The bioethicist Jacob Hale writes:
“This is not an endorsement of ‘surgery on demand,’ not even the more moderate view that surgery is a right to be granted upon request. Nor do I support Susan Stryker’s (1997) suggestion that the transsexual, rather than the psychotherapist, should ultimately determine what will happen to the transsexual’s body. Ultimately, decisions about whether to prescribe hormones and perform operations must be made by physicians – not prospective patients or mental health professionals – after careful patient-physician consultation and a thorough informed consent process” (Hale, C. J. (2007). Ethical problems with the mental health evaluation standards of care for adult gender variant prospective patients. Perspectives in biology and medicine, 50(4), 491-505.)
Although Hale disavows any kind of gatekeeping through the WPATH Standards of Care and advocates for an informed consent process, he mischaracterizes the nature of the shared decision making process by claiming that “ultimately” it is the doctor who decides what will happen to the trans person’s body.
If a trans patient comes into an IC clinic asking for HRT, the doctor checks for contradictions, and then decides to prescribe hormones, is it really the case that the doctor is “ultimately” making the final decision about what happens to the trans patient’s body? I think Hale is failing to distinguish between two different senses of what counts as the “ultimate decision”. On the one hand, the “ultimate decision” can mean the final step of the causal process, meaning that it is the doctor writing down the Rx on his pad that is the “final” decision. But in the other sense, the “ultimate” decision has already been made by the patient seeking HRT because it is their decision at a more fundamental level – they are the ones who stepped forward and made the decision to walk into the IC clinic with the intent on getting HRT. They are the ones who have decided to change their body.
Consider an analogy with an auto mechanic. A customer walks into the auto shop and requests a replacement of their exhaust system in order for it to sound louder. In one sense, it is the mechanic who “ultimately” decides what happens to the car because they are the ones who make the final causal step in agreeing to work on the car. But in another sense, it is really the customer who made the “ultimate” decision about whether to get a new exhaust system because it was their original desire for a louder exhaust system that brought them to the auto shop in the first place.