The first interview went smoothly, but the second was ‘terrible’, recalls Mrs. Rolletschke. She was judged on how she put on makeup, how she sat, how she moved. She was questioned about her romantic and sexual history; the implication was that she was somehow less of a woman if she was romantically interested in women. While the interviewer ultimately did not object to Ms. Rolletschke’s ability to change her name, she seemed to hold Ms. Rolletschke to a retrograde, even discriminatory, idea of what a woman was. Ms Rolletschke says that when she later read the report, she saw that the interviewer had misjudged her the entire time.
This stereotyping was far from coincidental, but one of the first goals of the gatekeeper model: to ensure that only people who could ‘fit’ were allowed to switch. A successful transition, it was thought, meant that no one would know the person was transgender. Conventional attractiveness – and gender conformity – became a proxy for a successful transition, a bias that still persists today.
But many transgender people no longer want to succeed. A June survey by the Williams Institute of the UCLA School of Law found that approximately 1.2 million Americans identify as non-binary. Not all non-binary people identify as transgender, and not all, if not most, non-binary or transgender people will undergo medical treatment. But many, like me, will. In my community it is now common for transgender people not to hide that they are transgender; many, like Mrs. Rolletschke with her prominent flag, choose to be very visible outside.
Medical Gate Guard Evolved not to protect the patient, but to protect the doctor, as Dr. Stef Shuster, an assistant professor of sociology at Michigan State University, argues in the new book “Trans Medicine: The Emergence and Practice of Treating Gender.” In the 1960s, German-born endocrinologist Harry Benjamin became the foremost physician in the United States helping people through menopause, but the work was so controversial that it threatened his reputation. dr. Benjamin and others like him realized they needed guidelines, ways to determine who was legitimately trans, both to bolster their authority and to protect themselves from the specter of the fraudulent transgender, the one who might try to trick them , or who was simply misled.
Then, as now, there was little evidence that anyone was fabricating a transgender identity. But then, as now, the fraudulent trans person was a powerful, even driving fear in the cis imagination. That fear contributed to the creation of an organization dedicated to transgender medicine, originally named after Dr. Benjamin, which would become the World Professional Association for Transgender Health (WPATH), the most authoritative international organization in the field.
WPATH is expected to release a set of guidelines this spring to help countries establish best practices for medical transition. The previous set of guidelines, issued in 2011 – a lifetime ago in transgender rights – pointed to the importance of informed consent, but also advocated gatekeeper practices. WPATH’s guidelines are not enforceable, but governments and medical organizations around the world are heavily influenced by the recommendations. The trans community is waiting to see how much the guidelines will change. A draft released in January contained language that would remove the requirement of mental health assessments for adults seeking HRT and move closer to a self-ID model, but many health care providers were concerned that it would go no further.
Unsurprisingly, many of the ideas underlying gatekeeping measures are dangerously outdated. Take, for example, the fear of regret. We now know that gender-affirming health care has one of the lowest rates of regret in medicine: A systematic review of the medical literature in 2021, with 27 studies and 7,928 transgender patients, found a regret rate of 1 percent or less. That’s significantly lower than something like weight-loss surgery: A 2019 study found a 5 percent regret rate for gastric bypass four years after surgery and a 20 percent regret rate for gastric banding. Ms. Rolletschke told me that in the rare instances of regret she has experienced in her community, regret is usually not caused by a change in the person’s understanding of their gender identity; it’s because something with the procedure didn’t go well medically — or because of the transphobia they faced after the menopause.
