American Psychiatric Association Dumps WPATH Standards of Care
July 6, 2012
The American Psychiatric Association (APA) has never issued any resource documents, treatment guidelines, or position statements on transgenderism since they inserted transgenderism as a pathological diagnosis into their DSM following the de-pathologization of homosexuality over thirty years ago.
Although the diagnosis of Gender Identity Disorder was created by the APA and the practice of medicalizing social sex roles is largely carried out on the authority of the APA’s professional membership, up until this point the psychiatric establishment has deferred to WPATH (World Professional Association for Transgender Health).
WPATH guidelines for psychiatric/medical/surgical “treatment” of “gender” have never been based on any research or study into the treatments they advocate. Instead, the guidelines were created by those interested in making a living off the burgeoning gender treatment market. As the practice of genderiam explodes in popularity (some clinics showing a doubling of business ANNUALLY) tension between the APA and WPATH has grown.
In April 2011 the APA formed a Task Force to evaluate transgenderism and issue recommendations for the formation of the APA’s own treatment guidelines and resources, which would remove APA members from practicing under WPATH guidelines and introduce professional standards based on actual medical research. WPATH responded to APA concerns (and the impending breach in WPATH authority) by attempting for the first time to attach research citations to the most recent version of their treatment guidelines (version 7), issued in September 2011. [PDF here: http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf%5D
As expected, the updated WPATH standards of care guide offered no pretense of objectivity or professionalism and reads as more of a genderist political manifesto. Citations attached were cherry-picked to support the WPATH political platform, many attached haphazardly. Indeed, WPATH 7 even uses previous (scientifically unsupported) versions of it’s own guidelines as a citation supporting the new ones! Kind of a big no-no. WPATH’s badly implemented strategy to introduce citations was inadequate to halt the momentum of the APA Task Force’s move to break from WPATH’s authority.
The APA Task Force issued their findings Monday in the 28 page “Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder” that you can access as either HTML or downloadable PDF here:
Here are a few random excerpts followed by the Task Force recommendations:
“After the announcement of the DSM-5 work group membership in May 2008, the American Psychiatric Association (APA) received many inquiries regarding the workgroup named to address the entities included under Gender Identity Disorder (GID) in versions III through IV-TR of the DSM. These inquiries most often dealt with treatment controversies regarding GID, especially in children, rather than issues related specifically to the DSM text and diagnostic criteria. In addition, the APA Committee on Gay, Lesbian, and Bisexual Issues had previously raised concerns about the lack of evidence-based guidelines for GID, and questions about whether such guidelines could and should be developed.
While the diagnosis and treatment of mental disorders are inextricably linked, they are separate issues and the evaluation of treatments is not addressed by the DSM work groups. The APA Board of Trustees, therefore, formed a task force on the treatment of GID under the oversight of the Council on Research. Members of the GID Task Force were appointed by the APA President, Dr. Nada Stotland, and charged by the Board of Trustees “to perform a critical review of the literature on the treatment of GID at different ages and to present a report to the Board of Trustees.” The report “would include an opinion as to whether or not there is sufficient credible literature to take the next step and develop treatment recommendations.”
“Transition Goals and Outcomes
The process of integration of transgender identity may also demonstrate substantial complexity due to the variation in outcome that individuals seek. For example, some never publicly transition gender, while some may delay openly transitioning for a variety of reasons, such as concern about the impact of disclosing the transgender identity on employment or child custody arrangements. These individuals may, nevertheless, utilize hormonal treatments to facilitate presentation in the psychological (trans)gender in private settings–sometimes for years prior to public transition. Others find that their best sense of psychological relief and self-comfort is obtained through adopting a combination of social gender signifiers, with or without reinforcing medical treatments, to facilitate private reinforcement, though not public recognition, of the transgender identity. For example, an older male whose gender identity is female, may spend his leisure time at a club frequented by transgendered individuals, dressed as a woman, but may continue to present as male in his retirement community. He may also take a small dose of estrogen for psychological relief, even if this does not result in full physical feminization.
The range of transition goals sought has also evolved over time. Among the male-to-female (MTF) transsexual adults in Lewins’ (1995) qualitative work, the final stage of transition was described as “invisibility,” i.e., assimilation into the general female population. Such “invisibility,” however, is not currently a desired outcome for many transgender individuals and other gender variant adults. As transgender people and groups have become more visible in society, and have gained a measure of relative acceptance, the possibility of a transgender identity as such, rather than as a transitional stage within a male–female divided social system, has become a more realistic option. The film, Coming Out Trans (Bockting & Kimberly, 2008), provides some first person accounts in that regard. Some individuals do hope to fully assimilate as women or as men; however, others find authenticity in presenting a blend of gendered characteristics, or of fully transitioning gender while continuing to value the earlier life experience in the other gender role, such as by maintaining interests and activities developed during the pre-transition years. The process of integration of the transgender identity can also continue after the completion of surgical transformation of the body.
The possibility of stopping the process of gender transition prior to completion, or of reversing some of the physical changes that have been attained, has gained more acceptance in recent years. Some individuals find that a measure of bodily change, without genital surgery, clarifies their understanding of their gender identity and desired gender presentation. For example, some adults who begin FTM transition discontinue androgen use after some physical masculinization has been achieved, finding that a masculine female (butch) identity is more authentically representative of the self than living as a man. Some adults who initially present with transgender concerns decide, during the process of psychotherapy, not to proceed with any form of public gender transition (Smith et al., 2005a). This can be a reasonable outcome to an exploratory psychotherapy, but elimination or “correction” of transgender identity is no longer considered a reasonable therapeutic goal. Pfäfflin (1992) (see also Pfäfflin & Junge, 1990, 1998) for example, describes the evolution in treatment of gender dysphoria from historic psychoanalytic approaches aimed at achieving gender congruence through resolution of presumed intrapsychic conflict, to a contemporary model of offering psychotherapy or mental health evaluations that are often followed by hormonal treatments and surgeries.
“The definition of treatment success is complex, because gender identity and gender dysphoria, as well as any perceived benefit of treatment of gender dysphoria are subjective experiences. Individuals seeking gender transition may also experience psychiatric symptoms or disorders that are unrelated to the gender identity concern, or that may have developed as a response to the distress of the gender dysphoria (e.g., addictive disorders) and require specific treatment.
DSM-IV-TR criterion D for GID states that “[t]he disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.” From this perspective, treatment can be considered successful if it relieves this distress or facilitates improvement in function in some substantive way. Some early outcome studies emphasized functional indices such as “job, education, marital, and domiciliary stability” (Meyer & Reter, 1979). However, many persons who present for medical services for transition are already functioning very well socially and occupationally. In these cases, relief of the gender dysphoria, satisfaction with treatment, and lack of regret regarding the decision to transition represent the primary measurable outcomes. (Among patients who experience some level of functional impairment, these may still be most important.) Some clinical situations are complex. For example, an individual with high levels of personality pathology and gender dysphoria may experience substantial emotional relief with transition, and yet remain disabled from employment by the co-existing psychiatric illness.
The importance of subjective satisfaction as opposed to regret on the part of the patient has gained emphasis in the literature during the last two decades (Carroll, 1999; Green & Fleming, 1990; Kuiper & Cohen-Kettenis, 1988; Lawrence, 2003; Snaith, Tarsh, & Reid, 1993). This may reflect a combination of factors, including a relaxation of prevailing biases regarding gender and sexual orientation, a greater commitment to patient autonomy in mental health and general medical services, and the emergence of transgender and gender variant persons as a recognizable political group with reasonable claims to civil rights and responsibilities, rather than a population regarded primarily as patients and clients. Cole et al. (2000) noted that treatment of gender dysphoria during the early and mid-twentieth century was based on prevailing gender stereotypes: “Transsexualism itself was considered a liminal state, a transitory phase, to be negotiated as rapidly as possible on one’s way to becoming a ‘normal’ man or ‘normal’ woman.” This viewpoint has gradually evolved to accommodate a greater variety of transgender experiences, and recognition of the importance of subjective outcomes as opposed to the ability to conform to majority cultural expectations. Kuiper and Cohen-Kettenis (1998) concluded, “…an evaluation of SRS can be made only on the basis of subjective data, because SRS is intended to solve a problem that cannot be determined objectively.”
The APA Task Force recommendations to the APA:
Recommendations for the APA
1. The opinion of the Task Force is that the current credible literature is sufficient to support treatment recommendations and that such recommendations are needed. The Task Force, therefore, recommends that the APA proceed with developing treatment recommendations. These recommendations should address, but not be limited to, those areas identified in this report for which recommendations are needed and substantial support is available from either research data or clinical consensus within the literature. With the possible exception of GID in adults, it is unlikely that GID/GIDNOS will meet the criteria to be prioritized by the SCPG for APA Practice Guideline development. If not, the Task Force suggests that recommendations for each of the groups discussed in this report (children, adolescents, adults, individuals with DSDs) be prepared as APA Resource Documents.
2. There is a critical need for an APA Position Statement on the Treatment of GID, and given the time it will take to develop treatment recommendations, a position statement should precede the development of recommendations. In recent years, the APA has received many requests from advocacy groups and the media inquiring about APA’s position on the treatment of individuals with GID. As the APA has never had any specific component charged with directly addressing such inquiries, such questions were usually referred by default to the Committee on Gay, Lesbian and Bisexual Issues which was sunset during the restructuring of APA components in 2008. Examples of questions received include: How can primary caregivers best nurture a child with GID? Does any APA documentation define what is considered humane and ethical treatment of individuals, especially children, with GID? What constitutes medically necessary treatment for individuals of different age groups who meet criteria for GID? To what level of GID-related care are individuals entitled if their care is provided, or paid for by, governmental bodies (e.g., adolescents in foster care, prisoners, military personnel and veterans)? Is SRS a standard treatment that should be routinely covered by insurance?
The APA first introduced GID as a category of diagnostic entities in 1980. Thirty years later, other than the DSM diagnoses, the APA has no official position statements pertaining to, or even mentioning, these diagnostic entities. In particular, the APA has not addressed the issue of what constitutes either ethical and humane or medically necessary treatment for the GID diagnoses. Requests for psychotherapeutic, hormonal, and surgical treatments for GID, or their reimbursement, are frequently denied because they are perceived by private and public third party payers as cosmetic or unnecessary procedures rather than medically necessary or standard medical and mental health care (Minter, 2003). A document by the WPATH board of directors and executive officers discusses the term, medically necessary, as it is commonly used among health insurers in the United States and lists those aspects of GID treatment that meet the definition (Whittle et al., 2008). While the existence of the diagnosis contributes to the stigma of affected individuals, the unintended result of the APA’s silence is a failure to facilitate full access to care for those diagnosed with GID. The Task Force, therefore, recommends that the APA consider drafting a resolution, similar to Resolution 122 of the American Medical Association (American Medical Association House of Delegates, 2008b). This resolution concludes that medical research demonstrates the effectiveness and necessity of mental health care, hormone therapy and SRS for many individuals diagnosed with GID and resolves that the AMA supports public and private health insurance coverage for medically necessary treatments and opposes categorical exclusions of coverage for treatment of GID when prescribed by a physician.
3. This Task Force strongly endorses recent medical and psychological guidelines that emphasize the desirability of, and need for, mental-health service providers with expertise in providing services to individuals with gender dysphoria, GID and DSDs (Consortium on the Management of Disorders of Sex Development, 2006a; Hembree et al., 2009; Hughes et al., 2006; Meyer-Bahlburg, 2008; Speiser et al., 2010). It is the opinion of this Task Force, however, that detailed restrictions on required qualifications of the mental health practitioners who provide these services are not desirable. Such restrictions might jeopardize existing providers rather than contribute to closing the gap in the availability of mental-health service providers. Instead, the Task Force recommends that the APA create opportunities for educating mental healthcare providers in this area of care. Such opportunities could include CME activities as well as workshops and similar venues at national meetings such as the APA and AACAP.
4. The Task Force recommends that a structure, or structures, within the APA be either identified or newly created and charged to follow up on the recommendations of this report, to periodically review and update resulting treatment recommendations, to identify areas where research is particularly needed to optimize treatment, and to identify means to facilitate such research.”