The Frighting Price of Gatekeeping
Late me say in the first paragraph: SOME level of screening for psychological conditions (such as dissociative disorder) masquerading as gender dysphoria is reasonable and appropriate. I’m not suggesting that all possible procedures should be completely wide open. I’ll get back to this in more detail below but I want it out there up front.
With that said…
This week their was a news item out of Colorado that caught my attention. Typically this sort of event doesn’t make it into the news and is only known within the small circle of people who had first hand knowledge and those they discuss it with. It is not epidemic in proportion, but is far more common than most of us would expect.
The story describes a trans women who made arrangement with an unlicensed amateur to have a home orchidectomy (removal of testicles). The man, who had apparently successfully accomplished the feat before having practiced originally on sheep, botched the procedure this time and the trans woman almost bled out in her home before being rushed to the hospital where her life was saved. According to a Reddit thread she started after she was out of recovery, she got to that desperate choice by way of a long series of obstructions raised by the too-demanding gatekeeping process set up to, supposedly, “protect” trans people.
The analogy to so-called “back alley” abortions is strong. In places where access to safe and legal abortion is restricted, desperate women do not always simply resign themselves to their fate but often put their lives at risk in questionable places with unreliable or even deceitful people. In a professed effort to “protect” lives, lives are lost.
Perhaps this story resonates so strongly with me because I can in some ways see myself in this woman’s shoes. While she is not yet 30, I’ve endured the presence of “the evil twins” for over four decades, but in the time since I began my transition some nine years ago, I’ve become keenly aware that almost everything involving physical transition, if done the medically safe and approved way, is beyond my financial reach. Things as basic as electrolysis and HRT are not locally available, not inexpensive (when you count office visits and blood tests for HRT) and not covered by insurance which is itself often prohibitively expensive. When one calls it a good month when all the utilities are paid and you don’t run out of food this month, thousands of dollars on surgical interventions might as will be millions of dollars but, even if one does scrimp and save the bitter reality is that the procedure itself is just the foundation of the expense.
With few exceptions, urologists (the surgeons who can preform such a procedure) require two letters from psychologist or psychiatrist in a very similar fashion to what WPATH Standards of Care recommend that surgeons which preform GRS demand. Some plastic surgeons who preform even breast augmentation flat out deny “born male” patients. Similar barriers face trans men who seek to have a hysterectomy or breast reduction. Moreover, sometimes the provider would be flexible but the insurance, if you are fortunate enough to have it, places those barriers in place anyway.
The problem with this, and the major flaw in the gatekeeping structure, is that there’s no limit or standard applied to how long a psychologist can milk you for very expensive visits before he or she is declared fit for the procedure. The woman at the heart of the above news story repeatedly had to “start over” with new psychologists because of unavoidable circumstances and so spent thousands of dollars to obtain “certification” only to come away empty handed. THIS is not at all uncommon. It’s almost routine that the single most expensive part of a transition journey is not the surgery, but the psychological screening.
Here’s an example of how wrong that is. At the current moment I’m in the process of preparation for gastric sleeve bariatric surgery. Care to guess how much time I had to spend in psychological evaluation to eliminate the potential of being motivated by a mental health issue? ONE session. Less than two hours. Why then are so many trans people played out for months and months and sometimes years before getting the required letters? It’s madness and intolerable. We cannot even begin to estimate how many women have died because of it. I know that for myself, were I a single person with no close family, I may very well have made that dangerous choice myself.
There are many things wrong with trans health care in this country:
Providers with abysmal knowledge who have to be taught by their patients;
Providers who refuse to provide transition care at all due to moral judgments;
Providers who won’t even accept trans people as patients for any condition;
Huge sections of the country with no trans-knowledgable and friendly care within hundreds of miles;
Complete absence of a robust and respectable informed consent care system;
Surgical options exceedingly rare and far between;
(even non-medical but necessary transition care such as hair removal is often too distant)
Many insurance providers with no coverage, or burdensome restrictions;
And on top of all that, we’re expected to take our hats in our hands and go begging for approval from a psychologist who may be happy to take months or years to grant the boon of a letter allowing you to direct the course of your own life. Enough already.
Photo by: Cory Doctorow