Current Policies, Practices and Recommendations Regarding Treatment of Gender Minorities (page 2)
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)
The previous chapter described the use of behavioral treatment strategies (Rekers, 1992; Rekers & Lovass, 1974; Zucker & Bradley, 1995) which have been used with children who are gender nonconforming. The objective of these rehabilitative treatments is to put children “on track” in terms of their gender role behaviors and to ultimately help defend against the social ostracism that such children typically experience (Raj, 2002). Critics of these treatment approaches argue that they make the mistake of conflating gender identity and sexual orientation and raise a number of ethical and treatment-related questions.
The 1990s also saw many changes in the treatment of other segments of the transgender community. The idea that had been promulgated by John Money and his colleagues at the Johns Hopkins School of Medicine in the fifties—that newborns are “neutral” when it comes to gender identity and that the assignment of sex at birth and rearing are the major determinants of gender identity—was strongly contested in the early 1990s (Zucker, 2005). The standard policies for the treatment of intersex newborns were also criticized on ethical grounds. In 1993, what was started by Cheryl Chase as a peer support group for intersexed adults became the Intersex Society of North America (ISNA). The ISNA’s goals are to stop the practice of genital surgery in infancy and provide parents and intersex children with professional mental health care. The controversy over this protocol continues even today. In 1997, intersex activists visited Congress to request the Law to Ban Female Genital Mutilation be enforced to protect intersex children as well. The recent APA policy statement and report of the Task Force on Gender Identity and Gender Variance purposefully exclude intersex persons because of the growing division between persons who are born with medical conditions many of whom prefer the label Disorders of Sex Development over intersex and those who alter their bodies through hormones and/or surgery (APA, 2008).
Beginning in the late 1980s and throughout the 1990s, changes in the medical and psychological treatment approaches across all segments of the transgender population have emerged in large measure through the political activism of coalitions formed across the transgender community (e.g., the International Foundation for Gender Education, American Educational Gender Information Service, Renaissance Transgender Association) (Denny, 2006). For example, Tri-Ess, the national organization introduced earlier, for cross-dressers and their spouses, joined other organizations in ratifying the Gender Bill of Rights and developing outreach educational programs for counseling-related organizations such as the American Association of Sex Educators, Counselors, and Teachers (AASECT) and the NASW (Fairfax, 2006).
A number of clinicians (e.g., Rosario, 2004; Seil, 2004) reported that many of those who requested sex reassignment during the 1970s fabricated descriptions of their experiences, often copying the same terminology (e.g., “trapped in the wrong body”) over and over again, in order to assure that they qualified under the medical evaluation standards that were used for gender reassignment treatments. Some believe that this practice continues and serves to alienate gender minorities from helping professionals. For example, Spade (2006), a transgender activist, described this experience quite vividly:
After attending only three discussion group meetings with other trans people, I am struck by the naiveté with which I approached the search for counseling to get my surgery authorizing letters. No one at these groups seems to see therapy as the place where they voice their doubts about their transitions, where they wrestle with the political implications of their changes, where they speak about fears of losing membership in various communities or in their families. No one trusts the doctors as the place to work things out. When I mention the places I’ve gone for help, places that are supposed to support queer and trans people, everyone nods knowingly, having heard countless stories like mine about these very places before. Some suggest therapists who are better, but none cost less than $50/hr. Most people simply offer different ways to get around the requirements. I get names of surgeons who do not always ask for letters. Someone suggests that since I won’t be on hormones, I can go in and pretend I’m a woman with a history of breast cancer in my family and that I want a double mastectomy to prevent it. I have these great, sad conversations with these people who know all about what it means to lie and cheat their way through the medical roadblocks to get the opportunity to occupy their bodies in the way they want. (p. 327)
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