The Informed Consent Model of Care for Accessing Gender-Affirming Hormone Therapy Is Associated With High Patient Satisfaction

Abstract

Background: There are 2 common approaches to assess an individual before commencing of gender-affirming hormone therapy (GAHT); a mental health practitioner assessment and approval or an informed consent model undertaken with a primary care general practitioner (GP). Aim: In a primary care clinic practising an Informed Consent Model of care to initiate GAHT, we aimed to firstly describe the proportion and characteristics of patients referred for secondary consultation to a mental health practitioner (MH referred) and secondly, we aimed to measure patient satisfaction. Methods: A retrospective audit of all new patients with a transgender or gender diverse identity presenting to a primary care clinic in Melbourne, Australia was performed between March 2017 and March 2019. In those newly seeking GAHT, de-identified data were obtained including presence of secondary mental health practitioner referral, time to GAHT commencement and co-occurring mental health conditions. A separate survey assessed patient satisfaction. Outcomes: Mental health conditions and overall patient satisfaction in those referred for secondary mental health consultation (MH referred) were compared with those who were not (GP assessed). Results: Of 590 new consultations, 309 were newly seeking GAHT. Referrals for secondary mental health assessment before GAHT occurred in 8%. The GP-assessed group commenced GAHT at median 0.9 months (0.5e1.8) after initial consultation compared with 3.1 months (1.3e4.0), P < .001 in the MH-referred group. The MH-referred group was more likely to have post-traumatic stress disorder (adjusted P ¼ .036) and schizophrenia (adjusted P ¼ .011). Of 43 respondents to the survey, a higher proportion in the GP-assessed group was extremely satisfied with their overall care compared with the MH-referred group (P < .01). Notably, 80% in the GP-assessed group chose to seek mental health professional support. Clinical Implications: Initiation of GAHT can be performed in primary care by GPs using an informed consent model and is associated with high patient satisfaction. Mental health professionals remain a key source of support. Strengths & Limitations: This retrospective audit did not randomize patients to pathways to initiate GAHT. Follow-up duration was short. Responder bias to survey with low response rates may overestimate patient satisfaction. This is one of the first studies to evaluate an informed consent model of care. Conclusion: More widespread uptake of an informed consent model of care to initiate GAHT by primary care physicians has the potential for high patient satisfaction and may be a practical solution to reduce waiting lists in gender clinics.

Enhancing Gender

“…The approach of the diagnostic model to gender affirmation healthcare has come under increased fire in recent years (Schulz 2018 ; Riggs et al 2019 ; Lipshie-Williams 2020 ; Spanos et al 2021 ). On this approach, those who seek access to gender affirming services must be granted approval by a mental health practitioner on the basis of meeting the criteria for a diagnosis of gender dysphoria or gender incongruence.…”

Southern African HIV Clinicians Society gender-affirming healthcare guideline for South Africa

“…Whilst the presence of some mental health disorders (particularly those with manic or psychotic features) may have an impact on an individual's capacity to provide IC, a recent meta-review showed that most clients with a severe mental disorder made appropriate decisions regarding their healthcare. 52 An Australian study 30 revealed that general practitioners needed to refer only 8% of their TGD clients to a mental health professional prior to HT initiation and most of these clients had either schizophrenia or post-traumatic stress disorder (PTSD). Over half (56%) of TGD clients in this study had a mental health condition, such as depression, anxiety, attention-deficit-hyperactivitydisorder, autism-spectrum disorder or bipolar disorder; however, this did not have an impact on their capacity to consent to HT.…”

“…Over half (56%) of TGD clients in this study had a mental health condition, such as depression, anxiety, attention-deficit-hyperactivitydisorder, autism-spectrum disorder or bipolar disorder; however, this did not have an impact on their capacity to consent to HT. 30…”

“…108 • If a significant medical or mental health concern is present, ensure that it is managed concurrently, without delaying HT. 30 • Gender dysphoria and real-life experience (a period of time in which a TGD individual has lived full-time in their identified gender role) are not prerequisites for the initiation or maintenance of HT. 6 Figure 1 shows a visual representation of the recommended process to follow when providing HT.…”

Initiating gender-affirming hormones for transgender and non-binary people: A qualitative study of providers’ perspectives on requiring mental health evaluations

“…The World Professional Association of Transgender Health (WPATH) Standards of Care, first published in 1979 and now on its seventh iteration [ 13 ], recommend universal evaluation by a mental health provider (MHP) and formal documentation that the patient is an appropriate candidate for GAH with a diagnosis of “gender dysphoria” prior to initiating care [ 14 ]. Gender dysphoria, defined in the 2013 version of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 [ 15 ], refers to emotional distress caused by the incongruence between a person’s sex assigned at birth and their gender identity.…”