Shifting Standards of Care and Right Relationships

 Back in October I posted a paper on this site exploring the relation between the medicalization of disability (as seen in Eli Claire's Exile & Pride) and the pathologization of transsexuality (as seen in Rachel Ann Heath’s The Praeger Handbook of Transsexuality: Changing Gender to Match Mindset.

(read the full paper here: /exchange/node/11075 )

In The Praeger Handbook of Transsexuality: Changing Gender to Match Mindset a lot of Heath's discussion of the medicalization of disability revolved around the standards of care (SOC), standards written by the World Professional Association for Transgender Health to guide doctors with transsexual patients. The Praeger Handbook was published in 2006 and critiqued the 6th edition of the SOC, published in 2001. It was this critique that I incorporated into my own work.

But right around the same time that I posted my thoughts, something happened that I didn’t know about until later. A new and revised SOC was published.

Here I will attempt to take up where my old argument left off, present some of the changes in the new SOC, and take a look at what the SOC says about the therapist-patient relationship through the lens of John Humbach's “right relationships.” This continuation will hopefully be useful to medical students and professionals who haven’t given much thought to the topic before.

First, some background. The 6th edition of the Standards of Care was published by WPATH (the World Professional Association for Transgender Health) in 2001. The standards of care are a set of guidelines, not laws, which many medical professionals voluntarily looks to for guidance. They are especially important to therapists and doctors who have not had much experience working with transgender clients; there is very little medical training around the subject of transgender health or transition, so these guidelines are very important.

The 2001 SOC included a number of restrictions and barriers to transition. Patients were expected to participate in months of psychotherapy and/or live full time as their identified gender before any surgery. Therapists were positioned as gatekeepers: individuals who wished to physically transition needed an official letter from a therapist in order to do so. In other words, therapists were trusted to “control” access to surgery-- for their clients' own good.

The SOC was widely criticized by members of the trans community therapy for pathologizing language: phrasing that made transsexuality seem like a disease, including the term “gender identity disorder.”

I will cite in full some of the conclusions I drew in my last paper because they are important to this discussion:

When discussing gatekeeping, the exercise of excessive authority by medical professionals over transsexed patients, Heath states only one reason: “With so much pressure placed on gender clinic personnel by eager aspirants for GRS [genital reconstruction surgery], responsibility is required to minimize the regret following GRS. This is undoubtedly the reason for gatekeeping,” (81). However, this conclusion makes no sense. Heath writes later that there are many similar cases—surgeries performed on patients with breast cancer, for example—which are of equal or greater risk, and which simply require informed consent from the patient. Additionally, she asks “why must transsexed people be labeled as “mentally ill” in order to begin their medically supervised transition when we know that the incidence of postoperative regret is so low, even lower than regret rates for breast removal for breast cancer patients?” (190).This question may be rhetorical, but I want to try to answer it.

Transsexuality is, in our society, transgressive. Medical professionals are figures with wide-ranging authority over different types of “abnormal” bodies—the sick, the injured, the disabled. It makes sense that in a society in which transsexed bodies are seen as abnormal, doctors are trusted to oversee the process of transition--- a process continually framed in this book and in general medical discourse as bringing a transsexed person in line with “normality.” In other words, in the pathologized model therapists and doctors work together to “cure” transsexuals by guiding them to a new, nontransgressive way of looking and being, which lines up with their gender identity. The subtitle of Heath's book, “Changing Gender to Match Mindset,” summarizes this process, though “Changing Sex to Match Gender” might be more accurate.

Throughout this book, a huge emphasis is placed on “passing.” Some of the emphasis comes from collected responses of transsexed patients, but much, interestingly, comes from medical figures and guidelines. Heath describes in detail the current standards of care for transsexed patients. These include certain steps, first counseling, then hormone treatment, then at least “a year's real-life experience in the opposite-gender role” (91). Only after this time has been successfully completed and evaluated by two independent professionals can a client receive GRS. This is the normalized path: counseling, hormones, living in a gender role, then surgery. In other words, a client is required to pass (or at least, do their best) for a year before obtaining surgery.

Heath does mention that not everyone follows this path, but also reinforces it as the norm: when certain clients do not wish to pass, and are not interested in surgery, “[t]his situation complicates the evaluation process as many gender clinics assume that, except for medical complications, all accepted clients will eventually progress to GRS,” (92). This narrative of progress, from sex-gender misalignment to sex-gender alignment, mirrors the medical narrative of disability treatment and search for a cure.

…

Heath’s alternative model of transsexuality, as a normal condition requiring some medical assistance, challenges the medical status quo. However, it never engages with the practice that the status quo facilitates: the guiding of individuals into a new socially acceptable role, in which sex aligns with gender so seamlessly that an observer cannot guess at the history, therapy and surgery which are part of the individual he or she sees. Even so, by taking away medical authority to decide who can transition when, she may be opening the door to new paths. In her sincere, well-researched plea to open up a space for marginalized voices to speak, she may be setting professionals and policymakers up to hear answers which no one expected.

In other words, I argue that the old standards of care were intended for other purposes than just avoiding postoperative regret and malpractice suits. They emphasized transition within a binary under an authoritative medical gaze:

Given this argument as background, what are the implications for the new 7th edition SOC?

From www.wpath.com

The new standards of care in many ways answer this call for a new, non-pathologized framing of transgender individuals. According to The Bilerico Project, which reported on the change right after the new standards of care were published, “this newest SOC represents significant forward progress in respecting trans people and affirming the necessity of medical transition care for trans and transsexual individuals who need it.”

-Read the rest here: http://www.bilerico.com/2011/09/new_standards_of_care_for_the_health_of_trans_peop.php

They go over some specific changes. In the ethics section WPATH denounces gender conversion therapy as cruel and unsuccessful. It also attempts to use the language of difference, rather than disease, throughout, explicitly stating

“transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available.” (SOC 7th ed)

The SOC also no longer supports the many time-consuming restrictions that had been routine. In general, this shows a shift from the role of therapist as gatekeeper to a model of informed consent,.

These new standards seem to frame the therapist as a facilitator rather than a gatekeeper. Specifically, there has been “Removal of the three month requirement for either "real life experience" (living in a congruent gender role) or psychotherapy before access to hormonal care.” http://www.bilerico.com/2011/09/new_standards_of_care_for_the_health_of_trans_peop.php

You can read the newest SOC in full here:

http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

Now I want to explore how the new SOC opens up a space for “right relationships” between therapists and transgender clients.

The idea of a “right relationship” comes from an essay by John A. Humbach called “Towards a Natural Justice of Right Relationships.” You can read the full essay here: http://www.restorativejustice.org/articlesdb/articles/2894

I've also written about right relationships on Serendip before in my project Communal Clarity: Making Sense of Media, which you can read here: /exchange/node/11432

In his essay, Humbach is exploring a new way of looking at justice. He argues that the concept of legal rights, applied in exactly the same way to everyone, is only one part of a just world. Rather than only thinking about justice in terms of these individual rights, we should also consider the importance of right relationships. According to Humbach,

Right relationships are human relations in which each (or all) seek, without abandoning themselves, to be attentive and responsive to the needs and emotions of one another, quite apart from considerations of entitlement. There are also several important 'negative' markers of right relationships, namely that they must be free of systematic oppression, exploitation or manipulation (2).

To me, 6th edition SOC was a form of systematic oppression: though intended as flexible guidelines, professionals who regarded them as hard-and-fast rules could easily damage their relationships with their clients. Why?

Because the old SOC framed transgender clients as disordered patients and therapists as experts who could evaluate and prescribe or deny treatment. This is not a good framework to build a right relationship, particularly when many clients didn't see themselves that way at all.

It isn't that there can never be a right relationship between an authoritative doctor and a sick patient. It's more that there cannot be a relationship in which a client who is not sick must convince the doctor that he or she is sick to get the help that he or she needs. This sort of dishonesty was nearly a requirement under the old SOC: if a transgender client protested that they were not sick, then they did not fit into the framework at all.

Humbach does not go into how an ideal right relationship can form between two people with a significant power imbalance. However, nothing in his framework rules out the possibility. He notes that

A tit-for-tat reciprocity of entitlement is characteristic of the justice of rights but not the justice of right relationships. Rather, the reciprocity of right relationships needs go no further than the mutual and effective commitments of both (all) members to one another (3).

This is important, because uneven relationships are common in everyday life-- between parent and child, student and teacher, doctor and patient. I believe that many of our relationships include a power imbalance of some kind, which can shift over time. I also think that the new SOC attempts to guide therapist and client into right relationships, in contrast with the old standards of care which set up a situation in which it was more difficult for this kind of relationship to form.

It matters a lot here that the new SOC rejects the language of pathologization, putting professionals and transgender clients on a more equal footing from the start. It also advises against gender conversion therapies, which seem completely against the ideal of a reciprocal right relationship.

But most importantly, therapy is no longer a lengthy and expensive requirement before surgery. Instead, the new SOC advises for psychotherapy when the client wants help with gender dysphoria, “painful distress with one's current physical sex characteristics or assigned or ascribed social gender role” (http://www.bilerico.com/2011/09/new_standards_of_care_for_the_health_of_trans_peop.php)

In other words, the client choose whether or not to undergo therapy. It's difficult to imagine a right relationship forming where one (or both) of the people involved doesn't want to be there.

Rights relationships are by their nature difficult to qualify and quantify-- their flexibility is what sets them apart from legal rights. And it's hard for me to quantify exactly how the new SOC will influence the relationships between transgender clients, therapists, and doctors, right or not. But it's hard to see this as anything other than the step in the right direction. To me it seems that the changed role of the therapist (from “mandated gatekeeper” to “voluntary facilitator”) will definitely lead to more honesty and flexibility in therapy. And how can that not be more right?