This piece is written in response to a recent incident which was conveyed to me by my friend, Bree.  Bree is a smart, talented, and beautiful trans woman who I have the great pleasure of calling my friend.  She’s got issues with anxiety, but she really is cool and fun to talk to, and I care about her very much.  However, as part of the process of transitioning, like all trans women, Bree has to get help from a therapist.  Which to be honest is not a bad thing, unless the therapist begins acting as a “gatekeeper”; that is, acting as a hindrance or barrier on her path to transition, rather than as a helping hand or advocate for her needs.

Before I start on this (as it may quickly start sounding like a rant), I want to say that my own therapist is awesome.  She’s caring, helpful, guiding, quick to listen and very understanding.  To be honest, it is her example which informs my own opinion of what a therapist should be; I am not a psychologist in any sense of the term, except perhaps as an armchair type.  I grew up in a household that was filled with psychology terminology and ideas, from both of my parents.  I believe that this environment was extremely conducive to a positive world view, where the focus is on understanding and working with the behavior of others as individuals.  However, I lean much more towards the sociological perspective which looks at the larger systemic and systematic causes and how they have an effect on human behavior.

So, with the understanding that I have no real formal training about being a therapist, I press on.

Bree’s last session was meant to involve her working with her therapist on locating a suitable place for her to get laser facial hair removal performed.  This is a necessary task, as despite the hormone replacement therapy that trans women undergo, the facial hair that begins to grow after puberty does not stop growing (it does slow its rate, however).  Right now, the two means of long-term facial hair removal for trans women are Laser and Electrolysis.  Electrolysis requires less up-front money, but requires a greater time commitment and eventually costs more; however, it is entirely permanent, or at least as permanent as facial hair removal can be.  Laser, on the other hand, requires a substantial up-front outlay of funds, but delivers results much faster and for much less money; it is considered a ‘permanent’ method of hair removal, though really, it’s only been proven to be a (very) long-term solution.  Right now, the typical regimen involves getting facial hair removal performed first, for six sessions or so until almost all the hairs have been removed, and then electrolysis to deal with the remaining smaller hairs.

Bree had apparently made this a high priority, and voiced this to her therapist, who had agreed to use this past session to help in the process of finding a place that she felt comfortable going to.  However, when she arrived, the therapist had changed his mind and determined that Bree should do other “less expensive” things first.  While the therapist is certainly justified in suggesting that Bree consider other options first (in order to increase the effectiveness of the procedure or maximize the efficiency of the money spent), simply stating that Bree should do other things and then refusing help after agreeing to help is out of line, in my opinion.  Once Bree made it clear that her first priority was hair removal, then that should have been enough– but it wasn’t.

The reason this stuck out for me is twofold.  First, because it had such a devastating effect on my friend.  Bree fell into a depressive episode following this, becoming discouraged– for someone with anxiety problems, this is not a trifling matter, it’s serious.  The therapist should’ve been more thoughtful about how he was going to handle this in order to prevent exacerbating her anxiety, and should have put her opinions and feelings first while considering how to present the idea of postponing this procedure.  Second, because this is something that seemingly happens all the time to trans people (especially trans women), in both therapeutic/counseling settings and in medical settings.  It’s a holdover of the old “gatekeeper” model, where mental health professionals and physicians placed themselves into a position of being barriers to treatment for trans people.

In the past, it was much harder for trans people to get the medical help they needed.  Only so many mental health and medical professionals would even deal with their situation to begin with, and all of them had their own ideas and schemes for determining if care was justified.  This forced many trans people to act out stereotypical roles for long periods of time and to go “full time” far before they were ready socially or legally in order to get the medical treatments they needed.  Trans women were pretty much required to dress as feminine as possible, regardless of suitability to their profession or social status and trans men (if they were acknowledged at all) were required to be as masculine as possible, regardless of their situation.

Medical professionals would not provide care until the trans person had gotten the okay of a therapist or psychiatrist.  The therapist or psychiatrist would not give the okay until they felt the person had “proven” themselves to be… well, “trans enough”, is the best way I can put it.  This set back not just individuals on their own paths to mental health and personal fulfillment, but also the entire field of research into trans people and the condition of transexuality, by creating a selection bias:  If you only recognize as transexuals those who fit your own personal prejudices about transexuality, then you taint the pool of patients that you can work with for understanding and coming up with better treatments.

Even then, medical professionals would set themselves up as all-knowing experts, the final gatekeepers for the physical aspects of gender transition.  They would deny or grant treatment only to those who fit the “type” they were already used to seeing; the prejudices of the physicians, rather than the evidence at hand, was the final word.  Again, by only recognizing those who fit the bias, they tainted the pool, setting back individuals and the entire field.  This ruined lives, leading to horrific results for those who were denied treatment by their “gatekeepers”.

The thing about being transexual is that there is no independent, absolute test.  It is just something that the individual knows, from personal reflection and understanding.  This is why therapy is key; it helps people sort through their issues, feelings, thoughts, and past in order to examine themselves and uncover the truth.  The therapist is to act as a guide, to help the person find what he or she really wants and needs, and to them help them figure out how to realize it.  While a therapist is still required to sign off the “magic letter” required for the initiation of Hormone Replacement Therapy, it should not be a question of whether the therapist is satisfied that the person is “trans enough” to begin it, but rather than the therapist is satisfied that the individual has explored all of his or her options first and done some real personal examination to find if they feel that they are trans.

Once that point is reached, then it should be a simple matter of helping the trans person to find out what he or she wants to do next, and then help them realize it.  That’s it.  There should be no obstruction, no gatekeeping, and none of the vestiges of paternalism from the old horrible order which destroyed untold lives.  That is why what happened to Bree is so striking to me; because I see in her case, the last bits of those old ways fighting to harm yet another person.  The “gatekeeper” model should be laid to rest for good– it is only through mutual respect between a therapist and her patient that proper treatment can commence.

I’m hoping that Bree will find the courage to stand up for what she wants and to demand to have more say in the path that her transition takes, because she sure deserves to as much as anyone else does.