Susan's Place Transgender Resources

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

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.

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.

 

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.   

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.

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.

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.   

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.

Quote from: suzifrommd on November 25, 2015, 07:59:34 PM
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.

Quote from: AnonyMs on November 26, 2015, 02:44:18 AM
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.

Quote from: Lagertha on November 25, 2015, 08:48:33 PM
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?

Quote from: Lagertha on November 25, 2015, 08:48:33 PM
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.

Quote from: AnonyMs on November 26, 2015, 05:50:15 AM

Quote from: Lagertha on November 25, 2015, 08:48:33 PM
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.

Quote from: suzifrommd on November 26, 2015, 05:05:49 AM
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. 

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?

Quote from: Lagertha on November 26, 2015, 07:07:42 AM
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?

Quote from: suzifrommd on November 26, 2015, 08:30:30 AM
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?

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.

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?

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.

Quote from: Lagertha on November 26, 2015, 08:48:18 AM
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.

Can you point me to those studies that prove that RLE helps people decide? I haven't come across any but I'd love to see them.

It's easy to say what people should or shouldn't to, but I have very good reason to want SRS before RLE, and maybe never RLE. And I'm not crazy, at least not according to my psych.

To say there's hard and fast rules is grossly unfair, and will lead to people being severely hurt. I'm not willing to let people threaten my life like that, and fortunately I'm in a position to do whatever I want. So many are not and I feel for them.

I needed the real life test as I called it. I needed to know I could function in society. I needed to know I could hold a job and be respected in my profession. I waited 18 months. I wanted to do it sooner but Dr. Biber had an accident. I know that one year seems rather arbitrary for some of us.

I do think it is a good idea to get out in the world as our true selves before making such a permanent commitment. As for the time period, I'm not so sure. If I could have had the surgery once I was sure where my life was headed, I would have done so. But I don't think that waiting hurt me in the grand scheme. It has been over thirty years since I started my transition. As I look back at that time, the wait seemed to take forever but I've had a rich life so far and that was such a short period.

As for this particular case under discussion? Everyone has their own challenges to face. It is our own responsibility to take them on and deal with them. We make mistakes along the way. But we must make these things ours and not blame the system or other people for our problems. It's not easy. But it is doable.

Chin up,
Cindi

Quote from: suzifrommd on November 26, 2015, 09:37:46 AM
Can you point me to those studies that prove that RLE helps people decide? I haven't come across any but I'd love to see them.

I don't need to see a study to realize how many people choose to stop transition or detransition, either after a month or few months, or year or two or more... You can have a read on this forum and others, or watch detransition videos on youtube, or meet people at local group. What else could it be than real life experience which makes people to realize that this is not for them (for whatever reason you can think of)?

I think the author is looking at this the wrong way. RLE is not something that is a barrier to transition. It IS transition. You say that you're living in the wrong gender? Then go and live in the right one. Today. Now. Go do it. It's called RLE.

People have this notion that transition begins with GRS. That's nonsense. Transition is like any other journey. It begins when you start it. During my RLE nobody questioned my gender or treated me as anything other than a woman, and my transition really became real with RLE. GRS didn't change a thing for me except make me happy(er).

And what of non-op trans folks? Are their real life experiences invalid? Hardly. Is their life without surgery not RLE?

People need to quit blaming WPATH for giving the medical community a treatment protocol they can use to help people. The medical schools haven't done it, so this is helpful.

If RLE is a burden then don't do it. Find a doctor who subscribes to the informed consent model ( http://www.icath.org (http://www.icath.org) ) and just transition without RLE. No worries.

Quote from: Michelle-G on November 28, 2015, 07:26:16 AM
If RLE is a burden then don't do it. Find a doctor who subscribes to the informed consent model ( http://www.icath.org (http://www.icath.org) ) and just transition without RLE. No worries.

I might agree if we could make just one small change.

"If RLE is a burden then don't do it. Find a doctor surgeon who subscribes to the informed consent model and just transition without RLE. No worries."

The other problem is that informed consent is not very common around the world.

Quote from: AnonyMs on November 26, 2015, 09:45:10 AM
It's easy to say what people should or shouldn't to, but I have very good reason to want SRS before RLE, and maybe never RLE. And I'm not crazy, at least not according to my psych.

To say there's hard and fast rules is grossly unfair, and will lead to people being severely hurt. I'm not willing to let people threaten my life like that, and fortunately I'm in a position to do whatever I want. So many are not and I feel for them.

I think I need understand where you are coming from better.

By real life experience you mean living full time in the new gender role right? Do you present at all? 

How do genitals which people cannot see help where living full time doesn't?

I am am not saying there are not good reasons for surgery before presentation but I can't think of any.

Quote from: Oliviah on November 28, 2015, 08:30:31 AM
I think I need understand where you are coming from better.

By real life experience you mean living full time in the new gender role right? Do you present at all? 

How do genitals which people cannot see help where living full time doesn't?

I am am not saying there are not good reasons for surgery before presentation but I can't think of any.

from a ftm point of view, and going on what i've read and been told by doctors about the system I'm in, RLE seems to be required for chest surgery, but its hard to present as male accurately to get the 'experience' in the first place without it. I'm always going to have to be female at the gym for example, because I can't walk fast in a binder + breathe, let alone cycle or run, and if i raise my arms above my head my chest becomes obvious. Any tighter a bind and it's physically dangerous.

I've also been told i need to do RLE before hormones too - and I'm not sure that i want them so i don't mind, but from the point of view of 'experience', there's no way to experience the unpredictable changes of hormones. If i could simulate them in some way i wouldn't need them? Up until i gain access to treatment, i'm experiencing life as an androgynous leaning to female with a lot of body anxiety issues, regardless of what clothes i wear or what pronouns i ask for. That doesn't seem like an accurate test to me!

I've got no objection to being told to take the time to decide that I want changes that are irreversible, but I don't think the emotional and physical risks of being chucked out there with no help are worth it. It feels like the 'experience test' causes more problems than it solves.

As for post surgery regret, that seems like it'll always be a possibility regardless of how long one waits first. You could be sure since you're 6 that you want babies, and regret the decision once the reality hits, pregnant at 30! That's just part of life.

You don't need RLE to have ftm top surgery. You are dealing with gatekeepers. You can find a surgeon who will do a surgery with informed consent. Much like any cisgender male person, or crossdresser, can have breast implants done. You dont have to be transsexual or transgender to have breasts removed, or augmented. Not every surgeon will be willing to do it, but some will.

What we are talking here having RLE before genital reconstruction surgery. 

Quote from: Lagertha on November 28, 2015, 09:56:09 AM
You don't need RLE to have ftm top surgery. You are dealing with gatekeepers. You can find a surgeon who will do a surgery with informed consent. Much like any cisgender male person, or crossdresser, can have breast implants done. You dont have to be transsexual or transgender to have breasts removed, or augmented. Not every surgeon will be willing to do it, but some will.

What we are talking here having RLE before genital reconstruction surgery.

This.  Top surgery for both mtf and ftm doesn't require RLE.  They are considered regular comedic surgery.  I male is allowed implants and female mastectomy just buy buying them.  Now getting them covered as gender confirming might be where you are having the problem I guess?

Quote from: Cindi Jones on November 26, 2015, 10:08:37 AM
I needed to know I could function in society. I needed to know I could hold a job and be respected in my profession."

^^^^^^^ THIS

During my RLE (Feb '94 - Mar '95) I found that I could function professionally, and have a life where new acquaintances, who didn't know me from before, accepted me as I presented myself — no questions asked. These are real, life-affirming milestones. I benefited by knowing I could survive in the real world as a woman. Today, within my circle of friends and acquaintances, no one knows anything about my first 48 years of life.

At this point in time, being trans is celebrated in the media. That won't last; nothing does. RLE is about establishing an identity as the gender (not assigned at birth) that will last a lifetime. If you're only interested in being the local ->-bleeped-<--de-jour for the rest of your life, have surgery on day 0.

My Résumé
I'm the new woman here, the n00biest of all n00bs. Body by Schrang in 1995. No regrets. I'll make an effort not to violate local taboos.

Quote from: Oliviah on November 28, 2015, 08:30:31 AM
I think I need understand where you are coming from better.

By real life experience you mean living full time in the new gender role right? Do you present at all? 

How do genitals which people cannot see help where living full time doesn't?

I am am not saying there are not good reasons for surgery before presentation but I can't think of any.

The key point is that I can, and even if no one else understands or agrees it doesn't matter. What I want is what's important. All else is gate keeping.

For the sake of discussion though I'll try to explain. I'm M2F, and I present male due to family and work issues. Typical stuff. I'd been on low dose HRT for years, and last year I had very bad depression and couldn't take it anymore. I started on a full transitioning level of HRT and that's made me feel great.

If I socially transition its likely to cost me badly and I want to avoid it. I'm sure we all do, but I'm really stubborn and I absolutely refuse to socially transition unless there's no other choice. This is not the right time in my life. Later would be so much better.

So HRT has helped a lot, but it helped a lot when I first started and that didn't last. Without social transition there's one more thing that I can do that might help and that's SRS. If it comes to it that's what I'll do, and hope for the best.

You could say that I've done RLE; I intend to present male after SRS, and I've plenty of practice at that. It's not what people mean though.

There's a slight possibility that I'm non-binary, but I don't think so. It also doesn't matter either way.

I can and will do this. I understand why so many others can't, and all I can say is that it doesn't apply to me.

I keep arguing this point not for myself, but because I've suffered a lot getting to where I am now and it upsets me to see others struggling with it.

Quote from: AnonyMs on November 28, 2015, 12:14:39 PM
The key point is that I can, and even if no one else understands or agrees it doesn't matter. What I want is what's important. All else is gate keeping.

For the sake of discussion though I'll try to explain. I'm M2F, and I present male due to family and work issues. Typical stuff. I'd been on low dose HRT for years, and last year I had very bad depression and couldn't take it anymore. I started on a full transitioning level of HRT and that's made me feel great.

If I socially transition its likely to cost me badly and I want to avoid it. I'm sure we all do, but I'm really stubborn and I absolutely refuse to socially transition unless there's no other choice. This is not the right time in my life. Later would be so much better.

So HRT has helped a lot, but it helped a lot when I first started and that didn't last. Without social transition there's one more thing that I can do that might help and that's SRS. If it comes to it that's what I'll do, and hope for the best.

You could say that I've done RLE; I intend to present male after SRS, and I've plenty of practice at that. It's not what people mean though.

There's a slight possibility that I'm non-binary, but I don't think so. It also doesn't matter either way.

I can and will do this. I understand why so many others can't, and all I can say is that it doesn't apply to me.

I keep arguing this point not for myself, but because I've suffered a lot getting to where I am now and it upsets me to see others struggling with it.

The medical profession is first to do no harm.  That is their ethos.  Surgeons shouldn't be cutting up people with out good cause.  If someone isn't going to present IMHO there should be no surgery.  It sounds like a suicide based in regret waiting to happen.

There are certainly doctors who would agree with this philosophy as I have seen people dye their eyes red and implant things to look like demons and what not.  If you want that kind of medical care be prepared for less than perfect results.  If you want a skilled ethical professional expect them to act like one.

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Quote from: Oliviah on November 28, 2015, 12:28:41 PM
The medical profession is first to do no harm.  That is their ethos.  Surgeons shouldn't be cutting up people with out good cause.  If someone isn't going to present IMHO there should be no surgery.  It sounds like a suicide based in regret waiting to happen.

There are certainly doctors who would agree with this philosophy as I have seen people dye their eyes red and implant things to look like demons and what not.  If you want that kind of medical care be prepared for less than perfect results.  If you want a skilled ethical professional expect them to act like one.

We'll have to agree to disagree.

I can get a good surgeon. I'm exceptionally good at problem solving.

 :police:

A reminder that this site needs to be a safe place for all trans people and that there are many ways to be trans and many ways to transition. A statement that one has more validity than another is a direct violation of item #10 of the Site Terms of Service. Comparison of transition related medical care to cosmetic procedures strays dangerously close to a violation of #9.

Thread locked.