Opinion | Who Should Be Allowed to Transition?

The first interview passed uneventfully, but the second was “terrible,” Ms. Rolletschke recalls. She was judged on how she applied makeup, how she sat, how she moved. She was interrogated about her romantic and sexual history; the implication was that she was somehow less of a woman if she was romantically interested in women. Though the interviewer ultimately did not oppose Ms. Rolletschke’s ability to change her name, she seemed to be holding Ms. Rolletschke to a retrograde, even discriminatory, idea of what a woman was. Ms. Rolletschke says that when she later read the report, she saw that the interviewer had misgendered her throughout.

Far from accidental, this stereotyping was one of the early aims of the gatekeeping model: to ensure that only people who could “pass” would be allowed to transition. A successful transition, the thinking went, meant that no one would know the person was transgender. Conventional attractiveness — and gender conformity — became a proxy for successful transition, a bias that still shows up today.

But many transgender people no longer want to pass. A June study by the Williams Institute at U.C.L.A. School of Law found that some 1.2 million Americans identify as nonbinary. Not all nonbinary people identify as transgender, and not all, or even most, nonbinary or transgender people will pursue medical treatment. But many, like me, will. In my community, it’s now common for transgender people not to hide that they are transgender; many, like Rolletschke with her prominent flag, choose to be very visibly out.

Medical gatekeeping evolved not to protect the patient, but to protect the doctor, as Dr. stef shuster, an assistant professor of sociology at Michigan State University, argues in the new book “Trans Medicine: The Emergence and Practice of Treating Gender.” In the 1960s, the German-born endocrinologist Harry Benjamin became the foremost doctor in the United States helping people transition, but the work was so controversial that it threatened his reputation. Dr. Benjamin and others like him realized they would need guidelines, ways of ascertaining who was legitimately trans, both to shore up their authority and to guard themselves against the specter of the fraudulent transgender person, the one who might be trying to trick them, or who was simply deluded.

Then, as now, there was little evidence of anyone making up a transgender identity. But then, as now, the fraudulent trans person was a potent, even driving, fear in the cis imagination. That fear contributed to the creation of an organization dedicated to transgender medicine, originally named after Dr. Benjamin, that would become the World Professional Association for Transgender Health (WPATH), the field’s most authoritative international organization.

This spring, WPATH is expected to release a set of guidelines to help countries arrive at best practices for medical transition. The previous set of guidelines, issued in 2011 — a lifetime ago in transgender rights — noted the importance of informed consent but also advocated gatekeeping practices. WPATH’s guidelines are unenforceable, but governments and medical organizations throughout the world are heavily influenced by its recommendations. The trans community is waiting to see how much the guidelines will change. A draft version that was released in January included language that would remove the requirement of mental health assessments for adults seeking HRT, moving closer to a self-ID model, but many providers were concerned that it did not go farther.

Unsurprisingly, many of the ideas that underlie gatekeeping measures are dangerously outdated. Take the fear of regret, for example. We now know that gender-affirming health care has some of the lowest rates of regret in medicine: A 2021 systemic review of the medical literature, covering 27 studies and 7,928 transgender patients, found a regret rate of 1 percent or less. That’s substantially lower than something like weight-loss surgery: A 2019 survey found a 5 percent regret rate for gastric bypass four years after surgery and a 20 percent regret rate for gastric banding. Rolletschke told me that in the rare cases of regret she has encountered in her community, regret most commonly isn’t caused by a change in the person’s understanding of their gender identity; it’s because something with the procedure has gone medically awry — or because of the transphobia they faced after transitioning.