Photo by Morgane Perraud on Unsplash

Gatekeeping Gender-Affirming Care

What do people mean when they talk about gatekeeping health care?

There is some nuance around gatekeeping gender-affirming care, at least for me. But, as the years go by with my kid and as my kid gets older, I appreciate the conversations I’ve had around this topic with trans people, as well as some of the insights I’ve been privy to on Twitter and other social media where I follow trans people.

Generally speaking, gatekeeping describes how trans people are required to meet specific benchmarks of pathology (experience enough gender dysphoria, be enough at-risk of self-harm, spend enough time considering options other than being trans) before they’re allowed to access gender-affirming care.

You can read more about how puberty blockers and hormone replacement therapy are prescribed and some of the gatekeeping practices around that care.

The OK and The Constraints

As a parent, having my child explore gender prior to starting any medical treatment (even treatment, like puberty blockers, that is reversible) felt appropriate.

But, I do wonder if that’s more about social expectation than any true feeling that my kid needed time to sort their experience. And I say that because parents of trans kids — especially parents like myself who may have had a rather large learning curve — are often told, via media, via well-intentioned family members and friends, to doubt their kids.

What do I mean by that? Almost every message a parent of a trans kid receives around gender-affirming care (except the information they receive from their kid and their kid’s health care workers) centers caution.

And of course, that sounds right. Right?

But there is a point where caution becomes gatekeeping, and you’re forced to forget that your kid’s experience is unique, which means their needs are unique.

For some kids, waiting makes absolute sense and I know that because I’ve witnessed trans kids request more time, saying themselves that they weren’t ready and putting off medical intervention until they figured out what they needed, if anything.

Other kids, though, know, and are undoubtedly ready but are still required to pathologize themselves in ways that are sometimes untrue. For example, some kids, like my son, naturally and authentically come to understand their truth but still need to confirm longstanding, detrimental gender dysphoria in order to access gender-affirming health care.

In reality, my son’s gender dysphoria, what he had, was more a tangible signal to him that transition was necessary and right. His body was signaling he needed change, and when kids are allowed to vocalize that need and access gender-affirming care, much of what trans kids are screened for — much of what they must indicate they experience to get care — isn’t present in the breadth or depth required by those who guard access.

Going In Circles

What happens when you talk about the latter, though, the kids who do know and are ready for gender-affirming care without long conversations about their mental health or aching dysphoria, is that you inevitably hear: Oh, then your kid’s not trans. They shouldn’t be able to transition.

That is where some of the harm is in such stringent gatekeeping. That is where some of the harm is in constantly framing trans kids with suspicion, asking they prove they’re not cis instead of simply trusting they know who they are.

Of course, someone will almost always reply to that with: But kids are so impressionable and will just follow their friends! Kids want to be all kinds of things, like dogs and cats and superheroes!

Read why trans kids are not a social contagion in the Common Myths Around Gender-Affirming Care section.

Not only is this idea wholly disingenuous, but saying kids have no ability to discern genuine internal feelings from play or pretend does not give them the credit they deserve, particularly as they grow older and particularly if they’re raised to trust themselves.

The times I have asked my kid about his certainty around gender-affirming care, his answer has always been some iteration of: “Mom, I wouldn’t do x if I didn’t feel right about x.”

That’s true of most — if not every — trans kid who is navigating gender. Trans kids are not a monolith, and instead of treating gender-affirming care as though it’s a screening process that will help limit the number of kids who are trans, we should look to the kids seeking care, ask them what they need, and trust what they tell us.

Because contrary to what the sensationalized reporting on this care suggests, not every kid is rushing to receive gender-affirming care — and not every kid wants to wait!

Approaching gender-affirming care as less a uniform set of requirements that need to be met and more as providing trans kids the individual health care they need to feel whole is what many parents, trans kids and providers would like to see.

Gender-affirming care for trans adults has moved toward more informed consent versus the gatekeeper model, where, for example, mental health assessments aren’t needed and a patient is educated on benefits and risks and allowed to make the decision for themselves. (Like this, for example).

Some may balk at this suggestion, but from my experience, it’s worth exploring how treating trans kids more as individuals than a homogenous patient demographic who must all meet specific requirements in order to access gender-affirming health care would be good for everyone.

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