Lesbian and Gay Parenting Questions & Answers Column With Arlene Istar LevDear Ari

A column by Arlene (Ari) Istar Lev


Posted By on August 14, 2010

Dear Ari:

Why do we need the WPATH standards of care? Haven’t we come far enough in the handling of folks with gender issues that rules like these aren’t needed?
—Lucinda, living full-time in Heartland

Dear Lucinda:

If I only had a dollar for each time I get asked this question, it would probably pay for my next trip to Italy for the bi-annual WPATH conference!

For those who do not know, WPATH is the World Professional Association for Transgender Health (formerly HBIGDA, the Harry Benjamin International Gender Dysphoria Association, Inc., named for Harry Benjamin –an endocrinologist – who was one of the first professionals to advocate for medical treatments for transsexuals.) WPATH is the only international professional organization devoted to the understanding and treatment of what has been referred to as “gender identity disorders.” Gender identity is not something I ever think of as “disordered,” and like many of you would prefer to see transgender issues de-pathologized, i.e., removed from the manual of mental illnesses.

Despite the difficulties inherent in this language, WPATH remains the only professional organization solely dedicated to working with people who are transgender and transsexual. Frankly I believe strongly that such collaborative communication is essential for quality medical and clinical treatment. I should probably disclose at this point that I am member of WPATH, and find my involvement to be one of my most meaningful affiliations in my professional life. I have discovered over the last five years that there are many misinformed “assumptions” about what WPATH and its membership is all about. WPATH is an organization with a wide international, inter-disciplinary membership, including physicians, psychologists, and social workers –some of who are transgender/transsexual themselves, and many interested non-professionals including a growing number of trans activists.

Contrary to popular belief, WPATH is not a bunch of middle-aged white male medical professionals in suits finding ways to hold back transgender people from transitioning. Last year in Ghent, Belgium I had a lovely conversation with a woman psychiatrist from Turkey, a Danish social worker, an Italian sexologist, and a cross-dressed child psychologist from Norway – professionals breaking ground on gender issues in their own countries. I listened to a Belgium transsexual doctor discuss fertility and sperm storage concerns for MTFs and two American therapists report on research on the families of trans people. Over an excellent mussel dinner, I heard a transman’s critique of Michael Bailey’s book, and had a lovely conversation with two transwomen scholars about aging issues within the gender community. WPATH is an unusual gathering of iconoclastic scholars, researchers, clinicians, and political activists, representing the continuum of gender presentations and possibilities. (One thing to bear in mind before judging gender specialists, is that – generally speaking – transgender medicine is not well-respected professionally, and we are often seen in the same disparaging light as the population of people we serve.)

At that last WPATH conference, I was pleased to be part of a panel discussion critiquing and debating the current Standards of Care. Many of the issues raised in WPATH are the kind of issues that I suspect that Lucinda is referring to in her original question. How do we get therapists out of the role of being gatekeepers for the medical professional, and yet protect our clients from rushing ahead without adequate knowledge and information about medical treatments? I know that for those of you who are absolutely clear about starting medical treatments, the WPATH Standards of Care can feel like a financially, time-consuming burden. However, I do know that many of the clients I work with are unsure if they want to begin treatment, have deep unresolved questions about work and career, family and children, passing and surgery. Therapeutic involvement can serve to help clients resolve their issues before they begin medical treatments, and throughout the transition process.

The Standards of Care are often misunderstood and unfortunately there are professionals who use them to withhold treatments and overly psychoanalyze clients. The goal of the SOC, however, is to set standards for medical treatments and eligibility for who can access those treatments. I understand that this may seem patronizing to some people, but the alternative to having SOC, is to have NO standards of care at all. Without some kind of standards, transsexuals would be at the mercy of uneducated and unscrupulous doctors, those not interested in state of the art treatments, but financial gain from an often-desperate population.

Although it is not common, people do seek transsexual treatment who have severe mental illnesses, where gender issues are part of other psychotic issues and they are not actually transsexual. Sometimes people seek medical treatment who have unresolved issues about sexual orientation, and believe that if they “change sex” and have a heterosexual relationship, this would be more acceptably socially or religiously than being in a homosexual relationship. People also seek treatment who are active alcoholics, or have misinformation about what treatment will do (“My hair will grow back on my head; a friend had this happen, honest!”), and need support resolving these issues before they begin transition. Many, many people who seek treatment are not thinking “clearly” about issues related to job security, or custody issues regarding children, or interpersonal issues with spouses, partners, and parents. It doesn’t mean these people are not eligible for gender related medical treatments, it just means they may need a more thorough evaluation and treatment plan to address the issues. The more people work through these issues, the more successful, and less traumatic, their transition process will be.

The SOC should not be rules (and personally I would run from any clinician who used them this way.) They are flexible guidelines, highlighting the knowledge gained within the last 40 years about what stumbling blocks trans people experience in transition, and ways to hopefully eliminate or minimize them. The goal is not to block trans people from needed services, but to advocate for clients requesting those services, and assisting them in the best possible transition.

Bear in mind that most medical and clinical experts are woefully ignorant about transgender people’s needs, and the SOC serve to set professional guidelines at the highest level of available medical and clinical knowledge. Most gender specialists are not using the SOC to control the lives of transgender people, but see themselves as advocates who can assist people and their families through the difficult quagmire of gender transition. Personally, I would be far more concerned working with a professional who never heard of the SOC, or completely disregards them, than one who is well-versed in them, and uses them as flexible guidelines that is individualized for each client. I suggest if you are seeking therapy or medical treatments interview a prospective therapist about their opinions and values regarding the SOC, and find someone compatible with your needs. Remember, the goal of therapy is to assist you in expressing your own authenticity and increasing your insight into your life so you become healthier and more whole. The relationships between client and therapist should be a mutually respectful partnership, and at its best can be a sacred shared journey.