Re-assessing the Triadic Model of Care for Trans Patients Using a Harm-Reduction Approach
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Re‑assessing the Triadic Model of Care for Trans Patients Using a Harm‑Reduction Approach A. F. Gruenewald1 Accepted: 21 October 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The World Professional Association for Transgender Health’s Standards of Care (WPATH SOC), now in its seventh edition, is a frequently cited, internationally recognized, evidence-based document that details a comprehensive framework for gender-related care of trans people. However, the WPATH SOC still relies heavily in some cases on gatekeeping practices, dubbed “triadic therapy,” or a process where a trans patient is encouraged to seek out psychotherapy, and hormone therapy, and only then be able to engage in surgical options for transitioning. I use G. Alan Marlatt’s harm reduction framework to argue that the triadic process creates its own set of harms that trans people have to contend with, especially insofar as it focuses on resolving gender dysphoria in a demanding, moralizing, and top-down way as opposed to enriching trans lives by reducing harms that prevent us from flourishing. Using Marlatt’s criterion that harm reduction ought to be bottom-up, low threshold, and not moralizing, I develop a list of suggestions for what ought to be centrally considered in treating trans patients. Keywords Harm reduction · Trans patients · Applied ethics · Philosophy of medicine · WPATH SOC
Introduction The World Professional Association for Transgender Health (WPATH) regularly releases Standards of Care (SOC) guidelines for the care of transgender patients. The WPATH SOC is a document extensively researched and written by a committee that includes a working group of psychiatrists, trans activists (mostly in an advisory capacity), scholars, medical practitioners of various forms, and others [18]. The WPATH guidelines aim to produce SOC for trans people that are internationally * A. F. Gruenewald [email protected] 1
Department of Philosophy, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada
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recognized, evidence-based, cross-disciplinary, and respect trans people’s own health needs and desired outcomes. Sadly, the document in many ways does not live up to this vision, particularly with respect to its recognition of the needs of trans patients themselves. This is important because the document, in its various iterations, does in fact seem to have a great deal of international uptake. Regardless of this uptake, many gender-care experts have critiqued the most recent, seventh version of the WPATH SOC released in 2011.1 Such critiques are compounded by the SOC needing to rely on less qualitatively rigorous research methods than would be ideal, such as “observational studies…and expert opinion”(1099).2 It is alongside these critiques that I argue that one of the central flaws of the WPATH SOC is its insistence on pursuing a model that engages in heavy gatekeeping and regulatory practices in order to ensure that trans people’s
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