The Ethics of Gatekeeping - or why the RLE test is problematic

[RachelsMantra]

The Ethics of Gatekeeping in Trans Healthcar

http://www.philpercs.com/2015/11/the-ethics-of-gatekeeping-in-trans-healthcare.html

11/25/2015 at 07:33 AM in Bioethics, Ethics, Gender Studies, R. Williams, Transgender Studies  | Permalink

[Vanora]

Is gatekeeping for HRT still happening in very many places? It seems like the USA has moved beyond it with informed consent doctors and with endocrinologists who will accept letters for HRT after some therapy but prior to RLE.

[CaptainxTatsuo]

I went through my RLE from 2007 to forever.
I did notice that after one to two sessions with
my therapist, I had the letter in my hand. Took
it to the endro and boom meds obtained. However
remember that it was sept 2015 and I have been
living as a MALE anyway with out T since 2007.
So I can see why they did not have to ask if I
was SURE about starting on T.

 

[Lagertha]

Who is it to blame when 2 months after genital reconstruction surgery a patient realizes that they are not really transsexual, and that they made a mistake and want to go back? If you have a hard time living 1 year before surgery as your true self, you should really think about that, and not about surgery.   

[RavenL]

What I have a problem with is how somone can get tons and tons of plastic surgery. You want horns on your head alright get on the table! Do you want a vagina? um nope you have to wait. Same goes for tattoo's (OK you can remove some!) but you don't see people walking around with it drawn on for a year before making it permanent.

[suzifrommd]

Very nice article, Rachel. I agree with pretty much everything. The WPATH guidelines no longer require RLE for hormones (they can't - we'd just go and get them from the Internet, and they know that), but we can perform surgery on ourselves so they can withhold that.

My main issue with the RLE requirement is it seems to have been made up from whole cloth. No one seems to know who came up with it (current thought is that it came from a friend of Harry Benjamin's) and there is NO SCIENTIFIC EVIDENCE that it helps in any way.

Alas, our community's voice is still to weak to be heard by the cisgender doctors and scientists who hold our fate in their hands.

[Lagertha]

I have a hard time understanding how someone with supposed extreme genital dysphoria was able to live 40 or 50 years and function normally not only in everyday life, but also sexually, and had multiple relationships, been married or not, and had more or less a normal sex life despite the supposedly ever present extreme genital dysphoria. Then they are suddenly unable to live 12 months as the gender they identify, without having the genital reconstruction first. I'm sorry, but it's very conflicting. Some trans people will try to make it seem like a SRS is not a big deal, and comparisons with common aesthetic cosmetic procedures are waaaay off. If it's not a cosmetic procedure, then don't compare it with cosmetic procedures. Consequences about someone making a wrong decision are far more serious, than consequences of someone making a wrong decision with breast implants.   

[ThaliaNyx]

I'd thought that RLE should definitely be required before SRS, although not before HRT, but this article does make a good point as to why it isn't a good idea. Still, even if I could, I don't think I would jump straight into SRS at the same time as HRT - I think it would be too much of a shock transitioning so quickly. Plus, I'm nowhere near being able to afford the surgery.

[AnonyMs]

My main issue with the RLE requirement is it seems to have been made up from whole cloth. No one seems to know who came up with it (current thought is that it came from a friend of Harry Benjamin's) and there is NO SCIENTIFIC EVIDENCE that it helps in any way.

I believe WPATH was created from a cultural standpoint; its not science. It is very slowly changing as our culture changes.

[suzifrommd]

I believe WPATH was created from a cultural standpoint; its not science. It is very slowly changing as our culture changes.

I think you're probably right. Problem is that WPATH claims to be based on science and to operate in the sole interest of ensuring the best care.

[suzifrommd]

Consequences about someone making a wrong decision are far more serious, than consequences of someone making a wrong decision with breast implants.   

Agreed. But does RLE actually prevent people from making wrong decisions? Or does it simply create an unnecessary (at best) and unhelpful barrier?

When you say to someone "I know what's better for you than you do, so I'm going to use my power to create obstacles", what responsibility do you have to to prove that those obstacles actually have benefit?

[AnonyMs]

Consequences about someone making a wrong decision are far more serious, than consequences of someone making a wrong decision with breast implants.   

Doctors have an appalling record on this, and many other things. Just because they are doctors doesn't make them right.

[Cindy]

Consequences about someone making a wrong decision are far more serious, than consequences of someone making a wrong decision with breast implants.   

Doctors have an appalling record on this, and many other things. Just because they are doctors doesn't make them right.

Let us not fall into the slippery slope of labelling or blaming groups. I think that I am a rather responsible medic and have some concern of being told that I have an appalling record!

I don't.

[Lagertha]

Agreed. But does RLE actually prevent people from making wrong decisions? Or does it simply create an unnecessary (at best) and unhelpful barrier?

When you say to someone "I know what's better for you than you do, so I'm going to use my power to create obstacles", what responsibility do you have to to prove that those obstacles actually have benefit?

What might be unnecessary and unhelpful barrier for you or me (it really wasn't for me) might save someone from making the worst decision of their life. Not everybody who decides to transition actually successfully transition. Some people (although minority) detransition, completely or in their own way. Some people realize after a year or two that they are not "trans enough" or truly transsexual and decide to go back. Some other after time cannot cope with the new life, not necessarily because of them, but because of how their direct society affects their life. This 12-month rule before irreversible surgery is in place for them. Because just like you and me and most they were 110% shure at the beggining that this is the path they need to take, and change they need to make. 12-month "RLE" or whatever you want to call it, is the least of what a responsible psychiatrist and your surgeon can expect to be enough for you to prevent you (someone) from making the mistake. 

[Peep]

RLE before hormones doesn't make sense to me - because they're so unpredictable there's no way to 'practice' first.

I find the assumption that without RLE, people wouldn't take GRS seriously a little patronising though. And aren't a lot of post-transition regret stories less to do with the surgery itself and more to do with social stigma?

[suzifrommd]

What might be unnecessary and unhelpful barrier for you or me (it really wasn't for me) might save someone from making the worst decision of their life.

Is there any evidence that RLE actually saves people from making bad decisions?

[Peep]

Is there any evidence that RLE actually saves people from making bad decisions?

This ^^^ It's impossible to know what having GRS will be like till you have it, and people still seem to experience regret even with RLE. I don't think there's anyone who gets GRS the day the idea strikes them. There's always going to be the possibility of regret, with 5 years RLE or three months. Why's a year the magic number?

[Lagertha]

There is evidence that some people detransition (for various reasons). Should we do SRS first, and then evaluate if it's the right decision, or it might be better the other way? And yes, RLE and hormone therapy has proven to be exactly the real life test which helps you to see if transition is the right decision or not.

[Peep]

Yeah everyone knows that some people detransition, what we're wondering is: didn't most of them have to do RLE first? Why didn't it work for them? If RLE doesn't guarantee that people won't detransition why bother?

[Lagertha]

Yes, most of them detransitioned during RLE and after already being on hormones. Real life test and hormone therapy test worked out fantastic!! and prevented them to just go straight for surgery and make disastrous mistake. A percentage of those who actually had SRS and regret it is thankfully very small.