Trans health policy has a history of authorising members of various health professions to verify whether a person is psychiatrically distressed-yet-safe-enough to access requested gender-affirming medical technologies. However, ongoing concerns about an approach that attributes authority to psychiatric knowledges to determine access to care have generated alternative visions for depathologisation that redesign healthcare systems to meet rather than regulate requests for body modifications. This is not simply because pathologisation structures harmful practices and relations but also because it is part of a mechanism that helps secure colonial state power and maintains populations on stolen Indigenous lands. This chapter offers a critical history of care in the present. It examines how requests for gender-affirming medical technologies became mental health problems that often require psychiatric assessment and diagnosis to enable “treatment” of the body. This genealogy traces the conditions and contestation of care. It shows how colonially inflected rationales and practices of governing gender are overlaid with different strategies and tactics for governing access. Understanding how people with self-designated genders have become psychiatrised subjects of care within projects of settler colonialism is integral to dismantling an illness model and critically evaluating an ascendant model of rights in trans health.