How Gatekeepers Isolate Us

The Price of Showing Gatekeepers What They Want to See

I need help with my various mental health issues. Ignoring the strain of transitioning, I am rebuilding my life in the wake of losing my home, my married family, and eventually my career. I’m grieving for my father, who died days before the rest happened. And I know I’m not alone in facing tremendous stress parallel to the strain of transitioning.

I’m lucky to live in a country with a national health service that administers and funds many aspects of medical transition, including hormone therapy and some surgeries. They will take care of it, but they have their process and those of us in the UK learn what the clinic needs to see - and what to hide. From my conversations with others elsewhere, I am certain that everywhere has its formula but I can only speak for the system I know. I only want to tell them what they want to hear.

I was miraculously lucky in that I found a general practitioner (GP) that was willing to prescribe hormone therapy before the gender identity clinic (GIC) saw me; such a thing is allowed but almost unheard of. Often, it’s a struggle to get cooperation from a GP even with the support of a private gender specialist.

“If you can’t get your anxiety under control, we’ll have to stop.”

The voice of my doctor, nearly a year ago, still rings in my mind. The words were almost fatal: I wasn’t making it to work; I was very ready to end myself. Four months into hormone treatment, much of my dysphoria was eased and I was experiencing the craziness of second puberty. I had a lot of new feelings I didn’t understand and I needed help. I went to the GP that was so understanding before only to be given that ultimatum: sort it or we’ll stop. Not adjust or review. Stop. I immediately stopped complaining.


There are certain vulnerabilities I have that someone with GIC support in the United Kingdom doesn’t. I was given the treatment on the basis of a GP’s judgement, which means they can use that same judgement to take it away. Once the GIC gives me their blessing, my GP won’t be able to simply stop my treatment in that way - though there are stories of exactly that happening.

My treatment is dependent on their perception that I’m fine. To complicate matters, all use of the health service is funnelled through my doctor’s surgery to be disseminated as and when other branches of the health service require it. That means I can’t access mental health services without my GP knowing. And if I can’t get it under control, we’ll have to stop.

I’ve been left to manage my depression and anxiety on my own for nearly a year now. As far as my doctors are concerned, I’m fine. I am not fine.

Others tell me I’m being overly cautious. That the prescription is on repeat at this point and I’ve been even luckier to have an endocrinologist recommend a more aggressive treatment. I’m not in the same danger I was last year. But this is the thing: it only takes one comment.

One careless remark from my doctor has ended my involvement with the health service as far as my mental health is concerned, and I’m wary of approaching them for anything but gender related treatments as well. My trust was destroyed in twelve words.

This is true about a lot of things: what subjects we like in school, how we feel about a person’s religion, whether being gay or transgender is OK. Whether our parents being divorced is normal. It only takes one comment. One laugh. One judgement.


I’m lucky to have a vast support system that will do the health service’s job while I feel unsafe contacting them. I’m fortunate in my friends; they rally around me and make sure to check in on me if I seem off. At this writing, I’ve actually retreated to a friend’s house in the countryside to decompress and recover from a particularly nasty episode. Not everyone is so blessed.

Because my use of the health service is all logged in one place, the GIC will see that I’ve accessed services, same as my GP will. My accessing those services could potentially raise the same questions I’m trying to avoid with the GP: I only want them to see what they want to see. It’s getting better - particularly in the last two or three years - but there are still enough stories about treatments being delayed due to complicating factors. No support is given to help a person resolve those things; they’re expected to contact relevant services themselves. In short, people are told to go away and come back when they’ve figured it out.

“If you can’t get your anxiety under control, we’ll have to stop.”

Words that are echoed and reinforced by accounts online, from clients, from friends. If you have a complicating factor, we can’t help you. But many of these factors are made worse for not getting help! Too bad. Go figure it out.

It’s almost as though they don’t need a reason to turn us away. It’s almost as though the objections have nothing to do with our health and safety. It’s almost as though they’re more interested in being a barrier than a solution.

All I can say is thank goodness for my friends. Those of you are alone, I hope you can get into support groups online or in person - I hope you find people. Whatever system you’re in, it’s abundantly clear that it’s down to us to help our own. If, like me, you have a strong support network, I hope you can spare the energy to become somebody to someone that has nobody.

As a community, I feel we are in many ways utterly alone. But that doesn’t mean any one of us has to be alone. We need to come together and hold each other up, because it’s highly unlikely anyone else will.

“If you can’t get your anxiety under control, we’ll have to stop.”

I truly “hate” the world of psychology, to offen the patient is viewed as weak minded, when the source of the problem is often situational leading to biological a condition, sometimes the issue begins biologically, but either way it has become a biological condition, most often requiring therapeutic and or medical help. I think the source of the anxiety, how long you’ve had it, it’s severity, matters, some anxiety is normal, some anxiety in/from transition is normal, comments such as your doctor CAUSES UNNECESSARY anxiety and IS damaging to the doctor patient relationship, if the anxiety is not from transition how is it relevant to continuing hrt, if the anxiety is related to transition in whole or part then the doctor must (assuming the doctor is responsible) do a risk benefit analysis in stopping, continuing, changing, adding, a treatment. Sadly, some doctors have been known to have other consideration, not fully understanding the necessity of transition, or the normal process of transition, for their patients when making such evaluations, none of that is limited to the transitioning community. Where I live and situation there is the option of finding another doctor, hint.

While I understand the problem of anyone being a gatekeeper, I think it's more a case of the GP feeling that since he is not qualified to diagnose anxiety. That, personally, could not continue to prescribe HRT, in case of any possible problems.
This sounds like it could be used as an argument against a GP to be able to write a HRT related prescription in the first place. There are a lot of factors effecting how truthful anyone feels that they can be with a psychiatrist and fear of rejection, on any level, is one of them.
Psychiatrist are the gatekeepers for a variety of drugs which a lot of people honestly believe they need, such as anti-depressants. As flawed as the system is, if there were a viable solution to this well known pressure to lie, then it is still undiscovered.
I advise you to tell your psychiatrist (not any other doctor) some of the symptoms and what you believe causes them, without mentioning the word anxiety. If the psychiatrist decides that it is anxiety, only then, mention to your GP that you are trying to keep things under control but then tell him what your psychiatrist thinks. I advise against saying to any of your doctors that you delayed in telling them. Trust is important and telling them that you believe you are managing, with the help of family and friends (as you wrote), gives weight to your openness and honesty as you work through these problems together.
Keep in mind that if they do stop, for a while, they just need to see whether it makes things better or worse before deciding where to go from there.

All medication, including medication for mental health, is prescribed by one’s GP in the UK. Specialists instruct GPs to prescribe things and at what dose, including notes on how it might be changed without further consultation. The only way to cut my GP out of the equation is to go private, and I don’t have the means.

I can tell you exactly why she made that comment. Bridging prescribtions are given as part of a harm prevention strategy. I was given HRT because I was suicidal and it was intended to ease that. I came back with similar complaints, so in her eyes that means the treatment isn’t working. I have no other way to get this treatment at this time. I just have to wait until the GIC sanctions it. Until then, the treatment needs to be seen to be solving my mental health issues.

But even after I get that blessing from the GIC, it’s in my best interests to keep it to myself. Other mental health issues can be seen as a complicating factor to dysphoria. It doesn’t always delay treatment, but it can. I won’t risk that, and so I’m on my own.

My gp wouldn’t refer me to the gic until my depression was ‘under control’. I switched from citalopram to venlafaxine. That delayed me by at least 6 mnths. Three years later, and only venlafaxine free for a week, i can more fully understand how the positive effects mentally from oestrogen have been ‘dampened’. This has been happening ever since the dosage decreased.

That’s just awful. I wish I could say it was an isolated thing. I refused antidepressants because I wanted to integrate feelings rather than suppress them. I had a lot of resistance on that one, but it also meant my GP had no way of verifying anything I said about my depression: I wasn’t having treatment so they had to take my word for it.

I'm so shocked and sorry that your GP said that to you, Clara. It was unbelievably cruel, and shows a real lack of understanding of both anxiety and the realities of being transgender. As if anxiety was something you could just choose to 'get under control'! Thank you for being brave enough to share this story and raise awareness. I'm in the UK too and working on self-help strategies and peer support systems to help LGBTQ+ people manage their mental health. Please check out the Reconnecting Rainbows website (we also have a free e-book) - it's a work in progress but hopefully you'll find something helpful, and do feel free to contact me via the website or schedule a free call through the bookings page.

Thank you. I have managed to get some therapy after a thorough investigation of what specific information they’re required to share with my GP and my therapist took the message that involving my GP might place me in serious danger, so I’m seeing someone at the minute.

It might be nice to connect anyway as I work for an LGBT+ support charity and I have a lot of people come my way in a similar situation. I’ll PM you.