Two weeks ago, the World Professional Association for Transgender Health (WPATH, formerly known as the Harry Benjamin International Gender Dysphoria Association [HBIGDA]) released a newly-revised edition of its well-known (and much-maligned) Standards of Care. First issued in 1979, this new revision of the Standards give the trans community cause for celebration, as they completely change the landscape of transgender health care. In order to understand just how momentous these new standards are, however, it’s important to give a little background regarding the barriers transpeople have faced within the health care system, and within the general public arena.
Transpeople have endured a long history of having to prove themselves to the powers that be. Neo-Freudians believed that gender-nonconforming people were unable to resolve their Oedipal (or Electra) issues in childhood, and that years of psychoanalysis might help them overcome these conflicts. Behaviorists rolled out a laundry list of causes of gender-nonconformity, including reinforcement of gender-inappropriate behaviors, punishment of gender-conforming behaviors, and the absence of adult models (parents in particular) who are the same sex as the child who can demonstrate appropriate gendered behaviors, suggesting that Pavlovian and Skinnerian therapies could help these individuals change these “maladaptive” behaviors. Radical feminists argued that transwomen, or “males-to-constructed-females,” as Janice Raymond put it in her anti-trans manifesto, The Transsexual Empire: The Making of a She-Male, are part of a male patriarchal conspiracy to overthrow the feminist movement. And many people in the medical, psychological, and lay communities argue that people who identify as “trans” don’t really have a nonconforming gender identity within a wrong-gendered body – instead, they have a serious disorder that needs to be treated through some form of gender-reparative therapy.
And transpeople have continued to have to prove themselves to their health care practitioners, telling the “right” story so that they will receive the care that they desire – and this is where the Standards of Care come into play. Although the intent behind the Standards of Care has always been to ensure “lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment,” they have also created a gatekeeping system that has been frustrating (at best) and invalidating and harmful (at worst) to many transpeople. Before starting the gender-reassignment process, a transperson needed to begin by seeing a mental health professional, receiving a diagnosis of Gender Identity Disorder, and beginning a long-term course of psychotherapy. While meeting regularly with a supportive and caring therapist during the transition process isn’t a bad idea, being given a psychiatric diagnosis kicks the process off to a very pathologizing start. From there, the Standards regulated that transpeople jump through several other hoops, including obtaining a letter from a health care professional before starting any hormone therapies, being evaluated according to a specific set of requirements to determine eligibility for any type of surgery, and living full-time for one year as a member of the sex they wish to live as before becoming eligible for genital surgeries (often referred to as the “Real-Life Experience”). These Standards have been met with mixed reception in the trans community, often being referred to as bureaucratic, pathologizing, and disempowering. Moreover, in order to obtain “permission” to undergo the sex reassignment process, transpeople needed to tell their health care practitioners a particular kind of “story” – a story that may or may not be the entire truth, but was a means to an end. In fact, the “transsexual narrative” – the “I’m a woman born in a man’s body” or “I’m a man born in a woman’s body” story – emerged directly from the expectations of the health care system. It’s an accurate depiction of some, but not all, transpeople’s experiences. And this, among other things, has figured into the surge of activist efforts to transform these standards.
That transformation has now occurred, and the changes are significant. As WPATH revision committee chair Eli Coleman stated, “We’ve set a whole different tone. It’s more about what the professionals have to do” and not about transpeople having to jump through hoops and prove their health needs to the professionals. The most significant changes include the following:
- elimination of the Gender Identity Disorder requirement;
- eliminating the psychotherapy requirement, although therapy is still encouraged;
- strong affirmation that attempts to change gender-nonconforming behaviors through reparative therapy are unethical;
- a strong focus on an individualized care approach, rather than a “one-size-fits-all” treatment plan;
- clear acknowledgment that “gender-nonconformity” and “gender dysphoria” are two different things, that a broad spectrum of gender identities exist, and that “gender-reassignment” may take a number of different forms;
- guidance regarding treatment for gender-nonconforming children and adolescents;
- more flexible standards for hormonal and surgical treatment, so that interventions can be tailored to the individual;
- information and guidelines involving non-medical treatments, including voice coaching;
- near-elimination of the Real-Life Experience, with the exception of some genital surgeries.
Although I don’t think most people are even aware of these Standards of Care or the recent changes that have been made, I do think that this recent revision is going to have a very significant impact in our culture. These Standards allow for more freedom of gender expression, more room for “genderqueers” who don’t necessarily fit clearly into the standard “transsexual narrative,” and more flexible and varied health care options. Because these Standards make room for a range of gender expressions, I think they set the stage for a more complex and nuanced conversation about gender identity. At the same time, I think that the trans community and the trans-positive health care community had better be prepared for a powerful cultural backlash against these standards. Some might harbor uneasiness about the elimination of some of the previous stopgap measures. Others might react against the idea of supporting a gender-nonconforming child or teenager (rather than changing their behavior). We’ll have to wait and see what unfolds.
If you would like to read the revised WPATH Standards of Care in its entirety, go to http://www.wpath.org.