Patient keeps asking about a letter from me for gender affirming surgery

[the5thelement]

County clinic M2F patient who wants to have gender affirming surgery wants a letter from me
that she is stable to have surgery. She said that the insurance company is asking for a letter from me
stating she is mentally sound and competent to under go the procedure. I thought psychiatrists
who usually work with surgeons to do these pre-op evaluations. Is this something psychiatrists
working in a county mental health department usually do?

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[comp1]

I imagine any clinician could get asked to write this sort of letter. Not all (maybe not most) gender clinics have the kind of integrated care you're imagining. I'm a little confused though. You're at a county clinic so her insurance is...Medicaid? Could you give us your state so we can get a better idea of what specifically is being asked of you?

 

[Sushirolls]

I think insurance companies want 2 letters? The last time I ran into this few years ago.
There is a whole criteria / guideline out there called WPATH?


Here is something I conjured up in the past:

Jane Doe is a patient in my care at SushiRollin' since DATE HERE. Jane Doe identifies as female and goes by she. Jane recalls first knowing her gender identity differed from assigned male sex at age HERE. Social transition has started with pronoun preference, clothes, hair, makeup, tucking and coming out. She has been successfully and consistently living in a gender role congruent with their affirmed gender since DATE. She has been consistently on hormone therapy since DATE. Despite these interventions, she reports significant anxiety, depression, and distress due to experience of dysphoria. By my independent evaluation of Jane, I diagnosed her with Gender Dysphoria (ICD-10 F64.1). Jane has expressed a persistent desire for surgery for ### years. The goals of surgery are “patient words here.” Surgery will address her gender dysphoria in these ways: improve sense of self, identity, wellbeing.

Jane is mentally healthy to undergo this surgery. Her current medications include MEDS. Her surgical history includes Sx Hx HERE. Jane has no issues with illicit drug use or abuse at time of evaluation.

Jane has more than met the WPATH criteria for SURGERY TYPE surgery. I have explained the risks, benefits, and alternatives of this surgery and believe she has an excellent understanding of them. She has capacity to make an informed decision about undertaking surgery. I believe that the next appropriate step for her is to undergo surgery, and I believe this will help her make significant progress in further treating her Gender Dysphoria. Therefore, I hereby recommend and refer Jane to have this surgery.

If you have any questions or concerns please do not hesitate to contact myself or my office.


Now, I no longer write these letters. Too many patients show up get letter, disappear. Not interested in a transaction type role of patient care.

 

[splik]

Yes. They usually need 2 letters. Here is a nice template

 

[splik]

Now, I no longer write these letters. Too many patients show up get letter, disappear. Not interested in a transaction type role of patient care.

Some people might just want a consult for the eval and not ongoing care. Some people offer services like that. Not really different to doing bariatric surgery evals or spinal cord stimulator evals or DBS evals or pre-op BSO evals for PMDD etc. Though I stopped doing the consults for the gender affirming ones because there was an expectation that pts are paying for you to rubber stamp them. While the majority of pts meet criteria, there are are some pts who just aren't stable and then there is the odd patient with factitious disorder trying to get gender confirming surgery. People don't like to talk about this because of how politicized the topic is, but it is definitely a thing that while uncommon is certainly not rare.

 

[the5thelement]

I imagine any clinician could get asked to write this sort of letter. Not all (maybe not most) gender clinics have the kind of integrated care you're imagining. I'm a little confused though. You're at a county clinic so her insurance is...Medicaid? Could you give us your state so we can get a better idea of what specifically is being asked of you?

California

 

[comp1]

Cool, here's the guide for Medi-Cal. https://healthlaw.org/wp-content/uploads/2020/02/NHeLP-MediServicesGuide-Complete-Ch5.pdf It might be slightly out of date, but in CA...if changed, it would be in a less restrictive way than described.

 

[Sushirolls]

Some people might just want a consult for the eval and not ongoing care. Some people offer services like that. Not really different to doing bariatric surgery evals or spinal cord stimulator evals or DBS evals or pre-op BSO evals for PMDD etc. Though I stopped doing the consults for the gender affirming ones because there was an expectation that pts are paying for you to rubber stamp them. While the majority of pts meet criteria, there are are some pts who just aren't stable and then there is the odd patient with factitious disorder trying to get gender confirming surgery. People don't like to talk about this because of how politicized the topic is, but it is definitely a thing that while uncommon is certainly not rare.

But when you make that clear up front, but yet consistently folks still are lost to follow up after the letter, meh, not how I want my practice.

Yes, there are consultative type practices, so folks can go there to those.

 

[Candidate2017]

You're the doctor. You can choose to get as enmeshed as you wish to be. Understand every act you take upon request of a patient comes with the full force and backing of your personal assets. This is why you are a respected doctor, a learned and trusted pillar of your community, upon which patients can rest easy knowing you will assume responsibility for your mistakes, including mistakenly deeming them appropriate for surgery.

My patients like to request all kinds of things from me too. Generally, I turn them down because I limit my practice to prescribing medications and magical words.

 

[Fan_of_Meehl]

County clinic M2F patient who wants to have gender affirming surgery wants a letter from me
that she is stable to have surgery. She said that the insurance company is asking for a letter from me
stating she is mentally sound and competent to under go the procedure. I thought psychiatrists
who usually work with surgeons to do these pre-op evaluations. Is this something psychiatrists
working in a county mental health department usually do?

I don't write 'letters' on demand.

Sounds like they are asking for a forensic opinion on something. Clarify your role (is it forensic or therapeutic?). If therapeutic/clinical, you could have a role conflict here.

If someone is asking me for a professional opinion (or set of conclusions) under my license, I have to figure out if I am competent/qualified to render such an opinion. What is the standard of care/practice with respect to such written opinions? I don't just provide written 'opinions' that people order up (like an order at Burger King). What if I find the opposite of what they want my opinion to be...to be my actual opinion?

 

[whopper]

I've written this before about being requested to clear a patient for a bariatric surgery or pain-device implantation surgery.

There is no academically or otherwise professional standard to clearing someone for such surgeries from a mental health perspective. Likewise, and I'm willing to hear if I'm behind and presented with newer data that corrects me, I don't know anything that clears someone for gender-affirming surgery

If there is something considered standard of care, of course yes I'd want to provide that so long as I could meet that standard. Otherwise I would tell the patient, and humbly state my own limitations, that I am not aware of the standards of what allows a health care provider to do this evaluation.

 

[Fan_of_Meehl]

I've written this before about being requested to clear a patient for a bariatric surgery or pain-device implantation surgery.

There is no academically or otherwise professional standard to clearing someone for such surgeries from a mental health perspective. Likewise, and I'm willing to hear if I'm behind and presented with newer data that corrects me, I don't know anything that clears someone for gender-affirming surgery

If there is something considered standard of care, of course yes I'd want to provide that so long as I could meet that standard. Otherwise I would tell the patient, and humbly state my own limitations, that I am not aware of the standards of what allows a health care provider to do this evaluation.

With respect, if there are no standards...then of what value is the 'evaluation?' This is a problem I often have with these sorts of requests. It's almost as if everyone wants someone to just give the 'thumbs up' (I am assuming so that they can tick off some box that the person giving the go ahead is assuming liability in case it is later determined that the patient was not an appropriate candidate (or should not have 'been cleared' to proceed with the surgery).

As I have said with respect to the whole 'I need a letter prescribing a service dog / ESA' issue...if the answer is always a 'yes' (and never a 'no') then we can't even claim that we're even doing an 'evaluation' here. Why go through the motions when the answer is always 'okay.'

Whether others have done so (or not) for the field, broadly speaking, anyone who is conducting an 'evaluation' would have to seriously consider:

(a) the circumstances under which it would be determined that they DO recommend proceeding as well as

(b) the circumstances under which it would be determined that they DO NOT recommend proceeding.

I wonder if anyone has ever written one of these letters and said, 'no...no I do not 'clear' Mr. X for these surgical procedures because of reasons m, n, and o.'

Again, if the answer is always 'yes,' and never 'no,' then how is this anything other than an empty, perfunctory, 'responsibility-accepting' ritual on the part of the letter-writer just in case the patient later has second thoughts about the surgery (10 years later, I no longer have my genitalia...I just realized that this is a BIG problem and I wasn't of sound mind when I agreed to this surgery)?

 

[whopper]

The analogy of an ESA animal doesn't fit the bill because there are standards and an evidence of data (edit-body of evidenced-based data) a physician can rely upon. It is also within the standard of care and accepted throughout the field that ESAs can help patients with their mental health needs.

With respect, if there are no standards...then of what value is the 'evaluation?'

You're asking the wrong guy cause if there are no standards, you cannot then IMHO accept the mission requested. That is clear someone for something where you do not know what standards must be fulfilled to say the person can be cleared.

I can think of benefits of an evaluation, but they would lead to open-ended evaluations that would not meet the closed-ended request that was made. An evaluation can help the psychiatrist better understand the patient, but unless the conditions were given that could be answered, then you could not answer them.

I wrote this down in a prior thread years back. I've been asked to psychiatrically-clear patients for spinal implant device surgery. I told the patient I knew of no standards upon which I could perform that task. So I called the neurosurgeon to provide me with a list of what satisfies such a clearance. He told me he didn't know and thought all psychiatrist knew to which I told him I've worked with top psychiatrists in the field and none of them know.

So he told me the device's manual says the device requires a mental health professional to provide "clearance." So to help my patient I called up the manufacturer. I told them since you guys put in the requirements, please tell me what must be satisfied to be considered "clearance." The manufacturer told me they didn't know themselves, but put that in the manual to CYA.

A few months later the patient got a surgery and told me the neurosurgeon referred her to a psychologist who wrote the clearance. I called the psychologist and asked him what's the criteria for clearance.

"Listen, I don't know. I do know I got paid a lot of money so I cleared it okay? That's what clears the patient."

Again, if the answer is always 'yes,' and never 'no,' then how is this anything other than an empty, perfunctory, 'responsibility-accepting' ritual on the part of the letter-writer just in case the patient later has second thoughts about the surgery (10 years later, I no longer have my genitalia...I just realized that this is a BIG problem and I wasn't of sound mind when I agreed to this surgery)?

Exactly my point.

I can tell you this. Some places such as Johns Hopkins have studied gender transition surgery so there is a body of data out there and people have studied it, but, and I would tell this to the patient, "In my own defense this is not within the standard of care to know, nor is part of the modern psychiatric training curriculum. This is a specialized set of data that all psychiatrists are not expected to know off-hand, but we are expected to know what is within the standard such as diagnosing and treating more common psychological ailments. I can refer to you to a specialist, but I couldn't do it myself."

A foundation of forensic psychiatric training is do not enter any arena and start a fight where you are not supposed to enter. Do not claim to be an expert without the proper training, authority, and expertise to back it up.

 

[mistafab]

This is a classic case of people involving psychiatry for reasons other than the practice of medicine.

The driver behind these ‘clearance’ requests is not even law - it’s mostly insurance. They don’t even usually specify that “mental health clearance” needs to be a psychiatrist - often it can be a PhD or masters level therapist. Anyone to absorb some risk and induce some barriers to save costs - such is the state of US “health” care.

Psychiatry has as much ethical obligation to clear someone to receive gender affirming surgery as it does to clear people for tattoos or other body modification.

For adults, this transgender stuff is about as mental illness related as being gay was in the early DSM iterations. Why society wants us to medicalize consenting adults doing what they want with their body is beyond me - but the result of that is insurance is forced to foot the bill unless they have religious exemption.

People are allowed to sign up at 18 to go overseas and kill people for the motherland, but we need psychiatrists to say if Johnny is allowed to get a boob job. Go ahead Johnny - I went to med school to treat schizophrenia and TRD, not to stop you from getting boobs.

We as a society need to come to terms with autonomy. Right now, gender dysphoria is “medical” so insurance has to pay big chunks of that cost - thus they set up these silly barriers and the system eats (and inflates) the costs. I’d rather we skip this charade and let people have at it on their own, on their own dime - not unlike getting tattoos.

 

[hamstergang]

The analogy of an ESA animal doesn't fit the bill because there are standards and an evidence of data a physician can rely upon. It is also within the standard of care and accepted throughout the field that ESAs can help patients with their mental health needs.

I hesitate to make this post because I really don't want to go down this derail, but I have to express my shock at you writing these things.

 

[ObsequiousAplomb]

I hesitate to make this post because I really don't want to go down this derail, but I have to express my shock at you writing these things.

I'm also really fascinated that he said this. Especially in the same post as saying that it's important to stay within your lane. I certainly don't recall ANY training on ESA letters in residency or medical school, other than people saying not to write them. I would feel completely outside of my scope of practice to write one of these, yet I don't mind at all doing evals for bariatric surgery because that was actually part of my training.

 

[whopper]

Psychiatry has as much ethical obligation to clear someone to receive gender affirming surgery as it does to clear people for tattoos or other body modification.

Aside from my own forensic training the APA is very clear in a very specific matter-driving.

Psychiatrists have no training in evaluating someone's ability to drive. If you're asked to clear someone to drive (and I've been asked) the APA clearly says don't get involved. Have them go to their DMV.

The fact that some people in prior threads entertained we should be clearing people for stuff we have no evidenced-based knowledge base on, have no training in, such as reading the mind of a celebrity and that it's justified cause we have several seasons of a TV show seriously is quackery plain and simple.

In this issue of gender transition surgery, there is an evidence-based data body out there, just that it's not within the realm of the standard of care for us to know it at this point in our field. Maybe in the future it will be, but not now. Do the right thing. Refer the person who actually has that expertise and don't bull$hit that you're an expert when you don't know WTF you're doing. If you have that expertise then great, do the evaluation.

 

[calvnandhobbs68]

Aside from my own forensic training the APA is very clear in a very specific matter-driving.

Psychiatrists have no training in evaluating someone's ability to drive. If you're asked to clear someone to drive (and I've been asked) the APA clearly says don't get involved. Have them go to their DMV.

The fact that some people in prior threads entertained we should be clearing people for stuff we have no evidenced-based knowledge base on, have no training in, such as reading the mind of a celebrity and that it's justified cause we have several seasons of a TV show seriously is quackery plain and simple.

In this issue of gender transition surgery, there is an evidence-based data body out there, just that it's not within the realm of the standard of care for us to know it at this point in our field. Maybe in the future it will be, but not now. Do the right thing. Refer the person who actually has that expertise and don't bull$hit that you're an expert when you don't know WTF you're doing. If you have that expertise then great, do the evaluation.

Oh man if you're having problems with "evidence based" stuff in psychiatry, let me tell you about this thing that every psychiatrist is apparently supposed to be skilled in doing and apparently is within "standard of care" called a "suicide risk assessment"...

 

[MacDonaldTriad]

This is an important and highly viewed discussion. The randomness of who decided that 2 psychiatry letters were required were probably a similar group that were sought out by some non-medical risk managers who determined we were involved in medical THC and support pets. Again, this is an other level and a different league so the comparison isn't a metaphor, but a comment on the lack of process. My guess is that this decision to set this standard was haphazard.

Do psychiatrists really have training or opinion about this in a way that will protect our surgery and endocrine colleagues from risk in a meaningful way? Are we comfortable with the power to approve or more significantly disapprove of gender reassuring interventions? Seems like standing on quicksand during an earthquake to me. I have nothing but encouragement and sympathy for the human beings who are asking for these letters as this was a hurdle that was placed in front of them. I can only imagine that they would have to be impressively tough and progressive in their view of psychiatry to not find this requirement less than a touch offensive.

 

[whopper]

h man if you're having problems with "evidence based" stuff in psychiatry, let me tell you about this thing that every psychiatrist is apparently supposed to be skilled in doing and apparently is within "standard of care" called a "suicide risk assessment"...

It is within the standard, just that even with the best we can do it's no where close to 100% accurate.

 

[whopper]

IF anyone thinks we psychiatrists can do clearance without a body of evidence to back up what we do kindly have them talk to me at a party. I'll tell the person I can tell, using my psychiatric training, they have a small penis, have fantasies about their mom, and have a suppressed memory they refuse to accept as reality of getting it on with a goat. When they protest, I'll tell them that because I'm a psychiatrist it's 100% true even though I can't back it up in any way shape or form, but my title is good enough.

 

[ObsequiousAplomb]

It is within the standard, just that even with the best we can do it's no where close to 100% accurate.

Is it even 50% accurate though?

 

[whopper]

 

[Sushirolls]

Concur with much of @mistafab above.
I wrote letters more in the past from libertarian perspective of its pointless, bureaucracy, and if someone wants a surgery let them.

I took my position as physician to more so cover the bases of an informed consent angle. Are there are any reasons to say this person is suffering from psychosis, mania, severe depression, etc. Has this person shown the pattern of truly being commited to this life changing role of gender transition? Are they 'walking the walking' and not just a whim for the past few months. Then, that letter basically documents that they know what they are signing up for.

To whoppers point, true, we shouldn't be doing them. But we can at least document a letter, which if basically covers, from a capacity angle.

 

[comp1]

There are standards... It's okay to say you aren't familiar with them and thus can't/won't render an opinion, but that doesn't mean there aren't clinical standards. I'm not sure how forensic got dragged into this. This is not a criminal or even legal question. This is a clinical question.

 

[Ironspy]

I write a letter saying that
1. They are under my care
2. They are psychiatrically stable and I have no safety concerns
3. They have a diagnosis of gender dysphoria as evidenced by a,b,c
4. They appear to understand the risks and benefits of surgery and have capacity to consent to [specific type of surgery]
5. They have stable finances and housing as well as social support
6. Edited to add: There is no psychiatric contraindication to surgery


The above letter requires no additional training. I don’t recommend whether or not the surgery will treat gender dysphoria as I can’t predict the future. I don’t think I should be involved in the decision at all in a stable patient who clearly has capacity but I’ll help my patients maintain their bodily autonomy.

 

[aim-agm]

I write a letter saying that
1. They are under my care
2. They are psychiatrically stable and I have no safety concerns
3. They have a diagnosis of gender dysphoria as evidenced by a,b,c
4. They appear to understand the risks and benefits of surgery and have capacity to consent to [specific type of surgery]
5. They have stable finances and housing as well as social support


The above letter requires no additional training. I don’t recommend whether or not the surgery will treat gender dysphoria as I can’t predict the future. I don’t think I should be involved in the decision at all in a stable patient who clearly has capacity but I’ll help my patients maintain their bodily autonomy.

I think this should be "There does not appear to be a psychiatric condition which impairs their capacity to consent to [specific type of surgery]"
You can't and shouldn't assess for capacity to consent to surgery, that question has to be answered by the surgeon.

 

[whopper]

I'm not sure how forensic got dragged into this.

I dragged it into this because it was only in forensic training where someone clearly, and unambiguously stated that we doctors (especially psychiatrists) aren't supposed to go into areas where we have nothing substantive to support us, and this is an important issue where the forensic psych curriculum has it built-in to go over this in detail. Unfortunately there is a strong history of case law where psychologists and psychiatrists said things in court with nothing evidenced-based to back up their statements other than "I am a psychiatrist."

Even in residency I saw attending psychiatrists not know what to do when asked to do clearance on something where we aren't supposed to get involved, and voiced their frustration. "Why are they asking me to do this?" I remember as a resident telling them "can't you just say you can't do it?," and the attending would state "I don't know."

I independently came up with on my own that it has to be common sense and acceptable by my PGY-2 then to say we have no expertise in the matter when asked to do things on consults such as clear for something like be able to drive, but no attending would back me up on it saying they weren't sure of what to do in such situations. Since my own attendings were not giving me an answer I had the hospital lawyer verify I could give this as an appropriate answer, but he never told me of any body of work saying it was appropriate. So it was affirming to see this standard as what was supposed to be done, see a large case-body where courts came up with that too during forensic training, and experts in the field already having settled this literally decades ago, but so many attendings didn't seem to know it.

As pathetic as it obviously is, this was a different era where psychiatrists back in my residency days still overused Freud, saying things like the treatment resistant depression was due to things like mommy-issues, or even say spontaneous and permanent remission of Schizophrenia was a real thing.

So while we've progressed, I just recently saw people in our own field state we should act as judges of psych based on popular media in our own forum.

Just off on the side, during the Nuremberg trials, the vice chancellor, Rudolf Hess, successfully convinced the evaluating psychiatrist he met the needed criteria of an insanity defense. After the report was submitted to the judges, Hess, stood up and admitted he fabricated everything. There was no good science on detecting lies or malingering back at that time. The entire thing is on film if you care to sit through it, and free on Youtube. but I don't remember the exact minute of this film that is several hours long where it happened, but I did see it myself. If only they zoomed in on the psychiatrist's face when Hess admitted it was all BS.

 

[clausewitz2]

I dragged it into this because it was only in forensic training where someone clearly, and unambiguously stated that we doctors (especially psychiatrists) aren't supposed to go into areas where we have nothing substantive to support us, and this is an important issue where the forensic psych curriculum has it built-in to go over this in detail. Unfortunately there is a strong history of case law where psychologists and psychiatrists said things in court with nothing evidenced-based to back up their statements other than "I am a psychiatrist."

Even in residency I saw attending psychiatrists not know what to do when asked to do clearance on something where we aren't supposed to get involved, and voiced their frustration. "Why are they asking me to do this?" I remember as a resident telling them "can't you just say you can't do it?," and the attending would state "I don't know."

I independently came up with on my own that it has to be common sense and acceptable by my PGY-2 then to say we have no expertise in the matter when asked to do things on consults such as clear for something like be able to drive, but no attending would back me up on it saying they weren't sure of what to do in such situations. Since my own attendings were not giving me an answer I had the hospital lawyer verify I could give this as an appropriate answer, but he never told me of any body of work saying it was appropriate. So it was affirming to see this standard as what was supposed to be done, see a large case-body where courts came up with that too during forensic training, and experts in the field already having settled this literally decades ago, but so many attendings didn't seem to know it.

As pathetic as it obviously is, this was a different era where psychiatrists back in my residency days still overused Freud, saying things like the treatment resistant depression was due to things like mommy-issues, or even say spontaneous and permanent remission of Schizophrenia was a real thing.

So while we've progressed, I just recently saw people in our own field state we should act as judges of psych based on popular media in our own forum.

Just off on the side, during the Nuremberg trials, the vice chancellor, Rudolf Hess, successfully convinced the evaluating psychiatrist he met the needed criteria of an insanity defense. After the report was submitted to the judges, Hess, stood up and admitted he fabricated everything. There was no good science on detecting lies or malingering back at that time. The entire thing is on film if you care to sit through it, and free on Youtube. but I don't remember the exact minute of this film that is several hours long where it happened, but I did see it myself. If only they zoomed in on the psychiatrist's face when Hess admitted it was all BS.

To be fair, Rudolph Hess did a lot of strange things that definitely call his ability to reason clearly into question. He spent most of the war as an Allied prisoner because he decided, unbeknownst to anyone else, to fly a plane by himself to Scotland to negotiate peace with the UK. He was hoping to meet with either the Duke of Hamilton or Ian Hamilton, either would do, as a back channel to the King, who he believed wanted to exile Churchill to Canada. He decided on trying to reach the Duke of Hamilton on the grounds that he was also an aviator so of course he would be willing to advocate on Hess' behalf. The two had never met.

These are not the actions of someone with a really firm grasp on consensus reality.

EDIT: it appears what he admitted to fabricating was amnesia, which is a very different thing than saying he successfully feigned a mental illness. He also seems to have been obsessed with faith healers and the occult, worth noting.

EDIT EDIT: and while in captivity he became convinced his food was poisoned and insisted that some of it be sent out for lab analysis. He also told his interrogators that Jews with psychic powers were controlling the minds of the British cabinet and keeping him from sleeping. This is what came out of his mouth when he was still trying to negotiate a peace treaty. Yeah, I'm comfortable making certain assumptions.

 

[PsyDr]

Legal action may change transgender care in America

Some detransitioners are starting to take their doctors to court

www.economist.com

 

[whopper]

These are not the actions of someone with a really firm grasp on consensus reality.

There certainly were a lot of questionable things, but these are grey areas that by today's standards would hardly, if anything offer a legal defense, and back in the day, and even today some psychiatrists back this up, the fact that they're a psychiatrist, people should listen to them without substantive evidence. E.g. the Nazi shared-delusion that they were descendants of ancient Atlantis, him flying over to Scotland (which was foolhardy), but if employed by a modern day defendant would be quickly punted as non-issues for a mental health legal defense.

Amnesia has been stated by SCOTUS as not an allowable defense, people with delusional beliefs such as belief in the Loch Ness Monster, Sasquatch, sovereign citizens, and flat-earthers would not be given free reign to allow these beliefs to be an excuse for a crime.

 

[Atreides]

To @whopper's point, WPATH guidelines state (or did, before the most recent revision):

"mental health professionals who recommend surgery share the ethical and legal responsibility for that decision with the surgeon"

Many insurance company guidelines still state this.

 

[comp1]

The new WPATH guidelines are pretty great in terms of respecting autonomy, but I don't think they exactly remove mental health provider roles entirely. They still say that a mental health provider is responsible for excluding other mental illnesses when considering a diagnosis of gender dysphoria.

 

[Fan_of_Meehl]

To @whopper's point, WPATH guidelines state (or did, before the most recent revision):


Many insurance company guidelines still state this.

I guess this will be decided in the courts (at some point).

 

[Stagg737]

To @whopper's point, WPATH guidelines state (or did, before the most recent revision): "mental health professionals who recommend surgery share the ethical and legal responsibility for that decision with the surgeon"


Many insurance company guidelines still state this.

I guess this will be decided in the courts (at some point).

There is a significant difference between saying someone is psychiatrically stable or that there aren't psychiatric barriers to a surgery versus actually recommending a surgery. The former maintains patient autonomy and allows them to make a decision without making treatment recommendations, the latter directs care. I'd imagine that if documented as such, the former wouldn't put us at higher legal risk as the lawyer would have to argue that the patient lacked ability to make decisions about their own care, in which case the lawyer would have to have a pretty twisted argument about how they can make all the other decisions in their medical care but not this one; while the latter could actually be attacked in court far more easily.

 

[splik]

To be fair, Rudolph Hess did a lot of strange things that definitely call his ability to reason clearly into question. He spent most of the war as an Allied prisoner because he decided, unbeknownst to anyone else, to fly a plane by himself to Scotland to negotiate peace with the UK. He was hoping to meet with either the Duke of Hamilton or Ian Hamilton, either would do, as a back channel to the King, who he believed wanted to exile Churchill to Canada. He decided on trying to reach the Duke of Hamilton on the grounds that he was also an aviator so of course he would be willing to advocate on Hess' behalf. The two had never met.

Even the Nazis thought he was a nutter. After he was captured by the Brits, pretty immediately they had him psychiatrically evaluated and believed him to be a psychopathic personality with schizophrenic features. He had amnesia in captivity which the psychiatrists believed to be mostly malingered rather than hysterical. For his competency evaluation for the Nuremberg trials he was evaluated by physicians (not all psychiatrists) from different countries. The Americans said he was hysterical but competent to stand trial and not insane. The Brits said he was a psychopath with hysterical tendencies and not insane. The Russians said he a psychogenic paranoid reaction with hysterical amnesia. The French psychiatrist Jean Delay (who brought us Thorazine) tried to do narcoanalysis but he refused (it's usually those malingering amnesia who refuse this in my experience).

Later it was argued that Hess was definitely psychotic rather than hysterical and the psychiatrists were too influenced by psychodynamic thinking. The recommended treatment for his amnesia at the time was ECT and nacosynthesis which may have caused him to proclaim he was faking. However whether he was faking and to what extent his amnesia was malingered is another question. It is not uncommon for psychotic defendants to claim they are making up symptoms to avoid treatment or being labeled lunatics.

 

[comp1]

Remember...you can be sued for anything at any time. Heck, you could be sued for creating barriers to care as trans people are a protected class in many states. It's honestly just not very likely you're going to be sued either way in these cases. Just do what's right for the patient to the best of your abilities.

 

[SeniorWrangler]

I don’t write letters except for established patients and I don’t write letters for owning a gun, child custody, etc. because I don’t feel qualified.

 

[whopper]

This is my smartphrase for access to a gun.

Due to the patient living in a setting with a firearm, I told the patient that firearms should be kept in accordance with federal, state, and local laws, unused guns should be locked, ammunition should be kept in a separate location to reduce risk of accidental use or suicide, and that I could not monitor the patient's safety once they leave my office. Several medications including all psychotropic medications could cause suicidal ideation (although very rare) as a side effect, and access to a loaded firearm while suicidal is extremely dangerous. Trying any psychiatric medication while in possession of a firearm should be handled accordingly by the patient on their own judgment because I will not be able to be with the patient 24/7. I recommended that the safest option would be to have not have possession of the firearm while trying the new medication, but it is the patient's choice to follow this recommendation, and responsibility to incur the risks if they made choices outside of the physician's authority, recommendation, and legal power..

 

[SeniorWrangler]

That’s pretty good! Did you do it, or a lawyer, or AI?

 

[whopper]

I did it all by myself.

Start at 1:45

 

[hippopotamusoath]

I once had a patient who had a pretty clear, active, psychiatric illness that was untreated and contributed to their misgivings about their current gender presentation (being vague on purpose). The patient very much expected a rubber-stamp from me, and was incredibly angry when I said no due to the above.

These days, I don't really want to be involved. I think it's a political minefield, and the science is not settled as far as what my role as a psychiatrist should be in this sort of evaluation. I think my patients benefit from a specialist opinion, so I send them to the local university's gender clinic for an evaluation. I guess it's avoidant on my part, but it feels like this is an attempt by the surgeon and insurance company to CYA, and I'll be left holding the bag for all sorts of bad outcomes which were completely out of my control.

 

[comp1]

This is an excellent thing to refer out for. It is a subspecialty for a lot of intents and purposes. The challenge for the OP is likely...Medicaid.

 

[Sushirolls]

What ridiculous states are prompting letters or smart phrases for CYA regarding guns?

 

[comp1]

I'm not sure firearm risk education/documentation of that education is state specific.

 

[whopper]

These days, I don't really want to be involved. I think it's a political minefield, and the science is not settled as far as what my role as a psychiatrist should be in this sort of evaluation. I think my patients benefit from a specialist opinion, so I send them to the local university's gender clinic for an evaluation. I guess it's avoidant on my part, but it feels like this is an attempt by the surgeon and insurance company to CYA, and I'll be left holding the bag for all sorts of bad outcomes which were completely out of my control.

I don't like it when we docs refer out due to laziness or cowardice, but this is a valid case to refer out. Our own training in the field, arguably not what it should be, is quite small and there are specialists who could do better than most psychiatrists.

The politics associated with this issue has stepped over into the ridiculous, and this is with all political extremes.
While this controversial issue does merit concern, it's become an intentional wedge issue brought up by both extreme sides. Some valid questions are the long-term outcomes of gender transition surgery, why are the rates of people identifying as trans skyrocketing?, and what deems capacity to make the decision for gender altering surgery. The answers should be done in a manner following the clear medical ethics and without the politics.