Abstract
The World Professional Association for Transgender Health’s Standards of Care (WPATH SOC), now in its seventh edition, is a frequently cited, internationally recognized, evidence-based document that details a comprehensive framework for gender-related care of trans people. However, the WPATH SOC still relies heavily in some cases on gatekeeping practices, dubbed “triadic therapy,” or a process where a trans patient is encouraged to seek out psychotherapy, and hormone therapy, and only then be able to engage in surgical options for transitioning. I use G. Alan Marlatt’s harm reduction framework to argue that the triadic process creates its own set of harms that trans people have to contend with, especially insofar as it focuses on resolving gender dysphoria in a demanding, moralizing, and top-down way as opposed to enriching trans lives by reducing harms that prevent us from flourishing. Using Marlatt’s criterion that harm reduction ought to be bottom-up, low threshold, and not moralizing, I develop a list of suggestions for what ought to be centrally considered in treating trans patients.
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Notes
This includes trans scholar C. Jacob Hale, psychiatrist Grief De Cuypere, surgeon Stan Monstrey, therapist Arlene Istar Lev, activist Jamison Green and others. Thank you to an anonymous reviewer for noting that the international uptake of the 7th edition involves use by non-Western clinics such as the Thai Suporn clinic, the GRS clinic in Montreal, as well as by insurers in the United States, and groups such as the International Endocrine Association. The apparent focus above on medical experts in a uniquely Western context is unmerited.
Nota bene: this point is elaborated further on as it relates to the non-inclusion in the SOC of evidence derived from RCTs.
Note that in the 7th Edition of the WPATH SOC no minimum amount of psychotherapy sessions prior to hormone therapy or surgery is recommended. This is to minimize the hurdles trans patients go through as well as the assumption that psychotherapy is only relevant at the beginning of the process.
For instance, Peter Dunne discusses how across Europe, mandatory sterility is justified under flimsy grounds, which broadly speaking include “the need for legal certainty…enforcing child protection…and preserving natural reproduction” (557). Dunne argues none of these grounds holds water as it’s unclear that the children of trans parents are any more likely to be alienated from their biological parents than are other groups (aka the “genetic, gestational, and social and psychological” (566) criteria for so called ‘natural parenthood’ are met in our case). Further, there is no evidence that the children of trans parents are actually any more subject to extreme social rejection as compared to other groups, and that there even is an obvious biological natural correlate to womanhood and manhood that is being interfered with in the case of individuals receiving gender affirming surgery.
Gruenewald [7] discusses how Havelock Ellis famously naturalized Krafft-Ebing’s psychiatric category of inversion. Ellis was a eugenicist but also believed in both “the creeds of […] radical secularism and scientific naturalism” (Crozier 2008, p. 188). Ellis believed in fostering autonomy and independence in individual subjects through encouraging education and secularization, so that people would ‘invest’ in the future of the so-called human race by determining whether they were fit for reproduction.
According to Marlatt, HR began during the 1970s in the Netherlands when the Narcotics Working Party (NWP) suggested policy changes to the government’s drug policy that led to the adoption of a Dutch Opium Act in 1976. The 1976 Opium Act legally differentiated between high- and low-risk drugs in terms of the potential harm they may cause to users (e.g., amphetamines and heavily psychoactive drugs of various kinds on the one hand, and hashish and marijuana on the other). This legislation moved the dialogue from one that considered substances in terms of legality/illegality alone towards one that involved calibrating actual risks to users as an important part of how the law was formed. Further, Marlatt discusses how the NWP was able to make the recommendations that lead to this change due to input from drug users themselves. Marlatt frames this as a humane and pragmatic shift in public discourse and law in the Netherlands, which honoured the first-person view of drug users themselves as authoritative.
Many careful approaches to HR currently exist. The difficulty with all these approaches is that they are either importantly and necessarily specific (e.g., Dell and Lyon’s harm reduction framework for First Nations populations [5]), or are more formal and abstract (e.g., Tony Mercer’s formal consequentialist approach [11]) than my use requires.
Indeed, Weiss and Green argue that the most recent edition of the SOC is far too stringent in its demand for two mental health letters prior to any form of surgery and as regards the mandatory time spent in a gender role [16]. Indeed, they are that these conditions are insulting to a clinician’s individual judgments (to say nothing of trans people’s individual judgments).
My view is further bolstered by evidence gathered by Katherine Rachlin that trans people often find therapy itself to be “belittling, challenging, or judgmental regarding [our] gender, which in some cases resulted in increased despair” no matter how long [therapy] goes on for [12]. Also, on a more personal level, C. Jacob Hale argues that the four principles approach9 to biomedical ethics demands that trans patients do not need to go through a mental health evaluation prior to being able to access hormones and surgical procedures [8]. Hale argues that needing a mental health evaluation prior to non-emergency surgical procedures is not medically standard, and requiring this evaluation for trans people fails to meaningfully balance the ethical medical principles of autonomy and non-maleficence [8].
Thank you to an anonymous reviewer who noted this history needed to be complicated, and that Cristan Williams’ archival research has uncovered many terms that predate Prince’s use, including: transgender, transgenderist, transgenderal etc.
Although it was Leslie Feinberg who popularized the word “transgender” (invented by activist Virginia Prince) in Transgender Liberation: A Movement Whose Time has Come [6], myriad trans women in particular characterized this period of intense transgender activism and the resistive gains we have derived from that to this day. Activists and scholars such as Susan Stryker [14], Ricki Ann Wilchin, Nancy Nangeroni, Kate Bornstein and others pushed forward a new age of trans-centered and pluralistic understanding of gender. For instance, Ricki Ann Wilchin’s “Read My Lips” [16] provided a critical lens with which to examine the ‘study’ of transgender people, whereby oppression is synonymized with externally imposed categorization, flipping the social script to centralize the multiple first-person knowledges and experiences of trans folks. In Sandy Stone’s article “The Posttranssexual Manifesto” [13], she argues that for trans folks to become part of traditional gender schemes is to be complicit in their totalizing narratives. Rather those narratives should be deconstructed and reconstructed anew around radically pluralistic gender identities. Susan Stryker’s “My Words to Victor Frankenstein Above the Village of Chamounix” [15] provided a reclaiming of the so called ‘monstrosity’ of trans bodies in our exceeding and confounding easy categories of identification, to a transcendental end. Most recently, trans masculinity has been massively moved forward by scholars like C. Riley Snorton.
Frankly, there has been some awkward uptake of such terms by the WPATH SOC; however, these terms have not substantively altered any aspect of the basic triadic recommendations the WPATH has provided since at least the fourth version of the SOC. The WPATH does acknowledge that “some patients may need hormones, a possible change in gender role, but not surgery; others may need a change in gender role along with surgery, but not hormones. In other words, treatment for gender dysphoria has become more individualized” [17]. Regardless, there are still rigid timelines placed on different parts of the process. For instance, in order to receive bottom surgery, patients are still expected to complete twelve months “living in an identity-congruent gender role” as well as spend an equivalent time on hormone therapy. Finally, trans people are still forced to be able to tell a coherent transnormative narrative about ourselves.
An important consideration in the application of an HR framework to gender care in lieu of the triadic process recommended by the WPATH SOC is that it does not run contrary to informed consent models for gender care. There are many people in favour of informed consent models over the WPATH SOC guidelines (despite the dominance of the latter). For instance, Florence Ashley describes how, given that hormone replacement therapy (HRT) has been shown to provide no greater risk than “other medical interventions for which no psychological assessment is required” [1], it actually denies us our epistemic authority over our identities to not be able to freely choose HRT. Given the ways in which my Marlatt-inspired harm reduction model foregrounds collaborative knowledge building exercises and asserting the authority of trans patients over what constitutes harms, an informed consent model as an alternative of the triadic process would need to be taken seriously.
Thank you to an anonymous reviewer for observing that obtaining quality empirical evidence that will be effective in shaping best clinical practice guidelines for trans health care may be extremely difficult. Referencing Deutsch et al. (2016) on the development of guidelines for trans care, the reviewer rightly notes that rigorous qualitative research methods such as RCTs may potentially “violate the principle of equipoise” [4], and therefore may be unethical. For instance, it is unclear that controlling for whether or not trans people receive hormone therapy won’t simply deny trans patients a treatment that has been proven, to a lower degree of confidence, to alleviate gender dysphoria, instead of allow for a state of affairs in which there is genuine uncertainty as to whether the administering of hormone therapy has this effect.
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Gruenewald, A.F. Re-assessing the Triadic Model of Care for Trans Patients Using a Harm-Reduction Approach. Health Care Anal 28, 415–423 (2020). https://doi.org/10.1007/s10728-020-00416-8
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DOI: https://doi.org/10.1007/s10728-020-00416-8