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Recommendations from the Endocrine Society and the World Professional Association for Transgender Health (WPATH) provide guidance on how and when to prescribe pubertal suppression (PS) and/or gender affirming hormones (GAH) to transgender (TG) minors seeking medical interventions. These guidelines emphasize the importance of mental health professional (MHP) involvement and parental consent but fail to address scenarios that may complicate the informed consent process e.g., MHP letters may be difficult to obtain, parents may not always be supportive, and adolescents may have variable decision-making capacity. This study sought to identify prescriber behaviors and attitudes surrounding the consent process for TG minors seeking medical interventions (PS and GAHs).
An online survey was distributed to providers involved in gender-related care of minors. The survey contained multiple choice and Likert-style ranking questions assessing provider behaviors and attitudes. Descriptive statistics were calculated, and free-text responses were coded and thematically analyzed.
79 providers (physicians (70%), therapists (12%), nurse practitioners (5.5%), social workers (5.5%)) responded. The majority specialized in adolescent medicine (72.5%), but pediatrics (10%) and endocrine (6%) were also included. Of providers who have prescribed pubertal suppression (N=26), 62% have prescribed without an MHP letter, 42% have prescribed without support from both parents, and 4% have prescribed without any parental permission. For providers of gender affirming hormones (N=36), 50% have prescribed without an MHP letter, 53% have prescribed without support from both parents and 16% have prescribed without any parental permission. Youth assent and parental permission had the highest median ranking of informed consent elements while the MHP letter had the lowest median for both pubertal suppression and GAH. Finally, themes illuminated by free-text responses include (1) there is variation in provider understanding of the purpose of MHP letters, (2) legal concerns and fear of lawsuits influence provider behavior, (3) reversibility and risk assumptions influence provider behavior.
Our data suggests that there is variability among provider behaviors and attitudes towards the informed consent process for transgender minors seeking PS and/or GAH, especially in cases where adolescents are seeking treatment without an MHP letter or without parental approval. Participants identified legal concerns, treatment reversibility, and the risk of potential harms to youth as factors that impact provider decision making. Current guidelines emphasize the value of an MHP letter prior to initiating treatment, but respondents consistently ranked this letter as “least important” when compared to other informed consent elements. Although the sample size is small, this study is the first to describe the behaviors and attitudes of providers toward elements of the informed consent process for minors seeking pubertal suppression and/or gender affirming hormones.
Sources of Support
This research was supported by the University of Virginia Department of Pediatrics.