The gender-affirming model of care

The primary philosophy underpinning the gender-affirmative model of care is that gender presentations can vary across cultures and that no gender identities are pathological [22,23]. Proponents of the gender-affirmative model of care encourage a curious clinical position, recommend fostering a neutral space for gender exploration without favouring any particular outcome, while also respecting an individual’s affirmed name, pronoun, and gender identity [23–25]. The World Professional Association for Transgender Health Standards of Care, version 7 (SOC-7), recommends for TGD adult care-seekers one professional assessment be completed prior to the initiation of gender-affirming hormones or chest/breast surgeries, and two for lower/genital surgeries.⁴ Assessments are completed by providers who are competent with the DSM and able to conduct an “assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings” and determine whether any mental diagnoses are present and “well-controlled” prior to initiating hormones/surgeries (p. 23) [4]. In practice, this means that a person seeking these interventions must undergo psychosocial assessments which may include discussions about social/familial supports, financial and housing considerations for surgeries and surgical aftercare, experience living in one’s felt gender, as well as an evaluation to assess mental health/illness [26]. In Canada, wait-times to access an assessment for pediatric, adolescent, or adult transition-related gender care can vary between a few months to over one year [27,28].

Opponents of the gender-affirmative model of care have argued that affirming young people’s TGD identities, in particular, may unduly encourage the pursuit of medical/surgical interventions that could be later regretted [10,29]. The updated SOC version 8 (SOC-8), released September 15, 2022, recommends a comprehensive assessment for adolescents seeking medical/surgical interventions, and that adolescents should be offered the opportunity to explore their gender without favouring any identity outcome [30]. For adults, the SOC-8 recommends a comprehensive assessment for only complex cases or for those who are requesting treatments with limited research evidence, and that assessors should be able to distinguish gender dysphoria from co-existing mental or psychosocial issues [30]. Our study was conducted prior to the release of the SOC-8.

The informed consent model

The informed consent model (ICM) does not require an assessment of gender identity or gender dysphoria prior to the initiation of gender-affirming hormones [31,32]. Assuming a gender-affirming position, the ICM proposes that TGD people who understand the risks and benefits of gender-affirming hormones can initiate treatment without a diagnosis of gender dysphoria and/or gender assessment [33,34]. The ICM emerged as an alternative to the SOC, to depathologize trans experiences [32,35], and to reduce barriers to care [36,37]. ICMs are heterogeneous, lying on a continuum ranging from “weak” (e.g., some emphasis on assessment from a perspective of collaboration and patient-led exploration of gender dysphoria) to “strong” (e.g., no assessment of gender dysphoria, while bolstering the informed consent process and patient education surrounding treatment options to meet individual embodied gender goals) [38]. The ICM may be reflective of broader trends in healthcare which move away from paternalism and toward patient collaboration, while centering the ethical principles of autonomy and self-determination—such as “relationship-centered care” [34]. A post-intervention survey administered to adult patients (mean age: 25, range 21–30) seeking gender-affirming hormones found that the ICM is associated with high patient satisfaction [39].

Still, scholars, care providers, and the authors of the most recent SOC-8 [30] have suggested that while the gender-affirming model of care can be complementary to the ICM, for some adolescents, identity fluidity may be developmentally-typical such that the ICM may not be appropriate. For example, the SOC-8 states that there are “no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment… [this approach] carries the risk that the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time” (p. S51) [30]. A Canadian prospective cohort study comprising 174 TGD youth (79% AFAB) selected from 10 pediatric gender clinics found that five of these clinics do not require a psychiatric or psychological assessment prior to initiating hormone blockers or gender-affirming hormones [40].

The gender exploratory therapy model

The gender exploratory therapy model is characterized by required, in-depth talk therapy over an extended period of time in an attempt to foster an understanding of underlying factors that may be contributing to gender-related distress [41]. Proponents argue that this approach is developmentally-informed while also enabling clinical discrimination between gender dysphoria and mental illness prior to facilitating medical/surgical interventions [41,42]. Practitioners of gender exploratory therapy also often view medical transition as a last resort availed to patients only after judicious therapy and evaluation [42]. To date, known practitioners of this model primarily work clinically with children and adolescents [43], however Spiliadis [42] states that gender dysphoric children, adolescents, and adults alike could benefit from gender explorative therapy.

Clinicians who promote the gender exploratory therapy model have raised concerns regarding both the gender-affirming care model and the ICM due to their “gender-affirmative” stance and for assuming that medical/surgical interventions alone can ameliorate the young person’s distress [41]. Marchiano states “therapists are contributing to the rise in transitioning by quickly validating a young persons’ self-diagnosis as transgender without careful differential diagnosis, exploration of trauma, questions about sexual orientation, etc” (p.357) [29]. She further states that some young detransitioned women—only after medical transition—come to understand themselves as gender non-conforming sexual minorities (lesbian, bisexual, or queer), without having been provided an opportunity to therapeutically explore their life histories as they relate to sexuality, trauma, and feelings of gender dysphoria [29].

To date, there are no known empirical studies that examine psychosocial or medical/surgical outcomes following the gender exploratory model of care and some authors have raised questions regarding its clinical practices. For instance, this model has been likened to gender identity conversion therapy given that some practitioners avoid using clients’ affirmed name and pronouns, while aiming to question trans identification in children and adolescents [44]. However, Spiliadis’ differentiates the exploratory model from identity conversion therapy, stating that practitioners of the former are advised to acknowledge patients’ gender identities, and to collaborate with them without any active guidance toward a specific identity or outcome [42]. Other authors have argued that by not providing an estimated length of time for explorative talk therapy, this approach raises ethical tensions given that delaying medical interventions may compound mental suffering in TGD young people [45]. Finally, it is important to note that many who promote the gender-affirming model of care do encourage gender exploration as a means of supporting a young person’s self-understanding and informed decision-making prior to making medical decisions [44,46].

Recruitment and data collection

To recruit participants, we circulated study flyers over social media, to private internet-based detransition support groups, and to clinicians in six urban centres across Canada. Adverts were also distributed to health centers and community organizations serving lesbian, gay, bisexual, trans, queer, and two-spirit (LGBTQ2S+) people in Canada. Following purposive and snowball sampling methods, participants with experience of reversing their gender transition and/or re-identifying with their birth-assigned sex were particularly encouraged to share study advertisements within their personal networks of detransitioners. To achieve greater demographic diversity in the sample, flyers specifically inviting individuals who were assigned male at birth (AMAB) and Black, Indigenous, and other people of colour (BIPOC) were also circulated. Participants who expressed interest in the study were screened to confirm they met eligibility criteria before being invited to participate. Eligibility criteria included: aged 18 and older, living in Canada, ability to participate in an interview in one of Canada’s two official languages–English or French–and self-identifying as detransitioning, retransitioning, detrans, retrans, re-identifying, experiencing a shift in gender identity after transitioning, or having stopped a gender transition. Gender transition was defined as inclusive of social, legal, and/or medical transition.

Participant recruitment and data collection occurred between October 2021 and January 2022. Data were collected in the form of in-depth, semi-structured, one-on-one virtual interviews that ranged from 50 to 90 minutes. A total of 28 participants met eligibility criteria and fully completed virtual interviews via Zoom, as well as a demographic questionnaire. Participants received a $30 CAD gift card for participating. Twenty-six interviews were conducted in English by either KM or GE and two were conducted in French by FA. We directly asked participants the following questions, among others: “To affirm a trans or nonbinary identity, what steps did you take to transition the first time?; Did you see a healthcare professional like a doctor, social worker, or psychologist?; What type of pathway did you go through to access gender-affirming healthcare?; At the time, how did you feel about physically transitioning (including taking hormones, having surgeries, or other physical interventions such as hair removal)?”. We also asked follow-up probing questions to gather more information relating to participants’ overall process of initiating gender care. To understand how participants felt about their decision to transition, we asked the question: “Looking back, do you feel like transitioning was the right or wrong decision for you at the time?” which offered them space to reflect and discuss feelings of decisional regret and/or satisfaction. Finally, participants were asked: “What are your main recommendations for care providers who want to provide better care and support people who are de/retransitioning?” which elicited rich feedback regarding their perspectives about gender care delivery.

Data analysis

We specifically analyzed narratives of seeking and receiving gender care, feelings of satisfaction or dissatisfaction with medical/surgical care interventions, and recommendations to improve care delivery. From these in-depth accounts we were able to discern the model of care each participant had experienced in the process of accessing interventions and how they felt about this clinical approach. We further analyzed narrative data to determine the extent to which participants felt decisional regret and/or undesirable outcomes with hormonal/surgical interventions to contextualize their overall perspectives on the care they received. When dissatisfaction with interventions or decisional regret emerged in the interview data, we closely analyzed these transcripts to understand how these participants described their transition journey and the care they received.

Our data collection and analysis process was iterative and inductive, following two primary analytic steps. First, upon completion of the first 20 interviews, KM and GE reviewed these transcripts and developed an initial draft coding framework which conceptualized preliminary findings thematically. In the second step of data collection and analysis, the final eight interviews were conducted, and these transcripts reviewed, to confirm data saturation. As we reached data saturation across the interviews, we finalized the thematic coding framework. All transcripts were read, re-read, and coded by a minimum of three authors (KM, GE, and WAG). Involving three project team members in reviewing transcripts and developing the coding framework contributed to study rigor by enabling the assessment of data saturation and open discussion among coders to consistently and reflexively interpret overarching themes from the interview data. Dedoose analytic software was also used to support systematic development of the coding framework, and to code the transcripts. As such, we followed a reflexive and inductive coding process to develop themes grounded in the data, as described by Charmaz who developed CGT methods [47,48]. During data analysis, we consulted with two Canadian psychiatrists who work in gender care and several detransitioners. Following data analysis, we contacted all study participants with an update regarding plans to share their anonymized narrative data over social media, to presentations to care providers, and in academic writing. Participants were provided the option to request for their anonymous narratives to not be shared, and one participant opted out due to privacy concerns, but did not withdraw from the study. For further description of our methods, please see [14].

Binary gender assessments and linear transitions

The vast majority of participants accessed medical/surgical transition through the gender-affirming model of care (SOC-7), with participants’ descriptions of assessments revealing little standardization of practice across different clinics/regions of Canada. Many also engaged in talk therapy with a mental health professional, such as a psychologist or psychiatrist, in order to receive a letter to start hormones because it was required by their prescribing physicians or by provincial healthcare policy at the time. The assessment process ranged from between one month to over one year. Only a few participants reported being provided hormones after one or two visits at what participants often themselves called “informed consent” clinics.

Participants observed that assessment practices, together with healthcare policies, ultimately put measures in place to prevent regret and detransition, which was thought to extend the time to access the desired interventions. As one participant put it:

The province [public insurance] puts up all these barriers being, like, “But are you sure? Are you mentally fit? Do you know that this is what you want? Are you going to change your mind?” … The way that the nurse actually described it to me was that they are just following the provincial rules… I contacted the trans [clinic], which, if you get any gender-affirming surgeries or hormones or anything in [province], you have to go through the [trans clinic]… And then if you say: “No, I don’t want to wait on that waitlist, I want to do it privately”, [psychologist name is] the only one in the entire province who is certified to do the [assessment and] referral (Participant # 11, nonbinary, age 26).

As a result of these structured, stepwise assessment procedures outlined by the SOC-7, and long waitlists, participants’ gender transitions largely conformed to a linear pathway, such as starting hormones prior to surgery—regardless of their own individual desires. In turn, many participants felt constrained or felt there was external pressure on their transition. Some pursued hormonal interventions that they later came to question or regret because this was required to access surgery.

For many, their gender transition was lengthy and drawn-out. One participant who had transitioned approximately twelve years prior to detransitioning had a therapist as well as fulfilled the SOC (version 6) criteria which included living for one-year in “your chosen gender” prior to initiating hormones, and then waited for the province to insure surgery:

At that time, you still had what’s called the Harry Benjamin Standards [WPATH], you had to be living as male, in your chosen gender for a year before they [providers] would give you hormones. So, I came out, I changed my name. I was binding, dressing as male, presenting as male at work and to my friends and family. And then I had a hysterectomy, and then I started testosterone right after that. And then, took testosterone for a number of years. Then surgery became covered in [province]. And then I had [chest] surgery and [genital] surgery at the same time (Participant #9, undecided (she/her), age 37).

This participant experienced what was called “the real life test” prior to initiating hormones, which was a practice in place at the time she transitioned. Her medical/surgical transition process was drawn out for years before she ultimately detransitioned following shifts in gender identity and genital surgery complications.

The process of being assessed for medical/surgical transition was not experienced as “gender-affirming” by any of the participants. They felt this approach was applied inflexibly and that it was less about offering support and ensuring they had good outcomes, and more about enforcing binary transgender identities and placing limitations on treatment options.

In my early 20s I started to look at what is gender, and I’ve never identified as a man, but a lot of people put that on top of me… I pursued top surgery… I got switched to a different psychiatrist who’s awful [and who said] “You can’t be trans because you don’t want to be on testosterone.” (Participant #12, gender-fluid, age 29).

Participants frequently felt a need to prove themselves eligible for care and “trans enough”, by jumping through pre-determined “hoops” set by healthcare policies and providers. That said, many participants still felt satisfied with the overall transition process and decided to discontinue gender-affirming hormones because they were content and/or because they shifted from binary transgender to nonbinary.

Dissatisfaction with “informed consent” practices and decisional regret

Despite informed consent clinics being described as scarce and hard to access, participants frequently endorsed the ICM, including one participant who explained that an “informed consent” provider “was the only doctor that I felt comfortable enough with to tell her that I had detransitioned.” (Participant #7, cis woman, age 29). However, participants largely described providers’ informed consent practices as being inconsistent with principles of informed consent such as having robust discussions about a range of treatment options and their known risks/benefits. Reflecting back years after initiating these treatments, many participants did not feel adequately equipped to make informed decisions. When decisional regret emerged as a theme, it was frequently described alongside dissatisfaction with care providers’ practices such as feeling under-informed about interventions. As reported elsewhere, one-third of this sample expressed regret or complicated, ambivalent feelings about their decision to transition [14].

Participants often reported unexpected, negative health issues they attributed to hormone-related treatments, or of being disappointed with the individual, embodied effects. For instance, the only participant who reported puberty blockade (Lupron) followed by testosterone shared that:

I think there should be more actual medical studies or medical awareness of what stopping testosterone means [after blockers], because I developed… a bunch of hormone disorders and I’d also never actually gotten my assigned female at birth puberty before [stopping testosterone]… I got my first menstruation at 19, and my body’s basically a disaster (Participant #13, transmasculine nonbinary, age 25).

As shown above, they felt they may have suffered negative health consequences, and that more research is needed to improve medical knowledge of this specific treatment pathway. Others recommended more transparent discussions to explore the possibility that the effects of medical treatments may not align with their individual embodiment goals and could thus be disappointing. For instance, one participant stated: “Nobody said ‘Hey, you go on testosterone you still might not look like a guy.’ That is possible, but no one tells you that.” (Participant #27, uncertain identity, age 25). Many explained that providers presumed they were already sufficiently knowledgeable, and some participants recalled receiving lengthy packets of information regarding prospective interventions with little verification that they had understood relative risks/benefits of the treatments.

Both participants who initiated medical transition at age 15 expressed regret and dissatisfaction with hormonal/surgical interventions’ lasting impact on their bodies, gender socialization, and gender expression.

My gender expression is not where I’d like it to be, but that’s for a future thing. I would definitely like to express myself more in a feminine way… I mean, they gave me hormones pretty much after just one appointment… I wasn’t really even like asked about my gender, really, during the appointment. I wasn’t asked about why I wanted to be a boy or challenged with that. I was just sort of screened for general mental illness—symptoms of hallucinations, or aggressive behavior, and stuff like that. I didn’t receive really any in-depth questioning. It was like: “Okay you think you’re a boy and that’s cool. We can do that for you.” I feel like I deserved better care in a sense… [That] they actually took the time to figure out … where those thoughts with wanting to be a boy were, why I wanted to go on testosterone? I was so young [age 15] at the time. Right? Like… I was just thinking, I want to get away from being a girl… I feel like if I would have been supported to say that there’s nothing wrong… with being a female who is interested in other females… this [transition] would not have happened. (Participant #14, female, age 23).

Like the above account, a few other participants felt that medical transition presented them with an opportunity to “escape” or to “get away from being a girl” without fully appreciating a deeper significance of this desire. As young adults with identities that are different today than when they first pursued medical transition, they described internal and external regrets, and felt their providers’ consenting procedures were not adapted to meet their age-specific developmental needs.

Several participants reflected there was a lack of transparency and communication with regard to treatment decisions in the context of mental health, with some speculating that an in-depth discussion about sexual and gender diversity and/or a comprehensive assessment may have identified factors contributing to their feelings of gender dysphoria—information thought to be important to fully exercise their autonomy and make informed treatment decisions. Some participants felt that their trans identity and/or pursuit of medical transition may have been partially motivated by ego-dystonic homosexuality, neurodivergence (e.g., autism), or a past trauma that was, at the time, not transparent to themselves nor proactively identified by providers.

When I detransitioned, it was about six years ago… I had some space to process some of the reasons why I thought I had to identify away from womanhood in the first place. And I know it’s not everyone’s experience, but for me, I realized that a lot of it was tied up with like other things like trauma, instead of my actual gender identity… Or like when I was growing up, I had undiagnosed autism, which I actually think does relate to my gender identity (Participant #7, cis woman, age 29).

These participants came to understand a range of other factors as intersecting with their embodied experience of gender/gender dysphoria only after detransitioning—signaling a missed opportunity during the care-seeking process. Another participant who, after detransitioning came to understand her past body-related distress through a lens of complex mental illness, questioned the context under which she provided consent, sharing that:

When I signed the consent forms in [month] 2017 for hormones, I was actually in the psychiatric hospital. So, I got a day pass from inpatient. I was sectioned. They did a Form 1 [psychiatric care admission under the Mental Health Act] and I was held for being a danger to myself, a high risk for suicide or self-harm. But they gave me a day pass so that I could go to see the endocrinologist and sign informed consent. And the question that I hold now is, “how is that informed consent?” If I’m a danger to myself and I’m not allowed to go home without the police coming and bringing me back to the hospital, am I really mentally competent to understand the long-term effects of hormone therapy?… (Participant #10, female, age 29).

This participant questioned how she was able to provide consent for treatment during “high risk” periods of her life, and also expressed regret with regard to all completed interventions (testosterone, chest masculinization surgery, oophorectomy). Others observed that some providers—in their desire to reduce service access barriers and offer support and affirmation to trans people—may not be completing thorough informed consent procedures. Another participant reflected the sentiment that there is a “fine balance between gatekeeping and doing due diligence” (Participant #15, nonbinary, age 29). A theme thus emerged of recommending a “middle ground” or “diligent” practice to mitigate the risks of delaying gender care, while providing care-seeking individuals time and space to clarify their gender identity, identify individualized mental healthcare needs, and whether they might be experiencing what some described as “internalized homophobia” or generalized societal homophobia which could impact feelings about their gender.

Supporting autonomy and individualized care pathways

Participants supported autonomy in patient decision-making and the ICM in particular. The need for an individualized approach to care, inclusive of mental healthcare and social supports, was frequently discussed. A majority of participants ultimately felt that medical/surgical transition was the right choice for them at the time, centered themselves as active agents involved in their own decision-making, and reported positive feelings about their gender transition. However, some also reflected on how they might have felt better supported in their decision-making process, particularly those who reported complex mental health challenges such as BPD, PTSD, or bipolar disorder. For instance, one participant shared that:

I definitely do not think everyone with BPD who transitions is going to detransition. I do not think that at all. But for some people, I think that would actually be something for professionals to kind of look into… Like even if it involved doing some sort of group therapy just to kind of help build up your sense of self. I think that would be really–something really important… because [gender-affirming] hormones really do take a lot of effects on you. (Participant #20, female, age 25)

Although she felt that transitioning was the right decision, and reported overall good relationships with her care providers, she also felt a more individualized care approach with therapeutic supports was warranted in her case, specifically due to her experience of living with BPD.

By contrast, a minority of participants felt medical/surgical transition was the wrong pathway and, at the time of interview, they shared that they wished they been provided with more supports and in-depth, “neutral” therapy to examine how their feelings about their sexual orientation or being gender non-conforming may be impacting their gender dysphoria. Some felt they would have benefitted from a more comprehensive assessment in order to be better prepared for treatment decision-making, because in hindsight, they realized medical/surgical interventions did not address their needs. Reflecting back, these participants felt that having time and space to explore their life histories and possible connections with gender dysphoria, gender identity development, and embodiment desires would be valuable for care-seeking individuals. For these participants, their narratives contained language indicative of feelings of suggestibility and the notion that social oppression (e.g., homophobia/heterosexism; sexism) may have shaped their life experiences and pursuit of medical/surgical interventions. Finally, it was recommended that providers take a “neutral” stance, listen, offer space for identity exploration, and identify individualized needs:

[Providers should] really just encourage the clients, or the patients, as individuals to speak on their own experiences and their own perceptions and to encourage that, and…not project their views on gender, or their views, on this person’s gender (Participant #13, nonbinary transmasculine, age 25).