gatekeeper vs candystore

[Meghan4now]

As I understand it, in the old days, it used to take a herculean effort for Trans folks to get a prescription for HRT. I've heard and read complaints about "Gatekeepers", etc. I'm sure some medical professionals still take this approach, or worse.

However, I am also noticing a fair number of people getting a scrip based on just a short consult and blood test, with very little review of medical and psychological history. Almost like handing out candy. Quite frankly I am surprised at how incredibly easy it is to get a script nowdays. I would think the fear of malpractice would slow these doctors down. Well with the opioid issue, and some of those Docs, I guess I shouldn't be surprised.

So my question is, what is your experience? Did you have to go through the gatekeepers, or just spend an hour or two telling some Doc that your are GID, and walk out with a script?

[Sarah Doepner]

I spent years in the closet, slowly inching out, before discovering through the internet that there were others like me. I continued to learn and expand my world and finally about 3 years ago went to a mental health therapist to sort everything out. Earlier this year I made an appointment with the doc in my area who is the most experienced in support of the Transgender community. That single appointment ended with an Rx. Could I have just made the appointment without the other steps? Maybe, but it's possible in our conversation she saw I had prepared for this choice.

She felt there have been too many gatekeepers and that may be one of the things that has held us back as a larger community for so long. That gatekeeper approach seems to represent "Non-conforming gender" as an illness of some sort rather than a natural aspect of human experience that can be treated in a non judgmental way.

[AllieSF]

We have informed consent here in California. No candy but valid and needed prescriptions. There are clinics that are there specifically for the LGBT community, especially low income, and they have a lot of nurse practitioners who can write prescriptions with and overseeing doctor's approval. If one is honest with their medical providers and has conflicting medical conditions, then I understand that the clinic or doctor will definitely take it higher up the medical chain to confirm or not that one can take the hormones. Now, the informal gatekeepers become the insurance companies who have not yet quite caught up with transgender medical care and may quickly approve a standard dosage prescription for hormones and then make it pure hell to get an insurance company approval for an increase away from that standard initial dosage.

[Devi SM]

I think that physical illnesses many times can be diagnosed just with the doctor's judgment or experience, sometimes, to be sure of what they suspect, they need blood tests or others exams before to prescribe a treatment or medicines. Mental illnesses are more complex because are sometimes tricky and hard to diagnose, so psiquiatrists need several sessions with the patient to arrive to a diagnose and sometimes they need someone else opinion. I wouldn't call them gatekeepers but responsible professionals.
In the case of us that in a sense is something very abstract, mental, no called today mental illness, related with behavior, they need to developed a kind of relationship with the customer, us, before prescribe a treatment or medicines, as well that your primary doctor concurr in agreement with the treatment.
Lastly, remember that endocrinologists don't do therapy, neither have the medical history or records accessing as well the primary doctor. There's no test to determine the gender orientation and even for us that had lived with this for all our life is confuse, I think that is correct they be sure before to prescribe something as hormones that have a huge influence in the body.
In my case, after a year on GT, the therapist mention the HRT, then I did my own research here and with others, then I mention it to my primary physician so finally the endocrinologist request the GT letter and after that he interviewed me for around one hour.
I wouldn't call them gatekeeper but responsible system.

[pamela7]

here in the uk, there are lengthy time-delay gatekeepers, but no real psychological probing of any substance. if one stays the course, seems to be enough.. not saying this is good or bad, just how it seems

[Rianna Humble]

I would also like to note that in the UK we have real informed consent - i.e. the people who prescribe (in this case) the hormones help you to set expectations about outcomes and any potential side-effects and obtain your agreement to the treatment.

Yes, it is becoming harder to get to see the people who are tasked with ensuring your wellbeing during transition because of lack of funding and increasing numbers of applications, but that is not gate-keeping.

[AllieSF]

So, Rhianna, are you saying that california's is not "real". Why Bold the "real"?

[LeaP]

I would also like to note that in the UK we have real informed consent ...

Well Said!!!

Meghan, my letter was written after appx. 6 months therapy. I didn’t ask about process or any gatekeeping roles my therapist might have adopted. I needed the counseling.

[AllieSF]

So Leap, since you agree with Rhianna, is California's informed consent not "real" and bad and why??

[Rianna Humble]

California's informed consent not "real" and bad and why??

I do not know what the Californian statutes say, so I can only comment on what has already been written here contrasting "informed consent" with care given by professionals.

If your interpretation of "informed consent" means that you can buy your way past checks and balances (like Charles Kane did and many people who have posted here in the past) and/or that you get to ignore warnings of possible side-effects because you are paying then IMNSHO it is bad.

People have contrasted their version of "informed consent" with the provisions available on the UK's National Health Service, but the NHS requires you to be informed of the arguments in favour of the proposed treatment and possible side (or negative) effects and to come to your own judgement before receiving the treatment - that is the very meaning of "informed consent"

[Lygophilia]

I technically needed up to a year for her to consider it, which was with two therapists (one quit her job) in order to get started on HRT. It's ironic, but I know now that of what I went through a year ago was with merit and that they wouldn't have put me on hormones if I knew about their location much sooner.

[kimdl93]

I wonder if we might be talking about different things. A primary care provider can legally and ethically provide hormone replacement therapy, based on their professional judgement. More extensive, irreversible treatment in the magnitude of SRS, on the other hand, would involve gatekeepers and prior authorization. That seems prudent.

[KymberlyOct]

LOL I couldn't remember at first how long I had to wait but I kept the empty bottles from my first doses of spiro and finestride so I just went and looked at the date. They are a keepsake such as old birthday cards, pictures etc.

It was 4 months from my first appointment with my therapist until I started any HRT. I didn't start E until immediately after my orchie. My medical doc at the transgender clinic is kind of uptight medically ( not socially) and she was freaked when reading my cardiologist report. She prescribed one sixth of the usual dose just to maintain bone density. My primary doc bumped it up to one third so it actually does SOMETHING.

Anyway, sorry TMI. Just walking down memory lane. It took me 4 months to get anything.

From what I have read the effects of spiro and fin are reversible however sometimes the effects of E are permanent. I think it is wise of providers to wait awhile before prescribing E. Also I think it is unwise to self medicate. Of course there are exceptions based on someone's situation but just because "I want to'
shouldn't be one of them.

[Dorit]

In Israel we have state funded health care, probably similar to the UK. On the plus side most of our needs are either free or heavily subsidized, like SRS and HRT. On the negative side, the wait can be long because the government does not allocate enough funding for transgender services. For HRT I had to have a letter from my psychologist that I was a suitable candidate for the therapy, and then the agreement of the head doctor of the endocrinology clinic after extensive blood tests and an interview. The cost of my drugs is about $20 per month. For SRS I have been going through the protocol of the state sponsored Gender Change Committee. It is basically about eight months of meetings with psychologists, psychiatrists, surgeons, endo, urology, and more. At the end you sit before the entire committee where they decide if you are a suitable candidate. If they agree, I get free SRS and breast enlargement, but not FFS. The only problem is after the eight months of the committee, a date is set for surgery that is currently two years away! That is why many Israel trans women, like myself, do their SRS outside of Israel privately. Incidentally, my final sitting before the committee is November 21. I believe they will accept me, and even though I am doing SRS on my own in the US next month, I will probably take the free BA.

[Anne K]

I visited an Integrative Medicine Physician with a boatload of experience in the LGBT community. When discussed the ups and downs of HRT. I gave him my therapist's contact information. A couple days later my prescriptions were ready for pick up. I have made him my Primary Physician and I couldn't be happier.

[LeaP]

I’m all for self-determination, given real knowledge. Unfortunately, that seems to be exceedingly rare. It’s also true that the experience of taking steps with consequences is often not what people expect or can predict. The gate should be open in the end, but I think a stiff challenge is warranted and reasonable first.

To those truly interested in this topic, I suggest some reading in medical ethics, particularly as it relates to the so-called informed consent MODEL for transgender care. I.e., not informed consent per se, which is quite different. I believe in responsibility, not waivers.

[Katya@]

When I started to consider going on hormones, I made an appointment with endocrinologist to get some answers on the questions I couldn't find answers. I didn't have a therapist. On my appointment, I mentioned that I am concerned with balding at that time and wanted to prevent it from progressing as it was giving me grief. I wasn't sure about T blockers or E at that time. So my endo (who works with trans community in my town), has ordered full bloodwork just in case and on the next appointment a month later, I got prescription for Finasteride. About 3 month in, I mentioned that I am considering to start E. He wanted me to think it over, discuss with my spouse and offered even for both of us to come and see him to let my wife a chance to ask questions. At the time of the appointment, I came well prepared with actual notes, questions, that showed my understanding of expectations and risk. By the next appointment (3 month later), I did come with my wife and reiterated my desire to start on E. My wife mentioned to doc that she supports it and is aware of the consequence. My endo prescribe me E that day (almost 1 year ago) but asked to complete the Informed Consent for Estrogen Therapy. He asked me and my wife to initial and sign it. It was mostly for him to make sure we are fully aware of all the risks. BTW, you can find the copy of the consent here: https://fenwayhealth.org/documents/m...en_Therapy.pdf
In general, while it was not hard to get a prescription, I feel like my doc new that I am aware, my spouse is aware, so he felt OK to prescribe it. It was not the law but it was his "best practice" and I agree with this approach.

[KymberlyOct]

I tend to write replies advocating for transitioning or at least exploring one's gender identity. While I certainly do not think all people with gender issues should transition I do come from the mindset that fear and making excuses prevents or postpones many people from transitioning that would ultimately be happier. Again, not everyone should transition, far from it.

That long disclaimer said, I do think it is more challenging when children are involved. I have 3 children ages 26, 24 and 23. The youngest two have severe Autism, require 24/7 care and have very limited communication skills. My oldest is very mildly affected but leads a normal life.

Regardless of the circumstances with children whether they be healthy and happy or not, that does not erase GD and feelings of GD are not doing anything 'wrong'. No one should punish themselves.

I also believe we should teach our children courage and to live honestly and openly. They learn from their parents at any age.

On the other hand would I have transitioned when they were 5 yrs old or 10 yrs old? Nope. That's just me. But I also believe the right thing to do if at that time in your life you have serious gender issues is to...

A. See a therapist, not for 'cure' rather to learn how to cope and live.
B. Be honest with the other parent.
C. Make a plan for transition if that's where you ultimately see your life going and follow through on that plan.

As someone that stayed in an unhappy (miserable) marriage for 18 years for the kids I speak from experience.
In retrospect I stayed too long, but I don't regret staying just maybe for the number of years I did.

But if you come to the conclusion that transition is where your life is heading make real plans and stick to them. Don't let 2 years turn into 5 into 10 into 20 into never.

I wish someone had told me this years ago but better late than never.

[pamela7]

If I may, I will seek to explain what I feel a proper gatekeeper is, and why one is a good plan.

1. just because we are a misfit does not mean we will be a fit post-transition (it means one has missed certain socialisations)
2. just because a person wants to have boobs and a penis does not mean they are a m2f ts (it means they have a sexual preference).
3. just because a person does not want to go bald is not a reason for suppressing T (by the way, it's genetic, not the T)
4. there are dozens of in-life conditioning experiences that might lead a person to prefer to play the other sex, and especially subliminally in the unconscious, and without due psychological process, it is a cosmetic surgery a person might well later regret
5. there are now brainscans which reveal brain gender, and which reveal ts brains also as something different - that would even provide an objective test.
6. most counselling process used to work with transgender clientele is seriously under-tooled in terms of being able to really dig in to whether it is life's traumas or inherent nature that sits behind the need to transition.
7. the wealth available to some to make a designer life choice means they could afford cosmetic transition - is that right?

So, a proper gatekeeper would require to be assured on the above criteria at least, and be trained to make such analyses.

[Meghan4now]

So far, what I am reading is that if one really wants to start HRT, one just has to find the right place, and that essentially there is no requirement for much of a psychological evaluation beyond some basic canned questions that can be easily coached ahead of time. That is not to say that there aren't good care givers out there, or that individuals won't carefully work through their issues. However, the door is certainly open for someone to "self diagnose" with limited data or introspection, and go get HRT without any significant counseling.

This, to me, is sad. And it confirms my own observation.

BTW Pam, I think that is the best post I've read from you. I think you've pointed out some reality we don't always like to acknowledge here. And before anyone starts ripping into your answer, I would like to point out that what you've identified is not an indictment of the whole Trans spectrum, but is a reality for some individuals.

[Nikki.]

People learned the right narrative to talk their way into SRS in the 60’s, 70’s and 80’s, before the internets. There was a standard script. People lie and are manipulative to get all kinds of different stuff they want. I don’t understand the desire to tell a sane adult who is able to comprehend the potential negative consequences of their decision they can’t take cross sex hormones because they want to.

[Meghan4now]

Nikki,

I understand what you are saying, and agree, but you qualified it with 1-Sane, 2-Adult, And 3-comprehend. My concern here is that there are individuals that do not fit that definition but are getting the quick pass. While all the characteristics are certainly subgective, a qualified professional should be able ferret that out. You know with simple questions like "gee who's insurance are you using" and "Tell me about your employment history" or "Have you spent any time presenting female in public?" Maybe "Are you self reliant?" And even "Do you have any real life friends and support?"

Any of these questions can have what might be considered a less than "mature" response, and still not be indicative of some one who is making a poorly informed decision. But as a whole, they would help to paint a picture for both the individual and the care giver as to the level of maturity the request is coming from.

[AllieSF]

I understand the need to be careful and and to utilize some form of gatekeeping to make sure that the people who may regret their decision in the future hopefully get screened out, especially when body changing medications and surgery comes into play. I would be very interested in seeing some reliable statistics that can document the number of regretter's and then compare that to the number of satisfied customers, so to speak. Also, how much therapy is the recommended minimum and what is considered timely and responsive care. Unfortunately, when it comes to transgender (umbrella term) statistics, for TS's to CD's, we are really lacking in knowledge about how many of us are out there, what is our makeup from across the population, to so many other data points that would help the specialists in their work and understand what we need. Do we need more gatekeeping like the years long one practiced by choice or lack of funding by the NHS in the UK or something less restrictive? Good data can take a lot of the debate out of the decision processes and be more accurate. I can't say what is best for someone. Since they are adults, the final decision is theirs, including to change an earlier decision.

Yes, we should worry about the regretter's, especially if there is a large number of them. But in any medical treatment for individuals there is always some risk and some people still suffer and sometimes die from the side effects. Somewhere along the line an acceptable limit is established, which permits some life saving drugs and treatments to be made available to those in need. Without good data, where does one set the gate?

[Dorit]

When I started the Israel process five months ago I learned that if I qualified at the end it would be a two year wait for surgery. So I then began my search for a solution, and in August made the commitment to SRS on December 14 in Philadelphia with Dr. Sherman Leis.

[Devi SM]

Wow! I'm so happy for you!
It's amazing and you're right. It's a confirmation for who you really are.
Well done Dorit. Congratulations! And when it's gonna be?