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).
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 United States.
WPATH Standards 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), formerly known as the Harry Benjamin International Gender Dysphoria Association Standards of Care, are the most widespread SOC used by professionals working with transsexual, transgender, or gender variant people. 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.
WPATH SOC, 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 (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.
Summary of WPATH-SOC For Gender Identity Disorders, Sixth Version
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 reconstruction. Two additional letters are needed for genital surgeries.
The Eligibility Criteria and Readiness Criteria in version 6 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 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. The assessment and treatment of children and adolescents is covered in section V.
Sections Five through Eight begin the actual guide to treatment. They specifically address the manner in which to assess and support gender non-conforming children and how to diagnose transgender identity or transsexualism in both teens 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," during which individuals seeking hormonal and other treatments are expected to begin transitioning publicly to their preferred gender role.
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. 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.
WPATH has also come under fire for adopting pathological language when referring to Intersex individuals in its latest revision, SOC 7. The SOC uses the term "Disorders of Sex development" even though many Intersex individuals don't consider their biological differences a disorder, and argue that the language used by the SOC is stigmatizing and offensive.
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 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.
- Britt Colebunders; Griet De Cuypere; Stan Monstrey (2015). "New Criteria for Sex Reassignment Surgery: WPATH Standards of Care, Version 7, Revisited". International Journal of Transgenderism. 16 (4): 222–233. doi:10.1080/15532739.2015.1081086.
- "Standards of Care - WPATH World Professional Association for Transgender Health". Wpath.org. Retrieved 4 May 2019.
- Grinberg, Emanuella (2018-07-20). "What is medically necessary treatment for gender-affirming health care?". CNN. Retrieved 2018-08-06.
- "Standards of Care, Version 7". Wpath.org. Retrieved May 9, 2018.
- "The Harry Benjamin International Gender Dysphoria Association's Standards Of Care For Gender Identity Disorders, Sixth Version" (PDF). Cpath.ca. February 2001. Retrieved 4 May 2019.
- "The Mental Health Professional." The World Professional Association for Transgender Health's Standards Of Care For Gender Identity Disorders. 6th ed. 2001.