“I Hope That As Our Selection Becomes More Accurate, the Number … Will Be Very Few”: The Creation of Assessment Criteria for Gender-Affirming Care, 1960s–1980s

Abstract

Mental health clinician assessment has historically been required for trans individuals to access genderaffirming medical procedures. This universal requirement that all trans adults undergo an assessment by a mental health provider specifically (vs. a healthcare provider generally) was not retained in the eighth version of the World Professional Association for Transgender Health Standards of Care. Still, insurance companies and surgeons may maintain universal mental health assessor requirements. The practice of mental health provider assessment for access to gender-affirming care was initially established via expert opinion. In the present analysis, I sought to examine the historical and cultural contexts of these expert opinions during the period from the 1960s through the 1980s. Study methods included Foucauldian genealogy and qualitative thematic analysis. Qualitative analysis regarding the creation of criteria for access to gender-affirming care generated three major themes: cure, prevention, and assimilation. Transgender individuals resisted psychological cures of gender variance, and some were able to access gender-affirming procedures they requested via adherence to normative clinician criteria. Clinicians can repair historical harms by becoming aware of ongoing discourse that positions gender-affirming care as a method of “last resort” and by advocating for access to care that respects patient autonomy.