WPATH’s Incongruous Response to “Gender Incongruence”

The World Professional Association for Transgender Health (WPATH) recently released its official reaction to the proposed changes to diagnoses related to gender identity in the upcoming fifth edition of the Diagnostic and Statistical Manual of mental disorders (DSM-V). Their report can be found at this link.

In this post, I explain why the report is a pleasant surprise. The post turned out to be longer than I expected, but some readers might be able to skip the “background” sections with little or no confusion.

Background on WPATH

WPATH is the world’s leading organization dedicated to telling doctors how to treat trans people. It is valuable for its basic stance that trans people deserve human rights and medical care, but notorious for its imposition of strict and arbitrary guidelines which limit their actual access to that health care. Its “Standards of Care” (which haven’t been updated since 2001, hence are listed under WPATH’s old name, the Harry Benjamin International Gender Dysphoria Association) influence medical and therapeutic decisions around the world to varying degrees.

The main flaw of the Standards of Care is their presumption that doctors must paternalistically limit transition-related care — essentially, to protect trans people from transitioning too easily, and to protect cis people from accidentally transitioning. For example, they instruct doctors not to prescribe gender-congruent hormones to trans people unless they undergo several months of psychotherapy (or a nearly complete social transition) to verify the legitimacy of their need. These restrictive guidelines and the attitudes that go along with them are sometimes derisively referred to as “gatekeeping” because they shift doctors and therapists away from their roles as providers of treatment and toward conflicting roles as guardians of treatment. Many socially-minded trans people suggest an informed consent model of trans-related care as an alternative to WPATH’s “gatekeeping” model.

WPATH is therefore relatively conservative for a trans-friendly group, as might be expected from any organization so large and thoroughly institutionalized.

Background on the DSM

The American Psychiatric Association maintains an 800+ page manual of all of the officially recognized mental disorders. Its main purpose is to provide specific criteria for diagnoses. The current edition is number four, published in 1994 and (barely) revised in 2000, but the process of writing version five is well underway.

The original, 1952 edition of the DSM contained a diagnosis for homosexuality, contributing to stigma and medical abuses against non-heterosexual people. Diagnoses directly related to sexual orientation were limited in the 1980 DSM-III and removed entirely in the 1994 DSM-IV. However, the DSM-III added a diagnosis for “Gender Identity Disorder,” contributing to (surprise!) stigma and medical abuses against trans people. This diagnosis has not yet been removed, although today’s institutionalized treatment practices generally reflect ambiguous WPATH-style gatekeeping rather than the unmitigated evil of reparative therapy.

The current draft of the DSM-V changes “Gender Identity Disorder” to “Gender Incongruence” and alters the diagnostic criteria to reduce the use of sexist and heterosexist stereotypes. The removal of the word “disorder” is obviously a step in the right direction, but the presence of the diagnosis in a manual of mental disorders makes that step pretty tenuous. Still, given the nasty histories of two of the panel members involved in the revision (Kenneth Zucker and Ray Blanchard), I was pleased to see any improvement at all.

There is an important sticking point regarding the effort to limit trans-related diagnoses in the DSM. Arguably, their inclusion helps justify the need for medical transition in the eyes of insurance companies, making them useful tools in the effort to increase coverage of transition-related medical expenses. But it is hard to tell how persuasive the DSM really is for US insurers, since most of them explicitly or implicitly discriminate against trans people anyway. It is clear that institutional recognition of the medical necessity of transition could contribute to insurance reform — but, since being trans is not a psychological problem, such recognition would make the most sense in a medical guidebook rather than a psychiatric one.

The Real News (WPATH’s Response)

Given WPATH’s reputation, I would have expected them to applaud the APA’s changes and stop at that. Instead, their reaction to the DSM-V draft contains a realistic assessment of its improvements and a firm indictment of its major flaws. Some of the WPATH document’s better points:

  • It acknowledges that “The change in name from Gender Identity Disorder to Gender Incongruence is an improvement. It is less pathologizing as it no longer implies that one’s identity is disordered.”
  • It legitimately applauds several technical improvements in the diagnostic criteria, including those which have been used to question the gender identities of gay and lesbian trans people on the basis of their sexual orientation.
  • It emphasizes that trans people are not mentally disordered, and points out that the inclusion of the diagnosis in the DSM is suspect for that reason, although it does not go so far as to recommend that the diagnosis be totally removed. (It appears that some people on the committee wanted to recommend removal, but the majority did not.)
  • It meticulously picks apart the diagnostic criteria, pointing out ways in which they could be used to categorize people who want no treatment as “pathological,” and arguing that this unnecessarily stigmatizes those people.
  • It challenges the APA’s decision to include diagnostic criteria exclusive to children which are based on gender norm violations rather than identity, pointing out that this could exacerbate the already-distressing stigma attached to kids who deviate from gendered conventions. (The proposed criteria in question include “a strong preference for the toys, games, or activities typical of the other gender.”)
  • It recommends that the diagnosis, if it is to be included at all, at least be categorized separately from the “sexual disorders.” (The APA has not yet decided where this diagnosis will be categorized, although in the past it has been in a section called “Sexual and Gender Identity Disorders.”)
  • WPATH then includes the following puzzling statement: “We suggest two alternatives: Placement in a chapter of Psychiatric Disorders Related to a Medical Condition (which might ensure better health insurance coverage of transgender-specific medical interventions) or placement in a chapter on childhood-onset disorders”. The first alternative is an excellent idea — given that removing the diagnosis entirely is now off the table, such a categorization would be the best way to mitigate the “psychiatric” nature of the diagnosis in favor of a medical emphasis. The second alternative, however, is so absurd as to seem out of character, even for WPATH. Many trans people don’t come to an understanding of their genders until puberty, and the pervasive myth that most or all know themselves to be trans from childhood makes many feel isolated and “less legitimate.” A categorization of transsexualism as “childhood-onset” would reify this damaging myth and hamstring efforts to obtain treatment later in life.
  • Still, WPATH concludes with a philosophy that makes basic sense: “while the name [Gender Incongruence] is a commendable attempt to depathologize, the way it is operationalized makes the diagnosis of a mental disorder applicable to more rather than fewer transgender individuals.”

WPATH’s report does contain two main flaws:

  • It proposes “distress”-based criteria for treatment (treatment and not merely diagnosis), even for adults, which could be used to deny treatment to trans people who don’t seem distressed enough or don’t want to express their distress in a clinical setting.
  • It suggests separate criteria for adolescents and other adults, which would probably result in even more barriers to treatment for young people, and seems like an unjustified instance of ageism.

Why It’s Important

It’s obviously nice to see a relatively powerful institution issuing ideas that I (mostly) agree with, because it increases the likelihood that those ideas will be implemented. But this report from WPATH is also promising for another reason: it may foreshadow revisions to their own treatment criteria. WPATH’s current “Standards of Care” depend on an outdated interpretation of what it means to be trans, and the reasoning in their response to the DSM-V draft seems to indicate a philosophical shift in the right direction.

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2 Responses to “WPATH’s Incongruous Response to “Gender Incongruence””

  1. Jessica Sideways Says:

    I hope so but a Standards of Care which resorts to gatekeeping does the trans community no favors.

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