From Harvard Medical School (Ms. Mosier-Mills and Drs. Kim and Keuroghlian), Massachusetts General Hospital, Boston, MA (Drs. Kim and Keuroghlian), The Fenway Institute, Boston, MA (Dr. Keuroghlian).
Harv Rev Psychiatry. 2024;32(3):96-100. doi: 10.1097/HRP.0000000000000397.
Adolescents seeking gender-affirming medical care (GAMC) face numerous barriers that may delay or inhibit their access to these services. Such obstacles include mental health professional (MHP) assessment requirements prior to initiating GAMC. MHP letters ultimately carry little benefit for patients. Their formulaic nature discourages nuance, reduces likelihood of capturing gender embodiment goals (beyond a narrow definition of gender dysphoria), and may cause clinicians to overlook presenting mental health concerns. MHP assessment requirements also reinforce the conception of gender dysphoria as a mental health disorder. Moreover, studies have not shown that requiring MHP assessment letters effectively reduces regret among patients. Fortunately, primary clinicians who provide GAMC are most often capable of assessing patients without additional input from an MHP. In this article, we provide an ethical framework for clinicians that prioritizes patient autonomy through an informed assent approach. We discuss Appelbaum's criteria and its application, and contexts in which MHP consultation is appropriate. We also address common questions about informed assent among clinicians, patients, and families. Finally, we advocate for bolstering multidisciplinary support teams involved in GAMC to facilitate the informed assent process. This approach upholds patient autonomy, expands access to GAMC, and utilizes the mental health workforce more effectively.
寻求性别肯定医疗护理（GAMC）的青少年面临着许多障碍，这些障碍可能会延迟或阻碍他们获得这些服务。此类障碍包括在开始 GAMC 之前进行心理健康专业人员（MHP）评估的要求。MHP 信函最终对患者几乎没有好处。它们的公式化性质阻碍了细微差别，降低了捕捉性别体现目标的可能性（超出性别焦虑症的狭义定义），并且可能导致临床医生忽略出现的心理健康问题。MHP 评估要求还强化了性别焦虑症作为一种心理健康障碍的概念。此外，研究并未表明要求 MHP 评估信函能有效地减少患者的后悔感。幸运的是，提供 GAMC 的主要临床医生通常能够在没有 MHP 额外投入的情况下评估患者。在本文中，我们通过知情同意方法为临床医生提供了一个优先考虑患者自主权的伦理框架。我们讨论了 Appelbaum 标准及其应用，以及 MHP 咨询适当的情况。我们还解决了临床医生、患者和家属之间关于知情同意的常见问题。最后，我们提倡加强参与 GAMC 的多学科支持团队，以促进知情同意过程。这种方法维护了患者自主权，扩大了获得 GAMC 的机会，并更有效地利用了心理健康劳动力。
