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Notes -
I realized that I don't know WHAT the gatekeeping is like for gender transitions for children, or even for adults. (Though I care more about with children.) Ideally, there'd be brain scans taken and default hormone levels taken, but I've never even heard of the former being done.
Does anyone have any reading material on this, preferably without an obvious bias?
You can read the Hillary Cass's review of how the diagnostic process Tavistock , the UK's gender clinic, actually worked.
But spoiler: nothing like what you imagine (I don't know that anyone uses brain scans as anything other than an online gotcha they know nobody will really dig into) and said report played a role in the shutting down of Tavistock.
Does that count as "bias"? Up to you.
I can't even imagine how you'd capture the general US view given all of the jurisdictions and state-level culture war fights.
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I'm not aware of any 'brain scan' standard; it's possible this reflects a certain piscine skepticism, but it's probably more just that they're outside of the scope of practice for shrinks.
Individual practices can vary, at least in the United States. You'll see a lot of references to the WPATH Standards of Care (or, less often, the APA's DSM), but these are not binding in a legal or most regulatory senses, either as minima or maxima, either on medical practitioners or even insurance companies. Where laws do bind around procedures-as-a-class (a less-recognized part of the Affordable Care Act put gender-related care on the minimum acceptable coverage list), they leave some sway to whether an individual procedure for a specific person at a specific time is "medically necessary" in the terms insurance providers use. In turn, it's always possible to pay out of pocket, or get lucky and have procedures okayed out-of-spec, or find a medical professionals that fudge things a little.
But while this means some people will go through processes far from these standards, most just see these standards or minor tweaks (the literature says that the average is more delayed, but then again, the research /would/). The relevant versions of the WPATH SoC now are v7 (2012-2022) and v8 (officially Sept 2022, though in practice not implemented much yet). A lot of gatekeeping discourse in trans spheres reflected practices based around WPATH SoC v6; while this officially only ran from 2001-2011 (most of that under the name Harry Benjamin International Genders Dysphoria Association), it had a pretty significant foundational effect and for historical reasons a lot of places kept closer to these standards until at least 2015.
Under v6:
Adults were encouraged to approach psychotherapy first, and there's a list of 'gender adaptations' that in practice was considered a necessary step by many practitioners. SoCv6 also uses the concept of "real-life experience", generally meaning to maintain employment or a volunteer role or a place in education, while living as that gender in all or almost all interactions, and (when possible) doing so under a gender-appropriate first name. "Real-life experience" supposedly required references from acquaintances, though in practice that rule varied dramatically in application.
Adult hormone therapy/mastectomy: At least 18 years old, (otherwise) stable mental health, clear understanding of the costs and ramifications of hormones, and at least one of three months psychotherapy, three months real-life experience, or a history of self-medicating with gray- or black-market hormones.
Adult genital surgery: at least one year continuous hormone therapy, and one year continuous real-life experience, one year psychotherapy contemporaneous with these processes recommended. Breaks in real-life experience are to be treated as contraindications for surgery in the future. Knowledge of multiple potential procedural providers and of ramifications of the procedures.
Adult Breast augmentation: At least 18 months hormone therapy.
Children (defined as anyone under age of legal majority) were strongly encouraged to delay physical interventions as long as possible. In addition to the above limits:
Puberty blockers: IF unavoidable, and the patient has passed Tanner Stage 2 (or has been reviewed by an endocrinologist and at least a second shrink), and has consent of the family, and the patient's distress has increased with puberty.
Hormone therapy: At least 16 years old, six months psychotherapy, consent from parents/family (unless above local age of medical consent), understanding of ramification of hormone therapy.
Mastectomy: any point after hormone therapy begins.
Genital surgery: At least 18 years old or two years lived experience.
Under v7:
Psychotherapy as palliative care downplayed, though still present.
"Real-life experience" as a term or requirement generally removed; "living in a gender role that is congruent with their gender identity" is its replacement, gets rid of the legal name change requirement, requires trans people to 'come out' to close friends and family (this was generally read to mean 'come out' as their gender role, rather than as trans, since a lot of people just built new friend groups, often after moving), and is specific only to genital surgery.
Breast augmentation : down to 12 months hormone therapy.
Genital surgery : reduced role of psychotherapy between hormone therapy stage and genital surgery, more recognized exception for hormone therapy time requirement in cases where patient avoids hormone therapy entirely (I don't know if this literally ever happens, tho), removal of requirement to shop around for surgeons turned to a multiple referral system.
"Children" as a class divided into pre-pubertal 'children' only listing social interventions, followed by 'adolescents'. For adolescents:
Puberty Blockers : at least Tanner Stage 2 with preference for later, and "Any co-existing psychological, medical, or social problems that could interfere with treatment" must be stabilized first.
Mastectomy is now only recommended after 1 year on hormone therapy.
Genital surgery: at least "legal age of majority", only one year living in the gender role.
Under v8:
Psychotherapy as palliative care largely reframed to "conversion treatment" that "should not be offered", interventions for children focused entirely to "gender-affirming care" (social-only).
"Children" as a class full separated from "adolescents", largely in response to perception that some practitioners treated almost all verbal patients as "adolescents".
Removal of psychotherapy requirements for hormone therapy (in almost all situations).
Removal of multiple referral system for surgical interventions.
Genital surgery set to six months hormone therapy, more explicit exception to hormone therapy requirement for people skipping hormones entirely.
Explicit listing of "medically necessary" procedures, largely aimed at insurance providers (and jails).
Nonbinary is recognized as a class (still not a very coherent one; afaik a lot of nonbinary hormone access tends to rely more on doctor pragmatics than appeals to the SoC).
Thank you. I'm mostly able to follow this, but there's one thing I'm still unsure of. Under v8, puberty blockers can start at Tanner Stage 2 (so around age 12), but does hormone therapy still start around 16?
It's... not really clear. On top of none of the WPATH standards really binding, v8 (and to a lesser extent v7) have largely framed especially the adolescent treatment section as a discussion of research for more controversial sections, rather than strict 'you must have this characteristic'. From v8:
And that :
(Referencing a study here, which finds that "Most research suggests that MDC is reached little before the age of 12 years.")
But the summary section just says:
Soc cons have read this to only require Tanner Stage 2 (note: especially for XX-chromosoned, this can be much earlier than 12; it's not unheard of to occur closer to 10 or even 9). And I don't doubt there's some practitioners that have tried to read it that way. I think a more honest read of the full standards is generally going to be at least 12 and normally closer to 14, but it's not actually spelled out, and that's true for both surgical and hormonal interventions.
I'm not sure if this reflects aggressive retreat from restrictions under active pressure, wanting to be vague out of concerns related to long duration puberty blockers (a lot of the data re bone growth problems seems tied to very high doses not used for trans-adjacent therapy, but there's certainly space for issues), or just wanting to avoid being use for/legitimizing statutes or other strict bans (eg, a UK's court holding 16 as a required minimum age for informed consent including for puberty blockers, later overturned, referenced WPATH at length).
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