As if trans people don’t have it hard enough on a daily basis, we are also required to prove our transness to cis health professionals. If we don’t, we won’t be able to seek the medical help we need. It’s as simple as that. Cis people are so far removed from trans lives and realities, that it’s outrageous that we are answerable to them. On the one hand, we are mocked for our transness and gender non-conformity by cis people (friends and strangers alike). On the other hand, we have to prove the same to health professionals. Our transness is enough for us to be harassed on the streets, while using public transport and loos, in educational institutes and office spaces, in our own homes even. But the moment we proclaim our transness proudly, our agency is doubted and our transness is considered dubious.
In India, one needs to see a psychiatrist to get a certificate of gender dysphoria. It is only now that the terminology has been updated. Earlier, it was a certificate of gender identity disorder. Often, the psychiatrist will refer the trans person to a clinical psychologist, who administers a personality test or two to check for pathology. This in itself is very problematic because transness has been pathologised for far too long. Medical manuals and outdated psychology textbooks continue to propagate this pathologisation. To think that a mental illness might be causing one to perceive one’s gender as different from the one imposed at birth is ridiculous. Being trans is but a normal expression of one’s innate gender identity. The intention behind the tests is that mental health professionals don’t want to ‘misdiagnose’ someone as being transgender. The medical fraternity is concerned with saving its own hide, rather than investing its energies in understanding the person behind a so-called patient or client.
Medical gatekeeping is a real problem and we need to address it when talking about trans healthcare. Medical gatekeeping refers to health professionals withholding the medical facilities being sought by a person. Essentially, a trans person has to articulate their complex, personal experiences with gender and their deepest discomforts with regards to their body, to complete (cis) strangers. There is also the additional burden of doing this in a manner that is easily digestible for the listener. It is based on this that said cis professionals will then determine if we are eligible to seek medical interventions such as hormone therapy, gender-affirming surgeries etc. These interventions are both life-changing and life-saving for some of us. They provide us with an affirming alternative to the debilitating dysphoria we learn to live with.
I studied clinical psychology and had the misfortune of working in various psychiatric OPDs (outpatient department) of public hospitals in Mumbai. I say misfortune because I didn’t enjoy my stint at these OPDs. I am also a trans masculine person who wishes to transition, physically. I had to consult a psychiatrist and a clinical psychologist for the same. One could say I have seen both sides of the same coin, up close. Hence, I think I have a unique vantage point on the issue of medical gatekeeping. I want to elaborate on an unfortunate incident from my days as a trainee clinical psychologist, to explain what medical gatekeeping looks like in practice.
A trans man from a village in Parbhani district, X, had come to Mumbai with the intention of transitioning. Even though I wasn’t out as trans back then, I jumped at the chance to talk to him. I volunteered to take his case history and administer tests, when a colleague wanted help with her caseload. X told me how he had to become the ‘man of the house’ after his parents’ death. Raising his younger siblings all by himself was no mean feat. After all of them acquired a certain degree of independence in their respective lives, he finally decided to take care of himself. It was about time, I thought to myself. He was keen on transitioning, medically, and requested me to do everything I could, in my capacity as a psychologist, to help him reach that goal.
I asked him to come back a couple of days later, given the amount of time it would take me to score his tests and prepare a report based on the collated results as well as my clinical opinion. I felt guilty about making X wait because I knew that he was putting up at a distant, transphobic relative’s place. The woman who accompanied him told me how everyone would stare at him in the ladies’ compartment of the local train or pass rude remarks about his gender expression. They lived in the outskirts of Mumbai and had to switch a couple of trains to make it to the hospital. Knowledge of this only added to my guilt, but I had no choice. I carefully prepared a report and handed it over to my mentor. My mentor was to have a one-on-one session with him, explaining the report and suggesting the best course of action for him. In my naivety, I assumed that because I had dotted all the i’s and crossed all the t’s, he would soon be on his way to transitioning.
X came to say goodbye to me after the session with my mentor. I asked him how it went and he said something noncommittal in response. Picking up on his stiffness, I asked him if I could walk him to the gate. He agreed. Once we left the hospital building, he opened up to me about what the clinical psychologist in-charge had told him. He said that he was asked to get a family member to accompany him and come to the hospital yet again, to receive his certificate of gender dysphoria. He told me how that’s impossible because the only person who supported his desire to transition was a grand aunt who was too old to travel. He was also discouraged from transitioning, citing the cost involved. X was told it would cost about INR 10 lakh, when he clearly didn’t have that kind of money. In a nutshell, he was advised to continue living like he was, all these years, so as to not disturb the social fabric of his family and village.
I heard him out patiently. I gave him a hug and the details of a queer CBO (community-based organisation) I knew of in Mumbai. X promised to call them before he made up his mind and we said our goodbyes. To this day, I don’t know if he managed to transition. After I grew more confident about my own transness, I started researching to see how much hormones and top surgery would cost, on average. I was aghast when I realised that the figure quoted to X then, was five times more than what it costs now. The treatment meted out to him was so unfair and I wonder if my mentor’s personal beliefs got in the way of his professional duty. That I couldn’t adequately help a trans brother in need, continues to be one of the greatest disappointments of my life.
When I try to think about why X was treated the way he was, many factors come to mind. What happened to him was not an isolated incident, but indicative of a larger, systemic problem. He was from a rural area with almost no social support. His trans vocabulary was limited although his experiences were infinite. He didn’t have the resources to counter the clinical psychologist’s (a professional he assumed to be on his team) atrocious claims. To the contrary, my caste-class privilege has enabled me to speak English and obtain a master’s degree, which has insulated me from some of the bigotry X had to endure. A loving sister and access to queer as well as trans networks has greatly improved my understanding of how I deserve to be treated and access to trans-affirmative health professionals.
Our transness is uniquely ours. We don’t owe any explanations to anyone, especially cis people. It’s unfair that we are forced to explain ourselves, again and again, as a prerequisite to accessing essential, medical interventions. It is quite obvious that the moralistic views of a cis-hetero-normative society have seeped into the medical (cis-)fraternity’s understanding (or lack thereof) of trans people.