Gatekeeping in the Transition Process

Gatekeeping within the transgender community is a term used to describe limiting or controlling access to medical interventions, such as hormone [Page 279]therapy and gender-affirming surgery, based on select criteria that determine eligibility or ineligibility for such interventions. The “gatekeeping model” was historically used by mental health and medical providers to distinguish “true transsexuals” (the term used to describe transgender people at the time), who were deemed to be adequate candidates for medical interventions, from other transgender people who expressed interest in medically affirming interventions but did not meet set criteria required and thus were denied access to treatment. The gatekeeping model originated with the medical model of transgenderism in the early 1950s, and despite several changes in the implementation of gatekeeping, forms of this model continue to exist within the field of transgender health care.

Harry Benjamin was an endocrinologist and sexologist who is often credited for his pioneering work in the field of transgender medicine. In the 1950s, transgender people were viewed as having a mental illness that could only be treated by years of psychotherapy with the stated aim of increasing alignment between the person’s gender identity and assigned sex at birth. In contrast, Benjamin believed that assisting transgender individuals in physical transition (i.e., social transition and medical transition) was the most appropriate course for treatment and began to develop clinical procedures with this aim in mind. Although Benjamin is often credited with increasing access to care for transgender individuals, his work also had the effect of constituting gatekeeping practices in transgender medicine. Eligibility for medical interventions at the time required extensive psychological evaluations, long-term psychotherapy (sometimes several years), early childhood history of cross-gender behaviors, the ability to “pass” (i.e., to be perceived by others as one’s identified gender), and even participation in research studies. Historically, criteria for hormone therapy and surgery were also often predicated on sexual identity. For example, transgender women were more likely to be granted access to medically affirming interventions if they described themselves as attracted to cisgender men, thus being able to live within heterosexual norms posttransition. Shockingly, level of perceived attractiveness as one’s identified gender was also at times used as part of gatekeeping criteria. Medical care under these circumstances excluded nonbinary identities, transgender people who did not experience dysphoria in childhood, transgender people who had queer sexual identities, and transgender people who did not sufficiently meet the cisgender expectations of gender presentation imposed by their medical providers. Transgender men were also often denied access to medical intervention, as clinical programs and researchers focused much more on the experiences of transgender women. Individuals who did not meet these specific criteria set by cisgender medical providers were denied access to care, while individuals who did meet specified criteria were completely reliant on their medical team for documentation to demonstrate that they met stated requirements in order to “open the gates” for desperately needed gender-affirming interventions.

The gatekeeping model of care was formalized in the first edition of the Standards of Care (SOC) published in 1979 by the Harry Benjamin International Gender Dysphoria Association, which is now known as the World Professional Association for Transgender Health (WPATH).

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