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Responding to objections to gatekeeping for hormone replacement therapy
  1. Toni C Saad1,
  2. Daniel Rodger2,
  3. Bruce Philip Blackshaw3
  1. 1 University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
  2. 2 Allied Health Sciences, London South Bank University School of Health and Social Care, London, UK
  3. 3 Philosophy, University of Birmingham, Birmingham, UK
  1. Correspondence to Toni C Saad, Hafen-Y-Coed, University Hospital of Llandough, Penlan Road, Llandough, Penarth CF64 2XX, Cardiff and Vale University Health Board, Cardiff, UK; ToniSaad{at}

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In this brief reply to Ashley’s rebuttal concerning the gatekeeping of hormone replacement therapy (HRT) for transgender people, we address some of the criticisms made of our original response to Ashley. We first re-examine Ashley’s attempted analogy between abortion and HRT for gender dysphoria and find it wanting. Our argument that it is reasonable to regard cosmetic surgery and HRT for gender dysphoria as comparable (including in terms of prior psychological assessment) is restated to show that Ashley’s previous objection to it is insubstantial. Our objection to Ashley’s simultaneous rejection of the traditional informed consent model while maintaining its language, and thus relying on its positive connotations rather than argument, is then clarified. Finally, we scrutinise the data on which rests Ashley’s claim that informed consent without assessment always yields positive outcomes, finding this conclusion to be overstated.


Ashley has responded to our response to ‘Gatekeeping HRT for transgender patients is dehumanising’.1–3 Ashley criticises some of our objections to their view that patients seeking HRT for gender dysphoria should not have to undergo a prior psychological assessment.1 Here, we clarify our objections, most importantly that concerning the parity between cosmetic surgery and the sort of intervention Ashley has in mind, showing that Ashley's criticism of our comparison is insubstantial. We start, however, by examining Ashley's comments regarding the analogy between abortion and HRT.After revisiting the subject of cosmetic surgery, we consider Ashley's use of the language of informed consent. We close by scrutinising the data on which Ashley relies to defend the claim that informed consent without assessment always yields positive outcomes, finding this conclusion to be overstated. Finally, even if Ashley’s arguments were vindicated, the claim that the gatekeeping of HRT is motivated by hostility towards transgender people remains unsupported.

Abortion and assessment

Ashley objects to our calling their analogy …

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  • Contributors Each coauthor has made equal contributions to this paper, both in planning and execution. TCS, DR and BPB each contributed sections of text to the draft and were involved in the editing process.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • We were informed by the editorial team that Ashley now wishes to be referred to by ‘they/them’ pronouns.

  • It is worth pointing out that there are other examples of where prior psychological assessment is recommended and considered routine prior to receiving treatment. One such example is bariatric surgery, which involves individuals who experience stigmatisation.7 The purpose of the psychological evaluation is to assess the patient’s ability to manage the preoperative and postoperative demands of the surgery on account of the high prevalence of psychiatric morbidity in this population.8 9

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