What’s Needed in the WPATH SOC8, Part 1: A Wish for Wings that Work*

Update 20181116

by Kelley Winters, Ph.D.

 

What Gets Measured Gets Done

I think this ancient axiom, often repeated by my old boss, Dave Packard, certainly applies to transgender health policy, especially when policy development lacks appropriate transparency, participation, and accountability to those whose lives and mortality are impacted by those policies.

The following table describes my own wish-list of urgent issues to be corrected or clarified in the pending 8th Version of the WPATH Standards of Care. It is a work in progress. This list is based on my observations as a member of the WPATH International Advisory Panel for the SOC7 in 2011(now eliminated from the SOC8) and feedback I have received from trans community members, supportive families, and care providers around the globe in the years since. I am not currently a WPATH member and am well outside of its deliberations for drafting the SOC8. I ask my trans community sisters, brothers, and non-binary sibs around the world for your feedback and suggestions in the comments below.

Urgent Issues for the SOC8
TYPE	DESCRIPTION	NOTES/QUOTES
False	The 80% Desistance Myth about young trans children is misstated as fact, though disputed by flaws in its underlying research.	“Relevant in this respect are the previously described relatively low persistence rates of childhood gender dysphoria” (p. 17).
Unsubstantiated	Unsubstantiated stereotype, implying that social authenticity in trans children turns cis kids trans.	“A change back to the original gender role can be highly distressing and even result in postponement of this second social transition on the child’s part” (p. 17)
Recent	Political weaponization of a recently invented “Rapid Onset Gender Dysphoria” Myth about trans adolescents requires a response.	The thoughtful WPATH Position Statement on so-called “Rapid-Onset Gender Dysphoria (ROGD)” should be restated in the SOC8, along with clarification that non-birth assigned identities in adolescents are not “social contagion.”
Unsubstantiated	Rigid, age of majority restrictions on corrective genital surgical care lack medical justification	“Genital surgery should not be carried out until…patients reach the legal age of majority in a given country” (p. 21, 60)
Omitted	Suicide as a trans health crisis	Suicide is a first-order health and mortality issue for trans people, yet constructive research and guidance for care of suicidal trans individuals are scarce. The word, “suicide,” is absent from the SOC7.
Inadequate	Health care standards for trans youth and adults in residential mental health settings	There are increasing reports of trans and non-binary youth experiencing abuse in mental facilities, while under involuntary hold following MH crisis. These include verbal misgendering, deadnaming, inappropriate strip searches, misgendered housing, punitive solitary confinement, and cold-turkey denial of prescribed HRT. The current seven-paragraph section of the SOC7 on institutional settings is focused on prison incarceration and inadequately defines a standard of care for trans youth and adults in MH and hospital facilities.
Omitted	Health care standards for trans seniors in residential and outpatient settings	With the aging of the post-WWII Baby Boom generation in Western nations, unprecedented numbers of trans and non-binary seniors living authentic gender roles are entering geriatric residential and outpatient care settings. Disturbing reports of misgendering abuse and medical neglect are increasing, yet standards of elder and hospice trans care are entirely omitted from the SOC7.
Inadequate	Continuity of hormonal and blocker care	Cursory mentions of “continuity of care” on pages 3, 65 (post-op), and 66 (cancer screening) fails to address the harm caused by abrupt discontinuation or established hormonal or blocker care.
Omitted	Hate crime/murder as a trans health crisis	Hate-motivated assault and murder of trans people, especially trans women of color, is a global epidemic. Yet, this is not mentioned in the SOC7.
Omitted	Health care issues in indigenous populations	Rich, ancient, indigenous super-binary gender traditions are found throughout the world. They offer a wealth of insight and social context to the understanding of contemporary global gender diversity; and they pose unique, culturally nuanced health care needs. Yet, this fundamental dimension of global trans health care is missing from the SOC7.
Omitted	Medical risk associated with minority stress and denial of public accommodation	The SOC7 includes good coverage of MH risk associated with minority stress and provides clinical guidance. However, it omits discussion about somatic, physical health risks brought by societal bigotry and consequential unemployment, homelessness, malnutrition, and poverty. For example, urinary and kidney disease caused by denial of public-accommodation human rights should be included in this description.
Inadequate	A clear, cogent definition of the distress of gender dysphoria is still lacking from requirement criteria.	WPATH used the generic, plain-language Fisk (1973) definition of gender dysphoria in its criteria for transition-related medical care, rather than specific (and misleading) mental health diagnoses in use at the time. However, when the DSM-5 codings of “Gender Dysphoria” were published in 2013 by the APA, many clinicians and insurers were confused by the disparate meanings. Neither definition of gender dysphoria adequately describes the multiple facets of distress and functional impairment that modern trans youth experience.
Inadequate	Criterion 2 for puberty suppression can cause false-negative assessment and denial of blocker care for affirmed trans youth. (Related to inadequate definition of gender dysphoria term, above)	“Criteria for puberty suppressing hormones…2. Gender dysphoria emerged or worsened with the onset of puberty” (p. 19) Youth who grow up assured of access to blocker care do not necessarily exhibit apparent distress about its onset.
Inadequate	Ambiguous “well controlled” language in Criterion 4 for hormonal and surgical care creates disparate and even paradoxical barriers for individuals diagnosed with MH conditions.	“4. If significant medical or mental health concerns are present, they must be reasonably well-controlled.” (pp. 34, 59, 60, 104, 105, 106)

 

The World Professional Association for Transgender Health (WPATH) published the 7th Version of Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (SOC) in September, 2011. The SOC7 brought significant progress in supporting the dignity of trans and gender diverse people, while clarifying the necessity of medical transition care for trans individuals who need it. Positive revisions included a statement that gender conversion psychotherapies are “no longer considered ethical” (pp. 16,32), a statement that non-birth assigned gender identities and expressions should “should not be judged as inherently pathological or negative” (p. 4), clarification that psychotherapy “is not a requirement” for access to transition related medical care (p. 28), clarification that “the presence of co-existing mental health concerns does not necessarily preclude access to feminizing/masculinizing hormones ” (p. 34), and an expanded role for qualified health professionals in allowing access to hormonal treatments through informed consent practices (pp. 34-36).

Although the 7th Version of the WPATH Standards of Care was much improved over its predecessors, it left much work left to be done. For example, in a section titled, “Social Transition in Early Childhood,” the SOC7 discouraged social authenticity in young trans children by promoting the 80% “desistance” dictum—alleging that gender dysphoria and non-birth assigned gender identities were just a passing phase that would spontaneously “remit” for approximately 80% of young trans children by adolescence. This axiom has since become ubiquitous in medical policy and conservative literature and weaponized in political discourse aimed at denying basic civil rights and education access to trans schoolchildren. It was stated as a scientific fact in the SOC7 with the full faith and credit of WPATH, despite strong opposition by many members and its International Advisory Panel at the time, including me.

Controversy surround the 80% “desistance” axiom centered on faulty clinical studies at the Toronto Clarke Institute of Psychiatry (now called the Centre for Addiction and Mental Health, or CAMH) and VU University Medical Center in Amsterdam that were long criticized for misrepresentation of null results at followup examination, sample bias that conflated gender dysphoria with gender nonconformity, cohort selection based on flawed DSM-IV criteria for the Gender Identity Disorder of Childhood diagnosis, neglect of confounding factors of harmful gender conversion psychotherapies practiced at the Clarke/CAMH clinic, and more. The WPATH Executive Committee erred in placing its reputation on a claim that fell so far short of the burden of proof demanded by scientific methodology. We will never fully know the toll in human suffering and suicide among trans youth, who were forced to spend their childhoods in birth-assigned closets of shame, as a consequence of this unsubstantiated and highly contested endorsement of the 80% “desistance” stereotype in the SOC7, seven years ago.

I urge WPATH members, directors, and SOC8 chapter leads to keep open minds to more transparency and more trans community connection to the formulation of this medical policy on which the health and lives of so many will depend.

* with apologies to Berke, Opus, and Bill

Copyright © 2018 Kelley Winters