Ruling Trans Health: Mapping How Clinical Documents Coordinate the Assessment Process for Transition-Related Medicine

RATIONALE

The Diagnostic and Statistical Manual of Mental Disorders (DSM) serves a powerful coordinating function in transition medical care for transgender people. Meanwhile, other standardizing clinical texts such as the World Professional Association of Transgender Health (WPATH) standards of care (SOC), also translocally regulate how trans people are approved for hormones and surgical interventions. We studied how the WPATH SOC constrained clinicians’ work of assessing suitability for transition, particularly for patients who experienced mental health challenges.

METHODS

Following the critical research tradition of institutional ethnography, we interviewed 25 key informants to elucidate how the actualities of transition care are shaped by the use of clinical texts in everyday clinical practice. Informants included trans patients, psychiatrists, clinician educators, residents, social workers, and policy experts. An iterative analysis of participant interviews and key texts allowed us to map the textually coordinated healthwork of transition medicine.

FINDINGS

The local interactions between trans patients and clinicians within transition care settings is ruled by the WPATH SOC. Although clinicians articulated skepticism of the DSM’s gender dysphoria diagnosis, the SOC requires clinicians to work with this diagnostic category to approve transition for patients. Clinicians evaluated patients’ overall mental health to rule out perceived contraindications to transition sexes for patients with complex mental health needs (e.g., acute suicidality). Trans patients provided accounts of the work of strategically withholding mental health concerns, including depression and suicidality, from providers during the mental health assessment period to help ensure their access to transition care.

CONCLUSIONS

The WPATH SOC shapes both clinicians’ and trans patients’ movement through the local transition care system. Clinicians are hooked into the SOC’s prescriptive requirements of diagnosing and gatekeeping transition care, while trans patients with complex mental health needs minimize or withhold current challenges, foreclosing opportunities to be referred to relevant mental health care services.