Tag Archives: biomedical ethics

The Traditional Gatekeeping Model of Trans Healthcare

Starting in 1933 with endocrinologist Christian Hamburger’s treatment of Christine Jorgensen, the triadic combination of psychiatric evaluation, hormones, and surgery became the default protocol for dealing with trans people who desired treatment. Not to mention that transgenderism itself was viewed by the professional community as a medical disorder – an idea that is now losing ground in wake of better knowledge about gender variance across cultures. The most comprehensive contemporary guideline for transgender healthcare is the Standards of Care (SOC) that comes from the World Professional Association for Transgender Health or WPATH. The WPATH guidelines provide a uniform set of standards for treating transgender and gender nonconforming people and have been the definitive source for transition guidelines for decades. When I talk about the “traditional” model of transgender healthcare I am referring to an amalgam of the WPATH guidelines prior to the 7th version( the current version, which came out in 2011), which has changed significantly to conform more towards the Informed Consent model. I’m focusing on the traditional model rather than the 7th version SOC because many healthcare providers across the world are still following the traditional model and using gatekeeping mechanisms to limit access to HRT and Gender Confirmation Surgery (GCS).

The first step in the traditional model is months of psychotherapy to evaluate whether the patient is genuinely transgender – often called the “trans enough” question. After this evaluation the patient would be diagnosed with gender identity disorder (GID) or “transsexualism” by a mental health professional.  Until 1998 the Harry Benjamin International Gender Dysphoria Association standards of care stated that “any and all recommendations for sex reassignment surgery and hormone therapy should be made only by clinical behavioral scientists.” (4th ed, 1990, quoted in Whipping Girl)

After getting a diagnosis of GID and starting psychotherapy, the patient would have to begin their “real-life experience test” (RLE) in which they are required to live full-time in their identified sex to experience what it is like living as their identified gender. Only after this real-life test, which could last for up to 1-2 years, would the therapist recommend the patient for hormone replacement therapy or sexual reassignment surgery. The WPATH 6th version recommends 12 months of RLE before irreversible physical treatment is started. The 6th edition WPATH Standards of Care state

“the act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. The real-life experience tests the person’s resolve, the capacity to function in the preferred gender, and the adequacy of social, economic, and psychological supports. It assists both the patient and the MHP in their judgments about how to proceed”

The underlying justification for these strenuous requirements was that the clinicians felt they were only trying to protect the trans people from having an “unsuccessful transition”, losing everything, and having deep regrets. As Julia Serano writes,

“Whether unconscious or deliberate, the gatekeepers clearly sought to (1) minimize the number of transsexuals who transitioned, (2) ensure that most people who did transition would not be ‘gender-ambiguous’ in any way, and (3) make certain that those transsexuals who fully transitioned would remain silent about their trans status.” (Whipping Girl)

The effects of gatekeeping in these early days can be seen in the fact that so few people ever got GCS despite the thousands of requests. The John Hopkins program accepted only 24 of the first two thousands requests for GCS.

Passing was considered a prerequisite for transitioning and thus for HRT – this bias still operates today implicitly and explicitly. Furthermore trans people were required to abide by heteronormative ideals such that a trans women should only show attraction to males and trans men only show attraction to females. The same applied to adherence to traditional gender expressions and gender roles, such as a trans women being femme and wearing makeup, heels, skirts, etc., or showing an aversion to “traditional” male activities or interests. Trans women still get turned down for HRT if they show up in jeans and a tshirt because this is evidence they are not “trans enough” or serious enough to begin medical transition.

The Stanford Gender Dysphoria clinic “took on the additional role of ‘grooming clinic’ or ‘charm school’ because, according to the judgment of the staff, the men who presented as wanting to be women did not always ‘behave like’ women…As Norman Fisk remarked, ‘I now admit very candidly that…in the early phases we were avowedly seeking candidates who would have the best chance for success” (Stone, 2006,  p. 227-228)

One of the most historically prominent endocrinologists, Christian Hamburger, was explicit in his recommendation of HRT only for those trans women who were not overly masculine. In discussing recommendations for HRT in trans women he writes:

“The attempts at feminization have better chances of being successsful in patients having a neutral or not pronounced masculine appearance. If the patients have a neutral or not pronounced masculine appearance, if the patient presents a black and vigorous growth of beard, deep voice, excessive hairiness on trunk and limbs, strong muscles and prominent veins, it is unlikely that the estrogen treatment will give a harmonious result. In such extreme cases it may be possibly wise to try to persuade the patient to abstain from any endocrine treatment unless the psychologic disposition makes such persuasion out of the question” (Green & Money, 1969, p. 302)

If a trans woman transitions yet maintains an masculine or androgynous appearance (such as a deep voice) then this would be considered “unharmonious”. This is a highly normative claim and builds a certain stereotype of what is to count as a “successful” transition. Can you be successful if people still read you as trans after your transition? Hamburger’s notion of “harmony” does nothing to address the question of psychological harmony: would going on feminizing hormones relieve dysphoria at all? If so, would not that be beneficial even if the patient was not harmonious with respect to the norms of society? Yet the medical gatekeepers who sought to prevent non-passing trans women from getting on HRT thought they were acting in the best interest of these patients, preventing them from harmful effects in society, post-transition regret, and a feeling of dissatisfaction with the results of HRT, which the doctors thought would leave these patients in a middle-state of ambiguity, neither male nor female and thus not able to fit into society in a functionally adaptive manner.

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Transition, Hormones, Informed Consent, and Gatekeeping

So I have been on the fence about going on hormone replacement therapy (HRT) since I realized I am trans about 2-3 months ago. One of the big reasons that I didn’t necessarily want HRT was because I had to decide whether I want biological children or not given that I cannot afford to bank sperm right now (being on a grad stipend). I eventually realized (1) I can adopt or use sperm donors and (2) going on HRT is more important now than my long-term desires for raising children. In other words Im doing some temporal discounting right now and placing my priorities on my short-term happiness with the understanding that my long-term desires might change as I make further progress in my transition. I know that HRT will make me happier. How can I not choose that?

Another reason why I didn’t want to just ASSUME that because I’m trans I MUST go on HRT is that I have always liked forging my own path. I’m not going to do something just because everyone else is doing it. I think it’s perfectly possible to fully transition without HRT. It’s harder but it’s doable. I thought seriously about taking that route. But ultimately I realized that I want the secondary sex characteristics that come with HRT (mainly breasts).

So having decided that I want to go on HRT I talked to my psychiatrist yesterday and asked her for a letter. She said yes! And I booked an appointment for an endocrinologist on Sep 1st! So hopefully that means I will have a prescription for estradiol in a little less than a month from now. I am so excited! Besides doing laser for my facial hair this is the most significant step in my transition. I could hardly sleep last night.

For those that don’t know, many endocrinologists will not prescribe HRT to trans people without a letter of recommendation from a psychiatrist or therapist. Traditionally this requirement has led to many trans people not being able to get the treatment they need to feel comfortable in their own bodies and to ease their gender dysphoria. Such requirements have been criticized for being a method of “gatekeeping” that is biased towards trans people who have won the genetic lottery and have passing privilege. It was a lot harder for people without passing privilege to gain access to treatment because it was assumed that they would be “unsuccessful” in their transition and this would lead to suicide or self-harm.

But now the new model for HRT access is the “informed consent” model that doesn’t require a letter from a therapist in order to start HRT. So long as you are of sound mind and understand all the risks that HRT entails then an endo will prescribe you them and help you monitor your blood levels for safety reasons. For obvious reasons I think the informed consent model is superior to the traditional model. The biggest advantage is that the informed consent model respects the autonomy of the patient to make healthcare decisions for themselves. Since the principle of autonomy is one of the major foundations of biomedical ethics it’s pretty easy to make arguments that the informed consent model is ethically superior to other models.

Think about it. We respect the principle of autonomy enough for people to get FACE transplants, a hugely risky procedure that was entirely experimental until recently. Why did we allow this? Because the patients gave their informed consent. They knew the risks but decided it was worth the risk. And the risks of HRT are significantly less than the risks of face transplants. So the only reason why HRT has not traditionally been on an informed consent model is because of transphobia, which translates to the idea that transitioning is so radical as to require some kind of paternalistic oversight from the medical profession. But paternalism does not respect the autonomy of the patient. The underlying assumption of paternalism for HRT is that trans people are not of sound enough mind to evaluate the risks of going on HRT so the medical professionals need to make this evaluation for them. But often the professionals end up projecting their own transphobia onto the patient and bias themselves against trans people who dont have passing privilege or fit into the “standard” trans narrative (“I’ve always been a girl/boy”).

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