What happens when a patient demands a medical intervention that the doctor is reluctant to give? How does informed consent play a role in protecting the autonomy of the patient? How far can we push that principle? If the doctor thinks the intervention will reduce the patient’s well-being, but the patient is rational and has assessed the risks/benefits, do we protect the doctor’s autonomy to practice medicine as they wish or do we protect the patient’s autonomy? Gatekeeping is when a medical professional restricts access to an intervention on paternalistic grounds. When is gatekeeping justified and when is it not?
In this post I will briefly explore the ethics of gatekeeping in transgender healthcare. Many trans people want access to Hormone Replacement Therapy (HRT) and surgery. But historically HRT and surgery was not given to just anyone. One had to fulfill a strict set of criteria and pass numerous hurdles before getting access to these interventions. First, you have to be in therapy for months or years to be diagnosed with “true transsexualism” in order to weed out the "pseudo-transsexual". Clinicians thought that only “true transsexuals” (whatever that means) will not regret transition. Clinicians also thought that regret was about the worst possible outcome of transition. So regret must be avoided at all costs by setting up strict and narrow criteria for the diagnosis of gender dysphoria as well as placing numerous obstacles in front of the trans patient before they get access to either HRT or surgery.
One obstacle that was used and is still used is the so-called “real life experience” test or just RLE. For RLE you are required to live socially in your gender for months if not years in order to determine if you are up to the challenge, whether you can blend into society well, and ultimately whether medical transition is appropriate. Often times the RLE test required trans people to get and keep a job in your "new" gender identity. Now keep in mind this test was historically used as a gatekeeping mechanism for HRT (now it is used more for surgery, which I discuss below). But many trans people cannot “pass” without HRT. So the RLE test did not actually simulate living in your gender - it simulates living as a visibly trans person in a transphobic society. Many people failed this test because of passing problems as well as difficulties transitioning in the workplace in a state without protections for gender identity or in finding a job in a transphobic society as a visibly trans person, especially if your legal documents are not in order.
Furthermore, forcing trans people to go out into the world as visibly trans before even getting access is HRT is an act of violence, especially for trans women of color (TWOC), who often face violence and harassment just for being visibly themselves. Forcing people to attempt to pass without the aid of HRT is cruel and dangerous because it exposes trans people to violence and harassment that they might have otherwise avoided if they had access to HRT. It also biases against the lucky few who can pass without HRT and ends up perpetuating stereotypes about who is a “true transsexual”. The petite feminine AMAB is assumed to be more “truly” trans than the large masculine AMAB because the petite AMAB can pass the real-life experience test easier - but whether you pass or not pre-HRT is a totally arbitrary criterion to judge someone's "true transness". So the RLE experience test is not an exercise is simulating lived experience in your true gender. It’s just a vehicle to see who can handle the social difficulties of being trans in a transphobic society - and it's a mechanism to test your resolve and determination.
The RLE test also violates autonomy because it fails to allow people to transition according to their own vision for how they want their life to go. Some trans people socially transition right away even before HRT. But other trans people start HRT first and then only socially transition later. For trans women a popular transition plan is the “boymode fail” strategy. You start HRT and present as male until people start gendering you female in public - your “boymode” is failing. Once this happens reliably you socially transition.
The point I’m making is that trans people should have the autonomy to choose the transition plan that is right for them. The RLE test is a one-size-fits-all solution that is tailored according to the biases of the clinicians. But if you actually listen to trans people, the RLE test is perceived as being counter-productive to the actual goals trans people have.
So those are arguments against the RLE test for HRT but one might still argue that RLE is a good idea for more “radical” interventions such as Gender Confirmation Surgery (GCS). Right now according to the latest World Professional Association for Transgender Healthcare (WPATH) Standards of Care (SOC) the requirements for GCS for FTM and MTF include “ 12 continuous months of living in a gender role that is congruent with their gender identity.” The rational is: “The criterion noted above for some types of genital surgeries—i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity—is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery.”
Some might argue that this form of gatekeeping is paternalistically justified. It’s simply in the best interest of trans people to undergo RLE before having “irreversible surgery”. But if paternalism is generally a bad model for accessing healthcare in other areas of medicine, how can it be justified for trans surgery? Why is trans surgery deemed more “radical” than other forms of surgery that do not have gatekeeping mechanisms in place? It can’t just be that trans surgery is “irreversible” because we allow people to do irreversible things to themselves all the time. Did Lizard Man need to spend 12 months living as a lizard before he received irreversible surgical modifications to look more like a lizard? If a person wants to get their 5th nose job, we don’t put gatekeeping mechanisms in place simply because the procedure is “irreversible”. There must be something else going on to justify the gatekeeping.
Perhaps it’s the idea that trans surgery involves the possibility of "radical regret". But if we think it’s abhorrent that pro-life advocates want to force pregnant people to have counseling before abortion because of the possibility of post-abortion regret - then it should also be abhorrent to justify paternalism for trans surgeries on the small chance of there being regret. As it turns out, most surveys show that the rate of post-operative regret for trans people is 1-2%. One might argue however that the low rate is low because of successful gatekeeping. However, there is an alternative hypothesis which is that the rate of regret would be just as low even without gatekeeping because the vast majority of people who decide to undergo GCS are (1) rational (2) informed of the risks and benefits of surgery and (3) highly desirous of the surgery. Trans people have often been grappling with dysphoria for decades. Their desire for surgical intervention to relieve dysphoria is very intense and persistent. Their understanding of the risks and benefits is often very high due to years of research on the internet - trans people are probably more informed about the risks and benefits than many doctors. Generally they are a class of medical patients that actually upholds the high standards for rational autonomy built into informed consent procedures. My thesis is that the rates of regret would be the same if the RLE test became recommended rather required.
Furthermore, I want to challenge the implicit assumption that post-operative regret justifies paternalistic gatekeeping. If the “worst outcome” is regret and detransition back to their assigned gender, is that really such a bad thing? If you actually read the stories of people who detransitioned you will find the narrative is more complicated than simply “regretting it”. Often people will say they would do it all over again, that they wouldn’t be who they are today if they hadn’t transitioned, that it was the right choice at the time, that it was necessary at the time to relieve their dysphoria, etc. Simply labeling it “regret” does not capture the nuance of detransition. Furthermore, someone might regret transition and still be a happy successful person living in their gender. Moreover, most of the reasons people regret transition and surgery are incidental to transition itself and more indicative of difficult social situations. If someone regrets transition because post-transition they were exposed to transphobic violence, that doesn’t really justify paternalistic gatekeeping as much as it justifies trying to make the world safer for trans people to live in.
The RLE test is just one of the obstacles in place for trans people. There are often other hurdles as well such as getting "letters" from therapists/psychologists but arguing why those are problematic will have to wait for another post.
This post stems from my dissertation research. If anyone has good examples of justified or non-justified gatekeeping in other areas of medicine, I would love to hear them.