Sharing decisions amid uncertainties: a qualitative interview study of healthcare professionals’ ethical challenges and norms regarding decision-making in gender-affirming medical care

Abstract

Background In gender-affirming medical care (GAMC), ethical challenges in decision-making are ubiquitous. These challenges are becoming more pressing due to exponentially increasing referrals, politico-legal contestation, and divergent normative views regarding decisional roles and models. Little is known, however, about what ethical challenges related to decision-making healthcare professionals (HCPs) themselves face in their daily work in GAMC and how these relate to, for example, the subjective nature of Gender Incongruence (GI), the multidisciplinary character of GAMC and the role HCPs play in assessing GI and eligibility for interventions. Given the relevance and urgency of these questions, we conducted a qualitative study among HCPs providing GAMC to transgender adults in the Netherlands. Methods In this qualitative research, we conducted 11 semi-structured interviews between May 2020 and February 2021 with HCPs (six mental health professionals, two HCPs in endocrinology, two in plastic surgery, and one in nursing) working in two distinct GAMC settings. We purposively sampled for professional background and years of experience in GAMC. We analyzed our interview data using thematic analysis. As some respondents were more inclined to speak about what should or ought to be done to arrive at good or right decision-making, we identified both ethical challenges and norms. Furthermore, in our analysis, we differentiated between respondents’ explicit and implicit ethical challenges and norms and ascertained the specific context in which these challenges emerged. Results Respondents’ ethical challenges and norms centered on (1) dividing and defining decisional roles and bounds, (2) negotiating decision-making in a (multidisciplinary) team, and (3) navigating various decision-making temporalities. These themes arose in the context of uncertainties regarding (1) GAMC’s guidelines, evidence, and outcomes, as well as (2) the boundaries and assessment of GI. Conclusions This interview study provides detailed empirical insight into both the explicit and implicit ethical challenges that HCPs experience and their ethical norms regarding decision-making. It also describes how uncertainties and (implicit) normativities concerning GAMC and GI pre-structure the moral environment in which these challenges and norms manifest. We provide normative reflections and recommendations on handling these ethical challenges in a way that is sensitive to the context in which they arise.

Desired decision-making role and treatment satisfaction among trans people during medical transition: results from the ENIGI follow-up study

“…While the informed consent model is in line with WPATH guidelines [1] and many clinics use this type of care for accessing hormones [26], one study showed that over 40% of clinicians support having the MHP alone decide when a person is ready for hormones/surgery while over 60% still supported a real-life test before treatment, whereas trans individuals in this study strongly disagreed with these steps [27]. A recent study describes the ethical challenges of health care professionals regarding decision-making in gender affirming medical care [28]. Amongst others these challenges center on dividing and defining decisional roles in the context of guidelines, evidence and outcomes of gender affirming medical care and boundaries and assessment of gender incongruence.…”

“…Non-binary individuals [41,42] and non-socially transitioned trans individuals [40] often differ from (socially transitioned) binary trans people in the types and number of TRMI they undergo, and they may request single treatments [42,43]. Although the SoC-8 addresses care for non-binary individuals, clinicians often seem unsure about TRMI for this population, often citing ethical and moral concerns [28]. This may be because followup studies on the outcome of TRMI over a longer period of time are not available yet, because a history of gender incongruence or dysphoria is sometimes less obvious/not present or uniquely experienced (e.g.…”

Doing and undoing transgender health care: The ordering of ‘gender dysphoria’ in clinical practice

“…This research is part of a larger study on shared decision‐making in gender‐affirming medical care for adults in the Netherlands (2019–2022). Our research team conducted 11 interviews in a previous qualitative study with health‐care professionals in academic and non‐academic gender‐affirming medical care (see Gerritse et al., 2022). Additionally, we interviewed five mental health professionals who work in transgender mental health care, a setting where clinicians offer counselling and psychological treatment to transgender people.…”

“…We purposively sampled interlocutors based on professional backgrounds and years of experience (Green & Thorogood, 2018). See Gerritse et al (2022) for the recruitment and selection of health-care professionals in gender-affirming medical care. The fourth author (BK) brought us in contact with a mental health professional working in transgender mental health care, through which we snowball sampled the other interlocutors.…”

“…They conducted the interviews between May 2020 and February 2021, nine of which took place via Microsoft Teams due to the COVID-19 pandemic. See Gerritse et al (2022) for the details of data collection.…”