A Horse Designed by Committee
A highly personal view of the 1998 version of the HBIGDA “Standards of Care”
January 1999
“A camel is a horse designed by a committee”
The moth-eaten cliche is the perfect description of this verbose and self-contradictory nonsense masquerading as a guide to clinicians in the treatment of trans people. Were this document to be presented as a research paper by a post-graduate student, a sensible professor would collapse in helpless derision, fail them and send them off to begin again.
And if those sound like the words of a very angry woman, that is because they are. Not the flash, fiery anger for which the Scots have a reputation and which subsides as quickly as it arises, but the slow, persistant anger of one of a community of people whose lives have been abused, restricted and damaged by the draconian conditions imposed by the industry which produced the SOC and whose manifesto it purports to be. And an industry it most certainly is. There are a great many people making a very comfortable living from trans people and the desire to ensure that the interests of this “gender industry” are protected seems to be the raison d’etre of the SOC. It is so shabbily and incompetently cobbled together that it is difficult to discuss it without mockery, but I shall do my best.
The great irony is that this redraft of the SOC was supposedly to respond to increasing criticism from within the trans community that the old SOC was oppressive, restrictive and contrary to the needs of trans people. Rather than addressing and trying to deal with those criticisms, the 1998 draft simply compounds everything that was previously wrong and adds a few more sources for resentment.
It is not that the methodology is flawed — there is no methodology. Instead of a coherent scientific approach, it is a morass of suppositions, presumptions, whimsical musings, prejudices and attempts to reconcile the mutually incompatible views and interests of the various members of the committee which drafted it. It has so many more holes than fabric that it simply disintegrates when handled.
The major consequence of the 1998 SOC, I believe and hope, will be that clinicians will recognise its complete irrelevance, ignore it and develop their own standards more closely related to the needs of their patients. I also believe that it gives us the opportunity to open up a debate on the whole notion of Standards of Care for trans people, but that is outwith the scope of this critique.
As the very opening paragraph makes abundantly clear, the overriding concern is not patient care, it is the protection of the posteriors of the professionals in the gender industry.
“The major purpose of the Standards of Care (SOC) is to articulate this international organization’s professional consensus about the psychiatric, psychologic, medical, and surgical management of gender identity disorders.”
Not a word about the care or treatment of trans people — the emphasis is exclusively on “management of gender identity disorders”. Thus are established the premises which permeate the whole of the SOC’s philosophy — dehumanisation, the failure to address us as people and the subsuming of our identities within a classification of a condition. It is appallingly bad clinical practise to refer to a patient by their condition, e.g., “I’m here to see the appendectomy”, yet this document does this, in the most offensive manner, from the very first paragraph. This opening paragraph is, by itself, sufficient justification for the tendency amongst the trans community to refer to the SOC as the “Standards of Control”.
It is absolutely unambiguous in its determination to pathologise trans people :
“The Gender Identity Disorders are Mental Disorders.”
In 1993, the Health Law Project of the International Conference on Transgender Law and Employment Policy (ICTLEP) put forward proposals for an alternative SOC based on the right to self-determination for trans people. It is instructive to compare the above quote with the ICTLEP Principle 1 :
“Transsexualism is an ancient and persistent part of human experience and is not in itself a medical illness or mental disorder. Transsexualism is a desire to change the expression of one’s gender identity.”
This Principle has as its fundamental idea the recognition that trans people have a history, that we are not a new phenomenon, that we are simply a natural variation within humanity.
The HBIGDA SOC, on the other hand, begins from a position of problematising and pathologising us. We are not viewed primarily as human beings, we are viewed primarily as a condition. This is reductionist and dehumanising. It completely ignores the evidence of history and bases its view exclusively upon the fact that, since 1980, we have been included in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association. In other words, thousands of years of human experience are casually shoved aside in favour of a 20 year old set of suppositions devised with the strategic objective of managing the condition rather than treating the individual.
And it is quite legitimate to use the term suppositions in this context. To quote again from the opening paragraph of the HBIGDA SOC,
“All readers should be aware of the limitations of knowledge in this area”
In other words, the absolutism of the minimum eligibility requirements laid down for treatment, the inflexible rigidity of the classifications of “Gender Identity Disorders”, the entire restrictive gatekeeping paraphernalia set out in such painstaking detail in this SOC, are based upon limited knowledge of what it is they are intended to be dealing with.
“and of the hope that some of the clinical uncertainties will be resolved in the future through scientific investigation.”
Quite how this wistful hope regarding scientific investigation is to be realised is unspecified. In reality, such a hope is a forlorn one.
The whole approach taken to trans people since Harry Benjamin has meant that, by setting themselves in the role of gatekeepers, the gender professionals have more or less guaranteed that, in order to get through the barriers to qualify for treatment, trans people have a vested interest in giving the professionals information about themselves tailored in such a way as to get them through the gates.
For example, if you know that the professional treating you has a frequently expressed stereotypical view as to what “a woman should look like” and that if you turn up for your appointment dressed in jeans and sweat shirt you will be told that “you don’t pass as a woman” and therefore risk refusal of treatment, there is a very powerful vested interest in turning up for the appointment dressed to conform to the stereotype. If such false presentations then form the basis of “scientific investigation”, it doesn’t take a genius to figure out how accurate the results are going to be.
The trap is that, in order to be given hormones and surgery within the conditions prescribed by the SOC, the first step is to be classified as “transsexual”, and, to successfully be classified as “transsexual”, one must present symptoms which conform to the clinician’s list of recognised symptoms. As this list of symptoms is drawn from observation of people who are only too well aware that if they require treatment they must appear to conform to those very symptoms, we are trapped in a self-perpetuating cycle of deception and the chances of obtaining reliable data from clinical observations are laughably slim.
The “experts” are basing their opinions upon a charade. As both patient and clinician have vested interests in perpetuating this charade, the whole process becomes a farce, with the diagnosis being based upon a series of carefully rehearsed deceptions. For instance, why does it seem never to have occurred to the professionals that there is something profoundly fishy about the fact that so many of their trans women clients try to look and dress like 1950’s Hollywood bit-part actresses? (And is it any wonder that so many feminists throw the criticism at trans women that we undermine everything they are fighting for by trying to conform to a stereotypical male fetish?)
In contrast to the precision and clarity of the ICTLEP principle, the HBIGDA SOC is verbose and vague in its attempts to describe us.
“In 1994, the DSM-IV committee replaced the diagnosis of Transsexualism with Gender Identity Disorder. Depending on their age, those with a strong and persistent cross-gender identification and a persistent discomfort with his or her sex or a sense of inappropriateness in the gender role of that sex were to be diagnosed as Gender Identity Disorder of Childhood (302.6), Adolescence, or Adulthood (302.85).”
No attempt to present any reasons for subdividing into these three categories, no results of clinical studies to back up the assumption that such categorisation is justified, nor to demonstrate any clinical value in its adoption. (It may seem unfair to criticise the SOC for what is, after all, merely quoting the DSM, but as they inflinchingly adhere to and have built their entire approach upon the assumptions of the DSM, then, if those assumptions are unsafe, any criticisms of the SOC for adopting them are entirely appropriate.) This arbitrary sub-classification is typical of many of the assumptions the gender industry makes, the previously held and now-jettisoned concepts of “Gender Identity Disorder of Adolescence”, “Adulthood Nontranssexual Type” and “True Transsexual” being classic examples of the casual ease with which such are adopted and abandoned.
“During the 1960s and 1970s, clinicians used the term “true transsexual”. The true transsexual was thought to be a person with a characteristic path of atypical gender identity development that predicted an improved life from a treatment sequence that culminated in genital surgery. […] Belief in the true transsexual concept for males dissipated when it was realized that: 1) such patients were rarely encountered; 2) those who requested genital reconstructive surgery more commonly had adolescent histories of fetishistic cross-dressing or autogynephilic fantasies without cross-dressing; 3) some of the original true transsexuals had falsified their histories to make their stories match the earliest theories about the disorder.”
And upon those well-established and scientifically reliable foundations of “limited knowledge”, “was thought to” and “belief in” has been constructed an entire series of absolute diagnostic criteria and qualifications for treatment for trans people. Even when such suppositions are later abandoned as discredited, as illustrated above, the methods and conclusions which were based upon or inevitably influenced by them continue to provide the rationale for the restrictions on access to treatment imposed by the SOC. Very scientific, indeed.
Had they said, “As we are operating largely according to untested theories with limited knowledge, our methods are necessarily provisional and we therefore welcome scrutiny as we continue to revise and test our theories”, they could at least be taken seriously. But there is no such humility; they present their directives and strictures as non-negotiable absolutes.
They repeatedly issue such absolute directives as
“Under no circumstances should a person be provided hormones who has neither fulfilled criteria #3 or #4”
“Under no circumstances” based upon “limited knowledge”, “was thought to” and “belief in”.
In any other area of medicine, this witchdoctory would be laughed out of existence and those responsible for it instructed to stop practising until they had some reliable research data upon which to construct suitable treatment programmes. For trans people, it forms the basis of our very access to treatment.
The compulsion to classify is relentless :
“For persons who did not meet the criteria, Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6) was to be used. This category included a variety of individuals—those who desire only castration or penectomy without a concomitant desire to develop breasts; those with a congenital intersex condition; those with transient stress-related cross-dressing; those with considerable ambivalence about giving up their gender roles.”
Note the inclusion in this category of “those with a congenital intersex condition”. So, people born with ambiguous genitalia or who are otherwise physically intersexed are classified as suffering from a mental disorder. Quite how this absurd non-sequitur has been elevated to the level of a clinical diagnosis confounds reason.
(Note also the implicit exclusion of trans men by the “those who desire only castration or penectomy” classification.)
“The designation of Gender Identity Disorders as mental disorders is not a license for stigmatization or for the deprivation of gender patients’ civil rights.”
Excellent. And I suppose the statement a few paragraphs later can be taken as an example of how they see this working in practise -
“Social Side Effects. There are often important social effects from taking hormones which the patient must consider. These include relationship changes with family members, friends, and employers. Hormone use may be an important factor in job discrimination, loss of employment, divorce and marriage decisions, and the restriction or loss of visitation rights for children.”
I cannot think offhand of any other field of medicine where the practitioner is instructed to warn the patient that their treatment might result in their falling prey to prejudice and bigotry and that this should influence their decision as to whether or not to proceed.
Does the SOC make any reference to the groups which exist to challenge and educate against this prejudice and bigotry? Does it draw attention to the fact that, in most countries, legislation now exists to afford some measure of protection for trans people against them? No. Instead, it contents itself with quaintly coining the wonderfully innocent-sounding euphemism “Social Side Effects”.
Let’s rephrase it to give it a bit of perspective …
“Social Side Effects. Being Black/ Jewish/ Irish/ Gay/ Female/ Catholic may be an important factor in job discrimination, loss of employment, divorce and marriage decisions, and the restriction or loss of visitation rights for children.”
To be fair, it does go on to reassure us that
“The social effects of hormones, however, can be positive as well.”
However, it avoids giving us further indications as to what it considers those might be. Like most of the statements made in the SOC, it is merely a blunt assertion without any substantiation — it is presented in the manner of received wisdom. “Just take our word for it, that’s the way it is.”
But the real hilarity begins once it moves away from the existential onto the practical.
“Hormones are not to be administered simply because patients demand them.”
Why not?
Oh, no reason — just because we say so.
At least, that’s the conclusion I draw from the fact that it is presented as a bald statement of fact without any supporting explanation or evidence. And that it is presented in the same paternalistic tone as a stern adult saying of a child, “they’re not to be given chocolate simply because they demand it”.
“Adequate psychological and medical assessment are required before and during treatment.”
Why?
Again, because we say so. No attempt to explain, no presentation of clinical evidence in support.
“Surgical treatment for a person with a gender identity disorder is not merely another elective procedure.”
Why not?
Because we say so.
“Typical elective procedures only involve a private mutually consenting contract between a suffering person and a technically competent surgeon.”
So why are the various surgeries required by trans people not dealt with in this way, as proposed by ICTLEP?
Because we say so.
“Surgeries for GID are to be undertaken only after a comprehensive evaluation by a qualified mental health professional.”
Why?
Because we say so.
“Surgery may be performed once written documentation testifies that a comprehensive evaluation has occurred and that the person has met the eligibility and readiness criteria.”
What eligibility and readiness criteria?
The ones we lay down in this SOC.
Oh, you mean the ones based on all the speculation and supposition discussed earlier?
“By following this procedure, the mental health professional, the physician prescribing hormones, the surgeon and the patient share in the responsibility of the decision to make irreversible changes to the body.”
i.e. so there’s no comeback if you change your mind later i.e. this is the professionals making sure their butts are well covered if you later decide you made a mistake.
Now, I have absolutely no objection to doctors and surgeons having guarantees against unwarranted litigation but all the above highly defensive verbiage can be circumvented by a very simple method, based on the ICTLEP proposals, which I describe now.
Treatment begins with a one hour appointment with a qualified psychiatrist. (Note, I say “psychiatrist” rather than the amorphous “mental health professional” so beloved of the SOC. A “mental health professional” can be someone who once did a 6-month course in psychotherapy.)
At the end of this appointment, the psychiatrist issues (or refuses, given justified reason) a document stating that the patient is of sound mind, is capable of making his/her own decisions and of accepting the consequences of those decisions and, most importantly, of understanding the significance of granting indemnities. (Any psychiatrist incapable of assessing this within an hour appointment should go back to school.)
Patient then takes this document and a signed letter of indemnity to the prescribing physician who prescribes appropriate hormones and makes arrangements for necessary endocrinological tests etc.
When and if the patient wishes and feels ready to do so and has arranged appropriate funding, whether privately or through the NHS, s/he approaches the chosen surgeon with the psychiatrist’s statement and a signed letter of indemnity, has surgery and proceeds to get on with his/her life.
If that person later yells that s/he made a mistake, the surgeon is protected, the prescribing physician is protected and the responsibility lies where it exclusively should — with the person who made the decisions.
None of this excludes counselling and/or psychotherapy if the patient has a need for them. But there is absolutely no convincing reason — and no attempt whatever to present such anywhere in the entire SOC — for the coercive, complicated and repetitive consultations, assessments, diagnoses, “Real Life Test/Experience”, restrictions on access to hormones and surgery and all the other nonsense laid out in the SOC.
Oops, sorry, I take that back. There actually is a justification presented — trans people suffer from a mental disorder, are therefore incapable of self-determination and so have to be protected from themselves.
So the circle is complete —
Who invented all these restrictive procedures?
We did.
Why?
Because you’re mentally disordered.
Says who?
We do.
Why?
Because otherwise there would be no reason for all these restrictive procedures.
And, I suggest, the unspoken rationale for this is — because if we allow people to choose their own identities for themselves and empower them to make their own decisions then life, civilisation and the universe as we know it will collapse into anarchy. It is our job to protect ourselves, society and you. And you come last on that list.
The SOC is terminally flawed. The whole philosophy is predicated on a mindset which is dangerously simplistic and to which it is quite astonishing that any of the medical professionals on the committee should have added their names and reputations - that that which requires medical intervention must necessarily be classified as sickness. Medicine should not be about sickness, it should be about life and preserving and improving the quality of life. Pregnancy frequently involves medical intervention, but to classify it as a sickness would be absurd. Why, then, this obsessive, desperate necessity to pathologise trans people? The SOC is unmitigating in its passionate desire to portray trans people as sick and goes to breathtaking lengths in its determination to protect us from ourselves and our right to make our own decisions and to accept the consequences of making them. The relationship between practitioner and patient thus created is therefore a paternalistic one and smacks of codependency.
This SOC is quite touchingly devoid of anything resembling self-criticism. Where the overwhelming evidence of experience has proven previous assumptions to be disastrously wrong, and the treatment principles which were drawn up as a result of these false assumptions therefore patently unsupported and unsound, it quite cheerfully says, “well, we used to believe that but we don’t any more” and, instead of reconsidering the methods derived from or influenced by these errors, it continues to present them as serious clinical methods whose efficacy is unquestionably well-established. And does so without the slightest attempt to give justification, explanation or reliable supporting research data. This persistant refusal to confront reality is well-nigh incredible.
Persistant refusal to recognise and deal with reality is normally regarded as a mental disorder. From where I’m looking, therefore, it’s clear who are in need of psychiatric help and SOCs - and it’s not trans people!
Mairi MacDonald, January 1999
(with thanks to Jay and Claire)