Eckstrand also points out that asking for more medical intervention is particularly difficult for transgender people, who are far more likely to face discrimination and stigma in the doctor’s office. Studies show that transgender people are less likely to seek out healthcare, and when they do, often face doctors who don’t know what they need. “We know that a good portion of transgender people who do access medical care end up teaching their provider about their needs and bodies,” she said. “The medical environment is tough for anyone but it’s particularly tough for transgender people.”

This isn’t to say that there should never be any mental health-checks on those seeking gender confirmation surgeries. “Note we are not arguing for an 'anything goes' approach,” Bouman wrote in the paper, “rather that, when undertaken within a multidisciplinary/interdisciplinary team, it is possible to provide a robust assessment and ongoing support to stable trans people such that the two-signature approval system is not necessary.”

Eckstrand says that to properly help transgender people, doctors should stop thinking about checklists and start paying attention to the needs of their individual patients. “As providers we need to do due diligence in figuring out what the best way to provide care for these individuals, and that can’t be a mental health check box.”

Alice Dreger, a historian who studies gender and medicine at Northwestern University’s Feinberg School of Medicine, agrees. “For some people, it’s crazy to require two signatures by mental-health professionals," she told me in an email. "They are genuinely fully informed already, have done a lot of thoughtful processing on their own, and know what they need. For some, screening by two people may not be enough. So it’s an imperfect model of care, to be sure, especially when you have mental-health professionals who vary all the way from genuinely anti-trans to anti-screening.”

That spectrum of care Dreger mentioned doesn’t just exist when it comes to the experience and points of view of mental-health professionals. It also exists geographically. Because the healthcare systems in Europe and the United States are so fundamentally different, these regulations impact transgender people living across the ocean quite differently. The WPATH standard of care guidelines aren’t technically rules—the organization simply writes their recommendations for the standards they think are appropriate. But in Europe the double referral is standard, Bouman says. “It is a requirement in the U.K., as it is in most other European countries,” he said.

In the United States, on the other hand, the two-referral suggestion is often not an issue. This isn’t because the U.S. is exceptionally fair to trans people, but rather because health insurance won’t pay for genital reconstructive surgeries in the first place, says Shannon Minter, legal director of the National Center for Lesbian Rights. (Minter himself transitioned 18 years ago at the age of 35.) Until recently, every state had a ban on any kind of Medicaid reimbursement for gender confirming surgeries. Most private insurance plans don’t cover them either. So trans people who want to pursue surgery are forced to finance their own procedures. “When you pay out of pocket, this two evaluation issues doesn’t tend to come up,” Minter said. In other words, those who are having to pay out of pocket for their own surgeries often simply pay the surgeon directly, rather than going through the standard channels.