No More Gatekeepers

Written by Dr. Carol Clark

Back in the day, therapists working with transgender people wanting hormone therapy or surgery were called “gatekeepers” and this was not conducive to a happy relationship. Many trans people said, rightfully so, that they were adults and did not need a therapist telling them what they could and could not do with their own bodies.

The World Professional Association for Transgender Health (WPATH) developed the “Standards of Care” (SOC) from Dr. Harry Benjamin’s work. In the 1950s, Dr. Benjamin came to realize that psychoanalysis was not going to change a person’s gender identity, and so he advocated for hormone therapy and surgery. By the 1970s, his standards of care became the “go to” guidelines for helping gender dysphoric people through the transition process in a responsible and ethical manner. The earlier versions of the SOC recommended timelines, including how long someone needed to be in therapy, how long they needed to be on hormones, or how long someone needed to live in their identified gender presentation. While those guidelines had a strong foundation, many therapists followed those standards rigidly, even though there is considerable variability among transitioning people. To this day, there are still therapists and even trans people who believe that these older standards still apply, which perpetuates the “gatekeeper” mindset.

When I began working with trans people in the 1990s, I followed the SOC in effect at the time. The timeframes had lessened but were still there and the order in which to make the transition steps was still followed. As I gained experience, I realized that insisting someone see me weekly for six months to a year was ridiculous and even unethical. I knew therapists who did that and got away with it because first, the SOC recommended it and second, because there were so few therapists who would write letters for hormone therapy and surgery that the transitioning person had no choice. So, the resentments built as clients paid a lot of money for “therapy” that they did not need as they waited months or even years for the therapist to green light their transition.

What I first did was to only see clients once a month so I could evaluate their commitment to transition over time. Eventually, I individualized my therapy to the point where I would see clients for as few sessions as we mutually agreed upon in order to meet the intention of the SOC, which was and continues to be so the transitioning person is fully informed about and prepared for their hormone therapy or surgery.

In essence, my job has been to evaluate a person’s readiness for hormone therapy or gender congruent surgery. I have never been a gatekeeper. I have always told my clients that I want to help them get where they want to be and that is what I have done.

While some clients are very informed about hormones and surgeries, others are not so much. A lot of people get their information from the internet and my job is often to correct misinformation. I also call what I do an evaluation, not therapy, so it is a finite process done with as much respect for time and money as responsibility and ethics allow. I follow the SOC as far as the letter-writing template goes and incorporate the information recommended, since it is based on sound practice. I have, in fact, seen some very unprofessional letters from therapists who either did not know how to write a good one or who have been around so long they get away with sloppiness and brevity. As insurance increasingly pays for hormones and surgery, these letters are often not accepted by those companies and the client ends up paying someone like me to do an evaluation and write an acceptable letter.

The takeaway here is that hormone therapy and gender confirmation surgeries are irreversible and so it is in everyone’s best interest, especially the transitioning person’s, to do everything possible to assure the best outcome. The client and I are a team working together for that end. Occasionally, someone does need therapy, and I either provide that or refer them to a local person, but that happens seldom and when it does, it is usually initiated by the trans client. I am first a mental health counselor, then a sex therapist, and finally a transgender care therapist, so there are many issues I can address. I have had more people than I can count tell me that I saved their lives.

Most of the time, I am a guide and educator. The 7th edition of the SOC has now caught up to the need to individualize each person’s transition plan and leaves it up to the therapist and client to formulate and follow that plan. I have helped people avoid or work through problems with family, friends, and work. I have helped them find the best endocrinologists and surgeons by informing them what to look for in a medical doctor. From all my years of practice and all the trans people with whom I have worked, I have gathered more experience and knowledge than any one person could, and I share that with everyone I evaluate.

The International Transgender Certification Association (ITCA) is comprised of therapists and educators (and yes, we have a trans woman on our board who is also a lead instructor) who bring all their knowledge and experience to the training of other therapists and healthcare providers. Transgender, gender non-conforming, gender variant, and non-binary – our mission is to help all who seek us go on to live their best lives as their true selves.