Many trans and gender-diverse (TGD) people seek surgeries to align their bodies with their gender identity. This contested field has historically been dominated by mental health professionals, whom TGD people have often seen as “gatekeepers.” Gaining access to medical treatments, while avoiding pathologization and stigmatization, is the central dilemma of TGD clients' relationship with clinicians. For clinicians, the dilemma is inverted—they seek to provide access to treatment but also to mitigate risks of harm to their clients and of legal action if clients regret surgery. In prominent cases, two former clients who regretted their surgeries sued the Monash Health Gender Clinic, precipitating a review of operations and a three-month closure. Internationally and in Australia, the approach to care has moved from psychiatric dominance toward a collaborative approach between clients and clinicians from varied disciplines to achieve the best individual outcome. This shift is partially reflected in changes to diagnostic criteria and clinical guidelines. These changes have increased access to treatments for many TGD people previously excluded. However, at this clinic, surgeons' requirements for approval by a mental health professional have changed little in forty years. This article provides a clear exposition of how clinicians in the most prominent Australian gender clinic approach approval of medical treatment. Clinicians have moved to depathologize their approach, but the tensions defining the clinician-client relationship remain in balance: the risks of regret after treatment versus self-harm without it; and access for clients' desired treatments versus medico-legal risk for the clinician.