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A Look at the WPATH Standards of Care (2011)

A Look at the WPATH Standards of Care (2011)

©2011 by Dallas Denny

Source: Dallas Denny. (2011, 19 September). A look at the WPATH Standards of Care. TG Forum.


TG Forum Version



I have mixed feelings about the Standards of Care of the World Professional Association for Transgender Health. I always have. I probably always will. And yet I fully support them.


Read the Standards of Care


My biggest reservation has to do with the restrictions the Standards place on people seeking hormonal and surgical interventions to change their bodies —not because they serve a gate-keeping function (which they certainly do), but because the same procedures are generally available to non-transsexual and non-transgendered people without checks, without balance, without gate-keeping.

Any woman can have her breasts augmented or reduced without having to obtain a letter from a therapist or jump other hurdles, and any man with gynecomastia can have his chest flattened—and yet transmen can’t. While the current Standards acknowledge the free availability of such breast surgeries to the general public, they state:

Female-to-male patients may have surgery at the same time they begin hormones. For male-to-female patients, augmentation mammaplasty may be performed if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormone treatment for 18 months is not sufficient for comfort in the social gender role.

– Version VI, p. 19

Now, it makes perfect sense for a transsexual woman to hold off on augmentation mammaplasty until hormones have a chance to do their work. In most cases natural breast growth will suffice; the woman won’t bother with surgery—and if she does, the outcome will be better, her dimensions unlikely to be changed by new growth. Non-transsexual women seeking augmentation already have mature breasts. So it makes sense. But as for the sentence about FTMs? Maybe not so much. There are millions of flat-chested women, and they live as women without having to obtain the approval of a therapist, and certainly without taking male hormones.

This calls to mind a number of problems I have with the Standards of Care. The first is this: transsexual men receive short thrift. The Standards don’t quite give them equal consideration. Certainly the Standards have come a long way, but in my opinion FTMs don’t quite yet have parity. I expect this to be remedied, or perhaps almost remedied, in Version VII, now in preparation.

My second problem with the Standards is they’re largely limited to the medical and psychological perspectives of the West. While the Standards draw upon the international ICD-10 as well as the American DSM, many non-Western countries have entirely different mental health systems and categories of helping professionals with no equivalent in the U.S. For instance, while the Islamic Republic of Iran does have psychiatrists, psychologists, and social workers, an assessment of the country’s mental health services by The World Health Organization reveals the majority of services are carried out by individuals with titles like behvarzes (multipurpose health workers) and professional and paraprofessional psychosocial counselors.

Happily, WPATH has moved away from defining mental health professionals by licensure (psychiatrist, psychologist, social worker) or requiring terminal degrees like Ph.D.s, but it’s difficult to know the equivalent of a master’s level psychologist or clinical social worker in a place like Rwanda, where advanced degrees are rare indeed.

This brings to mind a third problem— issues of class. How can marginalized people, unemployed and homeless, perhaps, afford expensive mental health services? Answer: they can’t. This quite frankly translates to the Standards being an avenue for middle- and upper-class transsexuals to buy their way through transition. Those without money or access to therapy that will lead to authorization letters for surgery either do without or seek dangerous treatment on the black market.

And then there’s the big problem. By their very nature the Standards single out transsexuals and other gender-variant people, restricting our ability to obtain the medical treatment we need to change our bodies while giving the green light to those who aren’t transsexual. It’s akin to the concept of autogynephilia, which pathologizes male-to-female transsexuals for their sexual feelings while claiming other categories of people with the same feelings —women, for instance—are for some secret reason exempt. I call bullshit on that.

If the desire to change one’s body by medical means is no longer in and of itself considered psychopathological, we’re left with an elephant in the living room: Why impose barriers to health care only on transsexual and transgendered people? Why not either set the same barriers for all populations or else drop them altogether?

Having worked with thousands of transsexuals just at that point where they’re about to explode from decades of repressing their feeling, I know for a fact the Standards of Care are a lifesaver. They provide a road map, replacing confusion and frustration with a clear path to transition. And I’m certainly not the only one who has seen that. In fact, that’s what the Standards are all about—clinical judgment that they lead to better outcomes for transsexuals. For more than 30 years the Standards have, in the estimation of almost everyone who works in the field, been of enormous benefit to transsexuals and professionals alike.

But is clinical judgment enough? Can an organization in good conscience limit access to medical treatment to a specific population and that population based only on its collective judgment? And if it’s all right to do so initially, is it okay to do so forever? Isn’t it critical to develop empirical data to demonstrate the effectiveness of the practice? And don’t those who find themselves singled out for special restrictions deserve those restrictions to be based upon science and not belief? I think they do.

I don’t have access to recent issues of WPATH’s International Journal of Transgenderism, but I can say that to my knowledge there have been no studies of the effect of the Standards of Care on outcome. Zero! Nada! None! I called this to the attention of then-HBIGDA more than ten years ago, but seemingly there has been no action.

I have to say that despite the wonderful things WPATH has done and is doing. the organization is remiss for not formulating an empirical basis for restricting access to medical care.

Those are my issues with the Standards. All but the last have been or are being addressed. WPATH has come a long way toward providing parity for FTMs, addressing third-world issues, and looking at issues of social class and income.

And WPATH has done so much that’s right!

The organization took a huge step more than ten years ago when it decided to apply the standards not only to transsexuals, but to other transgendered people seeking hormonal and surgical medical treatment. This was a game-changer for the organization, which has since flourished.

WPATH took another huge step forward when transgendered and transsexual people began assuming leadership roles. A number of us were members of the Version VI committee or were, like myself, advisors to it. Transman Stephen Whittle recently served as President, and another transman, Jamison Green, is President-Elect. That’s inspiring!

WPATH has done much to avoid the pejorative, pathologizing language of the XXth century, replacing it with new terminology—but as hard as the organization has worked and is working to modernize the Standards, we’re not yet all the way out of the swamp. Terminology is changing rapidly, and there’s just no way standards which are revised only once every ten or so years can keep up.

This change in usage clearly shows in the professional literature—not only in the language used in the titles and bodies of the papers, but in the research questions that are asked. With the exception of the autogynephilia researchers, most articles focus on practical matters and healthy models instead of objectifying us.

The Standards, born at a time when transsexuals were almost universally considered mentally ill, were devised as a path out of ignorance and subjectivism, and as such have been of immense value by marking a clear path to transition. I enthusiastically support them and I hope you will too.