The Gatekeepers
I am a 39-year-old trans woman and have been on hormone replacement therapy with a gynecologist in private practice since October 2015. I am currently shopping doctors that are closer to home as I have been driving a long distance to see my current doctor, who I’m otherwise pleased with. Let me also add that finding that doctor was a chore, too. The first therapist I saw was also in Downtown Orlando (not at all convenient for me) but I went because they were known for being “the place to go” specifically for trans therapy. Their office had two doctors which they referred to for transgender hormone replacement therapy, and only one accepted my insurance, a major carrier. While the office is an hour drive from my home, I felt respected and included in my care.
In searching for something closer to home, I made an appointment at a local Planned Parenthood because of their reputation of being inclusive, and their website showed that this office offers transition care. I made an appointment over the phone, which was discreet and gave a positive impression, and they were able to see me quickly.
I filled out the intake form online prior to arriving. The office is in an old strip mall and it showed age. But the office staff were pleasant and helpful. They got me back into a room fairly quickly and the assistant was fantastic. I remarked how pleased I was that they do blood draws on-site. Under my current care, seeing a gynecologist at a private practice, I was in the habit of having to schedule a second appointment at Quest Labs to have lab work done.
And then the invasive questions began:
When did you first realize…….?
That I’m transgender? Probably 13ish.
Who would you consider your support system?
My wife.
When was the last time you were tested for HIV?
Ummm I have no idea. It’s been a while…
At what age did you become sexually active?
Like, 17 I think?
How many partners have you had in the past year?
One.
Are your partners male, female, trans male, trans female, etc?
One, I said, and she’s my wife, a woman. Is this necessary?
Do you use condoms?
These hormones have basically made me asexual. I couldn’t tell you the last time I had sex.
How many partners have you had in your lifetime?
Ok, enough is enough. I’m here for hormone therapy, what the fuck does this have to do with hormone therapy?
It was beginning to feel like “we do STI/STD/Pregnancy/Sex stuff, but you can get a side order of trans care if you ask for it.” The intake form and questions prompted by the nurse were far too intrusive and showed a lack of understanding that trans issues – my issues – the purpose of my visit – are not at all about sexuality. While I understand this is a part of their normal services, how many partners, what gender they are, etc, are not necessary to the treatment of gender dysphoria/endocrine disorders. (Before you @ me for using the word “disorder”, my clinical diagnosis was “endocrine disorder”.) I have been happily married for years, and that information wasn’t relevant at all and felt inappropriate.
And the idea that trans care isn’t a core part of their mission, but rather a side gig became more and more affirmed as the appointment went on. After the unnecessary inquisition and blood draw, I was taken to meet the provider (doctor?) and that conversation went like this:
Hello, nice to meet you. Did you fill out the intake form yourself?
Yes, I filled it out online.
*Pointing to the letter “F” on my paperwork* Your birth gender was….?
Male.
Well, until you’ve had your name change, drivers license, social security and such, YOU DON’T HAVE THE RIGHT to mark your gender as “F”, you have to put “M”.
Lady, I went to court two years ago, dropped $400 on a name change, and have all my documents updated, HOW DARE YOU make assumptions about my gender marker status! She could have asked “What steps have you taken in your transition so far?” But she didn’t. She assumed that I didn’t have the right to my identity. She backpedalled briefly:
Oh, you’re good then. Most people put down Female because that’s what they’re transitioning to and I have to tell them that they …
My brain drifted away toward the need to escape this office, this situation. Maybe the majority of your clients are brand new to transition. Aside from the fact that I came here clearly communicating that I have been in hormone therapy for over two years and was just looking to transfer my care, even if I was a brand new patient seeking transition care for the first time, this is NOT how you speak to patients. I felt small. Like I’d been spoken down to – as if I were a child. And I don’t want anyone else to have to experience that ever again.
Even though I was transferring 2+ years of labs and medical records from my current doctor, they wanted me to come every 3 months with labs every time – and when I questioned this I was told “It’s the director’s policy of all new patients, regardless.”
Trans people have enough gatekeeping, especially from the medical community, thanks in large part to the World Professional Association for Transgender Health’s (WPATH) Standards of Care (SOC). Over the past decade, these Standards have evolved somewhat to remove barriers and gates, but it’s still lengthy, expensive, and gatekeeper-y to go through transition.
It wasn’t long ago that transgender people were required to spend a certain number of years in therapy before a referral could be written to start hormone therapy. Today, there’s no recommendation of a time limit, but we STILL need that letter, and that is completely at the discretion of the mental heath professional. Individual therapists may require a time frame, but I was fortunate that mine could tell right away that I was “classic gender dysphoria” and prepared to transition. From the start, my needs were considered. Other than needing that letter (which is an extra cost of course), there wasn’t much gatekeeping at this stage for me.
There used to be a requirement to “live in your target gender” for a specified period of time, no less than a year. This was called the “Real Life Experience” and was apparently supposed to help you make sure you were going to be able to handle living as another gender socially. They wanted you to work, go to school, and live “as a woman/man” before they would unlock the next gate. And that doesn’t even BEGIN to address the needs of non-binary people. Again, I was fortunate that this outdated idea had been dropped by the time I started transition.
Still, according to the WPATH SOC, one mental heath professional’s referral is required to access breast enhancement or mastectomy (though AFAB Brenda doesn’t have this gatekeeper for her “Real Housewives” upper-middle-class boob job), and two referral letters are required from separate therapists who have independently assessed me in order to access gender reassignment surgery. There’s a toxic idea out there that the medical/mental health gatekeepers need to make sure this is something we won’t regret. Something we’re sure about. This feeds into the notion that all of this is all a decision we enter into quickly or lightly, as if we haven’t tortured ourselves about our bodies for years before finally seeking therapy or other treatments.
No, this is all classic gatekeeping and while it’s improving, it’s still not great. The last thing I need is some doctor withholding my identity from me without even asking whether or not I’d already unlocked the previous 5 gates to “earn the right” to call myself a woman. Unacceptable.
I have a lot of cognitive dissonance about this experience. The progressive liberal in me wants to support Planned Parenthood and all they do. I mean, it was basically their inclusive reputation that got me in the door. But there’s clearly some housekeeping to do. I hope my feedback brings change. I hope this was an isolated incident, with one practitioner at one Planned Parenthood clinic. But I have a lot of doubts.
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