September 25, 2011 15 Comments
The World Professional Association for Transgender Health (WPATH) released it’s 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) in Atlanta today. The previous Version 6 was published in 2001. Overall, this newest SOC represents significant forward progress in respecting trans people and affirming the necessity of medical transition care for trans and transsexual individuals who need it. Although controversies and issues of transition care access remain in the SOC7, WPATH has announced a more frequent update process that will hopefully be more responsive to emerging evidence and clinical experience in the future.
First published in 1979, the SOC has provided clinical guidance to medical and mental health providers serving trans people, with an emphasis on transsexual individuals seeking hormonal and/or surgical transition care. In many parts of the world, particularly North America and Europe, the SOC has played a role in enabling access to medical transition care and in enabling medical and surgical practitioners to provide it. However, the SOC has been controversial among trans communities and supportive care providers. For example, prior versions have been critized for unreasonable barriers to medical transition care, pathologizing language of “disordered” gender identities and “gender‐disturbed children,” maligning pronouns and terms for transitioned individuals, and compulsory psychotherapy requirements. Fortunately, successive revisions of the SOC have trended toward greater respect for trans and transsexual people and fewer unjustified barriers to transition care. For example, mandatory urological examinations were dropped from the 4th Version in 1990, and mandatory psychotherapy requirements for those needing access to hormonal or surgical transition care were dropped from the 5th SOC in 1998.
Gender Conversion Psychotherapies are Unethical
Perhaps the most historic change in the SOC7 appears in the section of ethical guidelines:
Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.
Though long overdue, this condemnation of gender-conversion or gender-reparative psychotherapies sets a new ethical standard for the mental health professions. Sexual orientation conversion therapies have been rejected by the American Psychiatric Organization, the American Psychological Association, the American Medical Association, the National Association of Social Workers and many other professional associations for over a decade. Yet the mental health and medical professions have maintained a double standard for trans, transsexual and gender nonconforming people victimized by analogous gender-reparative therapies that are equally harmful.
I commend the WPATH leadership and the SOC committees for taking this historic step and call upon the American Psychiatric Association and other professional associations to follow WPATH’s leadership on this important issue.
De-psychopathologisation of Gender Difference
The 7th Version of the SOC goes further than prevous versions in employing respectful language and dispelling false myths that equate nonconformity to birth-assigned sex and gender roles with mental illness. A section entitled, “Being Transsexual, Transgender, or Gender Nonconforming Is a Matter of Diversity, Not Pathology,” prominently notes:
WPATH released a statement in May 2010 urging the de-psychopathologization of gender nonconformity worldwide (WPATH Board of Directors, 2010). This statement noted that “the expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon [that] should not be judged as inherently pathological or negative.”
We can only hope that the American Psychiatric Association and World Health Organizations will take guidance from this principle in future revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Statistical Classification of Diseases and Related Health Problems (ICD).
The de-psychopathologization principle is underscored by statements that, “Psychotherapy is not an absolute requirement for hormone therapy and surgery,” first introduced in Versions 5 and 6–
A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy – although highly recommended – is not a requirement.
The new standard clarifies gender dysphoria, from a greek root for distress, as the focus of treatment, replacing pathologizing language of “disordered” gender identity. Gender dysphoria is painful distress with one’s current physical sex characteristics or assigned or ascribed social gender role. Social role transition to a congruent, affirmed gender role and hormonal and/or surgical transition treatments (for those who need them) are well proven in relieving this distress. The SOC7 notes,
…transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.
The American Psychiatric Association has already proposed to replace the defamatory diagnostic title of “gender identity disorder” with Gender Dysphoria in the pending 5th Edition of the DSM.
Other Positive Changes
The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include:
- Concise and more cogent criteria for access to hormonal and surgical transition care.
- Relaxation of the age 18 restriction for access to hormonal transition care.
- Removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.
- Clarification that “the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones .”
- Removal of barriers to surgical care because of family intolerance or interpersonal issues.
- An expanded role for medical health professionals in granting access to hormonal therapies.
- Acknowledgement of informed consent model protocols, developed at community health centers worldwide for hormonal transition care.
- Emphasis of cultural competence and sensitivity for care providers.
- Expanded and clarified information on puberty delaying treatment for gender dysphoric adolescents.
- Clarification on the role of the SOC as flexible clinical guidelines that may be tailored for individual needs and local cultures.
Issues for Future Revisions
Although the 7th Version of the SOC is significantly improved over previous versions, there remain issues of concern to trans communities and their allies. One issue is promotion of a widely held myth that gender dysphoria in children will persist in only a small minority by adolescence, in other words, that gender identity in children is malleable and impersistent. These statements in the SOC are based on studies that conflated mere nonconformity of gender expression in children with the distress of gender dysphoria: painful distress with born sex characteristics or assigned gender roles. Among a new generation of gender dysphoric children from supportive families, children who have actually transitioned to affirmed roles congruent with their gender identities, there is so far very little evidence of impersistence. Hopefully, future revisions of the Standards of Care will quickly incorporate research findings on these new populations of affirmed youth, as they become available.