How Gatekeepers Can Better Appreciate the Autonomy of Transgender Patients

Abstract

Often primary care providers are called upon to judge the legitimacy of patients’ requests for gender-affirming care. Such requests are not necessarily based on best practices but exist nonetheless. Understanding the basis of such requests and objections to them can assist PCPs in navigating their role as gatekeepers. We address common objections raised to such requests and use common clinical scenarios to show that these objections are based on an incomplete understanding of autonomy. We conclude with a discussion of how a contemporary understanding of how gender identity is constructed might help primary care providers understand their role and how to help patients with their requests, both in gender-affirming care and more generally.

Primary care providers are often called upon to assess the requests for gender-affirming care of transgender and gender-diverse people. An objection frequently raised to gender-affirming care is that people’s wishes for gender-affirming treatment, including surgery or medications, do not reflect stable preferences and are unduly influenced by social pressures and trends.¹

Beauchamp and Childress include among their criteria for autonomy the notion of self-governance without coercion²; how the exclusion of coercion is meant to apply in daily life, when everyone’s decision-making proceeds in the context of constraints, is a critique leveled against these criteria.³

Here, we will consider gatekeeping of gender-affirming care, using examples from other areas of medicine in which patients’ autonomous decision-making might be at odds with medical recommendations. Such comparisons can help illuminate how gender-affirming care is alike, or unlike, general medical care. Transgender and gender-affirming care involve assessments on the part of clinicians of a patient’s autonomous decisions, like any other clinical decision.

In the care of transgender patients, those providing gender-affirming treatment are called upon explicitly and frequently, by specialists and by insurance companies, to serve as gatekeepers to the legitimacy of the patient’s wishes.⁴ Billing entities, coding reviewers, the lay press, and politicians ask whether transgender people are making authentic decisions regarding this treatment. Both the positive and negative elements in Beauchamp and Childress’ definition are brought to bear in these queries of transgender people’s motivation. Transgender people are thought to be controlled by social contagion⁵ and are also accused, or assumed, to be suffering from mental illness by virtue of their gender identity.⁶

In this paper, we will consider a case of a transgender person who comes to a provider for approval of their gender-affirming care, to understand how philosophical critiques of their autonomy might impact a gatekeeper’s consideration of such approval.

Case

Consider two patients who present to the same primary care provider. One is a 19-year-old woman requesting breast reduction surgery. The other is a 21-year-old transgender man requesting breast masculinization. How should the primary care provider understand these requests? What does it mean for someone to make an autonomous decision, if their decision is affected by outside factors, for example, societal expectations of appearance or of gender?⁷

As a gatekeeper, the primary care provider is asked to judge the authenticity of patients’ gender expression. While there have been objections to the common practice of so-called mental health letters which justify a patient’s request for gender-affirming care, and current guidelines (e.g., SOC-8) do not require such letters, they remain standard practice for many insurance payors and thus institutions. While these requirements remain in place, can gatekeepers refine their own understanding of patients’ gender identities and how they relate to autonomy?

AUTHENTICITY OF PATIENTS’ DECISION-MAKING IN THE CONTEXT OF AUTONOMY

The philosophical literature on autonomy provides various potential foundations to judging the authenticity of patients’ desires. Due to constraints of scope, and due to our clinical experience, we choose to focus on two of these reasons which are most commonly advanced as reasons to doubt transgender patients’ autonomy.⁸ We will point out how these objections are insufficient and reflect both a potential violation of the autonomy of transgender patients, as well as an instance of epistemic injustice. In this regard, it is helpful to consider the concept of hermeneutical injustice, in which a person is denied the resources or knowledge to make sense of their own experiences. Being a member of a marginalized community can be associated with heightened susceptibility to such injustice.⁹

DOUBTING TRANSGENDER PATIENTS’ EXERCISE OF AUTONOMY: REQUIRING COHERENTISM

The internist approach to determining whether autonomy is legitimate considers the content of the patient’s point of view (that is, internal to the person). According to this approach, the requirement of coherentism dictates that decision-making should be consistent or harmonious with the patient’s point of view on the action. For example, if a patient has stated that they do not believe that medications are effective for hypertension, and we then see them taking such medication, it might be possible that they have changed their mind, but if not, then there is a possibility that their decision is not fully autonomous.

To take another example, a patient who is a committed ballet dancer refuses to undergo a minor procedure which might save her from the need for amputation. Given her commitment to dance, this decision might be thought incoherent with her previous wishes, and thus inauthentic.¹⁰ A clinician might likely probe to understand why she might not be acting in a coherent manner, but a lack of coherence might remain perceived even after such probing. (To analogize this to criteria used in gatekeeping of gender-affirming care, the so-called mental health letters, not technically required for gender-affirming treatment or surgery but recommended by the World Professional Association for Transgender Health, often include a statement that a patient has lived continuously for a certain period of time according to their gender identity.¹¹) The idea is that consistent behavior reflects a patient’s consistent point of view. In the case discussed above in the introduction, both patients (the transgender and the cisgender patient) can be said to be meeting criteria of coherentism.

Coherence, or some version of it, appears to be implied in the objection of Lemma and Savulescu.¹² They argue that accepting a claim for transition to promote well-being requires that the individual be correct that they are transgender. That is, “the distress felt to reside in the body does not result from another psychological and/or societal problem) [and[ the medical interventions they are seeking will help them to realise their preferences.” Their objection seems to rest on the claim that “the distress felt to reside in the body” might not actually justify self-diagnosis as transgender, which is, instead, due to outside factors. Thus, they object that a patient’s decision-making regarding gender-affirming care is not actually related to the patient’s self-diagnosis.

However, how are we to determine that a cisgender person’s self-diagnosis (with breasts that need reduction) is “correct”? We need to rely on their own understanding, which presumably is coherent enough to motivate their presentation for a procedure. Similarly, the same can be said about a transgender person’s motivation for chest masculinization.

Another objection to the applicability of coherentism to the definition of autonomy in transgender care has to do with the potential changes in one’s own gender definition over time. Gomes Virseda et al., in their consideration of relational autonomy in the context of end-of-life decision-making, argue for an expansive notion of autonomy which takes into account the non-binary, non-discrete nature of autonomy which comprises more than individual decisions.¹³ Part of their discussion addresses the diachronic nature of autonomy, with the understanding that in end-of-life decision-making, patients’ decisions might change over time. Such is also the case in transgender care.¹⁴ Just as autonomy in the context of a relationship might include decision-making as developing over time and not a discrete act, so too potential changes in decisions over time in the case of gender-affirming care can be understood as relational.

ANOTHER CLAIMED ESSENTIAL CHARACTERISTIC OF AUTONOMY: RESPONSIVENESS TO EXTERNAL REASONS

According to the externalist approach, a patient only governs themselves if their decision-making is responsible to external reasons. Again citing Gomez Virseda, we observe that decision-making exists in a social context, and decisions might be affected by, responsive to, in opposition to, or informed by such external reasons.

The distress felt to reside in the body can certainly both result (in part) from psychological and societal problems, but yet not be inconsistent with autonomy and be nonetheless in their own self-interest (or authentic, “correct” in Lemma and Savulesca’s terms). This health care trajectory, like most others, is impinged at every stage by outside (external) influences. If avoiding such “psychological or social problems” is impossible, as it is for all of us when we interact with the health care system, it is unclear whether Lemma and Savulescu could find that someone’s distress was ever not dependent on such external factors.

There are transgender patients whose gender-affirming care is done in opposition to negative external incentives. As a prominent strain of thought found mainstream media and among those in political power holds that gender-affirming treatment is by definition either based in mental illness or the product of mentally pathological social trends, when a transgender patient acts fully autonomously in seeking, for example, gender-affirming hormone treatment, they are opposing those external reasons which Lemma and Savulesca would have them conform to.¹ Similarly, and by comparison, the cisgender patient in our case above seeking breast reduction could be imagined to be doing so in a way responsive to external reasons, or not, depending on their situation, and both might be legitimate.

WHEN IS AUTONOMY LEGITIMATE: WHAT GATEKEEPERS MIGHT THINK ABOUT

What is lacking in the autonomy literature, especially regarding transgender patients, is a notion of cultural, economic, and social influences, as well as material inequities, which are characterized in their diversity, rather than whether they are “coherent” or “external” influences.

A step towards this characterization was proposed by the philosopher Florence Ashley. Her account of gender subjectivity calls into question (in the vein of Gomez and Virseda) the applicability of the common coherentist and externalist objections.¹⁵

Gender identity, according to Ashley’s account, is “how we make sense of our gender subjectivity, the totality of our gendered experiences of ourselves. [...] The totality of our gendered experiences is gender subjectivity and forms the basic substrate of gender identity. It is the stance we take towards [this], how we interpret it, that defines who we are as gendered beings, as individuals with a gender identity.”

Consider a person who seeks to pursue a particular variety of gender-affirming care. Given that, according to Ashley, the sum total of their experiences does not fully determine their gender identity, one might be tempted to see that some sort of cognitive process (coherent, or externalist) could justify someone’s given gender identity. This would then help us, the gatekeepers, figure out what kind of decision-making properly reflects autonomy.

According to Ashley’s account, however, the construction of gender subjectivity is not accessible to conscious control, and thus presumably could not necessarily be characterized as following one or another type of approved cognitive process. We can add this, as an objection to coherentism or externalism, to the objections above, but it is more foundational. Gender identity is authentic by virtue of its groundedness in someone’s gender subjectivity. Just as one’s own personality is founded on the sum total of one’s experiences, and by virtue of that is authentic, gender identity is not fully determined by cognitive criteria. The comparison above to the cisgender person’s request for breast reduction can motivate the observation that there are other health-related decisions, as well, that are not fully determined by cognitive criteria, and practitioners might implicitly realize that when they legitimate a patient’s subjective accounts of their illness.

If the objections above are correct, that authentic decision-making about one’s gender identity cannot be subject to critique on the basis of coherentism or externalism, or, alternatively, that the subjectivity of gender identity makes it infeasible to demand particular cognitive requirements regarding its formation, then how is a provider or a gatekeeper to judge whether such identity-forming processes are authentic?

One answer is that there should not be any gatekeeping.¹ To put it another way, to be transgender in the context of other people being transgender should be recognized as an equally legitimate path to recognize autonomy in gender-affirming care, and the circumstances of that context and dependence should be actively sought out on the part of patients, advocates, and providers, so as to motivate and guide collaborative care.

Practically, this means that requiring letters that justify someone’s gender identity should not be required as a matter of normative ethics, nor should we gatekeepers try to make arguments for the authenticity of gender identity on the basis of their cognitive defensibility. This is not because transgender care is something alien or different from other sorts of care, rather, it is because cognitive standards for the allowability of patient requests are difficult to maintain.

This does not mean that eliminating superfluous bureaucratic requirements in itself will eliminate such gatekeeping. But understanding the autonomy of patients in their search for transgender and gender-affirming care requires both recognizing how systemic injustices cause ethical wrongs, and an appreciation for the interaction of seeking healthcare, itself, and the decision-making of the individual patient—both of which can influence each other.

Author Contribution

ZB provided all contributions to this article.

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Conflict of Interest

The author declares that he does not have a conflict of interest.