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) and find the care that better meets their needs.

I think you meant to post this link: http://www.icath.org/ 

Hugs, Devlyn

Yup!  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.