Slate, USA
Aug. 28 2015 9:18 AM
Do the New APA Guidelines for Transgender-Affirmative Care Go Far Enough?
By David S Byers and Joel Coburn
On Aug. 6, the American Psychological Association announced 16 basic
guidelines for transgender-affirmative psychological care. The
culmination of three years of work, they offer an introduction for
clinicians seeking to provide sensitive care for transgender and
gender-nonconforming clients. These guidelines do not replace
more specific assessment and treatment standards
established by the World Professional Association for Transgender
Health. Rather, the guidelines give a clear explanation of terms and
concepts, recommendations for supportive therapy and research, and some
acknowledgement of the violence, abuse, and stress many transgender and
gender-nonconforming people face. The guidelines are impressive for
their breadth and integration of research, but it is unclear what they
will actually do to improve experiences for transgender people currently
seeking support and treatment. As the APA authors put it, the
guidelines are “aspirational.” What, if anything, will—or can—they
accomplish?
The issues couldn’t be more urgent. This year, at least 17 transgender
women have been murdered in the United States, 15 of them transgender
women of color. The 2011
National Transgender Discrimination Survey,
a study of more than 6,000 transgender people, revealed critically high
rates of family rejection, bullying at school or work, assaults by
police officers, housing discrimination and homelessness, and refusals
by doctors and other health care providers to provide treatment.
Forty-one percent of participants said they had attempted suicide—at
least twice the rate for cisgender lesbian, gay, and bisexual people,
and nearly 10 times the rate in the general population. The rates were
highest for transgender people of color, ranging from 39 percent to 56
percent. Psychiatrists, psychologists, social workers, and other
clinical providers work with transgender people in clinics, hospitals,
schools, universities, shelters, and prisons. They can provide
life-affirming recognition or devastating rejection.
The APA guidelines are not the first initiative of this kind: In 2008, the National Association of Social Workers
issued a sweeping 24-point policy statement,
calling for transgender-affirmative professional development,
antidiscrimination work, public awareness and advocacy, and legal and
political action work. The same year,
the APA released a transgender nondiscrimination resolution, calling for affirmative care. In 2009, the American Counseling Association approved their own far-reaching “
Competencies for Counseling With Transgender Clients,” outlining eight “best practices.”
Many of the APA’s 16 new guidelines also follow from the decision in 2013 of the American Psychiatric Association (the other APA) to remove the diagnosis of Gender Identity Disorder from the fifth edition of the
Diagnostic and Statistical Manual, replacing it with Gender Dysphoria. This change shifted the focus from gender identity itself to emotional distress stemming from the discrepancy between a person’s expressed/experienced gender and how others gender them. (This change resembles the American Psychiatric Association’s decision to remove homosexuality from DSM-II in 1973 and replace it in 1980 in DSM-III with “ego-dystonic homosexuality”—homosexuality that causes distress for the person. That diagnosis was removed in 1987.) The DSM-5 authors explained that transgender clients often need a diagnosis to access services, and they claimed that gender dysphoria won’t “be used against them in social, occupational, and legal areas.” Both points could be debated, but in the current context, the new DSM-5 diagnosis is nevertheless a pragmatic tool for connecting clients to a range of services. The new diagnosis also affirms a gender continuum, with some important implications. For example, trans men have often been denied access to gynecological care because insurance plans use binary gender constructs. Now insurance companies can be pushed to revise their policies, to ensure a range of affirmative—not prescriptive—medical and psychosocial care.
But more basic changes in everyday practice—how clinicians actually behave towards their clients—can be frustratingly slow and uneven. Studies have shown that clinical practice guidelines may have little direct impact on clinician conduct. Clinicians may not read them or may simply disregard them. In practice, the APA guidelines are aimed at clinicians who are already receptive and eager to take practical and immediate steps to improve affirmative care. For them, the guidelines can provide a crucial introductory framework. Clinical psychologist Sand Chang is chair of the APA’s Committee on Sexual Orientation and Gender Diversity and served on the task force to write the new guidelines. Chang explained to us by phone that until now, the APA had only created practice guidelines concerning sexual orientation. As Chang told us, “I felt this was one tangible way the APA could make a concrete effort to address the T in LGBT. Do I think that everyone’s going to read it? Not at all. But I do think mental health providers and people within the mental health field have a lot of impact on the ways that trans people are able to access health care.”
The problem, Chang reflected, really begins with graduate training. A
2009 survey
of psychologists and psychology graduate students found that only 30
percent of participants reported familiarity with the kinds of issues
that transgender and gender-noncomforming people experience. Chang
recalled taking a first-year course in graduate school in which sexual
orientation was discussed for only one lecture, “and we definitely
didn’t talk about gender identity.” In Chang’s view, despite their
limitations, one way the guidelines might help is by influencing
curriculum. “If we’re able to educate more mental health providers,
hopefully we can reduce stigma, reduce barriers, and reduce
microaggressions in interactions between mental health providers and
trans folks.”
But for the moment these are long-term hopes, not a concrete strategy. In a recent conversation, New York University professor James Martin, founder and co-chair of the independent Caucus of LGBT Faculty and Students in Social Work, also praised the APA guidelines and was hopeful about their potential interdisciplinary contributions. At the same time, Martin warned that focusing too heavily on psychological experiences can mean minimizing and failing to address the impact of underlying social oppression. Martin said, “It’s hard for me to imagine how we could talk about working with transgender and gender-nonconforming people professionally without a really, really heavy focus on the severe economic and social injustice issues [they face], in particular violence.” Martin added that he was “disappointed” that the document mentioned violence against trans women so briefly. “It didn’t really do justice to the kind of horrifying level of violence that many transgender people experience, especially trans women of color, which is of course so often ignored.”
As Martin noted, there is cursory acknowledgement of discrimination and
violence in the new APA guidelines, but it is surprising that the APA
would not take this opportunity to more plainly diagnose the racist,
economic, and gender oppression undermining and devaluing so many
transgender and gender-nonconforming lives. To this point, it is also
remarkable that nowhere in the 55 pages of guidelines does the APA
address violence by psychologists, social workers, and other clinicians
themselves, whether they fail to provide basic affirmative treatment or
practice so-called reparative therapies, conversion therapies, and
sexual orientation change efforts (SOCEs). Reparative therapies and
SOCEs can range from talk therapy to transform the client’s sense of
identity and desire, to behavioral aversion therapies including shock
therapy, freezing, and burning, as well as sexual violence. In 2009,
the APA passed a resolution
discouraging SOCEs for lesbian, gay, and bisexual people—an update on
their first statement, “Appropriate Therapeutic Response to Sexual
Orientation,” from 1997. Neither resolution mentioned transgender
people, even though SOCEs typically conflate gender expression, gender
identity, and sexual orientation. While the APA has endorsed
transgender-affirmative therapeutic work, they have also failed to take
any broad action against psychologists who continue to practice SOCEs:
One of the APA’s own past presidents, Nicholas Cummings, remains
an outspoken defender.
Similarly, NASW issued a statement against reparative and conversion therapies for lesbian and gay men in 1992. It has been
repeatedly updated,
most recently in 2015,
to “condemn” use of these techniques with transgender people as well as
with lesbian, gay, and bisexual people, “by any person identifying as a
social worker or any agency that identifies as providing social work
services.” But is discouraging or even condemning harmful practices
enough? Mental health and social service organizations have historically
rationalized and perpetuated oppression of LGBT people. In simply
repudiating reparative therapy, the APA and NASW fail to hold themselves
accountable for when and where it still occurs. They will continue to
do so, until they take clear and concerted steps against transphobia and
homophobia in clinical practice.
The very same week the APA released its new guidelines, the organization
also announced a crucial and far-reaching resolution, finally banning
psychologist cooperation with national security interrogations of
detainees. As with reparative therapies, previously the APA had strongly
discouraged psychologists from participating in interrogations. In
1985, the APA went so far as to join with the American Psychiatric
Association to “
condemn torture wherever it occurs,”
acknowledging how “psychological knowledge and techniques may be used
to design and carry out torture.” Yet these strong statements failed to
prevent some psychologists from participating in torture, especially
with the opportunistic legal redefinitions of torture during the Bush
administration. The failure of these previous statements, and eventual
resolution to institute a ban, raises important questions about the
limits of non-binding guidelines. The APA’s transgender-affirmative
guidelines are, as they’ve said, aspirational—a blueprint for positive
clinical practice, which, if followed, could save and improve lives and
go some of the way toward promoting more justice. But these same
clinicians are surrounded by many others in the field who are unlikely,
or even unwilling, to read them.
In the absence of more decisive action from professional organizations,
efforts to ban SOCEs have instead been left largely to individual
states—in 2012, California became the first state to officially ban
attempts to change the sexual orientation or gender expressions of
minors. Similar bans have since been passed in Washington, D.C., New
Jersey, Oregon, and most recently,
Illinois,
with legislation pending in 13 other states. (Bills were defeated or
stalled this year in three states—Florida, Colorado, and Virginia.)
The effort to ban SOCEs nationwide received the endorsement of President Barack Obama in 2015, following the
suicide by an Ohio transgender youth, Leelah Alcorn. In
a suicide note,
Alcorn described her parents’ attempts to discourage gender transition,
taking her to Christian therapists. One potential limit to state bans
is that they will vary: The Nevada bill currently makes no mention of
gender expression or identity. Lawyer Jacob Victor has
argued that bans are also particularly vulnerable
to objections based on the First Amendment. Victor instead recommends
the approach taken by the successful New Jersey case against JONAH (Jews
Offering New Alternatives for Healing): The court found that JONAH’s
claims to “convert” gay men
amounted to consumer fraud.
In our recent conversation, NYU’s Martin suggested that while state bans may be more effective than professional ethical codes when it comes to regulating practice, the ruling in New Jersey could also have important repercussions for professional organizations, since they already prohibit deception in clinical practice. Former NASW President Jeane Anastas added in a recent email exchange that clients can already bring complaints to NASW and state licensing boards about experiences in SOCEs. She also noted that clinicians using these techniques are vulnerable to malpractice lawsuits.
The success of some state bans and lawsuits does not necessarily rule out the potential contributions of professional bans—which would provide recourse for complaints from all across the nation—and which would be more likely than state bans to address clinical work with adults as well as minors. Clinical providers must follow professional ethical standards as well as state and federal laws—and sometimes those ethical standards and laws contradict. People may seek help from psychologists and social workers despite great legal and personal risk—of prosecution, deportation, discrimination, and judgment. Professional organizations and state licensing boards have infrastructures for prosecuting legal but unethical conduct—such as sexual contact between a clinician and adult client, or participation in interrogations that might use torture. Laws cannot determine ethical standards. At present there does not seem to be consensus among mental health providers that the use of conversion therapies (or non-affirmative treatment generally) is quite so acute a problem. Aspirational guidelines and broad resolutions serve an important function, but they also risk masking a deep, persistent, and pernicious ambivalence among mental health care providers. This must also be recognized and accounted for.
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David S. Byers is a Ph.D. candidate at Smith College School for Social Work. He is based in New York City and Saratoga Springs, New York, where he is a visiting faculty member at Skidmore College.
Joel Coburn is a practicing clinical social worker in Greenfield and Northampton, Massachusetts, at ServiceNet, a community mental health agency. He is a graduate of the MSW program at Smith College School for Social Work.
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