I don't think they thought I was ready: How pre-transition assessments create care inequities for trans people with complex mental health in Canada

Transgender (trans) people experience high rates of mental health issues including depression and suicidality. Improving access to transition-related medicine such as hormones and surgeries is suggested as an important mechanism to address these mental health issues. Yet clinicians experience challenges assessing and referring trans people for transition-related medicine. Standardized assessment protocols have been therefore recommended to optimize care. Although standardized protocols are purported to expand access to hormones and surgeries for trans people, it is unclear whether these tools achieve this goal. We therefore conducted an institutional ethnography to explicate how standardized readiness assessments coordinate access to hormones and surgeries in Canada. We analyzed key texts, talked with trans people, clinicians, clinician-educators, and administrators (total n = 22), and observed clinician-education workshops. In the context of determining transition readiness, standardized protocols direct clinicians to explore alternative diagnoses and assess the degree to which any complex mental health condition is managed prior to initiating hormones or surgeries. In response, we found that trans patients downplay or withhold mental health concerns from clinicians, or otherwise do additional work (e.g., take up unwanted psychiatric interventions) to convince providers they are mentally ready to transition. This phenomenon is paradoxical in that transition-related medicine is recommended to mitigate trans people's psychosocial distress, but when patients reveal symptoms of distress they encounter significant barriers to treatment. We conclude that the logic underpinning pre-transition mental readiness assessments discredits the claim that standardized protocols optimize access to hormones and surgeries.