Case Western psychiatrist: Wild West mentality in gender clinics
Mental health evaluations not required, hormones provided after one visit

Dr. Steven B. Levine, professor of psychiatry at Case Western Reserve University, focuses on treating trans-identifying children and adolescents and has written extensively (see here and here) about the nature of informed consent for such patients. (In 2020, I discussed this work for Public Discourse in a two–part essay.) Although Levine, unlike many physicians, does not rule out GAT in all circumstances, he recognizes that medical interventions for gender dysphoria or incongruence profoundly implicate many aspects of a patient’s life: physical and mental health, social adjustment, family relationships, and romantic relationships. Decisions made now will determine whether the young patient ultimately flourishes or flounders.

Building on his earlier work, a new study by Levine and his colleagues E. Abbruzzese and Julia W. Mason, published in March 2022, finds that the informed-consent process is too often more of a box-checking exercise than a serious discussion and deliberation. In “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults,” the authors (to whom I will refer as “Levine” for short) lament that clinicians in the trans industry have gone beyond simple negligence or incompetence; instead, they are engaging in demonstrably unethical practices….

Levine describes a Wild West mentality in the rapidly proliferating “gender clinics” (including, increasingly, Planned Parenthood facilities) that desperate parents consult to handle their children’s gender dysphoria. Perhaps as early as preschool, or suddenly as adolescents or college students, skyrocketing numbers of youth are demanding medical interventions that raise—or should raise—a host of ethical concerns. These concerns “are amplified by the dramatic growth in demand for youth gender transition witnessed in the last several years that has led to a perfunctory informed consent process” (emphasis in the original).

The numbers are startling. Incidence of trans identity began to rise around 2006 and soared in 2015, such that, as Levine reports, “currently, 2-9% of U.S. high school students identify as transgender, while in colleges, 3% of males and 5% of females identify as gender-diverse.” Claims to be nonbinary (neither male nor female, or both male and female) have recently increased, with a new study showing 63 percent of trans-identifying youth also claiming nonbinary status.

According to Levine, this boom in demand, coupled with the absence of any well-considered standards of ethical practice, has led to the development of a new “informed consent model of care”:

Under this model, mental health evaluations are not required, and hormones can be provided after just one visit following the collection of a patient’s or guardian’s consent signature . . . The provision of transition services under this model of care is available not just to those over 18, but for younger patients as well.

Levine’s assessment of this model of care is blunt:

[W]e believe this model is the antithesis of true informed consent, as it jeopardizes the ethical foundation of patient autonomy. Autonomy is not respected when patients consenting to the treatment do not have an accurate understanding of the risks, benefits, and alternatives.

Among the ethical violations Levine finds in current practice are “poor quality of the [patient] evaluation process . . . and incomplete and inaccurate information that the patients and family members are given….”