Standards of Care for transgender people

Standards of Care (sometimes abbreviated SoC) are a set of guidelines created by gatekeepers to control access to trans health services. The general trend is moving toward informed consent for adults, where health services are provided once clients acknoweldge they are aware of the potential benefits and drawbacks. As an example, the Howard Brown Medical Center in Chicago, which provides health services to the LGBT community, has a program called THInC (Trans Hormones - Informed Consent), created in 2010 to allow trans people to bypass costly and time-consuming therapy required under certain providers:

http://howardbrown.org/hb_services.asp?id=37

As more and more people opt for these informed consent programs, Standards of Care will continue to decline in importance. In the meantime, you may need to follow them in order to receive services from some providers.

It's important to know "The Rules"

This is a general overview which contains certain generalizations and omissions because it's a summary. 

The original Standards of Care (sometimes abbreviated SoC) are a set of guidelines devised and maintained by the Harry Benjamin International Gender Dysphoria Association (HBIGDA). They were drafted in 1979 as a protocol for dealing with gender identity therapy and care, although they have come under fire in recent years for not representing the wishes of those they are designed to serve.

In 2006, they changed their name to WPATH (World Professional Association for Transgender Health).

Ritual document

Some (myself included) consider it a "ritual document" with little clinical usefulness. I believe its primary purposes are first and foremost to protect health care service providers and to legitimize our access to health care service by medicalizing gender variance.

It's best to think of them as a guideline rather than a strict set of rules. Some procedures are done completely outside of these protocols. For instance, facial feminization surgery rarely requires any sort of "approval," and many believe that access to hormones and other surgeries through overseas sources will continue to erode the relevance of these protocols.

The SoC primarily governs the so-called "triadic therapy":

  • Real-life experience
  • Hormones
  • Genital surgery

While these are important parts of a gender change, I think hormones and surgery are overemphasized in terms of therapeutic effect. I feel the real therapy lies in the ability to interact with others successfully in your chosen gender. For this, the real-life experience is the most important indicator of future success. It should never be thought of as something you have to get through in order to obtain surgery.

No one lives in a vacuum. In order to have self-acceptance, I believe it's vital to get validation from society in general that they accept you in your chosen gender. Those women I know who are not accepted in society face many more blows to their self-esteem on a daily basis. In most cases, societal acceptance is strongly linked to your ability to present as female. Anyone who falls outside the range deemed acceptable by society will face greater challenges in employment, interpersonal relationships, and self-acceptance.

I'll discuss all this later, but be advised that the HBIGDA Standards of Care are followed carefully by many therapists, physicians, and surgeons, so you probably need to count on playing along unless you can afford to grease a few palms or are clever enough to bypass some of these safety measures.

A divisive issue

I basically followed the Standards of Care very closely, and I'm glad I did. I think it forces you to stop and consider what you really want and what is going to make you happy. It's a very conservative approach to dealing with transsexualism, and I personally feel that a cautious route carefully planned and implemented has a greater chance of leading to happiness.

However, some are adamantly opposed to the notion that we are unable to make decisions concerning our bodies on our own. I can see that argument, too.

The main problem is that there is no required counseling for similar life decisions like marriage or bearing children. It's insulting in some ways to be forced to submit to analysis, when any other woman can go see a plastic surgeon and have anything they want done, including genital modification.

The Standards of Care are also a bit too cookie-cutter in their approach to the wide spectrum of women who present themselves for gender therapy. I think it's highly situational. The SoC also seem lacking in their ability to distinguish between stable, socially adjusted women and those who are in need of serious counseling.

Rules are made to be bent

Care for women in our community has come a long way since the middle of last century. Back in the bad old days, you had to live as a woman for a year before you could even begin hormones. Things are better and far more flexible today, but there's still a long way to go.

I think in general the SoC still err on the side of caution. That's not necessarily a bad thing. Because I think a conservative, well thought-out transition is smartest anyway, I saw the SoC as just so many hoops to jump through. It's actually not that difficult to find alternative ways to negotiate these obstacles if you desire.

Personally, I'm willing to jump through a few hoops if it will keep one unfit candidate from making a grave error. However, I'm not convinced the SoC even do that.

You are only limited by your imagination and resourcefulness as far as dealing with the SoC. For instance, see how I got scheduled surgery after a four-month real-life experience here.

Standards of Care and alternative links

HBIGDA Standards of Care Version Seven

The 2011 version is a significant improvement, particularly in de-emphasizing the "triadic therapies" and in its dealing with adolescents.

US Trans Health Priorities: Eliminating Disparities (PDF)

Several activist groups are working together to address trans health needs from a client perspective. One of the most forward-thinking summaries is this one.

Gender Identity Research & Education Society (GIRES) is a UK-based group which has been doing excellent work in summarizing current research on medical aspects of transsexualism, and addressing the needs of young trans clients.

Atypical Gender Development: A Review (PDF)

Gender Identity Disorder & Transsexualism: Synopsis of Etiology in Adults (PDF)

Hormonal Medication for Adolescents

Guidelines for Endocrinological Intervention in Adolescents (PDF)

Health Law Standards of Care for Transsexualism (1993) by International Conference on Transgender Law and Employment Policy, Inc. is a consumer-friendly alternative to the HBIGDA Standards

Feature: Transgenderism (2005) by Norman Spack, MD at the Harvard Medical School is a good overview of current ethical considerations. Dr. Spack has been a great advocate for treating those who transition early in life.

This emerging trend holds great promise for a new era of self-determination and personal responsibility regarding our unique health needs.