How to Start Testosterone or Estrogen Without Gatekeeping

Come see me.

Jk, but no really- for real- just come see me.

Gender-affirming care is constantly evolving, and not nearly fast enough. Groups like the World Professional Association for Transgender Health (WPATH) update their consensus guidelines periodically, but it’s nearly impossible to do this in a way that keeps pace with new contributions to the scientific evidence and growing social awareness.

The WPATH standards of care (SOC) were first published in 1979, based on a very restrictive model of gatekeeping care for persons experiencing gender dysphoria. Care would only be provided to individuals who were working with a psychotherapist and could obtain a letter of support for their transition. Another requirement, known as the “real-life test,” held that patients should socially transition for up to a year before being granted hormone therapy or surgical interventions. That standard is almost as old as I am (but hasn’t aged nearly as well). 

Fast forward to version five of the WPATH SOC, published in 1998 in response to criticism of all this gatekeeping. For the first time, transgender individuals were asked to contribute through a trans-led Advocacy and Liaison committee. A letter of support was still recommended, but not required, and the standards still classified expansive gender identity as a disorder, with the caveat that this should not be taken as a license to stigmatize patients.   

In 2001 the SOC was updated to allow the initiation of hormone therapy without passing the “real life test” or participating in psychotherapy, but only in cases where it could be considered harm reduction. This version also drew distinctions in readiness criteria between top surgery and bottom surgery, increasing access to top surgery for some.

Version seven, released in 2012, covered a lot of new ground, including topics on epidemiology, voice therapy, reproductive health, folks living in institutions, and lifelong preventive and primary care- woot! This version dove deep into the language describing the spectrum of trangender experiences, making a point to distinguish that trans identities are not inherently disordered identities. We also see an assertion that trans rights are civil and human rights, and a shift toward an informed consent model that places more emphasis on the wishes of the patient. Unfortunately this version still required fairly strict criteria for surgical referrals.

The latest version came out in 2022, with much revision due to criticisms of its earlier drafts. The SOC 8 changed adolescent gender incongruence requirements from “several years” to “marked and sustained.” Early drafts lowered age minimums for a variety of gender-affirming surgical procedures, but the Secretary of the Department of Health and Human Services at the time said “Not good enough- you need to get rid of those age restrictions.” WPATH balked at this until the American Academy of Pediatrics threatened to withdraw their endorsement of the guidelines if age limits were included. 

These moves seem to point to a widespread understanding among the medical community that each person’s development of gender identity occurs at their own pace and on their own terms. They seem to indicate that patient autonomy in knowing their identity and charting their own path to alignment with their identity is of primary concern when providing gender-affirming care. And to be clear, every American medical association with a published opinion on the topic- at least that I’ve seen- appears to concur. 

But unfortunately these consensus opinions and updated standards do not reach every provider. Just last month I was asked for a top surgery clearance that included a request for a psychiatric evaluation as part of my assessment. I declined to provide one, and the surgery is still moving forward, but it definitely begs the question “Are you asking for psych evals on your Brazilian butt lift patients?” Yeah, I bet you’re not. 

I know this surgeon is not an isolated example, because folks regularly reach out to ask if I offer “informed consent,” meaning “will you make me see a therapist and get a letter before you’ll prescribe hormones for me, or is my word good enough to establish my need for care?” My answer to you, dear human, is “Your word is good here. You belong here.”