The continuum of informed consent models in transgender health

  • Florence Ashley, Colton M St. Amand, G Nic Rider
  • Family Practice, June 2021, Oxford University Press (OUP)
  • DOI: 10.1093/fampra/cmab047

In transgender health, some informed consent models are better than others

Photo by Matheus Ferrero on Unsplash

Photo by Matheus Ferrero on Unsplash

What is it about?

(Free version of the paper available under “Resources” on the right.) Traditionally, transgender people have needed to get a letter from a mental health professional confirming that they are trans and have gender dysphoria before getting hormone therapy. Trans communities often praise informed consent models for doing away with this unnecessary gatekeeping. When praising informed consent models, we tend to treat them like they are one ‘thing’ instead of a collection of approaches that differ widely in terms of how much they gatekeep access to hormone therapy. To correct that misunderstanding, we identify three types of informed consent models: Strong, Weak, and No-Letter. Under the Strong approach, giving free and informed consent is the only requirement for hormones and the job of the doctor is to help you decide based on your individual goals. Under the Weak approach, your doctor centres your autonomy and informed consent, but still does an assessment of gender dysphoria to turn away those they think may be misled about being trans. Under the No-Letter approach, doctors do a comprehensive assessment of gender dysphoria with all the gatekeeping it entails, but they either do the assessment themselves or ask a colleague in their team to do it instead of asking you to get a letter from an external mental health professional.

Why is it important?

Treating informed consent models as a single ‘thing’ is problematic because it lets off the hook clinicians who continue to gatekeep while saying they practice an informed consent model. Not all informed consent models respect trans communities equally. We should push back against those that pathologize trans people and force them to prove that they are ‘really’ trans, whether or not they ask for a psychologist’s letter.


Florence Ashley
University of Toronto

Writing this article with Colt St. Amand and Nic Rider was absolutely thrilling. It is my first collaboration with them, and I value them immensely as scholars and friends. Publishing the article was surprisingly difficult, as journals kept rejecting it for not being important enough, before even sending it to peer review. I’m glad it’s finally out there, because I think it’s a conversation we really need to be having in trans health and something we need to be more aware of in trans communities.

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The following have contributed to this page: Florence Ashley