Mental Health and Gatekeeping in Trans/Gender Affirmative Care

diagnosispowercollaborative care
Written By Shakira Smith

Often trans care requires a diagnosis of (and sometimes ongoing treatment of) Gender Dysphoria from a mental health professional in order to receive gender affirming therapies, like hormone replacement therapies/gender affirmation hormone therapies. This model makes the clinician a gatekeeper and the client is required to perform diagnosis in order to access the care needed.

In such mainstream treatment models, the mental health professional determines a client’s “eligibility” for gender affirmative health care services, and to be eligible, they must meet criteria to be diagnosed with Gender Dysphoria according to the DSM5. In the DSM5, Gender Dysphoria is diagnosed (in adults and adolescents) when:

  • There is a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)

  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)

  • A strong desire for the primary and/or secondary sex characteristics of the other gender

  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

The identified symptoms/experiences or “condition” must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Right off the bat, there are problems with this approach...

  • Is the clinician competent to assess the nuanced and dynamic experience of trans-ness and transition in order to provide this assessment in an ethical way? (Hopefully, if they have agreed to provide this care... but in my experience, its unlikely).

  • “Distress” and “functioning” are subjective terms... (In this model, the clinician gets to set the baseline).

  • Not everyone experiences limitations of function or clinical distress related to their gender or trans-ness. Does that mean such a person should be prevented from obtaining care? (No!).

  • “... primary and/or secondary sex characteristics of the other gender”... (I just — ).

Shulz (2018) rightly describes this model of care as a “diagnostic/gatekeeping model”. In detailing this model, they provide three major critiques:

One, the cause of internal distress that people who are of trans- gender experience is not necessarily a result of individual pathology, as is suggested by the diagnostic criteria, but is a result of societal non-acceptance and discrimination toward the transgender community. Two, the diagnostic model roots the transgender experience in a narrative of distress, while reinforcing the binary system of gender, thus potentially creating conflict about the goals of mental health treatment between the therapist and the client and overshadowing the importance of authenticity in the therapeutic alliance. Finally, the psychotherapy requirements may result in a significant and unnecessary financial burden to transgender clients seeking care under the diagnostic model.

They go on to describe an alternative model of care, The Informed Consent Model, wherein:

This approach to transgender health care (a) promotes a departure from the use of the diagnosis of gender dysphoria as a prerequisite for accessing transition services and (b) attempts to impact the way that transgender individuals experience and access health care by removing the psychotherapy/gatekeeping requirement. Instead of a mental health practitioner assessing eligibility for and granting access to services, transgender patients themselves are able to decide on whether they are ready to access transition-related health services. In this model, the role of the health practitioner is to provide transgender patients with information about risks, side effects, benefits, and possible consequences of undergoing gender confirming care, and to obtain informed consent from the patient. The Informed Consent Model was developed as an alternative to the mainstream diagnostic model, in response to a growing number of transgender patients and practitioners who view the role of the mental health gatekeeper as a barrier to receiving health care. In this model, therapy is considered an option, but not a requirement or prerequisite for access to hormones and surgical interventions. According to the Informed Consent Model, an individual who is transgender should not have to prove distress about identity in order to gain access to desired health services; instead, they have to “possess the cognitive ability to make an informed decision about health care,” including voicing an understanding of the risks, benefits, and information needed to make an informed decision about moving forward with medical services related to transition (Informed Consent for Access to Trans Health, n.d.). In the Informed Consent Model, a transgender client must attend one appointment with a counselor or medical provider to discuss the social, financial, occupational, and familial aspects and consequences of receiving medical transition services. Access to services is granted based primarily on the ability to consent to care, not whether or not the clients meets the criteria for psychiatric diagnosis.

Citations

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Schulz, S. L. (2018). The informed consent model of transgender care: an alternative to the diagnosis of gender dysphoria. Journal of humanistic psychology, 58(1), 72-92.

Below you’ll find a resource list of clinics or providers in Texas that provide Hormone Replacement Therapy using the Informed Consent Model of care.

This list was created from the following original resource map:

https://www.transunity.net/us-hrt-informed-consent-map-from-erin/

This is resource list, not a recommendation based on experience (with one exception).

I have personal experience with The Kind Clinic in San Antonio, Texas and highly recommend them for sexual health care needs. I have not engaged The Kind Clinic for HRT, but experienced the clinic as queer- and trans- affirmative.

Austin

Brownsville

  • Planned Parenthood - Brownsville Health Center

College Station

Corpus Christi

  • Coastal Bend Wellness Foundation

Dallas/Ft. Worth Area

El Paso

  • Planned Parenthood - El Paso Health Center

Galveston

Harlingen

  • Westbrook Clinic

  • Planned Parenthood - Harlingen Health Center

Houston

  • Planned Parenthood - Northville Health Center

  • Houston Heights Primary Care - Todd O'Neal

  • Village Medical - Dr. Kovacs

  • Legacy Community Health - Montrose Clinic

  • Planned Parenthood - Prevention Park-Family Planning Health Center

  • Braeswood Endocrinology

Lubbock

McAllen

  • Doctors Hospital At Renaissance - Dr. Michelle Cordoba, endocrinologist

    • 2717 Michael Angelo Dr Suite 200, Edinburg, TX 78539

    • 956-362-2250

    • dhrhealth.com

Nacogdoches

  • Dr. James Koerener

    • 1018 N Mound St #201, Nacogdoches, TX 75961

    • 936-560-2763

Paris

San Antonio

San Marcos

  • Texas State University Student Health Center

Tyler

  • Dr. James Koerener

    • 1018 N Mound St #201, Nacogdoches, TX 75961

    • 936-560-2763

Shakira Smith
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