* Psychologists in their role of gatekeeper work on mitigation of risks for a doctor
* Transgender people want what is best for themselves: the right care at the right time
* These interests don’t always lead to the same result!
Blackmail with care
Blackmail with care takes place in many areas. This already begins with mental care: patients are forced to do something about their mental problems as part of the transgender treatment. This is also approved of in the Standards or Care (SoC), for instance read along here: "[...] Possible concerns include: anxiety, depression, self-harm, a history of abuse and neglect, compulsivity, substance abuse, sexual concerns, personality disorders, eating disorders, psychotic disorders, and autistic spectrum disorders (Bockting et al., 2006; Nuttbrock et al., 2010; Robinow, 2009). Mental health professionals should screen for these and other mental health concerns and incorporate the identified concerns into the overall treatment plan. These concerns can be significant sources of distress and, if left untreated, can complicate the process of gender identity exploration and resolution of gender dysphoria (Bockting et al., 2006; Fraser, 2009a; Lev, 2009)."
Let’s be clear about this: if patients choose to do something about these problems, than can prove to be very useful. However, in our opinion this should not be seen as a necessary requirement to get access to hormones or operations: there can be very good reasons to leave problems from the past behind. Also look at the conditions for the supply of hormones, the fourth item listed: "If significant medical or mental concerns are present, they must be reasonably well controlled." We think there are different ways to diagnose whether mental problems are reasonably well controlled than by extensively discussing which problems have existed in the past and how those problems still affect the patient’s daily life. Being controlled can also mean the problems do not play a significant role in the patient’s daily live any longer and they do not like to be reminded of them. The Standards of Care also respect this approach: see for instance the non-mandatory character of psychotherapy (p. 34) and the information about Informed Consent on page 41, the SoC respect Informed Consent and do not reject it.
English language source text of the Standards of Care (p. 30, p. 34, p. 40, p. 41)
Dutch translation of the Standards of Care (p. 27, p. 30, p 35, p. 36-37)
There are also gatekeepers who see it as their job to include requirements from doctors in their mandatory conversations with transgender people. Some gatekeepers worry about the blood levels of diabetic transgender people and therefore object to the prescription of hormones: in their opinion the transgender person must first work on their diabetes before hormones can be prescribed. But this person usually has been working on that for a long time, without (much) success. He/she thinks it would be a good idea to first take away some of the distress, after which working on the diabetes would be a lot easier. We are inclined to agree with this transgender person. We know how difficult it is to have a body that doesn’t fit you. Gatekeepers in general do not know this from their own experience and many psychologists who decide on treatments lack the empathy to realize what it is like to live in the wrong body and what that does to one’s psyche. (If you too find it difficult to understand what that feels like, read the personal story from 2007 elsewhere on this site). The more stress somebody has, the more difficult it is to improve the diabetes. Blackmailing transgender people with care increases their stress and will make it even more difficult for them to reach the targets set by the gatekeeper.
And it is not just about diabetes: similar things can be said about alcohol, substance abuse, smoking, overweight, underweight, social circumstances, mandatory social transition (Real Life Experience), etc... Alcohol, substance abuse, smoking, overweight, and underweight can serve as survival mechanisms to cope with the difficulties of life. Forcing people to experience their feelings in a non-attenuated way makes their lives (much) more difficult than necessary. It would be a lot smarter to first provide the transgender person with hormones/operations, which will reduce the stress about a wrong body shape and make it much easier to work on other problems. In the Netherlands we have a TV-commercial about skin burns. Its slogan is "first water, the rest comes later". In transgender care the slogan should be "first the requested care, the rest comes later". We do understand it is difficult for therapists: after they have given permission for hormones or operations, they have no way to exert pressure on the patient to make them work on the problems that should -also- be solved. But let’s be honest: is force-feeding care really healthy for the patient?
In diagnostic consultations and in reading DSM-5 and the SoC we notice that psychologists with a gatekeeping role make erroneous assumptions. We have already done a poster presentation about this at the EPATH in Ghent. The disadvantage of such erroneous assumptions in gatekeepers is that they can have a hugely negative impact on our care program. You can find the poster presentation and more explanation here.
Gatekeepers often ask much more than they need to know. For instance, they ask questions about sexual orientation, as if gatekeepers aren’t aware of the fact that being a transgender person has nothing to do with their sexual orientation.
There are also gatekeepers who ask about sexual fantasies, as if the answers to such questions are relevant for the diagnosis. You can (if you believe in self-determination) read what your psychologist is looking for when he asks such questions here.
It seems like we are forced to give an excessive amount of information. Some transgender people value their right to privacy and are not happy with the fact that psychologists interfere so much with their lives, read for instance this blog by Androgendernaut.
Confusion of roles
Psychologists can have several different roles in our process. The four most important roles are:
- Gatekeeper: judges whether someone is or isn’t a transgender person and checks for comorbidities (mental disorders). If a gatekeeper is a member of a gender team, the patient sometimes has to keep seeing him after the diagnostic phase so that the gatekeeper can check the progress over a longer period of time. In that situation the gatekeeper can advise the hormone expert to temporarily or definitively stop the supply of hormones.
- Curing psychologist: has a caring role. A curing psychologist can help you find out about your feelings, opinions and assumptions about gender. They also offer a sympathetic ear for the (sometimes) terrible experiences you may have had. Some transgender people value a person who helps them in their transition, others dislike curing psychologists because in their opinion they interfere with their personal quest. The main difference between curing psychologists and gatekeepers is that curing psychologists give you full freedom of choice: you can to make use of their services or not. If you stop seeing them, it has no implications for your hormone therapy, operations or registration in the government administration.
- Researcher: researchers investigate particular developments in transgender people. Such an investigation can be about all sorts of topics: for instance the number of people who have non-binary feelings, or the sexual development of transgender people. For researchers it is very nice if people are registered and often see the same researcher: in that way the researcher can watch the development of particular feelings over time.
- PR person: psychologists can try to show the outside world that patients have thoroughly considered "their choice" prior to the hormone therapy or operation to prevent regrets afterward. They may also try to create the image that "we have had a difficult life and THERFORE need help". Indeed, some of us have had a difficult life and some transgender people don’t think well enough before they request a treatment. But the percentage of transgender people who do not think well enough before their treatment is smaller than outsiders say it is. Most transgender people are perfectly capable of making their own choices. This also shows in the Informed Consent model: 0.8% of the transgender people who have been treated according to this model experience regrets later. Internationally this percentage is between the 0.5% and 3% (*). So patients are very well capable of making their own choices and to choose for themselves whether they need help from a psychologist. It would be better for the outside world if psychologists would publicly admit this and emphasize that the word "choices" doesn’t adequately represent the need felt by individual patients. If psychologists would do this, it would reduce the taboo on transgender therapies. That would help reduce the fear for problems a lot better than boasting their "meticulous checks" and their "comprehensive care for all transgender people".
(*) Informierte Zustimmung in der Trans*-Gesundheitsversorgung, Erfahrungen eines US-amerikanischen Community Health Center - Anita Radix und Justus Eisfeld, Z Sexualforsch 2014; 27; 31-43
- Gatekeepers have as their primary task weighing risks for the care provider who asks for an assessment report or a status report.
- Curing psychologists have as their primary task to help transgender people forward with their request for (mental) help.
- Researchers have as their primary task to collect and supply objectively measurable statistical data.
- PR persons work on the image about transgender care to the outside world.
In practice these roles often interfere with each other. This has a number of disadvantages:
- Gatekeeper + caregiver + PR person (VUmc, UMCG, Tanja van Hengel, Alwin Man): The interests of the person for whom the gatekeeper does an investigation (e.g. a hormone specialist) are often different from the interests of the patient. These interests can be in conflict: it can be best for the patient to get hormones immediately, while the hormone specialist wants to give the impression to the outside world that there is a very thorough screening process. He can prove there has been a meticulous screening if each patient has had minimum number sessions with a psychologist. (*)
The effects of combining the roles of gatekeeper and care provider are often underestimated: care providers sometimes say that people would never have sought their help if transgender people weren‘t obligated to see a gatekeeper. So, what would have gone wrong if they hadn’t? Gatekeepers think this would lead to disastrous mistakes, but is that fear justified? Aren’t these psychologists so used to searching for risks, they forget to wonder if it is necessary to test for all these risks in every transgender person? Also see our page with examples for examples of how things can turn out well if transgender people take their own responsibilities!
Hormone specialists often mention the possibility for a psychologist to immediately intervene (give care) if he finds out something goes wrong during the supply of hormones (gatekeeper). What the hormone specialist means, is that the supply of hormones can be immediately stopped in such a situation, so that he is no longer responsible for supplying hormones. How honest will a transgender person be to a mental caregiver, when he knows there is a chance that the result of a talk with the psychologist might be that the supply is hormones will be stopped (temporarily or permanently)? And is stopping the supply of hormones really the most logic first step when something goes wrong?
What often happens at VUmc is that transgender people modify their decisions to follow advices from care providers because the care providers are gatekeeper as well. We know several trans men who get the advice to wear their hair in a ponytail or to have it cut short, and the transgender person follows this advice because he thinks that it will help him to sooner get the mastectomy he needs. These trans men told us that they would not, or only later, have adjusted their gender expression if the psychologist had given fewer directives about the way they look. Trans women who always wear pants also get the question if they ever wear a skirt or a dress. It is not clear to us whether these questions are related to the diagnosis or whether they are intended as help in the transition process. It would certainly not be appropriate if they were part of the diagnostic process: in our view clothes and passability are not the right criteria for deciding whether or not customizations of body parts are needed (see our other website www.betterassumptions.nl for more information about this).
(*) There are many arguments against this, for instance that such a hormone expert doesn’t comply with his doctor’s oath to do no harm. Unfortunately, doctors often have a different view on this: they feel responsible for the care they do provide, but not for care they don’t provide (or provide too late). In our view, doctors who demand an assessment report from psychologists are partly responsible for the damage caused by these psychologists who decide on treatments.
- Gatekeeper + researcher (VUmc): In the diagnostic phase (gatekeeper) many lies are told about feelings because that will make people eligible for obtaining hormones sooner. Example: when investigating how many people have non-binary feelings and the investigation is based on data from the diagnostics, there is a big chance that the researchers will find relatively many “real” men and “real” women, compared to an investigation that is not related to any diagnosis. It turns out this does happen indeed: research by VUmc shows that 70% of transgender people have binary male/female feelings and 30% have non-binary feelings. But research by Rutgers (investigative role only) into transgender people’s sexual health shows that 57% of the respondents have binary male/female feelings and 43% have non-binary feelings.
Another disadvantage is that gatekeepers are mainly searching for what they already know (they are looking to which extent a specific transgender person does or does not fit in a generic model), while researchers with an open mind should be searching for possible relations. For people who are fitting transgender people into categories every day it is much more difficult to think outside these beaten tracks than it is for an independent researcher.
The research by VUmc: was presented to us during the WPATH pre-conference, see the FreePATHH website for a report.
Research by Rutgers WPF (free download): http://www.rutgers.nl/producten/een-wereld-van-verschil
- Caregiver + researcher (VUmc): For someone who provides care, it doesn’t matter whether he sees somebody one time, ten times or one hundred times (*). The only relevant question for a caregiver is: can I help this person. If the person isn’t willing to accept help, you cannot help them. From the point of view of a care provider it is best to stop helping in that situation. For researchers it is convenient to see people on a regular basis to monitor possible development in their psyche. A psychologist who is both caregiver and researcher will be more likely to steer towards multiple follow-up consultations than a true caregiver who will ask himself, and the customer, whether a follow-up would be useful at the end of each session.
(*) Unless the caregiver has difficulties to find enough clients, in which case there is a conflict between their own interest to earn an income and the interest of the patient. Our reasoning is based on the situation of care providers who don’t have a problem in getting enough clients.