How much influence should any one person have over another’s body? Why are there gatekeepers to gender affirmation?
As a trans woman, I’m both fascinated and directly affected by how much influence therapists and other mental health professionals have over trans people’s transitions. Though often earnestly invested in helping transgender individuals live authentically, most therapists have no idea what gender dysphoria feels like.
The experience of being trans is not an academic exercise. To be understood, gender dysphoria must be experienced, not just theorized about and studied. Without an effective understanding of the experience, a provider might not diagnose a person with gender dysphoria—and without that diagnosis, that person would struggle to access vital care.
Why is the gate to medical treatment kept almost exclusively by those who will ask me to prove I’m “trans enough,” according to criteria created by cis people? Where are the therapists who understand the trans experience firsthand?
To be understood, gender dysphoria must be experienced, not just theorized about and studied.
I started medically transitioning in 2018, as a first-year grad student at a notoriously progressive institution that was, thankfully, equipped to handle transgender issues. When I called the university's medical center to set up a consultation, excitement and anxiousness washed over me. Despite supporting many transgender friends through their own transitions, I didn’t know what to expect from the meeting.
My doctor, a cis woman, was knowledgeable and sympathetic, taking time to carefully explain what medically transitioning would entail. I was told that male-to-female hormone replacement therapy (HRT) might increase my risk of blood clots, because of the effects of estrogen.
I also learned that if I ever stopped HRT, some of the physical changes it created, like breast development, would be permanent. I was given an informed consent form to sign; if signed, I would start HRT aware of the potential risks.
The following week, a bottle of estrogen sat on my coffee table.
This was only the beginning of my experience. It wasn’t until I began considering further gender-affirming treatments, and saw more cis clinicians, that I realized how underrepresented my community is in medicine.
I can not describe how reassuring and affirming it is for your doctor to literally feel your pain.
To undergo gender affirmation surgeries, (like vaginoplasty, subcutaneous mastectomy, facial feminization surgery, etc.), a trans person needs the written approval of a mental health professional in accordance with WPATH guidelines.
Many trans people who are treated by cis doctors don’t receive the informed and compassionate care I did.
What are WPATH guidelines?
The World Professional Association for Transgender Health (WPATH), sets criteria known as the WPATH guidelines: “internationally accepted Standards of Care (SOC) for the treatment of individuals with gender dysphoria.”
Available in 19 languages, the organization’s guidelines are implemented by therapists and doctors with the goal of helping them understand gender dysphoria, work out how to diagnose a transgender person, and determine how mental and primary care should be provided.
For example, in WPATH’s handbook, the section “Options for Psychological and Medical Treatment of Gender Dysphoria” explains that HRT can be used to “feminize or masculinize” the body, and that individuals can engage in psychotherapy to build “social and peer support.”
Another section titled “Competency of Mental Health Professionals Working with Adults Who Present with Gender Dysphoria” lists out the qualifications practitioners should possess before working with trans people.
They recommend skills like “Competence in using the Diagnostic Statistical Manual of Mental Disorders (DSM) and/or the International Classification of Diseases (ICD) for diagnostic purposes,” having the ability to recognize and diagnose mental health issues other than gender dysphoria, and having a master’s degree (or equivalent) in “a clinical behavioral science field.”
And then there’s section five: “If Applicable, Assess Eligibility, Prepare, and Refer for Surgery.” Section five gives guidelines for how a surgery letter—a letter written by a medical professional giving the “green light” on gender-affirming surgery, which is required for trans individuals to obtain these treatments—should be approached and supplied.
Guidelines include ensuring potential patients have realistic expectations of surgery outcomes, sufficient aftercare procedures established, and full knowledge and opportunity to take advantage of their reproductive options. (For instance, trans women undergoing vaginoplasty or orchiectomy must be informed that in order to have biological children, they must freeze their sperm before treatment.)
To undergo gender-affirming genital surgeries, patients must obtain two separate referrals from two different mental health professionals.
The American Psychological Association has similar guidelines and recommendations for assisting people with gender dysphoria.
A diagnosis of gender dysphoria is itself also a requirement of obtaining many gender-affirming treatments, both surgical and otherwise (such as HRT and masculinizing or feminizing voice therapy).
In fact, the medical system can be outright hostile to trans people: 28% of trans people report having been harassed in medical spaces.
The truth is, our healthcare system all-too-frequently misunderstands and mistreats trans people—and it has dangerous consequences. Considering these circumstances, trans people are often hesitant to seek medical attention, fearing potential discrimination and abuse.
Given the current political landscape, the fact that some doctors and medical professionals care enough and are informed enough to focus effectively on transgender physical and mental healthcare is a huge success for LGBTQ+ equality. But in a medical space directly addressing people's gender identity, it’s vital to have transgender people represented in the workforce who can look beyond diagnostic criteria, and through the lens of personal experience.
Involving more providers with firsthand understanding of trans experiences would likely reduce the loneliness and mistreatment trans people face when seeking treatment, and this is a crucial step for inclusive healthcare.
Throughout my transition, I’ve worked with multiple doctors and therapists to plan my HRT process, schedule surgery plans, and get my letters. Only one is transgender.
I can not describe how reassuring and affirming it is for your doctor to literally feel your pain, to know from both training and experience the answers to questions like “is it normal for my breasts to be sore?” or “will the injections hurt?” I have panic attacks at the thought of referring to certain body parts; my doctor understood and respected that without hesitation, and it vastly improved my experience
Is this fair? Should anyone have the right to decide whether a transgender or gender non-conforming person is “allowed” to transition? That’s another essay.
But for the moment, it’s the reality and system we live in, and the fact that most trans people need the permission of someone who hasn’t lived with gender dysphoria in order to live their lives holistically must change, and that change can start with more trans therapists.
Safer, J. D. (2014). Hormone therapy is safe in transgender adults when carefully monitored. Retrieved October 27, 2020, from EndocrineWeb website: https://www.endocrineweb.com/news/reproductionsexuality/14298-hormone-therapy-safe-transgender-adults-when-carefully-monitored
WPATH. (2020). WPATH World Professional Association for Transgender Health. Retrieved October 27, 2020, from Wpath.org website: https://www.wpath.org/
World Professional Association for Transgender Health (WPATH). (2020). Ethics and standards. Retrieved October 27, 2020, from Wpath.org website: https://www.wpath.org/about/ethics-and-standards
Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People The World Professional Association for Transgender Health. (n.d.). Retrieved from [PDF] https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341
New report reveals rampant discrimination against transgender people by health providers, high HIV rates and widespread lack of access to necessary care - National LGBTQ Task Force. (2010, October 13). Retrieved October 27, 2020, from National LGBTQ Task Force website: https://www.thetaskforce.org/new-report-reveals-rampant-discrimination-against-transgender-people-by-health-providers-high-hiv-rates-and-widespread-lack-of-access-to-necessary-care-2/
Supreme Court Expansion of Transgender Rights Undercuts Trump Restrictions. (2020, June 15). The New York Times. Retrieved from https://www.nytimes.com/2020/06/15/upshot/transgender-rights-trump.html
Great Valley Publishing Company, Inc. (2020). Transgender Patients Discriminated Against for Health Care Services. Retrieved October 27, 2020, from Socialworktoday.com website: https://www.socialworktoday.com/news/dn_031414.shtml
Movement Advancement Project | Healthcare Laws and Policies. (2019). Retrieved October 27, 2020, from Lgbtmap.org website: https://www.lgbtmap.org/equality-maps/healthcare_laws_and_policies
thisisloyal.com, L. (2020, May 21). Conversion Therapy and LGBT Youth - Williams Institute. Retrieved October 27, 2020, from Williams Institute website: https://williamsinstitute.law.ucla.edu/publications/conversion-therapy-and-lgbt-youth/
Bever, L. (2019, September 11). Conversion therapy associated with severe psychological distress in transgender people, study says. Retrieved October 27, 2020, from Washington Post website: https://www.washingtonpost.com/health/2019/09/11/conversion-therapy-associated-with-severe-psychological-distress-transgender-people-study-says/?outputType=amp
The Lies and Dangers of “Conversion Therapy.” (2019). Retrieved October 27, 2020, from HRC website: https://www.hrc.org/resources/the-lies-and-dangers-of-reparative-therapy
Schmidt, S. (2020, August 17). Federal judge blocks Trump administration from ending transgender health-care protections. Retrieved October 27, 2020, from Washington Post website: https://www.washingtonpost.com/dc-md-va/2020/08/17/federal-judge-blocks-trump-administration-ending-transgender-healthcare-protections/
The Trevor Project. (2020). 2020 National Survey on LGBTQ Youth Mental Health. New York, New York: The Trevor Project. https://www.thetrevorproject.org/wp-content/uploads/2020/07/The-Trevor-Project-National-Survey-Results-2020.pdf
2005-13: Demographics of the U.S. Psychology Workforce. (2015). 2005-13: Demographics of the U.S. Psychology Workforce. Retrieved October 27, 2020, from https://www.apa.org website: https://www.apa.org/workforce/publications/13-demographics
thisisloyal.com, L. (2020, April 27). How Many Adults Identify as Transgender in the United States? - Williams Institute. Retrieved October 27, 2020, from Williams Institute website: https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/