Understanding the Autonomy of Transgender Patients: A Broader Appreciation for Gatekeepers

While bioethicists define autonomy as self-governance without coercion, how self-governance actually proceeds in the constraints of daily life, the external environment, and varying life perspectives requires consideration. In the care of transgender patients, those providing gender affirming treatment are called upon to serve as gatekeepers to the legitimacy of the patient’s wishes. Billing entities, coding reviewers, the lay press and politicians ask whether transgender people are making autonomous decisions regarding this treatment.

The philosophical literature on autonomy understands the foundation of self-governance in two ways. The coherentist approach requires that decision-making be consistent or harmonious with the patient’s point of view on the action, which describes some transgender patients but not all, as one’s own self-representation of gender can change over time. According to the externalist approach, a patient only governs themselves if their decsion-making is responsible to external reasons; but, again, there are transgender patients whose gender-affirming care is done in the teeth of negative external incentives. What is lacking in the autonomy literature, especially regarding transgender patients, is a notion of cultural, economic, and social influences, as well as material inequities, which provide not reasons in themselves but a sense of self that might not be either primarily responsive to external reasons or consistent with regard to internal point of view.

To be transgender in the context of other people being transgender should be recognized as an equally legitimate path to recognize autonomy in gender-affirming care.