To me, a gatekeeper in the traditional sense is kind of like a check [list] 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."

Marti Abernathey, a trans woman and the founder of Trans Advocate

A trans patient is referred to your practice. This patient has indicated interest in having phalloplasty and requires two reports stating that he is ready for this lower surgery. You agree to meet with the patient for the purpose of a pre-surgical assessment.

Background

Jim is 25 years old and began his medical transition 5 years ago. He started testosterone at the age of 20, and at age 21 he had chest surgery. The referring physician indicated that Jim has a diagnosis of borderline personality disorder and that he was hospitalized twice in his early 20s for acute suicidality.

The Scenario

You begin your session with Jim as you do with other trans clients. You first tell Jim that no matter how the session goes, you believe that trans people have the right to make medical decisions about their bodies. You explain to Jim that you will provide him with a report in support of phalloplasty, and that your job is not to decide for him. You explain that your role is to have an open, explorative, and supportive conversation about all the psycho-social implications of lower surgery, and potential risks and benefits of having phalloplasty.

You start by asking Jim a few questions about his gender identity, his goals for transition, and what he knows about the risk and benefits of phalloplasty. Jim knows a lot about the various phalloplasty techniques, but he still has a few questions. Together, you look at the lower surgery decision-making aid for trans men, which helps to answer some of Jim’s questions. You explain to Jim that the surgeon will be able to answer more specific questions about the different surgical techniques.

You remind Jim again of your commitment to provide a report in support of phalloplasty, and you ask him what he’s most looking forward to following surgery. He replies that it will make his life easier and worth living and that he will feel more “whole” and it will give his life more “stability”.

You want to address that the WPATH standards state that any mental health issues must be “very well controlled” prior to lower surgery. However, in your practice you flexibly interpret “well controlled” in the context of the patient’s life and goals, so you ask:

What is your mental health care plan for after surgery?

Who are your main supports?

What have you done in the past when you have had bad days, or the desire to harm yourself? What has that looked like?

What do good days look like for you?

Have you recovered from a surgery in the past? What was that like?

Have you had other medical issues that may have impacted your mental or physical health? How was that for you? How did you manage?

It is revealed through this discussion that Jim had a successful care plan in place for his chest surgery recovery. You and Jim talk about what worked well about his previous surgical care plan, and what he might need to plan to do differently this time around, given that the recovery for phalloplasty may be more extensive and typically has a longer recovery time.

Discussion

Bring things back to the principles of patient-centred care and collaboration in medical decision-making. Emphasize that even if clinicians don't think that trans people are "ready yet" or "stable enough" for surgery, they can offer to support trans people, but should not withhold a referral letter. For example, some clinicians may feel that their clients/patients require more counselling, or psychotropic medication prior to accessing hormones or surgeries. But it is important to recognize that ultimately mental health treatment is a personal decision and these are not treatment decisions to be made under duress. For example, trans people may feel coerced into mental health treatments in order to gain access to hormones or surgeries.

When trans people are experiencing mental health issues at the time they are medically transitioning, they may feel caught in a double-bind. They may feel they have to deny or downplay any mental health issues in order to strategically gain access to hormones or surgeries. Or they may feel they have to prolong medical transition until after seeking mental health support. But this scenario creates a medically risky situation. Trans people with mental health struggles may miss out on being presented with treatment options if they feel they have to choose between transition-related medicine, or seeking mental health support. On the other hand, delaying medical transition for some trans people risks exacerbating mental health issues.