Current Policies, Practices and Recommendations Regarding Treatment of Gender Minorities
Few professional organizations offer policy and practice guidelines and policies specifically for gender minorities. However, in August 2008, the Governing Council of Representatives of the APA passed a resolution banning discrimination on the basis of gender identity. The APA policy statement calls for additional practice guidelines, training and research (APA, 2008). The most popular treatment protocol for gender minorities, the Standards of Care (SOC) for Gender Identity Disorders, was established by the Harry Benjamin International Gender Dysphoria Association (HBIGDA) in 1979. Now in its sixth version (Meyer et al., 2001), the SOC prevails in most places throughout the world. The HBIGDA is an international organization whose membership consists of 500 psychiatrists, psychologists, mental health professionals, and physicians. According to Ekins (2005), the membership of HBIGDA also contains a “significant number of transgendered professionals” (p. 307), many of whom objected to the term gender dysphoria and to the assumption of pathology inherent in the treatment guidelines. It was for this reason that the organization voted to rename itself the World Professional Association for Transgender Health (WPATH) in 2006 (http:/ /www. wpath. org).
The SOC, which were last revised in February 2001, represent a consensus of opinion about how to provide medical and psychological care to persons with gender identity disorders. The SOC’s minimal training requirements for those mental health professionals who work with adults and children include a master’s degree and specialized training in the assessment and treatment of gender identity issues. According to these guidelines, mental health professionals must provide documentation letters for hormone therapy or for breast surgery to physicians who will provide medical treatment. Letters of documentation are also required in order for genital surgery, referred to as sex reassignment surgery, to be performed. The SOC also list additional responsibilities that are germane to the work of mental health professionals, including (1) accurately diagnosing gender identity disorder and any other co-morbid mental disorders, (2) discussing the range of treatment options and the risks and benefits associated with these, (3) making an evaluation and formal recommendation to medical personnel, (4) educating family members and others, and (5) conducting follow-up with clients. The SOC also contain eligibility criteria for hormone therapy, including either a real-life experience for three months prior to administration or a period of psychotherapy of not less than three months.
There have been a number of criticisms of the SOC. According to Denny, because the SOC are minimal standards, they have often been inappropriately applied:
Access to hormones and surgery were oft-promised and seldom delivered, and were, in fact, frequently used like carrots at the end of stick. Some transsexuals were kept in abeyance for years with false promises. Others were required (read forced) to make changes in their sexual orientation, marital status, career, manner of presentation, name, and physical characteristics. Many were required to live full time for extended periods before hormonal therapy. (Denny, n.d., p. 1)
Many believe that the Standards of Care are too restrictive. For example, at the second International Conference of Transgender Law and Employment Policy in 1993, the membership adopted Health Law Standards of Care for Transsexualism. These standards were less restrictive than the HBIGDA/WPATH SOC and stipulated that medical providers who perform hormonal and sex reassignment therapy must also conduct periodic blood chemistry checks and seek informed consent and waiver of liability from their patients (http:/ /www. transgendercare. com/ guidance/ resources/ ictlep_soc. htm).
Another criticism of the SOC is their omission of gender minority persons who do not want hormones or surgery (Martin & Yonkin, 2006). There are increasing numbers of gender minorities who choose not to transition through hormones (NoHo) or surgery and instead employ nonmedical strategies (behavior, dress, and speech) to express their gender identities (Denny, 2006; Lombardi & Davis, 2006; Martin & Yonkin, 2006). There are also increasing numbers of persons who choose to present themselves androgynously (Denny, 2006; Lombardi & Davis, 2006).
The decision to live in a gender identity that defies traditional notions of male and female (or notions about the medical transition from one sex to another) should be respected as a viable alternative to transitioning to a new gender. (Lombardi & Davis, 2006, p. 355)
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