Illuminations with Dr. Caretto: Standards of Care 8, Part 2

Missed Standards of Care 8, Part 1? Read the entry.

I will now talk about the suggestions for SOC8 which I see as potentially controversial. The two general areas of debate can be divided into those that are about mental health and those that are about medical intervention. Before addressing a handful of topics within each, I will first mention two glaring issues in the Adolescent chapter.

WPATH always wants to put current thoughts into an historical framework and as a result the introduction to the proposed chapter on adolescent care attempts to address the hot-button topics of ROGD and retransition. Unfortunately, the text uses the word “detransition” which suggests regret rather than evolution and does not explicitly de-bunk ROGD. Critics believe that even mentioning these concepts gives them some iota of credence and relevance and would like to see them removed, but I believe these topics will still be addressed, hopefully with use of the term “retransition” and clarity around the fact that ROGD is not a diagnosis.

The other part of the proposed chapter that is a glaring fight-looking-for-a-place-to-happen is the suggestion that trans teens must have questioned their gender for several years. This is not compliant with diagnostic criteria which only requires 6 months of dysphoria. There is no way that WPATH membership is going to slip in “several years” when DSM5 only requires six months.

The mental health specific areas of potential conflict include three flash points. There is disagreement about: the role of the mental health professional; the comprehensive assessment; and the exploration of gender. The crux of the issue is the range of opinions about role of mental health and mental health professionals in the care of trans youth. Opinions range from welcoming to witch hunt and the fighting has already begun on various list-serves and professional forums.

It is clearly stated in the proposed guidelines that those who are not mental health professionals can perform a comprehensive assessment. Critics of the chapter note that it does not make that point explicit enough. I believe SOC8 will not restrict evaluation to mental health professionals due to lack of access to timely care in some regions and a desire to depathologize the diagnosis. So, the revised SOC will open the door for pediatricians and others to diagnose gender dysphoria. There are people who would like to see mental health taken out of the equation all together.

The second area of back-channel chatter is the comprehensive assessment. The comprehensive assessment is not clearly defined and as a result, some believe that a comprehensive assessment implies questioning which is a priori steeped in transphobia. To my mind, WPATH will struggle to both allow non mental health professionals to make the diagnosis and still require a comprehensive assessment. I believe WPATH will leave comprehensive assessment vague and will buckle under the pressure to diminish the mental health part of care. The third sensitive mental health topic shows the vehemence about the mental health demon.

The proposed chapter encourages exploration of gender identity and states explicitly that this should be done in a way so that no particular outcome is favored – yet critics are concerned that there is no way to guarantee that bias does not contaminate the process. Though many would agree that everyone could benefit from open exploration of gender, some worry that this is somehow a buzzword for conversion therapy and many advocates are overly suspicious and critical of mental health professionals in general.

There are those who strongly reject the suggestion that mental health counseling should be mandatory for anyone. They worry about stigmatization and gatekeeping and note that mental health problems often improve with gender-affirming medical care. Exploration of gender identity will be the proverbial baby thrown out with the bath water. WPATH will change this suggestion to say something about gender exploration being an option or encouraged for those who are interested. At most they may suggest 3 months of therapy as they did for adults in SOC6.

One final mental health area that will get heated debate is around the proposed SOC8 making explicit mention of the fact that gender dysphoria is not a requirement of a transgender identity. As mentioned in my previous piece about tucutes and truscums, this is a contentious opinion. Some insist that requiring dysphoria restricts access to care while others argue that not requiring it runs the risk of making medical transition a type of choice rather than a medical necessity, thereby giving ammunition to those who believe in choice and contagion and would therefore deny care to everyone. This statement that gender dysphoria is not a requirement of a transgender person will stay in the guidelines.

We can nicely bridge the gap between mental health and medical intervention with the topic of fertility preservation. The proposed guidelines make explicit the expectation that fertility be addressed. At first blush this seems innocuous, yet some advocates protest that forcing a child to consider the topic is emotional blackmail and traumatizing. Others consider it part of informed consent. I think SOC8 will water it down to something like “the opportunity to discuss fertility must be presented” and it will become a checkbox on a form and nothing more. Providers who insist upon addressing it will be labeled as gatekeepers.

The remainder of the significant proposed changes I will mention have to do with medical interventions and are mostly related to minimum age requirements. I believe some if not all of these will be highly debated because they are so arbitrary. I do not believe there is any research to back any of these parameters, just an effort to give more access to care to youth.

The first proposed change is a lowering of the age for hormones to 14 from 16 – which is closer to cisgender peer adolescent development. Again, it seems like a no-brainer, yet some argue against any guidelines which place age parameters. They note that maturity and degree of dysphoria is so variable and more relevant than chronological age. Also, while fourteen is closer to peer development, it is still delayed, especially for females. Nonetheless, WPATH will lower it to 14 and will leave the case-by-case option as a compromise for providers who want to prescribe to younger kids.
It is proposed that one reach an age of 15 or above for chest masculinization instead of the prior guidelines which just stated it could occur before age 18. To my knowledge this is a random and arbitrary number. This change moves away from any consideration of time spent living male. WPATH is clearly committed to putting minimum ages on all medical interventions and may attempt a compromise by punting: No earlier than age 15 unless there are special circumstances.

It is also suggested that youth reach the age of 16 and above for breast augmentation and (most) facial surgery. Augmentation is currently suggested no earlier than age 18 and an age for FFS (facial feminization surgery) has never been addressed before. It would make sense to lower augmentation to 15 to correspond with chest reconstruction but that doesn’t allow for 2 years on hormones to maximize breast growth and I believe the idea is that 16 allows for that. But WPATH doesn’t want to open that can of worms and have insurance companies want to make it part of the adult protocol.

A minimum age on facial surgery is a joke. Disposable income determines who gets surgery and a suggested minimum age is not going to change that. Some would argue that it is so wrong to set guidelines on these procedures when cisgender females can have them at an earlier age. I think the fact that it is lower than 18 for both procedures will cause many to willingly accept it as reasonable, even though it is so arbitrary.

A big, proposed change is the suggestion that one attain an age of 17 instead of 18 for hysterectomy, orchidectomy, metoidioplasty, vaginoplasty. I think this one is going to be a fight because these are such varied procedures both in terms of invasiveness and fertility. I think WPATH is going to have to separate these in some way, though I think they will still suggest the age of 17 for most all of them.

For whatever reason it remains that the age 18 be attained before phalloplasty. I believe that there will be an argument that phalloplasty and vaginoplasty are comparably invasive and should have similar age parameters. I think WPATH will have to move phalloplasty to 17 rather than moving vaginoplasty back to age 18.

I hope this Illumination has given you a glimpse into the possible proposed changes and the range of opinions even among professionals. Keep in mind that WPATH struggles to write guidelines that can be applicable across regions and countries including nations that are heavily religious and oppressive and those that have socialized medicine and progressive attitudes. The other challenge within WPATH is that just as transgender itself is a continuum, the definition of what it means to be transgender spans a range of definitions.

In closing, I remind us of the parable of the elephant adapted from a poem by Rumi:

Some Hindus were exhibiting a huge elephant in a large dark room. And many people, not knowing what an elephant was, gathered to see it. But as the place was too dark to permit them to see the elephant, they all felt it with their hands, to gain an idea of what it was like. One felt its trunk and declared that the beast resembled a water-pipe. Another felt its ear and said it must be a large fan. Another its leg and thought it must be a pillar. Another felt its back and declared the beast must be like a great throne. According to the part which each felt, each person gave a different description of the animal…

Antonia Caretto, Ph.D. is a fully licensed Clinical Psychologist and a graduate of the University of Michigan and the Alliant International University California School of Professional Psychology. Dr. Caretto’s 1991 doctoral dissertation research was on “Familial Homosexuality Among Women and It’s Relationship to Childhood Gender Role Non-Conformity and Adult Sex Role.”

Dr. Caretto has a solo private practice in Farmington Hills, MI, and gender identity development continues to the focus of much of her work.