Revisiting the Impossibility of Informed Consent for Transgender Interventions

The ideology glorified by “Pride” month has overtaken much of the medical profession. Burgeoning numbers of trans-identifying individuals demand euphemistically labeled “gender affirming treatment,” or GAT (puberty-blocking drugs, cross-sex hormones, surgeries), and clinicians in the thriving trans industry are often happy to provide it.

At the very least in this experimental area of medicine, these professionals should be scrupulous about obtaining truly informed consent before proceeding. Informed consent is the process by which physicians educate patients about the risks and alternatives of a medical intervention, to ensure that patients can fully understand and consent to the path chosen.

But in too many cases, this critical process that protects the dignity and authority of the patient is not happening. The marginalization of informed consent is contributing to the worst ethical scandal in the medical profession since the lobotomy craze ended in the mid-twentieth century. One hopes that this latest scandal will lead to an end to this dark chapter in the profession.

Dr. Steven B. Levine, professor of psychiatry at Case Western Reserve University, focuses on treating trans-identifying children and adolescents and has written extensively (see here and here) about the nature of informed consent for such patients. (In 2020, I discussed this work for Public Discourse in a two–part essay.) Although Levine, unlike many physicians, does not rule out GAT in all circumstances, he recognizes that medical interventions for gender dysphoria or incongruence profoundly implicate many aspects of a patient’s life: physical and mental health, social adjustment, family relationships, and romantic relationships. Decisions made now will determine whether the young patient ultimately flourishes or flounders.

Building on his earlier work, a new study by Levine and his colleagues E. Abbruzzese and Julia W. Mason, published in March 2022, finds that the informed-consent process is too often more of a box-checking exercise than a serious discussion and deliberation. In “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults,” the authors (to whom I will refer as “Levine” for short) lament that clinicians in the trans industry have gone beyond simple negligence or incompetence; instead, they are engaging in demonstrably unethical practices.

A Wild West Mentality

Levine describes a Wild West mentality in the rapidly proliferating “gender clinics” (including, increasingly, Planned Parenthood facilities) that desperate parents consult to handle their children’s gender dysphoria. Perhaps as early as preschool, or suddenly as adolescents or college students, skyrocketing numbers of youth are demanding medical interventions that raise—or should raise—a host of ethical concerns. These concerns “are amplified by the dramatic growth in demand for youth gender transition witnessed in the last several years that has led to a perfunctory informed consent process” (emphasis in the original).

The numbers are startling. Incidence of trans identity began to rise around 2006 and soared in 2015, such that, as Levine reports, “currently, 2-9% of U.S. high school students identify as transgender, while in colleges, 3% of males and 5% of females identify as gender-diverse.” Claims to be nonbinary (neither male nor female, or both male and female) have recently increased, with a new study showing 63 percent of trans-identifying youth also claiming nonbinary status.

According to Levine, this boom in demand, coupled with the absence of any well-considered standards of ethical practice, has led to the development of a new “informed consent model of care”:

Under this model, mental health evaluations are not required, and hormones can be provided after just one visit following the collection of a patient’s or guardian’s consent signature . . . The provision of transition services under this model of care is available not just to those over 18, but for younger patients as well.

Levine’s assessment of this model of care is blunt:

[W]e believe this model is the antithesis of true informed consent, as it jeopardizes the ethical foundation of patient autonomy. Autonomy is not respected when patients consenting to the treatment do not have an accurate understanding of the risks, benefits, and alternatives.

Among the ethical violations Levine finds in current practice are “poor quality of the [patient] evaluation process . . . and incomplete and inaccurate information that the patients and family members are given.”

Lifetime Medicalization

Levine decries the tendency of gender clinicians to give short shrift to psychological evaluations of their young patients before forging ahead with medical interventions. (An extreme example of this is the pediatrician Johanna Olson-Kennedy, who dismisses the need for psychotherapy with the quip that she doesn’t send a diabetic youngster to therapy before prescribing insulin.) “Confirming the young person’s self-diagnosis of gender dysphoria or gender incongruence is easy,” Levine observes. “Clarifying the developmental forces that have influenced it and determining an appropriate intervention are not.”

Taking the easy path means that many clinicians are ushering children and adolescents onto the conveyor belt of lifetime medicalization without any meaningful examination of what underlies their gender dysphoria.

Poor evaluation is often accompanied by failure to disclose crucial information to patients and their families. As Levine describes, the type of information frequently withheld includes the strong likelihood that gender incongruence will resolve on its own, and the experiences of regretful “detransitioners” who went through the GAT process and now want their authentic bodies and lives back.

Critical information that is frequently withheld is the “widely recognized” low quality of the scientific evidence supporting GAT. Despite the pro-GAT positions of the hierarchy of the American Academy of Pediatrics and Endocrine Society, “the best available evidence suggests that the benefits of gender-affirming interventions are of very low certainty.” By contrast, Levine says, the negative effects of such interventions are “quite certain:”

For example, puberty blockade followed by cross-sex hormones leads to infertility and sterility . . . Surgeries to remove breasts or sex organs are irreversible. Other health risks, including risks to bone and cardiovascular health, are not fully understood and are uncertain, but the emerging evidence is alarming.

Levine criticizes many gender clinicians for simply ignoring red flags such as the contributing factor of social contagion. “[P]roviding treatments with permanent consequences to address what may be transient identities in youth poses a serious ethical dilemma.”

GAT and Suicidality

Clinicians seem to justify their minimization of these risks and circumstances by parroting the ubiquitous but largely unexamined suicide argument. Frightened parents are persuaded to consent to immediate GAT by claims that without it, their troubled youngsters will kill themselves. This narrative, Levine says, “is both factually inaccurate and ethically fraught.”

Levine debunks the studies used by GAT clinicians as unreliable because of suspect methodology and sloppy data analysis. In fact, other studies Levine cites confirm that suicidality of trans-identifying young people “is only somewhat elevated compared to that of youth referred for mental health issues unrelated to gender identity.” These issues include depression, eating disorders, and autism—the kinds of conditions routinely ignored by GAT-promoting clinicians.

Nor do most clinicians disclose substantial evidence that GAT does not reduce suicidality. “Clinicians working with trans-identified youth,” Levine says, “should be aware that although in the short term, gender-affirmative interventions can lead to improvements in some measures of suicidality . . . neither hormones nor surgeries have been shown to reduce suicidality in the long-term.”

Pushing the “transition or die” narrative, Levine warns, not only “hurts the majority of trans-identified youth who are not at risk for suicide,” but also harms the minority who are at risk “and who, as a result of such misinformation, may forgo evidence-based suicide prevention interventions in the false hopes that transition will prevent suicide.” Levine concludes that clinicians should understand that “gender transition is not an appropriate response to suicidal intent or threat, as it ignores the larger mental health and social context of the young patient’s life.” This failure is, simply, grossly unethical.

Erroneous Assumptions

But why are clinicians engaging in such unethical practices? Levine reports that many of them operate under erroneous assumptions. For example, failure to evaluate the source of gender dysphoria is perhaps related to the problematic assumption that the frequent co-occurring psychiatric symptoms present in these patients—such as depression, anxiety, or suicidal ideation—result from social prejudice and discrimination against their gender nonconformity. But Levine cites multiple studies casting doubt on this “minority stress” theory, as such symptoms frequently predate the gender dysphoria and are not resolved by GAT.

Another such assumption concerns the clinician’s role in the process, as distinct from that of the patient. Because young patients are passionate and insistent about their alternative gender identity and their demand for GAT, clinicians “see their role as validating the young person’s fervent wishes for [GAT] . . . In so doing, they elevate the ethical principle of patient autonomy . . . over their obligations of beneficence and non-maleficence.”

In other words, they allow the child or adolescent to self-diagnose, and they give him what he wants.

“Perhaps the single most problematic assumption held by some gender clinicians,” Levine argues, “is that the young patients have simply been ‘born in the wrong body.’” This “reductionist approach” —adopting the unproven and almost certainly false assumption that atypical genders have a biological basis—eases the ethical burden of clinicians who insist that, in essence, they are merely correcting a birth defect.

Changing Minds, Not Reality

The Levine review closes with recommendations for a more meaningful informed-consent protocol. It also insists on respectful involvement of the family, rather than dismissing as “transphobic” any parents who resist GAT as the answer, since they know their child better than any professional can. “We maintain,” Levine and his co-authors conclude, “that the claim that children can consent to extremely life-altering intervention is fundamentally a philosophical claim . . . Our view in this matter is that consent is primarily a parental function.”

Levine provides a thoughtful analysis of what is happening in the trans industry and the assumptions that undergird much of it. But even the most charitable reading of the motivations of clinicians—that some may be genuinely trying to help suffering individuals rather than using them as political pawns or tickets to escalating riches—does not excuse their conduct.

These clinicians bear responsibility for their actions. They are highly trained professionals. They know how to uncover and evaluate research, and they have an ethical obligation to do that before administering experimental interventions that may destroy lives. They have an ethical obligation to exercise common sense, to pay attention to warning signs, and to exercise the basic gumption to recognize and properly address obvious mental disturbances.

Viewed in this light, the conduct of these clinicians looks less like innocent miscalculation than willful blindness.

Levine provides a valuable blueprint for navigating the trans morass in the limited subcategory of informed consent, but he stops short of a broader conclusion: that “gender affirming treatment” is a fundamentally flawed concept that should not be on the table, any more than diet pills and liposuction should be considered appropriate treatment for anorexics. Perhaps all focus should be on changing the mind to match reality, not the other way around.