In the last several years, there has been a lot more media attention on transgender people and transgender issues, and more transgender people are stepping into the limelight as visible advocates and activists for their community. Part of this new visibility is due to changing public perception about LGBT people and a greater feeling of safety about being visible in the trans community. As society grows more accepting of trans people and employers are adopt workplace protections for their trans employees, some trans men and women have greater freedom to be open about their lives and to speak out as their own advocates in social and political roles.
But one aspect of transgender community history suggests that there is an additional reason why more trans folks feel safe coming forward with their personal histories. We now have increased access to quality transgender health care that empowers transgender people and respects their autonomy.
In 2011, the World Professional Association for Transgender Health adopted new standards for care for the transgender community. Standards of Care number 7 made some significant changes in how mental and physical health care providers were advised to work with the transgender community.
The previous changes, (Standard of Care # 6), had been adopted in 2001, and were very outdated and needed a change. Those older standards of care (and all previous standards of care, dating back to 1979) were also very paternalistic, and had the effect of allowing health care providers the rationale to withhold transition-related medical care from trans folks in many circumstances, and for often arbitrary reasons. Until the last few years, for many transgender people, silence about their identity was a defacto requirement to acquire medical care from therapists and doctors.
As Dallas Denny notes in 2013 (Stealth is Soul-Destroying):
In the past the medical model of transsexualism demanded stealth; those who were accepted for treatment by gender clinics were required to close all ties with their past and live as if they were nontranssexual. Things began to change in the early 1990s as a new community-fueled transgender model began to replace the medical model.
Denny wrote an article in 2011 for the Journal of Gay & Lesbian Psychotherapy that provided a window into that older model of care that forced transgender people into silence if they wished to pursue transition-related care. (Changing Models of Transexualism):
It was an unfortunate fact that treatment under the model punished transsexuals for telling the truth. It also placed them at risk for abuse from professionals who controlled access to hormones and SRS. Transsexuals have long complained about this. The literature documents the excesses of the gender programs, some of which required their transsexual clients to divorce, change their names, quit their jobs, dress and behave in stereotypically masculine or feminine ways, and agree to participate in follow-up studies by offering the promise of hormonal therapy and SRS. Stone (1987, p. 142) wrote “All transsexual patients receiving hormone therapy at the clinic were asked to submit to a semi-structured interview, including a medical history, and a problem-specific physical examination. Participation in the study was mandatory if the patients wished to continue to receive hormone therapy at the clinic (emphasis added; see also Denny, 1992).
In the early years of transgender health care, the most visible members of the transgender community were from one of two groups. The first was people who had enough money to be free of workplace discrimination and to defy the stealth requirements of the health care providers. Trans people who had the option of switching from one care provider to another, and who could travel for access to the best medical care could pick and choose their doctors and therapists. These folks were paying for their own care out of pocket, free from constrains of insurance or medical networks.
The second group of visible transgender people were working poor transgender people who were cut off from medical networks because of lack of funds, either because they were denied employment due to their transgender status or because they didn’t fit stringent medical requirements. These folks were able to agitate for change for the trans community, but often at great personal cost to themselves.
Even though ethical changes in medical and mental health care began in the 1990’s, They didn’t completely make their way through the fields of transgender health care until the last five years. “Stepping Forward” — an advocacy pamphlet for informed consent models of care — notes that even recently, health care providers have not revised their practices:
And to be clear, there have been incredible amounts of abuse – we’ve had providers;
- delay medical assistance with transition for years (or even decades)
- force trans people to pay for expensive amounts of psychotherapy
- force trans people to go “full time” before getting hormones, a practice that is highly discriminatory to those who do not “pass” before hormones and has absolutely no diagnostic or deterministic value
- force trans people to divorce their partner (still happens)
- force trans people to cut off communication from everyone in a trans person’s life (friends, siblings, children, parents, spouses, etc) thereby eliminating our support networks at a time when we need it most.
- subject trans people to the same kind of treatment a child molester would receive
- told trans women seeking treatment to go and have anonymous sex at a gay bar to “see if they are gay”
Even up until 2015, mental and physical health care providers I’ve spoken to here in Indiana were still asking for their clients to engage in the pre-2011 model of care that required “Real Life Experience” tests before offering them letters of recommendation for HRT, prescriptions for HRT and access to transition-related surgeries. To prove you were ready for hormones or transition-related surgeries, you had to show you could “pass” as your appropriate gender for anywhere from three months to a year before treatment would be awarded to you.
From the defunct WPATH Standards of Care #6:
IX. The Real‐Life Experience
The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real‐life experience. The real‐life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences with their patients. Change of gender role and presentation can be an important factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real‐life experiences. However, not all changes are negative.
Parameters of the Real‐Life Experience.
When clinicians assess the quality of a person’s real‐life experience in the desired gender, the following abilities are reviewed:
1. To maintain full or part‐time employment;
2. To function as a student;
3. To function in community‐based volunteer activity;
4. To undertake some combination of items 1‐3;
5. To acquire a (legal) gender‐identity‐appropriate first name;
6. To provide documentation that persons other than the therapist know that the patient functions in the desired gender role.
The effect of this outmoded demand for “real life experience” passing as the correct gender was that often transgender people didn’t speak out about about being trans. Sometimes this was still at the direction of their therapists or doctors, and sometimes because the defacto circumstances required by “passing” discouraged it. Disclosing your status publicly once you had “successfully transitioned” could be considered ‘backsliding’ in the passing game of life, and could cause you to lose access to care.
In addition, gender non-binary and gender-diverse people who were not interested in “passing” as a binary gender were left out of any model of care and access to medical transition.
To be fair, there have always been health care providers who were strong advocates of the autonomy and self-fulfillment of transgender people, and not all providers engaged in practices that were abusive. But community-wide veil of silence that existed for so many years discouraged people from being open about their lives, their needs and the community they were a part of.
But now more trans Hoosiers are supported by a health care community that respects their dignity and worth. Fewer people have to worry where their next HRT shot is coming from, or if they “pass” enough to get transition-related surgeries, and more trans people are free to become political and community advocates. Trans people still need civil rights protections in housing, employment, schools and public accommodations. But our new options in health care have unlocked a door for many of us.
WPATH, Standards of Care 6, 2001
The Journal of Gay & Lesbian Psychotherapy, Changing Models of Transsexualism, 2004
Autostraddle, Transgender People, Transitioning and Those Darn Standards of Care, 2011.
Gender Blog, RLE- Really!? Why requirement for “Real Life Experience” is/was detrimental, 2013.
Susan’s Place, RLE is a Civil Rights Issue, 2015
Everyday Feminism, 6 Ways the Healthcare Industry Needs to Stop Abusing Trans People, 2015