Now Reading: Choosing Wisely : Standards of Care for the Health of Trans People

The overall goal of the SOC [standards of care] is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment.

The standards are published by WPATH, the World Professional Association for Transgender Health, in 2011, and are the 7th version. I read the 6th version (published in 2001) also and see a huge progression in the knowledge and understanding in the care of trans people (the term that I’m using inclusively here).

If you already deliver (or receive care) under these guidelines, you are not the audience of this post, unless you’re evaluating my ability to learn :).

Here are some key pieces of knowledge I obtained.

  • Gender dysphoria is well explained: discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics. This term is currently proposed to replace “gender identity disorder” in DSM-5, being released this May, 2013.
  • Gender should not be imposed as a binary view, different people will find different comfort zones for their gender expression that match the appropriate physical characteristics. There are terms including bigender, genderqueer that are more accurate in these situations.
  • Significant change in proscribing approaches to treating gender dysphoria – not everyone needs psychological, hormonal, or surgical treatments. Some people do. This is individualized. Psychotherapy is no longer an absolute requirement.
  • Important in the standard of care, beyond providing the care itself: “be prepared to support and advocate for patients within their families and communities (schools, workplaces, and other settings)”
  • Gender dysphoria treatment is successful – with satisfaction rates as high as 87% for MtF and 97% of FtM
  • Treatment aimed at trying to change a person’s identity and expression to be congruent with sex assigned at birth is unethical (just as it is for “reparative therapy” for lesbian, gay, or bisexual individuals)
  • Prevalence figures range from 1:11,900 to 1:45,000 for MtF to 1:30,400 to 1:200,000 for FtM , although the prevalence may be higher due to methodology. This is important in conversations that involve denying health care coverage based on false premises about claim burden.
  • Gender dysphoria is not a mental disorder and trans people are not disordered. The distress of dysphoria may lead to a diagnosis that requires additional treatment. “Such a diagnosis is not a license for stigmatization or for the deprivation of civil and human rights.”
  • This is a spectrum – 12-27% of gender dysphoria in childhood persists into adulthood – the majority does not. Many will identify as gay or lesbian without dysphoria in adulthood.

I think those are enough facts from the 68 pages to set the stage that this is (a) a rare condition that can be understood (b) one that is treatable successfully (c) through listening and supporting patients.

The L Word – Listening

It’s interesting that as I read this, the specifics melt away and these could be standards of care for any human, who is respected and valued.

In order to understand how surgery can alleviate the psychological discomfort and distress of individuals with gender dysphoria, professionals need to listen to these patients discuss their symptoms, dilemmas, and life histories. 

The T Word – Total Health

Also interesting, that what this guideline is really about is helping health care do what it is supposed to do for every patient, who don’t aspire to have great health care, they aspire to have great lives.

Health is promoted through public policies and legal reforms that promote tolerance and equity for gender and sexual diversity and that eliminate prejudice, discrimination, and stigma.

We aren’t Choosing Wisely here, yet (but we will)

Choosing Wisely is a wonderful campaign sponsored by the most respected medical professional organizations in the United States. It produces long lists of tests and procedures, most of which are covered by health insurance, done frequently, that are unnecessary or harmful.

This document (WPATH SOC 7) describes tests and procedures that are effective and successful at treating a rare condition, often uncovered by health insurance, often stigmatized, often made worse by the health professionals who are tasked to make it better. This is a community that uses social media so examples are easy to find, here’s just one example on YouTube. Note how this patient describes the worst doctor visit she’s ever had, and then a much better one, with people who understand.

This is also a community of people who are often paying premium dollars for the care that is being provided at great cost, in an unwise fashion, in order that they may not have access to the care (and the health) that could be wisely provided as describe here.

By extension every person who has health insurance is part of that community, who are paying for excess unwise care for those who don’t need it, while denying wise care to those who would benefit – and ultimately, what’s the cost of treating that unnecessary suffering?

Our generation will change that.

Add your thoughts in the comments, of course 🙂

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Ted Eytan, MD