Do the New APA Guidelines for Transgender-Affirmative Care Go Far Enough? 

Are “aspirational” guidelines enough?

Photo by wavebreakmedia/Shutterstock

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.