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

September 10, 2008

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.


26 Responses to “The Standards of Care: violence, economics, and abuse (they matter)”

  1. Allison said

    Right on!

    (Now go close your tags.)

  2. One of the most abusive experiences of my life was when I was trying to get hormones – Twice the psychiatrist added further requirements before he’d prescribe, and this meant adding two additional months.

    It was that he did it twice. Even once was bad enough.

    The first was that he insisted he needed to speak to one of my parents. I was an adult at the time, but apparently he couldn’t decide if I was trans until he forced me to out myself to my family before I was ready so he could determine from them if what I said about myself was really true.

    Never mind that I hadn’t told my family where I was living to avoid my mother’s abusive husband, who made it clear after I came out that he wanted to stop me from transitioning.

    Anyway, after that, he wanted me to come in a dress. It wasn’t that coming in a dress wasn’t possible, it’s that it was oppressive. I required a dress code to get the medical care I needed. A dress code he didn’t reveal until after coercing me into coming out to to my family. A dress code he required after he had already agreed that I am transsexual and needed this treatment.

    • Jacqueline B. said

      Lisa, that is absolutely horrible. I can hardly imagine how that must’ve felt to you. I so want to hug you now. 😦

  3. And while it was two months, that was too months after spending a year living on the hope that once I turned 18 I could start hormones and transition.

  4. Cedar said


    Two months isn’t the point–the point is that said doctor withheld treatment in order to control you, and the SOC were central to his ability to do that. The time issue is only a matter of the enforcement of that control–that is, it’s the wound he inflicted until you accepted his control over you, and it would’ve been longer (he would’ve kept hurting you) until you did. …If someone just hits you once because you then did what they told you to do, it’s not any better than someone who hits you 10 times and then you do what they tell you to…

  5. You’re right on all those points.

    And he shifted the requirements. “You have to X.” “Now you have to do Y.”

  6. […] two is about how the standards of care basically abuse trans people, by Cedar at Taking Up Too Much […]

  7. Tarald said

    I agree. The SOC is not perfect. But how would you like it to be? Would you like to delete them entirely? Whot would that do to our treatment? Or shoul they be changed? How?

  8. […] I read Cedars post at Taking up too much space and realise that the SOC really can be used to defend the basic ideology at the gender clinic: […]

  9. shiva said

    “If I want an orchi, I need to be willing to take either estrogen or testosterone for the rest of my life, ”

    Or to live with the consequences of taking neither.

    (I am currently considering the idea that for some people, possibly including myself, the optimum for their brains is having no sex hormones at all, ie equivalent to the pre-pubescent or post-menopausal state… and, of course, every individual gets to define their own optimum…)

    Otherwise, agreed wholeheartedly on everything. Going to go and read a lot more of your blog…

  10. Cedar said

    Or to live with the consequences of taking neither.

    Yeah, you’re right. Just that the consequences suck rather much, but that could still be what someone wants.

    *goes to edit*

  11. drakyn said

    Tarald, informed consent sounds much better. Because then you are given all the consequences and side-effects and you decide whats right for you. There are lodes of ways to permanently change your body (and lodes of things that could cause health risks) that we don’t have SOCs for.
    Everything from getting a tattoo to pregnancy to eating a different diet all change your body and may carry health risks.

  12. God, it’s great that there’s someone who can analyse this and take it apart to show just why it’s all wrong. I’m still stuck on “What are you doing to me? Are you *trying* to drive me to suicide?”

    I have to write a personal essay about how I understand myself and what kind of man I would like to become, in order to convince a psychiatrist that I deserve a referral to a gender clinic. And if I don’t make a good enough job of pretending I want a bunch of surgeries that scare me, I won’t get the hormones I’m not sure I can get by without. So much control, and how can it possibly be for my benefit?

  13. Yeah, I agree.
    To add to what you are saying about access to hormones, non-expired, non-suspect testosterone is nearly impossible to get without a prescription. in house pharmacy won’t sell it.

  14. Dyssonance said


    Thanks. I will give it further thought.

    One thing I’d like to point out.

    If, at any time, you were denied by a therapist something you needed, then fire the SOB.

    I don’t care how good they are, how many others they’ve helped. They are *your* employee.

    And should be regarded as such. From the get go. And if they don’t like it, well, f them.

    I do not do gender counseling, but I do work with my brothers and sisters every day. One thing I do know is that if one removes the SoC, one removes the ability of doctors to treat anything.

    No surgery. No hormones. BA? fine. FFS? Fine. The rest, though, only if you sacrifice your rights and spend a lot more money than we do now.

    Can it be better? Absolutely.

    But on the points involved, I am going to think hard. There’s good stuff there — stuff that is going to force me to read the very document condemned here more closely.

  15. Cedar said

    If, at any time, you were denied by a therapist something you needed, then fire the SOB.

    And should be regarded as such. From the get go. And if they don’t like it, well, f them.

    The point of the post is that the SOC make that impossible–the whole unified front piece. Furthermore, the therapist doesn’t ever have to do *anything* for the system to be abusive.

    One thing I do know is that if one removes the SoC, one removes the ability of doctors to treat anything.

    No, there are such things as informed consent models, that work in, like, every large city in the US. Genital surgery is the only thing you really can’t get under informed consent if you live in Chicago, LA, New York, or other places big enough. But if you live too far from those places or if you don’t know about them, you’re screwed.

  16. alma cork said

    Hello, I followed the link at QT and, hell, I agree with all of this. I’d like to add something else that the SOC seems to do, at least in the medical comunity I had to wade through….

    I believe it actually makes it harder for trans people to gain access to other aspects of medical care, especially mental health services. The SOC seems to need you to be completely ‘stable’ before certain ‘goals’ can be reached or granted. It utterly ignores the fact that transition can be a draining difficult process. I’m not the only person I know who hit depression during their ‘treatment’ and then became terrified that the psychs might find out and withold further treatment (which i knew would only make things worse). Fortunatly, I had a GP who offered to deal with it and not mention anything to the gender clinic, effectively aiding me in lying to them. I have to ask the question, though, if you need to lie or withhold information to these people to gain access to the resources you feel you need then, really, what is the point of them being there in the first place. It just seems, you know, insane.

  17. I’m reading this again following yet another horrendous meeting with the shrink, and it’s struck me that he seems to be using your second point against me. He told me that I can be a man without going on hormones, which of course is true, but being a man who everyone assumes is a woman and having an F on all my documents (need medical approval even to change that!) doesn’t sound like a recipe for a contented existence.

    But I find that whenever I try to talk to cis people about any of this, it turns into a demand that I provide my grand unified theory of gender, and whatever answer I give, it’s wrong.

  18. Cedar said

    …I mean, I can see the relation, but he’s still not reframing it in terms of mitigating health risks to you (which is the point of #2); he’s still working under the approving/denying transition rubric, right? He’s still in this inherently abusive position of knowing best/testing/etc.

  19. […] inaccurate distortion of the truth: That the WPATH (formerly HBIGDA) Standards of Care are intended to convince trans people that we don’t want to transition. How ignorant do you have to be to insist that people are being pushed into transitioning by […]

  20. […] when you finally break free of that, the medical institutions that supposedly are there to help you use your need for their help as a means to control you (everything from making you diet to making you quit your job)–in that case, how the hell are […]

  21. […] 31, 2009 As with my post about the Standards of Care, I find myself not wanting to wade into the fray about Bailey/Blanchard/Lawrence or […]

  22. […] medicine in how much it hurts to have your body not look or feel or move like you want it to, I frame it in terms of risk of violence, of economics, of freedom of movement, of control of the bod…, but *why* one wants to transition I leave out. I don’t frame being transsexual as being […]

  23. Z said

    There’s a trans site that, every time anyone comes on wondering if they’re trans, someone will pipe up with “You can’t know if you’re trans- only a gender therapist can tell you”.

    That’s right. Trans people aren’t allowed to know their own gender without a licensed professional verifying it.

    I’ve also heard a LOT of stories like Lisa’s. I’ve even seen someone who’s therapist required her mother give consent- even though she’s an adult. I don’t think she was in any way dependent on her mother, either, but the therapist still felt it was important to have her mother’s consent before she could start on hormones.

    “Or live with the consequences of taking neither”

    WHAT consequences of taking neither? If you know I’d genuinely like to! I know intersexed people who’ve had doctors practically demand they take estrogen without giving any reasons why they should aside from “what if you might want to give birth?”. The only consequences I’ve seen of not having either is an increased risk of osteoporosis- which non-IS cis faabs have to deal with at some point anyways.

    Generally, to my knowledge, you can’t get an orchiectoy or ovectomy without being on hormones or getting a prescription for them. The medical community seems hell-bent on keeping people from not having either estrogen or testosterone in their system, and I don’t know why. I really would like to know, though, it seems like the best idea for me but I can’t even weigh the consequences because no one will tell me what they are.

  24. […] that sex to, to have more control over how we change our bodies (if we change our bodies), to fix the currently abusive system required to change said bodies, to stop the enforced sterilization of trans people and medical […]

  25. […] that sex to, to have more control over how we change our bodies (if we change our bodies), to fix the currently abusive system required to change said bodies, to stop the enforced sterilization of trans people and medical […]

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