Transidentité et dépsychiatrisation : enjeux éthiques. Enquête nationale auprès des psychiatres en formation

Abstract

Objectives

This article focuses on the ethical issues surrounding gender-affirming care for transgender people (i.e. A person whose gender does not correspond to their sex assigned at birth), particularly the respect of the rights of transgender patients to autonomy during psychiatric evaluations. This topic gives leave to a deeper investigation into the principles of non-maleficence when diagnosing gender dysphoria and into the principles of justice when providing essential medical care for transgender people in France.

Materials and methods

Firstly, a review of the literature was carried out in order to explore the historicity of sex, its definition and variations, and the concept of gender identity. To establish the latter's relationship to psychiatry, the evolution of gender dysphoria through psychiatric classifications and guidelines was reviewed, as well as the role of the psychiatrist in the process of gender-affirming treatment. A reflection was also carried out concerning the ethical issues of the medical care of trans people, through the autonomy of choice, beneficence and non-maleficence of access to the hormonal-surgical transition, and the societal issues involved in the evolution of the consideration of gender. A study was conducted via a websurvey and a questionnaire was sent to psychiatric residents completing their studies in France. A total of 70 respondents were included. The questionnaire asked residents to give their opinion on transgender people's right to autonomy (and how to respect them) during psychiatric assessments and psychological inputs.

Results

The answers from the residents indicate that they are mainly in favor of upholding transgender people's right to autonomy, with an emphasis on their capacity and their right to self-determination. Conversely, 15% of the respondents viewed transgender identities as a mental disorder and were more in favor of a medicalized model of treating gender dysphoria. A psychiatric assessment prior to receiving gender-affirming care was still perceived as necessary in order to eliminate differential diagnoses and to evaluate the capacity for informed consent, however, this may be perceived as excessive pathologization for transgender people. On the other hand, this feeling of pathologization is perceived as diminished if this consultation is performed by a psychologist. These answers suggest the necessity of carrying out a comparison with the feelings of the concerned individuals, for a more ethical management of transidentity.

Conclusion

The issue of meeting the demands of the transgender population is still being debated. It is legitimate to ask whether we can, under cover of their freedom of choice, let the persons concerned make the decision without having first undergone a medical evaluation, and whether the individual's autonomy must take precedence over potential irreversible negative outcomes. Through this study, it appears that the sampled psychiatry residents sense that those individuals seeking transgender care have the feeling of pathologization that is induced by a consultation with a psychiatrist before starting gender-affirming care. On the other hand, if the consultation is conducted by a psychologist this feeling of pathologization is less a factor. This assumption should obviously be affirmed with the concerned persons.