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

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The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal or surgical transition to the other sex. Clinicians' decisions regarding patients' treatment are often influenced by this standard of care (SOC). They are most widespread SOC used by professionals working with transsexual, transgender, or gender variant people.^[1][2][3] However, other sets of SOCs, protocols and guidelines do exist, especially outside the United States.

History[]

Prior to the advent of the first SOC, 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 (WPATH)) 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."

The WPATH-SOC are periodically updated and revised. The latest revision was released September 25, 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.^[4]

Sixth Version[]

The sixth revision^[5] 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 reconstruction. Two additional letters are needed for genital surgeries.^[6]

The Eligibility Criteria and Readiness Criteria in version 6 give certain very specific minimum requirements as prerequisites to HRT or sex reassignment surgery (SRS). Section Nine covers "The Real-life Experience," during which individuals seeking hormonal and other treatments are expected to begin transitioning publicly to their preferred gender role. 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." For this and other reasons, the WPATH-SOC is a 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.

The assessment and treatment of children and adolescents was covered in section V of version 6.

Version 7[]

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 (masculinizing or feminizing; 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.

The seventh edition also includes acknowledgements of the ever-evolving language used to describe and treat transsexual, transgender, and gender non-conforming individuals. There is an emphasis placed on the idea that identifying with these labels does not inherently qualify someone as disordered, and that treatment should be focused on the alleviation of any suffering caused by gender dysphoria. They make a stance against the "deprivation of civil and human rights” on the grounds of someone's gender identity. This version, much like its predecessor requires referrals for surgical procedures based on set criteria, but notes the importance of informed consent and listening to the wishes of the patient. ^[4]

Treatment for Children and Adolescents[]

The seventh edition includes a section distinguishing between cases of gender dysphoria and non-conformity for children and adolescents, as well as recommended treatment paths for each. ^[4]

For children, it is noted that the likelihood of persistence into adulthood is around 6-23% for biological males and 12-27% for biological females, and that the rate of occurrence ranges from 3-6 times more likely for biologically male children than biologically female children. It is also “relatively common” for these children to have coexisting disorders such as anxiety and depression. For children, the recommended treatment is primarily counseling services without a pushed bias towards conforming towards one presentation or another. Medical opinion on supporting the child in transition to a different gender role has not yet reached consensus.^[4]

For adolescents, the rate of persistence of dysphoria into adulthood seems to be much higher, although no formal studies have been conducted to analyze prevalence. Adolescents have not been reported to have a significant connection between gender dysphoria and coexisting disorders, and the rate of gender dysphoria between biologically male and female adolescents is 1:1. For adolescents whose dysphoria persists beyond counseling, it is recommended that a three stage approach be taken for treatment. This first is fully reversible interventions such as hormone blockers, which prevent the onset of puberty. The second is partially reversible interventions such as hormonal therapy designed to masculinize or feminize the body. Finally, the third stage is in the form of irreversible intervention in the form of surgical procedures. It is recommended that adequate time be given between stages to accommodate for the assimilation of effects for the adolescent and their parents, and that progression from one stage to another only occur if gender dysphoria persists.^[4]

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^[7] — 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. For many, it is safe only to express gender outwardly in limited settings (8/7, 12/7 or 18/7) rather than all day, every day (24/7). This is now taken into consideration in version 7.

The WPATH SOC version 6 and 7 allow for referral for puberty blocking medication to be prescribed to youth experiencing puberty, starting at Tanner stage 2 or above. Referral after that age could lead to bodily changes reversible only with surgery (facial shape, secondary sex characteristics); surgically risky (voice pitch); or, irreversible changes (skeletal structure or height). The WPATH SOC version 7 has also removed the set length of time for psychotherapy, in order to facilitate support and referral to transition services in a timely way, should they be required. These changes have led some critics to claim that the criteria are too loose, however, an individualized approach that provides prospective, supportive follow-up and education to families about how to affirm expression, and create an environment for safe exploration has always been recommended.

Other SOCs, protocols and guidelines for treatment of Gender Dysphoria[]

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 those who want to medically transition, as opposed to those 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.

See also[]

• Transgender health care
• List of transgender-related topics

References[]

External links[]

• WPATH Standards of Care
• Health Law Standards of Care for Transsexualism