Transgender People Need Family, Not Therapy

Mila Madison

If you come out as transgender and decide to transition, you are essentially forced to get some kind of “professional” approval through each step of your journey in order to exist. We have to jump through a million different hoops just to prove that we know who we are. Many of us had to go through months of therapy before we could get a letter that would allow us to even see a doctor who could prescribe hormones. Want bottom surgery? That is two letters, and yes, you must have lived in your true gender for at least a year. The standards of care, the established guidelines for treating transgender people, made with the best of intentions I am sure. It is a built in waiting period designed to make sure we make the right decision for our own lives. If we are lucky to even reach this point, we then have to find a way to get healthcare that covers us, or even harder, to pay for it all on our own.

The keys to the doors that lead to each staircase we have to climb to get to be ourselves are usually held by a cisgender person who really has no idea what it is like to be transgender. That is the hypocrisy of the institution that was created to properly treat us. It is also the reason that many people resort to DIY treatments rather than see a professional, but there are many dangers to taking that route and going it alone. In so many cases we often have to educate those who are treating us, yet they are the ones who have the power to decide whether or not to allow us to continue with our transitions. The truth is that we all experience some form of gatekeeping in our lives, whether it is from doctors or our families. It is something we all have to struggle with.


Now I am not knocking therapy here. For so many of us it is essential to our care, and there are some great therapists out there. What I am calling out is the notion of why the therapy is needed. There is the impression that gender therapy is there to help us make sure that we are actually transgender and that we are of sound enough mind to endure the process of transition. The reality is that we need the therapy to deal with living in a society that doesn’t accept us. It is the root of the pain and torment we go through. Many of us need the therapy to deal with all the bigotry we receive and the loss of all those who turn away from us.

Think about it for a moment. We have to go through the process of accepting ourselves because many of us were told who we are is wrong for most of our lives. From the moment we first ask ourselves the ultimate question of “Am I trans?” we begin to worry about acceptance. How do I tell my parents? How will they react? Will my partner leave me? Will I lose my job? These are just some of the questions many of us wrestle with. I wonder if the answer to “Am I trans?” was truly “So what if you are?” would we really need therapy? If being transgender were no different than having red hair, would therapy still be needed? Probably not. The actual truth is that being transgender is no different. Some people are born with red hair, some are born with other traits, and yes, some people are born transgender. The only difference is that for the most part, society accepts or at least tolerates many of the distinguishing qualities that differentiate us, but when it comes to being transgender they usually don’t.

An eye opening moment happened for me after starting a peer support group for the transgender community in my area. We were a group that started with about 5 people and eventually had grown to 30 who attend regularly with many more coming from time to time. We were all of different ages. Almost all of us were in therapy while each of us was at a different point in our transitions. What had started with the hope of just bringing some people together ended up turning into so much more. Over time our group became a family. We were able to fill the holes that were left in our lives by the family members and friends who had turned their backs on us. I watched as people began to bond and be there for each other. I saw relationships build and people spending time together outside of our little group. People who seemed so scared and quiet when we had started eventually began to open up and flourish. In just a few months, many of us were progressing at a rate of success that years of therapy couldn’t achieve.


In most places you can get a gun by showing a license and passing a background check. You can drive a car if you can pass a road test. If your transgender, just to be yourself, you have to go through years of therapy and getting letters. It is an institution that has become very lucrative for all the providers who are involved. The process we have to endure just to be who we are is daunting. We have to face a society that doesn’t accept us while we navigate a medical system of gatekeepers where we have to prove that we are who we say we are. It is designed to make us need the therapy.

What I learned is that having a sense of family that supports you is much more important than therapy, or perhaps it is the ultimate kind of therapy. Though gender therapy is a helpful tool, it is not the end all be all. We need support systems. We need community. The answer is in finding each other, supporting each other, and creating our own safe spaces. Start a peer group. Bring people together. Create those spaces if they don’t exist where you live. Make new families to replace those we have lost. It is when I see this kind of support I often see people thrive. All it takes is the will to start.

Comments (4)
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Six therapists and two were good, one was awesome. I did doctor research and eventually have a good support system however it is not easy and not cheap. It is IMHO set up to burn you out and discourage you to the point that you give up. If I were to get on my soap box I think for most WPATH is obsolete and needs to be set aside and ICATH adopted. Keep fighting, keep commenting and Mila, please keep writing. We will get there eventually.


I disagree. The only reason I have a therapist right now is because I found a local not for profit that matched me up with an intern who has since graduated and gotten her degree. She has been kind enough to keep seeing me at the discounted rate I was given before she got her diploma. The entire program is overseen by a Psychologist with a lot of experience, but they are constantly getting overwhelmed with trans people wanting therapy and/or letters. The waiting list is often 3 or 4 months long, sometimes much longer. Most of us go long enough to get a letter and that's it. In some cases, such as myself, the damage is much deeper and we can either continue to pay and go to therapy or we can live with the self-harm, Social Anxiety, Depression, and suicidal thoughts.

You see, my insurance company doesn't have any mental health people "in network" here. My company is based in another state, so I suppose it's a low priority. My insurance was so terrible in fact, I actually had to pay $600 out of pocket for blood work and $200 out of pocket for each visit to my doctor, not to mention what I was paying for medications! And that was in network! So before getting a therapist, I did some research and found out that I could be looking at almost $1,200 out of pocket for every visit!

This may not be gatekeeping as it was previously defined, but it is a form of gatekeeping. Any time you have to jump through hoops or endure a hardship that cis people don't have to deal with, it's gatekeeping. They are literally punishing you for being transgender. Financially and emotionally now that it's frowned upon to go around physically assaulting us. I've had to choose whether or not I could afford to see my doctor or pay the bills. But lucky for me, my doctor has been kind enough to bill my visits as general care or something mundane. If not, I'd be on the hook for all of it because my insurance company won't cover transgender related care. And I make just enough money to NOT qualify for any assistance as well!

So I'm looking for a better job with better insurance, but it isn't easy. I'd love to go back to school and finish out my degree so that I could maybe find something with it. But then I have to make a choice. Save every extra penny for my surgery and hope the sky doesn't fall on me before I have enough? Or pay a college to give me a piece of paper that says I'm qualified to do a job that I've been doing for the past twenty years so that MAYBE I'm not hired in for another 'entry-level' position? And all the while dealing with the dysphoria and trials that come with having the wrong set of parts between my legs.

....all because I was born different, my parents couldn't accept me, the teachers and school staff couldn't accept me, other kids couldn't accept me, and society couldn't accept me. I didn't have mental illness before, I was given mental illness by THEM. I did nothing to deserve this other than be born. I had no choice in the matter. Yet, I'm expected to get letters and pay out of pocket for a surgery to correct something that happened to me in the womb. Young, single mothers who get pregnant on a booty call get more help than us. Young men who go cliff diving and break a leg get more help than us. And we didn't make any bad decisions. In fact, we made one good decision. We decided to live authentically and try to be happy for once in our lives. And we get punished for it. THAT is gatekeeping.


Therapist and Doctors were coined gatekeepers because they would hold patients to “their” views of what a transgender individual should look like, emotionally, and physically (I don’t hear much about that anymore), gatekeepers have also been known to also impose their own personal, political, and or religious standards, onto their patients (which is still out there). This is where the patient must do their homework/research on their providers.

Therapy for the transition is a good thing, for the patient, for the community, no one wants people transitioning when it’s not indicated, and necessary, or when the individual isn’t capable of giving informed consent due to other unrelated psychological issues.

Therapist and Doctors are not a problem in and of themselves, because they make us jump through hoops, because they cost money (reasonable amounts), Therapist and Doctors only become gatekeepers when they leave the standard of care to impose their own ideology onto others, or those that refuse to tailor treatment plans to meet the individual needs of the patient. Nothing here is unique to the transgender community, although it has been more problematic in the community.

If you don’t like or can’t work with your doctor, find another one, I know that’s not always easy or possible, but what other good answer is there?


I've worked with at least 10 therapists over the past 30+ years. These included licensed therapists, psychologists and psychiatrists. Only the first counselor and my current (and final) therapist knew anything about gender identity dysphoria AND had experience working with transgender people. I've spent more than 6 years of my life in counseling with these therapists. I wholeheartedly agree with you that we need support to help us through these difficult times of our lives. I have been fortunate to find a counselor who has extensive experience with gender issues. I've also had enough experience with counselors that I knew the right questions to ask when I first interviewed my current therapist. When I first met with her a year ago, I said to her that I'm interested in working with a therapist who has experience working with gender issues and who will help me make the transition to living as a woman. Just as importantly, I've become involved with a local transgender support group and with kindred-spirited people, which is indeed becoming an extended family for me. I did not have the Internet back in the 1980's. All I had was a chat room for transsexuals on CompuServe. Today, the Internet is alive with resources for us to connect with others and find the resources we need to survive and to transition. Thank you for a well articulated article.

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