Gatekeeping: The Dark History of Trans Health Care

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Trans people, desperate for treatment, learned to conform at the time to the patriarchal, homophobic standards enforced by the gatekeepers they encountered. Trans people, desperate for treatment, learned to conform at the time to the patriarchal, homophobic standards enforced by the gatekeepers they encountered.
By Leela Ginelle, PQ Monthly At the start of my transition, I recall talking to a friend about my medical plans. "Well," he said, interrupting authoritatively, "before having surgery you'll have to live for a year as a woman, correct?" I bristled at hearing this person, who, by his own admission had never previously known someone trans, confidently recite for me the hurdles that had been laid out in order to align my body to my gender identity. Even at the time, however, I hesitated to blame him, personally. For in our culture, I was aware, it's an article of faith that all people's gender expressions are policed, and that trans people, who must interface with the medical establishment, find theirs policed most vigorously. Why is this so, though? Where did such regulations come from, and why do they persist? The one year requirement cited by my friend, and sometimes referred to as the "real life test" was a part of the now outdated, "Harry Benjamin International Gender Dysphoria Association Standards of Care," named for the man who pioneered trans health care in the U.S. An endocrinologist, Benjamin first began treating trans patients in the 1920s, and wrote with sympathy about the desperation he witnessed in them, the stigma they faced, and the high rate of suicidality he discovered in their community. While Benjamin became a beacon for trans patients over the next few decades, he's faced criticism for his reinforcement of binary norms, and the often patronizing stance he developed with the patients who sought his help. These tendencies only rigidified in the second half of the century for U.S. patients who sought to transition. Due to the widespread public disapproval of trans identities, gatekeepers put great obstacles in the way of their potential patients. For instance, trans people at this time were referred to gender clinics by therapists. Those attaining referrals underwent a two-year "real life test" prior to receiving hormones. A form of hazing, this limited the pool of potential transitioners to those who (a) could afford the therapist and clinical fees, and (b) could exist reasonably comfortably in a hostile social environment expressing their internal gender without the benefits of hormones, ie: those with means who could "pass." This exorbitantly long period also meant trans people seeking relief from their gender dysphoria received none for years. Surgeons played a large role in limiting the numbers of trans individuals who received the treatment they needed, as well. A survey of the Johns Hopkins University gender program, revealed doctors there approved only 24 of the first 2,000 requests submitted for gender confirming surgery. Trans people, desperate for treatment, learned to conform at the time to the patriarchal, homophobic standards enforced by the gatekeepers they encountered. As Julia Serano writes in her book "Whipping Girl," "Most trans women understood that they needed to show up for their psychotherapy appointments wearing dresses and makeup, expressing stereotypically feminine mannerisms, insisting that they had always felt like women trapped inside men's bodies, and they'd identified as female since they were small children, that they were attracted to men but currently avoided intimate relations because they did not see themselves as homosexual, and that they were repulsed by their own penises." Gatekeepers in this period almost uniformly insisted trans people hide their trans identities. Patients were often advised to cease contact with their families, and children, if they had them, change their place of employment, and even the cities where they lived. This forced trans people into shame and secrecy, and eliminated the possibility of trans people creating community for themselves and organizing for their rights. As Serano points out, such demands by service providers placed the comfort of a transphobic society above the well-being of the trans folk being treated. The protocols described above became codified in 1979 in the original Harry Benjamin International Gender Dysphoria Association (HBIGDA) Standards of Care. The standards have evolved, undergoing six revisions since that time, the most recent coming in 2011. In 2007, the HBIGDA changed its name to WPATH — the World Professional Association for Transgender Health. The newest edition of the Standards of Care eliminates, finally, most of what was problematic in the early gatekeepers' approaches. Gone are the "real life tests," the pathologizing language, and the stigmas against same sex attraction. The new standards, instead, place their onus on the service providers charged with alleviating the dysphoria of their patients. My experience accessing medical care during my transition, however, suggested to me that the Standards' long, ugly shadow has lingered within the medical providers' practices. When I sought my first surgery, just prior to the most recent revision, I had to search for a therapist willing to write me a letter, despite my not having "completed" a full year of living in my affirmed gender. Fortunately, living in Portland, I was able to, but I interacted with therapists, ones who advertised themselves as being trained to work with trans patients, who merely parroted the Standards' guidelines back to me, as though that document was a better judge of my needs than I was. Likewise, though I paid for both my surgeries out of pocket in full, my surgeons each anxiously required letters from my endocrinologist and therapist. In each case, they confessed they were worried about accountability, as though their choice to provide the procedure, and my choice to attain it were somehow insufficient, and instead, the Standards were needed to ward off skeptics, particularly those who oppose offering treatment of any kind to trans patients. I don't begrudge a panel of experts, like those who make up WPATH, wishing to suggest best practices to professionals serving the trans community. I do begrudge, though, having been made to jump through hoops, particularly hoops that question my mental well-being, in pursuing the procedures I needed to align my gender expression to my gender identity. Why aren't hormones, for example, sold over the counter? And why do gender confirming surgeries require letters from mental health professionals? Why, at any level, are our genders still policed by gatekeepers?