How to Spot Gatekeeping in Gender-Affirming Care
Navigating gender-affirming care can be exciting but also challenging. Unfortunately, some clinicians impose unnecessary barriers, intentionally or unintentionally. This post highlights common forms of gatekeeping, explains why they are problematic, and provides facts to help you advocate for yourself.
What is Gatekeeping?
Gatekeeping involves controlling access to care, information, or resources through rigid rules or unnecessary barriers. In general, it appears when someone sets arbitrary standards, criticizes others' efforts, withholds key information, or treats some people like they belong and others like they don’t.
In healthcare, gatekeeping can show up as:
Limiting access to treatments or letters unnecessarily
Requiring extra appointments, documentation, or tests that are not clinically justified
Criticizing a patient’s readiness or identity
Creating confusion or fear about what is required
Key red flags include unnecessary secrecy, excessive criticism, making people feel incompetent, and obstructing access to care.
Requiring Unnecessary Therapy or Extended Evaluations
Some clinicians require a set number of therapy appointments before writing letters or moving forward with care. This often isn’t based on clinical necessity, but on the provider’s personal comfort, fear of liability, or belief that “there needs to be a required number before I feel ready” rather than focusing on the individual’s specific needs and readiness.
This is misinformation and not grounded in standards of care.
Some clinicians are vague about how many appointments you will need or why. This lack of clarity can create confusion, anxiety, and delays, leaving patients unsure what is actually required.
Arbitrary Waiting Periods and “Watchful Waiting”
Some providers impose a set waiting period—weeks or months— before moving forward with letters or treatment. These timelines are often not based on your individual needs or clinical evidence, but rather the provider’s comfort or outdated practices.
Some providers delay gender-affirming care without a clear health-based reason, using an approach called “watchful waiting.” This means the provider requires a patient to wait for a certain period before accessing care, often to “see if they are ready” or if their gender identity persists. Watchful waiting is not supported by any affirming organizations.
Waiting unnecessarily can create stress, confusion, delays, and only increases shame. Care varies from person to person. You can and should ask why a waiting period is required and whether it is truly necessary for your care.
Costly Psychological Evaluations
Some clinicians also require full psychological evaluations with formal testing. At this time, there are no agreed-upon or widely used testing batteries or psychological assessments for letters of support. Many standardized assessments still require choosing a gender of male or female and provide limited guidance on use with transgender or non-binary individuals.
It’s important to note that these evaluations are different from typical mental health screeners. Most providers do need basic depression, anxiety, trauma, and substance use screeners on file to track your mental health over time, which is standard practice for measurement-based care.
Psychological assessments, on the other hand, include more extensive tests and items that go beyond routine screening, often adding unnecessary cost and time without improving your access to care. Requiring these evaluations can add unnecessary cost, time, and stress. Always ask why such testing is necessary and how it informs your specific treatment plan.
Narrow Definitions of Gender or Identity
Some clinicians impose their own ideas about what it means to be transgender or non-binary. This can show up as requiring patients to fit a certain narrative, present in a specific way, or express rigid certainty about their identity.
Pressure to Perform or “Prove” Readiness
Gatekeeping can appear as repeated questioning about your identity, emotions, or decisions to ensure you are “ready” for care. Some providers may expect patients to show unwavering certainty, emotional perfection, or linear progress.
Other Harmful Practices
Other concerning practices are directly tied to attempts to control or change gender identity, similar to conversion or aversion therapy (also called Gender Identity Change Efforts). This includes referencing “Rapid Onset Gender Dysphoria” as a reason to question a patient’s experience or overstating rates of regret. These practices are not evidence-based, can create unnecessary barriers and undermine trust in care.
Know the Facts
There is no agreed-upon number of therapy sessions required for letters or gender-affirming care. Requirements based on a provider’s personal comfort or belief that “there needs to be a required number before I feel ready” are misinformation.
Waiting a set amount of time to “prove readiness” is not required by standards of care and should be based on your individual needs, not the provider’s comfort.
Delaying gender-affirming care without a clear health-based reason, using “watchful waiting” is harmful and only increases shame.
Readiness is assessed individually based on your history, mental health, and supports. Temporary uncertainty, anxiety, or ambivalence is normal.
Standards of care emphasize individualized assessment, not a fixed timeline or arbitrary rules.
Distrust or caution around gatekeeping is normal and does not mean you are “resistant” or unready.
Basic mental health screeners (depression, anxiety, trauma, substance use) are standard for measurement-based care. Full psychological assessments with extensive testing are not required for letters and often include outdated gender assumptions.
There is no single “correct” way to be transgender or non-binary. Your identity, expression, and journey are valid regardless of someone else’s expectations.
Engaging in conversion or aversion therapy, referencing “Rapid Onset Gender Dysphoria,” or overstating regret rates are all considered harmful practices and are not supported by current standards of care.
A Final Note
It is reasonable to feel frustrated or challenged by gatekeeping practices. The important thing is knowing how to identify them, protect your autonomy, and move forward safely. Understanding the red flags can help you advocate for yourself while still receiving safe, competent, and affirming care.
