I'm thinking about how the UK trans healthcare model prevents any meaningful therapeutic approach to gender dysphoria, and how that also limits the meaning of "informed consent".

When your clinicians are granted the power to grant or deny you the healthcare you want, you cannot have a therapeutic relationship with them.

Trans people in a gatekeeping system have always been in an oppositional relationship with clinicians.

The history of trans healthcare is the history of clinicians setting up arbitrary barriers based on unscientific theories, bad research and personal whims, and of trans people teaching each other how to get over those barriers to get the healthcare they want.

Trans people have no reason to be honest with our clinicians. We know their decision-making is without scientific or medical basis, so there's no point giving them full and honest information. We know they're not therapists, so there's no point asking for emotional help.

Instead, since formal trans healthcare began, trans people have simply learned what gender clinicians want to hear and given it to them. Our healthcare has been dependent on the quality of our performance.

There are genuine attempts from trans-supportive clinicians to improve this situation and move UK trans healthcare towards informed consent. But while the threat of gatekeeping is there, this is not possible. You're too afraid of the consequences of your speech to speak honestly.

This is made worse because there is next to no therapy or meaningful mental healthcare on the NHS, and certainly no therapy for gender dysphoria independent of the gatekeeping system. If you want expert help working through dysphoria you have to pay for it.

I spend a good bit of time reading about and talking to people who identify as detrans, because a good trans healthcare system has to look after everyone with dysphoria, their experiences are meaningful, and they're part of trans community.

Something I hear a lot from detrans folk is that they were offered no other route to dealing with gender dysphoria than hormones and surgery: no therapeutic approach at all. So if hormones and/or surgery don't work for them, what are they supposed to do?

This leads some detrans folk to argue for *more* gatekeeping for trans healthcare. And I think I understand. If your experience of transition is traumatic, or just doesn't work, or you couldn't get the support you needed, then of course you want a solution for that not happening.

But I think the problem is in the gatekeeping model itself, and the lack of support for therapy and mental healthcare in the NHS. *Everyone* needs therapeutic support to work through dysphoria, whether or not hormones and surgery are also what you need.

Imagine if, when you went to a gender clinician, they said "Yes, I can give you hormones if you want, and that's not conditional on anything. Here's our best research on all of that. And also, can we support you with therapy to help you make a decision?"

In the absence of publicly-funded therapeutic support for dysphoria, trans community has stepped in. There are trans communities that offer good advice, that help people work through gender dysphoria in different ways, that open up multiple pathways for transition, for being.

But trans communities are also traumatised, politically embattled, and fighting the gender clinic. Not every community is healthy, not all advice is good, and being locked in an oppositional relationship with medicine and society does not make for good therapeutic conditions!

To be clear, what I am not saying is that every trans person should do therapy before taking hormones. I think that most people benefit from therapy and it should be an option, but I think that trans people, like all patients, should be trusted in their decision-making.

What I'm also saying is that gatekeeping *doesn't work*, doesn't lead to good outcomes. It can't successfully separate people who will regret transition from the majority, because it encourages lying & performance from patients. But meaningful informed consent might be able to.

I'm not a medical expert. I'm an opinionated tran who reads a lot of research, talks to a lot of trans people of varied experience, and has been negotiating trans healthcare for years. This thread is thinking-through and not a definite answer. But I think the questions are good.

Thank you all for your shares and thoughts on this. I appreciate the conversations very much, and am glad I voiced things that rung true for folk. Here are some next-day follow-up thoughts:

When we talk about "gatekeeping", it's not an abstraction. It is a very real, violent and absurd process of enforcing gender conformity in trans people that is still very present. This is a very, very common story: https://twitter.com/LauraPlattMusic/status/1259097504915886082

My understanding of the problems with trans healthcare draws very much on conversations with disability and chronic illness politics. Trans healthcare is particularly absurd, but gatekeeping and under-resourcing of mental health are everywhere: https://twitter.com/gsnedders/status/1259041583036596224