Gatekeepers vs. Informed Consent: Who Decides When a Trans Person Can Medically Transition?
http://www.slate.com/blogs/outward/2016/03/11/transgender_patients_and_informed_consent_who_decides_when_transition_treatment.html
Slate/By Vanessa Vitiello Urquhart 03/11/2016
"While not every transgender person seeks to transition physically—whether through hormone therapy or other means like surgery—when one does, who should be allowed to make the decision? Is it a clear matter of personal choice? Or should doctors or therapists have a say?"
I thought the article was ok, but it would have helped a lot if there had been more information about the abusive aspects and history of gatekeeping.
The international aspect is interesting as well, especially in Europe.
I thought it was a balanced article.
It still surprises me, when I post here about this, the number of trans people who back the gatekeeping model, who are comfortable with the notion that doctors and medical folks know our gender better than we do.
Hello everyone, pretty much old school thinking here. Where there's a will, there's always a #@$%*& way...around 'the rules'.
I used 'informed consent' as my only tool to crash the gate and make a run for it. Having a firm understanding that the Standards of Care are only a guideline proved to be powerful bonus.
YTMV - Your transsexualism may vary.
Thank you,
Anne
Quote from: OCAnne on March 13, 2016, 06:53:50 AM
Hello everyone, pretty much old school thinking here. Where there's a will, there's always a #@$%*& way...around 'the rules'.
I used 'informed consent' as my only tool to crash the gate and make a run for it. Having a firm understanding that the Standards of Care are only a guideline proved to be powerful bonus.
YTMV - Your transsexualism may vary.
Thank you,
Anne
that's pretty much what I did. I was at deaths door when I decided to try to stay alive and sure as hell wasn't going to let someone else make that decision for me.
Gate keeping is nonsense. I hate it. I got an orchiectomy so estrogen is medically necessary for me and I don't think a primary care doctor can refuse it now.
The part that transgender people are viewed as mentally ill by the medical profession doesn't help the situation. With so some protocols and requirements that doesn't seem to be in the patients best interests. Medical professionals should be mindful that many trans people have had to deal with a lot of stuff for a lot of years.
It's important to point out the pros and cons of surgery/hormones but I believe that the decision is ultimately up to the patient. I've known several trans people that they would have killed themselves if hadn't had surgery or given hormones.
😊
Quote from: Amy1988 on March 13, 2016, 04:44:16 PM
Gate keeping is nonsense. I hate it. I got an orchiectomy so estrogen is medically necessary for me and I don't think a primary care doctor can refuse it now.
I don't think doctors have any obligation to treat you. They can just say no.
Quote from: OCAnne on March 13, 2016, 06:53:50 AM
Hello everyone, pretty much old school thinking here. Where there's a will, there's always a #@$%*& way...around 'the rules'.
I used 'informed consent' as my only tool to crash the gate and make a run for it. Having a firm understanding that the Standards of Care are only a guideline proved to be powerful bonus.
YTMV - Your transsexualism may vary.
Thank you,
Anne
Yay, Anne! I very much agree with you. I have talked about this with my therapist, and she says pretty much the same thing. Everything is negotiable - with the possible exception of insurance coverage.
~Terri
I think the ICATH model will grow and overtake WPATH because so many of the SOC guidelines are hopelessly outdated. WPATH holds you to a "Show us what you want to be and prove you can be it" standard before you can do anything. That exemplifies gatekeeping.
I see people around here (Boston) who bend gender in a knot. They're not seeking any treatment, they're just living how they want to. That's the world you need to blend into, an accepting world. The world lets you be who you want to be now. Thrusting people into the past to see if they can be June Cleaver doesn't help anyone.
Hugs, Devlyn
I thought this was a pretty good article, and the distinction is made between current trends toward patient autonomy vs. the archaic standards of gatekeeping (described in the fourth paragraph).
I think the term "gatekeeper" tends to be either overused or improperly used, usually applied by those who don't understand that medical professionals have ethical and legal obligations to provide clinically sound care. A trans person's frustration about the apparent slowness of their own transition does not trump that.
Just because a provider wants to keep their job and avoid lawsuits from angry family members or regretters does not make them a gatekeeper. It makes them a responsible provider.
Informed consent exists. Anyone who feels hindered by SOC need merely tap into the informed consent network (www.icath.org (http://www.icath.org)) and find the care that better meets their needs.
I think you meant to post this link: http://www.icath.org/ ;)
Hugs, Devlyn
Yup! :embarrassed: Thanks!
[fixed it]
Quote from: suzifrommd on March 13, 2016, 06:52:44 AM
It still surprises me, when I post here about this, the number of trans people who back the gatekeeping model, who are comfortable with the notion that doctors and medical folks know our gender better than we do.
I'm not comfortable with the traditional gatekeeping model, especially as it virtually always consists of cis people, and medical people at that (who are on the average
less able to understand or appreciate perspectives different from their own) judging whether we are "really trans" or "trans enough" for medical transition services.
On the other hand, right now, I'm getting HRT under the Informed Consent model, and I feel pretty unsupported. They kind of go, "you want hormones? what dose? okay, here's a prescription. See you in six months." I'd really like a little more hand-holding. What I'd really like is something a little closer (but not close) to the gatekeeper model, but by people who actually can
understand and appreciate what we're going through. It probably means trans people, since most cis people will never be able to understand. I'm fortunate that I have a therapist who has a lot of experience with trans people and transitioning, but she and my endo don't talk to one another and there isn't any mechanism or protocol for them to do so.
Atul Gawande (a surgeon who writes essays on medical practice) wrote an essay ("Whose body is it, anyway?", in
Complications) about the current trend to place all medical decision-making in the hands of the patients, and he points out that sometimes that's just as hard on the patients as having the doctors make all the decisions. What patients usually are happiest with is for the doctor to understand and respect where the patient is coming from, and then use the doctor's greater experience and training to do the treatment that the patient would have chosen, if they had that experience and training and weren't so personally involved.
The problem with the old model was that it was adverserial: providers presumed that patients were wrong or lying and it was up to the patient to prove to the providers that they deserved the desired treatment. Trust was pretty much excluded. Couldn't it be possible to set up a
cooperative model, where medical providers trust and try to understand their patients and see it as their job to provide treatments that are best
from the patient's perspective?
Quote from: Asche on March 18, 2016, 06:53:36 AM
On the other hand, right now, I'm getting HRT under the Informed Consent model, and I feel pretty unsupported.
'
Do you have a gender therapist? For me, my therapist was the missing piece of the puzzle, the person who helped me figure out whether what I was doing was right for me.
I could have done it without a therapist, but it helped me because the thought of being trans was so strange that being around someone who knew hundreds of trans people was validating.
I would suggest that this is not informed consent but hormones on demand. I think hormones on demand and surgery on demand is very dangerous.
I think the support of a well trained therapist is not only an advantage but in most cases essential.
Gate keeping is a misinformed term. Every medic gate keeps for everything with the possible exception of trauma surgeons.
What you call gate keeping is very often making sure your client understands what is going to happen to them and the potential consequences.
If you mean someone is blocking you, that is different. That is not gate keeping.
Hormones and or surgery on demand is, in my opinion very dangerous.
I see the consequences on the Forum.
Quote from: Asche on March 18, 2016, 06:53:36 AM
Quote from: suzifrommd on March 13, 2016, 06:52:44 AM
It still surprises me, when I post here about this, the number of trans people who back the gatekeeping model, who are comfortable with the notion that doctors and medical folks know our gender better than we do.
I'm not comfortable with the traditional gatekeeping model, especially as it virtually always consists of cis people, and medical people at that (who are on the average less able to understand or appreciate perspectives different from their own) judging whether we are "really trans" or "trans enough" for medical transition services.
On the other hand, right now, I'm getting HRT under the Informed Consent model, and I feel pretty unsupported. They kind of go, "you want hormones? what dose? okay, here's a prescription. See you in six months." I'd really like a little more hand-holding. What I'd really like is something a little closer (but not close) to the gatekeeper model, but by people who actually can understand and appreciate what we're going through. It probably means trans people, since most cis people will never be able to understand. I'm fortunate that I have a therapist who has a lot of experience with trans people and transitioning, but she and my endo don't talk to one another and there isn't any mechanism or protocol for them to do so.
Atul Gawande (a surgeon who writes essays on medical practice) wrote an essay ("Whose body is it, anyway?", in Complications) about the current trend to place all medical decision-making in the hands of the patients, and he points out that sometimes that's just as hard on the patients as having the doctors make all the decisions. What patients usually are happiest with is for the doctor to understand and respect where the patient is coming from, and then use the doctor's greater experience and training to do the treatment that the patient would have chosen, if they had that experience and training and weren't so personally involved.
The problem with the old model was that it was adverserial: providers presumed that patients were wrong or lying and it was up to the patient to prove to the providers that they deserved the desired treatment. Trust was pretty much excluded. Couldn't it be possible to set up a cooperative model, where medical providers trust and try to understand their patients and see it as their job to provide treatments that are best from the patient's perspective?
Quote from: Cindy on March 19, 2016, 05:35:55 AM
I would suggest that this is not informed consent but hormones on demand. I think hormones on demand and surgery on demand is very dangerous.
Using the standard medical definition of informed consent I think that's technically correct (or course). As far as I can tell the informed consent model practiced in the USA makes it very easy to get HRT, and I don't see how a doctor can make an evaluation that someone is both informed and mentally capable of consenting in the short time they give.
In Sydney as far as I can tell you typically go to a session or three with a psych and get your HRT letter. I doubt the psych I went would make any judgement as to your being trans enough, he's just checking you're informed and mentally capable of giving consent (not crazy). I think that's technically informed consent, and I think it's a good model.
I believe its also the correct model for surgery.
I think there's pretty clearly gatekeeping in its worst meaning going on in some countries of Europe. I find RLE before HRT unacceptable for example. I quite ready to believe there's a fair bit of it in the USA as well, or at least has been until recently. Not all doctors are professional.
I also agree its dangerous, but we do dangerous things all the time, and I'm unsure the difference. Some crazy people jump out of airplanes, others climb mountains, and yet others have cosmetic surgery. Is it that there's a higher rate of mental illness than average among trans people, or that the consequences of getting it wrong are higher, or that there's a social stigma about matters gender related and we're a small minority?
Its curious there's been such a swing from one extreme to another. Perhaps its some social reaction to the past. Perhaps it also that we can't trust people to be perfect and better to have freedom to make our own decisions and mistakes than giving control over our lives to others.
It is well known that about 60-80% of TG clients have few issues beyond PTSD which is usually easily dealt with by some therapy.
About 40-20% include some who are axis type 2 group B. These clients require support. They may make incorrect decisions based on their issues.
I am not happy with dismissing these people who require support to facilitate a quick turn around for those who do not.
I'll put it another way, we screen the majority of people for bowel cancer to detect the few who need help. We screen all woman over 50 for breast cancer to detect the few who have cancer.
Should we not do the same screen for people who present as TG?
It is easy and I think facile to bring up argument about people who want tattoos etc. personally I would suggest councilling before tattoos, especially since over 50% want them removed. A process that in many cases is not impossible.
I think it is reasonable to put in protection mechanisms for the vulnerable in society. TG people are vulnerable. And I see that often on the Forum.
I'm not arguing right or wrong here, I thing everything is very complicated and shades of gray.
Its entirely reasonable to protect the vulnerable, but society is very inconsistent as to how that's applied, and being human everything tends to extremes if we're not careful. Its also not going to happen in general as people don't care enough and don't want to increase taxes.
I assume this on demand HRT/informed consent is coming out of the USA, and I'm not sure choosing between gate keeping and proper informed consent is a choice that we get to make. It may be a theoretical approach that won't work in that culture. I don't really understand what goes on there, but its seems most people have very little social protection unless they are a member of a special protected class. People have to stand up for themselves, or else. Perhaps in that environment when you lose the "protection" of the "gatekeepers" you're on your own, no middle ground.
Australia seems able to find some balance, and I assume once things are sorted out in South Australia it will come to a middle ground of proper informed consent rather than veering off to the other extreme.
I may be selfish, but personally I'd way rather have the American system than the European one. I'm kind of liking it in Sydney though. I may of course be seeing this through the lens of my own cultural experience.
Quote from: Cindy on March 19, 2016, 05:35:55 AM
I think the support of a well trained therapist is not only an advantage but in most cases essential.
Gate keeping is a misinformed term. Every medic gate keeps for everything with the possible exception of trauma surgeons.
What you call gate keeping is very often making sure your client understands what is going to happen to them and the potential consequences.
What I call gatekeeping is giving therapists veto power over some aspect of our transition care. When you require a therapist's letter you are doing just that.
Once you do that, it becomes up to each individual therapist to decide what hoops their client must jump through before they write that letter. Here are some hoops I was made to jump through as late as 2012:
* I was asked intrusive questions about my sexual interests, whose answers were shared with my wife.
* Another therapist was given a secret directive from his boss (who had evaluated me as a condition of being seen) that he was to talk me out of transitioning. I had to demand to see my medical record before that directive was shared with me.
* A third therapist refused to write a surgery letter, giving as a reason that I was still living with my wife.
There is no recourse against these therapists. I lodged complaints against the first and the third which went nowhere.
The power needs to be taken away from these dangerous people. I shudder when I think of how many trans people may have killed themselves when faced with similar treatment. The only way to make sure that doesn't happen is to make such intervention recommended but not required. A doctor recommends we see a therapist before receiving HRT or surgery, but it is not required. The final decision needs to rest with us.
Quote from: suzifrommd on March 19, 2016, 07:58:42 AM
The power needs to be taken away from these dangerous people. I shudder when I think of how many trans people may have killed themselves when faced with similar treatment. The only way to make sure that doesn't happen is to make such intervention recommended but not required. A doctor recommends we see a therapist before receiving HRT or surgery, but it is not required. The final decision needs to rest with us.
Maybe there's another way, if you could sue a therapist for denying you the letter and they had to justify it. A truly crazy person probably couldn't win. Or a poor one, but it would likely change the behavior of therapists. Its never going to happen of course.
I think the tradeoff either way is in who gets hurt, as it is with so many things in society. People will get hurt with on demand informed consent, just not me. I don't have much faith in fixing the bad medical professionals.
I'm not sure why its good here, perhaps I just got lucky.
Quote from: Cindy on March 19, 2016, 05:35:55 AM
What you call gate keeping is very often making sure your client understands what is going to happen to them and the potential consequences.
At least in my experience, the informed consent model is founded on ensuring the patient clearly understands the impact of the medical interventions. I was required to acknowledge the information and advice I was given before being prescribed meds. And this was fine with me. But, having explained implications to me carefully and thoroughly, no one stood in my path or required letters from a therapist.
Suzi,
I agree.
Your treatment was utterly wrong and unacceptable.
But that means the system you went through is wrong. It does not mean that a good system is inappropriate.
Accreditation standards are being put in place for the USA by WPATH because the USA system is wrong. These recommendations have largely been rejected by Canada and Australia because what they have in place is already superior.
AnonyMs is a special case and I think they know that (we have met and talked) and I continue to enjoy or Skype talks.
I'm trying to say that a good system works well. A bad system will never work, and if you have been a victim of a bad system you will never agree to any system.
In my case I had totally supportive people who helped me, never doubted me and looked after me before and after surgery.. Since I had such a great experience with loving and caring therapists, of course I am biased. What I went through should be the norm. What you went through is just plain disgusting, wrong and illegal. So of course your bias is against the crap you went through.
In my case I keep in touch with my therapists because I like them, and they like me.
Do I need them? No. Do I respect them? Yes.
Would I recommend them? You bet.
I'm transitioning on the NHS in the UK at the moment, and while I don't object to the idea that patients should be aware of the effects and consequences of HRT, so far I haven't been given any information about that by the NHS - I'm only aware via research that I've done by myself here and elsewhere. If I hadn't, the only information I would have received from the NHS so far is that:
- society looks down on trans people (shocker, i know)
- i might end up being perceived as male like i want to - or I might end up looking like (exact quote) 'an ugly girl with a beard'
- vague implications that major surgery might just be difficult (because I must have been thinking having chunks of flesh removed would be easy)
Admittedly, I'm early on - I've only had the GP meeting to request the referral, and two psychologist meetings. But if it's the gender identity clinc's job to talk to me about HRT and its effects etc, and the psychologist's job to check that I'm emotionally ready and don't have any unrelated issues, why did she only talk to me about how terrible an idea transitioning is/ that I'll never ~pass/ that I'm not as burly and butch as she expected?
I feel like if it wasn't a gatekeeping meeting, and was actually about my mental health, i wouldn't have been asked those questions - about my sexuality or my sex life, or about if i was prepared to become a social pariah. I was asked if I'd done any research of my own, and i said I'd researched online both through the NHS's own website and resources, this forum, and youtube videos of actual trans people talking about their lived experiences. The psych didn't seem to think this was enough - but didn't give me any alternative resources. They didn't even ask what my research had taught me so for all they know i could have an entirely incorrect idea of what HRT does. What if I had done no research at all? How can they assess if I'm ready for changes if they can't be sure that I'm even aware of what these changes are?
I expect that I'll be given better info by the GIC when I eventually get a meeting there, but I don't understand how the two meetings i had with psychology would have told the NHS anything about my mental state or competency as most of what we talked about aside from the scare tactics about how i'm too pretty to pass as male, was me trying to explain the concept of bisexuality and clarifying that I haven't already had a chest reduction, I'm just binding.
To me those meetings didn't feel useful, they felt like they were designed to put me off, or test that i'm willing to put the effort in to push for a referral and that i'm not just transitioning on a whim - and they made me very depressed for weeks. They were not designed to educate me or support me in any way. I wasn't asked if i feel anxious or depressed i was told that i should feel anxious, unsafe and depressed.
Bear in mind that I can't afford to go private, and that this psych was the only one in my area and is working with the GIC that I'll be referred to. I've heard that bridging hormones is sometimes possible on the NHS - meaning that it's possible for my GP to proscribe me HRT but only at their discretion, and most GPs would likely be uncomfortable proscribing without first consulting with psychology or with a GIC first anyway. Part of the problem with gate keeping is that for a lot of us the options are very limited. If the NHS was to turn me away I wouldn't be able to transition for years, if at all.
I also understand that there's a lot of pressure on the NHS but perhaps that could be relieved somewhat by not referring me to a psych for two useless meetings?
I support WPATH and the standards of care however, I feel firmly they are guidelines and not concrete rules. Ultimately, I see being transgender as a medical issue and even though I went to a place that was "informed consent" after a time of Self-medication with occasional medical supervision and I still had to meet with a therapist before treatment would be given, just to ensure that I understood the ramifications of my choices and that I was able to make those choices of sound mind.
I don't mind any of that. I view it as advantageous to the community to keep GID as a Pathalogical condition for the sake of arguing for our rights. It is much easier to win the argument that trans people need medical care for a medical condition than it is to explain to those outside of the TG community that some people elect to get treated without any diagnosis and some don't but, some of us absolutely get our lives cut short by not getting that treatment and it is a life or death matter that it be covered.
Basically one is a much cleaner narrative and if there is one thing I have learned during my transition is that an additive that requires nuance is beyond the general publics understanding.
Mixed emotions on this one. Two individuals I know of. Can't imagine anyone signing a mental health letter for. "If" I worked at a guy store I would never.. repeat never.. sell them a gun or ammo. "If" I worked at the bar or the 7/11.. I would certainly think twice about selling them alcohol. HRT?.. Might be exactly what they need??? Then the 1000's of articulate, informed, sane, sober individuals in this community? In Thailand. If you're tall enough to reach over the pharmacists counter.. cash wadded up in your little hand.. You're gonna walk down the street with hormones. Seems to work. ??? ???
Quote from: Hikari on March 19, 2016, 01:57:39 PM
I support WPATH and the standards of care however, I feel firmly they are guidelines and not concrete rules.
Well, they ARE guidelines. Recommendations, actually, and it says that very thing in the SOC. People seem to want to regard WPATH SOC as if they are law, and it just ain't so.
In my experience, physicians themselves tend to be more strict with what they require from a trans patient than the SOC recommends. If someone is having a problem getting what they need from a doctor then they ought to know that it's the doctor who has the final say. The first question one should ask the doc is if they use WPATH SOC as a guide to inform their practice. If not, your results may vary.
I changed my mind on this matter in past couple months... Im 110% against any requirements for genital reconstruction, or penectomy or orchiectomy. People who are sane can obviously decide for themselves what choices they make and what works the best for them... and people who are insane, god bless them, I dont mind if they want to have their private parts reconstructed, if they pay for it themself. It doesnt affect me in any way. There are probably some cis guys who for whatever reason start to believe that they are in fact transsexual, and want to have SRS... Let them have it! Its actually funny (in a very twisted way) if you think about it...
Surgeons and psychiatrists should better make sure to protect themselves legally though.
Quote from: mmmmm on June 21, 2016, 10:25:04 PM
I changed my mind on this matter in past couple months... Im 110% against any requirements for genital reconstruction, or penectomy or orchiectomy.
I changed my mind too. There's too much abuse in the current system and not much chance of it getting fixed.
Quote from: mmmmm on June 21, 2016, 10:25:04 PM
People who are sane can obviously decide for themselves what choices they make and what works the best for them... and people who are insane, god bless them, I dont mind if they want to have their private parts reconstructed, if they pay for it themself. It doesnt affect me in any way. There are probably some cis guys who for whatever reason start to believe that they are in fact transsexual, and want to have SRS... Let them have it! Its actually funny (in a very twisted way) if you think about it...
Funny? No. I think its sad, but we are only human and no matter what rules we come up someone's going to suffer. I side with more freedom, less overall suffering and more good, and to be selfish about it, someone else doing the suffering.
We even had to go through a psych eval for Fertility treatment a while ago... at least that was only one session...
It is a problematic situation, especially on the surgery topic. This is truly major surgery - I do believe everyone willing to go that route has thought about it for quite while and hopefully knows what he is up for. Any kind of surgery comes with lengthy consent forms to sign. So yes, having to add years of therapy still feels like being trans is treated like a mental illness. My hope is that the current ongoing discussion will improve the situation. The current requirements make it especially hard for "non binary leaning m or f" - Having SRS would absolutely help my mental state no matter how much transitioning I am planning to do or not.
I think I have mentioned this before, my preference would be SRS first, then HRT then decide how much I want to be out in public. Or SRS and HRT at the same time.
My insurance follows WPATH (and of course does not pay the "cosmetic" portions). Same applies to all of the potential places for SRS I looked at. Does not make me happy and I hope the thinking evolves. I am actually doing pretty well right now and the only reason for me to see a therapist would be to get insurance to cover meds and surgery. Not a very good reason. I do believe HRT needs to be monitored so yes - medical supervision should be required here. Everything else is just doctors covering their backs and ensuring that another doctor can buy a yacht.
So.. I do believe that informed consent would be the better option.
Quote from: AnonyMs on June 22, 2016, 03:03:08 AM
Funny? No. I think its sad, but we are only human and no matter what rules we come up someone's going to suffer. I side with more freedom, less overall suffering and more good, and to be selfish about it, someone else doing the suffering.
... in a world where people kill innocent people because they dont share the same sincerely held religious beliefs, and children still die from hunger, I could probably find 10000 things that will be more sad than someone mistakenly thinking they are trans ends up having SRS.
Quote from: mmmmm on June 21, 2016, 10:25:04 PM
I changed my mind on this matter in past couple months... Im 110% against any requirements for genital reconstruction, or penectomy or orchiectomy. People who are sane can obviously decide for themselves what choices they make and what works the best for them... and people who are insane, god bless them, I dont mind if they want to have their private parts reconstructed, if they pay for it themself. It doesnt affect me in any way. There are probably some cis guys who for whatever reason start to believe that they are in fact transsexual, and want to have SRS... Let them have it! Its actually funny (in a very twisted way) if you think about it...
Surgeons and psychiatrists should better make sure to protect themselves legally though.
Yeah, and there are people who think fifty LGBT people gunned down in a nightclub is funny, too. There's a word for people like that...but we can't use it on the forum.
Quote from: Devlyn Marie on June 22, 2016, 10:53:10 AM
Yeah, and there are people who think fifty LGBT people gunned down in a nightclub is funny, too. There's a word for people like that...but we can't use it on the forum.
I disagree, "evil" is a perfectly usable word on the forums.
Quote from: Dee Marshall on June 22, 2016, 11:37:32 AM
Quote from: Devlyn Marie on June 22, 2016, 10:53:10 AM
Yeah, and there are people who think fifty LGBT people gunned down in a nightclub is funny, too. There's a word for people like that...but we can't use it on the forum.
I disagree, "evil" is a perfectly usable word on the forums.
:police: "evil" is a four letter word, young lady! :laugh:
Hugs, Devlyn
Snicker! You called me young! A new co worker thought that I was 20 years younger than I am. Being transgender is an awfully expensive (in time, money, and anguish) fountain of youth.
Sent from my SHIELD Tablet using Tapatalk
While I believe that gatekeepers are needed in some capacity, people need to be careful of harming individuals through implementation of rigid and unwaiverable policies.
Today is my first visit back here in almost four years. Since my last visit I learned to live and enjoy life. I learned to put my female self before my trans side, often going weeks or more without ever really thinking about my long past transition. I was no longer "transitioning," but had, instead evolved to embrace myself as a woman rather than a transgender woman.
When I put my trans side behind me, all of my legal work was done EXCEPT for the sex marker on my Texas birth certificate. I was recently informed that it was finally possible to change that, so I took it upon myself complete the legal side of my transition as well. One key document required to petition the court is a letter from a doctor attesting that I had completed appropriate treatment..." No problem, right? WRONG
The doctor I approached for help didn't feel comfortable writing a letter so soon. I obviously need more therapy to deal with my gender issues. HOGWASH
I'm now 13 years post op. I've gone back to school and graduated. I've worked in multiple occupations "in stealth" without issues. My family issues were even behind me, and I was finally accepted as a daughter, sister, niece and granddaughter.
I was able to go weeks without even thinking about gender related issues, but because of rigid gatekeeping practices, I'm pulled out of the "I'm a woman" mentality, and being forcefully made to revert to the repressive "I am, and always will be transgender" mentality. Unwavering gatekeeping designed to help people cope with transition have caused anxiety and depression. Happy ==> depressed. Completed transition ==> restarting the cycle for the sake of "rules and guidelines." Ugh
Some rules are needed, but they need to be flexible enough to accommodate the needs of each individual.
Peep's story brings out an important point:
Medical advice should not be biased.
It is already difficult, on many levels. Medical practitioners cant make discomfort go away just by telling you 'oh you dont fit all the boxes on our trans-meter so its better if you stay where you are'. 'Oh and by the way this trans-meter isnt free and you have to pay 300+ per session'
This is B.S. Just let people know all the relevant (unbiased) info and then give them the treatment. Chances of them regretting it are slim, and getting it on a whim are nonexistent.
I think that at a certain point, delays and prevarication under WPATH become de facto gatekeeping. Especially when horrendous waiting lists for hormones and surgery - to which you will *not* be added without therapist approval - are involved. I've spent nearly a year waiting for therapy, getting therapy (that I'm not at all certain that I needed or substantially benefited from) and (finally) sitting on a half year waiting list for HRT. If I could have afforded it and another option were available (and it turns out there was, I just wasn't told about it) I would have gone elsewhere and received faster treatment. I can well understand that medical providers have an ethical responsibility, but dithering and dilly dallying isn't good care either when someone is drowning in gender dysphoria despite having (as I already had by that point) come out of work, come out to family, started to dress as a man full time, begun the legal process of changing their name ... Did I really need therapist approval of my decision or my gender clarified for me in some fashion before being put on the waiting list? No. I don't really think so.
I wonder if they're questioning without coming out and saying directly whether being transgender is a mental illness or just a personal decision. Did anyone else wonder that?
My first therapist I saw about gender dysphoria said he couldn't write any letters because many of the people regret it and commit suicide and he also said some abusive things despite the fact that he was listed to deal with transgender patients which some in my area won't deal with. My current therapist said he had no right to do that and wasn't following the rules. She said the only reason for them to refuse a letter would be if you were psychotic, and he shouldn't just refuse it because he doesn't believe how I said I feel or agree with the decision to start T.
Quote from: suzifrommd on March 19, 2016, 07:58:42 AM
What I call gatekeeping is giving therapists veto power over some aspect of our transition care. When you require a therapist's letter you are doing just that.
Once you do that, it becomes up to each individual therapist to decide what hoops their client must jump through before they write that letter. Here are some hoops I was made to jump through as late as 2012:
* I was asked intrusive questions about my sexual interests, whose answers were shared with my wife.
* Another therapist was given a secret directive from his boss (who had evaluated me as a condition of being seen) that he was to talk me out of transitioning. I had to demand to see my medical record before that directive was shared with me.
* A third therapist refused to write a surgery letter, giving as a reason that I was still living with my wife.
There is no recourse against these therapists. I lodged complaints against the first and the third which went nowhere.
The power needs to be taken away from these dangerous people. I shudder when I think of how many trans people may have killed themselves when faced with similar treatment. The only way to make sure that doesn't happen is to make such intervention recommended but not required. A doctor recommends we see a therapist before receiving HRT or surgery, but it is not required. The final decision needs to rest with us.
The same type of thing happened to me with the first therapist I went to about getting a hormone letter. He used my past mental health issues against me and emotionally abused me. My new therapist said that he's got pending cases against him with our local transgender alliance for abusing his power, and they're sure he's done it, but it's hard to prove or have anything done about it.
Quote from: Peep on March 19, 2016, 09:52:53 AM
I'm transitioning on the NHS in the UK at the moment, and while I don't object to the idea that patients should be aware of the effects and consequences of HRT, so far I haven't been given any information about that by the NHS - I'm only aware via research that I've done by myself here and elsewhere. If I hadn't, the only information I would have received from the NHS so far is that:
- society looks down on trans people (shocker, i know)
- i might end up being perceived as male like i want to - or I might end up looking like (exact quote) 'an ugly girl with a beard'
- vague implications that major surgery might just be difficult (because I must have been thinking having chunks of flesh removed would be easy)
Admittedly, I'm early on - I've only had the GP meeting to request the referral, and two psychologist meetings. But if it's the gender identity clinc's job to talk to me about HRT and its effects etc, and the psychologist's job to check that I'm emotionally ready and don't have any unrelated issues, why did she only talk to me about how terrible an idea transitioning is/ that I'll never ~pass/ that I'm not as burly and butch as she expected?
I feel like if it wasn't a gatekeeping meeting, and was actually about my mental health, i wouldn't have been asked those questions - about my sexuality or my sex life, or about if i was prepared to become a social pariah. I was asked if I'd done any research of my own, and i said I'd researched online both through the NHS's own website and resources, this forum, and youtube videos of actual trans people talking about their lived experiences. The psych didn't seem to think this was enough - but didn't give me any alternative resources. They didn't even ask what my research had taught me so for all they know i could have an entirely incorrect idea of what HRT does. What if I had done no research at all? How can they assess if I'm ready for changes if they can't be sure that I'm even aware of what these changes are?
I expect that I'll be given better info by the GIC when I eventually get a meeting there, but I don't understand how the two meetings i had with psychology would have told the NHS anything about my mental state or competency as most of what we talked about aside from the scare tactics about how i'm too pretty to pass as male, was me trying to explain the concept of bisexuality and clarifying that I haven't already had a chest reduction, I'm just binding.
To me those meetings didn't feel useful, they felt like they were designed to put me off, or test that i'm willing to put the effort in to push for a referral and that i'm not just transitioning on a whim - and they made me very depressed for weeks. They were not designed to educate me or support me in any way. I wasn't asked if i feel anxious or depressed i was told that i should feel anxious, unsafe and depressed.
Bear in mind that I can't afford to go private, and that this psych was the only one in my area and is working with the GIC that I'll be referred to. I've heard that bridging hormones is sometimes possible on the NHS - meaning that it's possible for my GP to proscribe me HRT but only at their discretion, and most GPs would likely be uncomfortable proscribing without first consulting with psychology or with a GIC first anyway. Part of the problem with gate keeping is that for a lot of us the options are very limited. If the NHS was to turn me away I wouldn't be able to transition for years, if at all.
I also understand that there's a lot of pressure on the NHS but perhaps that could be relieved somewhat by not referring me to a psych for two useless meetings?
I don't understand why the doctors or therapists would think anyone would be fraudulently trans because it's such a serious thing. They [the first therapist] seemed to think I was following a trend because of Caitlyn Jenner. I knew how serious the hormones and the surgery was and what a harsh journey it would take to make me fully fulfilled. I understand, Peep.
Quote from: mmmmm on June 21, 2016, 10:25:04 PM
I changed my mind on this matter in past couple months... Im 110% against any requirements for genital reconstruction, or penectomy or orchiectomy. People who are sane can obviously decide for themselves what choices they make and what works the best for them... and people who are insane, god bless them, I dont mind if they want to have their private parts reconstructed, if they pay for it themself. It doesnt affect me in any way. There are probably some cis guys who for whatever reason start to believe that they are in fact transsexual, and want to have SRS... Let them have it! Its actually funny (in a very twisted way) if you think about it...
Surgeons and psychiatrists should better make sure to protect themselves legally though.
I don't understand how a cis man can want to be transgender. If he "wants" to be transgender he would already have had to have been unconsciously all along and just discovered it when he saw others coming out and transitioning.
Quote from: alienbodybuilder on August 11, 2016, 09:21:35 AM
I don't understand how a cis man can want to be transgender.
I think this is simply, direct and true. Especially with the first step to HRT, the anti-androgen component will do something, relatively quickly, and its either going to be a huge, "omg, what have I done!" moment, which will reverse in a week or two after the dude flushes the hormones down the toilet... or, a "praise the lord, why didn't I do this on my 18th birthday!" moment, in which case, proceed.
Probably more complicated FtM because T is so subtle on that side; but MtF? T is a giant bludgeon of unhappiness crushing everything in its path that doesn't want to be masculine. For a dude thinking its a cool idea? No chance.
So I think the IC way is fundamentally a good thing, but I am also more tolerant of bad outcomes on outlier cases. This conflicts with the general US approach to medicine, where a significantly bad outcome, even on a small number of cases, can radically restrict how a protocol or drug is used. So I dunno really; some form of gatekeeping should be fine, but I think it needs to adjust to making that first step to HRT very rapidly; essentially "hormone on demand" but with 0 refill; come talk to me and convince me you like the change (and gimme another blood sample so I don't blow up your liver..:-D)
caveat: being that I intend to stay with HRT but no-op; my perception might just have a bit of bias.....
(2) if mods think I'm posting too much for a new member, please feel free to say, "shut up already"... this place is amazing and I don't want to annoy yall..
Quote from: rwOnnaDesuKa on August 11, 2016, 09:52:14 AM
(2) if mods think I'm posting too much for a new member, please feel free to say, "shut up already"... this place is amazing and I don't want to annoy yall..
If you think you are posting to much for a new user, look at my early posting history on the site. I was noticed at 300 posts and asked about becoming a moderator. At 750 a more formal request was made and at 1,500 posts, about 4 months after I joined the site I ended up with this chain around my leg keeping me near the computer. :icon_userfriendly:
Comrade, you're looking at your glorious free ankle bracelet in all the wrong ways! >:-)
When I was transitioning, I had a friend who was also in the early stages of her real life test. This was 1991, so back then we had to live in our new gender, full-time, for one year before SRS. I don't know what is usual now.
What happened to her is that she was finishing pharmacy school and had a lot of difficulty finding a job due to her status. She was up front with potential employers and she just couldn't find a position. She finally gave it up and decided that she would go back to living as a man. My friend needed to survive.
Whenever I think about the process that was required, I think about my friend and that very difficult decision she was faced with. I will never judge her for her decision because it was hers to make. I will say that I think that the process may have done her a service, in a way. She did have difficulty passing in a public-facing profession and the discrimination she faced may have been wrong but it was real. There is no easy path for us (you'll hear me say this again and again).
It's frustrating to wait, I know, but real life isn't a prom night. It's messy and full of trials. As a trans-person, we get an extra helping of complicated.
While I do believe that the choice ultimately belongs to the individual, I believe that discovering the reality of life in our new gender role before surgery is a good thing. Therefore, I am not for "surgery on demand" but perhaps, "surgery after the appropriate steps are taken." Something like that.
-Rhonda (MTF SRS 1991 new girl here)
Quote from: Rhonda Lynn on August 13, 2016, 10:13:05 PM
When I was transitioning, I had a friend who was also in the early stages of her real life test. This was 1991, so back then we had to live in our new gender, full-time, for one year before SRS. I don't know what is usual now.
What happened to her is that she was finishing pharmacy school and had a lot of difficulty finding a job due to her status. She was up front with potential employers and she just couldn't find a position. She finally gave it up and decided that she would go back to living as a man. My friend needed to survive.
I've not transitioned, but I don't think I'd survive without HRT and as for SRS who's to know if you don't tell them?
Quote from: AnonyMs on August 13, 2016, 11:01:06 PM
I've not transitioned, but I don't think I'd survive without HRT and as for SRS who's to know if you don't tell them?
It can be very complicated when you're transitioning with a career. There are your identification documents that may not match the name and gender that you are using. There are college transcripts that may not match. At some point, questions come up and the truth may be the best option.
Quote from: Rhonda Lynn on August 13, 2016, 11:35:22 PM
It can be very complicated when you're transitioning with a career. There are your identification documents that may not match the name and gender that you are using. There are college transcripts that may not match. At some point, questions come up and the truth may be the best option.
For each choice you can make it seems like some tried it and it worked out happily and others did the same and it was a disaster. If only you could try each option in turn until you found the one that worked, but unfortunately some of them are not easily undone. Life's complicated.