Contradictions and Compromises of Principle in the SOC8. Part 3.

Depsychopathologization of Gender Diversity

Kelley Winters, Ph.D.
2022 October

Standards of Care for the Health of Transgender and Gender Diverse People (SOC) have been published by the World Professional Association for Transgender Health (WPATH, formerly HBIGDA) since (1979). Prior to the current 8^th Version, SOC revisions have followed a trend of slow progress toward acceptance of human gender diversity and affirming, culturally competent medical and mental health practices. The SOC have evolved from an instrument of denied medical care, toward an actual standard of medical and mental health care for underserved Trans and Gender Diverse (TGD) people. However, this arc of forward-progress has greatly slowed in the SOC8, especially pertaining to pre-pubertal children and adolescents.

The principle of depsychopathologization of Transgender and Gender Diverse people means removal of gender diverse identities and expressions from mental disorder classifications and dispelling false stereotypes historically based on those nosologies. It impacts health and wellbeing of TGD people in at least three ways (Winter, Diamond, et al., 2016):

(1) the view that transgender people are mentally disordered is an accident of history rather than one founded on scientific evidence…
(2) The psychopathologisation of gender incongruence therefore leaves transgender people stigmatized. The stigma is particularly pernicious since it is transgender people’s identities that are pathologised…
(3) psychopathologisation can undermine transgender people’s claims for recognition in their affirmed gender. The view that a transgender woman’s identity is a mentally disordered one implies that she is a mentally disordered man. The transgender man is, by implication, likely to be seen as a mentally disordered woman.… (p. 393)

Public policy statements that asserted international professional consensus on principles of medical necessity of gender-affirming care (WPATH, 2008; 2016) and depsychopathologization of human gender diversity (2010) were key milestones in WPATH’s evolution toward respectful, affirming treatment of TGD people. These bedrock principles of ethical professional practice were prominently stated in the Seventh SOC Revision (WPATH, 2011), even though their implementation in the SOC7 fell short of consistent or respectful.

The SOC8 has more than twice the page count of the 7th Version and dwarfs the prior six Standards of Care documents. Version 8 contains a great deal of thoughtful, evidence-based, affirming content. However, its positive attributes are undermined by contradiction and compromise of previously established principles of ethical and effective TGD health care. The SOC8 reflects a struggle between factions within WPATH—between those who advocate affirming, medically necessary care and those who do not. In violation of WPATH’s own public policy statements and SOC7 declarations, discredited stereotypes of psychopathology of TGD people and compulsory delay or denial of affirming medical care persist in the SOC8, as in prior revisions.

This series of essays is my petition to WPATH leadership and editors of the SOC8 to consider the harm inflicted on the most vulnerable Transgender and Gender Diverse people by contradiction and regression on established principles of ethical care, including the depsychopathologization of gender diversity and access to affirming medical treatments. I urge WPATH to prioritize correction of these shortcomings in the Standards of Care.

Contradiction and confusion in the SOC8 on these foundational WPATH principles will certainly be cherry-picked and exploited by transmisist factions of governments, political parties, theological institutions, and health care systems to deny Trans and Gender-Diverse individuals access to confirming and affirming care. Sheer size and complexity make the SOC8 more difficult for reference by TGD people, families, and health professionals to advocate for access to care and defend against medical discrimination. These essays are intended to provide a concise and accessible reference of information in the SOC8 that is pertinent to overcoming these barriers. Finally, I hope that these essays will be useful to continuing study of TGD health policy and contribute to the record of this difficult period of Transgender history.

WPATH Policy Statement on Depsychopathologization

More than a decade ago, WPATH released a Depsychopathologisation policy statement, urging that human gender diversity, including non-birth-assigned gender identities and expressions, is not mental disorder:

The WPATH Board of Directors strongly urges the depsychopathologisation of gender variance worldwide. The expression of gender characteristics, including identities, that are not stereotypically associated with one’s assigned sex at birth is a common and culturally-diverse human phenomenon which should not be judged as inherently pathological or negative. The psychopathologlisation of gender characteristics and identities reinforces or can prompt stigma, making prejudice and discrimination more likely, rendering transgender and transsexual people more vulnerable to social and legal marginalisation and exclusion, and increasing risks to mental and physical well-being. WPATH urges governmental and medical professional organizations to review their policies and practices to eliminate stigma toward gender-variant people.” (WPATH, 2010)

The current SOC8 references the (2010) WPATH depsychopathologization statement. Additionally, WPATH has reaffirmed this seminal principle in numerous other public policy statements and papers (2010B, 2014, 2016B, 2019B). Typical among these:

Transgender and Gender-Diverse Youth Diversity in gender expression and variations in gender identity represent normative developmental processes for children and adolescents and are not inherently pathological aspects of the human experience. (2019B)
At all times, it is important to account for and critically question existing power inequalities in one’s clinical practice, encounters, and writing, so as to join trans-health care users in dismantling pathologizing structures. (2016B)

WPATH Policy Statement on “ROGD” Pseudo-science

In 2018, a wave of transmisist publicity and political debate followed publication, editor apology, and re-publication of a scientifically specious article in PLOS One (Littman, 2018) about Trans and Gender Diverse adolescents. From a chain-referral sampling survey of literal, anti-trans online hate group members, the author mischaracterized coming out as TGD in adolescence as “rapid-onset gender dysphoria” and a transmissible “social contagion” of mental illness (Serano, 2018; Restar, 2019; Ashley, 2018; 2020; Winters, 2022). No TGD adolescents were directly interviewed or surveyed in this study.

WPATH (2018) responded with a cogent public position statement that refuted the faux “ROGD” diagnostic term and renounced psychopathologization, misrepresentation, and fear-mongering of TGD youth and their access to appropriate, affirming care:

The term “Rapid Onset Gender Dysphoria (ROGD)” is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation.

… adolescent gender identity development and the factors influencing the timing of anyone’s gender declaration are multifactorial and that all persons—especially adolescents—are deserving of gender-affirmative evidence-based care that adheres to the latest standards of care and clinical guidelines.

WPATH also urges restraint from the use of any term—whether or not formally recognized as a medical entity—to instill fear about the possibility that an adolescent may or may not be transgender with the a priori goal of limiting consideration of all appropriate treatment options in accordance with the aforementioned standards of care and clinical guidelines.

Depsychopathologization Policies by Other Medical and Mental Health Authorities

A year before WPATH released its Depsychopathologization policy statement, the American Psychological Association Task Force on Gender Identity and Gender Variance questioned the prevailing orthodoxy that had long equated gender diversity with mental illness:

Rather than continuing to pursue causal factors, comorbidity, psychopathology, and personality differences, researchers began to focus on the experiences of gay and lesbian people and asked the questions that were most relevant to their lives. (2009, p. 26)

The fact that sex reassignment can, in theory, only be accessed with a referral from a mental health professional has been criticized by some members of the transgender community as unnecessarily pathologizing. (p. 33)

Six years later, the American Psychological Association released TGD practice guidelines that cited the WPATH depsychopathologization policy and noted that assumptions of psychopathology in gender diversity are discriminatory:

A person’s identification as TGNC can be healthy and self-affirming, and is not inherently pathological. (2015, p. 835)

Discrimination can include assuming a person’s assigned sex at birth is fully aligned with that person’s gender identity, not using a person’s preferred name or pronoun, asking TGNC people inappropriate questions about their bodies, or making the assumption that psychopathology exists given a specific gender identity or gender expression. (p. 838)

In the Rationale for Proposed Revisions for the 5^th Edition of the Diagnostic and Statistical Manual of Mental Disorders (2013A), the American Psychiatric Association announced a change in the title of diagnostic categories associated with TGD care, from “Gender Identity Disorder” to “Gender Incongruence.” This was intended to lessen stigmatization of diagnosing gender identities, per se, as mentally “disordered,” by placing the diagnostic focus on incongruence experienced by individuals in need of care:

It is proposed that the name gender identity disorder (GID) be replaced by “Gender Incongruence” (GI) because the latter is a descriptive term that better reflects the core of the problem: an incongruence between, on the one hand, what identity one experiences and/or expresses and, on the other hand, how one is expected to live based on one’s assigned gender (usually at birth) (Meyer-Bahlburg, 2009a; Winters, 2005). In a recent survey that we conducted among consumer organizations for transgendered people (Vance et al., in press), many very clearly indicated their rejection of the GID term because, in their view, it contributes to the stigmatization of their condition. (APA, 2010)

The APA eventually chose “Gender Dysphoria,” rather than “incongruence,” for the DSM-5. They clarified that gender nonconformity is no longer considered to be mental disorder:

DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.

…Part of removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is “disordered.” (APA, 2013B)

It is important to note that the term, “gender dysphoria,” has two meanings in medical and mental health contexts (Winters, 2018B). It was originally defined by Fisk (1979) in its plain-language context of distress with one’s physical sex characteristics or birth-assigned social roles. However, the term remains anachronistic and lacks nuance to describe the necessity of care for all gender diverse people. The second meaning is a label of mental disorder in the DSM-5, whose placement in the APA’s Manual of Mental Disorders still contradicts its utility for adult and adolescent access to somatic, medical and surgical treatments. Shifting the diagnostic focus away from the false stereotype of “disordered” gender identity, the “gender dysphoria” title was an incremental, though incomplete, acknowledgment of the depsychopathologization principle by the APA (Winters, 2011; 2013). Further changes by the APA to Gender Dysphoria categories in the Text Revision of the DSM-5 (2022) were minor terminology updates, such as “experienced gender” and “gender affirming medical procedures” (APA, 2022B).

The most significant embodiment of depsychopathologization of gender diversity was published by the World Health Organization in the 11th Revision of the International Statistical Classification of Diseases and Related Health Problems, ICD-11 (WHO, 2019). It is a worldwide diagnostic manual for both physical medical conditions and mental conditions.

The ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health believes it is now appropriate to abandon a psychopathological model of transgender people based on 1940s conceptualizations of sexual deviance and to move towards a model that is (1) more reflective of current scientific evidence and best practices; (2) more responsive to the needs, experience, and human rights of this vulnerable population; and (3) more supportive of the provision of accessible and high-quality healthcare services. (Drescher, Cohen-Kettenis, & Winter, 2012)

Diagnostic codings related to TGD care were renamed, Gender Incongruence (the term previously considered for the DSM-5), and removed entirely from Mental and Behavioural Disorders chapter (previously known as F-Codes) of the ICD-11.

HA60 Gender incongruence of adolescence or adulthood

Gender Incongruence of Adolescence and Adulthood is characterised by a marked and persistent incongruence between an individual´s experienced gender and the assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual´s body align, as much as desired and to the extent possible, with the experienced gender. The diagnosis cannot be assigned prior the onset of puberty. Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis. (2019)

The Gender Incongruence codings were recategorized in a new, non-psychiatric chapter in the ICD-11, “Certain conditions related to sexual health.” WHO also eliminated victimless sexual paraphilia categories from the manual, including F65.1, Transvestic Fetishism. Another archaic, defamatory diagnosis, F64.1, Dual-role Transvestism, was also eliminated from the ICD.

The WPATH depsychopathologization principle, debunking socially punitive and scientifically capricious stereotypes of mental disorder about Trans and Gender Diverse people, was established as ethical health practice long before publication of the SOC8 in 2022. It was acknowledged by the American Psychological Association and the American Psychiatric Association and operationalized as global health policy by the World Health Association.

To be continued in Part 4.

Copyright © 2022 Kelley Winters

References

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Winters, K. (2008). Gender Madness in American Psychiatry: Essays From the Struggle for Dignity. GID Reform Advocates. Dillon, CO. https://www.amazon.com/Gender-Madness-American-Psychiatry-Struggle/dp/1439223882

Winters, K. (2011). The Proposed Gender Dysphoria Diagnosis in the DSM-5. GID Reform Weblog, June 7. https://gidreform.wordpress.com/2011/06/07/the-proposed-gender-dysphoria-diagnosis-in-the-dsm-5/

Winters, K. (2013). The Proposed Gender Dysphoria Diagnosis in the DSM-5. GID Reform Weblog, June 13. https://gidreform.wordpress.com/2013/06/13/gid-reform-in-the-dsm-5-and-icd-11-a-status-update/

Winters, K. (2018). What’s Needed in the WPATH SOC8, Part 1: A Wish for Wings that Work. Trans Policy Reform Blog, Sep 26. https://transpolicyreform.wordpress.com/2018/09/26/whats-needed-in-the-wpath-soc8-part-1-a-wish-for-wings-that-work/

Winters, K. (2018B). What’s Needed in the WPATH SOC8, Part 2: A Cogent Definition of Gender Dysphoria. Trans Policy Reform Blog, Nov 7. https://transpolicyreform.wordpress.com/2018/11/07/a-wish-for-wings-that-work-part-2-a-cogent-definition-of-gender-dysphoria-for-the-soc8/

Winters, K. (2022). Transgender Affirmation in Retrograde: Historical Context for the Littmanian “ROGD” Media Blitz, Trans Policy Reform Blog. Jan 08. https://transpolicyreform.wordpress.com/2021/11/29/transgender-affirmation-in-retrograde-historical-context-for-the-littmanian-rogd-media-blitz/

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World Professional Association for Transgender Health. (2008) WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. June 17. https://web.archive.org/web/20101130201438/http://wpath.org/publications_public_policy.cfm

World Professional Association for Transgender Health. (2009) WPATH Responds to Alberta, Canada’s Decision to Delist Sexual Reassignment Surgery as a Covered Medical Benefit. Apr 2021. https://amo_hub_content.s3.amazonaws.com/Association140/files

World Professional Association for Transgender Health. (2010) WPATH De-Psychopathologisation Statement. May 26. https://www.wpath.org/policies

World Professional Association for Transgender Health. (2010B) WPATH Reaction to DSM-V Criteria for Gender Incongruence, May 25. https://amo_hub_content.s3.amazonaws.com/Association140/files/WPATH%20Reaction%20to%20the%20proposed%20DSM%20-%20Final.pdf

World Professional Association for Transgender Health. (2011A) WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide. Captured 2011Feb05. https://web.archive.org/web/20110205134357/http://www.wpath.org/medical_necessity_statement.cfm

*World Professional Association for Transgender Health (2011B). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. https://wpath.org

World Professional Association for Transgender Health. (2014). WPATH Statement Concerning Cross-dressing, Gender-Nonconformity, and Gender Dysphoria, July 15. https://amo_hub_content.s3.amazonaws.com/Association140/files/WPATH%20Statement%20Concerning%20Cross-dressing_15%20July%202014.pdf

World Professional Association for Transgender Health. (2016). Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. December 21.
https://www.wpath.org/media/cms/Documents/Web%20Transfer/Policies/WPATH-Position-on-Medical-Necessity-12-21-2016.pdf

World Professional Association for Transgender Health. (2016B). Language and Trans Health, Dec. 15. [also cited, Bouman, Schwend, et al. (2016) Language and trans health, International Journal of Transgenderism, 18:1, 1-6, DOI: 10.1080/15532739.2016.1262127] https://www.wpath.org/media/cms/Documents/Resources/Language%20Policy.pdf

World Professional Association for Transgender Health. (2017). Letter to Roger Severino, U.S. Department of Health and Human Services. Aug 15. https://wpath.org/policies

WPATH Position Statement. (2018). WPATH position on “Rapid Onset Gender Dysphoria (ROGD).”
https://www.wpath.org/media/cms/Documents/Public%20Policies/2018/9_Sept/WPATH%20Position%20on%20Rapid-Onset%20Gender%20Dysphoria_9-4-2018.pdf

World Professional Association for Transgender Health. (2019). WPATH Board Responds to Health Care Policies and Practices Imposed by Certain Religious Institutions. May 17. https://wpath.org/media/cms/Documents/Public%20Policies/2019/5-16_Religious%20Institution%20Health%20Policies.pdf

World Professional Association for Transgender Health, et al. (2019B) WPATH, USPATH, EPATH Statement in Response to Calls for Banning Evidence-Based Supportive Health Interventions for Transgender and Gender-Diverse Youth. Nov. 22. [also cited, Leibowitz, S., Green, J. et al. (2020) Statement in response to calls for banning evidence-based supportive health interventions for transgender and gender diverse youth, International Journal of Transgender Health, 21:1, 111-112, DOI: 10.1080/15532739.2020.1703652]
https://www.wpath.org/media/cms/Documents/Public%20Policies/2019/FINAL%20Statement%20in%20Response%20to%20Calls%20for%20Banning%20Evidence-Based%20Supportive%20Health%20Interventions%20for%20Transgender%20and%20Gender-Diverse%20Youth%2011-20-2019.pdf

World Professional Association for Transgender Health. (2020A) WPATH / USPATH Statement on Resumption of Gender-Affirming Surgery During COVID-19 Pandemic. May 8. https://wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Joint%20WPATH%20USPATH%20Statement%20On%20Resumption%20of%20Medically%20Necessary%20Surgeries%20During%20COVID.pdf

World Professional Association for Transgender Health. (2020B) WPATH Sends Letter of Support to Republic of Kazakhstan. July 1. https://wpath.org/media/cms/Documents/Public%20Policies/2020/Republic%20of%20Kazakhstan%20-%20Letter%20of%20Support%20July%201%202020.pdf

World Professional Association for Transgender Health. (2021) Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. Apr 5. [Also cited as: de Vries, et al. (2021) Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. International Journal of Transgender Health, DOI: 10.1080/26895269.2021.1904330]
https://www.wpath.org/media/cms/Documents/Public%20Policies/2021/Bell%20v%20Tavistock%20and%20Portman%20NHS%20Foundation%20Trust%202020%20EWHC%203274%20Weighing%20current%20knowledge%20and%20uncertainties%20in%20decisions%20about.pdf

*World Professional Association for Transgender Health (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. https://wpath.org

* Revisions of WPATH Standards of Care were traditionally published twice, on the WPATH (formerly HBIGDA) web site and in behavioral journals, including the Journal of Psychology & Human Sexuality, International Journal of Transgenderism, and, most recently, International Journal of Transgender Health. For brevity and accessibility, SOC documents published directly by WPATH are referenced here.

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Contradictions and Compromises of Principle in the SOC8. Part 2.

Medical Necessity of Affirming Care, continued

Kelley Winters, Ph.D.
2022 October 13

Medical Necessity Policy in Early SOC Revisions

In many ways, early revisions of HBIGDA/WPATH Standards of Care served, not so much as actual standards of medical care than as gauntlets of obstacles to care. This intent to minimize access to care was prominent in the SOC1 (HBIGDA, 1979, pp. 1-2):

[Definition] 3.1 Standards of care. The Standards of care, as listed below, are minimal requirements and are not to be construed as optimal standards of care. It is recommended that professionals involved in the management of sex‐reassignment cases use the following as minimal criteria for the evaluation of their work. It should be noted that some experts on gender identity recommend that the time parameters listed below should be doubled, or tripled. (WPATH, 1979, pp. 1-2)

Nevertheless, the SOC1 made reference to medical necessity, even while limiting care to few of those who needed it:

4.1.2. Principle 2. Hormonal and surgical sex‐reassignment are procedures requiring medical justification and are not of such minor consequences as to be performed on an elective basis.
(p. 2)

The first explicit statement that gender-affirming or confirming medical and surgical care is medically indicated and necessary appeared in the SOC6, three years before release of the WPATH medical necessity policy statement:

Sex Reassignment is Effective and Medically Indicated in Severe GID.

In persons diagnosed with transsexualism or profound GID, sex reassignment surgery, along with hormone therapy and real‐life experience, is a treatment that has proven to be effective. Such a therapeutic regimen, when prescribed or recommended by qualified practitioners, is medically indicated and medically necessary. Sex reassignment is not “experimental,” “investigational,” “elective,” “cosmetic,” or optional in any meaningful sense. It constitutes very effective and appropriate treatment for transsexualism or profound GID. (WPATH, 2005, p. 102)

Medical Necessity Policy in the SOC 7

Published three years after the original WPATH medical necessity policy statement, the 7^th Revision of the WPATH Standards of Care (2011B) made frequent reference to the principle of medical necessity for gender-affirming care (pp. 5, 8, 33, 54, 55, 58, 64, and 97, among others). For example, in the chapter, “Overview of Therapeutic Approaches for Gender Dysphoria,” the SOC7 states:

Indeed, hormone therapy and surgery have been found to be medically necessary to alleviate gender dysphoria in many people. (p. 8)

To WPATH’s credit, the SOC7 brought forward-progress in policies that acknowledged the medical necessity of affirming puberty suppression, hormonal, and surgical care (Winters, 2011). These included recognition of informed consent protocols for hormonal care (WPATH, 2011, pp. 35-36), clarified guidance on puberty delaying care for gender incongruent adolescents (pp. 18-20), and removal of arbitrary delays of three months before hormonal care, pending mandatory psychotherapy or “real life experience,” from prior SOC revisions (p. 34).

However, the SOC7 retained and introduced barriers to care that contradicted WPATH’s long-held medical necessity principle. For example, access to hormonal care and all surgical procedures was obstructed unless diagnosed mental health conditions were “well controlled” (pp. 34, 59, 60, 104, 105, 106). Ambiguous language of “well controlled,” with no specific relevance to affirming medical care, created insurmountable, paradoxical barriers for individuals traumatized by denial of affirming care. Moreover, capricious age-of-majority restrictions on confirming surgical care (pp. 21, 60) prioritized political vagaries over medical necessity.

While the SOC7 was far from consistent with the WPATH medical necessity principle, it furthered progress in acknowledging medical necessity of affirming and confirming care. The SOC7 brought optimism for more progress and unambiguous closure on this issue by release of the SOC8, more than a decade later.

Medical Necessity Policy in the SOC 8

Version 8 of the WPATH Standards of Care for the Health of Transgender and Gender Diverse People (2022) fell short of clarity and closure on the principle of medical necessity of gender-affirming care, for those TGD individuals who need it. Instead, it seemed to further cloud the issue with contradiction and compromise.

The cornerstone statement of the medical necessity principle in the SOC8 is Statement 2.1, in the chapter, Global Applicability:

Statement 2.1 We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.

Medical necessity is a term common to health care coverage and insurance policies globally. A common definition of medical necessity as used by insurers or insurance companies is “Health care services that a physician and/or health care professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.” The treating HCP asserts and documents that a proposed treatment is medically necessary for treatment of the condition. (p. 16)

This is a positive restatement of the WPATH medical necessity principle. The supporting text of Statement 2.1 describes, “medically necessary clinical interventions” required by gender incongruence as well as “benefits in quality of life and well-being of gender-affirming treatments” (pp. 17-18). Like the WPATH public policy (2016), Statement 2.1 repeats that affirming treatments are “not considered experimental, cosmetic, or for the mere convenience of a patient;” are “safe and effective at reducing gender incongruence and gender dysphoria;” and should be provided without exclusions by health care systems (p. 18).

To the credit of its authors, Statement 2.1 is referenced liberally throughout the SOC8 (pp. 31, 45, 50, 81, 88, 93, 194, 110, 125, 128, 143, 156, 171). However, one reference to Statement 2.1 in Chapter 7, Children, is misleading and requires clarification:

This chapter describes aspects of medical [sic] necessary care intended to promote the well-being and gender-related needs of children (see medically necessary statement in the Global Applicability chapter, Statement 2.1). (p. 67)

In the SOC8 and prior revisions, childhood refers to prepubertal youth, when no somatic medical treatments related to gender incongruence are available or recommended.

The current WPATH position statement on medical necessity (2016) is listed in the Reference section of the SOC8 (p. 245), but, inexplicably, no in-text citations can be found with Statement 2.1 or anywhere in the document. Given the historical importance of the WPATH medical necessity policy, this omission merits correction in the SOC8.

The following table summarizes Statement 2.1, which defines the principle of medical necessity of gender-affirming care for the SOC8, with examples of explicit and implicit endorsements of medical necessity, as well as guidance on harm that may be caused by denial or deferral of care.

Table 1: SOC8 Endorsements of the Medical Necessity Principle

SOC8 Statement 2.1 Defining Medical Necessity Principle

Ch. 2, Global Appl., St. 2.1,p. 16 We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.

Ch. 2, Global, St. 2.1,p. 17 gender incongruence that causes clinically significant distress and impairment often requires medically necessary clinical interventions.

Ch. 2, Global, St. 2.1,p. 18 There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments …they are not considered experimental, cosmetic, or for the mere convenience of a patient …They are safe and effective at reducing gender incongruence and gender dysphoria …WPATH urges health care systems to provide these medically necessary treatments and eliminate any exclusions. …Medically necessary gender-affirming interventions are discussed in SOC-8.

SOC8 Explicit Endorsements of Medical Necessity Principle

Introduction, p.5 Healthcare systems should provide medically necessary gender-affirming health care for TGD people.

Introduction, p. 7 the medical necessity of treatment and care is clearly recognized for [people] who experience dissonance between their sex assigned at birth and their gender identity. …in some countries these diagnoses may facilitate access to medically necessary health care…

Introduction, p. 8 for many individuals, [non-prescribed hormonal therapy] is the only means of acquiring medically necessary gender-affirming treatment that is otherwise inaccessible.

Ch. 5, Adults, p. 31 This chapter provides guidance for the assessment of transgender and gender diverse (TGD) adults who are requesting medically necessary gender-affirming medical and/or surgical treatments (GAMSTs) to better align their body with their gender identity.

Ch. 5, Adults, p. 32 Access to assessment and treatment for TGD people seeking GAMSTs is critical given the clear medical necessity of these interventions and the profound benefits they offer to TGD people.

Ch. 5, Adults, St. 5.7, p. 41 The existence of these rare requests [to detransition] must not be used as a justification to interrupt critical, medically necessary care, including hormone and surgical treatments, for the vast majority of TGD adults.

Ch. 8, Nonbinary, p. 81 Some nonbinary people seek gender-affirming care to alleviate gender dysphoria or incongruence and increase body satisfaction through medically necessary interventions

Ch. 8, Eunuchs, p. 88 The 8th version of the Standards of Care (SOC) includes a discussion of eunuch individuals because of their unique presentation and their need for medically necessary gender-affirming care.

Ch. 11, Institutional, St. 11.3, p. 104 People should have access to these medically necessary treatments irrespective of their housing situation within an institution.

Ch. 11, Institutional, St. 11.3, p. 106 As with all medically necessary health care, access to gender-affirming hormone therapies should be provided in a timely fashion when indicated

Ch. 12, Hormone, p. 110 [TGD] persons may require medically necessary [GAHT] to achieve changes consistent with their embodiment goals, gender identity, or both. …Ever since the first [WPATH SOC] was published in 1979…GAHT has been accepted as medically necessary. …In these cases [of the early stages of puberty], pubertal suppression is considered medically necessary.

Ch. 12, Hormone, St. 12.4, p. 114 We recognize even though GnRHas are a medically necessary treatment, they may not be available for eligible adolescents…Therefore, other approaches should be considered in these cases.

Ch. 13, Surgery, p. 128 Medically necessary gender-affirmation surgery (GAS) refers to a constellation of procedures designed to align a person’s body with their gender identity.

Ch. 15, Primary Care, p. 143 Whether TGD patients receive medically necessary gender-affirming hormone therapy (GAHT) from a specialist, e.g., an endocrinologist, or a PCP may depend on the availability of knowledgeable and welcoming providers…

Ch. 16, Reproductive, p. 156 Medically necessary gender-affirming hormonal treatments (GAHTs) and surgical interventions that alter reproductive anatomy or function may limit future reproductive options to varying degrees.

SOC8 Implicit Endorsements of Medical Necessity Principle

Ch. 5, Adults, St. 5.1.a, p. 33 Avoiding unnecessary delays in care is critically important.

Ch. 5, Adults, St. 5.1.d, p. 34 The presence of psychiatric illness or mental health symptoms do not pose a barrier to GAMSTs unless the psychiatric illness or mental health symptoms affect the TGD person’s capacity to consent to the specific treatment being requested or affect their ability to receive treatment. This is especially important because GAMSTs have been found to reduce mental health symptomatology for TGD people.

Ch. 5, Adults, St. 5.3.b, p. 36 There is evidence the use of rigid assessment tools for “transition readiness” may reduce access to care and are not always in the best interest of the TGD person

Ch. 5, Adults, St. 5.3.c, p. 37 There is no evidence to suggest a benefit of withholding GAMSTs from TGD people who have gender incongruence simply on the basis that they have a mental health or neurodevelopmental condition.

Ch. 5, Adults, St. 5.3.d, p. 37 Treatment for mental health problems can and should occur in conjunction with GAMSTs when medical transition is needed. It is vital gender-affirming care is not impeded unless, in some extremely rare cases, there is robust evidence that doing so is necessary to prevent significant decompensation with a risk of harm to self or others. In those cases, it is also important to consider the risks delaying GAMSTs poses to a TGD person’s mental and physical health

Ch. 5, Adults, St. 5.3.d, p. 37 Delaying access to GAMSTs due to the presence of mental health problems may exacerbate symptoms.

Ch. 6, Adolescents, p. 45 these gaps [in scientific understanding] should not leave the TGD adolescent without important and necessary care.

Ch. 12, Hormone, St. 12.21, p. 126 Withholding hormone therapy based on the presence of depression or suicidality may cause harm. …the practice of withholding hormone therapy until these symptoms [of depression and anxiety] are treated with traditional psychiatry is considered to have iatrogenic effects.

Ch. 12, Hormone, St. 12.21, p. 127 If psychiatric treatment is indicated, it can be started or adjusted concurrently without discontinuing hormone therapy.

Ch. 15, Primary Care, St. 15.5, p. 149 Although age itself is not an absolute contraindication or limitation to gender-affirming medical or surgical interventions, TGD elders may not be aware of the current range of social, medical or surgical options…

Ch. 18, Mental Health, p. 171-172 Addressing mental illness and substance use disorders is important but should not be a barrier to transition-related care. Rather, these interventions to address mental health and substance use disorders can facilitate successful outcomes from transition-related care, which can improve quality of life.

Ch. 18, Mental Health, St. 18.2, p. 172-173 The benefits of mental health treatments that may delay surgery should be weighed against the risks of delaying surgery and should include an assessment of the impact on the patients’ mental health delays may cause in addressing gender dysphoria.

Unfortunately, these SOC8 references to WPATH’s long-established medical necessity principle are frequently undermined, and even directly contradicted, by conflicting Statements of Recommendation and supporting text. Some egregious examples are listed in Table 2. This is not an exhaustive list.

Table 2: SOC8 Contradictions to the Medical Necessity Principle

SOC8 Contradictions to Medical Necessity Principle and Statement 2.1	Remarks
Ch. 5, Adults, St. 5.3.c, p. 36 Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments.	Statement 5.3.c presumes, without citation, scientifically unsupported stereotypes that gender diversity is caused by underlying mental illness. It undermines the WPATH medical necessity principle by asserting that affirming care be delayed indefinitely, pending a psychopathologized fishing expedition for behavioral “causes” of gender incongruence, with no scientific basis. Statement 5.3.c is contradicted by its own supporting text (Table 1).
Ch. 5, Adults, St. 5.5, p. 40 The authors posited when clients are adequately prepared and assessed under the care of a multidisciplinary team, a second independent assessment is unnecessary.	This sentence incorrectly implies that a second, independent (comprehensive bio-psycho-social…) assessment, with consequential delay of medically necessary care, would be compelled for adults who selected their own affirming health professionals, outside of a centralized “multidisciplinary team,” or were initially assessed within a medical practice. Ironically, it is contradicted by the immediately preceding sentence, describing “paternalism” and “potential breach of the autonomy” in health care systems.
Ch. 6, Adolescents, pp. 45-46 A key challenge in adolescent transgender care is the quality of evidence evaluating the effectiveness of medically necessary gender-affirming medical and surgical treatments (GAMSTs) (see medically necessary statement in the Global chapter, Statement 2.1), over time.	This section undermines the WPATH medical necessity principle and throws unfounded fear, uncertainty, and doubt on two decades of clinical history of affirming adolescent puberty suppression and hormonal care. It fails to consider the social and ethical limitations of research on a persecuted, closeted class of human beings. It relies on a questionable citation on detransition by (Littman, 2021), while omitting key longitudinal work (Olson, et al., 2022) and study of provider attitudes and fears (MacKinnon, Ashley, et al., 2021). This section asserts a double-standard for TGD care and does not cite or call for extraordinary, long-term study of common hormonal treatments for cisgender adolescents, deep into adulthood.
Ch. 6, Adolescents, St. 6.3, p. 50 comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care,…[comprehensive biopsychosocial] assessment should occur prior to any medically necessary medical or surgical intervention under consideration (e.g., puberty blocking medication, gender-affirming hormones, surgeries).	Statement 6.3 deprioritizes medical necessity of affirming care, instead asserting that medical care for all adolescents should be delayed, pending compulsory, protracted MH assessment of indeterminate duration—regardless of whether specialized MH services were indicated by clinical intake assessment or by prior care providers. It directly contradicts guidance on p. 45 that “gaps [in understanding] should not leave the TGD adolescent without important and necessary care.”
Ch. 6, Adolescents, St. 6.3, p. 51 There are no studies of the long-term outcomes of gender-related medical treatments for youth who have not undergone a comprehensive assessment. Treatment in this context (e.g., with limited or no assessment) has no empirical support and therefore carries the risk that the decision to start gender-affirming medical interventions may not be in the long-term best interest of the young person at that time.	This paragraph instructs HCPs to disregard the medical necessity of affirming care for adolescents who were not referred for specialized, long-term MH care at intake assessment and were not subjected to the compulsory, protracted MH assessment process, cited for adolescent subjects of Dutch, VU University research. The last sentence is a “denying the antecedent” logical fallacy, asserting a hysterical, frightening conclusion for an inverse condition for which the authors offer no data. This directly contradicts guidance on p. 45 of the same chapter (Table 1).
Ch. 6, Adolescents, St. 6.11, p. 58 cases in which the parent(s)/caregiver(s)’ questions or concerns are particularly helpful in informing treatment decisions and plans…situations in which a young person experiences very recent or sudden self-awareness of gender diversity and a corresponding gender treatment request, or when there is concern for possible excessive peer and social media influence on a young person’s current self-gender concept.	Lacking citations, this paragraph is another uncritical, back-door endorsement of the biased and unfounded axioms of “rapid-onset gender dysphoria” and “social contagion” (Littman, 2018). It undermines the WPATH medical necessity principle for TGD adolescents who cannot safely come out of the closet to their families early in childhood. Moreover, it fails to consider the global political weaponization of Littman’s scientifically questionable stereotypes against affirming TGD health care in recent years (Winters, 2022; Ashley 2020).
Ch. 6, Adolescents, St. 6.12b, p. 61 Critically, these findings of low regret can only currently be applied to youth who have demonstrated sustained gender incongruence and gender-related needs over time as established through a comprehensive and iterative assessment (see Statement 6.3).	This statement undermines the WPATH medical necessity principle for TGD adolescents who cannot safely come out of the closet to their families early in childhood or communicate their gender incongruence or medical needs until the latter become urgent. It asserts unsupported fear of detransition outside of long-term, iterative MH assessment, without acknowledging that all longitudinal research involves iterative assessment. It offers no evidence of disproportionate detransition rates for adolescents receiving care under informed consent/harm reduction model protocols (SOC7, pp. 35-36), where intake assessment found no reason for specialized, third-party, MH therapy.
Ch. 6, Adolescents, St. 6.12d, p. 62 Evidence indicates TGD adolescents are at increased risk of mental health challenges, often related to family/caregiver rejection, non-affirming community environments… A young person’s mental health challenges may impact their conceptualization of their gender development history and gender identity-related needs…	These two sentences conflate correlation with causality and are paradoxical, suggesting without evidence that gender diversity is caused by mental disorder, which is caused by family rejection of gender diversity, which is caused by mental disorder, and so on. This serves to undermine the medical necessity of puberty suppression or hormonal care care for adolescents.
Ch 13, Surgery, St. 13.7, p. 133 We recommend surgeons consider gender- affirming surgical interventions for eligible transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.	This statement subordinates the medical necessity of confirming surgical care to inflexible gatekeeping by mental health clinicians. In some cases, a trusted, long-term medical provider, qualified in TGD care, may be better situated to perform appropriate assessment. This statement also contradicts Statement 18.2 text in the Mental Health chapter: “The benefits of mental health treatments that may delay surgery should be weighed against the risks of delaying surgery and should include an assessment of the impact on the patients’ mental health delays may cause in addressing gender dysphoria.”

These SOC8 assertions, typified by examples in Table 2, are not problematic because they require diagnostic assessment. Medical assessment and some form of diagnostic coding are ubiquitous in clinical and hospital practice around the world (excepting preventative care and well-care), and they are needed to establish individual medical necessity. Intake assessment commonly includes psycho-social screening, with referral to specialized mental health care when indicated. These assertions in the SOC8 are objectionable because they single out Trans and Gender Diverse individuals for disparate deferral of medically necessary care, pending indefinite mental health assessment/treatment, simply because they are Trans and Gender Diverse.

For example, Statement 6.3 in the Adolescents chapter requires that medically necessary pubertal suppression or affirming hormonal treatment be delayed, preempted by completion of compulsory “comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns” (p. 50). This is to be administered by a third-party mental health provider, rather than a qualified medical practitioner or clinic that might have years of prior familiarity with the patient. It further suggests invasive (and often offensive) “psychometrically validated psychosocial and gender measures” (p. 51). The latter place a further burden of proof upon TGD youth to repeatedly demonstrate their competence and authentic selves. In contrast, adolescents of cisgender privilege would never be subjected to delay of medically necessary endocrine treatment, with prerequisite, long-term psychological examination, only because they are cisgender. The double standard is unabashed. Moreover, these assertions are contradicted within the same chapter and in the Adults and Mental Health chapter:

While future research will help advance scientific understanding of gender identity development, there may always be some gaps. Furthermore, given the ethics of self-determination in care, these gaps should not leave the TGD adolescent without important and necessary care. (p. 45)

There is evidence the use of rigid assessment tools for “transition readiness” may reduce access to care and are not always in the best interest of the TGD person. (p. 36)

individuals should not be referred for mental health treatment exclusively on the basis of a transgender identity. (p. 117)

The medical necessity of affirming care is a long-settled principle of ethical practice and is no longer a legitimate topic of debate. It is frequently restated and endorsed within the SOC8 (Table 1). Yet other statements and text of the SOC8 are preoccupied with relitigating this bedrock WPATH principle and turning back the clock on access to affirming and confirming treatments (Table 2).

As a consequence, contradictions to the medical necessity principle in the SOC8 will be harvested and weaponized by those opposed to TGD health care. Trans and Gender Diverse people needing care, along with their affirming providers, will face additional barriers from governments and health systems—barriers worsened by ambivalence, where clarity is so crucially needed in medical policy.

I urge the WPATH leadership to place its highest priority on a corrected SOC8.1 point-revision, that resolves these shortcomings with consistent, unambiguous cogency on the medical necessity of gender affirming treatments and procedures.

Acknowledgments

I am grateful to Dr. Antonia D’orsay and members of the International Transgender Health Forum (www.facebook.com/groups/transgenderhealth) for their extensive, collaborative analysis and dialogue on the WPATH SOC8.

Copyright © 2022 Kelley Winters

References

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American Medical Association. (2008) Resolution 122: Removing Financial Barriers to Care for Transgender Patients. https://web.archive.org/web/20120412224003/http://www.ama-assn.org/ama1/pub/upload/mm/16/a08_hod_resolutions.pdf

American Medical Association. (2022) Removing Financial Barriers to Care for Transgender Patients H-185.950. https://policysearch.ama-assn.org/policyfinder/detail/H-185.950%20Removing%20Financial%20Barriers%20to%20Care%20for%20Transgender%20Patients?uri=%2FAMADoc%2FHOD.xml-0-1128.xml

American Psychiatric Association. (2012) Position Statement on Access to Care for Transgender and Gender Variant Individuals. Aug 16. Archived: http://www.psychiatry.org/File%20Library/Advocacy%20and%20Newsroom/Position%20Statements/ps2012_TransgenderCare.pdf

American Psychiatric Association. (2018) Position Statement on Access to Care for Transgender and Gender Variant Individuals. July. https://www.psychiatry.org/about-apa/Policy-Finder/Position-Statement-on-Access-to-Care-for-Transgend;
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American Psychiatric Association. (2020) Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth. July. https://www.psychiatry.org/about-apa/Policy-Finder/Position-Statement-on-Treatment-of-Transgender-(Tr

American Psychological Association, “Resolution on Transgender and Gender Identity and Gender Expression Non-Discrimination,” 2008, https://www.apa.org/about/policy/resolution-gender-identity.pdf

American Psychological Association. (2009) Report of the APA Task Force on Gender Identity and Gender Variance. Washington, DC., Revised, August 2019. https://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

American Psychological Association. (2015) Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. December. https://www.apa.org/practice/guidelines/transgender.pdf

Ashley, F. (2020). A critical commentary on ‘rapid-onset gender dysphoria.’ The Sociological Review Monographs, Vol. 68(4) 779 –79. https://www.florenceashley.com/uploads/1/2/4/4/124439164/ashley_a_critical_commentary_on_rapid-onset_gender_dysphoria.pdf

Harry Benjamin International Gender Dysphoria Association. (1979) Standards of Care: The hormonal and surgical sex reassignment of gender dysphoric persons. February 12. https://wpath.org

Littman, L. (2018). Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLOS ONE 13(8): e0202330. doi.org/10.1371/journal.pone.0202330

Winters, K. (2011) New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. GID Reform Weblog, Sep 25. https://gidreform.wordpress.com/2011/09/25/new-standards-of-care-for-the-health-of-transsexual-transgender-and-gender-nonconforming-people/

Littman, L. (2021). Individuals treated for gender dysphoria with medical and/or surgical transition who subsequently detransitioned: A survey of 100 detransitioners. Archives of Sexual Behavior, 50(8), 3353–3369. https://doi.org/10.1007/s10508-021-02163-w.

MacKinnon, K., Ashley, F., Kia, H., Lam, J., Krakowsky, Y., Ross, L. (2021) Preventing transition “regret”: An institutional ethnography of gender-affirming medical care assessment practices in Canada. Social Science & Medicine, 291 114477. https://doi.org/10.1016/j.socscimed.2021.114477

Olson, KR, Durwood L, Horton R, Gallagher NM, Devor A. (2022) Gender identity 5 years

after social transition. Pediatrics. doi: 10.1542/peds.2021-056082

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World Professional Association for Transgender Health. (2011A) WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide. Captured 2011Feb05. https://web.archive.org/web/20110205134357/http://www.wpath.org/medical_necessity_statement.cfm

*World Professional Association for Transgender Health (2011B). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. https://wpath.org

World Professional Association for Transgender Health. (2016) Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. December 21.
https://www.wpath.org/media/cms/Documents/Web%20Transfer/Policies/WPATH-Position-on-Medical-Necessity-12-21-2016.pdf

World Professional Association for Transgender Health. (2017) Letter to Roger Severino, U.S. Department of Health and Human Services. Aug 15. https://wpath.org/policies

World Professional Association for Transgender Health. (2019) WPATH Board Responds to Health Care Policies and Practices Imposed by Certain Religious Institutions. May 17. https://wpath.org/media/cms/Documents/Public%20Policies/2019/5-16_Religious%20Institution%20Health%20Policies.pdf

World Professional Association for Transgender Health. (2020A) WPATH / USPATH Statement on Resumption of Gender-Affirming Surgery During COVID-19 Pandemic. May 8. https://wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Joint%20WPATH%20USPATH%20Statement%20On%20Resumption%20of%20Medically%20Necessary%20Surgeries%20During%20COVID.pdf

World Professional Association for Transgender Health. (2020B) WPATH Sends Letter of Support to Republic of Kazakhstan. July 1. https://wpath.org/media/cms/Documents/Public%20Policies/2020/Republic%20of%20Kazakhstan%20-%20Letter%20of%20Support%20July%201%202020.pdf

World Professional Association for Transgender Health. (2021) Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. Apr 5. (Also cited as: de Vries, et al. International Journal of Transgender Health, DOI: 10.1080/26895269.2021.1904330)
https://www.wpath.org/media/cms/Documents/Public%20Policies/2021/Bell%20v%20Tavistock%20and%20Portman%20NHS%20Foundation%20Trust%202020%20EWHC%203274%20Weighing%20current%20knowledge%20and%20uncertainties%20in%20decisions%20about.pdf

*World Professional Association for Transgender Health (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. https://wpath.org

* Revisions of WPATH Standards of Care were traditionally published twice, on the WPATH (formerly HBIGDA) web site and in behavioral journals, including the Journal of Psychology & Human Sexuality, International Journal of Transgenderism, and, most recently, International Journal of Transgender Health. For brevity and accessibility, SOC documents published directly by WPATH are referenced here.

Contradictions and Compromises of Principle in the SOC8 Part 1.

Medical Necessity of Affirming Care

Kelley Winters, Ph.D.
2022 October 10

Since publication of the first Standards of Care for Transgender and Gender Diverse (TGD) health services by the Harry Benjamin International Gender Dysphoria Association (1979; now the World Association for Transgender Health, WPATH), clinical attitudes and health policies have very slowly trended toward acceptance of human gender diversity and more affirming, accessible, and evidence-based approaches to care. Key milestones in WPATH’s evolution toward cultural competence were public policy statements that asserted international professional consensus on principles of medical necessity of gender-affirming endocrine, surgical, and other care (WPATH, 2008; 2016) and depsychopathologization of gender diversity and the need for affirming care (2010). These foundational principles of ethical and respectful treatment of TGD people were prominently reflected in the Seventh SOC Revision (WPATH, 2011). They were implemented far from perfectly in the SOC7. However, their appearance gave hope for a future when Trans and Gender Diverse and cisgender privileged human beings, alike, might participate authentically in society and access medical and surgical services with equal agency and dignity. These hopes were dimmed, with publication of the Eighth SOC Revision (WPATH, 2022) two weeks ago.

The SOC8 contains a great deal of thoughtful, evidence-based, affirming content. However, its positive attributes are undermined by contradiction and compromise of previously established principles of ethical and effective TGD health care. Developed amid growing theo-political extremism that targets TGD people worldwide as a scapegoated class, the SOC8 reflects a struggle between factions within WPATH—between those who advocate affirming, medically necessary care and those who see TGD people primarily as mental patients and only reluctantly, begrudgingly, see them as recipients of medical services. Archaic stereotypes of psychopathology and dogmatic delay or denial of affirming medical care persist in the SOC8 as in prior revisions, especially for TGD adolescents.

WPATH Policy Statements on Medical Necessity

In 2008, WPATH released a policy statement on medical necessity to address barriers to care in the United States, which presumed that gender-affirming or confirming treatments were experimental, unproven, inefficacious, unnecessary, cosmetic, or elective:

WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A.

…The current Board of Directors of the WPATH herewith expresses its conviction that sex reassignment, properly indicated and performed as provided by the Standards of Care, has proven to be beneficial and effective in the treatment of individuals with transsexualism, gender identity disorder, and/or gender dysphoria

…The medical procedures attendant to sex reassignment are not “cosmetic” or “elective” or for the mere convenience of the patient. These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition

…These medical procedures and treatment protocols are not experimental: decades of both clinical experience and medical research show they are essential to achieving well-being for the transsexual patient. (WPATH, 2008)

Additionally, WPATH reaffirmed the medical necessity principle in numerous other public policy statements and papers (2009, 2017, 2019, 2020A, 2020B, 2021). Typical among these:

The Board of Directors of the World Professional Association for Transgender Health (WPATH) affirms the medical necessity of gender affirming treatments and procedures for those individuals whose lives are impacted by gender incongruity and for whom such care is deemed appropriate by their health care providers in concert with the patients and their families whenever possible, according to the latest edition of the Standards of Care (Version 7). (WPATH 2020B)

WPATH expanded the scope of the medical necessity policy statement from the U.S. to “Transgender and Transsexual People Worldwide” and tabbed its content directly to the WPATH home web page (2011B). In (2016), WPATH updated terminology in the medical necessity position statement to its current form, clarifying “gender affirming/confirming treatments and surgical procedures.” Inexplicably, its scope was once again limited to the U.S. in the title. The current SOC8 references the 2016 WPATH medical necessity statement.

Medical Necessity Policies by Other Medical and Mental Health Authorities

The efficacy and medical necessity of affirming pubertal suppression, hormonal, and surgical care for TGD individuals who need them has been long been recognized by a consensus of medical authorities. Beyond WPATH/HBIGDA, these include the American Medical Association, the American Psychiatric Association, the American Psychological Association, and the American Academy of Family Physicians.

Accompanying the first WPATH “Clarification on Medical Necessity” in 2008, the American Medical Association and the American Psychological Association passed their own similar resolutions that same year. They asserted the medical necessity of affirming care and opposed discriminatory health barriers to care in health systems:

An established body of medical research demonstrates the effectiveness and medical necessity of mental health care, hormone therapy and sex reassignment surgery as forms of therapeutic treatment for many people diagnosed with GID…Health experts in GID, including WPATH, have rejected the myth that such treatments are “cosmetic” or “experimental” and have recognized that these treatments can provide safe and effective treatment for a serious health condition. (AMA, 2008)

APA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments. (American Psychological Association, 2008)

The AMA resolution has been updated over the following years and is now listed as Resolution H-185.950 (2022).

The next year, the American Psychological Association published a comprehensive Report of the APA Task Force on Gender Identity and Gender Variance, which stated:

For individuals who experience such distress, hormonal and/or surgical sex reassignment may be medically necessary to alleviate significant impairment in interpersonal and/or vocational functioning. Indeed, when recommended in clinical practice, sex reassignment surgery is almost always medically necessary, not elective or cosmetic. (2009)

This was followed by similar statements of medical necessity in Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (American Psychological Association, 2015).

A year after publication of the SOC7, the American Psychiatric Association (2012) and the American Academy of Family Physicians (2012) issued similar policy statements that endorsed the medical necessity of affirming medical and surgical care. The APA “Position Statement on Access to Care for Transgender and Gender Variant Individuals” was most recently updated in July (2018). This was followed by an APA position statement, specific to care for Trans and Gender Diverse youth:

Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth. (APA 2020)

The medical necessity of affirming care for TGD adolescents and adults was publicly acknowledged by WPATH, AMA, AAFP, and both APAs, repetitively, across fourteen years, before publication of the SOC8 in 2022. Expert consensus on this fundamental principle of ethical care, and the harmful consequences of withholding affirming care from those who needed it, were well established when the SOC8 working groups were convened.

To be continued in Part 2.

References

American Academy of Family Physicians. (2012) Resolution No. 1004: Transgender Care. May 3. https://www.aafp.org/dam/AAFP/documents/about_us/special_constituencies/2012RCAR_Advocacy.pdf

American Medical Association. (2008) Resolution 122: Removing Financial Barriers to Care for Transgender Patients. https://web.archive.org/web/20120412224003/http://www.ama-assn.org/ama1/pub/upload/mm/16/a08_hod_resolutions.pdf

American Medical Association. (2022) Removing Financial Barriers to Care for Transgender Patients H-185.950. https://policysearch.ama-assn.org/policyfinder/detail/H-185.950%20Removing%20Financial%20Barriers%20to%20Care%20for%20Transgender%20Patients?uri=%2FAMADoc%2FHOD.xml-0-1128.xml

American Psychiatric Association. (2012) Position Statement on Access to Care for Transgender and Gender Variant Individuals. Aug 16. Archived: http://www.psychiatry.org/File%20Library/Advocacy%20and%20Newsroom/Position%20Statements/ps2012_TransgenderCare.pdf

American Psychiatric Association. (2018) Position Statement on Access to Care for Transgender and Gender Variant Individuals. July. https://www.psychiatry.org/about-apa/Policy-Finder/Position-Statement-on-Access-to-Care-for-Transgend;
https://www.psychiatry.org/File%20Library/About-APA/Organization-Documents-Policies/Policies/Position-2018-Access-to-Care-for-Transgender-and-Gender-Diverse-Individuals.pdf

American Psychiatric Association. (2020) Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth. July. https://www.psychiatry.org/about-apa/Policy-Finder/Position-Statement-on-Treatment-of-Transgender-(Tr

American Psychological Association, “Resolution on Transgender and Gender Identity and Gender Expression Non-Discrimination,” 2008, https://www.apa.org/about/policy/resolution-gender-identity.pdf

American Psychological Association. (2009) Report of the APA Task Force on Gender Identity and Gender Variance. Washington, DC., Revised, August 2019. https://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

American Psychological Association. (2015) Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. December. https://www.apa.org/practice/guidelines/transgender.pdf

Harry Benjamin International Gender Dysphoria Association. (1979) Standards of Care: The hormonal and surgical sex reassignment of gender dysphoric persons. February 12. https://wpath.org

Winters, K. (2011) New Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. GID Reform Weblog, Sep 25. https://gidreform.wordpress.com/2011/09/25/new-standards-of-care-for-the-health-of-transsexual-transgender-and-gender-nonconforming-people/

Winters, K. (2018) What’s Needed in the WPATH SOC8, Part 1: A Wish for Wings that Work. Trans Policy Reform Blog. Sep 26. https://transpolicyreform.wordpress.com/2018/09/26/whats-needed-in-the-wpath-soc8-part-1-a-wish-for-wings-that-work/

World Professional Association for Transgender Health. (2008) WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. June 17.
https://web.archive.org/web/20101130201438/http://wpath.org/publications_public_policy.cfm

World Professional Association for Transgender Health. (2009) WPATH Responds to Alberta, Canada’s Decision to Delist Sexual Reassignment Surgery as a Covered Medical Benefit. Apr 2021. https://amo_hub_content.s3.amazonaws.com/Association140/files

World Professional Association for Transgender Health. (2010) WPATH De-Psychopathologisation Statement. May 26. https://www.wpath.org/policies

World Professional Association for Transgender Health. (2011A) WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for Transgender and Transsexual People Worldwide. Captured 2011Feb05. https://web.archive.org/web/20110205134357/http://www.wpath.org/medical_necessity_statement.cfm

*World Professional Association for Transgender Health (2011B). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, Version 7. https://wpath.org

World Professional Association for Transgender Health. (2016) Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. December 21.
https://www.wpath.org/media/cms/Documents/Web%20Transfer/Policies/WPATH-Position-on-Medical-Necessity-12-21-2016.pdf

World Professional Association for Transgender Health. (2017) Letter to Roger Severino, U.S. Department of Health and Human Services. Aug 15. https://wpath.org/policies

World Professional Association for Transgender Health. (2019) WPATH Board Responds to Health Care Policies and Practices Imposed by Certain Religious Institutions. May 17. https://wpath.org/media/cms/Documents/Public%20Policies/2019/5-16_Religious%20Institution%20Health%20Policies.pdf

World Professional Association for Transgender Health. (2020A) WPATH / USPATH Statement on Resumption of Gender-Affirming Surgery During COVID-19 Pandemic. May 8. https://wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Joint%20WPATH%20USPATH%20Statement%20On%20Resumption%20of%20Medically%20Necessary%20Surgeries%20During%20COVID.pdf

World Professional Association for Transgender Health. (2020B) WPATH Sends Letter of Support to Republic of Kazakhstan. July 1. https://wpath.org/media/cms/Documents/Public%20Policies/2020/Republic%20of%20Kazakhstan%20-%20Letter%20of%20Support%20July%201%202020.pdf

World Professional Association for Transgender Health. (2021) Bell v Tavistock and Portman NHS Foundation Trust [2020] EWHC 3274: Weighing current knowledge and uncertainties in decisions about gender-related treatment for transgender adolescents. Apr 5. (Also cited as: de Vries, et al. International Journal of Transgender Health, DOI: 10.1080/26895269.2021.1904330)
https://www.wpath.org/media/cms/Documents/Public%20Policies/2021/Bell%20v%20Tavistock%20and%20Portman%20NHS%20Foundation%20Trust%202020%20EWHC%203274%20Weighing%20current%20knowledge%20and%20uncertainties%20in%20decisions%20about.pdf

*World Professional Association for Transgender Health (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. https://wpath.org

* Revisions of WPATH Standards of Care were traditionally published twice, on the WPATH (formerly HBIGDA) web site and in behavioral journals, including the Journal of Psychology & Human Sexuality, International Journal of Transgenderism, and, most recently, International Journal of Transgender Health. For brevity and accessibility, SOC documents published directly by WPATH are referenced here.

Copyright © 2022 Kelley Winters

Transgender Research Informed Consent (TRICON) Disclosure Policy: 2022 Update

Kelley Winters, Ph.D.

The Transgender Research Informed Consent (TRICON) disclosure policy was developed by administrators of the International Transgender Health Forum in 2019 to:

Empower Transgender and Gender-Diverse (TGD) community members to make informed decisions on participation in research studies, within a historical context of decades of research that is all too often biased, defamatory, misgendering, exploitive, or non-consensual. Moreover, these disclosures give exemplary research teams an opportunity to show off their cultural competence on TGD research issues and set positive examples for other scholars.

TRICON consists of ten disclosure questions, to be repeated an answered by investigators of research on TGD populations in all announcements, communication, and social media posts that solicit study participants. These questions were updated in 2022 to improve clarity, press for transparency on inclusion of TGD scholars in IRB and research oversight, and add a new line item on consensual participation in research, without unethical coercion.

The current TRICON policy document is available here and may be freely shared and adopted as policy by academic and clinical institutions and practices, everywhere:

202210triconcDownload

The Transgender Research Informed Consent (TRICON) Disclosure Policy by Kelley Winters, Antonia Elle D’orsay, Vreer Sirenu, and AR Con, administrators of the International Transgender Health Forum, is licensed under Creative Commons, CC BY 4.0. We encourage all institutions conducting research on Trans and Gender-Diverse populations and all organizations that serve TGD communities to adopt the TRICON disclosure policy, with CC attribution to the original authors.

https://creativecommons.org/licenses/by/4.0/
https://www.facebook.com/groups/transgenderhealth/permalink/2408448745866204/

The International Transgender Health (ITH) Forum is a private social media group of over 9000 global members, representing intersectional TGD communities and affirming medical and mental health professionals, family members, scholars, and advocates. ITH is a safe space for exchange and dialogue on policies and practices of affirming Transgender and Gender Diverse health care. It is currently hosted by Facebook, and expanded web services are planned for the future.

https://www.facebook.com/groups/transgenderhealth