It’s time to leave the Benjamin Standards behind

We are in the moment of the transgender revolution, or whatever you feel like calling it: Transgender people are here, we are noisy, and we are slowly but steadily making social inroads. That’s becoming especially evident in the health care field, where we now enjoy more protections when it comes to things like forcing insurance companies to cover transition care. But all isn’t rosy in health care: Many transgender people around the world who are seeking some degree of medical and/or surgical transition run up against the Benjamin Standards, now called the World Professional Association for Transgender Health (WPATH) standards of care.

Cis people often know very little about the WPATH standards, but the way they think about the trans community is profoundly shaped by them, and a lot of trans people, especially nonbinary people, are pushing to changes in the way we think about transgender health care and transition services. These changes could revolutionise care for trans people, making it much, much easier for them to access the care that they need. Unsurprisingly, there’s resistance to that idea.

I’m fortunate in that I go to a gender clinic that doesn’t tightly adhere to the WPATH standards, and I don’t have to endure the torment, humiliation, and outright cruelty employed by some care providers, some of whom genuinely are acting in good faith. For me, accessing the services I needed was easy and straightforward, and it was one reason I opted to go with Kaiser in the first place — their Oakland-based transitions clinic is excellent, Kaiser doesn’t fight over paying for necessary treatment, and I have received flawlessly trans-competent health care throughout my experiences across the Kaiser system. That is highly unusual.

Not having experienced the WPATH standards directly, I’m in the vantage point of seeing how wrong, outdated, and dangerous they are. They were actually developed, though, with the best of intentions, as care providers struggled with how to care for trans patients. Even today, numerous aspects of transition care are off-label, ‘experimental,’ and poorly understood and covered by health insurance and care providers. The idea was to come up with a general framework for delivering services. The effect was somewhat different.

One of the things the WPATH standards do is medicalise and pathologise transgender care: If you’re trans and you want insurance coverage and transition care, you have to be diagnosed with dysphoria (formerly ‘gender identity disorder’) in order to get it. That sets being trans up as some kind of pathology that needs to be fixed, something that has real social consequences — look at how transgender people are treated as ‘deviant’ and mentally ill, in part because we are listed in the DSM. This medicalisation to secure access of care can be frustrating, humiliating, and dangerous.

There are deeper problems with the WPATH standards, though, and they revolve around the expectations for trans people seeking care from providers and/or clinics who use them. These people are expected to perform transness for a set period of time and to the satisfaction of their care providers, even when it’s dangerous and not feasible, or when it triggers dysphoria. Oddly enough, being told that you cannot access hormones and/or surgery until you’re presented as a given gender full-time socially for a set period of time can be incredibly emotionally stressful.

This insistence sets up the notion that there is a correct way to be trans, and a benchmark of ‘trans enough,’ notions that filter into society as well. People have expectations for how trans people should look, act, and think, and there’s a feedback loop with the WPATH standards, which place a heavy emphasis on passing, but also on binarism. Some nonbinary trans people are forced to ‘transition’ as the wrong gender and then shift their gender presentation later on, after they’ve secured the services they need. (This also gives rise to the myth that nonbinary people can’t or don’t transition — we can and do, it just doesn’t look like what the WPATH standards says it’s supposed to, because we don’t exist in that framework.)

It also means that trans people are effectively being tortured, denied the medical care they need until they do what their ‘care providers’ want them to. There’s an attitude that ‘transition regret’ is a real thing and that trans people need to be told what’s good for them, and it’s deeply patronising and offensive. You see the same pattern playing out with, for example, abortion, where pregnant people are informed that they shouldn’t have bodily autonomy, and that people are exerting control over them ‘for their own good.’ This, we are told, is to ‘protect’ trans people, who haven’t been asked if they want, or benefit from, this kind of protection.

Trans people are being treated to a dose of ‘trans enough’ and some arbitrary tests by care providers who seem convinced that they know how to do gender. These kinds of controls are actually pretty unusual in health care, and when they do arise, it’s frequently around reproductive health and sexual autonomy. Some health care plans and clinics, for example, require a one month waiting period before getting a tubal ligation. On the other hand, many plastic surgeons will perform a cursory consult before booking a cosmetic procedure (elective or medically necessary).

A trans person who wants to go on hormone replacement therapy has to go through an arduous and often humiliating process in many regions to get a ‘letter.’ Youth who want to start blockers (which are wholly and easily completely reversible) have to endure prolonged counseling. People interested in various transition-related surgeries are similarly required to wait.

This is an incredibly unjust system, and there’s no reason it needs to be that way. Trans patients should be able to meet directly with endocrinologists and surgeons without referrals to talk about what they need — or should be given rapid referral by their primary care providers in a medical system that doesn’t allow for direct appointments. Patients who want counseling, for medical or other issues, should have ready access to it, but their medical care shouldn’t be contingent on counseling. And no trans person should be forced into a performative presentation of gender just to get basic health care.

While the standards, and many of those that use them, have noble goals in mind, it’s time for trans people to be writing our own health care best practices recommendations. Decades of research debunks myths like ‘transition regret’ and shows only that the longer care is delayed, the worse the outcome is for the patient. The WPATH standards no longer reflect the latest social, medical, and scientific understandings of gender and transition, and it’s time for a radical overthrow.

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Image: Stepping Stones, youn-sik kim, Flickr