Abolish The Standards of Care, Respect Transgender Agency

The standards of care are an outdated relic and reflect a bigoted view of trans people. It is time to get rid of them.

During much of my transition I have had the luck of being able to attain care that followed a more or less informed consent model. In the most simple terms, this means that my care was not predicated on the approval of mental health professionals providing me with a green light, but was instead structured around the assumption that I was informed of the risks and effects of transgender related medical care, and that I was a competent adult capable of deciding to undergo such healthcare on my own. This model treated me not as a sick individual who needed the approval of an expert to determine what is best for me, but as an adult trans woman who is as capable of deciding what’s in my best interests as easily as any other person.

Unfortunately, my situation has changed and I no longer have access to care that operates on the principles of informed consent. My current healthcare providers instead use a system which adheres to the The World Professional Association for Transgender Health’s Standards of Care (WPATH SOC for short). The WPATH is an organization founded in 1979 to offer a unified voice to health care providers who oversee the care of transgender patients. The organization was originally called The Harry Benjamin International Gender Dysphoria Association, named after the groundbreaking doctor and surgeon Harry Benjamin. The WPATH publishes a document called the Standards of Care which outlines standardized procedures for the treatment of transgender patients. The SOC explains common courses of treatment and also establishes standard criteria that patients must meet in order to be eligible for care. Prior to the recent rise of the informed consent model, the WPATH SOC were the standard guidelines for transition.

WPATH do acknowledge the increasing popularity of an informed consent model, but ultimately provide justifications for preferring the SOC in its place. The current edition of the SOC states that the SOC and an informed consent model are not totally irreconcilable, as the criteria laid out in the SOC simply seek to create a standardized framework, and individual care providers are free to modify criteria based on the needs of individual patients. The distinction between the SOC and informed consent lies in the former’s “greater emphasis on the important role that mental health professionals can play in alleviating gender dysphoria and facilitating changes in gender role and psychosocial adjustment.” In contrast, informed consent attempts to employ a more voluntarist harm reduction model where the role of mental health professionals is reduced to providing support when requested, rather than requiring mental health intervention as a prerequisite for receiving other forms of care. While this should give you a sense of the general attitudinal differences between an informed consent model and the WPATH SOC, its worth more carefully examining the practical ways that this plays out in clinical practice.

One of the first difference is likely to be differing approaches to diagnostic criteria. Informed consent models do not primarily focus on diagnosing Gender Dysphoria (previous Gender Identity Disorder in previous DSM editions). A patient testifying that they have persistent long lasting dysphoria is usually enough to an informed consent clinic to offer hormone replacement therapy at the very least. On the other hand, clinics that follow the WPATH SOC are much more likely to spend time assessing diagnostic criteria for Gender Dysphoria. The SOC repeatedly mention the role of mental health providers performing a holistic psychological assessment of patients, in order to assure that gender dysphoria is a primary symptom and not a secondary symptom resulting from another untreated disorder. Put more simply, patients will be expected to demonstrate that their dysphoria is part of a long time pattern in line with a set of criteria to determine that they are from a clinical perspective, suffering from primary gender dysphoria as a result of being transgender, rather than experiencing dysphoria like symptoms from OCD, Schizophrenia, or any other disorders.

Even more practically, this diagnostic focus can mean answering humiliating and invasive questions as a prerequisite for trans related healthcare. The current DSM lists seven criteria, of which a patient must meet at least two in order to receive a diagnosis of Gender Dysphoria. These include, among other criteria, a desire to transform into the other gender, an intense need to do away with sexual characteristics, a strong sense of having the characteristics of the other gender, and a demonstrated dysfunction in one’s life as a result of these feelings. This means that in order to gain access to trans related care under the SOC, patients often are forced to endure questions such as “Do you wish you did not have a penis/vagina?” Patients might be asked to describe traumatic details of how their dysphoria has hurt them. Patients may be asked to disclose deeply personal histories of self harm. All of this often in the context of sitting down and discussing with a mental health provider that patients have just met. This process can be humiliating, and trans patients often describe a feeling of having to prove that they are truly transgender enough to deserve care. Ultimately, the decision regarding access to care at all is taken out of patients’ hands and put in the hands of a stranger who is presumed to be more knowledgeable merely on the basis of awkward and embarrassing diagnostic interviews. The informed consent model generally avoids this by trusting that transgender patients are adults with decision making capabilities, who can determine for themselves whether trans related healthcare is right for them.

In my own experience, this diagnostic component has been particularly frustrating. I had already been in the process of socially and medically transitioning for several years at the point that I ended up under the care of a clinic run in accordance with the WPATH SOC. I had been on hormones for over three years, with the last 9 months having been at a much lower dose due to precarious access as a result of becoming uninsured. Despite having already been on hormones, already legally changing my name and my gender, and already having been socially transitioned for years, the SOC compliant clinic required me to wait a month to get a screening appointment in which I had to go through the diagnostic process all over again. This meant sitting down with a stranger for several one hour sessions and being asked invasive questions about my earliest childhood memories, about how my dysphoria made me feel, and about how I felt regarding specific body parts. This was all medically unnecessary, as I was already transitioned and clearly have primary gender dysphoria that I have addressed through medical intervention. However, the SOC’s own insistence on the role of mental health professionals providing diagnostic screenings meant that I had to go through this whole process, which ended up delaying my access to a stable and legal source of hormones by several months. This is directly a result of the framework of the SOC, and is an experience that would have been avoided in an informed consent clinic.

The second difference between an informed consent model and the SOC that one is likely to notice is how a continued focus on mental health plays out over the course of one’s transition. Even if patients are able to get diagnosed with primary gender dysphoria, mental health professionals can still limit access to care. The SOC’s criteria for hormone replacement therapy states that in order to access HRT, patients must demonstrate that concurrent mental health concerns are “reasonably well managed.” This same criteria extends well beyond hormone replacement therapy, popping up as a criteria for all trans related surgeries as well. This means that under the SOC model, mental health professionals have the ability to limit patients access to health care until said professional had deemed that a patient’s mental health is reasonably well managed. The current edition of the SOC states that this does not mean that mental health concerns necessarily preclude access to transition treatments, but the possibility is left open, and the document seems to suggest that badly insufficiently managed mental might be a reason to question whether a patient is able to consent to treatment. The SOC do insist that ultimately it is a client’s decision whether or not to pursue transition related care, but they simultaneously provide a framework for mental health professions to limits patients decision making capabilities, or at least significantly slow down the timeframe for patients to access often urgent treatment such as hormone replacement therapy.

I can best practically explain how this plays out by again referencing my own experience. When attempting to access hormones through and SOC compliant clinic, I had to fill out a mental health questionnaire about ongoing symptoms. I checked some symptoms of anxiety and depression. This makes sense as I have been diagnosed with both. Upon seeing this, my trans care case manager interrogated me about just how bad my depression and anxiety were, stressing that having both well managed would be a prerequisite for access to more hormones. While I was able to talk the situation down and demonstrate that even with some symptoms, my mental health is mostly well managed, other trans people are not always so lucky. I have had friends who have had to go on psychiatric medication or undergo certain periods of therapy in order to be determined to have “reasonably well managed” mental health. Again, because this is a criteria for both hormones and surgeries, this means that mental health professionals can stall the progression of a patient who is already on hormones but wants to move on to accessing various surgeries. This means that patients are in many ways incapable of being totally honest with mental health professionals who oversee there cases, often choosing to conceal information in order to access care. In this sense, the SOC can actually undermine the relationships between patients and mental health providers.

There are other differences between the SOC framework and an informed consent model, but I hope the examples that I have brought up demonstrate the core difference between the two: a differing attitude towards trans patients as agents capable of making decisions for themselves. Informed consent models treat transgender patients as competent adults. They extend a basic respect towards trans people as decision makers. This is fitting as many trans patients research gender dysphoria as well as transition care extensively prior to seeking treatment. Often times trans patients I know will remark that they are more familiar with relevant procedures than the mental health professionals overseeing their care. Informed consent models at least leave room for acknowledging this reality. The SOC, on the other hand, takes a fundamentally condescending view of trans patients. It assumes that they are ignorant of transition options and protocols. It presumes that mental health professionals are necessary guides through the process who ought to have the final say in whether or not a patient is ready to receive access to often life saving care. The SOC framework takes a fundamentally paternalistic stance towards trans patients.

It’s worth acknowledging that while the SOC framework is harmful and patronizing, it is part of a broader debate within the history of trans care in the west regarding whether to view trans people as fundamentally disordered or as a normal part of human society. Medical professionals have maintained a largely pathologizing view of trans patients since the emergence of literature documenting such patients. In 1886, Richard von Krafft-Ebing wrote about something akin to transgender people in his Psychoathia Sexalis, chalking the phenomena up to a disorder that needed to be treated by bringing patients back in line with their birth gender. Later, a German doctor named Magnus Hirschfeld would provide his own theories of “sexual inversion” alongside providing hormone treatment for transgender patients. Rather than seeing trans people as fundamentally defective, or as broken cis people, Hirschfeld suggested that trans identity was a part of a broader more diverse human experience. In this sense, he offered a much less pathologizing conception of transgender identity. Hirschfeld’s approach was much more progressive than Krafft-Ebing’s but was ultimately sidelined when the Nazis attacked Hirschfeld’s institute and burned his research. Unfortunately this set back psychological understandings of transgender identity for quite some time.

In the United States, much of the theoretical framework for understanding trans people from a medical and psychological perspective was developed by Harry Benjamin. While Benjamin unquestionably provided lifesaving care for many patients, he also proposed a harmful theoretical typology called the Benjamin Scale. Benjamin continued somewhat in the tradition of Krafft-Ebbing, choosing to see trans patients as suffering from a disorder. He diverged, however, in proposing that the best treatment for this disorder was to allow patients to transition into living as their desired gender. In order to determine who would get access to transition related care, he applied his Benjamin Scale. This scale was meant to distinguish between what he called “pseudo-transsexuals” and “true transsexuals.” For Benjamin, pseudo-transsexuals were mere crossdressers or fetishists who should not be given access to surgical care, where as true transsexuals were extremely feminine, only attracted to men, and report lifelong dysphoria, and thus should gain access to surgery. The Benjamin scale brought in a host of bigoted assumptions that most would object to today. He suggested that true transsexuals had to be feminine, had to only be interested in sex with men, and had to more or less conform to traditional western norms of womanhood. Benjamin was able to offer such strict criteria because he felt that trans people were disordered and sick, and transition related surgery was nothing more than a treatment for those who needed it most. This pathologizing view of trans people allowed Benjamin to insert homophobic and misogynistic ideals into his criteria.

While the Benjamin scale is no longer used, one can see how the fundamental assumptions of the SOC fall more in line with the pathologizing view of trans identity found in Benjamin’s work than the more accepting view founding Hirschfeld’s. This should be unsurprising, as the WPATH (the organization who produces the SOC) used to be named after Harry Benjamin. The WPATH represents and can trace its history to an outdated mode of thought that still assumes an underlying pathology responsible for gender dysphoria, rather than simply seeing gender dysphoria as a normal human experience that some people have always had. The problems with the SOC are not just found within the document itself, but result from the lineage that it traces back to an outdated view of transgender identity.

The informed consent model is not perfect, but it avoids a lot of the baggage that the SOC carries with it. While individual clinicians who use the informed consent model will have varying views regarding transgender identity, the model does not presume a pathological view as a starting point. Ultimately, having experienced both models, I found that my healthcare was addressed with more compassion, greater speed, and more respect under an informed consent model. The difference between the two has been so stark that I have found that working through a SOC compliant clinic has actually begun to negatively affect my mental health due to invasive questioning, constant SOC related loopholes to jump through, and the knowledge that my continued access to health care is predicated on the opinions of a health care professional I barely know. Ironically, I don’t feel that I have the ability to address those mental health concerns, for fear that my access to further treatment might be hindered by bringing them up.

Despite these shortcomings of the SOC framework, many healthcare providers continue to employ it. This may not be totally out of malice. The SOC present themselves as the gold standard for trans care, and care providers who are ignorant of relevant debates surrounding ideal practices may be unaware of the controversy. Unfortunately, the SOC can cause great distress for trans individuals regardless of the intentions of healthcare providers.

At the end of the day, health care providers have to ask themselves a simple question: do I believe that my transgender patients are competent adults as capable of making decisions as any other competent adult? If the answer is yes, then providers should not only steer clear of the SOC framework, but should also advocate against it within their field. If the answer to that question is no, doctors ought to consider that they are following in a destructive, bigoted, and medically harmful tradition of seeing trans people as sick rather than as free decision making agents. The standards of care condescend to patients and treat them in a very patronizing manner. This helps no one. Instead we ought to recognize the agency that trans people have to make their own decisions, and provide appropriate care in line with those decisions. For that to happen, the SOC will have to go.

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