New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People

Kelley Winters, Ph.D.
GID Reform Advocates

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.

Download the SOC Version 7

About Kelley
Dr. Kelley Winters is a writer and consultant on issues of gender diversity in medical and public policy. She is the author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity (2008) and a past member of the International Advisory Panel for the World Professional Association for Transgender Health (WPATH) Standards of Care, the Global Action for Trans* Equality (GATE) Expert Working Group, and the Advisory Boards for TransYouth Family Allies (TYFA). She was recognized in the 2013 Trans 100 Inaugural List for work supporting the transgender community in the US. Kelley has presented papers and presentations on gender policy issues at annual conventions of the American Psychiatric Association, the American Psychological Association, the American Counseling Association and the Association of Women in Psychology. Kelley wanders the highways of America in an old Mazda, ever in search of comfort food.

15 Responses to New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People

  1. christine says:

    Thank you so very much for all of your hard work and dedication to the community impacted by these changes. Thank you as well for keeping people like myself informed of current changes/issues.
    Bless you,

  2. Susan Golightly says:

    A simple thank you seems hardly enough, but it comes with intense gratefulness. It is people like you, that have enabled people like me to live a relatively normal life. Now, if only the DSM V committee will take note and make the much needed changes.

    Thanking you again,

  3. HenryHall says:

    SOCv6 versus SOCv7 in pertinent parts:
    SOCv6: ” … Sex Reassignment is Effective and Medically Indicated in Severe GID. In persons diagnosed with transsexualism or profound GID, sex reassignment surgery, along with hormone therapy
    and …
    SOCv7: “… a criterion for all breast/chest and genital surgeries is documentation of persistent gender dysphoria by a qualified mental health professional. …”

    Thus, whereas treatment under SOCv6 was based on GID which is based on behavior, treatment under SOCv7 is based on gender dysphoria which is based on mental distress.

    This means that many people now qualify for medical treatment under v7 who did not qualify under v6. And, oddly, vice versa.

    • gidreform says:

      > And, oddly, vice versa.

      This is a really good point.

      The SOC7 uses the 1974 Fisk definition of gender dysphoria, which lacks clarity around the diverse ways that people express gender dysphoria. (It could be worse– at least they do not use the DSM-5 definition of gender dysphoria, which is currently a mess) I urge WPATH to use an updated four-cornered definition of gender dysphoria, drafted by Lev, Alie, Ansara, Deutsch, Dickey, Ehrbar, Ehrensaft, Green, Meier, Richmond, Samons, Susset and me. It includes not only direct distress with the junk you got (to paraphrase), but also distress with deprivation of the junk you need to be healthy and functional in your affirmed, congruent gender role. Here is a summary of the improved gender dysphoria definition

      • HenryHall says:

        There are a number of problems. First “distress” is understood by some to mean “mental distress” but by others to have a broader meaning to include somatic distress (think of a ship sending up a distress rocket – it’s not because they are distraught, it’s because water is coming in!).

        Second, not all transsexual people are dysphoric. Some even say they are gender euphoric.

        Thirdly, mental distress arises almost entirely from discrimination, bullying, stigmatization and disrespect. Especially disrespect by elders, including the health profession. Not really anything to do with gender, more to do with unthinking villainy by others.

        I fear those who have suffered great mental distress have projected their experience onto the general transsexual population and caused undue focus thereon to the exclusion of needy people without mental distress.

        The title Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People is misleading because nothing is offered except for the gender dysphoric. You have to be non-conforming in a very specific and narrow way to qualify for surgery.

        Gender variance is not mental illness, but gender dysphoria is, and treatment is offered only for gender dysphoria.

  4. Vibe says:

    “Persistent, well documented gender dysphoria;”

    Whether this is an improvement over the 3 month RLE criterion depends on your provider, because this criterion leaves the psych* absolute power in determining what constitutes persistent and well-documented.

    In Denmark several years of observation prior to referral is not uncommon at the official GIC and they require life long cross-gender behavior. With the previous version of the standards we had an argument against those durations, whereas the new one does not leave us that argument.

    With different criteria for hysterectomy and vaginoplasty effectively alot of transgender women around the world have to meet RLE requirements prior to legal recognition, which are not demanded by transmen. That is a serious issue!

    • gidreform says:

      Thanks for raising these issues, Vibe. I’d like to better understand the policies in Denmark. I’ve heard that it can be difficult there. Please feel free to contact me offline. I see how ambiguity in the definition of gender dysphoria in the SOC could be abused by adversarial gatekeepers. I think this is a problem in Version 7. Would it help if the definition of gender dysphoria included, “distress with deprivation of the physical sex characteristics necessary to be healthy and functional in one’s affirmed, congruent gender role.” Deprivation language in the Lev, et al., definition and my definition of gender dysphoria are inspired by Dr. Anne Vitale’s work in San Francisco.

      I think the Revision Committee was correct in dropping the RLE requirement before HRT access for this reason– For many TS people, a RLE requirement before access to hormonal treatment is an insurmountable barrier to transition. Many people are unable to pass or socially function in their affirmed roles without hormones first. I think this policy change will save lives.

      It’s true that RLE requirements were relaxed for hysterectomies for TS men and not for vaginoplasties for TS women. However, it is equally true that RLE requirements were relaxed for orchiectomies for TS women and not for metoidioplasties for TS men, with equally serious legal consequences in some countries.

      Version 6 required 12 months RLE for all genital surgeries, MTF and FTM. In Version 7, the RLE requirement was dropped for orchi procedures for TS women and for hysterectomy and ovariectomy procedures for TS men. The 12 month continuous living in a congruent role requirement was retained for metoidioplasty or phalloplasty for TS men and vaginoplasty for TS women. I don’t see a disparity here between treatment of TS women and men. The question is– is it a positive change that rigid RLE requirements were relaxed for some procedures at all? What do you think?

      • HenryHall says:

        Beyond doubt the v7 increases the discretionary powers of the mental health professionals.

        Whether that is a good thing or a bad thing in an individual case comes down to high tightly regulated the mental health profession is in the locality and how free one is to shop around (especially overseas) for someone who better meets one’s needs. As contrasted with being forced to take the providers offered or having a very limited choice.

        For pre-op transsexual people the provider-patient relationship is still inherently adversarial and the adoption of the term “Gender Dysphoria” by the DSM-5 activity is not good. “Gender Dysphoria” already has a VERY specific meaning in UK law and formalizing the term in psychiatry will cause much mischief.

        At the very least WPATH must regard it as a priority to publish a definition of Gender Dysphoria as they see it. Sadly, I would expect a fluff document of many words that in the end says very little definitive. And that hedges as to whether Gender Dysphoria (in the sense used by WPATH) is, or is not, a mental disorder and won’t confront that question head-on by refusing to give a yes or a no answer. The trans community could work equally well with either yes or no, but fudging the issue damages transfolk.

  5. Gina says:

    This document is unacceptably pathologising of Intersex. Constructed without Intersex consultation or inclusion .
    This organisation has previously instituted a policy against Disorders and other pathologising language for Trans and seeks to have the DSMV remove GID because of its negative effect on those so described .

    It now pathologises Intersex in exactly that way by describing us as Disorders of sex developement and in ned of psychological counceling if a doctor gets our assignment wrong.

    • gidreform says:

      This is true, Gina. The SOC7 is inexplicably disrespectful of people born with intersex conditions and misassigned to the wrong gender roles. I apologize that I did not note this in my post.

      For example, the SOC now suggests psychological gatekeeping for those with intersex conditions before transitioning socially– a barrier that it does not impose on trans people who are not diagnosed with intersex conditions:

      “Only after thorough assessment should steps be taken in the direction of changing a
      patient’s birth-assigned sex or gender role. (p.71)

      and then, there is this bizarre statement:

      “it is advisable for patients with a DSD to undergo a full social transition to another gender role only if there is a long-standing history of gender-atypical behavior,…” (p.71)

      In other words, misassigned people with intersex conditions, who have been shamed into the closet of conformance to their misassigned roles, are told they should stay in the closet and not transition to an affirmed role.

      I hope that IS community advocates will engage WPATH on reforming this language in the Standards of Care.

  6. Pingback: Day of Action: Stop Medical Oppression of Trans* Communities

  7. Thanks to my father who told me on the topic of this blog,
    this blog is in fact remarkable.

  8. Christien says:

    Hi THANK YOU for the work you have done, as myself being a transgender. I hope and trust the Medical Schemes will help shortly or in the not too distant future by paying for the surgeries and treatments, this being what we need to be our true self’s. The medical schemes at present do not want to help us, not seeing it as a needed surgery, they still classify it as cosmetic surgery. So we are still trapped in that incorrect shell or body. We all know if you want your body to be in line, it cost you just about your life’s earnings.

  9. Pingback: Trans Segment #49: Myth: The Standards of Care (SOC) have always been there to help trans people transition safely. « goodbyelazarus

  10. Pingback: RLE- Really!? | Gender Blog by Darlene Tando, LCSW

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