Moving Beyond Psychiatric Gatekeeping for Gender-Affirming Surgery

  • This topic has 25 replies, 5 voices, and was last updated 4 days ago by Rikki.
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    • #135204
      Rachel
      FREE

      “Gatekeeping in gender-affirming care refers to unnecessary and harmful barriers to gender-affirming hormone therapy (GAHT) or gender-affirming surgery (GAS). What constitutes gatekeeping vs reasonable precautions to ensure surgical candidacy has been controversial.”

      The first sentence of the article pretty much says it all. This stuff is controversial, and any opinions rendered after that statement become suspect at best.

      Personally, I think a certain amount of psychological gatekeeping is necessary to protect patients from themselves. Let’s face it, there are plenty of dumb people out there. Leaving this completely up to patients isn’t the answer. But how much is too much? What’s reasonable?

      Leaving this to individual doctors to decide seems reasonable, until we realize that those same doctors have a financial interest in certain outcomes. Moreover, there are plenty of doctors I wouldn’t trust to give me change for a dollar. Let’s be real, this isn’t the answer either.

      So, what is the answer? Idk. Someone who makes a lot more money than me needs to decide that. I’ll just say I’m pretty certain that zero requirements would result in harm to patients, same as too many.

      3 users thanked author for this post.
      • #135236
        Barb
        BRONZE

        “…there are plenty of dumb people out there.”

        True that! LOL!!

        I think gender-identity and self-identification are human rights. The only ones to presume otherwise would be your medical practitioner without any political restrictions. Thatโ€™s how it is in my world up here in Canada.

        When you include “safeguards”, you’re presuming that trans people are inherently inferior in some way. They are not. We are beautiful!!

        We ainโ€™t perfect, but weโ€™re getting thereโ€ฆ

        :B

        • #135262
          Rachel
          FREE

          Barb!

          Omg I love Canada ๐Ÿ’•

          Let me first say that I agree, gender identity and self-expression should be considered human rights. But that’s not exactly what we are talking about here, is it? Medical intervention is not necessarily required for either of those things. Moreover, our self-expression is already restricted in plenty of situations.

          What happens in Canada if a person who suffers from a severe mental disorder asks a doctor for breast augmentation? Is it up to the doctor to determine whether or not the treatment is in the patient’s best interests? Do we want plastic surgeons determining the mental capacity of their patients? Or, do we want them to just perform any surgery a patient can afford?

          There will always be some sort of safeguard, even if it’s just the front-line doctor saying no. It seems maybe the question is more about where to draw the line, rather than whether to draw one at all.

          As usual, Barb, I’m glad you chimed in. Squuuuuuueeeeeezeeee.

          Edit to add: What would happen if a person who didn’t have appendicitis requested an appendectomy? Is there a safeguard?

          • #135265
            Barb
            BRONZE

            Ooooo!! An excellent repartee!

            However, even if someone has a mental disorder, that doesn’t make their need to transition any less valid. A clinical narcissist may have a few screws loose, but they may still have a legitimate need to transition.

            Moreover, the notion that anyone would alter their bodies for illicit access to services (like women’s prisons and bathrooms) is a scare mongering tactic by “the other side” to suppress trans rights and vilify the community.

            The BIG question for Canadians is “who pays for it?”. Since we have a universal healthcare system that is supposed to ONLY pay for life-saving procedures, it has morphed into much, much more, like adding mental healthcare to the mix. Many Canadians, however, don’t like to publicly pay for things like breast augmentation, tummy tucks, electrolysis, and things like that that impact the trans community. So, trans folx here need to oftentimes push their medical practitioners to sigh off on their surgical procedures since the public-purse is currently stressed.

            :B ๐Ÿ’—

          • #135267
            Rikki
            GOLD

            Rachel and Barb

            May I comment?

            In my little corner of the world, doctors are power individuals who shouldn’t be trifled with; here they make between a quarter and a half million a year; surely much more in other places. They don’t have to worry about customers; people go because they have to.

            I’ve known one personally: a good guy which brings me to another point; a thing that has always bothered me about us, LGBT, is that we demand the right of self expression, ( and we should have it) and almost in the same breath, deny it to others. The concern I get from people most often about me being me is kids; I’m counter by saying that kids can’t be sheltered from the world especially with the media of today. This is to no avail and I had kids, three girls who for various reasons don’t always agree with my positions; chief reason, their kids. As we would say here “Ain’t no perfect world”.

            Please forgive me for butting in but it is in public format.

            Hugs
            Rikki

          • #135270
            Barb
            BRONZE

            Oh, not at all, Rikki!! Please speak your mind with aplomb and zest! ๐Ÿ™‚

            Ah, yes… what about the kids…? Another “the other side” tactic to demonize the trans community. This is why the immensely popular Drag Queen Story Time in public libraries is attacked by “those guys”. They fear the normality of alternative lifestyles that will one day become the norm.

            Is anyone here on TGH a demon?

            In my world, I’ve never seen an example of someone from the LGBTQ+ community denying anyone the right to self-express or identify, not that I’m saying it doesn’t happen, it’s just never been a point of conversation here at home. Perhaps another myth? In fact, self-expression is encouraged in my community!

            Education is the key to acceptance and love, and that’s why some jurisdictions are vehemently and wrongly cutting LGBTQ+ programming in their schools. Pity…

            :B

          • #135272
            Rikki
            GOLD

            Well put Barb!

            I think parent’s worry is kids don’t always agree with their parents…OR… kids are watching their parents all the time and maybe know how they feel more than parents realize.

            Demons? I white out that word and insert sinners, which everyone is… not going to the big R though.

            Digressing, I traveled across Ontario once…got in the car in Mississippi in July, temp 97…got out in Sarnia, temp 76… beautiful country. The money exchange was worrying but that’s traveling.

            Hugs

            Rikki

             

          • #135273
            Rachel
            FREE

            What a great thread! Rikki, join in anytime, please! It is a public forum. I want to hear what you have to say.

            I get all the discussion about how we are vilified or marginalized as transgender people, and maybe that’s a part of the problem. Nobody would argue that a person who wants to have an arm amputated because he sees bugs crawling on it which nobody else sees should be referred for a mental health evaluation. Similarly, if a person wanted to have an arm amputated because they identified as a one-armed person, should the surgeon operate?

            These types of safeguards already exist, I hope. I s’pose the question is should they be applied to transgender patients.

            In terms of who’s gonna pay for it, that’s defined by whether or not a given procedure is “medically necessary”, I would think. Without involving a mental health professional, how could one determine the necessity of treatment for a condition like this?

          • #135274
            Rikki
            GOLD

            I wish I could remember the movie/song? with “they’re coming to take me away, ha ha; they’re coming to take me away, he he”๐Ÿ™‚.ย  Here as long as I appear in public “normal” I’ll probably be okay. Don’t really like it… but ๐Ÿ™„.

          • #135283
            Rachel
            FREE

            I’d like to be clear about one thing: the condition for which we are discussing treatment is gender dysphoria. It is not being transgender. Being trans is not a “condition” at all, as trans people can lead healthy, happy, long lives just like anyone else.

            As we know, the condition of gender dysphoria is common among trans people. However, plenty of us never experience it, or experience it only sometimes. Being transgender by itself is not a condition which requires treatment.

          • #135284
            Rikki
            GOLD

            Rachel

            I agree that being trans is not a condition; it’s who we are for reasons I’ve already posted, ( in my belief structure). For me there’s no going back within the limitations of living here.

            With all due respect to whomever, may I say that I enjoy writing back and forth.

            I don’t have gender dysphoria because it’s not an option and mostly because I am going to have small breasts and a larger, sensitive rear for the rest of my life, ( I wonder what they will bury me in…male… feminine?โ˜บ๏ธ) so there’s no going back.

            The questions I would ask about treatment is what are the stats; does it keep changing; what are the side effects… effects… effects.

            I can tell you this for sure… my mother was parinoid schizophrenic instutioalized and nothing they did, which kept changing, helped. I’m not suggesting that compares to dysphoria, it just throws up a red flag. Are people informed? I’m on the update with this stuff. Please don’t be angry.

            Hugs

             

             

      • #135209
        Rikki
        GOLD

        Hormones are tricky. I’ve been reading about trans for years and some it drives crazy; it didn’t happen to me even though I was on my own and self perscribed. I think this site is just trying to help and I can appreciate that; not meant to be offensive.

        Could it be that this is the reason for the testiness here?

        1 user thanked author for this post.
        • #135213
          Rachel
          FREE

          Yes, hormones are tricky!

          Testiness? Why, whatever do you mean? [insert eyelash batting here]

          • #135214
            Rikki
            GOLD

            Oh nothing… apologies Rebecca… sometimes I feel like a fish out water here. I suppose that’s because I haven’t come out and don’t understand… apologies.๐Ÿ™ƒ

          • #135215
            Rachel
            FREE

            There is certainly no need to apologize. Moreover, the fact that you haven’t come out yet doesn’t negate your opinions, thoughts, or feelings. Your experience of transness is just as genuine and valuable as anyone else’s, no matter which path they chose.

            I would point out, though, that my name isn’t Rebecca ๐Ÿ˜†

          • #135216
            Rikki
            GOLD

            Arggh! I’m so sorry about that name mixup… please forgive. Could have been a Freudian slip; more likely it was vodka.

            Thanks for the affirmation. When I was talking the aforementioned herbs, I was quite beside myself for a while

            Co-workers said I was “pmsing”. Of course, everyone knew because this is a small place; I didn’t tell anyone.

            The point that doing this on my was dumb could also be made. Bottom line…it scared the s__t out of me. The aforementioned physical changes have remained to this day undeminished.

            Hope you have a good day… Rachel

          • #135219
            Rachel
            FREE

            It’s difficult to imagine those types of effects from a regime of non-prescription supplements. What were you taking, if I may ask? You said herbs, so does that mean OTC supplements, no doctor?

            Whatever it is, these things are always better with the supervision of a professional. We all know that. Lab tests that monitor things like liver function are an essential part of this treatment.

            Anyway, back to my point: your experience is valid. In fact, this conversation is mostly about people like you, people who may have to deal with gatekeeping by medical professionals. I’m curious to know if your decision to use these types of dietary enhancers had anything to do with avoiding all the nonsense it takes to see a physician and get on a normal regimen, or if there’s another reason why you chose that option.

          • #135220
            Rikki
            GOLD

            Good questions Rachel.

            I’m not comfortable saying what I took, especially here for precisely the medical/ safety reasons you mention; I will say, and I hope everyone gets a hoot out of this; I formulated the “prescription” from the back pages of trans porn magazines.

            As to why I chose this path, it’s something I haven’t been yet able to communicate; I have a house here and plan to stay here and to have chosen to go the normal route would NEVER have been allowed here; I’ve seen gay who were too out have to move away. To put it another way, I snuck it and hoped I survived; fairly good local connections helped. I always point out ’76 movie Ode to Billy Joe as the way things are here still; that was about gay but…

            I think it’s impossible for people to imagine who live in other places.

            I’ve lived in NJ and Milwaukee and know that attitude is completely different there.

            Thanks for listening! Thanks for taking an interest.

          • #135224
            Rachel
            FREE

            I totally get all of that. It’s very understandable.

            I appreciate you sharing all that with me. ๐Ÿ™‚

          • #135225
            Rikki
            GOLD

            Thanks Rachel. It’s great to finally lay it out to someone.

            With all due respect to a significant other, how has your journey been?

          • #135233
            Rachel
            FREE

            Oof, my journey? It’s been a crazy ride ๐Ÿ˜†

            I began transition in 2008. That was before Informed Consent, and gatekeeping was the norm. We had to jump through quite a few hoops to get a doctor to prescribe hormone therapy, which is why so many of my friends back then used black market meds (mostly from Mexico).

            When it came to surgery, options here in the US were extremely limited. Today there are hundreds, maybe thousands of doctors performing GAS in this country. Back then, it was less than ten. (Six, I believe.) All of them followed WPATH guidelines religiously, as they were under a microscope themselves.
            Eventually, I was able to get the treatments I needed, and today I’m doing much better. I haven’t fully eliminated dysphoria, but it’s become manageable.

            I’m really glad you decided to share your thoughts. Thanks ๐Ÿ™‚

          • #135248
            Rikki
            GOLD

            Thanks Rachel for sharing.

      • #135207
        Michelle Lawson
        MANAGING AMBASSADOR

        Rachel, you have helped answer that question. The answer is discussion and education through our personal perspectives. And I thank you for that. My wish is that all of the controversial issues could be dealt with in a similar manner, then they wouldn’t be so controversial. Hugs, Michelle

        1 user thanked author for this post.
    • #135003
      DeeAnn Hopings
      AMBASSADOR

      For 2 reasons, I believe this approach has some flaws.

       

      From the Fenway Health link:

      “If there is concern that uncontrolled mental health problems in patients may interfere with a patientโ€™s capacity to consent to surgery, the surgeon should require evaluation by a mental health provider prior to surgery.”

      Doctors enter the field of surgery in order to become surgeons. Developing some useful degree of mental health expertise is not what they signed up for.

      I agree that statistically the number of people who regret transitioning is low. There are some anti-trans activists who would like you to believe that it is much higher than what it is, but it simply isn’t true. However, without some degree of gate-keeping, I suspect the numbers will rise. The downside to that it that is give anti-trans activists more ammunition.

      It used to be that some places required that a person live as their target gender for a year. Exclusive of any therapy, if you were not reasonably successful during that year, you probably shouldn’t go any further. In effect, it’s similar to doing an internship. If therapists can be fooled in there evaluations of trans people (Walt Heyer, for example), I would think that anyone else would be less effective.

      1 user thanked author for this post.
      • #135004
        Michelle Lawson
        MANAGING AMBASSADOR

        DeeAnn, I do agree with you on the vast number of people/patients. In my case, the therapy was merely a formality as I had already done my due diligence in learning about the who, what, where, & how of why I felt the way I did, and what needed to be done to get things on the right track. And I’m certainly not some remarkable person, but I do think there is a segment of the transgender community that could be in similar shoes as me. But for the vast majority of people/patients, there probably does need to be the therapeutic path as a first start. Maybe a joint therapist/surgeon process. I guess only time will tell. Michelle

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