This is why gatekeeping is important

[Megan G]

So i have always been a supporter of gatekeeping, i know many view it as bad but honestly what i seen this week is a perfect example of why it is so important.

So i am a nurse that works in a specialized unit at my local hospital.... and i am going to be vague to protect confidentiality... i had a patient admitted to me that honestly looks like Santa Clause but years ago he transitioned privately... in a manner that his family did not know.... he was on HRT and had GRS.... but for some reason he never did transition publicly. He remained living as a man but altered his body. When his breasts grew too large to hide he had surgery to have them removed. This is a failed transition..... and he kept it from his family...

But here he is suffering from a debilitating health issue and i will be discharging him shortly with his family being responsible for his personal care.... and they have no idea he has a vagina or did any of this stuff to himself....

So this is exactly one reason why gatekeeping is so imperative... this is why RLE is a must.... why full time means 110% of the time.... because one person did something he regretted and his family is about to get the shock of their life.....

They say regret is rare? I call BS as this is the first trans person i met since i started in healthcare a year ago....

[Aunt Kelly]

Megan,
Thank you so much for sharing this sad story. I dearly hope that it serves as a wakeup call to those here who are considering irreversible steps to "be more feminine". None of those steps are without risk. For the life of me I can't understand why someone would go through all that, just to hide it. The medical community let this patient down, IMO.

[Lana Mae]

Yes, there must be gatekeeping! Sometimes it is missing but sometimes people don't use common sense! Don't start HRT on your own! Doctor's supervision should be a priority because of the levels and side effects! You need to be following some kind of guidance in all of this; such as WPATH! As one wise doctor said, it is a slippery slop and not for the faint of heart! A sad reminder of what can happen if we are not careful! Hugs Lana Mae

[Nikki.]

There isn’t enough information provided to judge if this was a failed transition. Maybe they shared more but you feel like you can’t share, which is fine. To me it sounds like a person who medically transitioned but didn’t want breasts. I don’t get it, but it’s not my life. Did they express regret to you over having srs?

Why can’t someone want to look like santa claus but prefer to be female bodied? There was an occasional member here who often spoke about having DD breasts, a baritone voice and not socially transitioning. They seemed to be content with their life and body, singing in the church choir, etc.

Why should one human have control over the body altering decisions another can make, assuming no mental illness(including dysmorphia)?

[LeaP]

Megan, thank you, and I agree with you.

[Megan G]

There isn;t enough information provided to judge if this was a failed transition. Maybe they shared more but you feel like you cant share, which is fine.

I can’t dive deeper into this to protect confidentiality as if someone could pin point this to him i would loose my job and Licence. I wish i could but can’t.

With me being one of his nurses, him and I have talked, and i have access to full medical records so i know the back story. This is a failed transition and that’s all i can really say.

The reason i shared this is while yes i don’t spend too much time here what I have noticed the last little while is more and more people doing serious medical things behind spouses backs and so on... it is my hope that with me sharing this story may give someone a wake up call back to reality.

Transition is not a joke.... altering your body and trying to hide it from others is not avoiding a difficult conversation.... it is just pushing it to another time and like this man it’s going to be way worse of a conversation now...imagine suddenly finding out your loved one was not who you thought they were.... and even worse.... they felt they could not share that with you. They will be devastated, angry and very confused....

No one ever thinks that someday a health issue could pop up (car accident, heart attack, stroke) and suddenly your family members may become your personal care givers in an very personal, intimate and embarrassing way....

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The medical community let this patient down, IMO.

I’m don’t share that opinion but do respect it and the reason i say that is everyone pushes for informed consent. ( just look at the topics here on it). Everyone is in a rush to start HRT and other steps.... they want to skip the gatekeepers and are very quick to sign their life away just to start it. What they miss in that process is the tough questions. I never once asked my psychologist to tell me that i am trans... that i am a woman... i did not want easy.... i told her i wanted her to push me... ask me the hard ones... make me work for it, make me uncomfortable....make 110% sure I was before i did anything i may regret.

So i don’t blame medical community, i blame the community for screaming to the mountains to get gatekeeping removed totally as honestly once i started HRT (6-7years ago?) there were zero barriers to catch a mistake... only dotted lines to sign on.

In the end the person responsible is the patient...

[Nikki.]

I kinda figured. Sounds like a pretty sad story.

For the record, because I think it’s important to know where people are coming from, to me it’s way more important to be out and known as a trans person than it is to physically transition. Being in the closet has been the most anxiety provoking part of my almost 50 years on this planet. So much so that I’m out in most aspects in my life, though I present male most of the time currently. I’m the queue for ffs(about a year out) and have been on hrt for 9 months. This has given my spouse and family plenty of time to adjust and so far so good. I id as nb with a femme gender presentation.

I could have easily lied my way through the gatekeeping. I could lie today about fte and my therapist wouldn’t know. I didn’t, but plenty of people did in the past, learning the right script to spout to talk their way into srs, way before the internet. Gatekeeping has a history of transphobia and sexism- CIS men determining who could and who couldn’t transition based on physical attractiveness and passability.

Other than ensuring no significant mental illness that would interfere with making a rational informed decision about altering one’s body, I don’t believe in it. But I could be convinced otherwise if one could control for the above

[Nadine Spirit]

I hear what you are saying Megan.... and I have great sympathy for the choices that man made, but I believe in everyone's right to chose their own path.

Nobody seems to care if cis people will regret their surgeries. A large number of cis people who have cosmetic surgery end up regretting it, but society as a whole never seems too concerned about those people. However, even if a small number of trans people regret their transition, it is always too many. Some hold a fictional belief that if we put enough steps in place we can get that number to be so small that we as a community will never have to hear of anyone who ever stands up and says they regret it.

If there are not equal gatekeeping practices associated with every elective surgery, gatekeeping with trans care is discriminatory. I believe in freewill and equality.

[Ineke Vashon]

Permit my naive question: What is Gatekeeping?

Ineke

[Dorit]

Permit my naive question: What is Gatekeeping?

Ineke

I believe Gatekeeping is a word that describes a health system that has professionals deciding whether or not you qualify for certain medical procedures.

The US with its unique, entirely private health care, seems to have informed consent for just about anything medical. This is more or less the opposite of gatekeeping. Israel has a state funded health care system, there is no such thing as informed consent here. You cannot have a prescription for HRT without a psychological evaluation and the approval of one of the endocrinologists that specifically deal with transgender patients. In order to qualify for SRS you have to go through about eight months of evaluation, including a psychiatric assessment. The disadvantage to all this gatekeeping is there are long waits, but the advantage is that besides being cost free there would be no examples like Megan brought up.

This is a tragedy, but I hope that the person involved will eventually find acceptance and love from his family.

[Jin Xer]

I think I'm with Nikki on this one. You've made some generalizations which I would challenge.

From what you've written, I think it's more of a personal issue between the patient and his/her family. Difficult indeed, but I don't consider it a rally cry for more regulation.

[Teresa]

Meghan,
While I appreciate the confidentiality of your patient . Is is a correct assunption he lived alone rather than in a marriage with children ? The family you refer to may be parents ( if still living ) and brothers and sisters . It sounds almost impossible to transition being a husband and father without them knowing .

It is a sad case , is it an obvious assumption the transition didn't satisfy the dysphoria ? Despite all this I hope he does get the full support and care from family and friends if his health is not good and may not fully recover .

I'm wondering how many mores cases may be happening similar to this , as it is possible to find somewhere in the world where very few questions are asked as long as the money is up front .

Dorit,
The UK has the same system within the NHS , so the waiting times are long and getting longer , speeding the process up in private clinics still requires the basic giudelines .

[Paula DAngelo]

First let me say that I understand the reasoning behind gate keeping. Having said that' I have to also say that I disagree with it. The way I see it there are only two things that need to be addressed before approval should be given. First am I mentally fit to make decisions about my self, and second do I have the mental capacity to understand the impact of my decision. This is my body, my reasons for wanting to modify it are really my business and mine alone. People have elective surgeries all the time and don't have to convince others that their reasons are valid. Now if insurance companies want to have guidelines/gate keeping in place to insure that a procedure is medically needed that is a whole different thing as they are now footing the bill as a medical necessity as opposed to an elective procedure.

Let's be fair about this, if something is elective then it should be treated the same regardless of what it is, and if it's a needed then again treat it the same as any other need procedure.

[Jodie_Lynn]

A tragic story indeed.

And a very complex issue, or ball of issues here, and I find myself of two minds.

Question: at what point in time do we have authority over our own bodies? I'm not talking about legal rights of minors, but rather, when does a self-reliant, functional adult human have the right to alter their own body?

Where is the line drawn that says 'you can do this, without authorization, but not that'?

People have cosmetically & surgically altered their bodies in every way from split tongues, nose jobs, tummy tucks, boob jobs, and some have altered their bodies in even more extreme ways (google 'the human Barbie'). There are even GM's out in the world who have submitted to voluntary castration! Not just a vasectomy, but complete removal of their testicles, and not because of any ailments. No one had to give them the green light to have 'permission' to make their own appearance fit how they saw themselves, or how they desired to see themselves.

Are all of those people without regret? Probably not. I'm sure they have days when they look at themselves and say "WTF was I thinking?!?!"

In fact, the only reason I can see the need for a gatekeeper, would be in the case of medically assisted self-termination.

[Teresa]

Jodie,
In the UK under the NHS they may look at it as who now picks up the pieces , is it gatekeeping or sensible guidance ?

[AllieSF]

I am with the con to strong gatekeeping. I like what Nadine, Jodie, Paula and Nikki have stated. I think that as with any type of elective surgery there will be the exceptional regret, or maybe highly complicated life styles or feeling after. I appreciate your need for privacy, but am wondering, did this person regret "everything" that they have done, or is just the facts of their case? I am pro minimal gatekeeping. I am 72 years old, and would hate to be under the NHS or any other similar gatekeeping medical service control. That is way too much over control and wasted time for most needy adult trans patient. I did therapy, minimal, I have my letters from a therapist and a psychologist, both working in the trans area. They know how to pick out most of those who need more therapy an on hormones. I had an orchiectomy and am getting BA and FFS in the future. I do not need gatekeeping's unnecessary delays. I need to be able to live my life as I chose if that does not physically harm nor break any laws. Life is too short, especially when you can see that bright light at the other end of life's tunnel.

How many true regrets do trans people have when compared to other people when choosing how to live their lives? Since we do not have accurate statistics about a very personal and private sides of our individual lives, most of us who wonder can only reply on sites like this, Susan's Place and other similar ones, few actual professional studies, which usually have a limited number of participants and one's own interaction with other trans people. I only know of one MtF woe transitioned back to their birth defined gender.

So, as with anything in life we decide, get results and then, if necessary and able to, we make another decision and get new results and so on.

[Aunt Kelly]

We're missing the point here, folks.

Here is what we know. The subject under discussion had GRS and, at least, bottom surgery, in order to feminize his body. He never transitioned, choosing to live his life a male, despite the body modifications. The subject then had at least one surgery to undo some of those changes.

IMO... Given the choice to surgically erase the visible breast size, it is reasonable to assume that there was at least some regret. This is further supported by the subject's choice to never transition. Making permanent changes to your body without considering, understanding, and accepting the consequences is not exactly the sign of an healthy psyche.

May I posit another angle... The subject, having managed to achieve the physical changes he did, found the prospect of transition too daunting, personally, professionally, or socially, and made the decision to retain the advantages of his straight male status. I don't know, but I think that might be a still sadder story.

Regardless, it is folly to equate this person's case with tatooing, piercing and other "body modification". Those things are done for the sake of themselves, as a form of expression. This was not that. Not by a long shot.

[AllieSF]

Kelly,

I was not even thinking about tattoos, nor piercings in my reply. I have met several cis-women who had BA and then years later regretted the extra size and projection as they mature. My daughter in law is one of them. They were not concerned about medical issues when the implants were removed, except for the risks associated with any surgery. I have also met other people that regretted having a doctor recommended medicinal or surgical treatment that resulted with them getting the negative results or side effects cautioned about. I had that happen with my prostate cancer removal. There were several options for treatment, two of which involved surgery. I picked one to avoid the side effects and, whether due to my physical anatomy or my doctor's precision during surgery that day, I was prevented from avoiding those side effects. Did I have enough gatekeeping, do enough research prior to selecting what to do? I think that I did.

I understand the seriousness and possible or probable reasons for the issues for this person. With the number of potential side effects from medicinal and surgical treatments for most issues, many, many more people would be dead if never given the opportunity to try those treatments. Most of us agree here that gender dysphoria can be a very serious and dangerous issue for some and the treatments for it carry certain risks. However, they should not be unrealistically withheld due to some overly strict, bureaucratic and overloaded health care system in the UK, Canada, USA or other place. If you need the therapy and psychologist letters for GRS, then to me that is enough. Let those specialists do their work realizing like any other treatment, emotional, mental or physical, some will unfortunately slip through the cracks, or will pay unscrupulous providers to let them through those cracks.

The person in question is being used as an example to maintain strong gatekeeping where it already exists and to promote for stronger gatekeeping where they do not. I disagree with the "strong" part of that.

[kimdl93]

Totally agree that gate keeping is important. I don’t know what this person’s situation was, but clearly going to such extent as GRS.... I don’t know if the medical community failed this person or if he made efforts to circumvent safeguards. Perhaps a bit of both

[Mirya]

Two years ago, at Susan's Place, there was a man who detransitioned. Before his detransition, he genuinely believed he was a trans woman. He posted literally hundreds of times at Susan's Place and was very active in the trans community. He even went on a TV talk show (on BBC1) and publicly defended trans rights as a trans woman on television. I remember watching the YouTube clip of that - he was quite articulate on camera and presented as a woman very well. He had HRT, FFS, and orchiectomy. He worked with therapists. He even had the support of his wife. It's not like he was doing this in secret. And he lived in the UK, which I think has proper gatekeeping, right?

Anyway, after all of that, he realized it was all a huge mistake. He deeply regretted his transition to female and desperately tried to find a way to transition back to male, and find ways to get testosterone again. He realized that his female gender identity was actually a false identity - a false persona that he had subconsciously created as a reaction to childhood abuse and adult trauma. KellyJameson mentioned this possibility when she brought up her comments in post #21, earlier in this thread. There is a lot of truth in her post:

Identity when exposed to trauma is very malleable. Identity when exposed to mass hysteria is easily disrupted. Individual identity is fragile.

Identity can be subservient to sexual arousal in that a person can become (Identify with) that which they tie sexual pleasure to. This makes gender identity an attribute of or expression of a sexual fetish.

This creates many different paths to identity.

We tend to be arrogant in thinking that we as our identity are concrete and resistant to change.

This could not be further from the truth.


Gatekeepers are very limited in what they can do because those who are most at risk for self harm through transitioning are also the ones most likely to circumvent the gatekeepers.

I agree that gatekeepers are limited in what they can do.

I don't know if I'm allowed to post links to Susan's Place, but if you're interested in reading the relevant threads there, where this man posted about his journey, send me a private message and I will send you the links. All of his hundreds of posts are still there and you can read his entire journey through his post history from HRT to orchiectomy (which he was so happy about after he got it) to despair at making the wrong decision about transition to anger at the system failing him, and deep regret.

[LeaP]

In the US, at least, physicians (incl. surgeons, of course) work under a variety of oversight organizations, committees, boards, etc. that impose and standards of care. Some of the SOCs are guidelines (WPATH is a good example). Some are legal (abortion regulations, though not often thought of in this way). Some are held to a review standard that can affect licensure, board or society membership, hospital privileges, professional status and seniority, prescription writing, and a whole lot more.

An employed physician in a large organization such as a major hospital or major practice will typically be the most restricted - or perhaps better managed and guided is a better characterization. There's a reason that patients prefer to go to, say, Johns Hopkins, Mass General, the Mayo Clinic, etc. when they can. The standards under which they manage care are a major factor in their outcomes statistics. A patient falling outside their SOCs may still receive their specialized, high-quality, and (usually) expensive care, but the case will have to be presented and pass review. Such decisions, reviews, case histories, and the SOCs themselves are routinely examined in exhaustive fashion by insurance companies when claims are made, boards and societies when complaints come before them, and the courts and arbitration panels when the lawsuits kick in.

The "Informed Consent Model" (which is not the same as simple informed consent) is not, some opinions to the contrary, a wholesale replacement for SOCs (or elimination thereof, roadmap around, risk transfer mitigation of, etc.). Nor are physicians drug and surgery order-takers. Patients go to physicians and practices for THEIR services, which most definitely include the various regimes under which they practice, and not for ala-carte medical whatever. If you can get a BA without therapy, letters, etc., it's because the relevant standards allow it.

Now a physician in an individual practice can do pretty much what he or she likes, following their own professional judgement. It's up to you whether that's rainbows and unicorns or Doc Henry's Operatin' Place where they (usually) wash up before cuttin'. There's some gems and geniuses out there along with the ones that pop up on the Plastic Surgery Gone Wrong shows!

Last but not least - gatekeeping is a very perjorative way to characterize today's care, which is easily available, exceptionally transparent, and consultative. Patient desires are not only heard, but care standards often give special attention to them. The term "gatekeeping" as applied to trans people comes from a time when care barriers were monumentally difficult to overcome and the number of those who passed them were vanishingly few.

Good luck with your Informed Consent Model piece of paper. I'll take the road more traveled.

[Laura912]

As one who has sat on the other side of the desk, I appreciate Lea’s comments.

[natasha]

No system is perfect. It doesnt matter what it is, there will always be exceptions to whatever is being contemplated. Society in general likes to point out an anomaly as being representative of the whole.

[KellyJameson]

There are examples on this forum similar to the one posted at Susan's Place.

There are many reasons other than gender identity as drivers of transitioning.

Internalized homophobia is one example and it has at least two expressions that I have encountered.

One is the "MtF" that transitions to "Normalize" sex with men so they are not confronted with their own internalized homophobia.

Gay men often distain the MtF who they believe has transitioned for exactly that reason. As an act of cowardice.

The other is transitioning to have sex with "Straight men" so the person feels validated as being normal because they feel abnormal as a gay man.

In both cases this is about sex and not gender identity.

Another example is the crossdresser who wants their own breasts not as an expression of identity but as possession of that which they sexually or psychologically desire for reasons that have nothing to do with gender identity. This is an extension of the sexual objectification of women's bodies.

Eventually when the bodies start to stack up the gatekeepers will return in force and those with cross sexed gender identity will pay the price.

This forum as taught me much about men. You see the display of authoritarianism and dominance as an expression of testosterone and social conditioning on display here all the time. Always presented as the expert who distributes the wisdom that only men can know, especially him.

Until I joined this forum I did not realize how many straight men place women on a type of pedestal where they see her as something superior to men simply for being born a woman. A goddess in need of being worshipped.

I see it as a inverted form of misogyny driven by contempt for men including themselves as well as a fear of the power women have over them.

In this world women are either virgins or Wh...es and nothing in-between.

In my opinion there are very few people transitioning as a innate biologically formed gender identity at cross purposes to their body.

An identity that was thrust upon them like a curse not sought out as some form of achievement.

[Jodie_Lynn]

@KellyJameson: Is that your personal opinion, or do you have references to cite to support your claims?