistribution, clitoral growth). As for surgeries, they argue that someone who goes through a mastectomy as part of their ‘gender journey’ is no different than someone who gets a mastectomy due to cancer — and any attempt to differentiate these experiences must come from bigotry.

Significantly, unlike cancer patients, the breasts of gender dysphoric patients are physically healthy and functional body parts. And despite what practitioners like Dr Johanna Olson-Kennedy claim, a person can’t just get fully functional breasts back once they’ve been removed. The best one can do is get a cosmetic facsimile involving breast implants, scarring, and lost sensation.

Before I critique their arguments further, let me at least highlight some points on which we agree:

1) In the past, doctors were paternalistic gatekeepers who had the power to withhold care from people based on their own preconceived biases rather than on any evidence base. This was a cruel state of affairs that should not be repeated.

2) As a consequence, patients who believed they were trans would often sanitize or change their life stories to fit into a narrative the doctors were more likely to buy, to gain access to medical interventions such as hormones and surgery.

3) People need a space to explore their feelings, doubts and thoughts in a safe, non-judgemental environment. This kind of honest exploration cannot happen when a client needs to prove their transness to their doctor to access medical care.

While these points lead the authors to dismiss assessments entirely in a display of all-or-nothing thinking, my own view is that we need to better define the role of assessments so that both practitioners and clients understand the value and purpose of the process.

What is a gender assessment?

Ashley et al. contrast what they call a ‘traditional’ gender assessment with their preferred informed consent treatment model. They argue that ‘gender assessments’ do nothing to prevent decisional regret in detrans individuals and create unnecessary barriers for trans individuals.

A few points about psychotherapy and assessments: While therapy often includes an assessment process, an assessment process is not by itself psychotherapy. Assessments in the mental health field serve to focus the work of psychotherapy, but therapy itself is a process of deepening self-exploration and self-understanding separate from mere assessment.

In the mental health field, assessments have different purposes and processes depending on the type. At least 4 common types of assessment can occur:

a) Diagnostic assessments

b) Biopsychosocial assessments

c) Functional assessments

d) Safety and risk assessments

Each type has its own purpose, utility and limitations. For example, in North America a diagnostic assessment is used to diagnose someone with a condition listed in the Diagnostic and Statistical Manual of Mental Disorders (currently we are at version DSM-5-TR). Diagnostic labels are particularly useful for insurance companies/reimbursement as the insurance companies typically want to know what people are being treated for and the DSM provides a common language for healthcare providers (e.g. psychiatrists, family doctors, psychologists, social workers).

A large limitation of diagnostic labels is that they are decontextualized, situating mental health problems within the individual as some kind of brain malfunction. Yet we know that mental health issues are not simply biomedical brain misfirings — mental health is influenced by people’s interaction with their environment and their environment’s interaction with them. Another limitation of DSM labels is that popular understandings of them often diverge from their clinical utility. DSM diagnoses can become life limiting for people, even if they are not meant to be. Some people can become trapped in seeing their diagnostic label as central to their identity rather than as a changeable component of it.

A biopsychosocial assessment, on the other hand, typically involves a mental health provider taking a careful history of a client’s background to identify all the possible contributing factors that might be influencing a client’s distress. Most mental health providers embrace some form of biopsychosocial understanding of their clients. They recognize that mental health is influenced by genetics, epigenetics, psychological and socio-cultural influences. Understanding a person’s medical history, their family background and developmental history, as well as their socio-cultural identities can help to better understand the person in context. It can also help identify a client’s internal and external resources, strengths, and supports. Unlike DSM diagnostic assessments, biopsychosocial assessments are not seeking to label a client with a particular condition, but are seeking to develop an individualized understanding of the person’s issues within the unique conditions of their lives.

Functional assessments can form part of a biopsychosocial assessment and tend to focus more on how a person’s symptoms might impact on their daily ability to perform tasks, meet responsibilities and take on different social roles. Functional assessments often focus on client strengths and limitations, and treatment plans are directed at improving a client’s overall quality of life. For example, a functional assessment might look at things like personal hygiene, interpersonal skills, life skills like cooking, cleaning, managing finances, and work performance. Once skills gaps in these areas are identified, treatment plans can target the skills that are missing to get the client to where they want to go.

Safety and risk assessments are common when addressing potentially life-endangering eventualities such as suicide, self-harm or domestic violence. In a domestic violence situation, for example, the therapist might devote the first few sessions to doing a structured interview with a client who has used violence in their intimate partner relationship to better understand the factors that might increase the risk of this occurring again. When working with a client who has been victimized, the therapist might spend a good proportion of time thinking through with the client, step-by-step, the warning signs of oncoming violence and the ways that the client might go about minimizing risk to self and children (if children also live in the home). While this assessment process might rely on validated formal tools, it is also something that is informally integrated throughout the therapy process.

In each of these cases, the assessment is meant to complement and inform psychotherapeutic interventions and can itself be therapeutic by helping clients think through and identify their own patterns of behaviour, socio-cultural influences, functional barriers, and safety risks. Rather than seeing the assessment process as an attempt to put barriers in the way of the client, assessments are better framed as a tool for targeting interventions more effectively.

Which type of assessment the authors are referring to when they critique ‘gender assessments’ is unclear and seems to shift as needed to benefit their argument that assessments as a whole should be removed from gender medicine.

Their emphasis on the importance of the patient’s decision-making control suggests that they believe that clients ultimately should decide their own treatment. But this is clearly an untenable position that directly contradicts a shared decision-making model, considering that those who access treatment may not fully grasp the risks, benefits or consequences of medicalization. Despite the authors’ suggestions to the contrary, an informed healthcare professional plays a pivotal role in the shared decision-making process.

While a client may be the expert in their own experience, the healthcare professional brings valuable expertise in (hopefully) understanding the existing research evidence and scientific debates in the field. However, because GAC activists within leading medical organizations such as WPATH have effectively silenced those who speaks about harms, clients are not currently getting an accurate picture of possible negative outcomes from gender affirming medical interventions. Unsuspecting clients go into assessment thinking they are getting an objectively neutral assessment when this is not the case.

Also the authors seem to believe that clients go into ‘gender assessments’ seeking medical care right off the bat, when in my own experience many go in seeking a space where they can think through whether they want medical care or not. They often want to be challenged so that they can think through their motivations and needs more thoroughly. But such challenging by a clinician can easily be misconstrued as ‘bigotry’ or ‘attempts at conversion therapy’ if the purpose of the assessment process is not clear from the start.

Proponents of an informed consent model of gender medicine often claim that as long as clients are given information about the benefits and potential risks, clients are best positioned to make a decision over whether medicalization makes sense. I would argue, however, that few are currently experiencing true informed consent. I’ll use myself again as an example — detransition was not discussed as a potential outcome with me, nor was I informed that gender shifts are actually pretty common post medicalization. From discussions with others who have gone through medicalization more recently than I, risks and complications of hormones and surgeries are often underemphasized while benefits are exaggerated given the body of evidence that currently exists. The research suggests more caution is called for than is currently practiced.

The ongoing denial of harm

Ashley et al.’s paper seems intent on placing the responsibility for regret squarely on the shoulders of detransitioners who experience regret and the clinicians who they say want to gate-keep everyone. They argue that detransitioners may lash out at their practitioners due to their own internalized shame and “unreasonable expectations”. I find this interpretation especially galling, as it reads as subtle victim-blaming and erases the many very real ways that people have described being actively encouraged by figures of authority (e.g. school counsellors, counsellors, nurses, social workers or physicians) to go down a medical path too quickly. While the authors acknowledge the ways clinicians might fail their clients, they attribute this failure to clinicians’ devotion to ‘transnormativity,’ rather than considering that these mistakes might be a consequence of rushing to interventions before proper assessments have occurred.

The authors write: “Instead of understanding detransition as a personal or institutional failure, clinicians should see detransition as one of many possible steps in a person’s gender journey”; a truly offensive notion that removes responsibility for these failures from the systems of care that contributed to them.

The authors also argue that: “Gatekeeping practices are often predicated on the beliefs that neurodivergence and mental illness can make people falsely believe that they are trans, and that disabled and mentally ill people cannot be trusted with deciding for themselves whether to initiate gender-affirming care.” This is yet another attempt to downplay the harm that happens when a clinician for whom every problem is a nail, uses a hammer in every case, rather than seeing that people are more than the gender issues they bring forward.

The link between neurodivergence and gender dysphoria is well documented and I see little value in denying that the characteristics that often accompany ASD, for example, might influence a patient’s belief that they are ‘really trans’ (e.g. these clients might struggle with obsessive, rigid thinking patterns or have difficulty fitting in socially and seek an explanation for this). In my own case, had I had a better understanding of my own neurodivergence prior to medicalizing, I may well have made very different medical decisions. To acknowledge these complexities is not bigotry.

Counter to what the paper claims, assessments are not antithetical to building a therapeutic alliance; rather, the assessment process can serve an important function in creating time (and space) for the client and healthcare provider to better understand the many complexities of the client’s unique presenting problem(s). This takes time but it is an intentional use of time that can contribute to a stronger therapeutic alliance and better longterm outcomes, if the client allows for it. But with GAC activists often actively encouraging gender-distressed clients to see any questioning within a healthcare context as an ‘erasure’ of their identity, clients often miss out on a potentially valuable exploratory process.

Final reflections

A common refrain from those who support a gender affirming model of care with no assessment, is that it is cruel to “force” people into psychotherapy or an assessment. The authors make that argument too: “Requiring gender exploration, psychotherapy or an assessment of co-occurring conditions raises severe ethical concerns, as they would not be fully consensual and undermine patients’ ability to end clinical relationships without prejudice.”

It’s an odd sleight of hand to describe common, relatively non-invasive healthcare practices like assessments and psychotherapy as “unethical” or “cruel” while apparently denying the many very real ethical concerns and harms of administering irreversible hormonal and surgical “treatments” to individuals who may not fully comprehend what they are signing up for.

To propose psychotherapy as as the first-line treatment for gender distress in youth, for example, is hardly a radical concept. To argue that patients should have the ‘right’ to the most invasive treatment possible for their ‘embodiment goals’ is to undermine healthcare’s most basic ethical tenet of ‘do no harm’. In fact, one might argue it is not healthcare at all.

There is a difference between client-led care and client-centred care. The authors seem to believe that client-led care is the ideal. I beg to differ. It may sound paternal (so be it) but clients do not always have a full understanding of the consequences of their own wishes, especially as minors. This is not to deny client agency or autonomy, but to allow that healthcare providers have an equally important voice in the shared decision-making process.

As an analogy: recently a loved one told me about how she has been suffering with severe menstrual cramps. She went to her doctor to ask for a hysterectomy. The doctor, assessing the risks and benefits for her client who had a physical disability that made a hysterectomy more risky than usual, talked my loved one out of it and offered an alternative, less invasive treatment instead. Was that conversion therapy? Or good, ethical healthcare based on shared decision-making principles?

A client with gender distress may want to undergo a sex change (for a variety of reasons) but that does not necessitate the doctor or therapist to immediately move forward with it. To do an assessment is to create the space for client and healthcare provider to better understand what might be driving their distress prior to moving too quickly to serious medical interventions with high complication rates. Remove the assessment process and you remove responsible care.