Anyone looking to provide or access gender affirming healthcare will likely come across two common approaches to providing this care. These are the World Professional Association of Transgender Health (WPATH) Standards of Care, and the “Informed Consent Model” of gender affirming care. The differences between these models are nuanced and complicated by outdated information, assumptions about intent, and the fact that both approaches are only guidelines that are often interpreted differently, bent, and changed by individual providers with individual patients.
WPATH Standard of Care
The World Professional Association of Transgender Health Standards of Care (SoC) are the oldest and most commonly used SoC in the world. Originally called the Harry Benjamin Standards of Care, the WPATH SoC date back to the 1970’s and are now in their 7th edition . WPATH “promotes the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People. The SOC are based on the best available science and expert professional consensus.”
For anyone with a basic familiarity with gender affirming care, WPATH is likely the model you have been exposed to. It is the most common model for adult care in the world, and the only generally accepted model for pediatric and adolescent care. This model often includes or requires a sign-off from a mental health professional before beginning medical transition, and emphasizes the role of mental health and medical providers as experts who evaluate and provide care to transgender people.
Transgender community advocates have long been critical of components of the WPATH SoC. However, the 7th edition includes substantial improvements and brings WPATH closer in approach to informed consent models. The 8th edition, a byproduct of the most community-inclusive process to date, brings the models much closer together.
Despite some remaining critiques, WPATH has a number of advantages. In Maine, for example, WPATH is the basis for prior authorization for MaineCare coverage of gender affirming care, and many private insurance companies and surgeons’ offices use it as well. It is commonly used; most providers who do gender affirming care are familiar with it; and large medical and health institutions are comforted by it’s broad adoption globally. Due to these factors, efforts to advance transgender health often include advocating the use of WPATH as a reference or basis for what care should be provided and how.
The Informed Consent Model
A leading alternative to the WPATH standards, especially in the United States, is a collection of approaches commonly grouped together as the “Informed Consent Model.” The Informed Consent Model emphasizes a relationship between medical provider and patient, and generally doesn’t require a mental health diagnosis of gender dysphoria, or a relationship with a mental health provider to offer gender affirming hormone care.
This model is increasingly common. It prioritizes trust in trans people’s self knowledge and agency. It is frequently cheaper and easier to implement than WPATH, as a single prescriber can use the model rather than the network of care needed under WPATH. Many providers in Maine, such as Maine Family Planning, Mabel Wadsworth Center, and Planned Parenthood use variants of the informed consent model. It is important to note, however, that while this model generally has fewer hoops to jump through than WPATH, much more about providing care is left up to the practitioner’s judgment and discretion. In some cases, providers may prescribe hormones after 1-2 appointments and some blood tests, while others may require the appointments to be spread out, or may request a patient gets supporting documentation from a mental health provider should they have any concerns about providing gender affirming care in a specific case.
In a rural state like Maine, the flexibility offered by Informed Consent is useful. There is a severe shortage of mental health providers who offer evaluation and diagnosis of gender dysphoria. By not requiring that evaluation before beginning care, the informed consent model makes care more affordable, accessible, and faster to access. That saves lives. Trusting transgender people is a good approach too.
Informed Consent Models and training on their use are often led by major LGBTQ+ focused community clinics and Federally Qualified Health Centers such as the Fenway Health in Boston, and Callen-Lorde in New York City.
What’s the Difference?
The key difference between WPATH and Informed Consent is the role of the mental health provider, and the level of trust given to transgender patients. Mental health providers offer important support to transgender people under both approaches, but under WPATH they often act as Gate Keepers to care and evaluators with a focus on diagnosis. Under informed consent, medical providers trust transgender people to know themselves and speak with them about their transition goals. The 8th edition of WPATH is expected to move much closer in approach to the informed consent model.
Which do you recommend?
Before we answer that, we just want to make it clear that we aren’t giving medical advice here.
The short answer is: a little bit of both.
MaineTransNet advocates for and refers primarily to Informed Consent clinics in Maine, and Mabel Wadsworth Center is a leader among those clinics. The informed consent model most closely aligns with our values of feminist, holistic, health care and health justice while providing the greatest access to care for the most number of patients.
For pediatric and adolescent care, WPATH is the ONLY generally accepted approach, and the additional safeguards offered by the greater role of mental health providers can be sensible for children and youth still figuring themselves out, and for families who need an extra helping hand. Pediatric care is generally provided by specialized gender clinics where access to both mental health and medical providers is provided under one roof.
But providing care under either model is still a great way to increase access to gender affirming care, and we are happy to have providers in Maine who provide care under both approaches. Transgender people deserve a choice in how they want their care structured. Informed consent seems to work for most of the people we support, but some people like the more traditional approaches offered by WPATH providers and that is fine too.