Thursday, October 25, 2018

Gatekeeping, Ignorance, Transphobia

Do you know what gatekeeping is?  Here is an acceptable definition:

the activity of controlling, and usually limiting, general access to something.

How exactly does that apply to trans folk?  Normally it is interpreted as - you cannot do this thing, take hormones or have surgeries, until you have met the following predefined characteristics.  Those characteristics are outlined within WPATH's(World Professional Association for Transgender Health) SOC (standards of care.)  The SOC have never been an issue for me until recently.

About six months ago I had a pretty big panic attack when my pharmacy told me they would not be able to refill my spironolactone scrip due to being out of that medication, and further more they had no idea of when they were going to be getting anymore.  Admittedly I was going to a very poorly run CVS, but still!  They advised me to start calling around.  Which I immediately did.  My panic levels slowly rose with each phone call and denial I received.  If you don't know, it is the spironolactone which keeps me from absorbing that wonderful, naturally produced steroid called testosterone.

Pretty much no one, especially me, wants me operating on testosterone ever again.  It is not a pretty scene.  Anywho..... after a multitude of phone calls and a few in person visits, I finally found a pharmacy willing to work with me, who calmly explained that they would easily fill the script, just with a different manufacturer's version of the drug.  Whew!  Close one.

But it drove the point home, that it radically pisses me off that I am not in control over my own body.  I don't naturally produce the hormones that I should, and further more, my very own body is constantly in a battle to poison me with that nasty testosterone!  (I get that if you like it T can be just as awesome as E, as long as that is what you are wanting and expecting.  I also understand that T is not a poison, I'm just stating it for dramatic effect!)

Okay, so super long prelude to discuss something that many of you may not wish to read about - So this is your fair warning part - if you would rather not read about personal intimate surgeries, then go no further as this is exactly what will be discussed - and it will involve those private of privates, genitals!

Are you sure you want to proceed?

Really sure?

Okay, but don't tell me I didn't warn you!!

I want to have my testicles removed.  There, I said it.  Yeah, I know, thrilling.  Well actually for several people in my life, this decision kind of freaked them out.  Me?  Nope, I've been wanting it for awhile now.  My wife, nope, she totally gets where I am coming from and is in full support of me.  However, some others?  Not so much.

Whatever..... this procedure, if you don't know, is called an orchiectomy.  It is a fairly small procedure, which lasts about an hour and can be done either under a general or a local anesthesia.  However, in order to qualify for this surgery, certain hurdles need to be passed.  I have had no issue with passing all of these hurdles, except for one.  Most doctors willing to do this procedure need 3 letters, 1 from my hormone doctor, 1 from my therapist, and 1 from a mental health professional with a doctorate degree.  My doctor readily gave me hers, my therapist is working on hers, but I don't have the third.  My therapist recommended a psychologist who I had heard of.  What transpires is our interaction.

(I did try and remove any identifying information from this person, but if want to know who it is, email me and I'll share it with you personally.)

 Hi  -

I am a transgender middle school math teacher in California.  I have been working with my doctor, Julie Nicole for my hormones, and my therapist Carol Montgomery Brosnac, for about the past year and a half.  Carol is who recommended me to you.  I have been researching doctors to help me with an orchiectomy.  Several of the places I have spoken to are requesting a 2nd letter from a mental health expert and I was wondering if you can help me out with that.

I live in the Central Valley, near Bakersfield, so possibly doing an online appointment would be ideal.  However, I think you are closer to the Bay Area, and it is possible for me to drive on up that way if that is what would be best.  

Please let me know if you are able to assist me with this. 

Thank you!

Dear Kelly

I will be glad to help you with this matter. I am familiar with both
Carol and Julie and feel good about following up on their work with you.

I am open to working with you over Skype. Before we set a date please
read my new client information page
(on her website)  If you agree with the
conditions I have listed there, get back to me with your consent and I
will get back to you to set up an appointment via skype.

My fee is $150 per session. If all goes well, I should have enough
information in one session to feel competent in writing the letter.
There is an additional fee of $50 for my time writing the letter.

Thank you for your inquiry. I look forward to hearing from you.

Dear _______-

Thanks for the prompt reply.  I have read your client information and all seems good.  However, before we proceed to an actual appointment I do have a concern.  While Dr. Nicole and Carol are both in support of me in receiving an orchi, WPATH guidelines clearly state that I need to have been living in my preferred gender role for at least 1 year.  That is the area in which I am a bit fuzzy.  Talking to Carol she said it is a recommendation and in version 8 of the SOC, it may be removed in regarding just an orchi.  Just a brief bit about me - I was convinced that I was non-binary for the past 8-10 years or so.  During that time I went to work, and lived my life in a half and half appearance.  Meaning, everything I wore was feminine, clothes, jewelry, painted nails, using a purse, etc, however I did not have anyone address me as female.  I thought I was doing well until I had a bit of a break down and realized I was not addressing the real issue.  Which of course is that I am actually a woman.  That is when I began hormones.  Which was July 3rd, 2018.  I then let everyone at my job know that I am trans as I had to dispute my employers discriminatory health care policy,  I made an appeal, they denied, I took them to EEOC, we mediated, and as it turns out they are totally legally able to deny my health care benefits based on being a private pay insurance.  Sorry for the long story - it was at that point that I began to pursue my legal transition.  I got my legal stuff done on June 28.  Woo-Hoo!!  Thus I then began this school year with my new legal female name, and had students switch to Mrs. I have decided to make my appearance decidedly much more feminine to help others in my life with the changes.  Oh and yeah, my wife has always known, married for 22 years, together for 32, my sister, my only remaining family has known for at least 10 years or so.  And at this point I don't think there is anyone who doesn't know.

Okie dokie, so now here we are, and I am pursuing an orchi but many places wont even talk to me until I have 3 letters.  Being as you are a WPATH doctor, would you be willing to hear my story and at least consider writing me a letter recommending an orchi, even though technically I have not been "full time" for the 1 year period?  If it helps at all, most likely the orchi would not take place until next June.  

If this is acceptable to you then I would for sure be willing to meet with you.  If not, I'd rather not waste more of both of our time, so please let me know your thoughts on the matter.

Thank you!

Thank you for the informative reply. My first take on what you have told me is why do you want an orchiectomy so early into your transition? Is there a medical need for one--i.e. you can't tolerate large doses of estrogen? If that is the case there would be no one year RLE requirement. Another question...if you are not planning on having the orchi until next June, why do you want the letter now? One of the reasons a letter is required is for the surgeon to know you have been examined by a mental health provider and can make an informed consent to the surgery. Having that examination 8 months in advance does not qualify as timely. He or she may want a more current letter later on. Another you have a surgeon set up for this? Perhaps you have already discussed this issue with him or her and have some sort of agreement.
Having said that, I remain open to seeing you for the evaluation. Keep in mind that the letter would note your state of mind as of the date we see each other and that you will not have satisfied the SOC until June 2019. At that point it will be up to you and the surgeon to decide what  to do. 
Let me know how you want to proceed.

Hi -

1.  Why do I want an orchiectomy so early into my transiton?
I do not consider where I am at to be early into my transition.  Personally I see my transition as having been a long drawn out one.  True, there are those who would view my transition as having just started.  But that view point is highly limited in its definition of transition.  There are those out there that do indeed go from appearing as nothing but one gender and then abruptly change to appearing as the opposite one.  But that is not me.  And that is certainly not how those in my life have viewed me.  I would estimate that my social and professional transition began at least 10 years ago.  That is the point at which I decided to stop appearing as a typical male would.  I began dressing, full time, as a blend of genders.  Pretty much the only difference in my appearance between then and now is that now I wear a wig and makeup on most days as opposed to just some days.  There is the difference as well with having legally transitioned.  But assuming that I am early in my transition erases non-binary entities entirely.  I would more accurately describe this stage of my transition as far closer to the end of my transition than the beginning.

2.  Why do I want the letter now being as I am not planning on having the procedure until June?
Many surgeons will not even have a consultation with me until I have 3 letters.  In fact I am finding it extremely difficult to find surgeons who are willing to work with me as I am only interested in an orchi and that I do not have insurance coverage.  The other issue, I did mention I am a math teacher right?  As such I like to have my "ducks" in a line as much as possible.  Most of the places that have published information on surgeon's desires have stated that for most insurance companies the letters need to be dated within the last 12 months.  Placing my desire to obtain this gate-keeping letter at this point well within that time range.

3.  Do I have a surgeon setup for this?
As of now, no.  However the most promising of my inquiries has been with the TG surgery center in Philadelphia.  Which I finally heard back from late last week.  They actually do not require 3 letters, only 2 for an orchiectomy.  Which would make our conversation here moot.

4.  I will not have met the SOC until June 2019.
Again, I feel that is a very narrow and limited view of what a transition consists of.  Which makes me question why this is the ultimate date marker for me.  Would you consider that to be the official date of living as my preferred gender due to me having received my court ordered name and gender change in June?  As if that is the moment that I began presenting as my preferred gender full time?  So does it negate the one year full time requirement if I chose to not wear my wig and makeup on one or both weekend days?  Personally what this makes me ponder is, do the SOC apply to non-binary individuals?  Or if you are non-binary will you not ever qualify to have any genital surgeries?  One can have breasts installed or removed.  One can have FFS.  But one cannot have their testicles removed unless one is the stereotypical transexual woman and presents as a stereotypical cis-woman does?  So, what if I legally change everything, however I don't present as some think I should, would I not ever qualify then?  

Basically, what I am seeing is a deficit in the way the SOC are applied towards non-binary humans.  The SOC are fine, if you think that gender is a binary and humans are either one or the other.  And that even if I wear women's clothes full time, along with my nails painted, along with using a purse, along with wearing nothing but feminine jewelry, along with telling everyone in my life that I am transgender, that I am somehow less of a transgender human being because I am not conforming to someone else's idea of what gender is.  

As a non-binary human, I went to my job and fought for the rights of all transgender individuals.  I went before a public committee and argued that our company should cover all transgender healthcare procedures.  When that appeal was denied, I took my concern to the EEOC.  I participated in mediation, attempting to have my company's policies changed,  And what I am currently hearing is that even if my company changed their policies, I personally would not have benefited from that change until I presented full time?  

Much of this reeks of a trannier than though attitude.  Those who are deemed transgender enough, by those who are in positions of power, wield that over other individuals in an attempt to get them to conform to their view of the world.  This process does not seem any different than the transphobic attitudes expressed by our current POTUS.  You will express your gender the way I say you should express your gender, otherwise I will not give you the same basic civil rights because I deem you to be somehow lesser.  

I know that I am opinionated, and I hope that I have not personally offended you.  For while even expressing my opinion I am terrified that at some point I will need to return to our interaction and ask you yet again for a letter that I should not have to need in the first place.  Cis-gender humans can have procedures done to themselves without a single letter from either a doctor, or any mental health professionals, they simply need to find a doctor willing to perform the procedure and be able to pay for it.  Should not all transgender human beings be afforded the same basic decencies?  

I will trust that you will remain a professional and that if in the future I will indeed need your services for this letter that you will remain open to working with me.  Thank you very much for your time in this matter.


That is quite a discourse on how you have been discriminated against by the SOC 7 (of which I am a co-author). All I did was ask a few basic questions as to where you were in the course of living your life. What I got back went way beyond that to being insulting. Comparing me to "POTUS", especially after the last couple of days, was beyond my ability to continue to be professionally objective about working with you in the future.

_______ -

Can I remind you of these couple of sentences, "Keep in mind that the letter would note your state of mind as of the date we see each other and that you will not have satisfied the SOC until June 2019At that point it will be up to you and the surgeon to decide what  to do."

That was not a simple ask to a few basic questions.  That was directly informing me that regardless of what transpired during our potential meeting, that June 2019 was the date at which I would be able to receive the procedure I am interested in.  

That was plenty clear.  If that was not what you meant, maybe it should have been stated otherwise.  It is unfortunate that you are unable to remain professional about this matter.  I will allow my therapist to understand that for non-binary individuals that you may not be the best resource to refer people to in the future.

This is why WPATH has gotten a bad rap for being a group of gatekeepers.  However, my therapist is a WPATH therapist and her opinion on the matter is far different than the one expressed by this doctor.  The other thing, if you didn't catch it, is that I found a surgeon willing to do the procedure with only my doctor's letter, and my therapist's.  Thus I luckily do not have a need for this letter.

As well, while closely reading the SOC I discovered that this particular psychologist, who claims to be a co-author of the SOC, is unaware that in Version 7, there is no need for any RLE (real life experience.)  Shouldn't someone claiming to be not only an expert, but a co-author be aware of what the SOC actually says?  I think they should.  Especially when they then attempt to use that as a basis for denying care!  Unreal! 

But isn't the real issue here transphobia?  It is only through a transphobic society that prerequisites are established for how one treats their own body, when it does not conform to expected gender norms.  Now I am not a professional surgery expert, and I certainly do not know everything there is to know about every possible surgery out there.  But with that being said, I also have not heard of any other surgical procedure that requires what transgender genital surgery does.  There are a multitude of prerequisites to be met in order to even be considered for those procedures.

Some of you may think that it is a good thing.  But I will again question you and ask, what other procedures require the consent of 4 people - the doctor performing the procedure, the doctor who gives you hormones, a therapist, and a psychologist?  As well as other requirements.  Look them up if you'd like.  Think this is good?  Then I better start seeing you protest to have similar "protections" put in place for similar cis-gender surgeries as well.  It's not going happen.  Want a facial surgery, go for it, want bigger or smaller or no boobs?  Go for it.  Want your vagina redesigned?  Yup, go for it!  Not one of those things require anything other than your desire and a doctor willing to do it.  Transphobic much?

Okay, I gotta stop!

I love you!

I hope you love yourself!


  1. I feel your pain, I had my second therapist meetings, I have my letters, I have been in therapy for 6.5 years and HRT for over two years, my physician put in the request for an orchi, only to be greeted by the gatekeepers at Regence Blue Cross using the WPATH Guidelines to tell me my magic date is February, 2019. I was scheduled for late September. I am frustrated beyond belief.

  2. Hi Nadine:
    You should read this article about Spiro. You might decide you don't need or want to use it:
    Dr. Reed in Miami FL only requires 2 letters for an Orchi, and is running a reduced cost of $2000. You can read about it here:

  3. Hi Nadine.
    I am continually amazed and frustrated with rules and regulations that are created by people that will not be impacted by their actions.
    Also just wanted to let you know that I REALLY liked your brand new drivers license.
    Hopefully all will work out sooner than later.
    Hugs Charlene 💕💕