The problem with gatekeeping

It might be surprising that as someone who is concerned about unnecessary gender transitions, I also oppose the gatekeeping system as it currently stands. For those who are unaware, the “gatekeeping system” is the process by which letters from therapists are required for transgender people to proceed with hormone therapy, or genital surgery. This process has become steadily more relaxed in recent years, as the “informed consent” model has become more popular, at least for hormone therapy. This system causes more harm than good for several reasons:

There is no gate to keep

There is no point in guarding a gate when there is a large hole in the wall next to it. There are always going to be therapists that are willing to write letters to anyone, and doctors that are willing to prescribe hormones to people without therapist letters. People can simply find out about these providers through word of mouth, and go to them if they want, at least in most major cities.

There are no evidence-based criteria for gatekeeping

The ostensible function of gatekeeping is to determine whether a person is an appropriate candidate for treatment, and to prevent those who are inappropriate candidates from having treatment. When I went to see a therapist about these issues, I was prescribed hormone therapy after just 2 sessions! Years later I was quite angry about that, as I thought of it as malpractice, and that my problems could have been avoided if it wasn’t for that. Then when I began to study to become a therapist, I was shocked to discover these criteria don’t exist at all! I attended four different trainings on therapy for trans people, and there were no criteria for evaluation discussed! There was a lot of discussion on cultural competence, and the issues that commonly arise, which is good, but no criteria for evaluation. Neither the DSM-V or the WPATH standards of care contain such criteria. The DSM-V criteria essentially state that someone has to be uncomfortable with their gender for at least 6 months, and the new WPATH standards expressly state that “Psychotherapy is not an absolute requirement for hormone therapy and surgery”. This means that therapists either use no criteria, or arbitrary criteria, both of which are problematic.

The use of no criteria or arbitrary criteria are both problematic

The use of no criteria is problematic, because it creates a kind of false endorsement of a person’s trans identity. I have heard several people argue to unsympathetic family members that they are “really trans” because their therapist has “diagnosed them with GID / Gender Dysphoria”. I used the same argument with my family when I first transitioned. This can choose to erase doubts in people’s minds about their gender and help to push them into transition. When as mentioned above, the diagnosis of Gender Dysphoria only means that one is distressed by some aspect of their gender, which they already knew, or they wouldn’t be seeing this therapist at all! If we lack diagnostic criteria, we should neither endorse nor oppose transgender identity and be honest about that fact.

The use of arbitrary criteria is also problematic. These arbitrary criteria are often based on gender stereotypes. Some criteria that were used in the past for MTF transsexualism include whether the person was exclusively attracted to men, or wore dresses and skirts. There were even male therapists that chose to determine whether their clients were “really women” based on whether the therapist was sexually attracted to her!

These arbitrary criteria lead clients that want treatment to simply lie about fitting these arbitrary criteria in order to get what they want. Besides being wasteful and unnecessary, this undermines any potential therapeutic relationship as the clients don’t feel safe in telling the truth to their therapists. Fortunately, this is happening less and less.

Gatekeeping creates a dual relationship which prevents healing

Dual relationships (when a therapist has to play multiple roles with the same client) are frowned upon in psychotherapy, although it is recognized they are sometimes unavoidable. When the therapist has to play the role of the gatekeeper it creates an immediate conflict. As gatekeeper, the therapist should be playing an evaluatory role, while as therapist they should be playing a healing role. In order to create a good therapeutic relationship conductive to healing, the client should feel safe, open and free to express what is on their mind. If the client wants something from the therapist, this will not occur, and the client will censor themselves acting as an impediment to healing.

This is doubly important in the case of trauma, where the client’s being in control is part of the healing. Part of trauma is not being in control of what happens to you, so being in control of the pace and the choice of whether to explore the trauma is important to healing. The gatekeeper relationship creates another situation where the client does not control things and this can add to the trauma rather than heal the trauma. People might disagree as to whether trauma plays a role in transgender identity formation, but almost everyone would agree that there is a lot of trauma in the community, and people in need of healing.

Many in the transgender community distrust the therapeutic community in part because of this issue. This prevents people from getting the healing they need, instead they see the therapist as an obstacle in the way of what they want.

Possible alternatives

The movement towards pure informed consent also creates problems and may lead to unnecessary transitions. A possible alternative would be to include a therapy requirement for transition, but allow the client free choice to participate in hormone or surgical treatment after therapy. This would prevent some of the problems with the gatekeeping system. However, even this would be difficult to implement because there really is no more gate as referenced above.

5 comments

  1. I am so glad you are blogging about this and it really nice to see another person out there. You have an excellent point about gatekeeping being essentially pointless as there is always someone else who can write a letter. I agree with your concerns that informed consent could lead to unnecessary transitions so that remains a worry. If we do move to an informed consent model where people can be legally recognized as any sex they say they are, then I think it will need to come with an accompanying recognition that “safe spaces” based on natal gender (or at least gender neutral options in the case of bathrooms, locker rooms, etc. ) are absolutely necessary.

  2. I was fortunate in that *I* wanted therapy for myself before going ahead in transitioning, and my therapist thought it best as well. I had plenty of anxieties to work out, which I did before entering the Benjamin Standards of Care process. I’m glad I did what I did, as life on the “other side” is something one really needs to be ready for. But it scares me how easily someone can conceivably get to hormones and surgery.

    1. Yes, I think that would be best for most folks considering transition. Especially if the therapist is a different person from the gatekeeper which I think will make therapy work better. My experience with gatekeepers stopped me from going into therapy until nearly 15 years later because I didn’t trust therapists so much after that experience.

  3. I agree completely! I’m just starting the process and I had to see my GP to get referred to a therapist (psychiatrist). I met with the psychologist a month later and he said is sounds like I fit the GD criteria. Then I was told to get some initial blood work, come back in 3 months so we could start HRT. I satisfied the “I’m not crazy” criteria, so it was pretty easy to get past the “gate”. I was honest with the psychiatrist, but I still feel a little guarded because if he could just snatch away the drugs then I have to be careful, right? It kind of defeats the purpose of therapy… I’ve also been doing a lot of personal research and soul-searching because I know that I have to take care of myself. I do wish I could talk about it a bit more, but so far only a couple people know…

    1. Yeah I think it is hard for real therapy to happen under those conditions. Also, it definately takes more than 1 session. I was guarded with my therapist during the time I went through my intial transition as well for just those reasons. It was only years later when I saw a therapist for other issues, that I really appreciated the value of therapy.

      I’m glad you are doing research and taking care of yourself, getting a lot of different perspectives is good. Feel free to chat some more if you’d like to talk about it more.

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