One of my biggest beefs [is] with the gender role experience… Is it reasonable to expect somebody to present for a year full-time in an identity congruent role with their family or friends or at work, when sometimes there are issues of safety? [T]he way that it’s worded [in the WPATH-SOC], it’s ‘yes/no’."

Clinician, as quoted in MacKinnon et al., (2019), Advances in Health Sciences Education
Do I have to follow the WPATH standards of care (SOC) when assessing/referring trans people for hormones and surgeries?

The WPATH-SOC are flexible clinical guidelines intended to “optimize” clinical work with trans people. Clinicians can decide independently how strictly, or loosely, they apply the WPATH psycho-social readiness assessments when working with trans people.1 Increasingly, researchers, clinicians, educators, and trans people are advocating for alternative, patient-centred care models.

Could I be at risk of malpractice if I don’t follow the WPATH-SOC strictly?

There is no evidence that a strict application of the WPATH-SOC is legally protective. Conversely, Deutsch (2012) surveyed clinicians who use an “informed consent” approach to initiating hormones for trans people and found no cases that resulted in malpractice claims.2

Also important to note, in legal contexts such as in malpractice claims, the courts rarely accept clinical practice guidelines as evidence of a single measurable standard of care.3

What if a trans patient regrets their decision for hormones or surgery and wants to de-transition?

All medical treatments come with a risk of regret. Although regret is uncommon, some trans people do come to regret their decision to transition, and some will decide to de-transition. Some clinicians cite the risk for transition regret as a primary rationale for strict adherence to the WPATH-SOC, but bioethicist McQueen (2017) argues that with medical-decision making on transition, regret is not an ethically sound reason to withhold treatment.4 De-transitioning is not a medical failure.

How many people regret transitioning, or go on to de-transition?

A small percentage of people may actually need to try hormones before deciding that transitioning is not for them. In terms of transition-related surgery, regret rates (~2%-4%) are similar to that of gastric banding, and much lower than with plastic surgery.5 6 Importantly, the risk of transition regret is not an ethically sound reason to delay or withhold hormones or surgeries.

Working collaboratively with patients may result in more patients trusting you, and after having a positive clinical experience they may recommend you to other people who are considering transition within their personal networks. Removing clinic-level barriers to transition-related medicine will not encourage more people to seek hormones and surgeries, though. But patient-centred care that emphasizes patient autonomy and informed consent may improve patient (and provider) experiences.

This online educational resource is intended for clinicians working with trans people over the age of 16. However, clinicians working with adolescents may find aspects of this resource useful. For more information regarding transition-related medicine for young people see: Gender Creative Kids Canada and the Transgender Youth Program at Ontario’s Sick Kids Hospital.

Although we don’t know the exact numbers, clinicians’ use of the informed consent model in community health centres across the United States was the reason the latest edition of the WPATH-SOC endorsed this model of care. Clinicians and trans health clinics across Canada are also increasingly promoting patient-centred care with trans people in the context of transition-related medicine.

When was the WPATH-SOC last updated?

The most recent 7th edition was published in 2012. The 8th edition of the WPATH-SOC is highly anticipated and expected soon. Significant scientific advancements have been made since 2012 in terms of how gender identity is understood, and the importance of reducing barriers to transition-related medicine.

Will the new edition of the WPATH-SOC be more consistent with the values of patient-centred care and important values in medical ethics such as autonomy and self-determination?

While this remains to be seen, it is crucial to underscore that the WPATH-SOC is a flexible clinical guideline. Strict adherence to the current 7th edition’s pre-transition psychosocial readiness assessments does infringe upon some medical ethics principles. For this reason, our resource teaches care providers how to more flexibly interpret the WPATH-SOC.

Footnotes
  1. Ehrbar, R.D. & Gorton, R.N. (2010). Exploring provider treatment models in interpreting the standards of care. International Journal of Transgenderism 12(4), 198-210. ↩︎
  2. Deutsch, M.B. (2012). Use of the informed consent model in the provision of cross-sex hormone therapy: A survey of the practices of selected clinics. International Journal of Transgenderism 13(3), 140-146. ↩︎
  3. Moffett, P., & Moore, G. (2011). The standard of care: Legal history and definitions: the bad and good news. Western Journal of Emergency Medicine 12(1), 109-112. ↩︎
  4. McQueen, P. (2017). The role of regret in medical decision-making. Ethical Theory and Moral Practice 20(5), 1051-1065. ↩︎
  5. Tannehill, B. (2016, February 2). Myths About Transition Regrets. Retrieved from https://www.huffpost.com/entry/myths-about-transition-regrets_b_6160626; ↩︎
  6. Parola, N., Bonierbale, M., Lemaire, A., Aghababian, V., Michel, A., & Lançon, C. (2010) Study of quality of life for transsexuals after hormonal and surgical reassignment. Sexologies 19(1), 24-28. ↩︎