What if Transition Were Treated Like Fertility?


Some months ago I penned a column calling for an end to RLE and similar psychological hoops transgender people are forced to jump through to prove that we are truly members of our identified gender. For those new to our world, RLE is the year required by medical professionals before they are willing to perform gender confirming surgery. Those same guidelines call for a diagnosis of gender dysphoria by a professional before we are allowed hormones that will make us chemically ourselves. My column claimed that it was patronizing and paternalistic, not to mention cisnormative to require us to prove we are members of our gender, while cisgender people receiving similar treatment do not need to prove anything at all.

The topic generated lively discussion. Many valid questions were raised. Before surgeons use their skills to perform irreversible procedures, don’t they need to know their patients will not likely experience regret? PillsHormone therapy has strong effects on the body, so shouldn’t it be documented as medically necessary before being administered? Don’t insurers need to know the services they cover are not just support for the patient’s whims and lifestyle choices? And aren’t obstacles to life-altering treatments necessary to prevent an increased incidence of post-treatment regret?

When applied to elective treatments for cisgender people, the medical community answers a resounding “NO” to all these questions.

Consider the way fertility medicine is practiced:

Patents can receive hormonal or irreversible surgical intervention without these safeguards. Insurance coverage is a given, and in some cases, mandated by law. Implicit in medical policy is the assumption that people can decide whether they want to be fertile. If someone who is infertile wants to be fertile, all sorts of treatments are available, some of them hormonal. Many are routinely funded by insurance. Likewise, if a fertile patient wants to be infertile, they are offered hormonal or surgical treatments based on the patient’s wishes. Even though surgery is difficult, if not impossible to reverse, there are no humiliating psychological tests required to figure out whether people are competent to make that decision. And no one needs to be diagnosed with Fertility Dysphoria to receive treatments to change their level of fertility.

Doctor-with-coupleDoctors assume restoring someone to their desired level of fertility is a worthy health goal and work to make it happen. The goal of that sort of medicine is to give patients medical options rather than protect them from possible regret. Despite the seriousness, irreversibility, and life impact, no one ever asks patients seeking fertility treatment to prove they really want a baby or those seeking contraception or sterilization to prove they don’t. Doctors simply take their word for it. Counseling is available to those who seek it, as it is for anyone else, but no letter from a psychologist, much less a lifestyle test, is required as proof.

Why couldn’t gender reaffirming treatments work the same way?

What if patients were assumed competent to articulate their gender? Whether cisgender or trans, they would not required to be diagnosed with any psychological condition to receive gender confirming care, or be given tests to see if they are psychologically healthy enough to decide.

If someone required medical intervention to make their body whole according to their gender, it would be covered the same way for cisgender people as for trans. A cisgender woman who loses a breast to cancer, for example, or a cisgender male who sustains an injury to his genitalia, are entitled to be made whole medically. Cisgender people whose bodies don’t produce sufficient hormones are prescribed hormone therapy to bring healthy levels for their gender.

Transgender patients would be similarly be entitled to receive hormones to bring their bodies in line with their gender. They wouldn’t need a dysphoria diagnosis. They wouldn’t be required to defend their gender any more than would a cisgender person needing the same intervention. They would simply be entitled to medical care to make them whole. Surgery would be handled similarly. A transgender patient who requests genital or top surgery to make their body whole would be treated the same as a cisgender patient with a similar issue. Safeguards against post-surgical regret would be exactly those provided for patients seeking fertility related interventions.

TherapyCounseling would still be available to anyone who is not sure of their gender, just as those who are not sure whether they want children are now free to discuss fertility options with a counselor. But mental health care would no longer be required for those seeking treatment to bring their body in line with their gender, any more than we require it for people who want to improve or remove their fertility. The purpose of counseling would change from its current role of protecting us from what we might regret, to helping us with a decision only when we need that help.

This does away with the humiliating cisnormative apartheid that requires transgender people in many cases to defend or justify their gender before accessing treatments cisgender patients are given without question. The cisgender privilege codified in today’s standards of care could be replaced by a system that treats cisgender and transgender patients equally when it comes to restoring their bodies. Transgender people would no longer require a dysphoria diagnosis. Instead, their diagnosis would be a body needing to be brought in line with gender, as would a cisgender person with similar symptoms.

Put aside for a moment the extreme discomfort that the cisgender medical establishment would have in putting transgender patients on a level with those who are cisgender, and the inevitable protests from insurance companies robbed of the meager portion of their profits derived from denying treatment to transgender patients who need it.

The first question needing an answer is “Would this be a better way?”


About Author

Suzi Chase writes about transgender issues through both fiction and non-fiction. She has had careers in teaching and software engineering and has raised two children.


  1. While I agree with the bulk of this article, having frequented some of the Childfree forums for a few years, I would like to note that choosing to become infertile is not actually that easy. Especially if you’re a cisfemale. Some doctors tell them they’ll change their mind. Some require permission from their husbands (gross) or other ridiculous things like that. Most of them just won’t sterilize you unless you’re over 30 with 3 kids. It changes after you have kids and the doctors consider you to be past your prime age for that, I imagine.

  2. I’m seriously frustrated that we require letters. I tried explaining to my mother this afternoon why I shouldn’t need a letter for hormones, especially so because all that I’m trying to do is switch the doctor who prescribes them. But I’m really frustrated with this article too. If anything, transition should be treated like fertility in that something is being done to correct the infertility that is brought on by transition. It should be treated in this way, and transpeople do not address the serious lack of reassignment and fertility procedures available to us.

  3. Well as someone who had actually been treated by a fertility clinic I see that some things in this article simply do not reflect reality.

    Insurers DO NOT routinely pay for IVF. In fact they often do their best to deny you. Those that do pay limit the number of cycles they will pay for. Ours limited us to three. That is their hard limit. They also cut off the drugs which are an essential part of it. Many of the things we did to obtain the medications are reminiscent of what a MTF would do if she was self medicating.

    They also require extensive testing and diagnosis before they do so. In my case I simply could not conceive with anyone as my testosterone levels and sperm count were so low, that assistance was absolutely required. Even so, 3 cycles and you’re out. It took us 6. In the end we spent over $60,000 out of pocket.

    For every octomom story there are 1000 others who face many of the same challenges with insurance and the medical establishment that we do.

    If you want an accurate comparison how about contraception. There is really nothing required to obtain birth control these days other than a doctor visit. And despite all the consternation over hobby lobby the drugs are dirt cheap. Abortion? An abortion is more widely available by far than informed consent hormones and the abortion lobby is 1000x more powerful than the transgender lobby, if there even is one.

  4. Until being transgender is no longer considered a mental illness by those other than the APA and AMA, doing away with RLE may be an uphill battle (although I’ve seen at least one website for trans-friendly therapists, who view the RLE and WPATH guidelines as merely suggestions, rather than hard and fast rules). Of course, you can’t force someone to believe the truth, and there will always be those who refuse to accept it (I.e., Holocaust deniers, moon landing deniers, young-earthers, flat-earthers, etc.), but it may take a generation or two, unfortunately (hopefully not!!), for the transgender condition to be seen for what it is, and for people to accept the research on the transgender condition the way they accept research on cancer, ALS, Alzheimer’s, etc. Too bad people can’t look at this the same way they would any other birth anomaly, and seek to support those of us who suffer from this, rather than treat us as pariahs or side-show freaks to be ridiculed and relegated to subhuman status.

  5. I worked in surgery and obstetrical suites for 33 years and assisted with hundreds of surgeries, paid for by insurance, to correct erectile dysfunction, post delivery vaginal trauma, morbid obesity, and reduce the size of women’s breasts. That is just a few of the common body altering surgeries commonly performed. I assessed their readiness for surgery and anesthesia with extensive pre-op testing and obtained “informed consent” after a thorough review of the procedure, risks and alternatives. I never once saw letters of support from mental health therapists and it was never “required.”

    Surgeons can refuse to perform surgery, refer the patient to someone else or ask the patient to seek mental health if they feel it is necessary. Patents can readily “shop” for the doc who will do what they want.

    We simply do not have equity with cisgender people when our very identity is questioned with complicity by the medical/ insurance industry of this country. This is my body and i expect absolute domain for myself as would any adult. Real equality and parity suggests we should be free to decide for ourselves about contraception or any surgical procedure readily available to cisgender people.

    Great article Suzi. Thanks for challenging us to think about it.

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