Hopping the Fence: An Historical Look At Gatekeeping and the Narratives that Helped Trans People Transition

​When I was coming out in early 2017, one of the first resources I found was a zine called Mascara and Hope. Although it was aimed at trans women in the UK navigating the NHS gender clinic system, it was one of my first glimpses at how trans people have had to contort themselves in order to be given the health care they so desperately deserve. While I am lucky that my experiences getting on hormones in Toronto was no where near as infuriating as it describes, I cannot help but think back to it and other materials in the wake of the Missouri Attorney General’s emergency rule that will increase barriers to access.

The front page of Mascara and Hope.

​​First posted on Tumblr on 30 November, 2013, Hacking Transition: Surviving on Mascara and Hope is a short 40 page zine meant to walk trans women seeking a medical transition through the complicated and confusing process of getting on hormones and getting surgery in the UK. The zine offers a humorous perspective on trying to navigate the system so that others can more effectively make their way through it. While some of the information is less useful and outdated (the gender clinics in the UK have only become more ineffective, for example), there is a lot of advice that is timeless, such as building a community.

The most useful (and relevant for this conversation) information comes about a third of the way through the zine. On page 11, Mascara and Hope describes what one’s first gender clinic appointment would look like and what to expect from it, namely disappointment. Trans women are not going to get hormones after one appointment, the authors emphasize, and the first appointment is not going to achieve much. Their presentation will be judged on whether it is sufficiently feminine or not and they will be asked unnecessary questions. In response, the authors recommend dodging the usual questions around topics like sexuality and mental health in order to “[not] give them reasons to delay [hormones].” The advice is to hide the red flags and confront them through one’s support group because these issues will only hinder further progress. ​

“The GIC are gatekeepers. They judge whether your gender is genuine enough to deserve treatment. We take umbrage with this. Even if you tick every box and get your script right on schedule, think: why the hell is there a schedule?” (Mascara and Hope, 14)

What develops out of this and the following pages is a narrative to follow. Trans women should be on guard when dealing with these gatekeepers. Keep personal details close to one’s chest and do not reveal anything that might delay the already painstaking process even more. The relationship is an adversarial one; the clinic and their employees do not exist to help trans people but to weed out those they deem to be “fake” trans people. As such, trans people must know the game when going in and be ready to play when they walk in. They are the gatekeepers, and giving them what they want to see and hear will help in the long run, even if it is counter to one’s own perception of themselves.
 
Here in Toronto, though, we have a different clinic system. And in the history of that, the Clarke looms large.
 
I am not sure when I first realized the history of the Clarke Institute, nowadays part of the Centre for Addiction and Mental Health (CAMH). Certainly by 2019, I knew its role as the major gatekeeper for Ontario and much of Canada. By the time I came out, CAMH was no longer the only clinic that one could go to in order to get provincial funding for transition related surgery, so I was spared the long waits that were common there. As a result, most of my experience with the Clarke and CAMH would come through research for my exhibition, Transition Related Surgery: Fight For Access. 

​The exhibition, linked above, explored the role that activists played in the history of transition related surgery in Ontario. As the only clinic that the Ontario government recognized for transition related care, the Clarke held enormous control over the lives of trans people in the province. It was here that harmful theories like autogynephilia, the belief that trans women are sexually aroused by the idea of being seen as a woman, were first introduced. For all intents and purposes, the Clarke’s gender identity clinic was exactly the sort of medical establishment that Mascara and Hope was advising its readers to navigate with caution.

The staff at the Clarke Institute, a variable Who's Who of Transphobic Psychiatry. Staff include Dr. Kenneth Zucker (first on the left) who ran the youth gender clinic at the Clarke that was known for practicing conversion therapy, and Dr. Ray Blanchard, originator of autogynephilia.

​Through my research on the Clarke, I came across an early reflection on the gender clinic, written by Dr. Betty Steiner, the head of the program. Entitled A Gender Identity Project: The Organization of a Multidisciplinary Study, the article discussed the steps that the Clarke Institute, along with the University of Toronto, took to set up a steering committee and the various stages that they expected trans people to navigate in order to get their medical needs met. By the time this article was published in February 1974, the clinic had already been operating for four full years, having opened in 1969.
 
I find the first stage of their diagnosis to be most revealing. It is here where Steiner and the other Clarke psychiatrists figure out “the degree to which they are involved in a transsexual life style [sic].” (Steiner et al., 8) A questionnaire would be given to the patients to fill out, describing their life experiences and how gender has played a role. The information provided would be cross referenced as the patient went further, ensuring that they were telling the truth. This was necessary, the authors state, because “the desire for a sex change operation is usually so great that information can easily be distorted to fit the assumed requirements of the project.” (Steiner et al., 9) If the patient was not willing to supply this information, they would not be allowed to continue.

“The desire for a sex change operation is usually so great that information can easily be distorted to fit the assumed requirements of the project. Equally, in terms of the 'life story', similar distortions occur; the patient's story being a mixture of his own perceptions, perceptions from the literature and information he feels he must give the investigators in order to proceed in the project to the goal of surgical sex reassignment. Data sets from later stages of the protocol may then throw some light on the construction of the biography, and the choice of photographs also gives some preliminary information about the patient's self perception. If the patient complies with these requests for data, appointments are made for him to begin clinical evaluation.” (Steiner et al., 9)

What I find most interesting is that, even in 1974, it was recognized that trans people were telling the psychiatrists and clinicians exactly what they wanted to hear. It thus became necessary to refer back to the information provided at the beginning in order to prove that trans people were not lying to the Clarke’s employees. Steiner, just like the authors of Mascara and Hope, saw the relationship as adversarial. It was their job to find what was truth and what was lies, in order to gatekeep transition. If one did not play the game properly, they would be kicked to the curb and the Clarke would refuse to help.
 
There is a very clear lineage between Mascara and Hope and Gender Identity Project. One creates the gates that must be overcome in order to prove a patient’s transgender identity, the other informs how to conceal and effectively maneuver around those gates. Although separated by nearly 40 years and an ocean, they clearly both speak to the lengths that trans people have had to go to in order to live their life. Neither side trusts the other, and as such, utmost caution is deployed wherever possible.
 
This history goes back even further, however. 40 years prior to Steiner’s article, the English translation of Lili Elbe’s biography Man into Woman: An Authentic Record of a Change of Sex was published. As Zoë Playdon describes in The Hidden Case of Ewan Forbes And the Unwritten History of the Trans Experience (my book review can be found here), Elbe’s biography was “a hidden narrative, a kind of underground railroad or secret route for trans women eager to access medical support.” (Playdon, 39)
 
Through Man into Woman, Elbe was able to offer other trans people a narrative that would be acceptable to the medical establishment of the day. Based upon an earlier case in Richard von Krafft-Ebing’s Psychopathia Sexualis, Elbe showed the readers that were able to read between the lines the sorts of life details to tell doctors. These included early cross gender experiences and an adolescent urge to be the other gender. (Playdon, 41) In essence, that they always knew they were trans. As Playdon notes, these details of Elbe’s life are also true for the trans man at the centre of her book, Ewan Forbes.
 
Looking at Playdon’s analysis of Man into Woman shows that the kinds of stories that Mascara and Hope was advising its readers to adopt and the Clarke was trying to sniff out were around even in the earliest days of transgender health care. Trans people would find what worked and share it with others. Even as trans health care became more prominent and standardized, the need for these narratives remained. The barriers to entry produced an adversarial relationship that saw all participants as untrustworthy.
 
Here in Ontario, things are far from perfect, but access has improved greatly from a dismantling of these barriers. The Clarke’s successor, CAMH, is no longer the only clinic one can go to in order to be prescribed hormones or get a reference letter for surgery. This was progress made over the past decade, with much further to go.
 
But unfortunately, that is not the direction that the wind is blowing at the moment. Since January 2023, there have been well over 400 bills introduced in the US targeting trans people. Many of these aim to limit transition related care for trans youth, with some of them even limiting access for adult trans people.

The most extreme example of this was made by the Missouri Attorney General on April 13th, 2023, yesterday at time of writing. Through an emergency rule, the Attorney General banned trans health care for minors and implemented a mandatory 3 year wait period with 18 therapy sessions before trans adults could access hormone replacement therapy. Anyone with autism or depression would be prevented from transitioning.

​It should be clear by now that instituting barriers like these do not protect anyone. All it will do is harm trans people and erode any trust between patient and doctor. The patient, in order to get access to the health care they seek, will develop a story that appeals to the doctor. In doing so, they will withhold medical histories that would otherwise limit their access. This has been proven time and time again; it was true for Lili Elbe and other trans people in the 1930s, it was true for the patients at the Clarke Institute in the 1960s, and it was true in the UK in 2013 and on. It will only become truer as more states and countries look to this recent wave of anti-trans activism as a movement to follow.

Oh my god.

Missouri AG just essentially banned gender affirming care for most trans adults via emergency rule.

Requires 3 years of dysphoria, 18 months of therapy sessions, doesn't allow people with autism/depression.

This is what elimination of transgender people looks like. pic.twitter.com/wHvembk1wk

— Erin Reed (@ErinInTheMorn) April 13, 2023

Barriers to access help no one, but harm many. It is imperative that they be fought at every step of the way.

Work Cited

​Hacking Transition: Surviving on Mascara and Hope. 2013.
Playdon, Zoë. The Hidden Case of Ewan Forbes: And the Unwritten History of the Trans Experience. New York: Scribner, 2021.
Steiner, Betty W., A. S. Zajac, and J. W. Mohr. “A Gender Identity Project: The Organization of a Multidisciplinary Study.” Canadian Psychiatric Association Journal Vol 19, No 1 (Feb 1974): 7-12.