Love Hate Relationship With The SOC

Okay first I have to say I have a bias, I am a social worker even though I am not clinical many of my friends are LCSW.

We as a community do not like the Standard of Care (SOC) that is put out by WPATH (World Professional Association of Transgender Health), when I do training for social workers I use this slide and I think it says it all.

There is an article on Slate about the gatekeepers,

Gatekeepers vs. Informed Consent: Who Decides When a Trans Person Can Medically Transition?
By Vanessa Vitiello Urquhart
March 11, 2016

While not every transgender person seeks to transition physically—whether through hormone therapy or other means like surgery—when one does, who should be allowed to make the decision? Is it a clear matter of personal choice? Or should doctors or therapists have a say?

In recent decades, transgender patients were expected to undergo extensive talk therapy in order to access medical interventions. Under this approach, also known as the “gatekeeper” model, the ultimate decision about who was or was not a candidate for treatments ranging from hormones to surgery rested with the therapist. More recently, transgender advocates have argued against what they see as red tape, favoring a system of “informed consent” in which, following appropriate education and advisement about the treatment in question, the ultimate decision regarding treatment choice rests with the patient alone. The informed consent model has been adopted at many centers that provide hormone replacement therapy (HRT), including the Planned Parenthood locations that offer it. Still, other providers continue to use the older model, requiring patients to produce a letter from a therapist regarding their psychological fitness before they can be evaluated medically as candidates for treatment.

First off the SOC states that it is only a guideline and not carved in stone, “The SOC are intended to be flexible in order to meet the diverse health care needs of transsexual, transgender, and gender-nonconforming people.” and the SOC doesn’t any more require three months of evaluation but instead it says, “A mental health screening and/or assessment as outlined above is needed for referral to hormonal and surgical treatments for gender dysphoria. In contrast, psychotherapy—although highly recommended—is not a requirement.” So we need a mental health screening and/or assessment and the criteria is vague in that it say,

Mental health professionals assess clients’ gender dysphoria in the context of an evaluation of their psychosocial adjustment (Bockting et al., 2006; Lev, 2004, 2009). The evaluation includes, at a minimum, assessment of gender identity and gender dysphoria, history and development of gender dysphoric feelings, the impact of stigma attached to gender nonconformity on mental health, and the availability of support from family, friends, and peers (for example, in-person or online contact with other transsexual, transgender, or gender-nonconforming individuals or groups). The evaluation may result in no diagnosis, in a formal diagnosis related to gender dysphoria, and/or in other diagnoses that describe aspects of the client’s health and psychosocial adjustment. The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to, or better accounted for, by other diagnoses.

For many trans people this is what gets our goat having to have an assessment, the article goes on to say that,

This divide among providers mirrors a tension within the larger trans healthcare advocacy community. On one side there are those who wish to de-medicalize the experience of transgender individuals to the greatest possible extent—these advocates generally see the role of medical professionals as providing the requested treatment to the consumer and staying out of the way. Others see medical practitioners as playing an important role in helping to prepare trans patients for the consequences of their decisions, guiding them away from uninformed choices or spur-of-the-moment impulses. While both sides ultimately want trans folks to get the care they need, the question of how much intervention is helpful is very much open.

I can see both sides of the argument and I lean towards having some kind of therapy because for many non-trans medical procedures there is some kind on assessment done.

The article goes on to say,

Even so, the consensus of medical providers who work with transgender patients has shifted a long way in favor of self-determination, and it may well shift further. There do, however, remain questions of emphasis. Although it’s rare for patients to regret transitioning, it can and does happen. There are also transgender patients who do not regret transitioning, but who come to regret the specific decisions that they made, the speed of the process, which providers they trusted, or how they dealt with their transition emotionally. For advocates like Abernathy, the potential for regret is not as important as the principle of access and control over one’s body—she believes that the existence of a few people who regret making a decision shouldn’t prevent adults from freely making the same decision as long as they’re fully informed about the potential risks and benefits.

Professionals like Dr. Green and the members of his organization have a different concern: making sure that patients and providers are protected from negative outcomes that could have been avoided.

I think some assessment should be required and I think the flexibility of the SOC is a step in the right direction.

Okay, here is one of my pet peeves; though out the article the author uses the medical term Hormone Replacement Therapy (HRT), the correct term is Cross-sex Hormone Therapy (CHT). So what is the difference, why am I making a big thing about the name? The levels of hormones that we take can be over 200 time more than HRT and HRT is on a cyclic 28 day schedule and it may also include progestin while CHT does not. In certain emergency situations it can make the difference between like or death.