Checking in With Osbo’s Bridge Club: Those Pesky Standards of Care

Okay, so please bear with me as this non tech-savvy therapist vents a bit on the fact that I just spent two hours writing only to have my column disappear while I tried to find The Penn State football game on Internet radio. Now I’m going to breathe…and try to start again. I’m assuming that there is something I’m supposed to learn from this, as I often tell my clients.

Okay, so most of you know that there is a professional organization called WPATH (World Professional Association for Transgender Health), formerly called HBIGDA, before a tempest in a teapot controversy resulted in a name change. Anyhoo, this is the organization that adopts professional guidelines for those seeking hormone therapy or genital surgery for gender identity issues. The Standards of Care, first published in 1979, is in it’s 6th version, and a new revision is currently underway. Over time, the document has been broadened and refined to include new understandings of the transgender phenomenon, and the inclusion of trans individuals on the relevant committees has been an invaluable addition to the process.

Many of you probably also know that there has been a fair amount of controversy around the SOC (as well as the diagnosis of Gender Identity Disorder, which I will take on in another column). Those arguing against the Standards feel that it is unfair and that transgender folks are subject to special requirements not applied to others seeking medical treatments such as elective cosmetic surgery. They feel that a simple model of informed consent would be more appropriate, and more respectful of the patient’s autonomy, not to mention his or her pocketbook. Moreover, this point of view maintains that retaining the standards contributes to the societal view of transgender folks as mentally unstable and outside the mainstream. These are all valid and compelling arguments.

Those favoring Standards argue that there need to be some officially agreed upon criteria for those requesting hormonal interventions and surgical procedures that are essentially irreversible and which have such a pervasive and powerful impact on the patient and his or her social/familial/vocational context. This point of view considers the patient’s welfare (i.e., optimal post-transtion adjustment) as well as the medical professional’s legal liability. In my experience, another advantage to having codified professional standards is that it makes those in the larger society breathe easier that we are following an accepted medical protocol rather than performing “surgery on demand.” In other words, the SOC legitimizes gender transition for a society needing such rules and regulations. I refer to the Standards frequently when trying to make it easier for transfolks to move through their lives, such as writing an “official” letter to explain a person’s crossdressed state should they find themselves in an uncomfortable position in public, or speaking to family members who are skeptical of the whole concept of transgenderism. On at least one occasion, I know that having the SOC was invaluable as I was called to testify on behalf of a transwoman in prison.

Whatever your feeling about the SOC, I’d like to go over them as they now exist. They come into play when a person is seeking 1) contrahormone therapy and 2) genital reassignment surgery. The standards specify that the patient needs to establish both eligiblity and readiness in order to receive a letter of recommendation from a qualified mental health professional. For contrahormone therapy or breast/chest surgery, one letter is needed. Eligibility requires that the subject be 18 years old, understands the risks and benefits of hormone therapy, and has either participated in a period of psychotherapy determined by the therapist (three months is customary) or has a documented real life transition experience of at least three months. Loopholes exist on this criterion, such as when a client has been on unsupervised or black market hormone treatment for a period of time. Readiness for hormone therapy specifies that the patient has shown signs of consolidation of gender identity during this period, has made progress toward addressing any exisiting mental health problems such as suicidality or drug use, and seems likely to be able to take the hormones responsibly.

For genital surgery, two letters are required, and the requirements for eligibility are that the patient is of legal age, has had 12 months of hormone therapy and real life experience, has participated responsibly in psychotherapy (not an absolute requirement), has demonstrated knowledge of all procedures and their cost, risks, and benefits, and has knowledge of the range of competent surgeons. Readiness for surgery involves further consolidation of gender identity (e.g. name changes, disclosure to all relevant parties) and demonstrable progress in dealing with work, family, and interpersonal issues that shows that the person’s mental health has improved during the transition period.

There are many, many other aspects to the SOC, and I would suggest that interested persons read the latest version at the WPATH website. I single out the eligibility and readiness criteria because they generate most of the complaints, and seem to force therapists such as myself into a “gatekeeper” role. I have been a therapist for 30 years, and have always seen myself as an advocate for my clients, not an obstructionist. I do think that the SOC are sufficiently broad as guidelines to take into account special cases, and I have followed their spirit rather than their letter on a number of occasions, using my experience and clinical instincts. Occasionally, I have felt obligated to rely on them to rein in clients who were clearly on that runaway transition train, and missing out on important cues in their social/interpersonal context which I believed might have produced disastrous results. Since I consider establishing a therapeutic alliance as paramount in my work, I usually make these interventions from a trust-based position. Most people do not object to the Standards and welcome the chance to take some time to look deeply at their lives and the choices they have made. Rarely, I have found myself in situations where the individual’s request is so out of step with the SOC that I have been unable to accommodate them. One challenging case at the moment would prefer to have genital surgery before any type of external transition, because of conflicts between his prominent public job and responsibilities to many employees and her overwhelming distaste for the body she suffers within. This person and I are continuing a spirited and mutually respectful dialogue about the issue.

Another recent experience I had that challenged all my constructs about body integrity was having worked with two different clients who each expressed an overwhelming wish to have a (healthy) limb amputated. In talking with these individuals, it was clear to me that neither was mentally ill, and their self-described feelings and experiences were uncannily similar to those I have heard over the years from my transgender clients (which is in fact why they sought me out and trusted me with their dilemmas). Although, I could not imagine myself supporting such a request, I tried my best to listen respectfully and understand these clients’ deeply held feelings that they were not supposed to have been born with two limbs. The gift of these clients to me was to help me to understand people who feel that it is fundamentally wrong to remove any healthy body part, as well as to deepen my respect for the incredible diversity of our senses of body identity and integrity.

Well, that’s it for this month Bridge Clubbers. I welcome your thoughts and comments, and may even figure out how to respond to them! Next month, I plan to go a little deeper into who might benefit from therapy, as well as what the role of the gender therapist should be and how to spot a good one. Until then, have a great month, and remember to vote!

Category: Transgender Body & Soul