Akari Tomita

Students at the University of Toronto are able to access gender-affirming care (GAC) at the Health and Wellness Center (HWC). I interviewed six trans students (portrayed below with pseudonyms) who are in the process of medically transitioning at the HWC. These students had often heard about and experienced medical gatekeeping around GAC – thus, their relationship with the HWC involved heightened awareness of the physician’s power to create barriers as a medical authority, within a system of medical authority (Staum and Larsen, 2006).

I found that students negotiated with medical authority through strategic communication and presentation that asserted their own authority. Firstly, the dysphoria diagnosis served as a tool for credibility and access to care (although interlocutors simultaneously critiqued it for their pathologizing effects of trans identity). Adonis (he/they) stated that the dysphoria diagnosis helped “prove that I’m not crazy or anything […] and this isn’t something that I am going into impulsively.”

Secondly, students proactively read reputable scientific resources to inform their discussions with their GPs, becoming authorities on personal treatment plans. For instance, Ana (she/her) and Squirrell (he/she) both mentioned having extensively researched the HRT medication options in order to communicate their preferences clearly. Ana also mentioned that – although very few – there have been instances where she knew information from GAC research that her physician did not know.

Thirdly, students presented themselves in certain manners to increase the credibility of their trans identity. For example, Adam (he/him) consciously leaned into transnormative ideals and avoided feminine presentations (in terms of posture, gestures, and voice) at the HWC, stating, “I think that would impact my gender-affirming care if they perceived me to still have connections to femininity.”

Fourthly, there is a strategic sharing of personal details in order to streamline the GAC process, which I consider to be strategic vulnerability. For example, Squirrel withheld details about his occasional depressive episodes partly out of concern that it would affect his ability to receive HRT. On the other hand, Ana prepared a list of specific examples from throughout her life that could demonstrate to the physician her confidence about her identity.

While active engagement in one’s health is valuable, there is a certain degree of proactivity and self-advocacy necessitated for trans patients in any gender-affirming care setting. This places a strange paradox upon trans patients seeking care, in which the system requires them to be agentive and active in their healthcare but simultaneously demands deferral to medical authority. This was especially the case for Adam when he was seeking GAC as a 14-year-old, in which he was actively attempting to access GAC – such as by finding an online physician by himself – but was only able to start hormone blockers after 3 years due to persistent resistance, questioning, and required waiting periods. To be clear, I assert that this is not quite a paradox, but rather the gatekeeping effect of a system historically built to do so.