Abstract
To depathologize transgender (trans) healthcare, revisions have been made to two documents used in the treatment of trans people. First, the 7th Version of the Standards of Care (SOC-7) removed a lengthy therapeutic relationship and real-life experience (RLE), replacing these with a gender assessment. The second was a shift in language from Gender Identity Disorder to Gender Dysphoria in the 5th Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), as well as its removal from the chapter on ‘sexual dysfunctions and paraphilias’. Despite changes, trans healthcare remains stigmatizing and gatekept. Through qualitative interviews with 20 U.S.-based health professionals, we expand current knowledge of the shifting treatment approaches for those seeking gender-affirming medical services. Data show that despite progressive document changes, providers continue to place the burden on patients to fit within a sex/gender dichotomous system and to prove mental stability and decision-making competency to access what are increasingly considered life-saving treatments. We illuminate resultant health disparities that can emerge when providers perceive trans people in need of their education and mental health support and advocate a move away from the current medicalized process towards a healthcare model situated in trans peoples' own lived experience.
Reflexive Statements
Having studied medical and therapeutic decision-making with transgender people seeking gender-affirming services since 2008, Dr. Jodie M. Dewey is committed to using research to address inequities experienced by transgender people. More than adopting methodologies to give voice to those silenced and ignored with the goal of eliminating inequities in health care, Dr. Dewey envisions reshaping evaluation and research strategies that honor the humanity and autonomy of trans people to live a self-directed and empowered life.
Ellie believes that trans healthcare is a fundamental human right and that trans people are experts of their own experiences. As a non-binary, trans person in academia, they are committed to ensuring that trans people have the opportunity to speak about their own lives within both academic and policy-making spheres. Ellie would like to move away from a world of trans healthcare and policy where trans people are spoken for rather than to. They want to produce work that reveals the social, historical, and political dynamics underlying legal and healthcare systems, and which demonstrates that these systems are not purely based on the 'objective' science and reason they are purported to be based upon. Ellie hopes to use their privilege as a white, middle-class person to do work that performs this function.
As a sociologist and health services researcher, Dr. Dennis P. Watson has a strong interest in how the social construction of medical diagnoses impact treatment processes and associated outcomes. A particular area of concern for him is how medical categories impact health disparities and equity at a societal level.
Introduction
Transgender (trans) medicine is a burgeoning and relatively new field. Its purpose is to assist individuals who are ‘transgender’/‘trans’, a self-applied term that denotes that one’s gender identity does not match the sex they were assigned at birth (Eustaquio et al. 2022). While not all who identify as trans seek out medical intervention, those who do confront several challenges in accessing hormones and gender-affirming surgeries. About 0.6% of the U.S. population identifies as transgender, with about 11% of medical encounters resulting in gender-affirming surgery. In fact, 9,576 gender-affirmation surgeries were performed in 2018 with the number increasingly rising due to changes in insurance, medical associations’ shift to deem such treatment as ‘medically necessary’, and an overall social acceptance of trans people (Nutt 2018). In trans health medicine, there is considerable international push-back within the activist community to remove the control psychiatry and medicine have on gender interpretation and expression. This control is thought to aid the pathologization and medicalization of normal variation, resulting in nonmedical and nonpsychiatric concerns becoming defined and ‘treated’ (Cannoot 2019; Conrad 1992). Further, there is minimal agreement about how to treat patients, a lack of evidence-based approaches, little to no formal training, and a limited number of professionals equipped or willing to provide treatment (Dewey and Gesbeck 2015). What does exist are two types of documents that impact how medical and mental health workers respond to trans-identified people who request their assistance: The World Professional Association of Transgender Health’s (WPATH) Standards of Care (SOC) (Coleman et al. 2011), which are clinical guidelines for treating trans people, hormonally, emotionally, and medically, and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA 2000) which is used to identify and diagnose Gender Dysphoria and other mental and behavioral health disorders. As living documents, both the SOC and DSM are continually revised and updated to reflect best practices in this quickly changing medical landscape. What is notable here is that work groups often describe changes as an effort to remove barriers to treatment access and as a step to depathologize trans identities. Despite the perception of progressiveness in practice, the evolving logic within trans medicine continue to sustain our dichotomous understanding of gender and narrow its possibilities.
How professionals understand and apply trans healthcare tools displays both the complexity of their work in treating trans people, as well as the factors that impact treatment responses. By investigating the process through which health professionals make treatment decisions with trans individuals seeking treatment, we can elucidate the scientific and cultural logic that drives care, and in turn, investigate how treatment decisions perpetuate and challenge broader anxieties about (trans) gender identities and care access. Furthermore, it allows us to explore cultural understandings of the relationship between sex and gender, with provider decision-making resulting from and setting the foundational logic on the relationship between sex and gender. With the recent release of the 8th revision to the SOC and the recent release of the DSM-5 text revision (TR), research considering their application is particularly urgent. Like previous updates, these revisions will be at the forefront of trans health, forever shaping medical and therapeutic decision-making and the very logic of how trans people, and gender more broadly, are understood.
This article presents findings from qualitative interviews conducted with 20 U.S.-practicing medical and mental health professionals. The goal of these interviews was to explore how providers make sense of their role in treating trans people who seek medical technologies. This was accomplished through an examination of how they perceived their role in treating this patient population, how they understood previous changes in the SOC-7 and DSM-5, and how they believed it impacted their treatment decisions. Findings show that despite a depathologizing shift in document language, the practice of treating continues to place the burden on trans individuals to prove they are mentally stable, competent decision-makers who fit within the existing dichotomous sex/gender system. We argue in the discussion that despite document changes that claim to demedicalize and depathologize treatment, providers continue to dole out services at a pace in which they are comfortable and therefore, little has shifted in the practice of treating this patient population. Further, through treatment decisions, providers strengthen a naturalistic framework that biologizes gender and conflates trans identity with mental illness, constructing trans people as inherently problematic and, justifying their continued regulation. This regulation forces trans people to participate in the very ideology, or transnormativity that negatively governs their lives outside of the medical and therapeutic context.
Literature Review
History of Professional Regulation in Trans Healthcare
The Diagnostic Statistical Manual (DSM) is a document created by the American Psychiatric Association (APA). Claiming the International Classification of Diseases (ICD) developed by the World Health Organization lacked empirical evidence, the APA developed the DSM to establish diagnostic uniformity for professionals (Dewey and Gesbeck 2015). Transsexualism, the first diagnostic term used, appeared in the 1980 release of the DSM-III. Trans identities, however, existed before they were codified as a mental illness in the DSM (Stryker 2008). The diagnostic criteria and language around transness have shifted, reflecting different perspectives over time (See Dewey and Gesbeck 2015). In current treatment approaches, one must be diagnosed with Gender Dysphoria, the recent term to access gender-affirming care, such as hormones and surgeries.
In a move to depathologize trans identity in the DSM-5, APA renamed the diagnosis from Gender Identity Disorder (GID) to Gender Dysphoria (GD), with the idea that GD emphasized the distress associated with the mismatch between sex assigned at birth and gender identity, rather than labeling all trans people disordered (APA 2022). In attempts to destigmatize, APA also removed the diagnostic label from the section on Sexual Dysfunction and Paraphilic Disorders to decouple gender identity from sexual deviance.
WPATH and SOC
Emerging in 1979, WPATH, formerly the Harry Benjamin International Gender Dysphoria Association, has grown into the international leader in the medical and therapeutic treatment of trans people. Loosely originating from the ideas of its namesake, this all-professional, U.S.-based group hoped to combine their experiences into a formalized and standardized system of treating trans people (Coleman 2009). While its inception saw no input from those who identified as trans, it slowly evolved to include trans people, professional and non-professional. Though the current WPATH president is a trans-identified medical professional, WPATH is built and mostly shaped by Western, white, and cis-male views of gender and health (see wpath.org).
WPATH’s SOC are clinical guidelines utilized in the treatment of trans people seeking transition-related medical assistance, such as the acquisition of gender-affirming hormones and surgeries (Meyer et al. 2002). The SOC are intended to be flexible and are presented as guidelines that can be modified based on the discretion of health professionals. While various changes developed with each new revision (See Dewey and Gesbeck 2015), the SOC-7 contained the most significant changes. SOC-7 saw the role of the professional change from evaluating and treating a disorder to assisting people improve their well-being and reduce harm (Selvaggi et al. 2012). SOC-7 also saw the removal of the need for a formal diagnosis of GD for every individual presenting with gender concerns. However, the function of this is unclear given that SOC-7 still specifies ‘persistent, well-documented gender dysphoria’ (2011:34, 59, 60) as a criterion for receiving all hormone therapy and for all surgeries. Another key change was the removal of the requirement of real-life experience (RLE), a period of time in which a trans person needed to live full-time in their identified gender role. Under SOC-7, individuals no longer required RLE to access hormone replacement therapy (HRT) or breast/chest surgery. However, individuals still required 12 months of RLE to access any genital surgeries (p. 106). Where SOC-6 had required psychotherapy prior to HRT or surgery if the individual did not have 3 months of RLE, SOC-7 removed the requirement for psychotherapy (Selvaggi et al. 2012). Under SOC-6, for those that required psychotherapy, the psychotherapeutic relationship culminated in a recommendation letter that was required by physicians and surgeons prior to administering hormones or surgeries. Instead of a letter following a psychotherapeutic relationship, under SOC-7 someone seeking these treatments could provide a referral letter or multiple referral letters as required for some treatments, from any mental health professional or health professional trained in behavioral health and competent in assessing GD. Under SOC-7, this letter must include a psychosocial assessment. The psychosocial assessment (what many call a ‘gender assessment’) requires providers have ‘the knowledge and experience to assess gender dysphoria’ which can be ‘a mental health professional or by an appropriately trained prescribing provider’ (2011:35). Further, despite the removal of a long-term therapeutic relationship, the SOC-7 advises a complete approach to health care that includes ‘regular communication among health professionals’ (2011:41).
These changes shifted the burden of care to the provider, removing the expectation that those seeking treatment would have to prove the existence of a gender identity different from that assigned at birth to access services with psychotherapy and RLE. Although these shifts in trans health appear progressive, medical and mental health providers continue gatekeeping gender-affirming services in a manner that regulates trans people’s bodies. In ‘treating’ gender, they sustain a rigid gender dichotomy (Fausto-Sterling 2000; Herling 2020, Shuster 2021), while controlling the tools to confer the legitimacy needed to successfully navigate many areas of life. Whether one desires medical interventions or not, proof of successfully navigating the medical and mental health field, especially in accessing hormones and surgeries, supports a system of tautological reasoning that establishes ‘legitimacy‘ of one’s gender and is needed to take further steps such as changing one’s name (Meadow 2010; Spade 2003). These ‘projects of excavation’, as defined by Meadows, enable ‘experts’ in legal, education, and medical spaces to ‘enumerate constellations of bodily and psychological indicia’ that continue to regulate why some gender markers matter more than others (Meadow 2010). Medical decisions are not just situationally regulatory but are what Johnson calls ‘conduits of transnormativity, a regulatory normative ideology that structures interactions in every arena of social life’ (Johnson 2016:466). Medicine names itself as the authority on trans health, controlling what constitutes evidence that informs knowledge production and ‘best’ practices in this field. Further, its authority and continual regulation of gender eliminate the possibility of diverse and expansive logic that moves beyond male/female and cis/trans identities (Darwin 2020).
Informed Consent Models
In the hope of depathologizing trans care, international trans activists have called for increased transparency in medical decision-making, the removal of gender diagnostic codes from the DSM, and a treatment model that focuses on informed consent rather than a psychiatric-driven assessment process (Schwend 2020). This model seeks to support the trans person’s right to make autonomous care choices. Under informed consent models, medical providers communicate the risks and benefits of interventions. The individual seeking treatment must have the capacity to understand and weigh up this information and where this is not the case a different model of care should be pursued (Cavanaugh, Hopwood, and Lambert 2016). Informed consent models do not remove the role of the medical professional or remove the requirement to discuss mental health and well-being. Instead, the clinician explores the potential psychosocial and life impacts of the intervention with the individual, allowing the individual to consider these and make the final decision. This approach recognizes that the individual seeking treatment is best placed to understand their own experiences and to decide which actions would be most beneficial to their lives. It is argued that an informed consent model may also improve the quality of the therapeutic relationship between the practitioner and the person seeking intervention as the perception of the professional as a gatekeeper may not develop (Cavanaugh, Hopwood, and Lambert 2016).
Lack of Trans Voices in Logic System Development
Neither the inception of SOC-7 nor DSM-5 extensively involved trans people and their families. During the inception of DSM-5, APA’s workgroup provided a website through which members of the public could view APA’s developments and comment by way of a survey administered to organizations concerned with trans peoples’ welfare (Duschinsky and Mottier 2016; Vance et al. 2010). However, it is unclear how the APA interpreted and used the input that derived from the workgroup, which consisted solely of cisgender sexologists and clinicians.
To elicit SOC-7 development input, WPATH leadership sent email to all full members requesting input on working sections of the document. Full membership is only allowed for those who are ‘professionals working in disciplines such as medicine, psychology, law, social work, counseling, psychotherapy, nursing, family studies, sociology, anthropology, speech and voice therapy and sexology’ (wpath.org). The professional requirement, along with the hefty $225 yearly membership fee excludes most members of the trans community. Further, previous work groups chosen to take part in document revisions required membership based on one’s status as a professional within a network of other professionals, as one had to form their own group prior to applying. There was an attempt to specifically elicit input from trans people through an eight-member International Advisory Council appointed by the board; however, it only provided feedback to the final draft (Coleman et al. 2011). One study participant shared his thought about the lack of trans voice while attending the yearly WPATH symposium: I wish there was more dialogue with that group of people [(trans providers)]….and why aren’t more transgender in the leadership of WPATH? So, I think we need to hear more voices loudly from transgender community to help in the direction of the next DSM and the next WPATH Standards of Care.
Trans activists also push back on the lack of inclusion of trans voices in trans healthcare, stating that psychologists, psychiatrists, and sexologists do not speak for them. Ruby Ryan (2009) states: We demand that we are the best experts on our own lives and experiences, and we deserve a place at the table for any policy decision which involves our lives. As the disability rights movement has often said: nothing about us, without us. And as we gain more cultural and intellectual capital, there are more and more of us with the same fancy titles and letters after our names as the experts who still attempt to colonize our lives. Alice Dreger, Michael Bailey, Kenneth Zucker, Ray Blanchard et al..: You do not speak for me, nor do you speak for the vast majority of transgender and intersex people that I know and love. Furthermore, I am not sure that you understand that you are making it harder for people like me to navigate the world through the work you are doing.
The inclusion of trans people to develop ethical care is a pathway to depathologization, a stance increasingly supported by international human rights activists (Schwend 2020). Further, by eliciting and normalizing the actual diverse experiences of trans people seeking services, we can eliminate the need for contrived, universal ‘transgender narratives’, something that perpetuates gender/transgender dichotomies (Darwin 2020) and inhibits the trusting medical and therapeutic relationship desired by both provider and patient (Dewey 2008).
The Current Study
The debates set out above lay the foundations of the current landscape of trans healthcare - a system still divided between those who demand a demedicalized, straightforward process of gender recognition based on self-identification, and those who desire to retain or tighten the current medicalized gender recognition model. Despite calls for the former, today’s guidelines follow the same basic medicalized focus of the 1979 SOC. Tight controls on gender-affirming healthcare result in overwhelming obstacles at various points of care access. The failures and strains of the trans healthcare system - as informed by the views of WPATH and its members and APA’s Workgroups-have considerable global impacts on trans communities. To better understand challenges to treatment access, we must better comprehend the logic underpinning provider decisions.
This paper seeks to explore how treatment providers understand their role in delivering trans medicine, how they interpret recent revisions to the SOC-7 and DSM-5, and how these changes impact their decision-making process with those individuals seeking medical care. We hope that by investigating the decision-making process, we will shed light on whether the goal of depathologization, as intended by recent document revisions, are met within the process of treating trans people. To explore this, we will present data based on qualitative interviews with 20 U.S.-practicing medical and mental health professionals.
Methods
This study followed a qualitative grounded theory approach. Grounded Theory is an emergent theory that allows for the iterative process of collecting, coding, and analyzing data to deepen the researcher understanding of participants’ experiences which allows interviewees the time to fully explain the treatment process and their role in it (Charmaz 2014). Qualitative research allows a deep exploration of uncommon practices and complex processes, especially among a population in which a paucity of research exists. Qualitative methods are ideal due to the scarcity of professionals who treat trans people – a result of the relative newness of the field, perceived liability associated with treating trans people, and the professional stigma that exists. The first author is a member of WPATH and has over 15 years of experience studying the medicalization of trans patients from both the perspective of trans people and doctors and therapists. Grounded theory was also used to shape the research process.
Sample and Data Collection
Data are from 20 semi-structured interviews conducted with U.S.-practicing medical and mental health providers who treat trans people. As a small and dispersed provider group, it was useful to pull the sample from WPATH membership, and therefore, all interviewees were listed on the WPATH member directory. Of the sample of 20 providers, half described themselves as medical providers while the other half worked in the mental health field. We group psychiatrists with mental health professionals, rather than other medical doctors, as this is more reflective of their role in gender-affirming healthcare delivery. About 50% of interviewees worked in private practice with the remaining employed by hospitals and/or universities. Years treating this patient group range between 3-46 years with only two indicating that they had received some type of formal course specific to trans health. Only 2 providers identified as trans with an additional 6 who identified as members of the LGBTQ community.
With approval from the organization and as a member, the first author was able to access provider contact information from the WPATH website. Only U.S. providers were included to adequately perform a comparative analysis as the cultural, political, and health systems vary across the global landscape. Interviews were conducted by the first author in 2015, a few years after the release of the SOC-7 and 2 years after the publication of the DSM-5. Interviews averaged 1.5 hours and were recorded and transcribed. Participants were asked several questions about their treatment approaches, perception of role and goals in treatment plans, and broader understanding of gender. They were also asked about their understanding of the recent changes to the SOC and DSM, the ways they incorporate these documents into their treatment approaches, and recommendations for future revisions. This project was conducted with institutional review board approval. To protect the identity of this otherwise small treatment community, all participants were given pseudonyms and professional titles were categorized into general categories.
Data Analysis
Data analysis occurred in various stages (Strauss and Corbin 1998). Beginning with line-by-line (open) coding, the author identified elemental issues and concerns in treating trans people. Then, the first author conducted focused, or axial, coding by isolating provider perception and idiosyncratic uses of the DSM and SOC. A coding scheme was developed from this practice and created in MAXQDA, a qualitative data organization, and analysis software program, where detailed, or selective, focused coding was undertaken. Codes and subcodes were created and compared across each practitioner until themes appeared and were repeated. Nuances that occurred were illuminated to show variances in decision-making. Summaries of these themes were created utilizing the context and backstory given by each provider. Coding was performed throughout the interviewing process so that when new themes emerged, they could be addressed and further explored in future interviews (Charmaz 2014).
Findings
Analysis process resulted in three main themes. Data reflect self-description of their treatment role, their clinical understanding of the DSM and SOC and their impact on their treatment decisions, and their understanding of the ‘gender assessment’. When parenthetically displaying a provider’s professional experience below, we refer specifically to the years for which they have provided trans healthcare services.
Perception of Treatment Role
Medical and mental health professionals often discussed the need for multiple roles to effectively treat trans people. Their descriptions fell within three general themes we call the (a) educator and guide, (b) stabilizer, and (c) assessor.
The educator and guide
Interviewees who described themselves as an educator or guide explained their role in terms of delivering needed information so patients could make informed decisions and transition safely. Guidance that Gail (social worker, 20 years’ experience) provided was focused on helping patients self-define what they desire of their life, with this initial work helping to set the course of treatment. Also, a self-described guide, Kathy (physician, 7 years’ experience) stated, ‘I’m like the person who helps carry your bags as [you] go through the jungle. And maybe sometimes pull out the map’. She went on to explain that she offered ‘suggestions’ as both an advocate and teacher. She explained that to prevent patients from becoming victims of poor care, she connected them with competent professionals who ‘will treat them with respect and dignity’, helping to avoid those ‘that might be nasty’. Part of her effort to ‘pave the way for people’. For example, in one case she contacted a doctor to let him know that the woman patient she was sending to him would have a penis and used she/her pronouns.
Participants saw themselves as educating patients about the medical and social challenges of transitioning. Sarah (physician, 6 years’ experience) provided knowledge on risks and benefits of medical interventions and troubleshooting potential side effects. Similarly, Joseph (physician, 15 years’ experience) assisted patients to consider surgical complications and how they planned to manage post-surgery responsibilities. Pediatrician Cassie (physician, 13 years’ experience) stated that her role is ‘to provide the medical help that they need to actualize who they think they are.’ She then explained that she desires to meet whatever goal patients have: ‘if someone wants full virilization (i.e. development of masculine traits through hormones) my goal is to fully virilize them, safely.’ Elaborating on the non-medical work she undertook, Gail (social worker, 20 years’ experience) explained that she may have to educate patients by giving them attorney referrals to assist with coming out at work, changing their name and identification documents, such as their social security, license, and birth certificate, anything she believes may ‘stand in their way of being grounded and healthy’, a goal that falls under the next theme, the stabilizer.
The stabilizer
Whether medical providers felt competent to address the social aspect of transitioning or not, all felt therapy was required for a stable transition. Several providers spoke about their role in this stabilization process. For some, stabilizing meant dealing with other mental health issues. Sarah (physician, 6 years’ experience) stated that she administers hormone therapy but that she also provides counseling. She stated: Family medicine is a huge percentage of counseling psychiatric conditions…navigating their psych issues, depression or anxiety and helping them with that. I end up being a counselor for their life as well because they can’t afford counselors and we talk about life issues or parents not understanding what the transition is or violence they have experienced.
Lilly (social worker, 20 years’ experience) stated her primary role among many was to listen and help with self-esteem work, especially by assisting patients to unravel childhood trauma they experienced for being trans. Although indicating that he himself did not want to be responsible for the social change he believes is needed to successfully transition, Max (physician, 24 years’ experience) required his patients to work with ‘a handful of therapists’ to ensure they ‘are better prepared’ because he preferred that patients were referred to him by a therapist that had already helped them with the ‘social transition piece’. Joseph’s (physician, 15 years’ experience) main goal was to treat patients with ‘kindness and respect’ in the effort to create a ‘place for them to come and discuss their feelings’ and to ‘make sure they are ok’.
In some cases, stabilizing means ensuring a patient does not have a substance use disorder. Kathy (physician, 7 years’ experience) explained that a history of drug and alcohol abuse created ‘lots of disruption’ which could undermine a successful transition. When deciding on providing hormones, she iterated the importance of a full medical history and required a letter from a therapist stating the patient has been seen for at least 3 months, and that ‘they are ready and eligible, that they meet the criteria and that they have no AOD [(alcohol and other drug)] issues and that they are mentally stable’. For those deemed ‘mentally instable, we first stabilize them and proceed’ which usually requires ‘a couple months, depending on if they need to go to therapy or not’. However, Chloe (addiction therapist, 5 years’ experience), shared that people use substances to ‘self-medicate their unhappiness’ and so she does not ‘freak out over substance use.’ Similarly, Elyce (nurse practitioner, 7 years’ experience) stated that ‘I think that the better you can make someone’s life the better their health in general’. Recounting her conversation with a patient who was ‘an alcoholic that did not want to quit drinking’, she decided the best approach was to work with them on their nutritional needs and that despite the drinking issues ‘you have to address their gender dysphoria if it needs to be treated because otherwise their life is going to suck’. Only a few providers truly shifted the treatment burden away from their trans patients. Emma (clinical counselor, 14 years’ experience), discussed her role as helping patients see the normality of gender expansiveness when explaining that her job is to ‘normalize their life. Normalizing who they are…that we are human beings’.
Simply providing education, guiding, or stabilizing patients through desired transition did not come without ethical and moral dilemmas. Joseph (physician, 15 years’ experience) shared his concern with treating younger trans patients seeking gender-affirming surgeries and grappled with whether counseling long-term should be required. He stated, ‘I’m operating on a 15-year-old. That’s a tough one. What’s right about that? Or what’s wrong about that? It’s really hard to try to figure out. Where do you draw the line?’ Ethical debates such as this often justify why providers might adopt the thematic identity of Assessor that is presented next.
The assessor
Several respondents spoke about their gatekeeping role in providing services to trans patients. This was most evident in their decision to formally diagnose prior to providing services, a requirement removed from the recent SOC revisions. Max (physician, 24 years’ experience) refused to see patients who had not been formally diagnosed through an active relationship with a therapist. Brenda (physician, 30 years’ experience) mirrored this concern when she clarified that her initial responsibility once a patient was referred was to ‘make sure the diagnosis is correct’. Similarly, David (social worker, 3 years’ experience) stressed the importance of diagnosing Gender Dysphoria before writing a letter to seek out medical services: It’s extremely different. One, I have the assessor hat on. I mean, I have an assessor hat on in general with all my clients, but with the people wanting [a letter], it’s trying to look at if there is gender dysphoria there, referring to the DSM, or what it is they are trying to accomplish, and seeing if I can support them with that. I let them know the process right up front and if I have any concerns, if I have red flags that would maybe delay me in writing a letter.
David’s response shows that anyone who desires medical interventions must first display dysphoria. Brenda (physician, 30 years’ experience) also ensures ‘there are no other issues’. For her, ‘other issues’ refer to any medical complication that may arise as ‘all therapies can be toxic’ and it is her job to ensure they are delivered in a ‘safe and controlled’ manner. Finally, although Kate (clinical psychologist, 20 years’ experience) states ‘I am a client-centered therapist so my job as I understand it is to provide a safe, respectful environment for the client and importantly to have no goals for the client. I feel like that is their work to figure out how far they want to go with this.’ However, when asked how she would approach a patient who was not dysphoric, she states: That is a really good and subtle question because I have had some clients who are not dysphoric. I have one right now who is 22 year young man who says very explicitly I don’t mind my body the way it is and I want to go on hormones and I am preparing to live as a woman. So in a way it’s like well what do you do with a person like this? Um, I mean first of all is his account, is he aware enough to actually fully know he feels about this? And that is something I think that will come out in time.
Perceived as a negative word in trans health care, ‘gatekeeper’ was rarely, if ever, uttered. Emma (clinical counselor, 14 years’ experience) sheds light on this: There is a huge trust factor because we are considered, ‘the gatekeeper’ and that is not a healthy title because they need to go through therapists to get letters. Most therapists are not comfortable doing the letters for surgery or hormone treatment.
Emma highlights the difficult position she and other providers are placed in when the ‘letter’ as a requirement of treatment undermines their ability to work with patients. A clinical counselor, Darlene (clinical counselor, 16 years’ experience) was one of two participants to use this term to describe her role when she stated that ‘to play the gatekeeper and the advocate [is to] figure out which hat to wear, [and] when’. For Darlene, her role was to ‘help them through a very intensive discernment process…to ascertain what the person is willing to lose for this transition.’ She is unwilling to write a letter for surgery unless she has: Their assurance that they are standing at the edge of their precipice looking back over their shoulder at everything and everyone they ever loved, or worked very hard for, and they’re ready to lose all of it because they come to me at that point where they say ‘I just don’t want to live another day in this body. I can’t do it.
This quote highlights the dangerous belief that ‘readiness’ for services or the realness of one’s identity requires a patient to be at the point of losing or ending it all. This is a narrow lens through which medicine and psychiatry view trans people as individuals who cannot be accepted or loved as they are, forcing a choice between life-saving health care and everything and everyone else. Limiting narratives also shape how professionals write letters. Discussing how she writes letters for doctors and surgeons, Chloe (clinical counselor, 5 years’ experience) states: Depending on what I have heard about the physician and how conservative I think they might be I will put more information in there (the letter) about childhood history, more gender-stereotyped behavior…and I also use a measure that I hate but Ken’s Zucker recalled gender identity questionnaire and I hate it because it is very focused on, it is very binary focused, it’s very gender stereotyped, kind of like ‘I play with dolls’, things like that.
This quote shows how current decisions are shaped by outdated, yet powerful, logic systems. It also reveals the way mental health providers construct their letters to convince doctors to provide services, displaying that this relationship is less about a multi-disciplinary team and more about upholding a potentially harmful knowledge system. So, while formally diagnosing a patient was rarely discussed, the process of assessing remained.
Clinical Understanding of Documents Used in the Treatment of Trans People
How providers discussed their understanding of the recent changes to the SOC and DSM, as well as their view of a gender assessment, provides deeper insight into how decisions are made. With little to no formal training and lack of evidence specific to trans medicine, providers often relied on their understanding of DSM criteria and SOC guidelines. Interviews were conducted in 2015, four years after the release of the SOC-7 and 2 years after the release of the DSM-5, providing ample time for providers to incorporate changes into their treatment decisions.
Perception of DSM-5 revisions
Some providers perceived the change from GID (DSM-IV) to GD (DSM-5) to be less stigmatizing as it decoupled the dysphoria some may experience from all people who identify as trans. Believing the shift depathologized her patients, Jocelyn (physician, 7 years’ experience) felt the new term provided ‘an out’, meaning ‘you are not permanently gender dysphoric, [and] you can recover from it so to speak’. While perceiving the change to reduce pathologization, medical provider Kathy (physician, 7 years’ experience) supported the need to retain a diagnostic category. She divulged that without a diagnosis, she and others would be unable to treat GD, something she believes is ‘a very painful’ experience with a clear treatment option.
While many providers did not believe a formal GD diagnosis was required to treat, some did see the utility in using a formal diagnosis to communicate and legitimize their patients’ request for gender-affirming services. Providers relied on GD and GD-related terminology to communicate with insurance companies and other health providers to secure and financially cover medical interventions. Sharing many participants’ sentiments, psychologist Emma (clinical counselor, 16 years’ experience) states that ‘you can’t get them (insurance companies) to pay if you don’t have a diagnosis’. Several respondents spoke about the challenges of getting insurance coverage for their patients and the various hoops they had to jump through to get things covered. Medical and mental health providers also saw value in using DSM labels as a shared language to communicate with other treatment professionals, such as when Gail (social worker, 20 years’ experience) indicated that using the diagnostic term was the only sure way to get surgeons to perform desired surgeries. Terminology was also often used in recommendation letters, Cassie (physician, 13 years’ experience), stated was a ‘more accurate diagnosis’.
More critical of DSM changes, some respondents felt diagnostic criteria did not inform their treatment decisions. Lilly (social worker, 20 years’ experience) stated that she ‘avoids [diagnoses] as much as possible’ because ‘people are people’ and so a ‘diagnosis should not drive treatment’. Perhaps the most critical of ‘the bible’ was Darlene (clinical counselor, 16 years’ experience) who felt that several DSM-5 committee members who were instrumental in crafting the newest version were not trans-positive. She argued that at least two members had a ‘bent toward this isn’t [a] real kind of thing [trans identity]’. Recounting one committee member’s approach to their own patients, she stated that ‘he would have parents send their children to him so that he could enculturate them more properly to their specific sex’ because he ‘believed they were confused’. She argued that identity cannot be disordered or a sickness. She explained that while the ‘collective’ intention of shifting the language of diagnostic coding was meant to depathologize patients, this goal was unmet because the committee did not go far enough to recognize that the anxiety and disorder that might emerge was because of one’s inability to fully express their gender within an unwelcoming society. Hence, the changes only worked to ‘muddy and complicate’ her existing approach of allowing patients to self-identify. Rather than provide the fluidity and space for all trans identities, the diagnostic criteria have narrowed it and makes it more ‘difficult for a therapist who wanted to do the right thing by their client’. The DSM and diagnoses were perceived as both an avenue and a roadblock for helping patients. Even if many avoided using the DSM, its logic and importance in treating trans people continued to emerge in how providers incorporated the SOC-7, providers’ main guide in making decisions with clients.
Perception of SOC-7 revisions
Provider perception of SOC-7 revisions fell into one of a few categories. Some described the SOC-7 as a template or guide for treatment decisions, others saw it as providing fluidity in treatment, while others believed it provided legitimacy to treatment decisions.
Standards as template
As a newly burgeoning area of medicine, and with little to no available formalized training in this area of health care, the SOC provided a basic template for treating trans people. Joseph (physician, 15 years’ experience) appreciated the guidance offered by these clinical directives because like him, many medical professionals are trying to ‘figure it out’. He saw the standards and the DSM as documents that gave support to ‘hang your hat on’ so that they could ‘get the job done’.
Standards also guided provider’s decisions when patients presented challenging issues. When referring to patients who wanted her to continue hormone treatment purchased without a prescription off the internet, Darlene (clinical counselor, 16 years’ experience) stated: WPATH has their thing, their ruling on that and I try to stick pretty close to the standards of care because I want to do it to the best of my ability how WPATH would deem this is appropriate….I trust the knowledge of the people who created it.
Shared, formalized guidelines also held providers accountable to a unified way of treating, as was the case for Anthony (physician, 30 years’ experience), who stated ‘it put a little bit more on me, so I’m a little bit more careful in my doing a little bit more gatekeeping duties’. Anthony (physician, 30 years’ experience) was conscious that he would be judged by his peers on his use of the standards and therefore, was more careful about how and when he provided transitioning services. Mental health provider, Emma (clinical counselor, 16 years’ experience), considered the guidelines as her ‘bible’, the use of which sent the message to patients and to other health care personnel that she had addressed all concerns in providing the best care.
Standards as allowance for treatment fluidity
The changes in SOC-7 were welcomed by some as they felt it increased fluidity and allowed for individualized treatment. Kathy (physician, 7 years’ experience), interpreted the shift from a required psychotherapeutic relationship to an assessment as ‘less pathologizing’ because when she conducted a ‘gender assessment, I’m not doing it as a gatekeeper. I’m doing it as a way to facilitate transition…we’re the doorman, showing you the way to the elevator.’ She went on to say that the fluidity brought on by these new changes makes her job easier ‘because I can refer to it a lot when trying to get services for patients’. Sarah (physician, 6 years’ experience) saw the guidelines as supporting individualized treatment and while she understood that counseling was no longer mandatory, she felt it was never a bad idea as ‘there are so many issues’. She also appreciated the increased focus on an interdisciplinary approach. Perceived as a ‘roadmap’ and ‘not set in stone’, Darlene (clinical counselor, 16 years’ experience) balanced knowledge from the SOC with the information provided by her patients, taking both into account to make treatment decisions. The increased fluidity of SOC criteria meant that Joseph could freely ‘do what I think is right at the time’, which for some, translated into postponement and denial of care
Standards as Justification to Postpone or deny care
Providers also referred to the standards when they were uncomfortable providing treatment or chose to deny care. Max (physician, 24 years’ experience) referenced the SOC to avoid being ‘pushed around’ by what he called over-demanding, entitled patients who accused him of refusing to treat when they are unable to access services. Adam (physician, 46 years’ experience) similarly referred to how he used the standards to deny medical services, stating that he utilized the DSM and standards not so much in how he treated trans people but if he treated them. Since a letter or referral following assessment is required by the SOC, he would always expect that they are seen by a psychologist or psychiatrist to ‘get their mind straightened out’ and to confirm this is ‘really where they want to go.’ In this sense, the interdisciplinary team that is perceived to offer holistic care for trans people also created the interlocking structure medical and mental professionals relied on to deny services.
Some referred to the standards when they were uncomfortable providing services at a patient’s request. Chloe (5 years’ experience), a mental health provider, stated, ‘a lot of clients are not ready for medical interventions which are mostly what the standards are set up for.’ Rowan (clinical counselor, 28 years’ experience) relies on the SOC when patients asked for services, she was not comfortable providing. Referring to a patient who wanted to continue to present as male at work while accessing hormones to continue her gender transition as a woman, Rowan referred to the SOC indicating that the patient must fully live as a woman for several months before accessing hormones and that going ‘back and forth’ between genders was not allowed. When reminded that the RLE was no longer required for HRT by the newest version of the SOC, Rowan admitted to not reading them because she had always felt that how she treated was ahead of how these documents understood and treated gender identity. These accounts demonstrate how the standards are used to justify the denial of services when patients do not present their gender in ways understood or accepted by providers.
Standards as legitimacy
Working in a hotly debated, and quickly changing field, providers referenced the standards in different ways to justify their approach and decisions with trans patients. Kathy (physician, 7 years’ experience) felt that the standards set an overall logic that allowed her and others to perceive trans patients as people in need of assistance, rather than sick people to be cured. In this sense, the SOC legitimized trans people in need of life-saving services. According to participants, this logic was especially useful in providing treatment to trans-identified children. Cassie (physician, 13 years’ experience) admitted that she only gave the new standards a quick look, stating that: I looked at them (but) it didn’t seem to change anything for me. I don’t follow the standards 100%. In other words, I prescribed hormones for kids well under 16 years of age. So to me they’re guidelines and…I think waiting until 16 for some kid is really very hard especially since we can’t get the puberty suppressing drugs…because parents cannot afford them.
She felt that her progressive approach to working with young people was not captured in the existing SOC. Several medical and mental health specialists also pointed to the standards to support their decisions to forgo lengthy therapeutic sessions prior to administering hormones. For these professionals, the standards provided the language to reshape and expand treatment practices, loosening formal gatekeeping functions and giving providers the language needed to expand treatment approaches. However, the practice adopted by some can continue to transform subjective strategies to regulate into ‘good practice’, using the guidelines to justify slower or more tightly regulated care. This was evident with Lilly, a mental health provider (social worker, 20 years’ experience) who admitted to not even reviewing the SOC-7, assuming the iterations had grown more progressive as the organization has included more trans people over time. She shared that ‘the more trans-positive they are, the happier I am because the better they suit my client’s needs’. The only change she stated she could remember was that female to male patients did not have to engage in a lengthy therapeutic relationship that included diagnosis and permission for hormones, something that actually is not stated in the SOC-7. She continues, ‘I understand the logic a little bit, and I talk to my patients about getting there slowly...baby steps.’ Despite her incorrect assumption about the progressiveness of the SOC-7, something she says she appreciates, she still admitted to slowing down the process of providing treatments which for her is that patients need to have told friends and family and engage in ‘the community that’s in town’.
View of SOC-7 Requirement for ‘Gender Assessment’
The shift from a lengthy therapeutic relationship (SOC-6) to a psychosocial assessment (SOC-7) was meant to demedicalize treatment, mainly by relieving trans people of the time and financial burden previously required to convince providers that they in fact had a gender different than the one assigned at birth and that they were appropriate for services. Despite what was intended by the original discussion groups that led to the SOC-7, how providers interpret and apply these changes is what will impact patients most.
When asked what they believed was meant by a gender assessment, both mental health professionals, David (social worker, 3 years’ experience) and Chloe (5 years’ experience) were confused if there were specific standards or an actual process. Emma (clinical counselor, 16 years’ experience) believed it was a diagnostic process to ensure somebody had GD and was not a cross-dresser. Darlene (clinical counselor, 16 years’ experience) described a gender assessment as a process that involved her seeing patients ‘for a while’ to be sure of her decision to treat. Kathy (physician, 7 years’ experience) indicated that it was a tool to find out ‘who is this person’ because she stated that trans people are ‘struggling with a lot of stuff’. Some of this ‘stuff’ is defined by Max (physician, 24 years’ experience) as the social part of one’s transition. He stated: Treating a trans patient is absolutely more involved. So, all of my patients that I see for any reason I find out what is going on socially because it is part of taking care of them but it is clearly a more involved situation for trans patients.
Kate (clinical psychologist, 20 years’ experience) elaborates on what she focuses her assessment of patients on before writing a letter, stating ‘their readiness, first of all their diagnosis, you know, are they gender dysphoric in rough terms? Are they aware of what they are getting into, you know? Do they know what this implies?’ She continues with the other areas she focuses: I then there is the format that I use which is kind of their family history, their education history, medical history, psychological history, drug abuse, substance abuse any injuries or wounds that might impact the surgery itself. Anything that would be dangerous to have surgery like if someone has a reoccurring vascular disease and is older. There are things that would be very important for the surgeon to know.
Only Jocelyn (physician, 7 years’ experience) felt the gender assessment could actually replace the letter that emerged from a lengthy therapeutic relationship required under the SOC-6, if the physician was ‘qualified’. When pressed, she defined being qualified as an expert in mental health assessment and someone able to write a letter that says the patient is both ‘stable’ and ‘meets the criteria’. So even if the letter is no longer technically required, the provider must be qualified to write one and present a believable letter based on knowing the patient enough to produce it. While perceiving the gender assessment as relieving them of gatekeeping functions, Cassie (physician, 13 years’ experience) saw her responsibility as merely the ‘second door’ that a patient entered after the ‘mental health provider does the measuring’. Kathy (physician, 7 years’ experience) explained how she handled a new patient who received hormones from another provider who ‘didn’t do an adequate gender assessment, just used informed consent.’ She continued: And this patient had very severe mental illness, bipolar, and was in and out of psych hospitals and after a short time decided that she wasn’t really trans after all and stopped her hormones so those are the kinds of things that have happened to me with informed consent. So, when I get somebody who’s been referred to me by a therapist I get a letter telling me who they are, who their family is, what their background is, what their education is, what their struggles are. I get a lot of knowledge about the patient, and I also get a person I can call if and when things start to get difficult, which often happens during transition and I think the informed consent people don’t acknowledge that. They sort of feel like this is a medical thing and you just see a doctor and get treated. But I don’t think that’s true. I think it’s a hugely transformative process that involves the whole body, mind, [and is] spiritual.
Although the intent of demarcating between gender identity and gender dysphoria in the DSM was meant to depathologize trans people, the evaluation process undertaken by providers repathologizes all trans people.
Discussion
Although drafters of the SOC claim the burden of transition has shifted from the patient to the practitioner, that patients no longer must prove their gender identity to receive treatment, practitioners still do not provide services freely. We see that part of the practitioner’s ‘burden’ is to create the client they need to justify their decision to provide services. The findings demonstrate that professionals see their roles as essential to educate trans people on the processes and impacts of transition on their lives, to offer mental health support through the transition, to stabilize trans people prior to offering any intervention, and to assess who is and is not ready or suitable for transition. Regardless of practitioner views on gender, all providers carved out what they viewed as an essential role for themselves in helping trans people transition. Providers’ self-perceptions as necessary educators, guides, stabilizers, and assessors remove autonomy from the trans person, positioning them as a patient with limited self-understanding who cannot make decisions for themselves.
Our data show that despite recent DSM-5 and SOC-7 changes meant to depathologize and demedicalize trans patients’ experience in accessing gender-affirming interventions, the practice of treating continues to adhere to more regulatory former versions of these documents and hence, retains its former regulation on trans peoples’ identities and transition experiences. Providers’ treatment decisions were made based on a culmination of how they perceived patients’ requests and needs, their perception of patient suitability, competency, and stability, provider comprehension of treatment documents, such as the DSM and SOC, and what they felt their role was in helping patients access gender-affirming care. While updates to the DSM and SOC were understood to relieve the previous burden the process placed on trans people to prove their identity and appropriateness for services, it appears that treating professionals continue to take on a paternalistic role, deciding who will receive services based on the same criteria used under former versions of these documents.
Despite guidelines, decisions often seem to be governed by clinicians’ own judgments pertaining to transness and its relationship to mental health. This is most apparent when providers attempt to ‘stabilize’ patients. The reliance on mental health as a criterion of suitability for services reveals that practitioners rely on outdated decision-making criteria found in previous versions of treatment documents. This process requires trans people to delicately balance appearing stable enough to make competent decisions yet unstable enough to ‘be at the precipice’ of losing everything which seemingly translates to one’s seriousness and realness of gender identity. Dictated by a regulatory process of proving that one’s gender is both stable and genuine, patients cannot safely and honestly discuss their medical and mental health concerns for fear of losing access to vital health care. Furthermore, if a practitioner’s role is to make decisions as to who will have access to services based on every aspect of a trans person’s life, then trans people will spend valuable time performing their transness to receive services rather than use the time to acquire health information. In this sense, the very experiential evidence that drives trans care is developed from a contrived interaction that undermines patient autonomy and forces trans people to participate in medicine’s role as a ‘conduit of transnormativity’.
Moreover, the interlocking, interdisciplinary approach perpetuated by doctors and therapists as a holistic-focused care model is shown to create more points of clinician control. Even professionals who advocated for easier access to medical interventions felt part of an interlocking system in which they needed to legitimize the trans persons’ requests to ensure further treatment. Those who wanted to tighten trans access to medical services used the interdisciplinary team to justify service denial, suggesting the trans person needed other interventions before they would be transition ready.
In a further attempt to demedicalize, the SOC has replaced the lengthy therapeutic relationship with a gender assessment. Although ‘gender assessment’ is meant to reduce the time and financial burden formally placed on trans people, in practice it essentially seeks out and produces the same information in which to decide when and how services will be doled out. While only one person described it as such, a gender assessment is a mental health assessment in which the physical, social, and emotional life of trans people are considered to ascertain who has a ‘real’ gender identity and when they are prepared to access gender-affirming services. Further, although providers understood the SOC-7 to be a great shift of burden from the patient to the professional, this has not necessarily worked in favor of the trans person seeking services; it has simply increased the professionals’ spheres of influence.
The finding that many professionals only provide services to those who they perceive as stable, competent, and serious about transition is concerning given the elevated levels of psychological distress and high suicide rates that accompany the denial of gender-affirming care, as well as other experiences associated with social stigma beyond health care (Almazan and Keuroghlian 2012). Given that SOC-7 itself specifies that gender-affirming medical interventions are a necessary treatment to alleviate psychological distress, it is perhaps surprising that professionals are using psychological distress as a reason to deny care to trans people. With self-identification not accepted as sufficient evidence, and providers continuing to make requirements that the trans person is sufficiently stable according to their own evaluation (e.g., no AOD or undertaking sufficient therapy) clinicians become obligatory passage points to obtaining gender-affirming medical interventions, gatekeeping trans identity while claiming to benefit trans people. Many providers themselves touched on this gatekeeping, citing what they perceived as an unnecessary need to phrase referrals or treatment plans within certain parameters to ensure their trans patients received the care they required. When providers continue to process patients at odds with the shifts in guidelines that frame their work, they retain a practice of regulation that is obscured under what appear to be progressive standards.
As researchers, we can illuminate the idiosyncratic experiences and disparities that occur across many domains, both within and in conjunction with medical and mental health care (Phillips et al. 2022). As witnessed during the AIDs crisis, depriving or withholding essential technologies from a community breaks down the boundaries between the medical, legal, and scientific communities and those traditionally considered lay outsiders that passively receive care (Epstein 1996). Similarly, these interviews highlight that when interventions for trans people are provided based on the current medicalized process, rather than a self-identification process, trans people become positioned as disempowered patients, who require education and mental health support from (mostly) cisgender professionals, based on guidelines produced almost purely by cisgender clinicians. The roles interview participants took on position transness as an entity within the medical jurisdiction that is best understood by professionals. This is incompatible with a view of transness as a celebratory and empowered identity that trans people can choose to embody based on their own lived experiences. In March of 2022, text revisions were released for both the DSM-5-TR and the SOC 8. Future research should examine how professionals understand these changes and what, if any, impact they may have on their treatment approaches and decisions with this population.
Despite the progressiveness of stressing an informed consent model, the SOC does not go far enough to ensure providers center patient self-identification and autonomy. Under the current model, patients must continue to prove they are competent and stable within a psychiatric system that continues to name and treat trans identity as an inherently problematic mental illness. Perhaps the fear is that by fully adopting an informed consent approach the standards, and the organizations they inform, would perhaps argue themselves out of relevancy and be incapable of sustaining and safeguarding their institutional authority in trans health and gender itself.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Correction (February 2025):
Article updated online to add “Introduction” heading and italicize Reflexive statements.