The Standards of Care: violence, economics, and abuse (they matter)

Trans folks love to debate about the standards of care, and I feel like there’s a similar dynamic to the male privilege thing happening — the “mature” trans person says, oh, but really it’s ok, you know, it’s not so bad. besides, why does it even matter? It’s not like we should be spending so much time on this. You’re being such a victim and not considering anyone but yourself, you selfish * you.

Without going into the various arguments commonly asserted, there are three that frequently get left out that are hugely important.

The sometimes included one:

1)Economics. The SOC impose a substantial financial barrier to trans people getting routine health care access. If you assume that, without insurance, therapy costs ~$100/session (at the cheap end), and that, without insurance, hormones cost ~$150/mo through inhouse pharmacy or the like (bodybuilder testosterone substantially less), three months of weekly therapy incurs an additional ~$1300 of expenses–an up front cost almost 9 times as large as the ensuing monthly cost. A year of biweekly therapy incurs $2600 of additional charges on top of that for a hysto, metiodioplasty, or orchiectomy– all of which are relatively inexpensive otherwise–one can obtain an orchiectomy for $1500-2000, a 130-173% increase in price– for a population suffering dramatic economic marginalization–economic marginalization potentially lessened by having said procedures, and, additionally, reducing the monthly cost of hormones. The economic issue is less pressing for phalloplasty/vaginoplasty, (FFS isn’t regulated) but for the cheaper surgeries it’s a huge deal.

The two I haven’t heard others say:

2)Procedures, not transition, not identity. There’s an almost universal assumption that these standards of care are in case a patient decides to “change hir mind” about transitioning. Putting aside of the implications of protecting trans people from themselves for a moment, transition regret is a red herring. No medical procedure can force you to live in a particular gender permanently. If I’ve been on estrogen for 10 years, have bottom surgery, facial surgery, the works, and decide I want to live as a man again? I start taking T, bind my tits, pack, and it’s no big deal. Yeah, it kinda sucks for me, but I’m not really any worse off than a female assigned at birth transsexual man (and, in fact, my situation would be remarkably similar to his).

–The point is, your informed consent is *not* about “being” a man or a woman (which no one can really truly understand in advance), it’s about the effects on your body (which, while variable, are fairly predictable). If I want an orchi, I need to be willing to take estrogen or testosterone for the rest of my life or be willing to live with the consequences of taking neither, and be willing to either store sperm or not have (more) biological kids–and what gender I plan on living as in the future is fairly irrelevant.

This point is particularly salient if, like me, you transitioned before having any medical intervention. A doctor cannot prevent you from living as a particular sex by not providing treatment–a doctor can only increase the risks associated with doing so. Which is to say, if a doctor refuses medical therapies it’s not a matter of “correct diagnosis” as it is so commonly framed by SOC apologists, it’s not a matter of refusing transition but a matter of refusing treatment known to reduce associated health risks such as discrimination, murder, and harassment (not to mention body dysphoria). Trans people who don’t transition when refused medical treatments are managing their health risks as best they can in the absence of basic medical care, something no one should have to do.

3)Boundaries, mental health, abuse, and control–

The SOC are damaging to trans people’s mental health¹ and growth, particularly in the setting of boundaries. Normally, one can say ‘what you just did to me was fucked up, you can’t do that or I just won’t be in a relationship with you; I have other options,’ but through the SOC therapists and doctors create a unified front through which to drastically reduce your options. They create a power relationship with you where you can’t say ‘no’, where you can’t keep the most fundamental control of your body and person to yourself. Medical professionals have the power to protect you from violence, and by withholding it until certain standards are met they use the threat of violence to maintain immense power to determine what you can and can’t do with your life, your body, and your appearance; they also take advantage of the intense emotional pain of body dysphoria to do the same thing. Even if individual professionals do not intend to impose rigorous standards on a person’s gendered actions, the fact remains that the institutional power arrangement concentrates power in the professional’s hands, power over things so basic to one’s body sovereignty and self-determination that one cannot afford to risk the potential consequences of rocking the boat. By creating a unified front, the SOC effectively force trans people to do what their provider wants them to do, without much hope that they could be held accountable. How are we preparing trans people to resist emotionally and physically abusive partners? Aren’t we telling trans folks that it’s ok for another person to control you, financially for instance telling someone that if they don’t have sex with you then you’ll kick them out of the house / they won’t get any spending money next month / etc? The SOC constitute direct abuse, a mix of sexual, emotional, physical, and financial or something separate but equally abusive…

1: I’m tabling important arguments about how it screws with your ability to access (actual) mental health treatment and therapy.