“In order to protect the practitioners and the transsexual from an irreversible mistake, power weighs on the side of the caretaker, and this fosters resentment by transsexuals. It is certainly a dilemma, especially in light of Pomeroy’s view that one of the major tasks of a therapist in treating a transsexual is to promote a nonevaluative and nonjudgmental therapeutic encounter…Yet this evaluation is at the crux of the unequal power relations and one that is unavoidable” (Bolin, 1988 p. 52)
Going to therapy because you know it is necessary to get treatment is likely to not inspire the greatest therapeutic involvement on the part of the patient. They know the right lines to say “I feel like I was born in the wrong body” and the patient ends up just going through the motions. There is a fundamental problem in truthfulness for patients who see therapy as a hoop to jump through.As Sandy Stone describes it, “[Transsexuals] had very clear agendas regarding their relation to the researchers, and considered the doctors’ evaluation criteria merely another obstacle in their path – something to be overcome” (Stone, 2006, p. 228)
Instead of working with the therapist and answering questions with honesty the patients end up analyzing everything they say in terms of how the therapist or doctor might potentially interpret it with respect to a decision about whether they are “really” trans and thus in need of HRT and surgery. Thus, gatekeeping serves as a barrier for effective treatment based on open and honest communication and it helps reinforce the stereotype that trans people are “deceivers” (Bettcher, 2007). Gatekeeping thus reinforces the idea that trans people are, as some researchers put it, “Unreliable historians…unable ot recall very well, or inclined to distort” (quoted in Meyerowitz, 2002, p. 161). But rather than thinking of trans people as “inclined to distort” it is more accurate to think of them as “desperate for treatment” and willing to game the gatekeeping system in order to gain access to scarce and limited options. Trans people feel afraid to be honest with their caretakers because they are viewing these caretakers as an obstacle to be overcome rather than people who have their best interest at heart. This model is fundamentally counter-productive when it comes to achieving better healthcare outcomes for trans people. Meyerowitz summarizes the historical tension succinctly: “In short, the patients mistrusted the doctors, and the doctors mistrusted the patients” (2002, p. 162).
Transgender healthcare almost inevitably brings up an ethical conflict between therapist as counselor and therapist as gatekeeper. As Meyerowitz describes it,
“…[T]he conflicts brought up questions of control. Who could decide whether a person was or should be a man or a woman? Who could decide whether to change the bodily characteristics of sex? Transsexuals hoped to decide for themselves, but they needed the consent and cooperation of doctors.” (2002, p. 153)
However, this conflict between therapist and patient is primarily a function of the traditional gatekeeping model that seeks to put obstacles in place for trans people. This sets up a problematic situation where, as one trans woman put it, “You need his expertise, so keep your mouth shut, let it pass, and don’t make waves” (Brevard, 2001, p. 3). This idea of not making waves, of not calling out transphobia and standing up to discrimination, is reinforced whenever trans people see medical professionals as putting obstacles in their path or hurdles to clear instead of passionate experts ready to assist you and heal your wounds be they physical or psychological. If there were no gatekeeping hurdles to cross, then the patient would feel more comfortable in the patient-therapist context and would not need to resort to stock narratives or cliches such as “I’ve always felt this way” or “I’m trapped in the wrong body”. The elimination of the gatekeeping model would also open the pathway for gender nonconforming people such as genderqueers or non-binary trans people to share their narratives without feeling the pressure to conform to the “standard trans narrative” in order to get a diagnosis or satisfy some checklist.
Seeing a therapist for 3-6 months on a regular basis can also be very expensive and outside the affordability of low-income trans people, especially with insurance, which many trans people lack. Making a specified period of psychotherapy a strict requirement violates the principle of justice because it fails to correct for the systematic injustices that prevent poor trans people from gaining adequate access to transition related treatments.