Two and a half years ago, I sat in a medical waiting room nervously rehearsing my reason for seeing the nurse practitioner. The words I needed to say to her — that I was transgender and wanted her help medically transitioning — I had once promised myself not to say to anyone. I thought I’d keep this part of my identity my deepest secret, one I’d known since childhood but would never reveal.
Back then, I wouldn’t have even known how to reveal it, what words to use — I only sensed that I wasn’t the girl everyone assumed me to be and that I wasn’t quite a boy like my twin brother, either. I had vivid dreams in which I could change the shape of my body, dreams from which I woke up heartbroken. I didn’t know how to articulate who I was or imagine a world in which others could truly see me. I only knew who I wasn’t.
As the decades went by, I found language that helped me articulate my nonbinary identity, language that led me to a community. I became more secure, more certain, more comfortable. I noticed a pattern: The more out I was, the more openly myself and recognized as such, the happier I became. I started to believe that a different life might be possible, one in which my body and my experience in the world more closely aligned with my self-knowledge. I decided I wanted to begin hormone replacement therapy, or HRT, which is how I had come to be in that waiting room, whose taupe walls were lined with photographs of the medical providers, smiling with stethoscopes slung around their necks.
Recently, conservative politicians have whipped up fears that doctors are agreeing too readily to treat people, particularly young people, for gender dysphoria. On Feb. 21, Attorney General Ken Paxton of Texas released a formal opinion declaring that under state law, gender-affirming medical care for transgender children — including nonpermanent options like puberty blockers — is considered child abuse. The next day, Gov. Greg Abbott issued a letter calling on teachers, doctors and other professionals to report parents who provide their transgender children with gender-affirming care. One investigation has already begun. Hundreds of new bills introduced nationally in the past few years seek to criminalize care for transgender children, and based on a January report by the Human Rights Campaign, hundreds more appear to be coming.
How best to support transgender kids is an important question, but there is no good evidence that they are being rushed into treatment. In fact, in many parts of the country, it is difficult even for adults to locate and get good care.
Where I lived in Maine made doing so possible. The clinic I chose operated under what’s known as the self-ID or informed consent model, which emphasizes trust in a trans person’s self-knowledge. Medical providers offer assistance and expertise, but they begin by listening. As a result, my own attestation that I was transgender turned out to be all I needed to get HRT. I was, to put it simply, believed.
My experience is far from the norm. Many, perhaps most, insurance companies in the United States insist that patients seeking gender-affirming medical care undergo lengthy assessments by medical providers to ascertain whether they’re “truly” trans. This model is known as medical gatekeeping. These assessments sound like they’re intended to protect the patient, but in practice they too often come down to a provider’s own ideas about transgender people, including racial and class biases. Black and brown trans people, particularly trans women, continue to face greater barriers to care. In surveys, doctors repeatedly indicate that they have little if any formal training in transgender health. They express frustration that any transgender issues are often collapsed into a few general L.G.B.T.Q. lectures, leaving many unprepared to conduct assessments regarding gender identity. Yet their conclusions are still prioritized by insurers over a patient’s self-knowledge.
That gender-affirming health care saves lives is clear: A 2018 literature review by Cornell University concluded that 93 percent of studies found that transition improved transgender people’s heath outcomes, while the remaining 7 percent found mixed or null results. Not a single study in the review concluded negative impact. But in a capricious medical environment in which access to care depends not only on a patient’s resources but also on a provider’s inclinations, too many patients may be left to suffer from the suicidality, depression, substance use disorders, eating disorders and other adverse life impacts that go with untreated dysphoria.
Last June, the Biden administration moved the United States toward the self-ID model for documentation when it changed the rules for obtaining a passport: Applicants now simply select the gender marker that matches how they identify, and they will soon have the option of choosing a nonbinary X. But many more-stringent state laws are likely to remain unchanged, so a person could soon have different genders on their passport and their state-issued driver’s license or birth certificate. This bureaucratic confusion is reminiscent of the situation faced by many gay and lesbian couples for the 11 years between Massachusetts’ decision to legalize gay marriage and the Supreme Court’s decision in Obergefell v. Hodges. During that time many couples were married in their home states but unmarried in the eyes of federal law.
The debate between these two schools of thought — the self-ID and gatekeeping models — lies at the heart of every argument we have about the lives of trans adults, from fights over access to gender-affirming procedures to whether transgender athletes should be allowed to compete. Is someone trans because they say they are? Or does it take an outside expert to know for sure?
How the world decides this question will have huge implications for the lives of transgender people. In recent years, self-ID has become the law in about 15 countries, including Ireland, Portugal and Uruguay, and it is likely to become law in Spain, where the government approved a draft bill last June. This week, a self-ID law was introduced in the Scottish Parliament. But elsewhere, transition treatment remains more complicated to get. Despite Germany’s liberated Weimar history, its requirements are outdated and onerous. Under the country’s 40-year-old Transsexuellengesetz (“Transsexual law”) — which forces people to undergo expensive, lengthy and often demeaning tests before they can transition — the process to change one’s name and documentation can take years.
A movement to change that law is underway. In September, two openly transgender women were elected to the Bundestag as representatives of the liberal Green Party: 27-year-old Nyke Slawik and 44-year-old Tessa Ganserer, whose supporters had to vote for her under her deadname because she has declined to undergo the government’s invasive process to change it. In late November, the new coalition government, which has united the Green Party with the Social Democratic Party and the Free Democratic Party, pledged to reform the law and move to self-ID for legal name change; they also plan to create a compensation fund for transgender people who were compulsorily sterilized as recently as a decade ago.
To better understand the toll of current gatekeeping measures in Germany and around the world, I traveled to Berlin in September to interview Felicia Rolletschke, a young woman who has become one of the faces of the push for change. High above her apartment in a converted shipping container in the woods of the Atl-Treptow neighborhood of Berlin waves a transgender flag, visible from the S-Bahn trains that pass by. The flag is secured to a five-meter-tall birch branch that she found in the woods and lugged home. “I was sore for a week!” she told me, laughing, as we sat on her balcony. But it was important to her that she have it. Without the flag, her neighbors might not know she’s trans.
By the time I met Ms. Rolletschke, she was about to turn 27 and had lived openly as a woman for six years. She told me that she had known she was transgender since childhood, but having been raised in a small conservative town in southern Germany, she had never met an openly transgender person and kept her identity a secret. Until 2011, all German parents were required to give their children sex-specific names. If a child grew up and realized they wished to change their gender, they were legally required to consent first to sterilization or gender reconstruction surgery.
When Ms. Rolletschke was 17, she moved to Berlin. At 21, she began the paperwork required to transition with the help of a therapist. To start hormones, the law mandated that she first live openly as a woman for a year. This has historically (and to many transgender people, offensively) been referred to as the “real-life test” and remains a requirement to get access to surgery in parts of the United States. The requirement can be brutal, even encouraging of abuse and discrimination, because it mandates that people present as one gender without the cosmetic help of medical transition while still carrying paperwork that outs them.
Ms. Rolletschke had a sympathetic therapist who understood the dangers of the requirement and agreed to circumvent it, allowing her to start hormones, but there was still the matter of her name and legal gender. She would need two psychotherapists to vouch that she was “truly” trans to qualify for the legal name change. To be evaluated by those experts would cost her 1,600 euros, money she did not have. An aunt eventually gave her the money, causing a family rift because other relatives were not supportive.
The first interview passed uneventfully, but the second was “terrible,” Ms. Rolletschke recalls. She was judged on how she applied makeup, how she sat, how she moved. She was interrogated about her romantic and sexual history; the implication was that she was somehow less of a woman if she was romantically interested in women. Though the interviewer ultimately did not oppose Ms. Rolletschke’s ability to change her name, she seemed to be holding 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 misgendered her throughout.
Far from accidental, this stereotyping was one of the early aims of the gatekeeping model: to ensure that only people who could “pass” would be allowed to transition. A successful transition, the thinking went, meant that no one would know the person was transgender. Conventional attractiveness — and gender conformity — became a proxy for successful transition, a bias that still shows up today.
But many transgender people no longer want to pass. A June study by the Williams Institute at U.C.L.A. School of Law found that some 1.2 million Americans identify as nonbinary. Not all nonbinary people identify as transgender, and not all, or even most, nonbinary or transgender people will pursue medical treatment. But many, like me, will. In my community, it’s now common for transgender people not to hide that they are transgender; many, like Rolletschke with her prominent flag, choose to be very visibly out.
Medical gatekeeping 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, the German-born endocrinologist Harry Benjamin became the foremost doctor in the United States helping people transition, but the work was so controversial that it threatened his reputation. Dr. Benjamin and others like him realized they would need guidelines, ways of ascertaining who was legitimately trans, both to shore up their authority and to guard themselves against the specter of the fraudulent transgender person, the one who might be trying to trick them, or who was simply deluded.
Then, as now, there was little evidence of anyone making up a transgender identity. But then, as now, the fraudulent trans person was a potent, 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, that would become the World Professional Association for Transgender Health (WPATH), the field’s most authoritative international organization.
This spring, WPATH is expected to release a set of guidelines to help countries arrive at best practices for medical transition. The previous set of guidelines, issued in 2011 — a lifetime ago in transgender rights — noted the importance of informed consent but also advocated gatekeeping practices. WPATH’s guidelines are unenforceable, but governments and medical organizations throughout the world are heavily influenced by its recommendations. The trans community is waiting to see how much the guidelines will change. A draft version that was released in January included language that would remove the requirement of mental health assessments for adults seeking HRT, moving closer to a self-ID model, but many providers were concerned that it did not go farther.
Unsurprisingly, many of the ideas that underlie gatekeeping measures are dangerously outdated. Take the fear of regret, for example. We now know that gender-affirming health care has some of the lowest rates of regret in medicine: A 2021 systemic review of the medical literature, covering 27 studies and 7,928 transgender patients, found a regret rate of 1 percent or less. That’s substantially lower than something like weight-loss surgery: A 2019 survey found a 5 percent regret rate for gastric bypass four years after surgery and a 20 percent regret rate for gastric banding. Rolletschke told me that in the rare cases of regret she has encountered in her community, regret most commonly isn’t caused by a change in the person’s understanding of their gender identity; it’s because something with the procedure has gone medically awry — or because of the transphobia they faced after transitioning.
Gatekeeping has also been driven by a misapplication of the Hippocratic oath to do no harm. Doctors have long been aware that in helping a person transition, they are sending that person out into a transphobic society. As Dr. shuster notes in “Trans Medicine,” they worried that performing surgeries and providing hormones could worsen a patient’s quality of life by resulting in visible gender nonconformity and social ostracism. An overwhelming majority of providers are cisgender, and the speculative harm of treatment may seem far more visceral to them than the well-documented and known harms of untreated gender dysphoria. The potential harm of doing something is easier to conceptualize than the harm of doing nothing — even in the face of overwhelming evidence of the latter.
All of these critiques reflect a growing awareness of the danger of substituting a provider’s idea of gender for a patient’s. As committees of physicians, psychologists and other stakeholders work on the new WPATH guidelines, they have come under escalating pressure to elevate informed consent and reduce gatekeeping for adults, and thus create greater room for patients to have their self-expression and identities recognized.
But whether the final guidelines will reflect the new consensus remains to be seen.
I am grateful every day for my experience in the nurse practitioner’s office, which opened up my life in ways I couldn’t have imagined. I look back now, as my voice drops further daily from testosterone and I feel more at home in my body than I ever thought was possible, and I’m thankful for what happened. But I’m also aware every day that with a different geographic location or skin color, I might have been turned away.
As we wait for the final WPATH guidelines, I often think of how I felt in 2015, as the Supreme Court prepared to rule on gay marriage. It was difficult to explain to heterosexual loved ones just how emotional and powerless I felt as I waited while nine strangers determined my future — decided whether I and people like me would be able to live and love as we are. It is difficult to explain to my cis loved ones now, who often can’t conceptualize what it feels like to be transgender, how unnerving and damaging it is to be in a system that doubts our identities.
Trusting adults to know who they are is not a radical thought. There is always a temptation to believe that history moves toward progress, yet the situation for transgender people in many countries, including this one, grows increasingly precarious and violent.
The simplest step might be the most important one: Trust us.
Alex Marzano-Lesnevich, an assistant professor at Bowdoin College, is the author of “The Fact of a Body: A Murder and a Memoir” and a forthcoming memoir on nonbinary identity, “Both and Neither.”
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