Standards of care for gender identity disorders
Encyclopedia
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are non-binding protocols outlining the usual treatment for individuals who wish to undergo hormonal or surgical transition to the other sex. Clinicians' decisions regarding patients' treatment are often influenced by this standard of care (SOC).
Prior to the advent of the first SOCs, there was no semblance of consensus on psychiatric, psychological, medical, and surgical requirements or procedures. Before the 1960s, few countries offered safe, legal medical options and many criminalized cross-gender behaviors or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin
International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment." These standards are still the most well-known; however, other sets of SOCs, protocols and guidelines do exist, especially outside the USA.
people. The WPATH-SOC are periodically updated and revised. The latest revision was released September 25th, 2011. This is the seventh version of the WPATH-SOC since the original 1979 document was drafted. Previous revisions were released in 1980, 1981, 1990, 1998, and 2001.
Included in the guidelines are sections on purpose and use of the WPATH-SOC, the global applicability of the WPATH-SOC, the difference between gender nonconformity and gender dysphoria, epidemiology
, treatment of children, adolescents and adults, mental health
, hormone replacement therapy (female-to-male
or male-to-female
; HRT), reproductive health, voice and communication therapy, sex reassignment surgery
, lifelong preventive and primary care, applicability of the WPATH-SOC to people living in institutional environments, and applicability of the WPATH-SOC to people with disorders of sex development
.
. Two additional letters are needed for genital surgeries.
The Eligibility Criteria and Readiness Criteria give certain very specific minimum requirements as prerequisites to HRT or sex reassignment surgery (SRS). For this and other reasons, the WPATH-SOC is a highly controversial and often maligned document among patients seeking medical intervention (hormones, and/or surgery), who state that their legally protected right to proper medical care and treatment is unjustly and unduly withheld or even denied based on the SOC.
WPATH-SOC sections One through Four are introductory in nature, explaining (section I) the purpose, intent, and need for the SOC, (section II) epidemiological considerations relating to transsexual people, (section III) diagnostic nomenclature, and (section IV) the job of the mental health professional.
Sections Five through Eight begin the actual guide to treatment. They specifically address the manner in which to diagnose transsexualism in both minors and adults, the manner in which to document the diagnoses and recommendations ("The Letter") and also covers requirements and treatment using hormones, including use and effects of hormones.
Section Nine covers "The Real-life Experience," formerly the "Real Life Test".
WPATH-SOC sections Ten through Twelve specifically cover the surgical treatment of transsexual people. Section Twelve, titled "Genital Surgery," deals directly with all concerns about sex reassignment surgery. It includes six "Eligibility Criteria" and two "Readiness Criteria", which are intended to be used by professionals for both diagnosis and guidance before providing patients "letters of recommendation."
The Thirteenth and final section covers "post-transition follow-up".
A criticism levied against surgeons who perform SRS deals with the rare non-SOC practice requiring patients to divorce their spouse before the surgery is performed.
The criticism about the WPATH-SOCs applies to these as well; some of these SOCs are based on much older versions of the WPATH-SOCs, or are entirely independent of them. A more lenient version that has been increasing in acceptance is the Health Law Standards Of Care, developed by the Health Law Project (also known as the ICTLEP guidelines), which is based on a harm-reduction model.
Treatment according to older SOCs is often reserved for transsexual people only, not for other transgender
people, who might not want to undergo the complete set of treatments, or who see themselves outside a binary gender system. Such older SOCs are often used to withhold medical interventions from transgender
people altogether.
In other regions, notably Latin America
, surgeons follow no particular set standards and use their own criteria for eligibility for surgery.
In Western countries the emphasis is on psychiatry
or psychology
; typically, in Latin America, the emphasis is on the ability to "pass
", and in Thailand the emphasis is on cross-living experience.
Prior to the advent of the first SOCs, there was no semblance of consensus on psychiatric, psychological, medical, and surgical requirements or procedures. Before the 1960s, few countries offered safe, legal medical options and many criminalized cross-gender behaviors or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin
Harry Benjamin
Harry Benjamin was a German endocrinologist, widely known for his clinical work with transsexualism. He was raised in an observant Ashkenazy Jewish home.- Early life and career :...
International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment." These standards are still the most well-known; however, other sets of SOCs, protocols and guidelines do exist, especially outside the USA.
WPATH standard of care
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health (WPATH-SOC) are the most widespread SOC used by professionals working with transsexual, transgender, or gender variantGender variance
Gender variance, or gender nonconformity, is behaviour or gender expression that does not conform to dominant gender norms of male and female...
people. The WPATH-SOC are periodically updated and revised. The latest revision was released September 25th, 2011. This is the seventh version of the WPATH-SOC since the original 1979 document was drafted. Previous revisions were released in 1980, 1981, 1990, 1998, and 2001.
Included in the guidelines are sections on purpose and use of the WPATH-SOC, the global applicability of the WPATH-SOC, the difference between gender nonconformity and gender dysphoria, epidemiology
Epidemiology
Epidemiology is the study of health-event, health-characteristic, or health-determinant patterns in a population. It is the cornerstone method of public health research, and helps inform policy decisions and evidence-based medicine by identifying risk factors for disease and targets for preventive...
, treatment of children, adolescents and adults, mental health
Mental health
Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...
, hormone replacement therapy (female-to-male
Hormone replacement therapy (female-to-male)
Hormone replacement therapy for transgender gender variant and transsexual introduces hormones associate with the gender that the patient identifies with...
or male-to-female
Hormone replacement therapy (male-to-female)
Hormone replacement therapy for transgender and transsexual people changes the balance of sex hormones in their bodies. Some intersex people also receive HRT, either starting in childhood to confirm the sex to which they were assigned, or later, if this assignment has proven to be incorrect...
; HRT), reproductive health, voice and communication therapy, sex reassignment surgery
Sex reassignment surgery
Sex reassignment surgery is a term for the surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble...
, lifelong preventive and primary care, applicability of the WPATH-SOC to people living in institutional environments, and applicability of the WPATH-SOC to people with disorders of sex development
Disorders of sex development
Disorders of sex development , sometimes referred to as disorders of sex differentiation, are medical terms referring to "congenital conditions in which development of chromosomal, gonadal, or anatomical sex is atypical." Lee et al...
.
Summary of WPATH-SOC
The sixth revision recommends that mental health professionals document a patient's relevant history in a letter, which should be required by medical professionals prior to physical intervention. One letter is required for hormone replacement therapy or either augmentation mammoplasty or male chest reconstructionMale Chest Reconstruction
In men with female breast growth, caused either by gynecomastia or by status as a trans man, a male chest reconstruction is often done to give the chest a more masculine appearance...
. Two additional letters are needed for genital surgeries.
The Eligibility Criteria and Readiness Criteria give certain very specific minimum requirements as prerequisites to HRT or sex reassignment surgery (SRS). For this and other reasons, the WPATH-SOC is a highly controversial and often maligned document among patients seeking medical intervention (hormones, and/or surgery), who state that their legally protected right to proper medical care and treatment is unjustly and unduly withheld or even denied based on the SOC.
WPATH-SOC sections One through Four are introductory in nature, explaining (section I) the purpose, intent, and need for the SOC, (section II) epidemiological considerations relating to transsexual people, (section III) diagnostic nomenclature, and (section IV) the job of the mental health professional.
Sections Five through Eight begin the actual guide to treatment. They specifically address the manner in which to diagnose transsexualism in both minors and adults, the manner in which to document the diagnoses and recommendations ("The Letter") and also covers requirements and treatment using hormones, including use and effects of hormones.
Section Nine covers "The Real-life Experience," formerly the "Real Life Test".
WPATH-SOC sections Ten through Twelve specifically cover the surgical treatment of transsexual people. Section Twelve, titled "Genital Surgery," deals directly with all concerns about sex reassignment surgery. It includes six "Eligibility Criteria" and two "Readiness Criteria", which are intended to be used by professionals for both diagnosis and guidance before providing patients "letters of recommendation."
The Thirteenth and final section covers "post-transition follow-up".
Criticism of the WPATH-SOC
Numerous criticisms have been made against the WPATH-SOC over the course of its history, some of which are reflected in later versions of the guidelines. Most of these criticisms are related to the strictness of the requirements, noting that the rate of post-surgical regret among transsexual people is very low — lower than many medically necessary and cosmetic procedures with less stringent requirements. Provisions related to the necessity of real-life experience (noting that requiring real-life experience in an incongruous anatomical/social role can be both mentally harmful as well as physically dangerous to the individual) have been particularly under fire, as is the SOC's very strict requirements on the treatment of minors. Under all but the most recent version of WPATH-SOC, even hormonal treatment to delay the onset of puberty was forbidden in all cases, leading to often irreversible bodily changes. This has been changed to allow for hormone treatment (both hormone blockers and hormones) in limited circumstances. The WPATH has also removed the set length of time for psychotherapy.A criticism levied against surgeons who perform SRS deals with the rare non-SOC practice requiring patients to divorce their spouse before the surgery is performed.
Other SOCs, protocols and guidelines for treatment of GID
In some countries or areas, local standards of care exist, such as in the Netherlands, Germany or Italy. Also, some health care providers have their own set of SOCs which have to be followed to have access to health care.The criticism about the WPATH-SOCs applies to these as well; some of these SOCs are based on much older versions of the WPATH-SOCs, or are entirely independent of them. A more lenient version that has been increasing in acceptance is the Health Law Standards Of Care, developed by the Health Law Project (also known as the ICTLEP guidelines), which is based on a harm-reduction model.
Treatment according to older SOCs is often reserved for transsexual people only, not for other transgender
Transgender
Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles....
people, who might not want to undergo the complete set of treatments, or who see themselves outside a binary gender system. Such older SOCs are often used to withhold medical interventions from transgender
Transgender
Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles....
people altogether.
In other regions, notably Latin America
Latin America
Latin America is a region of the Americas where Romance languages – particularly Spanish and Portuguese, and variably French – are primarily spoken. Latin America has an area of approximately 21,069,500 km² , almost 3.9% of the Earth's surface or 14.1% of its land surface area...
, surgeons follow no particular set standards and use their own criteria for eligibility for surgery.
In Western countries the emphasis is on psychiatry
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...
or psychology
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
; typically, in Latin America, the emphasis is on the ability to "pass
Passing (gender)
Passing refers to a person's ability to be regarded as a member of the sex or gender with which they physically present. Typically, passing involves a mixture of physical gender cues as well as certain behavioral attributes that tend to be culturally associated with a particular gender...
", and in Thailand the emphasis is on cross-living experience.