If you consult the “Gender Affirming Hormone Therapy” page of the Planned Parenthood League of Massachusetts, you will discover that you can get a prescription for testosterone or oestrogen after your first visit or on-line consultation. Of course, 16 and 17-year-olds need parental consent. If you are under 16, PPLM will be happy to refer you to another provider.

American gender specialists are processing their clients on an assembly line.

But a brief consultation – or even two or three –is not enough to determine whether a person is ready for life-changing “gender affirmation”, says Australian psychiatrist Robert D’Angelo in the Journal of Medical Ethics. He proposes psychoanalysis as an appropriate way for doctors to explore issues with gender-questioning patients. It is slower but it respects their autonomy and informed consent and is yields more accurate diagnoses.

There’s a catch. Psychotherapy for gender-questioning patients is increasingly being banned as a kind of rebadged “conversion therapy”.

It’s not, insists D’Angelo. Psychotherapy does have a chequered past, but it has evolved with the years. “To suggest that psychotherapy is a form of conversion therapy betrays a fundamental misunderstanding of psychotherapy. Psychotherapy resides outside the affirmation-conversion binary and aims to address the distress of gender-dysphoric youth rather than to correct a sense of misalignment.” He explains why psychotherapy is necessary for patients who request a sex change:

Informed consent is seriously compromised if the patient and clinician have an inaccurate or incomplete understanding of the cause of the patient’s distress or problem. Currently, we have no screening tools or protocols to determine in which individuals’ gender dysphoria is a carrier for another psychosocial or mental health issue. Similarly, we have no reliable way of predicting which young people will be helped by transition and which will not. The best, and arguably only, tool we have is detailed psychotherapeutic exploration that extends over a long enough period to allow significant, previously unknown or unconscious issues to become available for reflection.

To make an informed decision, we need to have all the facts. This arguably includes those facts that are not ‘readily apparent’ or outside awareness. If we accept that some of the factors that shape individuals’ decisions about medical transition are not conscious and take time to access, then robust informed decision-making is not possible without a detailed psychotherapeutic process that attempts to open up previously unacknowledged difficulties or areas of experience. Sensitive psychotherapeutic exploration is not about paternalism or gatekeeping. On the contrary, it protects autonomy by providing a space for careful, nuanced reflection in which complex, shared decision-making is encouraged and facilitated.