This is why gatekeeping is important

[Jodie_Lynn]

We're not talking about "choice" here, we are talking about "standards of care". The standards of care are there to establish competency. Responsible medical professionals observe those standards for a reason.

So where is the line drawn? What I can I do to or with, my body, before I require a mental evaluation?

Can I get a boob job? Or do I need someone's approval?
What about a GG who wants bigger breasts, because she feels they would complete her self image? Should she be required to be evaluated? What if, the only reason she wants bigger boobs, is because her husband is always ogling big busted women?

As I said, I am of two minds on this. Certainly, we don't want people lining up for SRS on a whim, but what exact criteria are we looking at here? Does a dysphoric individual have to say "I'd rather be dead than live like this any longer"? That would surely be a down tick as "suicidal tendencies", yeah?

And, with all the furor in the US about hetero shop owners refusing services to gays, what if your "gatekeeper" has strong religious convictions regarding the "weirdos" who want to undo Gods work? You could be denied your fulfillment, simply because someone else has "moral" reservations.

In the US, we have civil servants refusing marriage licenses to same sex couples; elected officials stating that gays should be "killed out", and a rise in violence against LGBT citizens. Are you going to tell me that ALL medical personnel are free from religious and/or organic homo/transphobia?

Basically, what I am getting from this discussion is that: I could live my life, 24/7 as a woman, with ID's to match, with no problem. BUT, once I decide to turn my "outie" into an "innie", I need psychiatric approval and guidance.

Does no one see a dichotomy in this?

[Nikki.]

Why are the standards of care for elective surgery to modify one’s body different for transgender people than cis people?

Assuming you’re referring to the wpath soc, page 40 of the 2012 edition (which is ancient considering the date of change regarding trans identities, mostly i believe is due to the exponential rate of people coming out, including gender non conforming people) states:

The criteria for hormone therapy are as follows:
. Persistent, well-documented gender dysphoria;

but then goes on to state:

“A number of community health centers in the United States have developed protocols for providing hormone therapy based on an approach that has become known as the Informed Consent Model -snip- These protocols are consistent with the guidelines presented in the WPATH Standards of Care, Version à. The SOC are flexible clinical guidelines; they allow for tailoring of interventions to the needs of the individual receiving services and for tailoring of protocols to the approach and setting in which these services are provided (Ehrbar & Gorton, "àà).

Essentially stating you should have GD to get the ‘mones, but if you don’t, we’re ok with that too.

And even if they didn’t, why can’t a person capable of making a well informed, rational, sane decision
decide to modify their body to appear closer to that of the opposite sex? Why should any other person have the authority to overrule another’s autonomy and self determination?

I’m ignoring health insurance coverage for the sake of the thought experiment.

[SIZE=1]- - - Updated - - -[/SIZE]

Megan, you went from having a reasonable discussion to reductio ad absurdism. A more reasonable comparison might be a petite woman who wants a huge set of bolt on’s that will cause adverse health effects, or a guy that wants a surgical penis extension just because.

[Jodie_Lynn]

Thanks for the supporting documentation Nikki!
I was definitely posting from the emotional centre.

[AllieSF]

Megan,

I greatly appreciate what you do and from where your opinion comes from. However, you are talking about that rare minority, unless you can provide some valid studies or statistics, who make some serious mistakes along their own life path. Paula was not talking about pain killers and more and your comment insinuates something that was not there. She is talking about the right of an adult to decide what body altering surgery they may want done to deal with their dysphoria. Abortion though not necessarily body altering is a decision that a woman has the right to decide without third party interference, unless doing the procedure has a significant risk to her. Should we put more gatekeeping on that, and just who would be those gatekeepers and who sets the rules for the gatekeeper to follow? Going down that road to much stricter gatekeeping would be opening a can of worms and end up reducing the rights that trans people have been fighting so long to have in order to just be themselves in peace and probably have only a minimal to zero positive effecoverall to the current situation here in the USA.

Third party gatekeeping can save lives and can also kill some. I bet there are very few if any statistics on how many transgender people who may have hurt themselves, killed themselves, suffered unnecessary mental pain and anguish, and maybe even irreparable mental/emotional damage when denied transgender care and surgeries because the gatekeeping system did not work or took too long. Under Informed Consent there is gatekeeping to get to the necessary referrals and mental health letters to convince a qualified doctor to perform the surgery and to eventually get insurance coverage to those that can afford that. All of the known GRS surgeons in the USA and overseas follow WPATH standards of care, so there is another part of the gatekeeping process in the Informed Consent model. I did that Informed Consent route with an LGBTQ+ clinic, Lyon Martin in San Francisco. They see people like me everyday and I feel confident that they are not just out for the money. Besides their Hippocratic Oath, they have their own reputations on the line every time they write a letter for GRS. That is gatekeeping. If you want to fine tune that system I will happily listen to your recommendations. However, to go to an overtaxed (not just to the taxpayer), bureaucratic, overly strict system that some universal health care systems have can, and is, causing more harm than they should. Why add fuel to the fire when looking at what our current Administration is trying to do to our Civil Rights, let alone our medical rights?

[Aunt Kelly]

You can call it what you want, in this case "standard of care",but we are talking about choice, the gate keeping has nothing to do with the standard of care, it has to do with deciding who can and can not alter their own body.

You, as well as several others here, have it backwards. Let me explain.

One of the first medical terms that a physician learns is "primum non nocere", which means, "first, do no harm". It is a fundamental tenet of western medical ethics and the reason that standards of care are established. So this is not about "deciding who can and can not alter their own body." It is all about deciding whose body the caregiver will modify. That decision is for the caregiver alone to make. Reputable caregivers will try to adhere to standards of care, for they are the ethical and legal frameworks that guide such decisions. "Because the patient wanted it..." is an utterly indefensible rationale for deviating from the standard of care.

[Jodie_Lynn]

That decision is for the caregiver alone to make. .

So, as a responsible, competent adult, I cannot make my own decisions regarding my own body or self image?

[Terrylynn]

While reading the responses, I remembered show on TLC that profiled a transabled individual, who from the age of 7 or 8 felt increasingly uncomfortable with having 2 legs. He tried mightily to deal with this issue but eventually decicided to pursue surgical removal of one of his legs. He had a very difficult time finding a surgeon who would remove a normal, healthy leg. Eventually he found a surgeon willing to amputate one of his legs. He had the surgery and seemed content with his choice. To me his decision was totally irrational. Was he mentally fit to make such a decision? What if he was refused surgery? Would he have standing to sue the doctors who refused to amputate his leg. Should a patient have the righ to force a doctor to violate the Hippocratic oath? Where should the line be drawn?

[Nikki.]

Yes, extreme body dysmorphia is a common contra argument anti trans people make in regards to transgender related surgery. They are unrelated and treated very differently by the psychiatric and health communities.

[Aunt Kelly]

So, as a responsible, competent adult, I cannot make my own decisions regarding my own body or self image?

I did not say that. I said that a caregiver's decision to pursue a given course of therapy is his/hers alone to make. The patient's desires should factor in, but only insofar as they do not cause a deviation from the standard of care.

You, on the other hand, are perfectly free to pursue whatever body image you want. We all are, but it is inaccurate to assert that this or that procedure or medication should be ours simply for the asking. No one is obliged to do something medically unsound just because the patient wants it.

Damn... Why is that so hard to understand?

[AllieSF]

Kelly,

That is an interesting answer. If I understand you correctly, a person is "free to pursue whatever body image " they may want. So, taking that as stated, if a person is successful in their pursuit does that mean that while most doctors follow standard practices of care with WPATH being one for transsexual individuals, there is no need for tightening current USA Standards or Practice to be harder to obtain those surgeries as Megan prefers (again my understanding of her posts)? Since it also seems like the WPATH recommendations are just that and that they have left some room for deviating from their own recommended standards, why do we need to change what we have, which seems to fit in well with the Informed Consent concept here in the USA? Are we discussing something that needs not be discussed? Megan, you input is welcomed here too.

I agree with your statement, "No one is obliged to do something medically unsound just because the patient wants it.". However, if a person is successful in their pursuit for body changing surgeries (BA, FFS and GRS) and they find a surgeon to do them, it appears that the existing Standards and recommendations with their room for deviation from that standard would work. Right? If something goes wrong with the surgery, or the patient later has second thoughts, that becomes their issue and they have to deal with it as best possible.

I went through gatekeepers, which I believe are right for me, but apparently not hard enough for some. I cannot speak for Jodie Lynn, but if I couldn't find a good recognized surgeon for my desired procedures, I would not look for someone who specifically does not follow the system, so to speak. Only if a very good doctor did not follow the current gatekeeping system, maybe because they work out side of the developing world like in Thailand, Argentina, Brasil and India, would I possibly consider them because their already good reputation and future incomes depends on having a successful record for good outcomes from their surgeries. It would a lot of extra research before deciding.

[Nadine Spirit]

Interesting discussion.

Recently I got an orchi done. Prior to it, I jumped the gatekeeping hoops. Most surgeons told me they would require 4 letters for my procedure. 1 - therapist, 2 - hormone provider, 3 - psychologist, 4 - cardiac clearance. Where my problem popped up was with #3. I contacted a well known psychologist who informed me that they would not provide my letter unless I proved to them that I had 1 year of Real Life Experience. In discussing this point with them, I upset them with questioning what exactly is meant by RLE. And whether or not my 15 years as living as an openly transgender person, though not having transitioned, counted towards any part of that year of RLE. They became upset that I questioned them, and were personally insulted as they were a part of creating the Standards of Care. Once that person was challenged, they told me that they refused to work with me anymore and would not provide me with any surgical referral.

My therapist informed me that for an orchi, the SoC did not require a psychologist letter, cardiac clearance, or any RLE, and that further more the SoC are recommendations. Why the deviations brought on by the surgeons requirements? We do not know, but most surgeons informed me that their malpractice insurance required it. Not the SoC, not them, an insurance company who interpreted and modified the SoC has set new, and stricter, requirements. For the best care of the patient, or for a protection of their bottom line? Money was the concern, not human beings.

Anwho..... from the SoC (all quotes taken from pg 2 of v7 of the SoC:

The SOC are intended to be flexible in order to meet the diverse health care needs of transsexual, transgender, and gender-nonconforming people.

As in all previous versions of the SOC, the criteria put forth in this document for hormone therapy and surgical treatments for gender dysphoria are clinical guidelines; individual health professionals and programs may modify them.

The SOC articulate standards of care but also acknowledge the role of making informed choices and the value of harm-reduction approaches.

So..... it is not SoC or informed consent. The SoC provide for informed consent as a recognized path to receiving transgender related medical care.

The reality of our world is that while some people receive procedures when they shouldn't, the vast majority of the difficulties for trans people are not open access to health care, but extremely limited access to health care.

[Megan G]

My comments about pain meds was just a quick and simple example of where a normally competent and cognitively aware person can make long lasting and potentially dangerous requests/decisions about their healthcare. They are in pain and it is that negative stimulus they feel that makes them make poor and irrational decisions sometimes...

And just an FYI reproductive gatekeeping does not just exist in gender reconstructive surgery. I know two women who are adamant that they do not wish to have children....EVER. They have made repetitive requests to doctors and surgeons to have surgery but every single one has placed a timeframe on them.... we will not do it now.... wait until your “XX” age and then if you still want this we will do it then...

Regrets are real.... and as i said before sometimes we as medical professionals must protect the patient from themselves....like it or not....

[Teresa]

Meghan,
I am still with you on this subject , to question someone who has had both hands on experience and also transitioned herself makes little logical sense . Just because we are adults doesn't mean we are all sane of mind . While you haven't mentioned the state of this patient's mind which is perfectly understandable he is in this difficult situation because he was allowed to chose and possibly ignore medical advice . So now the family have to pick up the pieces .

Nadine comments on the precedure she went through , she took some to task because she felt they were wrong but the important point is the procedures were in place for everyone's guidance , maybe they handled it poorly but at least the correct steps were in place . Total free choice without these guidelines is madness .

[AllieSF]

"Total free choice without these guidelines is madness ."

I guess that most of us discussing this interesting topic on the side of Informed Consent are being misunderstood. I do not believe that we are all in favor of total free choice. I believe that we are in favor of Informed Consent and the currently encountered gatekeeping that we encounter along the way, at least here in the USA. I had my therapy and medical appointments with medical professionals and based my decisions on what they recommended and/or approved. I was informed of the good and bad of what I needed to do to get where I wanted to go. They consented to what I wanted to do because I was informed, and what I wanted was just the standard process of transitioning from male to female.

I didn't need to wait 6 months to see a medical professional who acts as my gatekeeper to actually start seeing a qualified government paid (through tax payer payments) therapist another 3-4 months later. I also did not need one year of Real Life Experience, an antiquated approach required by some health providers. Some may need this, but definitely they are in the minority. How long does it take to get on hormones, then maybe an orchiectomy, or BA or FFS or GRS in a system like that? Maybe if they were properly funded they would provide more timely service and trans patience would not need to get suicidal before actually being cleared to talk to a therapist. But they are not and the needy patient, especially the trans patient.

That is not gate keeping. It is putting the trans patient at the back of the line and justifying all the delays as Standard of Care requirements. Good therapy should uncover the ones that may need more time in therapy before starting some of those first hard to reverse steps. That is gatekeeping and that is good. At the same time if someone knows what they want, are informed about what they are doing, and really do not need much, if any, therapy, then there is no reason not to move them quicker to the results that the want and know are best for them. Is this a perfect system? No! However, in this system errors are rare like the one that started this long discussion, and was it even the system's error or good lying on the part of the patient? Some things, like the rare lying patient, are just too difficult to catch.

[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.

[Nikki.]

Lea, John Hopkins probably isn’t the greatest example given Paul Mchugh, and David Reimer for that matter.

I agree with you today’s screening isn’t really comparable to what took place in the 60’s-80’s, and I do believe there should be rigorous screening for mental health conditions that preclude people from making a rational, well informed choice. I’ve encountered more than one person who was clearly exhibiting symptoms of schizophrenic psychosis tell me they were transgender. And while maybe they were, they were not in any position to make a choice regarding medical decisions.

Ultimately I think it should be equal treatment for cis and trans people for elective surgery, outside of insurance payment justifications. If a cis person wants a breast reduction or enhancement, male or female, the same screening should apply. Same for plastic surgery to the face. I’m glad RLE doesn’t apply for ffs anymore- that seemed torturous for someone with obvious male features who wanted to go stealth- if you can deal with a year of hazing, you’re in.

Since SRS isn’t a concern for me and i haven’t really thought about it, I don’t really have an opinion as to the screening or wait period that should be required. I doubt there’s any way to ensure zero post op regrets.

And yes, I get there are liability concerns for the medical industry, and some people refuse to take ownership for their mistakes, and ambulance chasers persuade some of them to sue. And following some sort of industry standard standards of care can aid in limiting liability.

[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?

[LeaP]

Lea, John Hopkins probably isn’t the greatest example given Paul Mchugh, and David Reimer for that matter.

LOL! Touche! The point, of course, was rhetorical.

...

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.

...

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.

So well said.

[Jin Xer]

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

Yes, I too, would like to know.
It sounds like you're referring to work by a guy named Ray Blanchard, who coined the word autogynephilia, which posits that transgenderism is mostly driven by sexual desire, not identity. He has a lot other theories which sound like they're straight out of Freudian doctrine. His work has been met with critical response by LGBT activists, with even WPATH rejecting his work and association with the DSM.

This subject has been discussed in the past, but I get the impression you have a very strong opinion in favor of it. I don't quite know what your post has to with this thread, except I think you just insulted many of the transgender members on this forum.

Here are a couple of links in case people want to read up on it.
Wiki links:
Ray Blanchard
Blanchard's autogynephilia theory

From the International Journal of Transgenderism:
The Case Against Autogynephilia by Julia M. Serano

I want to say I've immensely enjoyed reading this thread. I wish there was a like/thumbs up button. Lots of good talk and numerous opinions.
Jinny

[Kaitlyn Michele]

Ultimately I think it should be equal treatment for cis and trans people for elective surgery, outside of insurance payment justifications.

Well then its not equal treatment

Cis person wants plastic surgery Not covered
Trans person wants gender conforming (plastic ) surgery... covered...

on what basis?? and if there is a basis.(I think there is)

What are the standards to determine that basis? Who decides and how?

Why do we get special insurance treatment at all?

A woman wants bigger breasts or a cosmetic procedure on her vagina to feel better about herself... even FFS if she is very masculine and it makes her feel terrible all the time
you can she she wants to to feel more like the woman that she is..

why are we more important than her? she may have body dysphoria too...

we are not special.. if we want medical procedures they should be available in a way that protects us from harm as best as possible... just like everybody else.

Gender dysphoric people can be very vulnerable and I think its irresponsible to suggest they should ALL have free and unfettered access to any surgery, they should be protected by standards of care that help providers to do no harm

[Nikki.]

My statement was to qualify I was specifically not addressing payment for services, only the control of or permission to access them.