Transgender models of care

A model of care is a way to give people healthcare. Models of care control:

• who gets healthcare
• when it is done
• how it is done

This site is based on a harm reduction model that promotes the informed consent model for adults and the affirmative care model for youth.

Models for adults

Informed consent

• Most trans healthcare for adults is now is done by informed consent. The doctor tells you the good things and bad things about what you want to do:
  • risks (things that could go wrong or complications)
  • burdens (things you may have to deal with after)
  • benefits you may get
• You sign a form that says you understand. Then you can get what you want done.
• For example, transgender bottom surgery changes your body so you can never make children after surgery. Your doctor tells you this plus any complications that might happen. You must sign a paper that says you know the risks and want to do it anyway. Then you can get the surgery.

Consensus standards

• In the 20th century, the most common model was the Standards of Care published by the World Professional Association for Transgender Health. Version 1 was drafted in 1979, when the organization was known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). In 2006, HBIGDA changed their name to WPATH, and in 2012, WPATH published Version 7 of their Standards of Care.
• This model is sometimes called the “psychiatric clearance” model.
• It is sometimes referred to as “gatekeeping.”

Models for children and adolescents

Affirmative models

• In this model, young people who identify or express their gender differently than expected are allowed to be themselves. Adults allow them to explore their gender identity and expression. In some cases the children are allowed to make a social transition. Studies show that this helps young people do better, whether or not they make another social transition later or go on to take medical or legal steps.

Non-affirmative models

• Some people believe that being transgender is bad. They try to stop young children from being themselves. These experts believe that if they discourage young children from being themselves, the children will not make a gender transition.
  • Gender identity change efforts (GICE)
  • Reparative therapy
  • Conversion therapy
• Some people believe that delaying healthcare by requiring a lot of therapy will allow them to separate the “real” or “true” trans youth from those they do not consider deserving of healthcare. This non-affirming model has several names:
  • Watchful waiting
  • Gender exploratory therapy
• Dozens of organizations oppose non-affirming models, including the American Medical Association (AMA) and the American Academy of Pediatrics (AAP). In some places, this model is against the law.
• The AAP, ACOP, and HRC stated in 2016: “Reparative therapy attempts to ‘correct’ gender-expansive behaviors, while delayed transition prohibits gender transition until a child reaches adolescence or even older, regardless of their gender dysphoria symptoms,” the 2016 document reads. “While researchers have much to learn about gender-expansive and transgender children, there is evidence that both reparative therapy and delayed transition can have serious negative consequences for children.”

Other models of care

Harm reduction model

• The goal in this model is to reduce the chances someone might hurt or kill themselves. For instance, if someone is going to use illegal injected silicone, this model tells them how to lower the chances they will be disfigured, get sick, or die.

Background

In the past, trans healthcare was often hard to get because of standards of care. The rules were made to keep people from making a bad choice about transition. They also helped others see that transgender healthcare was not “experimental.” But they also helped doctors and others who did not want a lawsuit from transgender people. They were often used to stop trans people from getting medical care that they wanted.

Early Standards of Care models strictly controlled approval for the so-called “triadic therapy”:

• Real-life experience
• Hormones
• Genital surgery

For example, one standard of care used to make transgender people wait two years after their gender transition to get surgery. We also had to get letters from two therapists saying it was OK for us to get surgery. Some clinics turned away 90% of trans people. Imagine a cancer clinic doing that! Many of us thought the rules were not fair. We worked hard to change the rules.

By the 1990s, many trans people did not like the Harry Benjamin Standards of Care, a consensus standard used by many doctors. Lawyer Phyllis Randolph Frye led the trans organization that wrote an important informed consent model. On September 15, 1993 the International Conference on Transgender Law and Employment Policy (ICTLEP) adopted Health Law Standards of Care for Transsexualism. Drafted by Martine Rothblatt and revised by a committee led by Spencer Bergstedt, it was adopted by many doctors, especially endocrinologists and surgeons performing facial gender confirmation surgery.

Numerous informed consent models have been written and used since then. As an example, the Howard Brown Medical Center in Chicago, which provides health services to the LGBT community, has a program called THInC (Trans Hormones – Informed Consent), created in 2010 to allow trans people to bypass costly and time-consuming therapy required under certain providers.

As more and more trans people opt for these informed consent programs, standards of care will continue to decline in importance. In the meantime, you may need to follow them in order to receive services from some providers.

Ritual document

Some (myself included) consider standards of care a “ritual document” with little clinical usefulness. I believe its primary purposes are to protect health care service providers from litigation and to legitimize access to transgender health care by medicalizing gender variance.

References

Cavanaugh T, Hopwood R, Lambert C (2016). Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients. AMA J Ethics. 2016;18(11):1147-1155. https://doi.org/10.1001/journalofethics.2016.18.11.sect1-1611

Schulz S (2018). The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria. Journal of Humanistic Psychology https://doi.org/10.1177/0022167817745217

Levine SB (2019). Informed Consent for Transgendered Patients. Sex Marital Ther. 2019;45(3):218-229. Epub 2018 Dec 22. https://doi.org/10.1080/0092623X.2018.1518885

Resources

WPATH (wpath.org)

• Standards of Care Version Seven (PDF)
• The 2011 version is a significant improvement, particularly in de-emphasizing the “triadic therapies” and in its dealing with adolescents. Available in many languages

GIRES (gires.org.uk)

• Gender Identity Research & Education Society (UK)
• Informed Consent Forms

Phyllis Randolph Frye (transgenderlegal.com)

• Archive of ICTLEP’s 1993 Health Law Standards of Care for Transsexualism

ICATH (icath.info)

• Informed Consent for Access to Transgender Health (not a formal organization)
• Also icath.org via radianthealthcenter.info