This diary is prompted by a thoughtful NYT opinion piece by Mx. Marzano-Lesnevich (Mx. is the author’s designation in NYT), about transgender transition process, and I’ll include some personal examples from my daughter’s journey, to try to illustrate at least one person’s experience.
Amidst all the bad news (Texas, FL, South Dakota, everywhere Repub Governors run wild), it’s good to occasionally see a reasonable piece about transgender rights making it into mainstream news. Today’s NYTimes had a commentary about medical gatekeeping, that is, how accessing treatment depends on doctors deciding what your gender identity is, or should be. The real-life situation for many people is nothing like the paranoia espoused by conservatives, republicans, and (supposedly) religious folks who want to demonize trans people, especially trans girls and women. Today’s column was not a “good news” piece, but a thoughtful commentary from a woman who went through transition in a relatively good situation (although that ignores any earlier struggles she may have had), with a doctor who allowed her to start hormone treatment based on, get this, the patient’s self-recognized gender identity.
Before I delve into the laws, the reality, and my daughter’s personal experience with both, here is one piece of “good news”, with a caveat. As has been reported here at DKos, this NYT article by Mx. Marzano-Lesnevich mentions:
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.
So, one step forward, but obstacles abound.
The writer lays out some of the history and background for the still-too-difficult standards that doctors (the ones who will even consider helping people with gender dysphoria, i.e. people whose gender identity is at odds with, say, their birth certificate). As I’ve written before (in replies to other diaries), the World Professional Association for Transgender Health (WPATH) standards require patients to live (“out”) in their identity for a year before medical treatment – especially surgery, but sometimes applied even to puberty (hormone) blockers or hormone therapy.
As Mx. Marzano-Lesnevich observes, this can be an extremely dangerous proposition:
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 and while still carrying paperwork that outs them.
Try to imagine “living as a girl” in your high school, or as a woman in college. Or, out on the street, as many young transgender women find themselves.
Imagine even trying to seek out this professional help, if you lack family support (or insurance, or money), as many transgender individuals do.
Let me tell you, for my daughter it was extremely hard to get medical or legal help, even with my support, money, and insurance – once she trusted me enough to tell me. (Side note: I say “trusted me enough”, but really it was “desperate enough.” She saw only the options of suicide – which she tried, but told me just in time to get her to the hospital – or self-surgery, which she tried to train herself to do, for years).
Once we started down the road to finally get her the help she needed, there were so many roadblocks. We found a few doctors who would be willing to work with her – after one year of therapy and “living as”, mandated by WPATH. The very idea of waiting another year was odious and overwhelming for my daughter, but maybe she’d try… Except the therapists identified by the doctors said they had at least a 3-month wait list. We gave our names, but didn’t get an opening from anyone for OVER A YEAR. Which means the 1-year would now become 2, or more… of living in an extremely vulnerable state, hating her body, hating seeing anyone or anyone seeing her.
We found some side-channels. Doctors who we could barely trust, out of town, not covered by insurance. But doctors (one in particular) who would help us, with minimal evaluation by mental health professionals and the required letters. (In other words, working around the 1 year of therapy requirement). Some of the therapists my daughter went to, recommended by people supposedly in the know, were no help at all, had no clue what kind of letter was needed, and wouldn’t bother to figure it out, let alone write one.
But, step by step, she has proceeded. Given that this was all outside the “proper” channels (no WPATH letters and multi-year wait period), it was also very costly. Surgery, travel, home care, and more.
Then there were the legal issues, the name change, ID changes, implemented for every facet of life (work, school, voting, driving, passport). Much of it is a vicious Catch-22, where each agency wants proof from another agency before they’ll act. Luckily, we live in a state that (in recent years) makes it relatively “easy” by comparison to laws in other states. Besides, once she’d already had some surgery, it was accepted as proof enough (i.e., we broke outside the Catch-22). Some later surgeries were even covered by insurance.
And yet, despite the tremendous societal, monetary, medical and legal obstacles that transgender people have to overcome, Republicans continue to write and pass laws based on the assumption that someone is going to transition to gain competitive advantage in sports, or to get a sneak peek at someone in a bathroom. They have no idea what people actually have to go through, or the torture it is to live with your “dead name” and to be constantly told you’re something you’re not.
Almost as bad, we get concern troll pieces like this one from back in November, in WaPo (sorry if you hit paywall), by two therapists, one a transgender woman herself, who worry that other therapists and doctors make it too easy (I’m paraphrasing, but that was exactly their case). They worry because the number of young people identifying as transgender is “skyrocketing” (they cite 1.8%, others lower), which they seem to assume is impossible. Rather than saying isn’t it great that people can come out of the closet, they seem to worry it’s too easy. They cite a couple anecdotes about individuals who supposedly regret their transition (puberty blockers are easily reversible, but they seem to ignore that and focus on surgery).
So, as I said, today’s NYT piece was welcome. In this piece, Mx. Marzano-Lesnevich cites a recent metaanalysis which
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.
Moreover:
A 2021 systemic review of the medical literature, covering 27 studies and 7,928 transgender patients [post treatment], found a regret rate of 1 percent or less.
So, that’s not 0 people, but it’s very small. It’s dwarfed by the 93 % who report improvement in many life dimensions following transition. That is, improvement from suicidal thoughts, depression, substance abuse and other disorders; and sometimes improvement from living outside the bounds of what most of us consider safe society.
Marzano-Lesnevich notes about the origin of the WPATH guidelines:
Medical gatekeeping evolved not to protect the patient, but to protect the doctor
These guidelines are up for review, and seem to be leaning a bit more toward allowing self determination, rather than going through as severe a medical gauntlet as is now required. How far it goes is yet to be seen, but these days any positive step is welcome. As the writer concludes:
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.
