Gatekeepers vs. Informed Consent: Who Decides When a Trans Person Can Medically Transition?

Gatekeeper or guide?

While not every transgender person seeks to transition physically—whether through hormone therapy or other means like surgery—when one does, who should be allowed to make the decision? Is it a clear matter of personal choice? Or should doctors or therapists have a say?

In recent decades, transgender patients were expected to undergo extensive talk therapy in order to access medical interventions. Under this approach, also known as the “gatekeeper” model, the ultimate decision about who was or was not a candidate for treatments ranging from hormones to surgery rested with the therapist. More recently, transgender advocates have argued against what they see as red tape, favoring a system of “informed consent” in which, following appropriate education and advisement about the treatment in question, the ultimate decision regarding treatment choice rests with the patient alone. The informed consent model has been adopted at many centers that provide hormone replacement therapy (HRT), including the Planned Parenthood locations that offer it. Still, other providers continue to use the older model, requiring patients to produce a letter from a therapist regarding their psychological fitness before they can be evaluated medically as candidates for treatment.

This divide among providers mirrors a tension within the larger trans healthcare advocacy community. On one side there are those who wish to de-medicalize the experience of transgender individuals to the greatest possible extent—these advocates generally see the role of medical professionals as providing the requested treatment to the consumer and staying out of the way. Others see medical practitioners as playing an important role in helping to prepare trans patients for the consequences of their decisions, guiding them away from uninformed choices or spur-of-the-moment impulses. While both sides ultimately want trans folks to get the care they need, the question of how much intervention is helpful is very much open.

From the perspective of advocates for transgender rights—many of whom have themselves pursued HRT and/or other medical interventions to help their bodies conform to their inner self-conception—setting up gatekeepers between transgender patients and the treatments they feel they need is a problem. “To me, a gatekeeper in the traditional sense is kind of like a check box of things you need to say, or think, or be, in order to be what they think is appropriate for someone to start hormone therapy, or have surgery, or whatever,” explained Marti Abernathey, a trans woman and the founder of Trans Advocate, a news and commentary website. Abernathey went on to describe the narrow stereotypes that medical professionals once expected trans women to conform to in order to merit a medical transition: They would need to be sexually attracted to men, for example, and they should be very feminine. Informed consent sidesteps these kinds of biases.

“Informed consent is a medical provider laying out your risks and benefits, and the most current information they have about those risks and benefits, and giving you the choice about what to do with your own body. For me this is a basic human right, a matter of bodily autonomy,” Abernathey said.

Over the past few decades, the strictness of the standards that medical providers use to determine suitability for treatments such as HRT have been relaxed substantially. WPATH, the World Professional Association for Transgender Health, an organization of medical professionals involved in transgender care, publishes and promulgates the Standards of Care and Ethical Guidelines (SOC), a document which is widely used by medical professionals to inform and guide their practice with transgender patients. I spoke with Dr. Jamison Green, the current president of WPATH, about the why providers even need professional standards and the evolving role of informed consent in ethical practice.

Informed consent is a part of every step of the way in treatment of transgender patients. The SOC don’t exist to gatekeep. But if you want cross-sex hormones and/or surgery, and if you don’t have a body that is considered ill, that is considered problematic. You can’t get medical treatments without a diagnosis, and you certainly can’t get insurance to cover it. The system we have says that you need to have a diagnosis in order to get treatment.

WPATH was once known as the Harry Benjamin International Gender Dysphoria Association. Under that name the Standards of Care were stricter, more concerned with guiding practitioners through the process of deciding who was “trans enough” for treatment to be indicated. Dr. Green pointed to the progress that had been made toward putting patients in the driver’s seat, though with a caveat regarding surgery:

In the past, the belief was that people couldn’t make these decisions on their own, and the mental health screening could be brutal. It could go 2 or 3 years before you’d have any access to [hormone] therapy. The SOC acknowledge that it’s unethical to try to change someone’s gender identity, and they don’t require a year or more of therapy before you can get hormones—one or two visits is fine, as long as the therapist you’re seeing is comfortable. This is a complex and difficult thing, and if someone wants surgery it can be important that they slow down just a bit and think about what they’re doing. And, surgeons don’t feel qualified to evaluate who will be a good candidate for surgery—they want a therapist to do that.

Dr. Green, who is himself transgender, doesn’t believe that having ethical standards for providers to follow is incompatible with an informed consent model of treatment. It’s just part of achieving a system of care that meets the needs of patients and providers alike. Since the transgender community includes many individuals with mental health issues such as depression, as well as minor children who are not legally able to consent to medical procedures on their own, some version of the SOC will likely be needed for the foreseeable future.

Even so, the consensus of medical providers who work with transgender patients has shifted a long way in favor of self-determination, and it may well shift further. There do, however, remain questions of emphasis. Although it’s rare for patients to regret transitioning, it can and does happen. There are also transgender patients who do not regret transitioning, but who come to regret the specific decisions that they made, the speed of the process, which providers they trusted, or how they dealt with their transition emotionally. For advocates like Abernathy, the potential for regret is not as important as the principle of access and control over one’s body—she believes that the existence of a few people who regret making a decision shouldn’t prevent adults from freely making the same decision as long as they’re fully informed about the potential risks and benefits.


Professionals like Dr. Green and the members of his organization have a different concern: making sure that patients and providers are protected from negative outcomes that could have been avoided.

Finding the right balance won’t be easy. Although it’s true that every treatment requires a diagnosis, in most cases patients are unlikely to encounter a provider who is skeptical about their self-reported symptoms. A man experiencing erectile dysfunction, for instance, does not need to undergo months of therapy or provide proof of his lack of function in order to get a script for Viagra. Although the wishes of the patient have gradually been given more weight in the SOC, it’s not clear whether medicine will come to see being transgender as straightforward, like having erectile dysfunction, or complicated, like having a psychological condition. For transgender individuals, the desire to avoid the stigma of mental illness can make this subject very emotionally fraught. But in the end, the risk that certain people may impulsively or erroneously embark on treatments with permanent effects must be evaluated rationally, and weighed against the potential harm to patients for whom the requirements are onerous or whose treatment is needlessly delayed.

Article by Vanessa Vitiello

Accelerate gender parity

March 8 is International Women’s Day.


Celebrate the social, economic, cultural and political achievement of women. Yet let’s also be aware progress has slowed in many places across the world, so urgent action is needed to accelerate gender parity. Leaders across the world are pledging to take action as champions of gender parity.

Globally, with individuals pledging to move from talk to purposeful action – and with men and women joining forces – we can collectively help women advance equal to their numbers and realize the limitless potential they offer economies the world over. We have urgent work to do. Are you ready to accelerate gender parity?

Click here to Make A Pledge Now!

Jeremy Clarkson the great TV presenter and……

Racist, trans and homophobe biggot???

I regard Jeremy Clarkson as one of the best TV presenters in recent history. He is most famous for his outrageous and blatantly honest opinions on most cars on the famous before not so much now BBC motoring show Top Gear. It was by far my most favourite car show ever. I really enjoyed looking at these 3 bash cars and talk politics and “common sense”


“As far as I was concerned, men who want to be women were only really to be found on the internet or in the seedier bits of Bangkok. They were called ladyboys, and in my mind they were nothing more than the punchline in a stag night anecdote.”

jeremy clarkson

Jeremy Clarkson

More specifically, he then went on to criticise the parents of transgender children, for “poisoning the minds” of their families, by allowing their children to live their life as their preferred gender.

He added: “I wanted to seek out [the parents] and explain that they were free to live a lunatic life, they must not – and I was going to emphasise this with spittle – be allowed to poison the mind of a child…

“[Children] dream impossible dreams. You don’t actually take them seriously. You don’t take them to a hospital when they’re 10 and say, ‘He wants to be a girl, so can you lop his todger off?’”


He understandably got a lot of criticism for the above and I bet some people with threaten to boycott his new show which in a way, I understand. In his defence I need to point out the fact that people who never experienced body dysphoria might not be able to understand want trans people go through. To them it is as foreign as someone wanting to cut off certain or all limbs to achieve their full potential.

Yes I get upset wen people tell me I’m wrong and even question my sanity but you know what? Let them. You can try to educate some people, sometimes you can enlighten them, sometimes you can’t. You can’t always teach an old dog new tricks though age has very little to do with accepting changes like this.


For anyone who still thinks it is wrong, immoral or just simply unreasonable to transition to the opposite sex (or to non binary gender), look at it this way. If you never felt disappointment and disgust when looking into the mirror, obviously you would have a hard time understanding this condition, but imagine that 90% of your skin got burnt in an accident for a few minutes. Not that I wish this onto you by any means, but think of how hard your life would become. Presenting on the streets or in any public place would be difficult to say the least….. What if you could fix it? Would there be something you wouldn’t do to get well again? I realize that this is an extreme example and by no means do I wish this on anyone, but how dare does anyone tell me that it is wrong, immoral or unreasonable to transition? What right do you have to deny me happiness I have been longing for all my life?

So is it wrong to transition? The older I get the less I think so. I still believe it is more selfish than anything else because I am the only one directly benefiting from it, while it causes a lot of distress to everyone around me but after all we only live once. The thought of knowing I only have a few days left to live terrifies me. If I found out today I have a terminal illness and 6 months to go, only two things would get to me.

One is how much I wished for my spouse and best friend to have a long and happy life and I would not be there to see her achieve it and see her become wiser in the process, the other would be that I lived my whole life in denial and the world never got to know me the way I feel inside.

Day 30 of MTF HRT.


On the 30th day of my HRT journey I was tasked with filling my prescription for more T blocker which now doubles in dosage and adding E. (Estrogen which goes by the brand name Estrace) I’ve been dreading doing this for a while because some pharmacist get really confused when someone presenting as male goes in and asks for Estrogen. I was of course horrified of being asked what it’s for or whether or not I got the wrong prescription but upon presenting the slip of paper, the lady behind the counter really didn’t seem to care a whole lot just handed me a buzzer and said it was going to be ready in a few minutes. That was easy I thought….

Once the buzzer went off, she had some questions about my insurance slip then proceeded to hand me the card reader for payment. I was happy thinking to myself “Is that it????? I don’t know what the fuss is all about” She then told me to wait a minute so the pharmacists can talk to me about my meds. Great! I thought to myself. I am not getting off that easily after all.

The other lady had a big smile on her face and asked: “Are you getting a sex change?” Looking at her face my tension was immediately gone and felt at ease. I then began explaining to her with a grin on my face that the politically correct way of saying it is Gender Reassignment and that I’m not entire sure if that will be at the outcome because I don’t really know how far I’ll be taking this at this point. She was very embarrassed by this and couldn’t apologize enough to which I just laughed as she explained this is a small town in the boonies and she never met anyone else in her 15 years here.

She then asked me if I had any questions about the pills (Spironolactone and Estrace). To my firm NO response she still began explaining them in detail nonetheless, proceeding to tell me that spiro can cause you to be light headed and pee a lot while Estrogen, errr. She froze for a sec. “Will cause you to be awesome and live a happy life???? I finished the sentence for her. With a big laugh she wished me luck and sent me on my way.

MY makeup skills still stink but I’m making progress…..


How Ontario fails and damages transgender people Part1

I’m usually not the one to complain about ON because you have to admit, it’s a very place to live in. We have 4 seasons, decent roads, state financed health care and it is generally a very accepting and diverse place. It is also a province of nearly 14 million people which fine, unless you are struggling with your gender identity, expression and you are just simply confused about it. Everything I’m about to say here is simply based on my experience and doesn’t necessarily represent problems experienced by others, but they do seem fairly universal for ON.

So people struggling with Gender identity issues or dysphoria have fairly limited options which in all cases comes with lengthy wait times, occasional discrimination and general feelings of talking to the wall, or a rocking horse. At first I thought about saying talking to the cat but that can have certain calming effects so I changed my mind.

Here is what the process looked like when I approached my family doctor with my own struggles. She actually treated it really cool, didn’t even bother asking me very specific questions , she just began to proceed telling me what option(s) I had. The s had to be in brackets because the only official route with OHIP is to get referred to CAMH, the Centre for Addiction and Mental Health. Now keep in mind that this really is the only official OHIP sponsored institution prepared to deal with people struggling in a province of 14 million. Well population is one thing but the shear size of this great province of ours can also cause headaches considering that it’s in Toronto which can represent a serious issue for some people from up North. Luckily I’m always a two hour drive away from Toronto but I know there are many others who are not so lucky.

Upon presenting my story to my family doctor of nearly 12 years, she seemed to have taken it really well, I didn’t sense any judgment of any kind, she just told me she’s got other patients in the same situation with Vulcan like emotions. It was basically the same experience as when I visited her a few years ago with a nasty back pain. She informed me that the only option we have at our disposal is CAMH, she will have me referred there and that I should hear from them in less than 2 years (!). Now less than 2 years can meat 3 weeks, 9 months or 2 years -1 day. She said it’s obviously not a rush if I waited this long….. Granted I’ve been her patient for a long time and this was the first time I opened up to her about my issues, but still…. Once the flood gates are open, there is rarely ever turning back and this issue of mine has really been my obsession for a very long time. The choice for me to transition never really became clear until about a year ago after 50 or so sessions with my therapist. Up until beginning therapy, it remained just a fantasy really but never imagined it possible even though it has been haunting me since my earliest memories from childhood.

Hello world!


Finally I forked up the “balls” to start a blog to share my experiences with the world. My blog will only focus on transgender issues and related stories with only minor distractions. I am in on Ontario, Canada. I started seeking help to transition at 32 which is quite late compare to some, early to others. This is nothing new, I’ve had it all my life but always managed to sweep it under the rug due to different circumstances in my life. In my teens and tween years I thought it was manageable and my desire would remain a secret only to be carried with me to the grave but it is not to be so. My desire only grew stronger over the years and finally at 30 it became debilitating. I like to think of it as a simple equation. In my earlier years, my “condition” only occupied about 10% of my mental capacity and the there 90% was used for everyday stuff like, working, friends, technology and life in general. The issue that became obvious was the formula turning 10-90 to 90-10, building pressure and momentum that finally overtook me and I could no longer ignore it, pretend it to be non-existent. I’m VERY LUCKY. I have an awesome partner and some other very supportive people in her and my family. As I go on, I’ll get into family dynamics but I’m still very early on so that’s for much later. I also have a pretty cool job that pays the bills, keeps me occupied and it can be quite a lot of fun at times.

I actually wanted to start a blog to only rant and complain because getting medical help for transitioning in Ontario is not easy. It is a huge province of 14 million with VERY limited resources and lot’s of gatekeepers. I will do my best to write about my journey with all the ups and downs of fighting the system.