It's Time to Stop Gatekeeping Medical Transition
By Henri Feola
Standards for gender-affirming medical interventions place transgender people under intense, potentially harmful scrutiny. Research supports informed consent models of care.
February 18, 2022
Macroscope Ethics Medicine Policy Psychology Social Science
Being transgender comes with a burden of proof. I have to justify it, reaching into the recesses of my childhood like a Freudian psychoanalyst, cobbling together a satisfying arc from my still in-process life. Every trans person I know has shared that experience of needing to explain who we already know we are. But our personal experiences don’t stand alone; they are reflected and magnified many times over in the power structures that surround us.

That burden of proof plays out perhaps most notably in the healthcare system. When it comes to accessing gender-affirming medical interventions such as hormone therapy, chest surgery, or genital surgery, the medical field places trans people under excessive scrutiny to determine their eligibility for treatment. The World Professional Association of Transgender Health (WPATH) Standards of Care states that an individual seeking gender-affirming medical interventions needs one letter (and, depending on the procedure, sometimes more than one) from a mental health professional diagnosing them with gender dysphoria disorder and testifying to the patient’s readiness for treatment. According to the WPATH Standards of Care, readiness includes having lived in one’s “desired gender role” for a year, as well as having “reasonably managed” any other mental health issues. Although the Standards of Care are widely in use and endorsed by the American Medical Association, among other institutions, there is little evidence behind the requirements they put forth. Indeed, a growing body of research suggests that medical gatekeeping may have harmful consequences for transgender and gender-nonconforming people, particularly when it comes to mental health.
History of the Mental Health Requirement
Gatekeeping is nothing new for trans people. In the 1800s, as Western scientific interest in sexual “disorders” including homosexuality and transgenderism arose, so too did the need to determine both who could be considered transgender and who was eligible for medical transition. In 1910 German psychologist Magnus Hirschfeld published the first book on what was then known as “transvestism.” In it, he argued that cross-dressing or transvestism was a disorder in which those assigned male at birth—the exclusive focus of his studies—derived sexual pleasure from dressing in women’s clothes and adopting feminine attitudes. To support his argument that transvestism was a mental health condition, Hirschfeld endeavored to distinguish it from homosexuality, fetishism, masochism, and other categories he called "sexual disorders." Although his hypothesis about the “erotic drive” has since been discredited through scientific research and transgender advocacy, the idea that transgenderism is a mental health condition in need of a diagnosis continued, as did the focus on separating out those with other mental health issues. Despite these likely unintended consequences of his ideas, Hirschfeld was radical for his time. When Adolf Hitler rose to power in Germany, Hirschfeld’s body of work was deemed degenerate and his books were burned.
When medical transition became more available in the 1940s and 1950s, researchers sought to further differentiate types of gender disorders. Medical doctor Harry Benjamin, the founder of WPATH (formerly the Harry Benjamin Gender Dysphoria Association), coined the term “transsexual” in 1966 to describe the subset of “gender disoriented” individuals who were eligible for medical interventions. In his book The Transsexual Phenomenon, he identified five different types of transgender people, ranging from “simple transvestites” at one end of the spectrum to “true transsexuals” on the other. A common criterion for differentiating between these types was one’s intelligence, as measured by racist and inaccurate metrics such as the IQ test, and one’s mental health.
Paradoxically, although psychologists such as Benjamin listed profound distress as a defining trait of the “true transsexual,” they barred access to gender-affirming medical interventions for trans people with mental illnesses and advised that only those with “a reasonable degree of intelligence and emotional stability” could receive treatment. J. R. B. Ball, an influential doctor at the University of Melbourne who studied transgender people and performed gender-affirming surgeries, warned in a 1981 paper of the potentially disastrous consequences of providing gender-affirming medical interventions to “more unstable transsexuals.” The first WPATH Standards of Care, issued in 1979, states that any patient with “a psychiatric diagnosis in addition to a diagnosis of transsexualism… should first be treated by procedures commonly accepted as appropriate for such … psychiatric diagnoses” before they can undergo medical transition.
This decision to gatekeep transition based on mental health was not supported by any research at the time; rather, it was based on cisgender doctors’ biases and perceptions of what was best for transgender people and for society at large. For them, the goal of early gender-affirming medical interventions was not merely to alleviate the patient’s suffering, but also to produce a “successful woman” in the eyes of the medical establishment and of society at large. As Benjamin described in his book, a “successful woman” had to look and act the part by marrying a man, taking on a respectable job, or working as a housewife, preferably without ever disclosing her trans identity. The environment of clinical observation that patients were subjected to reads like a scene from the musical My Fair Lady. “Advice was given by the team, about dress and behavior,” Ball wrote. Sex work was unacceptable and “patients were advised to sever all possible contacts with the homosexual world.” According to a historical review by Jordan D. Frey of New York University Langone Medical Center and his colleagues, clinics selected patients based on their appearance, favoring those who already looked closer to their gender identity and were not generally perceived as trans. Barring medical treatment for trans people suffering from mental illness, or any kind of perceived instability, further ensured that only those able to conform to strenuous societal norms for women would get to transition.
The bottom line was that not just anybody could be trans. What we now call transgenderism presented such an uncomfortable challenge to heteronormative society that as soon as new methods of medical treatment emerged, the process of classifying and studying trans people became more involved. Seeking treatment as a trans person was less of a typical doctor-patient interaction and more like a college weed-out class: Only a select few individuals, those who meet the professor’s stringent, arbitrary, and often discriminatory standards, were allowed to continue. Or, as Ball put it in 1981, “If one chooses the best cases, aesthetically and for psychosocial stability, one gets the best results.”
Gender-Affirming Treatment and Mental Health
The medical establishment still follows this basic weed-out model today, but new research is considering the needs and perspectives of the trans and gender nonconforming community, thus challenging the gatekeeping norm. A multitude of studies have shown that, far from being detrimental, gender-affirming medical interventions can decrease symptoms in seemingly unrelated issues such as anxiety and eating disorders. Nic Rider, who is nonbinary and uses they/them pronouns, is a researcher at the University of Minnesota Institute for Sexual and Gender Health who has been at the forefront of this work. One of their studies, published in Health Psychology in 2017, found that trans and gender nonconforming people who had undergone gender-affirming medical interventions of any kind experienced more body satisfaction, more external affirmation, and fewer symptoms of disordered eating than those who wanted these procedures but had not had them yet. Rider says, “We were hopeful that the results would provide support for shifting away from withholding or gatekeeping practices. When we started analyzing the data and saw these clear patterns, we knew we needed to get these results published.”
Western medicine typically treats mental health issues as problems with the individual, sometimes extended out to the family unit through factors such as genetic inheritance or home environment. However, growing research suggests societal structures influence our mental health in complex ways, particularly for oppressed populations such as trans and gender nonconforming people. Trans people experience mental health issues, including eating disorders, at higher rates than their cisgender counterparts. Most research on eating disorders has focused on cisgender women, particularly on how societal beauty standards affect them, but trans people also internalize beauty standards in ways distinct from their cisgender peers. Binary ideals of beauty are difficult for those assigned a different sex at birth to attain, and they may not feel relevant or appropriate for people who do not see themselves fitting into either binary category. The internalization of societal standards of beauty has been found to increase eating disorder symptoms in trans and gender nonconforming people, as have feelings of gender incongruence.
In addition, failure to conform to those standards has real social consequences for trans and gender nonconforming people. Trans people who fit social norms for their gender identity are more likely to be gendered correctly, so many trans people develop eating disorders to reduce misgendering, says Rider. It’s no surprise then that experiencing anti-transgender discrimination such as misgendering, harassment, or violence, is associated with higher rates of disordered eating.
The research shows that gender-affirming medical interventions improve mental health by both reducing instances of misgendering and improving the sense of congruence and positive body image trans people feel. Then, according to Rider, withholding gender-affirming medical interventions because mental health conditions are not reasonably well managed “could be harmful, given their association with improvements in eating disorder symptoms.” This mental health requirement punishes trans people for an adaptive human response to oppression and bars them from accessing gender-affirming medical interventions that could alleviate mental health symptoms.
Evidence-Based Treatment
Researchers and activists are exploring alternative treatment models, however, such as informed consent. Informed consent is the standard for comparable procedures such as hormone treatment or breast reconstruction in cisgender people, and operates under the premise that if a patient is aware of the risks and benefits and is capable of giving consent, they can choose the course of treatment appropriate for them. The use of informed consent for trans and gender nonconforming patients remains understudied, but results have so far been positive. One study published last year found that patients who proceeded with gender-affirming medical interventions without a referral to a psychiatrist reported higher satisfaction with their treatment, and in a survey of 12 clinics in the United States that used informed consent, the authors found high patient satisfaction with few instances of regret and no legal issues surrounding the informed consent method.
The gatekeeping endorsed by WPATH and other institutions is a product of attempting to fit the infinite array of human gender diversity into a convenient box. It pathologizes trans people and dismisses our suffering and our survival. It punishes us for our anger, our hurt, and our coping mechanisms, and refuses to listen when we say we know what we need. Change is under way, though, with “more research from an intersectional lens and more research about us by us,” says Rider. The systemic oppression and social challenges trans people face “can definitely have a toll on mental health,” says Rider. “Yet there are so many strengths within trans and gender diverse communities too.”
Opening Image by Ted Eytan / CC BY-SA 2.0
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