One of the big privileges–and burdens–of being a healthcare provider is being a gatekeeper. Some of it is perceived (I’m sorry, but your insurance won’t cover a full-body CT scan without a good reason–I can’t make it happen) and some of it is real (Yes, I can beg the GI department to triple-book you for an emergency appointment next week and I can probably make it happen). The concept of ‘gatekeeping’ is a pretty touchy issue in the field of transgender health. Historically, many providers have followed something called the Harry Benjamin Standards of Care . These are guidelines for gender-affirming treatment (such as hormones), but many patients and providers feel that they are too restrictive and burdensome. Some providers–such as myself–practice an “informed consent” model of care, which relies less on a standard set of criteria that is applied to every patient and more on an individualized assessment of each patient’s knowledge and understanding. Since trans health is still a new-ish subspecialty, the length and breadth of assessment can vary widely from provider to provider.
After my last trans health-related posting on this blog, I was contacted by an acquaintance of mine. As a trans man himself, he was concerned about my treatment of the teenage transgender patient. He wondered why I had doubts about initiating hormones, and what right I had to judge the patient’s gender identity. He wondered why I didn’t give the patient hormones at the first visit, and why I cared that the patient had an official letter from a gender therapist (generally, I don’t require letters, though I do appreciate at least a prior visit with a therapist). All of these are questions I asked myself as well. I drafted an email to him in response, then thought that maybe I would share my thoughts on the blog. I will admit, there is a certain amount of gatekeeping involved in many aspects of my practice. I don’t mind sharing the thoughts behind the gate.
–One of the key things to remember about my provision of hormones is that I am a nurse practitioner, not a physician. That means that I have to review and discuss my work and my treatment with a “supervising” physician. None of the supervising physicians in my office have experience with trans care, and none of them are comfortable with it. That means that if I can’t justify my treatment plans to them, I am going to have a very hard time continuing my work. This is like gatekeeping for the gatekeeper. I care about keeping my job, ergo I am very careful about how I do my work.
–I am a primary care provider, not an Endocrinologist. My job is to provide primary care for people, and I believe that hormones can be integrated into primary care. However, when someone comes to see me as a new patient, my job is to get to know them and their medical history so I can treat them as a whole person. In order to be treated by me, the patient has to have their primary care at my office. I’m not a consult provider (unlike an Endo, who may see a patient once or twice and send them back to the PCP). I can’t adequately treat any condition, including diabetes, hypertension or depression, by seeing a patient once. Therefore, hormones on demand at the first visit doesn’t work for me. That is my personal philosophy. I understand that people who feel that their gender-affirming treatment was unnecessarily delayed might disagree with this.
–Something to consider about that young person that I saw is that I prescribed hormones on the 2nd visit, which was 1 week after our first visit. I don’t consider that undue burden, nor do I consider a week to be an unreasonable time to wait while I follow up on medical records, etc. At the first visit I had discussed a treatment plan, and included in that plan that we would start hormones at the second visit and follow up in 1, 3, 6 months. I do understand that many people in the trans community have felt that they were lied to by providers who led them along and then ultimately denied them hormones. With my patients I am careful not to portray my intentions as any different than they are. And if I have a plan, I lay it out for them. At least they can see where the gates are then, eh?