Imagine a society in which hormones are available at convenience stores and surgical clinics are as common as pizzerias, where people can change their legal name and gender at a local ATM-like kiosk. This is a world some fear we live in.
Those who believe that hormones and surgery are too easy to obtain worry that transition is becoming a fad, and that those who transition—especially children and young adults—may end up regretting their decisions.
At the same time, there are others who view our current system as too restrictive. They cite the multiple hoops that transgender people have to jump through—which often include psychiatric visits and referral letters—as prohibitive and argue that access is often limited to those with means.
In its early years, transition-related care was overseen by paternalistic physicians who viewed themselves as the best judges of what was likely to help their patients. Transgender clients, on the other hand, often viewed such providers as gatekeepers, standing in the way of much-needed resources. Today, many providers remain in gatekeeper roles, but as university gender programs have shuttered and LGBTQ+ health centers have assumed the role of health-care deliverers to this population, this has begun to change.
Many clinics and individual providers now use an Informed Consent model for the provision of hormones, a philosophy that Callen-Lorde describes as “a cooperative effort between patient and provider. . . . Patients who are well informed have a right to make their own decisions.” Informed Consent is an empowered approach to treatment in which risks and benefits are discussed and individuals retain the authority to make decisions about their own life and health care. Concerns such as uncontrolled substance use, extreme psychiatric instability, or memory problems sometimes warrant further evaluation, but this philosophy of care radically shifts the power dynamic from one in which the provider has authority over a client to one in which client and provider are peers. Clients are seen as having the authority to determine what might be best for their lives and are understood to have full rights to body autonomy.
In major cities with large LGBTQ+ health centers, obtaining hormones can sometimes (but not always) be relatively smooth; however, in rural areas it can often be difficult to find knowledgeable providers. A 2011 study published by Stanford University researchers in the Journal of the American Medical Association found that, on average, medical schools spend only five hours over the entire four years of study on education about LGBTQ+ health concerns, resulting in few physicians with any knowledge about transgender health. Lack of health insurance is another barrier to obtaining hormones, but even many employer-sponsored health plans specifically exclude transition-related care, and most state Medicaid programs do not cover hormones or surgeries.
Gender-affirming surgeons are often conservative, following the World Professional Association for Transgender Health guidelines and typically requiring one or two letters of recommendation (depending on the type of procedure) from a mental health or primary care provider before proceeding. The current version of the WPATH Standards of Care is meant to be flexible, but many surgeons fear they would be opening themselves up to liability if they did not follow the guidelines strictly. It can be time consuming and expensive for trans people to obtain multiple letters of reference. In addition, gender-related surgeries range in price, but many are expensive and out of reach financially for the majority of trans people.
Even with the numerous steps that trans people are required to take in order to gain access to hormones and surgeries, critics of current practices still argue that they are too easy to obtain. One of the biggest concerns is that those seeking hormones or surgery will regret the decision later on, but decades-long follow-up studies conducted by researchers around the world demonstrate extremely low regret rates (0–3 percent).
Many are concerned about these health-care interventions being applied to children, unaware that children do not physically transition with hormones or surgeries. Instead, children who express gender-nonconforming behaviors or thoughts and have supportive parents often work with therapists to explore their feelings, and some socially transition, adopting clothes, hairstyles, names, and pronouns that they feel fit them. There are times when children socially transition and then later decide that the gender they were assigned at birth actually fits more comfortably, and these individuals, in supportive environments, still thrive. The distress often experienced is more commonly due to an intolerant social atmosphere; it is more harmful to prevent children from exploring their gender identities than to follow them on their journeys, wherever they may lead.
Some adolescents are prescribed hormone blockers, which can be offered in the early stages of puberty to halt the development of secondary sex characteristics, or even later in puberty to prevent ongoing body changes and menstrual cycles, or to provide time for an individual to make decisions. However, hormone blockers are extremely expensive and financially prohibitive for most families. Teenagers with supportive families may have the option to start adult hormones like estrogen or testosterone if they are mature enough to understand their decisions.
Our current approaches to care for transgender people seeking hormones or surgeries are less restrictive than they were in the past, but far from making it too easy to obtain hormones and surgeries, these systems continue to put up numerous barriers. Unfounded fears related to regret rates, which are actually quite low, continued to drive opposition to efforts to increase access and make it harder for trans people to live as their authentic selves.