Dalla Lana researcher challenges international standard of care for trans patients

Kinnon MacKinnon, a postdoctoral researcher at the University of Toronto’s Dalla Lana School of Public Heath, has turned his PhD dissertation into a website tailored for clinicians on trans patient care.

His dissertation focuses mainly on equity in the administration of hormones and surgeries for trans people. As a trans person himself, he argues that the World Professional Association of Transgender Health Standards of Care (WPATH-SOC) guidelines – the trans health “gold standard” for clinicians – are not equitable and can cause more harm than good.

“There is a lack of inclusion of trans health issues in the formal health professional curricula,” says MacKinnon. “This online platform was developed to fill in that gap and to help clinicians to care for transgender people more equitably.”

For instance, the WPATH-SOC guidelines state that clinicians must first diagnose gender dysphoria. Trans health advocates, including MacKinnon, argue that this step pathologizes trans people’s experiences and their identities.

“Research has demonstrated that when a diagnosis is required to access medical treatment, trans people will strategically say whatever it is that they need to say to receive the care they need,” says MacKinnon.

“They feel they can’t be honest about depression, suicidal thoughts and they might not tell their doctors that to leverage access to medical treatment if needed. So what this creates is a medically risky scenario which will make trans people deny or downplay any mental health issues. If clinicians strictly adhere to the protocol, they will create more barriers, often preventing access to hormones or surgeries until the patient is deemed mentally ‘ready.’”

In his recently defended dissertation, MacKinnon spoke to 22 key sources, including clinicians, clinician-educators, and clinic administrators, about the WPATH-SOC guidelines. Suicide, depression and schizophrenia were deemed complex mental health issues, and many providers relied heavily on standardized clinical protocols for treatments. Some clinician-educators taught learners how to interpret the guidelines equitably for complex situations.

“The person is asking you for surgery. We need to get them to surgery – that’s the treatment. I’m using that language because people [learners] will go, ‘Yes, but.’ But what? If the person were diabetic and depressed, anxious, or whatever, you wouldn’t hold off on the diabetes treatment,” a clinician told MacKinnon.

The guideline also recommends that a patient’s mental illness must be “controlled” before receiving treatment. MacKinnon’s website reinterprets the international guideline ethically. In each reinterpretation, a rationale for the new interpretation, supported by research, is provided.

Rather than insisting on diagnosing gender dysphoria, for instance, the website recommends discussing a patient’s gender identity and transition goals. If a patient desires a course of treatment, says MacKinnon, clinicians should ensure that the patients understand the risk and consequences without strictly applying the WPATH-SOC guidelines.

Although the site is catered to clinicians, MacKinnon hopes trans people like himself will find value in the recommendations.

“This site promotes patient autonomy and self-determination in care which trans people, unfortunately, have not had a lot of,” says MacKinnon. “This site really aims to really focus on patient-centred care.”

MacKinnon presented the new site and his PhD study at the International Academy of Law and Mental Health Conference in Rome earlier this summer and will do so again later this month in Vienna at the general assembly of the Association for Medical Education in Europe.