In Which I Fail to Find You Any Gate-keeping

Carey Callahan
Feb 4 · 4 min read

Guys, this essay is a failure. I was thinking, “Hey, trans people with big audiences are saying detransitioners should have thought harder before transitioning. Maybe that will lead some people considering medical transition to ask where they could get a more structured, comprehensive process than one session at an informed consent clinic. Maybe I can point them on where to go in North America to get that process!”

This was more ambitious than I knew. Trans healthcare is guided by the World Professional Association for Transgender Health’s Standards of Care, now in its seventh edition. Here’s what’s interesting about the SOC: no one studies provider compliance with the tasks it requires. Whether your medical and mental health providers complete the tasks of the SOC is pretty much on you, the patient, to track. There is no organization that visits these clinics and investigates. The only negative consequence a doctor, therapist or clinic could encounter for failing to fulfill the tasks and standards of the SOC would be if the failure was documented and utilized in a malpractice or negligence suit.

The assumption is that every provider treating gender dysphoric people is following the SOC, but again, it would be hard for a patient to know who was not fulfilling the requirements if the patient wasn’t tracking malpractice lawsuits. Trans people who have experienced gender affirming surgeries highlighted a similar problem facing patients in an open letter last April, asking for WPATH to create a surgical accreditation because, “As evidenced by our experience, the guidance in SOC that directly address surgeon readiness and postoperative care is not being followed by a significant portion of WPATH-member surgeons.”

(It’s worth it to read the entire open letter to get a sense of what surgical patients have experienced, especially what was not disclosed to the patients about rates of complications and the experimental nature of procedures.)

For adult patients the SOC does not recommend psychotherapy as a clinical response to gender dysphoria (pg. 28.) The SOC does not make a recommendation regarding a minimum number of counseling sessions to assess, diagnose, provide information about options for gender identity and expression and possibly medical interventions. The SOC does state that a mental health professional is not required to perform counseling tasks, but rather “may be conducted by another health professional with appropriate training in behavioral health and with sufficient knowledge about gender nonconforming identities and expressions and about possible medical interventions for gender dysphoria, particularly when functioning as part of a multidisciplinary specialty team that provides access to feminizing/masculinizing hormone therapy” (Pg. 24.)

I created a checklist for you, the patient, to document which staff and on what dates the mental health tasks of the SOC were performed. Among the detransitioners I know that transitioned as adults the most common experience was to be given one session to address all the tasks the SOC describes. This is pretty wild, as some of the tasks required include:

“…educate clients regarding the diversity of gender identities and expressions and the various options available to alleviate gender dysphoria” (pg. 24.)

“discuss the implications, both short- and long-term, of any changes in gender role and use of medical interventions” (pg. 24.)

(Screen for)….”anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders” (pg. 24.)

How a staff member who isn’t a mental health professional screens for both autism spectrum disorders and personality disorders in the course of one session of counseling is not obvious to me. (As a Masters level clinician I would refer a client to a psychologist if I suspected an autism spectrum disorder, I would not make that call myself.) How a staff member would discuss the “various options available to alleviate gender dysphoria” when detransitioners get such exaggerated amounts of shit for discussing the alternatives we use to deal with ours is not obvious to me. Nevertheless, it appears the new norm is getting it all done in one visit, if Planned Parenthood’s confident tone is any sign.

It’s on you, the patient, to insist the staff members you encounter do a thorough job. Maybe it will make a difference if they know you’re writing down what tasks they actually get done.

I wanted to give you a list of referrals to clinics that require more than one counseling session to complete these tasks before referring you for HRT. I wasn’t able to find a clinic like that. I think your best bet would be going to an endocrinologist who still required the referral letter, and a therapist who refused to write the referral letter before a set amount of sessions. I wasn’t able to find that therapist. (If you are that therapist, write me and I’ll put your information at the bottom of this article!)

I’m sorry I couldn’t find you any gate-keeping. It’s sad because the existing research on medical transition’s impact on mental health is overwhelmingly on patients who went through structured, carefully sequenced “gate-keeping” clinics. Out of 52 studies cited on the “What We Know” website to support the conclusion that medical transition improves the well-being of trans-identified people, 26 are from structured “gate-keeping” clinics. (11 are surveys of participants recruited from the internet and community support groups, much like the recruitment methods Dr. Littman was criticized for using for her Rapid Onset Gender Dysphoria study.)

As patients, us gender-dysphorics are flying blind in a lot of ways- no one is studying alternative methods of managing gender dysphoria, no one is studying our outcomes when we receive informed consent care, and no one is even studying whether clinics fulfill the tasks the SOC says they are supposed to.

Good luck out there?

Carey Callahan

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LMFT/LPC, detransitioner, advocate for taking it easy