"Gatekeeping" Semantics - Flame Free

[Alainaluvsu]

Other people have just as drastic surgery to look VERY different than they do. How is that ANY different?

http://starcasm.net/archives/23945

She doesn't even look like the same person yet no one asked her to go through a bunch of psychotherapy. I could find much more extreme example of people with small, ugly chins having as massive of surgery as any MTF. I girl I know had her jaw broken and wired back to get rid of a slight overbite she had.

The difference here is cisgender people can't fathom wanting to change genders so they make up special rules for trans people because clearly we are all crazy. For that matter we are in the DSM and people on this forum are constantly cheering that we are! O.o

She wasn't partaking in facial surgery in order to appear to be the opposite gender. It has nothing to do with being a nutjob. It has everything to do with helping the individual make sure that they are making the right decision for them.

I mean seriously... if someone is crazy, why encourage their lunacy by letting them do what they want and acting like it's treatment. Just because it's listed under the DSM as a mental disorder doesn't mean somebody is a lunatic

[Rabbit]

While this is understandable in this context, and one could pose the question of whether these processes would still be seen as grossly unfair and invasive if everyone were suddenly treated the same and the cause of that resentment was removed, that's purely hypothetical and is something entirely different to what

Normal people would cry bloody murder.

[eli77]

Doesn't that speak more to the specific quality of the care, not the relevance of the process, though?

No, I was critiquing the unbalanced power dynamic inherent in the process, and the damage that can do. I was saying that the process itself negatively impacts the quality of care by pushing patients to lie to their therapists, therapists to come up with their own biased rules for gatekeeping (seriously, could the "readiness" criteria be any more subjective?), and by forcing vulnerable patients into the hands of therapists with questionable ethics.

I would favour a fixed and non-subjective system: 1 year of HRT for SRS, and informed consent for HRT. Under this system you could access mental health professionals for assistance at your discretion, without an unbalanced power dynamic distorting the relationship.

There you made me say it the boring way. I preferred my first version. 

[Alainaluvsu]

I had to take a psych exam in order to transition... I wonder what would have happened if I'd failed it. Maybe I'd have gotten help... or maybe I'd be dead. People are funny, delicate things. How many get a bad therapist and go home and slit their wrists?

As of Sept 2011, the Standards of Care released by WPATH basically say that psychologists should simply guide people through, instead of blocking the gate. They have in fact gone so far as to say that it is unethical to try to "fix" somebodies gender identity.

[Miki]

There you made me say it the boring way. I preferred my first version. 

Heh, sorry!  But..thank you for clarifying that.

I think if that unbalance of the dynamic was universal, experienced equally by everyone, fair enough.

It's really not, though.  Good and bad experiences seem 100% dependent on good or bad therapists, not the fact that seeing one is a facet of the existing process.

I absolutely agree with your take on a fixed and non-subjective evolution of the system, and hope it gets there some day. 

I want my medical interactions specialized to address the unique needs of transitioning.  Making the process and system more generic could lead to the care becoming more generic as well.  When a medical specialty becomes routine, standard and par for the course, advances in it tend to slow drastically.  That by removing that potential for an unbalanced dynamic might breed more generic treatment and more blind rubber stamping would be my only real concern.


-Miki

[Stephe]

No-one condemns the entire auto-repair industry because they got a ->-bleeped-<-ty brake job at a single garage.  They just find a better garage.

But the auto repair industry doesn't require you to go to the tire store first to have them tell the other shop it's OK to fix the brakes.

The whole point is, people who need therapy should go get it. No one is saying they shouldn't. I'm happy for the people who needed therapy and got it. I didn't need any.

I was am happy, not depressed and at peace with being trans. I was for all intents and purposes already fully transitioned, I had been living full time as a woman for several years. I just wanted to start -legal- HRT and to do so was FORCED to get therapy I didn't need. I have a feeling if I had needed therapy, the therapist I saw would have been very good and helpful. The reason I say she was clueless is because I never needed her services to start with. I also know if/when I decide to have GRS, I will be subjected to more of this.

Using my/your above example: what if you were forced to go to the tire store first before you were allowed to get your brakes fixed at the other place and they made you wait for several months before they would OK your brake job. Made you come in for several inspections at your cost. So you had to drive around for months with grinding brakes. You know you need brakes but you can't get them. Would you then say "I'm so glad I was forced to go to the tire store first because some people need their tires replaced, yet don't know it, and I want what's safe for them."? Of course not.

The ONLY reason they do this is: being transgendered is in the DSM and it IS considered a mental disorder.

[Stephe]

She wasn't partaking in facial surgery in order to appear to be the opposite gender.

Thank you for making my point. She can radically change her appearance for any reason as long as it's not to look like the other gender.. At that point you need a mental health professional's approval. And you feel this isn't because they think we are nuts for wanting to appear to be the other gender?

[Alainaluvsu]

Thank you for making my point. She can radically change her appearance for any reason as long as it's not to look like the other gender.. At that point you need a mental health professional's approval. And you feel this isn't because they think we are nuts for wanting to appear to be the other gender?

No

Because living as the other gender can be a bit more than somebody may have been prepared for. Simply being uglier or prettier is nowhere near as difficult a challenge for most people.

The "approval" imo should be more of a gut check of the patient than a "Ok I think you're crazy enough! You pass my nutso test! Go get your balls removed, your chin carved, and your penis turned inside out because you're a nutcase and there is no reasoning with you!" ... which btw, I highly doubt that's how anybody takes the process.

[Miki]

But the auto repair industry doesn't require you to go to the tire store first to have them tell the other shop it's OK to fix the brakes.

The whole point is, people who need therapy should go get it. No one is saying they shouldn't. I'm happy for the people who needed therapy and got it. I didn't need any.

I was am happy, not depressed and at peace with being trans. I was for all intents and purposes already fully transitioned, I had been living full time as a woman for several years. I just wanted to start -legal- HRT and to do so was FORCED to get therapy I didn't need. I have a feeling if I had needed therapy, the therapist I saw would have been very good and helpful. The reason I say she was clueless is because I never needed her services to start with. I also know if/when I decide to have GRS, I will be subjected to more of this.

Using my/your above example: what if you were forced to go to the tire store first before you were allowed to get your brakes fixed at the other place and they made you wait for several months before they would OK your brake job. Made you come in for several inspections at your cost. So you had to drive around for months with grinding brakes. You know you need brakes but you can't get them. Would you then say "I'm so glad I was forced to go to the tire store first because some people need their tires replaced, yet don't know it, and I want what's safe for them."? Of course not.

The ONLY reason they do this is: being transgendered is in the DSM and it IS considered a mental disorder.

I get it, and cannot disagree that in your case, that sense of frustration is completely warranted.  I'd be pissed off, too.  I'm kind of in the same boat, not unsure, not freaked out or ragged over it, not at my wits end or even slightly confused about my path forward.  I could resent seeing my therapist, but am actually finding it amazingly helpful for putting my choices in context of how it impacts and affects my relationships and those around me. 

Where my analogy, and any analogy honestly, breaks down is that what we're doing in not shopping for shoes or tires or getting a car fixed.

It is not a commonplace activity at all, and empirical data demonstrates that a wide range of co-morbid mental health issues can and do manifest side by side and addressing those is far more beneficial than ignoring them. 

The fact that our personal experiences don't fall into that category doesn't mean the category doesn't exist or is invalid across the board in context of any process.

What would transitioning look like if GID were removed from the DSM?  (Which I hope it will be eventually, but with some structured SoC still existing.)

How would reasonable checks and balances exist absent a medical validation via a diagnosis?

-Miki

[Stephe]

No

Because living as the other gender can be a bit more than somebody may have been prepared for. Simply being uglier or prettier is nowhere near as difficult a challenge for most people.

Bzzz try again, I was required to jump through all these hoops even though I was already living full time and had been for years.

That's the problem with this cookie cutter approach you guys are in favor of. Some people praise it because they fit into the needs/steps it sets up. There are many people who have no need for every step or got through those steps without "professional help".

Some people need professional help to walk out the front door of their house. Should everyone be required to get professional help before they walk out of their house because some people might? This is no different.

[Alainaluvsu]

Bzzz try again, I was required to jump through all these hoops even though I was already living full time and had been for years.

That's the problem with this cookie cutter approach you guys are in favor of. Some people praise it because they fit into the needs/steps it sets up. There are many people who have no need for every step or got through those steps without "professional help".

Some people need professional help to walk out the front door of their house. Should everyone be required to get professional help before they walk out of their house because some people might? This is no different.

First of all, I was supporting an idealistic approach, and not telling the world whatever happened to you was necessary. So, you BZZ try again.

Second of all, I'm not in favor of any cookie cutter approach, if you scroll back I said it should be individualized.

Third of all, your analogy of needing help walking out of their front door is ... completely out of range of what we're talking about. There's some people who need medical assistance with walking, and there's others who seek to change their gender. Gender is a social construct that society holds heavily

... oh dear God do I really need to explain this for another paragraph??

Oh, and fourth of all, have you read the new WPATH standards? You should, it's gone to a very individualized approach. They go so far as to say in order to get HRT, a psych eval is recommended, but not necessary. They also say you can get an orchiectomy with a well documented history of GID and 12 months of HRT. The HRT is necessary to sample hormones to the patient before they can make irreversible changes. No RLE is needed.

[Stephe]

What would transitioning look like if GID were removed from the DSM?  (Which I hope it will be eventually, but with some structured SoC still existing.)

How would reasonable checks and balances exist absent a medical validation via a diagnosis?

I feel HRT should be informed consent and any doctor who feels a patient isn't a good candidate, for whatever reason, can request/suggest therapy first. That could be part of the informed consent. I feel it being in the DSM is just proclaiming"You people are fruit loops"

GRS should require a time period on HRT, if nothing else, to make sure the patient can tolerate being on estrogen. I also see having RLE for a certain time being a requirement to make sure the person likes living as the gender they think they want to live as. Sometimes reality is different that what we think it will be. If someone has been on HRT for a year and RLE for even 6 months, I feel they should know if this is the path they want to take. Again if a doctor wants to make more stringent demands, that's up to them.

[Stephe]

First of all, I was supporting an idealistic approach, and not telling the world whatever happened to you was necessary.
......

Third of all, your analogy of needing help walking out of their front door is ... completely out of range of what we're talking about. There's some people who need medical assistance with walking, and there's others who seek to change their gender. Gender is a social construct that society holds heavily

First, the problem with an "idealized approach" is that it only works for specific cases. You assumed who ever was having surgery or wanting HRT had no concept of what living full time is like. You said as much in your post, which is why it was a fail..

Third, I was talking about agoraphobia. People who needs psychiatric therapy to walk out of their house. You assume here that everyone need psychiatric therapy to transition. There is absolutely no difference between the two in my analogy. Just because some people need psychiatric help to walk out their front door, doesn't mean everyone does.

As far as the "Gender is a social construct that society holds heavily ", I haven't found that to be as big a deal as a lot of people make it out to be. Most of the people who make this a huge deal are people here who haven't transitioned yet and assume it's a huge problem.

[Miki]

I feel HRT should be informed consent and any doctor who feels a patient isn't a good candidate, for whatever reason, can request/suggest therapy first. That could be part of the informed consent. I feel it being in the DSM is just proclaiming"You people are fruit loops"

GRS should require a time period on HRT, if nothing else, to make sure the patient can tolerate being on estrogen. I also see having RLE for a certain time being a requirement to make sure the person likes living as the gender they think they want to live as. Sometimes reality is different that what we think it will be. If someone has been on HRT for a year and RLE for even 6 months, I feel they should know if this is the path they want to take. Again if a doctor wants to make more stringent demands, that's up to them.

Stephe, you can't see it, but I am doing that whole thoughtful nodding thing reading this. ;p

So, you'd be in favor of a medical diagnosis governed by informed consent replacing a mental health diagnosis?

That looks good on paper, and it would not surprise me if that ends up being a huge aspect of how GID identification and treatment evolves.

You don't have any concerns at all that shifting to a purely medical condition would codify insurance/provider standards of care in unfavorable or more discriminatory ways? 

The medical industry is still profit based, and non-standard services and treatments tend to either become genericized as afterthoughts, thereby degrading the level of care,  or made inaccessible by higher pricing structures that categorize them as elective choices, not required treatments.

Would a purely medical diagnosis still make that critical distinction between need and want?  Choice and necessity?

-Miki

[Miki]

I hear what you're saying, Sarah.

Wanted to take a breather and thank everyone who is sharing in this thread.  I genuinely appreciate the variety of opinions and the very personal experiences that have crafted them. 

These types of discussions can't be parsed into simply right or wrong, and I'm thankful that some honest debate and questioning of why people hold certain viewpoints can occur both within the gray and without any raging infernos.

Thank you.

-Miki

[Beverley]

I think a lot of you have this backwards.

It is not that therapists are trying to stop me from transitioning, their primary purpose was to determine that I had no underlying mental illness that manifested transitioning as a symptom.

What if I had multiple personality disorder or some order form of illness that really needed treatment? What if they treated it and my desire to transition disappeared?

What they said to me was that I was free from mental illness and my condition was physical one that was set before I was born.

They still talk to me to ensure that my continuing journey does not introduce any mental illness. In short they are looking after my mental health as much as the doctors look after my physical health.

[Rabbit]

It is not that therapists are trying to stop me from transitioning, their primary purpose was to determine that I had no underlying mental illness that manifested transitioning as a symptom.

So, you don't see anything wrong with them telling you that because you are transgendered... you are unfit to make life-altering choices on your own (like normal people are able to)? That you are not allowed to decide what to do with your own body without someone else writing you a permission slip first?

For normal people, therapy is an OPTION for those going through difficult times and making life-altering choices.... not something forced on them before they are allowed to live their lives.

I guess I spent too many years as a "normal person" before I came out as transgendered. Just think, 14 months ago I was actually free to decide what I wanted to do with my body ~shrug~ Maybe I need to get used to this new status as a mentally questionable person.



To sum it up...

A normal person is, by default, assumed to be sane enough to make his or her own choices.

A transgendered person is, by default, assumed to be mental disturbed and unable to make his or her own choices.



That is where my problem is. I don't like to be thought of as crazy by default... I don't want to walk down the street and people look at me and question my sanity ... or needing to PROVE that I'm sane.

[Dana_H]

I think a lot of you have this backwards.

It is not that therapists are trying to stop me from transitioning, their primary purpose was to determine that I had no underlying mental illness that manifested transitioning as a symptom.

What if I had multiple personality disorder or some order form of illness that really needed treatment? What if they treated it and my desire to transition disappeared?

What they said to me was that I was free from mental illness and my condition was physical one that was set before I was born.

They still talk to me to ensure that my continuing journey does not introduce any mental illness. In short they are looking after my mental health as much as the doctors look after my physical health.

In my opinion, this cuts to the heart of the issue. Transition, whether surgical or non-op, is a very significant change to one's state of being. Given that GID and/or Gender Dysmorphia may sometimes be symptomatic of a deeper underlying condition, I think an overall evaluation to rule out other conditions as well as some ongoing transition guidance are very good ideas. However, I do oppose Gatekeeping practices that show a tendency to be generally biased against transition from the outset. Ultimately, it is your body and as long as you are thinking clearly and rationally you should ultimately have control over whether you pursue HRT, FFS, GRS, just crossdress once in a while, or even decide to continue living as your birth-assigned gender.

When I speak of "Gatekeepers", it is almost always in the sense of someone who decided to say "no" before you even entered the office, whereas I regard "Cheerleaders" as being the reckless opposite face of that coin. What is needed is someone who sits between these extremes and can help you choose your path ahead wisely, even if it eventually leads full circle into not transitioning at all; someone who is a counselor, information resource, shoulder to cry on, and facilitator.

In the publishing world, they are seeing the rise of "Book Shepherds". These are professionals who are not actual publishers or editors, but will guide you along the path of taking your book from rough draft to fully self-published high-quality paper book and/or ebook. They help you decide on the best approach for your project, help you identify what resources and services you will need (especially the ones you didn't even know existed), what the benefits and drawbacks are of various options, how to approach marketing, how to be taken seriously by booksellers, and so forth. You have to do all the work, but they provide knowledge and experience that a new author lacks and without which the book becomes just another amateurish overlooked poor-quality ebook among thousands already online.

In the context of all things trans, I think what we ideally need are more unbiased Transition Shepherds who can help ensure that you are, in fact, thinking clearly and are well-informed, and can help guide you to the necessary resources for your own personal path. If you have already been living as your self-identified gender for a good while and are happy that way, then the Transition Shepherd may just need to step back and be available to you in times of crisis, whereas if you are still deep in the questioning phase, the Shepherd may play a vital role in helping you figure out who and what you are as well as what path ahead will lead you to the best possible quality of life. This, I believe, is the general intent of Standards of Care even if they are not always implemented in accordance with that spirit or intent.

I think of my therapist as a Transition Shepherd because that is essentially the role she plays for me. The decision to transition is mine, but she plays an indispensable part in getting me safely to that destination and making sure I have realistic expectations of what life will be like when I get there.

If this seemed a bit rambling and incoherent, I can only plead sleep deprivation. Lots of long workdays and short nights lately. Vacation next week, though. Yippie!

[Beverley]

So, you don't see anything wrong with them telling you that because you are transgendered... you are unfit to make life-altering choices on your own (like normal people are able to)? That you are not allowed to decide what to do with your own body without someone else writing you a permission slip first?

No. Because that is NOT what they are telling me.

For normal people, therapy is an OPTION for those going through difficult times and making life-altering choices.... not something forced on them before they are allowed to live their lives.

And as I said, they ensured that I was a normal person and therefore that my life-altering choices were not being forced on me by some form of mental problem.

I cannot see the difficulty with this.

[Naturally Blonde]

The Gatekeeper situation is far worse in the U.K within the NHS GIC system. In the U.K regardless of your GD diagnosis they will stall you and stall your progress for as long as possible. It was 10 years ago now but In order for me to start of HRT I had to see a private psychiatrist in the end as I wasn't able to get on HRT through the NHS GIC system.

Because the U.K's NHS is tax payer run and not privately run they will give you all kinds of hassle to stall your transition.  Those were my experiences when I went through the NHS.