Gender-affirming care in the context of medical ethics – gatekeeping v. informed consent

Abstract

Introduction. For many transgender patients, access to healthcare – and specifically gender-affirming care (such as hormone replacement therapy) – is limited by a variety of different barriers. Despite evidence showing that access to medical transition is not only safe, but also improves suicide risk in transgender patients, these services are often subject to excessive gatekeeping by medical professionals and healthcare workers. 

Objectives. To evaluate the ethical merits of the two most prominent models of providing gender-affirming care to patients who identify as transgender. 

Methods. The author compares the gatekeeping model and the informed consent model of providing gender-affirming care, in terms of the well-recognised four fundamental ‘pillars’ of medical ethics, namely respect for autonomy, non-maleficence, beneficence and distributive justice. 

Results. The gatekeeping model is found to be in violation of all four principles, while an informed consent model of care respects these ethical pillars. 

Discussion. A variety of ethical factors are at play in the provision of gender-affirming care to transgender patients, and these need to be considered carefully in formulating approaches or models. There are many other factors that can present a barrier to gender-affirming care in a South African context, but an examination of the ethical considerations can be of immediate benefit to an already marginalised population. 

Conclusion. Clinicians should be aware of the ethical factors in withholding gender-affirming care from transgender patients, and the potential consequences thereof. An approach based on a model of informed consent, which respects a patient’s agency over their own body, is both clinically safe and ethically sound.