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Wpath Soc 2011 PDF
Wpath Soc 2011 PDF
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,
Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R.,
Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I.,
Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B.,
Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S.,
Wylie, K. R., & Zucker, K.
ABSTRACT. The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender
Nonconforming People is a publication of the World Professional Association for Transgender Health
(WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to
assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to
achieving lasting personal comfort with their gendered selves, in order to maximize their overall health,
psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic
and urologic care, reproductive options, voice and communication therapy, mental health services (e.g.,
assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based
on the best available science and expert professional consensus. Because most of the research and
experience in this field comes from a North American and Western European perspective, adaptations
of the SOC to other parts of the world are necessary. The SOC articulate standards of care while
acknowledging the role of making informed choices and the value of harm reduction approaches. In
addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or
distress that is caused by a discrepancy between persons gender identity and that persons sex assigned
at birth (and the associated gender role and/or primary and secondary sex characteristics) has become
more individualized. Some individuals who present for care will have made significant self-directed
progress towards gender role changes or other resolutions regarding their gender identity or gender
dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC
to help patients consider the full range of health services open to them, in accordance with their clinical
needs and goals for gender expression.
This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous
revisions were in 1980, 1981, 1990, 1998, and 2001.
Address correspondence to Eli Coleman, PhD, Program in Human Sexuality, University of Minnesota
Medical School, 1300 South 2nd Street, Suite 180, Minneapolis, MN 55454. E-mail: colem001@umn.edu
165
166 INTERNATIONAL JOURNAL OF TRANSGENDERISM
valuable for the accumulation of new data, which initiate a change in their gender expression
can be retrospectively examined to allow for and physical characteristics while in their teens
health care—and the SOC—to evolve. or even earlier. Many grow up and live in
The SOC articulate standards of care but a social, cultural, and even linguistic context
also acknowledge the role of making informed quite unlike that of Western cultures. Yet almost
choices and the value of harm-reduction ap- all experience prejudice (Peletz, 2006; Winter,
proaches. In addition, this version of the SOC 2009). In many cultures, social stigma towards
recognizes and validates various expressions of gender nonconformity is widespread and gender
gender that may not necessitate psychological, roles are highly prescriptive (Winter et al., 2009).
hormonal, or surgical treatments. Some patients Gender-nonconforming people in these settings
who present for care will have made signifi- are forced to be hidden and, therefore, may lack
cant self-directed progress towards gender role opportunities for adequate health care (Winter,
changes, transition, or other resolutions regard- 2009).
ing their gender identity or gender dysphoria. The SOC are not intended to limit efforts
Other patients will require more intensive ser- to provide the best available care to all in-
vices. Health professionals can use the SOC to dividuals. Health professionals throughout the
help patients consider the full range of health world—even in areas with limited resources
services open to them, in accordance with their and training opportunities—can apply the many
clinical needs and goals for gender expression. core principles that undergird the SOC. These
principles include the following: Exhibit re-
spect for patients with nonconforming gender
II. GLOBAL APPLICABILITY OF THE identities (do not pathologize differences in
STANDARDS OF CARE gender identity or expression); provide care
(or refer to knowledgeable colleagues) that
While the SOC are intended for worldwide affirms patients’ gender identities and reduces
use, WPATH acknowledges that much of the the distress of gender dysphoria, when present;
recorded clinical experience and knowledge in become knowledgeable about the health care
this area of health care is derived from North needs of transsexual, transgender, and gender-
American and Western European sources. From nonconforming people, including the benefits
place to place, both across and within nations, and risks of treatment options for gender dys-
there are differences in all of the following: phoria; match the treatment approach to the
social attitudes towards transsexual, transgender, specific needs of patients, particularly their goals
and gender-nonconforming people; construc- for gender expression and need for relief from
tions of gender roles and identities; language gender dysphoria; facilitate access to appropriate
used to describe different gender identities; care; seek patients’ informed consent before
epidemiology of gender dysphoria; access to and providing treatment; offer continuity of care; and
cost of treatment; therapies offered; number and be prepared to support and advocate for patients
type of professionals who provide care; and legal within their families and communities (schools,
and policy issues related to this area of health workplaces, and other settings).
care (Winter, 2009). Terminology is culturally and time-dependent
It is impossible for the SOC to reflect all of and is rapidly evolving. It is important to use
these differences. In applying these standards respectful language in different places and times,
to other cultural contexts, health professionals and among different people. As the SOC are
must be sensitive to these differences and translated into other languages, great care must
adapt the SOC according to local realities. be taken to ensure that the meanings of terms are
For example, in a number of cultures, gender- accurately translated. Terminology in English
nonconforming people are found in such num- may not be easily translated into other languages,
bers and living in such ways as to make them and vice versa. Some languages do not have
highly socially visible (Peletz, 2006). In settings equivalent words to describe the various terms
such as these, it is common for people to within this document; hence, translators should
168 INTERNATIONAL JOURNAL OF TRANSGENDERISM
be cognizant of the underlying goals of treatment of Medicine, 2011). Gender dysphoria refers to
and articulate culturally applicable guidance for discomfort or distress that is caused by a discrep-
reaching those goals. ancy between a person’s gender identity and that
person’s sex assigned at birth (and the associated
gender role and/or primary and secondary sex
III. THE DIFFERENCE BETWEEN characteristics) (Fisk, 1974; Knudson, De
GENDER NONCONFORMITY Cuypere, & Bockting, 2010b). Only some
AND GENDER DYSPHORIA gender-nonconforming people experience
gender dysphoria at some point in their lives.
Being Transsexual, Transgender, Treatment is available to assist people with
or Gender Nonconforming Is a Matter such distress to explore their gender identity
and find a gender role that is comfortable for
of Diversity, Not Pathology them (Bockting & Goldberg, 2006). Treatment is
WPATH released a statement in May 2010 individualized: What helps one person alleviate
urging the de-psychopathologization of gender gender dysphoria might be very different from
nonconformity worldwide (WPATH Board of what helps another person. This process may
Directors, 2010). This statement noted that “the or may not involve a change in gender expres-
expression of gender characteristics, including sion or body modifications. Medical treatment
identities, that are not stereotypically associated options include, for example, feminization or
with one’s assigned sex at birth is a common masculinization of the body through hormone
and culturally diverse human phenomenon [that] therapy and/or surgery, which are effective in
should not be judged as inherently pathological alleviating gender dysphoria and are medically
or negative.” necessary for many people. Gender identities
Unfortunately, there is a stigma attached to and expressions are diverse, and hormones and
gender nonconformity in many societies around surgery are just two of many options available
the world. Such stigma can lead to prejudice to assist people with achieving comfort with self
and discrimination, resulting in “minority stress” and identity.
(I. H. Meyer, 2003). Minority stress is unique Gender dysphoria can in large part be alle-
(additive to general stressors experienced by viated through treatment (Murad et al., 2010).
all people), socially based, and chronic, and Hence, while transsexual, transgender, and
may make transsexual, transgender, and gender- gender-nonconforming people may experience
nonconforming individuals more vulnerable to gender dysphoria at some points in their lives,
developing mental health problems such as many individuals who receive treatment will find
anxiety and depression (Institute of Medicine, a gender role and expression that is comfortable
2011). In addition to prejudice and discrimina- for them, even if these differ from those asso-
tion in society at large, stigma can contribute ciated with their sex assigned at birth, or from
to abuse and neglect in one’s relationships with prevailing gender norms and expectations.
peers and family members, which in turn can
lead to psychological distress. However, these Diagnoses Related to Gender Dysphoria
symptoms are socially induced and are not
inherent to being transsexual, transgender, or Some people experience gender dysphoria
gender-nonconforming. at such a level that the distress meets criteria
for a formal diagnosis that might be classi-
Gender Nonconformity Is Not the Same fied as a mental disorder. Such a diagnosis
as Gender Dysphoria is not a license for stigmatization or for the
deprivation of civil and human rights. Existing
Gender nonconformity refers to the extent classification systems such as the Diagnostic
to which a person’s gender identity, role, Statistical Manual of Mental Disorders (DSM)
or expression differs from the cultural norms (American Psychiatric Association, 2000) and
prescribed for people of a particular sex (Institute the International Classification of Diseases
Coleman et al. 169
(ICD) (World Health Organization, 2007) define that cultural differences from one country to
hundreds of mental disorders that vary in onset, another would alter both the behavioral ex-
duration, pathogenesis, functional disability, and pressions of different gender identities and the
treatability. All of these systems attempt to extent to which gender dysphoria—distinct from
classify clusters of symptoms and conditions, one’s gender identity—is actually occurring in a
not the individuals themselves. A disorder is a population. While in most countries, crossing
description of something with which a person normative gender boundaries generates moral
might struggle, not a description of the person censure rather than compassion, there are exam-
or the person’s identity. ples in certain cultures of gender-nonconforming
Thus, transsexual, transgender, and gender- behaviors (e.g., in spiritual leaders) that are less
nonconforming individuals are not inherently stigmatized and even revered (Besnier, 1994;
disordered. Rather, the distress of gender dys- Bolin, 1988; Chiñas, 1995; Coleman, Colgan, &
phoria, when present, is the concern that might Gooren, 1992; Costa & Matzner, 2007; Jackson
be diagnosable and for which various treatment & Sullivan, 1999; Nanda, 1998; Taywaditep,
options are available. The existence of a diagno- Coleman, & Dumronggittigule, 1997).
sis for such dysphoria often facilitates access to For various reasons, researchers who have
health care and can guide further research into studied incidence and prevalence have tended
effective treatments. to focus on the most easily counted subgroup of
Research is leading to new diagnostic nomen- gender-nonconforming individuals: transsexual
clatures, and terms are changing in both the DSM individuals who experience gender dysphoria
(Cohen-Kettenis & Pfäfflin, 2010; Knudson, De and who present for gender-transition-related
Cuypere, & Bockting, 2010b; Meyer-Bahlburg, care at specialist gender clinics (Zucker &
2010; Zucker, 2010) and the ICD. For this Lawrence, 2009). Most studies have been con-
reason, familiar terms are employed in the ducted in European countries such as Sweden
SOC and definitions are provided for terms that (Wålinder, 1968, 1971), the United Kingdom
may be emerging. Health professionals should (Hoenig & Kenna, 1974), the Netherlands
refer to the most current diagnostic criteria and (Bakker, Van Kesteren, Gooren, & Bezemer,
appropriate codes to apply in their practice areas. 1993; Eklund, Gooren, & Bezemer, 1988; van
Kesteren, Gooren, & Megens, 1996), Germany
(Weitze & Osburg, 1996), and Belgium (De
IV. EPIDEMIOLOGIC Cuypere et al., 2007). One was conducted in
CONSIDERATIONS Singapore (Tsoi, 1988).
De Cuypere and colleagues (2007) reviewed
Formal epidemiologic studies on the such studies, as well as conducted their own.
incidence3 and prevalence4 of transsexual- Together, those studies span 39 years. Leaving
ism specifically or transgender and gender- aside two outlier findings from Pauly in 1965
nonconforming identities in general have not and Tsoi in 1988, ten studies involving eight
been conducted, and efforts to achieve realistic countries remain. The prevalence figures re-
estimates are fraught with enormous difficul- ported in these ten studies range from 1:11,900 to
ties (Institute of Medicine, 2011; Zucker & 1:45,000 for male-to-female individuals (MtF)
Lawrence, 2009). Even if epidemiologic studies and 1:30,400 to 1:200,000 for female-to-male
established that a similar proportion of trans- (FtM) individuals. Some scholars have sug-
sexual, transgender, or gender-nonconforming gested that the prevalence is much higher,
people existed all over the world, it is likely depending on the methodology used in the
research (e.g., Olyslager & Conway, 2007).
3 Direct comparisons across studies are impos-
Incidence—the number of new cases arising in
a given period (e.g., a year). sible, as each differed in their data collection
4
Prevalence—the number of individuals having methods and in their criteria for documenting
a 4035 condition, divided by the number of people in a person as transsexual (e.g., whether or not
the general population. a person had undergone genital reconstruction,
170 INTERNATIONAL JOURNAL OF TRANSGENDERISM
versus had initiated hormone therapy, versus had Overall, the existing data should be consid-
come to the clinic seeking medically supervised ered a starting point, and health care would
transition services). The trend appears to be benefit from more rigorous epidemiologic study
towards higher prevalence rates in the more in different locations worldwide.
recent studies, possibly indicating increasing
numbers of people seeking clinical care. Support
for this interpretation comes from research by V. OVERVIEW OF THERAPEUTIC
Reed and colleagues (2009), who reported a APPROACHES FOR GENDER
doubling of the numbers of people accessing DYSPHORIA
care at gender clinics in the United Kingdom
every five or six years. Similarly, Zucker and Advancements in the Knowledge and
colleagues (2008) reported a four- to five-fold Treatment of Gender Dysphoria
increase in child and adolescent referrals to their
Toronto, Canada, clinic over a 30-year period. In the second half of the 20th century,
The numbers yielded by studies such as these awareness of the phenomenon of gender
can be considered minimum estimates at best. dysphoria increased when health professionals
The published figures are mostly derived from began to provide assistance to alleviate gender
clinics where patients met criteria for severe dysphoria by supporting changes in primary and
gender dysphoria and had access to health care secondary sex characteristics through hormone
at those clinics. These estimates do not take into therapy and surgery, along with a change in
account that treatments offered in a particular gender role. Although Harry Benjamin already
clinic setting might not be perceived as afford- acknowledged a spectrum of gender noncon-
able, useful, or acceptable by all self-identified formity (Benjamin, 1966), the initial clinical
gender dysphoric individuals in a given area. By approach largely focused on identifying who was
counting only those people who present at clinics an appropriate candidate for sex reassignment to
for a specific type of treatment, an unspecified facilitate a physical change from male to female
number of gender dysphoric individuals are or female to male as completely as possible (e.g.,
overlooked. Green & Fleming, 1990; Hastings, 1974). This
Other clinical observations (not yet firmly approach was extensively evaluated and proved
supported by systematic study) support the to be highly effective. Satisfaction rates across
likelihood of a higher prevalence of gender studies ranged from 87% of MtF patients to
dysphoria: (i) Previously unrecognized gender 97% of FtM patients (Green & Fleming, 1990),
dysphoria is occasionally diagnosed when pa- and regrets were extremely rare (1%–1.5%
tients are seen with anxiety, depression, conduct of MtF patients and < 1% of FtM patients;
disorder, substance abuse, dissociative identity Pfäfflin, 1993). Indeed, hormone therapy and
disorders, borderline personality disorder, sex- surgery have been found to be medically
ual disorders, and disorders of sex develop- necessary to alleviate gender dysphoria in many
ment (Cole, O’Boyle, Emory, & Meyer, 1997). people (American Medical Association, 2008;
(ii) Some cross-dressers, drag queens/kings or Anton, 2009; World Professional Association
female/male impersonators, and gay and les- for Transgender Health, 2008).
bian individuals may be experiencing gender As the field matured, health professionals
dysphoria (Bullough & Bullough, 1993). (iii) recognized that while many individuals need
The intensity of some people’s gender dysphoria both hormone therapy and surgery to alleviate
fluctuates below and above a clinical thresh- their gender dysphoria, others need only one of
old (Docter, 1988). (iv) Gender nonconformity these treatment options and some need neither
among FtM individuals tends to be relatively in- (Bockting & Goldberg, 2006; Bockting, 2008;
visible in many cultures, particularly to Western Lev, 2004). Often with the help of psychother-
health professionals and researchers who have apy, some individuals integrate their trans-
conducted most of the studies on which the or cross-gender feelings into the gender role
current estimates of prevalence and incidence they were assigned at birth and do not feel the
are based (Winter, 2009). need to feminize or masculinize their body. For
Coleman et al. 171
others, changes in gender role and expression Options for Psychological and Medical
are sufficient to alleviate gender dysphoria. Treatment of Gender Dysphoria
Some patients may need hormones, a possible
change in gender role, but not surgery; others For individuals seeking care for gender
may need a change in gender role along with dysphoria, a variety of therapeutic options
surgery but not hormones. In other words, can be considered. The number and type of
treatment for gender dysphoria has become interventions applied and the order in which
more individualized. these take place may differ from person to person
As a generation of transsexual, transgender, (e.g., Bockting, Knudson, & Goldberg, 2006;
and gender-nonconforming individuals has Bolin, 1994; Rachlin, 1999; Rachlin, Green, &
come of age—many of whom have benefitted Lombardi, 2008; Rachlin, Hansbury, & Pardo,
from different therapeutic approaches—they 2010). Treatment options include the following:
have become more visible as a community and
demonstrated considerable diversity in their • Changes in gender expression and role
gender identities, roles, and expressions. Some (which may involve living part time or full
individuals describe themselves not as gender- time in another gender role, consistent with
nonconforming but as unambiguously cross- one’s gender identity);
sexed (i.e., as a member of the other sex; Bockt- • Hormone therapy to feminize or masculin-
ing, 2008). Other individuals affirm their unique ize the body;
gender identity and no longer consider them- • Surgery to change primary and/or sec-
selves to be either male or female (Bornstein, ondary sex characteristics (e.g., breasts/
1994; Kimberly, 1997; Stone, 1991; Warren, chest, external and/or internal genitalia,
1993). Instead, they may describe their gender facial features, body contouring);
identity in specific terms such as transgender, • Psychotherapy (individual, couple, family,
bigender, or genderqueer, affirming their unique or group) for purposes such as explor-
experiences that may transcend a male/female ing gender identity, role, and expression;
binary understanding of gender (Bockting, addressing the negative impact of gender
2008; Ekins & King, 2006; Nestle, Wilchins, & dysphoria and stigma on mental health;
Howell, 2002). They may not experience their alleviating internalized transphobia; en-
process of identity affirmation as a “transition,” hancing social and peer support; improving
because they never fully embraced the gender body image; or promoting resilience.
role they were assigned at birth or because Options for Social Support and Changes
they actualize their gender identity, role, and
expression in a way that does not involve a
in Gender Expression
change from one gender role to another. For In addition (or as an alternative) to the
example, some youth identifying as genderqueer psychological- and medical-treatment options
have always experienced their gender identity described above, other options can be considered
and role as such (genderqueer). Greater public to help alleviate gender dysphoria, for example:
visibility and awareness of gender diversity
(Feinberg, 1996) have further expanded options • In person and online peer support re-
for people with gender dysphoria to actualize an sources, groups, or community organi-
identity and find a gender role and expression zations that provide avenues for social
that are comfortable for them. support and advocacy;
Health professionals can assist gender dys- • In person and online support resources for
phoric individuals with affirming their gender families and friends;
identity, exploring different options for expres- • Voice and communication therapy to help
sion of that identity, and making decisions about individuals develop verbal and nonverbal
medical treatment options for alleviating gender communication skills that facilitate com-
dysphoria. fort with their gender identity;
172 INTERNATIONAL JOURNAL OF TRANSGENDERISM
• Hair removal through electrolysis, laser 1984). Newer studies, also including girls,
treatment, or waxing; showed a 12%–27% persistence rate of gender
• Breast binding or padding, genital tucking dysphoria into adulthood (Drummond, Bradley,
or penile prostheses, padding of hips or Peterson-Badali, & Zucker, 2008; Wallien &
buttocks; Cohen-Kettenis, 2008).
• Changes in name and gender marker on In contrast, the persistence of gender dyspho-
identity documents. ria into adulthood appears to be much higher for
adolescents. No formal prospective studies exist.
However, in a follow-up study of 70 adolescents
VI. ASSESSMENT AND TREATMENT who were diagnosed with gender dysphoria and
OF CHILDREN AND ADOLESCENTS given puberty-suppressing hormones, all con-
WITH GENDER DYSPHORIA tinued with actual sex reassignment, beginning
with feminizing/masculinizing hormone therapy
There are a number of differences in the phe- (de Vries, Steensma, Doreleijers, & Cohen-
nomenology, developmental course, and treat- Kettenis, 2010).
ment approaches for gender dysphoria in chil- Another difference between gender dysphoric
dren, adolescents, and adults. In children and children and adolescents is in the sex ratios
adolescents, a rapid and dramatic developmental for each age group. In clinically referred,
process (physical, psychological, and sexual) gender dysphoric children under age 12, the
is involved and there is greater fluidity and male/female ratio ranges from 6:1 to 3:1 (Zucker,
variability in outcomes, particularly in prepu- 2004). In clinically referred, gender dysphoric
bertal children. Accordingly, this section of the adolescents older than age 12, the male/female
SOC offers specific clinical guidelines for the ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin,
assessment and treatment of gender dysphoric 2003).
children and adolescents. As discussed in section IV and by Zucker and
Lawrence (2009), formal epidemiologic studies
Differences Between Children and on gender dysphoria—in children, adolescents,
Adolescents with Gender Dysphoria and adults—are lacking. Additional research
is needed to refine estimates of its preva-
An important difference between gender lence and persistence in different populations
dysphoric children and adolescents is in the worldwide.
proportion for whom dysphoria persists into
adulthood. Gender dysphoria during childhood Phenomenology in Children
does not inevitably continue into adulthood.5
Rather, in follow-up studies of prepubertal Children as young as age two may show
children (mainly boys) who were referred to features that could indicate gender dysphoria.
clinics for assessment of gender dysphoria, the They may express a wish to be of the other
dysphoria persisted into adulthood for only sex and be unhappy about their physical sex
6%–23% of children (Cohen-Kettenis, 2001; characteristics and functions. In addition, they
Zucker & Bradley, 1995). Boys in these studies may prefer clothes, toys, and games that are com-
were more likely to identify as gay in adulthood monly associated with the other sex and prefer
than as transgender (Green, 1987; Money & playing with other-sex peers. There appears to be
Russo, 1979; Zucker & Bradley, 1995; Zuger, heterogeneity in these features: Some children
demonstrate extremely gender-nonconforming
behavior and wishes, accompanied by persistent
5 and severe discomfort with their primary sex
Gender-nonconforming behaviors in children
may continue into adulthood, but such behaviors are characteristics. In other children, these char-
not necessarily indicative of gender dysphoria and a acteristics are less intense or only partially
need for treatment. As described in section III, gender
dysphoria is not synonymous with diversity in gender
present (Cohen-Kettenis et al., 2006; Knudson,
expression. De Cuypere, & Bockting, 2010a).
Coleman et al. 173
It is relatively common for gender dysphoric first Tanner stages—differs among countries and
children to have coexisting internalizing disor- centers. Not all clinics offer puberty suppression.
ders such as anxiety and depression (Cohen- If such treatment is offered, the pubertal stage
Kettenis, Owen, Kaijser, Bradley, & Zucker, at which adolescents are allowed to start varies
2003; Wallien, Swaab, & Cohen-Kettenis, 2007; from Tanner stage 2 to stage 4 (Delemarre-van
Zucker, Owen, Bradley, & Ameeriar, 2002). de Waal & Cohen-Kettenis, 2006; Zucker et al.,
The prevalence of autism spectrum disorders 2012). The percentages of treated adolescents
seems to be higher in clinically referred, gender are likely influenced by the organization
dysphoric children than in the general popu- of health care, insurance aspects, cultural
lation (de Vries, Noens, Cohen-Kettenis, van differences, opinions of health professionals,
Berckelaer-Onnes, & Doreleijers, 2010). and diagnostic procedures offered in different
settings.
Phenomenology in Adolescents Inexperienced clinicians may mistake indica-
tions of gender dysphoria for delusions. Phe-
In most children, gender dysphoria will dis- nomenologically, there is a qualitative difference
appear before, or early in, puberty. However, between the presentation of gender dysphoria
in some children these feelings will intensify and the presentation of delusions or other psy-
and body aversion will develop or increase as chotic symptoms. The vast majority of children
they become adolescents and their secondary sex and adolescents with gender dysphoria are not
characteristics develop (Cohen-Kettenis, 2001; suffering from underlying severe psychiatric
Cohen-Kettenis & Pfäfflin, 2003; Drummond illness such as psychotic disorders (Steensma,
et al., 2008; Wallien & Cohen-Kettenis, 2008; Biemond, de Boer, & Cohen-Kettenis, published
Zucker & Bradley, 1995). Data from one study online ahead of print January 7, 2011).
suggest that more extreme gender nonconfor- It is more common for adolescents with gen-
mity in childhood is associated with persistence der dysphoria to have coexisting internalizing
of gender dysphoria into late adolescence and disorders such as anxiety and depression, and/or
early adulthood (Wallien & Cohen-Kettenis, externalizing disorders such as oppositional
2008). Yet many adolescents and adults pre- defiant disorder (de Vries et al., 2010). As in
senting with gender dysphoria do not report children, there seems to be a higher prevalence of
a history of childhood gender-nonconforming autistic spectrum disorders in clinically referred,
behaviors (Docter, 1988; Landén, Wålinder, gender dysphoric adolescents than in the general
& Lundström, 1998). Therefore, it may come adolescent population (de Vries et al., 2010).
as a surprise to others (parents, other family
members, friends, and community members) Competency of Mental Health
when a youth’s gender dysphoria first becomes Professionals Working with Children
evident in adolescence. or Adolescents with Gender Dysphoria
Adolescents who experience their primary
and/or secondary sex characteristics and their The following are recommended minimum
sex assigned at birth as inconsistent with their credentials for mental health professionals who
gender identity may be intensely distressed assess, refer, and offer therapy to children and
about it. Many, but not all, gender dysphoric adolescents presenting with gender dysphoria:
adolescents have a strong wish for hormones
and surgery. Increasing numbers of adolescents 1. Meet the competency requirements for
have already started living in their desired gender mental health professionals working with
role upon entering high school (Cohen-Kettenis adults, as outlined in section VII;
& Pfäfflin, 2003). 2. Trained in childhood and adolescent devel-
Among adolescents who are referred to opmental psychopathology;
gender identity clinics, the number considered 3. Competent in diagnosing and treating the
eligible for early medical treatment—starting ordinary problems of children and adoles-
with GnRH analogues to suppress puberty in the cents.
174 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Roles of Mental Health Professionals support, such as support groups for parents
Working with Children and Adolescents of gender-nonconforming and transgender
with Gender Dysphoria children (Gold & MacNish, 2011; Pleak,
1999; Rosenberg, 2002).
The roles of mental health professionals
working with gender dysphoric children and Assessment and psychosocial interventions for
adolescents may include the following: children and adolescents are often provided
within a multidisciplinary gender identity
1. Directly assess gender dysphoria in chil- specialty service. If such a multidisciplinary
dren and adolescents (see general guide- service is not available, a mental health profes-
lines for assessment, below). sional should provide consultation and liaison
2. Provide family counseling and support- arrangements with a pediatric endocrinologist
ive psychotherapy to assist children and for the purpose of assessment, education, and
adolescents with exploring their gender involvement in any decisions about physical
identity, alleviating distress related to their interventions.
gender dysphoria, and ameliorating any
other psychosocial difficulties. Psychological Assessment of Children
3. Assess and treat any coexisting mental and Adolescents
health concerns of children or adolescents
(or refer to another mental health pro- When assessing children and adolescents who
fessional for treatment). Such concerns present with gender dysphoria, mental health
should be addressed as part of the overall professionals should broadly conform to the
treatment plan. following guidelines:
4. Refer adolescents for additional physical
interventions (such as puberty-suppressing 1. Mental health professionals should not
hormones) to alleviate gender dysphoria. dismiss or express a negative attitude
The referral should include documentation towards nonconforming gender identities
of an assessment of gender dysphoria and or indications of gender dysphoria. Rather,
mental health, the adolescent’s eligibility they should acknowledge the presenting
for physical interventions (outlined be- concerns of children, adolescents, and their
low), the mental health professional’s rel- families; offer a thorough assessment for
evant expertise, and any other information gender dysphoria and any coexisting men-
pertinent to the youth’s health and referral tal health concerns; and educate clients and
for specific treatments. their families about therapeutic options,
5. Educate and advocate on behalf of gender if needed. Acceptance, and alleviation of
dysphoric children, adolescents, and their secrecy, can bring considerable relief to
families in their community (e.g., day care gender dysphoric children/adolescents and
centers, schools, camps, other organiza- their families.
tions). This is particularly important in 2. Assessment of gender dysphoria and men-
light of evidence that children and adoles- tal health should explore the nature and
cents who do not conform to socially pre- characteristics of a child’s or adolescent’s
scribed gender norms may experience ha- gender identity. A psychodiagnostic and
rassment in school (Grossman, D’Augelli, psychiatric assessment—covering the ar-
Howell, & Hubbard, 2006; Grossman, eas of emotional functioning, peer and
D’Augelli, & Salter, 2006; Sausa, 2005), other social relationships, and intellectual
putting them at risk for social isolation, functioning/school achievement—should
depression, and other negative sequelae be performed. Assessment should include
(Nuttbrock et al., 2010). an evaluation of the strengths and weak-
6. Provide children, youth, and their families nesses of family functioning. Emotional
with information and referral for peer and behavioral problems are relatively
Coleman et al. 175
common, and unresolved issues in a child’s de Waal, 2006; Di Ceglie & Thümmel,
or youth’s environment may be present (de 2006; Hill, Menvielle, Sica, & Johnson,
Vries, Doreleijers, Steensma, & Cohen- 2010; Malpas, 2011; Menvielle & Tuerk,
Kettenis, 2011; Di Ceglie & Thümmel, 2002; Rosenberg, 2002; Vanderburgh,
2006; Wallien et al., 2007). 2009; Zucker, 2006).
3. For adolescents, the assessment phase Treatment aimed at trying to change a
should also be used to inform youth and person’s gender identity and expression to
their families about the possibilities and become more congruent with sex assigned
limitations of different treatments. This at birth has been attempted in the past
is necessary for informed consent and without success (Gelder & Marks, 1969;
also important for assessment. The way Greenson, 1964), particularly in the long
that adolescents respond to information term (Cohen-Kettenis & Kuiper, 1984;
about the reality of sex reassignment Pauly, 1965). Such treatment is no longer
can be diagnostically informative. Correct considered ethical.
information may alter a youth’s desire 3. Families should be supported in managing
for certain treatment, if the desire was uncertainty and anxiety about their child’s
based on unrealistic expectations of its or adolescent’s psychosexual outcomes
possibilities. and in helping youth to develop a positive
self-concept.
Psychological and Social Interventions for 4. Mental health professionals should not im-
Children and Adolescents pose a binary view of gender. They should
give ample room for clients to explore
When supporting and treating children and different options for gender expression.
adolescents with gender dysphoria, health pro- Hormonal or surgical interventions are
fessionals should broadly conform to the follow- appropriate for some adolescents but not
ing guidelines: for others.
5. Clients and their families should be sup-
1. Mental health professionals should help ported in making difficult decisions re-
families to have an accepting and nurturing garding the extent to which clients are
response to the concerns of their gender allowed to express a gender role that is
dysphoric child or adolescent. Families consistent with their gender identity, as
play an important role in the psychological well as the timing of changes in gender
health and well-being of youth (Brill & role and possible social transition. For
Pepper, 2008; Lev, 2004). This also applies example, a client might attend school while
to peers and mentors from the community, undergoing social transition only partly
who can be another source of social (e.g., by wearing clothing and having a
support. hairstyle that reflects gender identity) or
2. Psychotherapy should focus on reducing completely (e.g., by also using a name and
a child’s or adolescent’s distress pronouns congruent with gender identity).
related to the gender dysphoria and Difficult issues include whether and when
on ameliorating any other psychosocial to inform other people of the client’s
difficulties. For youth pursuing sex situation, and how others in their lives
reassignment, psychotherapy may focus might respond.
on supporting them before, during, and 6. Health professionals should support clients
after reassignment. Formal evaluations of and their families as educators and advo-
different psychotherapeutic approaches cates in their interactions with community
for this situation have not been published, members and authorities such as teachers,
but several counseling methods have school boards, and courts.
been described (Cohen-Kettenis, 2006; de 7. Mental health professionals should strive
Vries, Cohen-Kettenis, & Delemarre-van to maintain a therapeutic relationship with
176 INTERNATIONAL JOURNAL OF TRANSGENDERISM
and consequently delay the physical formity and other developmental issues and (ii)
changes of puberty. Alternative treat- their use may facilitate transition by preventing
ment options include progestins (most the development of sex characteristics that are
commonly medroxyprogesterone) or other difficult or impossible to reverse if adolescents
medications (such as spironolactone) that continue on to pursue sex reassignment.
decrease the effects of androgens secreted Puberty suppression may continue for a few
by the testicles of adolescents who are years, at which time a decision is made to either
not receiving GnRH analogues. Continu- discontinue all hormone therapy or transition to
ous oral contraceptives (or depot medrox- a feminizing/masculinizing hormone regimen.
yprogesterone) may be used to suppress Pubertal suppression does not inevitably lead to
menses. social transition or to sex reassignment.
2. Partially reversible interventions. These
include hormone therapy to masculinize or Criteria for Puberty-Suppressing Hormones
feminize the body. Some hormone-induced
changes may need reconstructive surgery In order for adolescents to receive puberty-
to reverse the effect (e.g., gynaecomastia suppressing hormones, the following minimum
caused by estrogens), while other changes criteria must be met:
are not reversible (e.g., deepening of the
voice caused by testosterone). 1. The adolescent has demonstrated a long-
3. Irreversible interventions. These are surgi- lasting and intense pattern of gender non-
cal procedures. conformity or gender dysphoria (whether
suppressed or expressed);
A staged process is recommended to keep op- 2. Gender dysphoria emerged or worsened
tions open through the first two stages. Moving with the onset of puberty;
from one stage to another should not occur until 3. Any coexisting psychological, medical,
there has been adequate time for adolescents and or social problems that could interfere
their parents to assimilate fully the effects of with treatment (e.g., that may compromise
earlier interventions. treatment adherence) have been addressed,
such that the adolescent’s situation and
functioning are stable enough to start
Fully Reversible Interventions treatment;
Adolescents may be eligible for 4. The adolescent has given informed consent
puberty-suppressing hormones as soon as and, particularly when the adolescent has
pubertal changes have begun. In order for not reached the age of medical consent,
adolescents and their parents to make an the parents or other caretakers or guardians
informed decision about pubertal delay, it is have consented to the treatment and are
recommended that adolescents experience the involved in supporting the adolescent
onset of puberty to at least Tanner Stage 2. Some throughout the treatment process.
children may arrive at this stage at very young
ages (e.g., 9 years of age). Studies evaluating Regimens, Monitoring, and Risks for Pu-
this approach have only included children who berty Suppression
were at least 12 years of age (Cohen-Kettenis,
Schagen, Steensma, de Vries, & Delemarre-van For puberty suppression, adolescents with
de Waal, 2011; de Vries, Steensma et al., 2010; male genitalia should be treated with GnRH
Delemarre-van de Waal, van Weissenbruch, & analogues, which stop luteinizing hormone se-
Cohen Kettenis, 2004; Delemarre-van de Waal cretion and therefore testosterone secretion.
& Cohen-Kettenis, 2006). Alternatively, they may be treated with pro-
Two goals justify intervention with puberty- gestins (such as medroxyprogesterone) or with
suppressing hormones: (i) their use gives adoles- other medications that block testosterone se-
cents more time to explore their gender noncon- cretion and/or neutralize testosterone action.
178 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Adolescents with female genitalia should be with parental consent. In many countries, 16-
treated with GnRH analogues, which stop the year-olds are legal adults for medical decision-
production of estrogens and progesterone. Al- making and do not require parental consent. Ide-
ternatively, they may be treated with progestins ally, treatment decisions should be made among
(such as medroxyprogesterone). Continuous oral the adolescent, the family, and the treatment
contraceptives (or depot medroxyprogesterone) team.
may be used to suppress menses. In both groups Regimens for hormone therapy in gender
of adolescents, use of GnRH analogues is the dysphoric adolescents differ substantially from
preferred treatment (Hembree et al., 2009), but those used in adults (Hembree et al., 2009).
their high cost is prohibitive for some patients. The hormone regimens for youth are adapted to
During pubertal suppression, an adoles- account for the somatic, emotional, and mental
cent’s physical development should be care- development that occurs throughout adolescence
fully monitored—preferably by a pediatric (Hembree et al., 2009).
endocrinologist—so that any necessary inter-
ventions can occur (e.g., to establish an adequate Irreversible Interventions
gender appropriate height, to improve iatrogenic
low bone mineral density) (Hembree et al., Genital surgery should not be carried out until
2009). (i) patients reach the legal age of majority to
Early use of puberty-suppressing hormones give consent for medical procedures in a given
may avert negative social and emotional con- country and (ii) patients have lived continuously
sequences of gender dysphoria more effectively for at least 12 months in the gender role that
than their later use would. Intervention in early is congruent with their gender identity. The age
adolescence should be managed with pediatric threshold should be seen as a minimum criterion
endocrinological advice, when available. Ado- and not an indication in and of itself for active
lescents with male genitalia who start GnRH intervention.
analogues early in puberty should be informed Chest surgery in FtM patients could be carried
that this could result in insufficient penile tissue out earlier, preferably after ample time of living
for penile inversion vaginoplasty techniques in the desired gender role and after one year of
(alternative techniques, such as the use of a skin testosterone treatment. The intent of this sug-
graft or colon tissue, are available). gested sequence is to give adolescents sufficient
Neither puberty suppression nor allowing opportunity to experience and socially adjust in
puberty to occur is a neutral act. On the one hand, a more masculine gender role, before under-
functioning in later life can be compromised by going irreversible surgery. However, different
the development of irreversible secondary sex approaches may be more suitable, depending
characteristics during puberty and by years spent on an adolescent’s specific clinical situation and
experiencing intense gender dysphoria. On the goals for gender identity expression.
other hand, there are concerns about negative
physical side effects of GnRH analogue use (e.g., Risks of Withholding Medical Treatment
on bone development and height). Although the for Adolescents
very first results of this approach (as assessed for
adolescents followed over 10 years) are promis- Refusing timely medical interventions for
ing (Cohen-Kettenis et al., 2011; Delemarre-van adolescents might prolong gender dysphoria and
de Waal & Cohen-Kettenis, 2006), the long-term contribute to an appearance that could provoke
effects can only be determined when the earliest- abuse and stigmatization. As the level of gender-
treated patients reach the appropriate age. related abuse is strongly associated with the
degree of psychiatric distress during adolescence
Partially Reversible Interventions (Nuttbrock et al., 2010), withholding puberty-
suppression and subsequent feminizing or mas-
Adolescents may be eligible to begin feminiz- culinizing hormone therapy is not a neutral
ing/masculinizing hormone therapy, preferably option for adolescents.
Coleman et al. 179
assistance. For example, a client may be present- the prescribing hormone-therapy provider or a
ing for any combination of the following health member of that provider’s health care team.
care services: psychotherapeutic assistance to
explore gender identity and expression or to 2. Provide Information Regarding Options
facilitate a coming-out process; assessment and for Gender Identity and Expression and
referral for feminizing/masculinizing medical Possible Medical Interventions
interventions; psychological support for family
members (partners, children, extended family); An important task of mental health pro-
psychotherapy unrelated to gender concerns; or fessionals is to educate clients regarding the
other professional services. diversity of gender identities and expressions
Below are general guidelines for common and the various options available to alleviate
tasks that mental health professionals may fulfill gender dysphoria. Mental health professionals
in working with adults who present with gender then may facilitate a process (or refer elsewhere)
dysphoria. in which clients explore these various options,
with the goals of finding a comfortable gender
role and expression and becoming prepared to
Tasks Related to Assessment and Referral make a fully informed decision about available
medical interventions, if needed. This process
1. Assess Gender Dysphoria
may include referral for individual, family, and
Mental health professionals assess clients’ group therapy and/or to community resources
gender dysphoria in the context of an evaluation and avenues for peer support. The professional
of their psychosocial adjustment (Bockting et al., and the client discuss the implications, both
2006; Lev, 2004, 2009). The evaluation includes, short- and long-term, of any changes in gender
at a minimum, assessment of gender identity role and use of medical interventions. These
and gender dysphoria, history and development implications can be psychological, social, phys-
of gender dysphoric feelings, the impact of ical, sexual, occupational, financial, and legal
stigma attached to gender nonconformity on (Bockting et al., 2006; Lev, 2004).
mental health, and the availability of support This task is also best conducted by a
from family, friends, and peers (for example, qualified mental health professional, but may
in-person or online contact with other trans- be conducted by another health professional
sexual, transgender, or gender-nonconforming with appropriate training in behavioral health
individuals or groups). The evaluation may result and with sufficient knowledge about gender-
in no diagnosis, in a formal diagnosis related nonconforming identities and expressions and
to gender dysphoria, and/or in other diagnoses about possible medical interventions for gen-
that describe aspects of the client’s health and der dysphoria, particularly when functioning
psychosocial adjustment. The role of mental as part of a multidisciplinary specialty team
health professionals includes making reasonably that provides access to feminizing/masculinizing
sure that the gender dysphoria is not secondary hormone therapy.
to, or better accounted for, by other diagnoses.
Mental health professionals with the com- 3. Assess, Diagnose, and Discuss Treat-
petencies described above (hereafter called “a ment Options for Coexisting Mental Health
qualified mental health professional”) are best Concerns
prepared to conduct this assessment of gender
dysphoria. However, this task may instead be Clients presenting with gender dysphoria may
conducted by another type of health professional struggle with a range of mental health concerns
who has appropriate training in behavioral (Gómez-Gil, Trilla, Salamero, Godás, & Valdés,
health and is competent in the assessment of 2009; Murad et al., 2010) whether related or
gender dysphoria, particularly when functioning unrelated to what is often a long history of
as part of a multidisciplinary specialty team gender dysphoria and/or chronic minority stress.
that provides access to feminizing/masculinizing Possible concerns include anxiety, depression,
hormone therapy. This professional may be self-harm, a history of abuse and neglect,
Coleman et al. 181
compulsivity, substance abuse, sexual concerns, therapy (outlined in section VIII and Appendix
personality disorders, eating disorders, psy- C). Mental health professionals can help clients
chotic disorders, and autistic spectrum disorders who are considering hormone therapy to be
(Bockting et al., 2006; Nuttbrock et al., 2010; both psychologically prepared (e.g., client has
Robinow, 2009). Mental health professionals made a fully informed decision with clear and
should screen for these and other mental health realistic expectations; is ready to receive the
concerns and incorporate the identified concerns service in line with the overall treatment plan;
into the overall treatment plan. These concerns has included family and community as appro-
can be significant sources of distress and, if priate) and practically prepared (e.g., has been
left untreated, can complicate the process of evaluated by a physician to rule out or address
gender identity exploration and resolution of medical contraindications to hormone use; has
gender dysphoria (Bockting et al., 2006; Fraser, considered the psychosocial implications). If
2009a; Lev, 2009). Addressing these concerns clients are of childbearing age, reproductive
can greatly facilitate the resolution of gender options (section IX) should be explored before
dysphoria, possible changes in gender role, the initiating hormone therapy.
making of informed decisions about medical in- It is important for mental health professionals
terventions, and improvements in quality of life. to recognize that decisions about hormones
Some clients may benefit from psychotropic are first and foremost a client’s decisions—as
medications to alleviate symptoms or treat co- are all decisions regarding health care. How-
existing mental health concerns. Mental health ever, mental health professionals have a re-
professionals are expected to recognize this and sponsibility to encourage, guide, and assist
either provide pharmacotherapy or refer to a clients with making fully informed decisions
colleague who is qualified to do so. The presence and becoming adequately prepared. To best
of coexisting mental health concerns does not support their clients’ decisions, mental health
necessarily preclude possible changes in gender professionals need to have functioning work-
role or access to feminizing/masculinizing hor- ing relationships with their clients and suffi-
mones or surgery; rather, these concerns need cient information about them. Clients should
to be optimally managed prior to, or concurrent receive prompt and attentive evaluation, with
with, treatment of gender dysphoria. In addition, the goal of alleviating their gender dysphoria
clients should be assessed for their ability to and providing them with appropriate medical
provide educated and informed consent for services.
medical treatments. Referral for feminizing/masculinizing hor-
Qualified mental health professionals are mone therapy. People may approach a special-
specifically trained to assess, diagnose, and treat ized provider in any discipline to pursue feminiz-
(or refer to treatment for) these coexisting men- ing/masculinizing hormone therapy. However,
tal health concerns. Other health professionals transgender health care is an interdisciplinary
with appropriate training in behavioral health, field, and coordination of care and referral
particularly when functioning as part of a mul- among a client’s overall care team is recom-
tidisciplinary specialty team providing access mended.
to feminizing/masculinizing hormone therapy, Hormone therapy can be initiated with a
may also screen for mental health concerns and, referral from a qualified mental health profes-
if indicated, provide referral for comprehensive sional. Alternatively, a health professional who
assessment and treatment by a qualified mental is appropriately trained in behavioral health and
health professional. competent in the assessment of gender dysphoria
may assess eligibility of, prepare, and refer the
4. If Applicable, Assess Eligibility, Prepare, patient for hormone therapy, particularly in the
and Refer for Hormone Therapy absence of significant coexisting mental health
concerns and when working in the context
The SOC provide criteria to guide decisions of a multidisciplinary specialty team. The
regarding feminizing/masculinizing hormone referring health professional should provide
182 INTERNATIONAL JOURNAL OF TRANSGENDERISM
documentation—in the chart and/or referral appropriate) and practically prepared (e.g., has
letter—of the patient’s personal and treatment made an informed choice about a surgeon to
history, progress, and eligibility. Health perform the procedure; has arranged aftercare).
professionals who recommend hormone therapy If clients are of childbearing age, reproductive
share the ethical and legal responsibility for that options (section IX) should be explored before
decision with the physician who provides the undergoing genital surgery.
service. The SOC do not state criteria for other surgical
The recommended content of the referral procedures, such as feminizing or masculinizing
letter for feminizing/masculinizing hormone facial surgery; however, mental health profes-
therapy is as follows: sionals can play an important role in helping their
clients to make fully informed decisions about
1. The client’s general identifying character- the timing and implications of such procedures
istics; in the context of the overall coming-out or
2. Results of the client’s psychosocial assess- transition process.
ment, including any diagnoses; It is important for mental health professionals
3. The duration of the referring health pro- to recognize that decisions about surgery are
fessional’s relationship with the client, in- first and foremost a client’s decisions—as are
cluding the type of evaluation and therapy all decisions regarding health care. However,
or counseling to date; mental health professionals have a responsibility
4. An explanation that the criteria for hor- to encourage, guide, and assist clients with
mone therapy have been met and a brief making fully informed decisions and becom-
description of the clinical rationale for ing adequately prepared. To best support their
supporting the client’s request for hormone clients’ decisions, mental health professionals
therapy; need to have functioning working relationships
5. A statement that informed consent has with their clients and sufficient information
been obtained from the patient; about them. Clients should receive prompt and
6. A statement that the referring health pro- attentive evaluation, with the goal of alleviating
fessional is available for coordination of their gender dysphoria and providing them with
care and welcomes a phone call to establish appropriate medical services.
this. Referral for surgery. Surgical treatments for
gender dysphoria can be initiated by a refer-
For providers working within a multidisciplinary ral (one or two, depending on the type of
specialty team, a letter may not be necessary; surgery) from a qualified mental health profes-
rather, the assessment and recommendation can sional. The mental health professional provides
be documented in the patient’s chart. documentation—in the chart and/or referral
letter—of the patient’s personal and treatment
5. If Applicable, Assess Eligibility, Prepare, history, progress, and eligibility. Mental health
and Refer for Surgery professionals who recommend surgery share the
ethical and legal responsibility for that decision
The SOC also provide criteria to guide with the surgeon.
decisions regarding breast/chest surgery and
genital surgery (outlined in section XI and • One referral from a qualified mental health
Appendix C). Mental health professionals can professional is needed for breast/chest
help clients who are considering surgery to surgery (e.g., mastectomy, chest recon-
be both psychologically prepared (e.g., client struction, or augmentation mammoplasty).
has made a fully informed decision with clear • Two referrals—from qualified mental
and realistic expectations; is ready to receive health professionals who have indepen-
the service in line with the overall treatment dently assessed the patient—are needed
plan; has included family and community as for genital surgery (i.e., hysterectomy/
Coleman et al. 183
2004). Typically, the overarching treatment goal challenging—often more so than the physical
is to help transsexual, transgender, and gender- aspects. Because changing gender role can have
nonconforming individuals achieve long-term profound personal and social consequences, the
comfort in their gender identity expression, decision to do so should include an awareness
with realistic chances for success in their re- of what the familial, interpersonal, educational,
lationships, education, and work. For additional vocational, economic, and legal challenges are
details, see Fraser (Fraser, 2009c). likely to be, so that people can function success-
Therapy may consist of individual, cou- fully in their gender role.
ple, family, or group psychotherapy, the lat- Many transsexual, transgender, and gender-
ter being particularly important to foster peer nonconforming people will present for care
support. without ever having been related to, or accepted
in, the gender role that is most congruent
Psychotherapy for Transsexual, Transgen- with their gender identity. Mental health pro-
der, and Gender-Nonconforming Clients, fessionals can help these clients to explore and
Including Counseling and Support for anticipate the implications of changes in gender
Changes in Gender Role role, and to pace the process of implementing
these changes. Psychotherapy can provide a
Finding a comfortable gender role is, first and space for clients to begin to express themselves
foremost, a psychosocial process. Psychother- in ways that are congruent with their gender
apy can be invaluable in assisting transsexual, identity and, for some clients, overcome fears
transgender, and gender-nonconforming indi- about changes in gender expression. Calculated
viduals with all of the following: (i) clarifying risks can be taken outside of therapy to gain
and exploring gender identity and role, (ii) experience and build confidence in the new
addressing the impact of stigma and minority role. Assistance with coming out to family and
stress on one’s mental health and human de- community (friends, school, workplace) can be
velopment, and (iii) facilitating a coming-out provided.
process (Bockting & Coleman, 2007; Devor, Other transsexual, transgender, and gender-
2004; Lev, 2004), which for some individuals nonconforming individuals will present for care
may include changes in gender role expression already having acquired experience (minimal,
and the use of feminizing/masculinizing medical moderate, or extensive) living in a gender role
interventions. that differs from that associated with their
Mental health professionals can provide sup- birth-assigned sex. Mental health professionals
port and promote interpersonal skills and re- can help these clients to identify and work
silience in individuals and their families as they through potential challenges and foster optimal
navigate a world that often is ill-prepared to adjustment as they continue to express changes
accommodate and respect transgender, trans- in their gender role.
sexual, and gender-nonconforming people. Psy-
chotherapy can also aid in alleviating any Family Therapy or Support for Family
coexisting mental health concerns (e.g., anxi- Members
ety, depression) identified during screening and
assessment. Decisions about changes in gender role and
For transsexual, transgender, and gender- medical interventions for gender dysphoria have
nonconforming individuals who plan to change implications for, not only clients, but also their
gender roles permanently and make a social families (Emerson & Rosenfeld, 1996; Fraser,
gender role transition, mental health profes- 2009a; Lev, 2004). Mental health profession-
sionals can facilitate the development of an als can assist clients with making thoughtful
individualized plan with specific goals and decisions about communicating with family
timelines. While the experience of changing members and others about their gender identity
one’s gender role differs from person to person, and treatment decisions. Family therapy may
the social aspects of the experience are usually include work with spouses or partners, as well
Coleman et al. 185
as with children and other members of a client’s most recent literature pertaining to this rapidly
extended family. evolving medium. A more thorough description
Clients may also request assistance with their of the potential uses, processes, and ethical
relationships and sexual health. For example, concerns related to e-therapy has been published
they may want to explore their sexuality and (Fraser, 2009b).
intimacy-related concerns.
Family therapy might be offered as part of
the client’s individual therapy and, if clinically Other Tasks of the Mental Health
appropriate, by the same provider. Alternatively, Professionals
referrals can be made to other therapists with Educate and Advocate on Behalf of Clients
relevant expertise for working with family mem-
bers or to sources of peer support (e.g., in
Within Their Community (Schools, Work-
person or offline support networks of partners places, Other Organizations) and Assist
or families). Clients with Making Changes in Identity
Documents
Follow-Up Care Throughout Life
Transsexual, transgender, and gender-
Mental health professionals may work with nonconforming people may face challenges in
clients and their families at many stages of their their professional, educational, and other types
lives. Psychotherapy may be helpful at different of settings as they actualize their gender identity
times and for various issues throughout the life and expression (Lev, 2004, 2009). Mental health
cycle. professionals can play an important role by
educating people in these settings regarding
E-therapy, Online Counseling, or Distance gender nonconformity and by advocating on
Counseling behalf of their clients (Currah, Juang, & Minter,
2006; Currah & Minter, 2000). This role may
Online or e-therapy has been shown to be
involve consultation with school counselors,
particularly useful for people who have difficulty
teachers, and administrators, human resources
accessing competent in-person psychothera-
staff, personnel managers and employers,
peutic treatment and who may experience
and representatives from other organizations
isolation and stigma (Derrig-Palumbo & Zeine,
and institutions. In addition, health providers
2005; Fenichel et al., 2004; Fraser, 2009b).
may be called upon to support changes in a
By extrapolation, e-therapy may be a useful
client’s name and/or gender marker on identity
modality for psychotherapy with transsexual,
documents such as passports, driver’s licenses,
transgender, and gender-nonconforming people.
birth certificates, and diplomas.
E-therapy offers opportunities for potentially
enhanced, expanded, creative, and tailored
delivery of services; however, as a developing Provide Information and Referral for Peer
modality it may also carry unexpected risk. Support
Telemedicine guidelines are clear in some
disciplines in some parts of the United States For some transsexual, transgender, and
(Fraser, 2009b; Maheu, Pulier, Wilhelm, gender-nonconforming people, an experience in
McMenamin, & Brown-Connolly, 2005) but not peer support groups may be more instructive
all; the international situation is even less well regarding options for gender expression than
defined (Maheu et al., 2005). Until sufficient anything individual psychotherapy could offer
evidence-based data on this use of e-therapy is (Rachlin, 2002). Both experiences are poten-
available, caution in its use is advised. tially valuable, and all people exploring gender
Mental health professionals engaging in e- issues should be encouraged to participate in
therapy are advised to stay current with their community activities, if possible. Resources for
particular licensing board, professional associ- peer support and information should be made
ation, and country’s regulations, as well as the available.
186 INTERNATIONAL JOURNAL OF TRANSGENDERISM
individual receiving services and for tailoring of Physical Effects of Hormone Therapy
protocols to the approach and setting in which
these services are provided (Ehrbar & Gorton, Feminizing/masculinizing hormone therapy
2010). will induce physical changes that are more
Obtaining informed consent for hormone congruent with a patient’s gender identity.
therapy is an important task of providers to
ensure that patients understand the psycholog- • In FtM patients, the following physical
ical and physical benefits and risks of hormone changes are expected to occur: deep-
therapy, as well as its psychosocial implications. ened voice, clitoral enlargement (variable),
Providers prescribing the hormones or health growth in facial and body hair, cessation
professionals recommending the hormones of menses, atrophy of breast tissue, and
should have the knowledge and experience to decreased percentage of body fat compared
assess gender dysphoria. They should inform to muscle mass.
individuals of the particular benefits, limitations, • In MtF patients, the following physical
and risks of hormones, given the patient’s changes are expected to occur: breast
age, previous experience with hormones, and growth (variable), decreased erectile func-
concurrent physical or mental health concerns. tion, decreased testicular size, and in-
Screening for and addressing acute or current creased percentage of body fat compared
mental health concerns is an important part of the to muscle mass.
informed consent process. This may be done by a
mental health professional or by an appropriately Most physical changes, whether feminizing
trained prescribing provider (see section VII or masculinizing, occur over the course of two
of the SOC). The same provider or another years. The amount of physical change and the
appropriately trained member of the health care exact timeline of effects can be highly variable.
team (e.g., a nurse) can address the psychosocial Tables 1a and 1b outline the approximate time
implications of taking hormones when necessary course of these physical changes.
(e.g., the impact of masculinization/feminization
on how one is perceived and its potential
impact on relationships with family, friends, and TABLE 1a. Effects and Expected Time Course
coworkers). If indicated, these providers will of Masculinizing Hormonesa
make referrals for psychotherapy and for the
assessment and treatment of coexisting mental Expected Expected maximum
health concerns such as anxiety or depression. Effect onsetb effectb
The difference between the Informed Consent Skin oiliness/acne 1–6 months 1–2 years
Model and SOC, Version 7, is that the SOC Facial/body hair 3–6 months 3–5 years
puts greater emphasis on the important role that growth
mental health professionals can play in alleviat- Scalp hair loss >12 monthsc Variable
Increased muscle 6–12 months 2–5 yearsd
ing gender dysphoria and facilitating changes in mass/strength
gender role and psychosocial adjustment. This Body fat 3–6 months 2–5 years
may include a comprehensive mental health redistribution
assessment and psychotherapy, when indicated. Cessation of 2–6 months n/a
menses
In the Informed Consent Model, the focus is Clitoral 3–6 months 1–2 years
on obtaining informed consent as the threshold enlargement
for the initiation of hormone therapy in a Vaginal atrophy 3–6 months 1–2 years
multidisciplinary, harm-reduction environment. Deepened voice 3–12 months 1–2 years
Less emphasis is placed on the provision of a
Adapted with permission from Hembree et al. (2009). Copyright
mental health care until the patient requests it, 2009, The Endocrine Society.
b
unless significant mental health concerns are Estimates represent published and unpublished clinical observa-
tions.
identified that would need to be addressed before c
Highly dependent on age and inheritance; may be minimal.
hormone prescription. d
Significantly dependent on amount of exercise.
Coleman et al. 189
Expected maximum
Effect Expected onsetb effect b
The degree and rate of physical effects de- categorized as follows: (i) likely increased risk
pends in part on the dose, route of administration, with hormone therapy, (ii) possibly increased
and medications used, which are selected in ac- risk with hormone therapy, or (iii) inconclusive
cordance with a patient’s specific medical goals or no increased risk. Items in the last category
(e.g., changes in gender-role expression, plans include those that may present risk but for
for sex reassignment) and medical risk profile. which the evidence is so minimal that no clear
There is no current evidence that response to conclusion can be reached.
hormone therapy—with the possible exception Additional detail about these risks can be
of voice deepening in FtM persons—can be found in Appendix B, which is based on
reliably predicted based on age, body habitus, two comprehensive, evidence-based literature
ethnicity, or family appearance. All other factors reviews of masculinizing/feminizing hormone
being equal, there is no evidence to suggest that therapy (Feldman & Safer, 2009; Hembree
any medically approved type or method of ad- et al., 2009), along with a large cohort study
ministering hormones is more effective than any (Asscheman et al., 2011). These reviews can
other in producing the desired physical changes. serve as detailed references for providers, along
with other widely recognized, published clinical
Risks of Hormone Therapy materials (Dahl, Feldman, Goldberg, & Jaberi,
2006; Ettner, Monstrey, & Eyler, 2007).
All medical interventions carry risks. The
likelihood of a serious adverse event is depen- Competency of Hormone-Prescribing
dent on numerous factors: the medication itself, Physicians, Relationship with Other
dose, route of administration, and a patient’s
Health Professionals
clinical characteristics (age, comorbidities, fam-
ily history, health habits). It is thus impossible Feminizing/masculinizing hormone therapy
to predict whether a given adverse effect will is best undertaken in the context of a complete
happen in an individual patient. approach to health care that includes comprehen-
The risks associated with feminizing/ sive primary care and a coordinated approach to
masculinizing hormone therapy for the trans- psychosocial issues (Feldman & Safer, 2009).
sexual, transgender, and gender-nonconforming While psychotherapy or ongoing counseling
population as a whole are summarized in Table is not required for the initiation of hormone
2. Based on the level of evidence, risks are therapy, if a therapist is involved, then regular
190 INTERNATIONAL JOURNAL OF TRANSGENDERISM
knowledge and experience in this field. Clini- phases of hormone treatment, a patient
cians can increase their experience and comfort may wish to carry this statement at all times
in providing feminizing/masculinizing hormone to help prevent difficulties with the police
therapy by comanaging care or consulting with and other authorities.
a more experienced provider, or by providing
more limited types of hormone therapy before Depending on the clinical situation for providing
progressing to initiation of hormone therapy. hormones (see below), some of these respon-
Because this field of medicine is evolving, clin- sibilities are less relevant. Thus, the degree of
icians should become familiar and keep current counseling, physical examinations, and labora-
with the medical literature and discuss emerging tory evaluations should be individualized to a
issues with colleagues. Such discussions might patient’s needs.
occur through networks established by WPATH
and other national/local organizations. Clinical Situations for Hormone Therapy
There are circumstances in which clinicians
Responsibilities of Hormone-Prescribing may be called upon to provide hormones without
Physicians necessarily initiating or maintaining long-term
feminizing/masculinizing hormone therapy. By
In general, clinicians who prescribe hormone
acknowledging these different clinical situations
therapy should engage in the following tasks:
(see below, from least to highest level of com-
plexity), it may be possible to involve clinicians
1. Perform an initial evaluation that includes
in feminizing/masculinizing hormone therapy
discussion of a patient’s physical transition
who might not otherwise feel able to offer this
goals, health history, physical examina-
treatment.
tion, risk assessment, and relevant labo-
ratory tests. 1. Bridging
2. Discuss with patients the expected effects
of feminizing/masculinizing medications Whether prescribed by another clinician or
and the possible adverse health effects. obtained through other means (e.g., purchased
These effects can include a reduction in over the Internet), patients may present for
fertility (Feldman & Safer, 2009; Hembree care already on hormone therapy. Clinicians
et al., 2009). Therefore, reproductive op- can provide a limited (1–6 month) prescription
tions should be discussed with patients be- for hormones while helping patients find a
fore starting hormone therapy (see section provider who can prescribe long-term hormone
IX). therapy. Providers should assess a patient’s
3. Confirm that patients have the capacity current regimen for safety and drug interactions
to understand the risks and benefits of and substitute safer medications or doses when
treatment and are capable of making an indicated (Dahl et al., 2006; Feldman & Safer,
informed decision about medical care. 2009). If hormones were previously prescribed,
4. Provide ongoing medical monitoring, in- medical records should be requested (with the
cluding regular physical and laboratory patient’s permission) to obtain the results of
examination to monitor hormone effective- baseline examinations and laboratory tests and
ness and side effects. any adverse events. Hormone providers should
5. Communicate as needed with a patient’s also communicate with any mental health pro-
primary care provider, mental health pro- fessional who is currently involved in a patient’s
fessional, and surgeon. care. If a patient has never had a psychosocial
6. If needed, provide patients with a brief assessment as recommended by the SOC (see
written statement indicating that they are section VII), clinicians should refer the patient
under medical supervision and care that in- to a qualified mental health professional if ap-
cludes feminizing/masculinizing hormone propriate and feasible (Feldman & Safer, 2009).
therapy. Particularly during the early Providers who prescribe bridging hormones
192 INTERNATIONAL JOURNAL OF TRANSGENDERISM
need to work with patients to establish limits hormone regimens have been published (Dahl
as to the duration of bridging therapy. et al., 2006; Hembree et al., 2009; Moore
et al., 2003), there are no published reports
2. Hormone Therapy Following Gonad of randomized clinical trials comparing safety
Removal and efficacy. Despite this variation, a reasonable
framework for initial risk assessment and on-
Hormone replacement with estrogen or
going monitoring of hormone therapy can be
testosterone is usually continued lifelong after an
constructed, based on the efficacy and safety
oophorectomy or orchiectomy, unless medical
evidence presented above.
contraindications arise. Because hormone doses
are often decreased after these surgeries (Basson,
2001; Levy, Crown, & Reid, 2003; Moore, Risk Assessment and Modification for
Wisniewski, & Dobs, 2003) and only adjusted Initiating Hormone Therapy
for age and comorbid health concerns, hormone
management in this situation is quite similar The initial evaluation for hormone therapy
to hormone replacement in any hypogonadal assesses a patient’s clinical goals and risk factors
patient. for hormone-related adverse events. During the
risk assessment, the patient and clinician should
3. Hormone Maintenance Prior to Gonad develop a plan for reducing risks wherever
Removal possible, either prior to initiating therapy or as
part of ongoing harm reduction.
Once patients have achieved maximal fem- All assessments should include a thorough
inizing/masculinizing benefits from hormones physical exam, including weight, height, and
(typically two or more years), they remain on blood pressure. The need for breast, genital,
a maintenance dose. The maintenance dose is and rectal exams, which are sensitive issues
then adjusted for changes in health conditions, for most transsexual, transgender, and gender-
aging, or other considerations such as lifestyle nonconforming patients, should be based on
changes (Dahl et al., 2006). When a patient individual risks and preventive health care needs
on maintenance hormones presents for care, (Feldman & Goldberg, 2006; Feldman, 2007).
the provider should assess the patient’s current
regimen for safety and drug interactions and Preventive Care
substitute safer medications or doses when
indicated. The patient should continue to be Hormone providers should address preventive
monitored by physical examinations and labo- health care with patients, particularly if a patient
ratory testing on a regular basis, as outlined in does not have a primary care provider. Depend-
the literature (Feldman & Safer, 2009; Hembree ing on a patient’s age and risk profile, there
et al., 2009). The dose and form of hormones may be appropriate screening tests or exams for
should be revisited regularly with any changes in conditions affected by hormone therapy. Ideally,
the patient’s health status and available evidence these screening tests should be carried out prior
on the potential long-term risks of hormones (see to the start of hormone therapy.
Hormone Regimens, below).
Risk Assessment and Modification for
4. Initiating Hormonal Feminization/ Feminizing Hormone Therapy (MtF)
Masculinization
There are no absolute contraindications to
This clinical situation requires the greatest feminizing therapy per se, but absolute con-
commitment in terms of provider time and ex- traindications exist for the different feminizing
pertise. Hormone therapy must be individualized agents, particularly estrogen. These include
based on a patient’s goals, the risk/benefit ratio previous venous thrombotic events related to an
of medications, the presence of other medical underlying hypercoagulable condition, history
conditions, and consideration of social and of estrogen-sensitive neoplasm, and end-stage
economic issues. Although a wide variety of chronic liver disease (Gharib et al., 2005).
Coleman et al. 193
Other medical conditions, as noted in Table 2 1997). While there is no evidence that PCOS
and Appendix B, can be exacerbated by estrogen is related to the development of a transsexual,
or androgen blockade and, therefore, should transgender, or gender-nonconforming identity,
be evaluated and reasonably well controlled PCOS is associated with increased risk of
prior to starting hormone therapy (Feldman diabetes, cardiac disease, high blood pressure,
& Safer, 2009; Hembree et al., 2009. Dhejne and ovarian and endometrial cancers (Cattrall
et al., 2011). Clinicians should particularly & Healy, 2004). Signs and symptoms of PCOS
attend to tobacco use, as it is associated with should be evaluated prior to initiating testos-
increased risk of venous thrombosis, which is terone therapy, as testosterone may affect many
further increased with estrogen use. Consulta- of these conditions. Testosterone can affect the
tion with a cardiologist may be advisable for developing fetus (Physicians’ Desk Reference,
patients with known cardio- or cerebrovascular 2010), and patients at risk of becoming pregnant
disease. require highly effective birth control.
Baseline laboratory values are important to Baseline laboratory values are important to
both assess initial risk and evaluate possible both assess initial risk and evaluate possible
future adverse events. Initial labs should be future adverse events. Initial labs should be
based on the risks of feminizing hormone based on the risks of masculinizing hormone
therapy outlined in Table 2, as well as individual therapy outlined in Table 2, as well as individual
patient risk factors, including family history. patient risk factors, including family history.
Suggested initial lab panels have been published Suggested initial lab panels have been published
(Feldman & Safer, 2009; Hembree et al., 2009). (Feldman & Safer, 2009; Hembree et al., 2009).
These can be modified for patients or health care These can be modified for patients or health care
systems with limited resources and in otherwise systems with limited resources and in otherwise
healthy patients. healthy patients.
Efficacy and Risk Monitoring During Femi- Monitoring for adverse events should in-
nizing Hormone Therapy (MtF) clude both clinical and laboratory evaluation.
Follow-up should include careful assessment
The best assessment of hormone efficacy for signs and symptoms of excessive weight
is clinical response: Is a patient developing a gain, acne, uterine break-through bleeding, and
feminized body while minimizing masculine cardiovascular impairment, as well as psychi-
characteristics consistent with that patient’s atric symptoms in at-risk patients. Physical
gender goals? In order to more rapidly predict examinations should include measurement of
the hormone dosages that will achieve clinical blood pressure, weight, pulse, and skin, as well
response, one can measure testosterone levels as and heart and lung exams (Feldman & Safer,
for suppression below the upper limit of the 2009). Laboratory monitoring should be based
normal female range and estradiol levels within on the risks of hormone therapy described above,
a premenopausal female range but well below a patient’s individual comorbidities and risk
supraphysiologic levels (Feldman & Safer, 2009; factors, and the specific hormone regimen itself.
Hembree et al., 2009). Specific lab monitoring protocols have been
Monitoring for adverse events should in- published (Feldman & Safer, 2009; Hembree
clude both clinical and laboratory evaluation. et al., 2009).
Follow-up should include careful assessment for
signs of cardiovascular impairment and venous
Hormone Regimens
thromboembolism (VTE) through measurement
of blood pressure, weight, and pulse; heart and To date, no controlled clinical trials of
lung exams; and examination of the extremi- any feminizing/masculinizing hormone regimen
ties for peripheral edema, localized swelling, have been conducted to evaluate safety or effi-
or pain (Feldman & Safer, 2009). Laboratory cacy in producing physical transition. As a result,
monitoring should be based on the risks of wide variation in doses and types of hormones
hormone therapy described above, a patient’s have been published in the medical literature
individual comorbidities and risk factors, and (Moore et al., 2003; Tangpricha et al., 2003;
the specific hormone regimen itself. Specific van Kesteren, Asscheman, Megens, & Gooren,
lab-monitoring protocols have been published 1997). In addition, access to particular medica-
(Feldman & Safer, 2009; Hembree et al., 2009). tions may be limited by a patient’s geographical
location and/or social or economic situations.
Efficacy and Risk Monitoring During For these reasons, WPATH does not describe
Masculinizing Hormone Therapy (FtM) or endorse a particular feminizing/masculinizing
hormone regimen. Rather, the medication
The best assessment of hormone efficacy classes and routes of administration used in most
is clinical response: Is a patient developing a published regimens are broadly reviewed.
masculinized body while minimizing feminine As outlined above, there are demonstrated
characteristics consistent with that patient’s gen- safety differences in individual elements of vari-
der goals? Clinicians can achieve a good clinical ous regimens. The Endocrine Society Guidelines
response with the least likelihood of adverse (Hembree et al., 2009) and Feldman and Safer
events by maintaining testosterone levels within (2009) provide specific guidance regarding the
the normal male range while avoiding supra- types of hormones and suggested dosing to
physiological levels (Dahl et al., 2006; Hembree maintain levels within physiologic ranges for a
et al., 2009). For patients using intramuscular patient’s desired gender expression (based on
(IM) testosterone cypionate or enanthate, some goals of full feminization/masculinization). It is
clinicians check trough levels while others prefer strongly recommended that hormone providers
midcycle levels (Dahl et al., 2006; Hembree regularly review the literature for new informa-
et al., 2009; Tangpricha, Turner, Malabanan, & tion and use those medications that safely meet
Holick, 2001; Tangpricha, Ducharme, Barber, & individual patient needs with available local
Chipkin, 2003). resources.
Coleman et al. 195
loss or damage to their gonads are people with blockers or cross-gender hormones. At this time
malignancies that require removal of reproduc- there is no technique for preserving function
tive organs or use of damaging radiation or from the gonads of these individuals.
chemotherapy. Lessons learned from that group
can be applied to people treated for gender
dysphoria. X. VOICE AND COMMUNICATION
MtF patients, especially those who have not THERAPY
already reproduced, should be informed about
sperm-preservation options and encouraged to Communication, both verbal and nonverbal,
consider banking their sperm prior to hormone is an important aspect of human behavior and
therapy. In a study examining testes that were gender expression. Transsexual, transgender,
exposed to high-dose estrogen (Payer et al., and gender-nonconforming people might seek
1979), findings suggest that stopping estrogen the assistance of a voice and communica-
may allow the testes to recover. In an article tion specialist to develop vocal characteristics
reporting on the opinions of MtF individuals (e.g., pitch, intonation, resonance, speech rate,
towards sperm freezing (De Sutter et al., 2002), phrasing patterns) and nonverbal communica-
the vast majority of 121 survey respondents felt tion patterns (e.g., gestures, posture/movement,
that the availability of freezing sperm should facial expressions) that facilitate comfort with
be discussed and offered by the medical world. their gender identity. Voice and communication
Sperm should be collected before hormone ther- therapy may help to alleviate gender dysphoria
apy or after stopping the therapy until the sperm and be a positive and motivating step towards
count rises again. Cryopreservation should be achieving one’s goals for gender role expression.
discussed even if there is poor semen quality.
In adults with azoospermia, a testicular biopsy Competency of Voice and Communication
with subsequent cryopreservation of biopsied Specialists Working with Transsexual,
material for sperm is possible, but may not be Transgender, and Gender-Nonconforming
successful. Clients
Reproductive options for FtM patients might
include oocyte (egg) or embryo freezing. The Specialists may include speech-language
frozen gametes and embryo could later be used pathologists, speech therapists, and speech-
with a surrogate woman to carry to pregnancy. voice clinicians. In most countries the
Studies of women with polycystic ovarian dis- professional association for speech-language
ease suggest that the ovary can recover in part pathologists requires specific qualifications and
from the effects of high testosterone levels credentials for membership. In some countries
(Hunter & Sterrett, 2000). Stopping the testos- the government regulates practice through
terone briefly might allow for ovaries to recover licensing, certification, or registration processes
enough to release eggs; success likely depends (American Speech-Language-Hearing Associ-
on the patient’s age and duration of testosterone ation, 2011; Canadian Association of Speech-
treatment. While not systematically studied, Language Pathologists and Audiologists; Royal
some FtM individuals are doing exactly that, College of Speech & Language Therapists,
and some have been able to become pregnant United Kingdom; Speech Pathology Australia).
and deliver children (More, 1998). The following are recommended minimum
Patients should be advised that these tech- credentials for voice and communication spe-
niques are not available everywhere and can cialists working with transsexual, transgender,
be very costly. Transsexual, transgender, and and gender-nonconforming clients:
gender-nonconforming people should not be
refused reproductive options for any reason. 1. Specialized training and competence in the
A special group of individuals are prepubertal assessment and development of commu-
or pubertal adolescents who will never develop nication skills in transsexual, transgender,
reproductive function in their natal sex due to and gender-nonconforming clients.
198 INTERNATIONAL JOURNAL OF TRANSGENDERISM
surgeons, and patients share responsibility for of their own patients, including both suc-
the decision to make irreversible changes to the cessful and unsuccessful outcomes;
body. • The inherent risks and possible complica-
It is unethical to deny availability or eligibility tions of the various techniques; surgeons
for sex reassignment surgeries solely on the should inform patients of their own compli-
basis of blood seropositivity for blood-borne cation rates with respect to each procedure.
infections such as HIV or hepatitis C or B.
These discussions are the core of the informed-
Relationship of Surgeons with Mental consent process, which is both an ethical and
Health Professionals, Hormone- legal requirement for any surgical procedure.
Prescribing Physicians (if Applicable), Ensuring that patients have a realistic expec-
and Patients (Informed Consent) tation of outcomes is important in achieving a
result that will alleviate their gender dysphoria.
The role of a surgeon in the treatment of All of this information should be provided to
gender dysphoria is not that of a mere technician. patients in writing, in a language in which they
Rather, conscientious surgeons will have insight are fluent, and in graphic illustrations. Patients
into each patient’s history and the rationale that should receive the information in advance (pos-
led to the referral for surgery. To that end, sibly via the Internet) and given ample time to
surgeons must talk at length with their patients review it carefully. The elements of informed
and have close working relationships with other consent should always be discussed face-to-face
health professionals who have been actively prior to the surgical intervention. Questions can
involved in their clinical care. then be answered and written informed consent
Consultation is readily accomplished when a can be provided by the patient. Because these
surgeon practices as part of an interdisciplinary surgeries are irreversible, care should be taken
health care team. In the absence of this, a to ensure that patients have sufficient time to
surgeon must be confident that the referring absorb information fully before they are asked
mental health professional(s), and if applicable to provide informed consent. A minimum of
the physician who prescribes hormones, is/are 24 hours is suggested.
competent in the assessment and treatment of Surgeons should provide immediate aftercare
gender dysphoria, because the surgeon is relying and consultation with other physicians serving
heavily on his/her/their expertise. the patient in the future. Patients should work
Once a surgeon is satisfied that the criteria with their surgeon to develop an adequate
for specific surgeries have been met (as outlined aftercare plan for the surgery.
below), surgical treatment should be consid-
ered and a preoperative surgical consultation Overview of Surgical Procedures for the
should take place. During this consultation, the Treatment of Patients with Gender
procedure and postoperative course should be
Dysphoria
extensively discussed with the patient. Surgeons
are responsible for discussing all of the following For the Male-to-Female (MtF) Patient,
with patients seeking surgical treatments for Surgical Procedures May Include the
gender dysphoria: Following:
• The different surgical techniques available 1. Breast/chest surgery: augmentation mam-
(with referral to colleagues who provide moplasty (implants/lipofilling);
alternative options); 2. Genital surgery: penectomy, orchiectomy,
• The advantages and disadvantages of each vaginoplasty, clitoroplasty, vulvoplasty;
technique; 3. Nongenital, nonbreast surgical interven-
• The limitations of a procedure to achieve tions: facial feminization surgery, lipo-
“ideal” results; surgeons should provide a suction, lipofilling, voice surgery, thyroid
full range of before-and-after photographs cartilage reduction, gluteal augmentation
Coleman et al. 201
Criteria for breast augmentation (im- These criteria do not apply to patients who are
plants/lipofilling) in MtF patients: having these procedures for medical indications
other than gender dysphoria.
1. Persistent, well-documented gender dys-
phoria; Criteria for metoidioplasty or phalloplasty
2. Capacity to make a fully informed decision in FtM patients and for vaginoplasty in MtF
and to consent for treatment; patients:
3. Age of majority in a given country (if
younger, follow the SOC for children and 1. Persistent, well-documented gender dys-
adolescents); phoria;
4. If significant medical or mental health con- 2. Capacity to make a fully informed decision
cerns are present, they must be reasonably and to consent for treatment;
well controlled. 3. Age of majority in a given country;
4. If significant medical or mental health
Although not an explicit criterion, it is recom- concerns are present, they must be well
mended that MtF patients undergo feminizing controlled;
hormone therapy (minimum 12 months) prior to 5. 12 continuous months of hormone therapy
breast augmentation surgery. The purpose is to as appropriate to the patient’s gender
maximize breast growth in order to obtain better goals (unless hormones are not clinically
surgical (aesthetic) results. indicated for the individual).
6. 12 continuous months of living in a gender
role that is congruent with the patient’s
identity.
Criteria for Genital Surgery (Two Referrals)
Although not an explicit criterion, it is recom-
The criteria for genital surgery are specific to mended that these patients also have regular
the type of surgery being requested. visits with a mental health or other medical
professional.
Criteria for hysterectomy and salpingo-
oophorectomy in FtM patients and for orchiec- Rationale for a preoperative, 12-month
tomy in MtF patients: experience of living in an identity-congruent
gender role. The criterion noted above for some
1. Persistent, well-documented gender dys- types of genital surgeries—i.e., that patients
phoria; engage in 12 continuous months of living in a
2. Capacity to make a fully informed decision gender role that is congruent with their gender
and to give consent for treatment; identity—is based on expert clinical consensus
3. Age of majority in a given country; that this experience provides ample opportunity
4. If significant medical or mental health for patients to experience and socially adjust
concerns are present, they must be well in their desired gender role, before undergoing
controlled. irreversible surgery. As noted in section VII,
5. 12 continuous months of hormone therapy the social aspects of changing one’s gender role
as appropriate to the patient’s gender are usually challenging—often more so than the
goals (unless hormones are not clinically physical aspects. Changing gender role can have
indicated for the individual). profound personal and social consequences, and
the decision to do so should include an awareness
The aim of hormone therapy prior to gonadec- of what the familial, interpersonal, educational,
tomy is primarily to introduce a period of vocational, economic, and legal challenges
reversible estrogen or testosterone suppression, are likely to be, so that people can function
before the patient undergoes irreversible surgical successfully in their gender role. Support from
intervention. a qualified mental health professional and from
Coleman et al. 203
peers can be invaluable in ensuring a successful cologists, plastic surgeons, or general surgeons,
gender role adaptation (Bockting, 2008). and board-certified as such by the relevant
The duration of 12 months allows for a range national and/or regional association. Surgeons
of different life experiences and events that may should have specialized competence in genital
occur throughout the year (e.g., family events, reconstructive techniques as indicated by docu-
holidays, vacations, season-specific work or mented supervised training with a more experi-
school experiences). During this time, patients enced surgeon. Even experienced surgeons must
should present consistently, on a day-to-day be willing to have their surgical skills reviewed
basis and across all settings of life, in their by their peers. An official audit of surgical
desired gender role. This includes coming out outcomes and publication of these results would
to partners, family, friends, and community be greatly reassuring to both referring health
members (e.g., at school, work, other settings). professionals and patients. Surgeons should reg-
Health professionals should clearly document ularly attend professional meetings where new
a patient’s experience in the gender role in techniques are presented. The Internet is often
the medical chart, including the start date of effectively used by patients to share information
living full-time for those who are preparing for on their experience with surgeons and their
genital surgery. In some situations, if needed, teams.
health professionals may request verification Ideally, surgeons should be knowledgeable
that this criterion has been fulfilled: They may about more than one surgical technique for gen-
communicate with individuals who have related ital reconstruction so that they, in consultation
to the patient in an identity-congruent gender with patients, can choose the ideal technique for
role or request documentation of a legal name each individual. Alternatively, if a surgeon is
and/or gender-marker change, if applicable. skilled in a single technique and this procedure
is either not suitable for or desired by a patient,
Surgery for People with Psychotic the surgeon should inform the patient about
Conditions and Other Serious Mental other procedures and offer referral to another
Illnesses appropriately skilled surgeon.
When patients with gender dysphoria are also Breast/Chest Surgery Techniques and
diagnosed with severe psychiatric disorders and Complications
impaired reality testing (e.g., psychotic episodes,
bipolar disorder, dissociative identity disorder, Although breast/chest appearance is an im-
borderline personality disorder), an effort must portant secondary sex characteristic, breast pres-
be made to improve these conditions with ence or size is not involved in the legal definitions
psychotropic medications and/or psychother- of sex and gender and is not necessary for
apy before surgery is contemplated (Dhejne reproduction. The performance of breast/chest
et al., 2011). Reevaluation by a mental health operations for treatment of gender dysphoria
professional qualified to assess and manage should be considered with the same care as
psychotic conditions should be conducted prior beginning hormone therapy, as both produce
to surgery, describing the patient’s mental status relatively irreversible changes to the body.
and readiness for surgery. It is preferable that this For the MtF patient, a breast augmentation
mental health professional be familiar with the (sometimes called “chest reconstruction”) is not
patient. No surgery should be performed while different from the procedure in a natal female
a patient is actively psychotic (De Cuypere & patient. It is usually performed through implan-
Vercruysse, 2009). tation of breast prostheses and occasionally with
the lipofilling technique. Infections and capsular
Competency of Surgeons Performing fibrosis are rare complications of augmentation
Breast/Chest or Genital Surgery mammoplasty in MtF patients (Kanhai, Hage,
Karim, & Mulder, 1999).
Physicians who perform surgical treatments For the FtM patient, a mastectomy or “male
for gender dysphoria should be urologists, gyne- chest contouring” procedure is available. For
204 INTERNATIONAL JOURNAL OF TRANSGENDERISM
many FtM patients, this is the only surgery of surgery and frequent technical difficulties,
undertaken. When the amount of breast tissue which may require additional operations. Even
removed requires skin removal, a scar will metoidioplasty, which in theory is a one-stage
result and the patient should be so informed. procedure for construction of a microphallus,
Complications of subcutaneous mastectomy can often requires more than one operation. The
include nipple necrosis, contour irregularities, objective of standing micturition with this tech-
and unsightly scarring (Monstrey et al., 2008). nique can not always be ensured (Monstrey et al.,
2009).
Genital Surgery Techniques and Complications of phalloplasty in FtMs may
Complications include frequent urinary tract stenoses and fistu-
las, and occasionally necrosis of the neophallus.
Genital surgical procedures for the MtF Metoidioplasty results in a micropenis, without
patient may include orchiectomy, penectomy, the capacity for standing urination. Phalloplasty,
vaginoplasty, clitoroplasty, and labiaplasty. using a pedicled or a free vascularized flap, is a
Techniques include penile skin inversion, pedi- lengthy, multi-stage procedure with significant
cled colosigmoid transplant, and free skin grafts morbidity that includes frequent urinary com-
to line the neovagina. Sexual sensation is an plications and unavoidable donor site scarring.
important objective in vaginoplasty, along with For this reason, many FtM patients never un-
creation of a functional vagina and acceptable dergo genital surgery other than hysterectomy
cosmesis. and salpingo-oophorectomy (Hage & De Graaf,
Surgical complications of MtF genital surgery 1993).
may include complete or partial necrosis of the Even patients who develop severe surgical
vagina and labia, fistulas from the bladder or complications seldom regret having undergone
bowel into the vagina, stenosis of the urethra, and surgery. The importance of surgery can be
vaginas that are either too short or too small for appreciated by the repeated finding that quality
coitus. While the surgical techniques for creating of surgical results is one of the best predictors
a neovagina are functionally and aesthetically of the overall outcome of sex reassignment
excellent, anorgasmia following the procedure (Lawrence, 2006).
has been reported, and a second stage labiaplasty
may be needed for cosmesis (Klein & Gorzalka,
2009; Lawrence, 2006). Other Surgeries
Genital surgical procedures for FtM pa-
tients may include hysterectomy, salpingo- Other surgeries for assisting in body feminiza-
oophorectomy, vaginectomy, metoidioplasty, tion include reduction thyroid chondroplasty
scrotoplasty, urethroplasty, placement of testic- (reduction of the Adam’s apple), voice modifica-
ular prostheses, and phalloplasty. For patients tion surgery, suction-assisted lipoplasty (contour
without former abdominal surgery, the laparo- modeling) of the waist, rhinoplasty (nose correc-
scopic technique for hysterectomy and salpingo- tion), facial bone reduction, face-lift, and ble-
oophorectomy is recommended to avoid a lower- pharoplasty (rejuvenation of the eyelid). Other
abdominal scar. Vaginal access may be difficult surgeries for assisting in body masculinization
as most patients are nulliparous and have often include liposuction, lipofilling, and pectoral
not experienced penetrative intercourse. Current implants. Voice surgery to obtain a deeper
operative techniques for phalloplasty are varied. voice is rare but may be recommended in some
The choice of techniques may be restricted by cases, such as when hormone therapy has been
anatomical or surgical considerations and by a ineffective.
client’s financial considerations. If the objectives Although these surgeries do not require
of phalloplasty are a neophallus of good ap- referral by mental health professionals, such
pearance, standing micturition, sexual sensation, professionals can play an important role in
and/or coital ability, patients should be clearly assisting clients in making a fully informed
informed that there are several separate stages decision about the timing and implications of
Coleman et al. 205
be denied on the basis of institutionalization or ward, or pod on the sole basis of the appearance
housing arrangements. If the in-house expertise of the external genitalia may not be appropriate
of health professionals in the direct or indirect and may place the individual at risk for victim-
employ of the institution does not exist to assess ization (Brown, 2009).
and/or treat people with gender dysphoria, it is Institutions where transsexual, transgender,
appropriate to obtain outside consultation from and gender-nonconforming people reside and
professionals who are knowledgeable about this receive health care should monitor for a tolerant
specialized area of health care. and positive climate to ensure that residents are
People with gender dysphoria in institutions not under attack by staff or other residents.
may also have coexisting mental health condi-
tions (Cole et al., 1997). These conditions should
be evaluated and treated appropriately. XV. APPLICABILITY OF THE
People who enter an institution on an ap- STANDARDS OF CARE TO PEOPLE
propriate regimen of hormone therapy should
be continued on the same, or similar, therapies
WITH DISORDERS OF SEX
and monitored according to the SOC. A “freeze DEVELOPMENT
frame” approach is not considered appropriate
care in most situations (Kosilek v. Massachusetts
Terminology
Department of Corrections/Maloney, C.A. No. The term disorder of sex development (DSD)
92-12820-MLW, 2002). People with gender dys- refers to a somatic condition of atypical de-
phoria who are deemed appropriate for hormone velopment of the reproductive tract (Hughes,
therapy (following the SOC) should be started Houk, Ahmed, Lee, & LWPES/ESPE Consensus
on such therapy. The consequences of abrupt Group, 2006). DSDs include the condition
withdrawal of hormones or lack of initiation that used to be called intersexuality. Although
of hormone therapy when medically necessary the terminology was changed to DSD during
include a high likelihood of negative outcomes an international consensus conference in 2005
such as surgical self-treatment by autocastration, (Hughes et al., 2006), disagreement about lan-
depressed mood, dysphoria, and/or suicidality guage use remains. Some people object strongly
(Brown, 2010). to the “disorder” label, preferring instead to
Reasonable accommodations to the institu- view these congenital conditions as a matter
tional environment can be made in the delivery of diversity (Diamond, 2009) and to continue
of care consistent with the SOC, if such ac- using the terms intersex or intersexuality. In the
commodations do not jeopardize the delivery SOC, WPATH uses the term DSD in an objective
of medically necessary care to people with and value-free manner, with the goal of ensuring
gender dysphoria. An example of a reasonable that health professionals recognize this medical
accommodation is the use of injectable hor- term and use it to access relevant literature as
mones, if not medically contraindicated, in an the field progresses. WPATH remains open to
environment where diversion of oral prepara- new terminology that will further illuminate
tions is highly likely (Brown, 2009). Denial the experience of members of this diverse
of needed changes in gender role or access to population and lead to improvements in health
treatments, including sex reassignment surgery, care access and delivery.
on the basis of residence in an institution are
not reasonable accommodations under the SOC Rationale for Addition to the SOC
(Brown, 2010).
Housing and shower/bathroom facilities Previously, individuals with a DSD who also
for transsexual, transgender, and gender- met the DSM-IV-TR’s behavioral criteria for
nonconforming people living in institutions Gender Identity Disorder (American Psychiatric
should take into account their gender identity Association, 2000) were excluded from that
and role, physical status, dignity, and personal general diagnosis. Instead, they were catego-
safety. Placement in a single-sex housing unit, rized as having a “Gender Identity Disorder-Not
208 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Otherwise Specified.” They were also excluded The type of DSD and severity of the con-
from the WPATH Standards of Care. dition has significant implications for deci-
The current proposal for DSM-5 sions about a patient’s initial sex assignment,
(www.dsm5.org) is to replace the term subsequent genital surgery, and other medical
gender identity disorder with gender dysphoria. and psychosocial care (Meyer-Bahlburg, 2009).
Moreover, the proposed changes to the DSM For instance, the degree of prenatal androgen
consider gender dysphoric people with a DSD exposure in individuals with a DSD has been
to have a subtype of gender dysphoria. This correlated with the degree of masculinization
proposed categorization—which explicitly of gender-related behavior (that is, gender
differentiates between gender dysphoric role and expression); however, the correlation
individuals with and without a DSD—is is only moderate, and considerable behavioral
justified: In people with a DSD, gender variability remains unaccounted for by prenatal
dysphoria differs in its phenomenological androgen exposure (Jurgensen et al., 2007;
presentation, epidemiology, life trajectories, Meyer-Bahlburg, Dolezal, Baker, Ehrhardt, &
and etiology (Meyer-Bahlburg, 2009). New, 2006). Notably, a similar correlation of
Adults with a DSD and gender dysphoria prenatal hormone exposure with gender iden-
have increasingly come to the attention of health tity has not been demonstrated (e.g., Meyer-
professionals. Accordingly, a brief discussion of Bahlburg, Dolezal, et al., 2004). This is un-
their care is included in this version of the SOC. derlined by the fact that people with the same
(core) gender identity can vary widely in the
Health History Considerations degree of masculinization of their gender-related
behavior.
Health professionals assisting patients with
both a DSD and gender dysphoria need to be Assessment and Treatment of Gender
aware that the medical context in which such Dysphoria in People with Disorders of Sex
patients have grown up is typically very different Development
from that of people without a DSD.
Some people are recognized as having a Very rarely are individuals with a DSD
DSD through the observation of gender-atypical identified as having gender dysphoria before a
genitals at birth. (Increasingly this observation DSD diagnosis has been made. Even so, a DSD
is made during the prenatal period by way diagnosis is typically apparent with an appro-
of imaging procedures such as ultrasound.) priate history and basic physical exam—both
These infants then undergo extensive medical of which are part of a medical evaluation
diagnostic procedures. After consultation among for the appropriateness of hormone therapy
the family and health professionals—during or surgical interventions for gender dysphoria.
which the specific diagnosis, physical and Mental health professionals should ask their
hormonal findings, and feedback from long- clients presenting with gender dysphoria to have
term outcome studies (Cohen-Kettenis, 2005; a physical exam, particularly if they are not
Dessens, Slijper, & Drop, 2005; Jurgensen, currently seeing a primary care (or other health
Hiort, Holterhus, & Thyen, 2007; Mazur, 2005; care) provider.
Meyer-Bahlburg, 2005; Stikkelbroeck et al., Most people with a DSD who are born with
2003; Wisniewski, Migeon, Malouf, & Gearhart, genital ambiguity do not develop gender dyspho-
2004) are considered—the newborn is assigned ria (e.g., Meyer-Bahlburg, Dolezal, et al., 2004;
a sex, either male or female. Wisniewski et al., 2004). However, some people
Other individuals with a DSD come to the with a DSD will develop chronic gender dys-
attention of health professionals around the age phoria and even undergo a change in their birth-
of puberty through the observation of atypical assigned sex and/or their gender role (Meyer-
development of secondary sex characteristics. Bahlburg, 2005; Wilson, 1999; Zucker, 1999).
This observation also leads to a specific medical If there are persistent and strong indications that
evaluation. gender dysphoria is present, a comprehensive
Coleman et al. 209
evaluation by clinicians skilled in the assessment ries may include a great variety of inborn genetic,
and treatment of gender dysphoria is essential, endocrine, and somatic atypicalities, as well as
irrespective of the patient’s age. Detailed various hormonal, surgical, and other medical
recommendations have been published for treatments. For this reason, many additional
conducting such an assessment and for making issues need to be considered in the psychosocial
treatment decisions to address gender dysphoria and medical care of such patients, regardless of
in the context of a DSD (Meyer-Bahlburg, the presence of gender dysphoria. Consideration
2011). Only after thorough assessment should of these issues is beyond what can be covered
steps be taken in the direction of changing a in the SOC. The interested reader is referred
patient’s birth-assigned sex or gender role. to existing publications (e.g., Cohen-Kettenis
Clinicians assisting these patients with treat- & Pfäfflin, 2003; Meyer-Bahlburg, 2002, 2008).
ment options to alleviate gender dysphoria may Some families and patients also find it useful to
profit from the insights gained from providing consult or work with community support groups.
care to patients without a DSD (Cohen-Kettenis, There is a very substantial medical literature
2010). However, certain criteria for treatment on the medical management of patients with a
(e.g., age, duration of experience with living DSD. Much of this literature has been produced
in the desired gender role) are usually not by high-level specialists in pediatric endocrinol-
routinely applied to people with a DSD; rather, ogy and urology, with input from specialized
the criteria are interpreted in light of a patient’s mental health professionals, especially in the
specific situation (Meyer-Bahlburg, 2011). In the area of gender. Recent international consensus
context of a DSD, changes in birth-assigned conferences have addressed evidence-based care
sex and gender role have been made at any guidelines (including issues of gender and of
age between early-elementary-school age and genital surgery) for DSD in general (Hughes
middle adulthood. Even genital surgery may be et al., 2006) and specifically for Congenital
performed much earlier in these patients than Adrenal Hyperplasia (Joint LWPES/ESPE CAH
in gender dysphoric individuals without a DSD Working Group et al., 2002; Speiser et al., 2010).
if the surgery is well justified by the diagnosis, Others have addressed the research needs for
by the evidence-based gender-identity prognosis DSD in general (Meyer-Bahlburg & Blizzard,
for the given syndrome and syndrome severity, 2004) and for selected syndromes such as 46,
and by the patient’s wishes. XXY (Simpson et al., 2003).
One reason for these treatment differences is
that genital surgery in individuals with a DSD
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Breast cancer approved for use (Dahl et al., 2006; Moore et al.,
2003; Tangpricha et al., 2003). Spironolactone
• MtF persons who have taken feminizing has a long history of use in treating hypertension
hormones do experience breast cancer, but and congestive heart failure. Its common side
it is unknown how their degree of risk effects include hyperkalemia, dizziness, and
compares to that of persons born with gastrointestinal symptoms (Physicians’ Desk
female genitalia. Reference, 2007).
• Longer duration of feminizing hormone
exposure (i.e., number of years taking Risks of Masculinizing Hormone Therapy
estrogen preparations), family history of (FtM)
breast cancer, obesity (BMI >35), and the
use of progestins likely influence the level Likely Increased Risk
of risk.
Polycythemia
The aim of hormone therapy prior to go- 5. 12 continuous months of hormone therapy
nadectomy is primarily to introduce a period of as appropriate to the patient’s gender
reversible estrogen or testosterone suppression, goals (unless hormones are not clinically
before a patient undergoes irreversible surgical indicated for the individual);
intervention. 6. 12 continuous months of living in a gender
These criteria do not apply to patients who role that is congruent with their gender
are having these surgical procedures for medical identity.
indications other than gender dysphoria.
Although not an explicit criterion, it is rec-
ommended that these patients also have regular
Metoidioplasty or Phalloplasty in FtM Pa- visits with a mental health or other medical
tients and Vaginoplasty in MtF Patients professional.
The criterion noted above for some types
1. Persistent, well-documented gender dys- of genital surgeries—that is, that patients en-
phoria; gage in 12 continuous months of living in a
2. Capacity to make a fully informed decision gender role that is congruent with their gender
and to give consent for treatment; identity—is based on expert clinical consensus
3. Age of majority in a given country; that this experience provides ample opportunity
4. If significant medical or mental health for patients to experience and socially adjust
concerns are present, they must be well in their desired gender role, before undergoing
controlled; irreversible surgery.
Coleman et al. 229
of general population samples (Asscheman et al., those before 1986; this reflects significant im-
2011; Dhejne et al., 2011). An analysis of data provement in surgical complications (Eldh et al.,
from the Swedish National Board of Health 1997). Most patients have reported improved
and Welfare information registry found that psychosocial outcomes, ranging between 87%
individuals who had received sex reassignment for MtF patients and 97% for FtM patients
surgery (191 MtF and 133 FtM) had significantly (Green & Fleming, 1990). Similar improve-
higher rates of mortality, suicide, suicidal behav- ments were found in a Swedish study in which
ior, and psychiatric morbidity than those for a “almost all patients were satisfied with sex
nontranssexual control group matched on age, reassignment at 5 years, and 86% were assessed
immigrant status, prior psychiatric morbidity, by clinicians at follow-up as stable or improved
and birth sex (Dhejne et al., 2011). Similarly, a in global functioning” (Johansson, Sundbom,
study in the Netherlands reported a higher total Höjerback, & Bodlund, 2010). Weaknesses of
mortality rate, including incidence of suicide, in these earlier studies are their retrospective de-
both pre- and postsurgery transsexual patients sign and use of different criteria to evaluate
(966 MtF and 365 FtM) than in the general outcomes.
population of that country (Asscheman et al., A prospective study conducted in the Nether-
2011). Neither of these studies questioned the lands evaluated 325 consecutive adult and
efficacy of sex reassignment; indeed, both lacked adolescent subjects seeking sex reassignment
an adequate comparison group of transsexuals (Smith, Van Goozen, Kuiper, & Cohen-Kettenis,
who either did not receive treatment or who 2005). Patients who underwent sex reassignment
received treatment other than genital surgery. therapy (both hormonal and surgical interven-
Moreover, transexual people in these studies tion) showed improvements in their mean gender
were treated as far back as the 1970’s. However, dysphoria scores, measured by the Utrecht Gen-
these findings do emphasize the need to have der Dysphoria Scale. Scores for body dissatisfac-
good long-term psychological and psychiatric tion and psychological function also improved
care available for this population. More studies in most categories. Fewer than 2% of patients
are needed that focus on the outcomes of current expressed regret after therapy. This is the largest
assessment and treatment approaches for gender prospective study to affirm the results from retro-
dysphoria. spective studies that a combination of hormone
It is difficult to determine the effectiveness of therapy and surgery improves gender dysphoria
hormones alone in the relief of gender dysphoria. and other areas of psychosocial functioning.
Most studies evaluating the effectiveness of There is a need for further research on the effects
masculinizing/feminizing hormone therapy on of hormone therapy without surgery, and without
gender dysphoria have been conducted with the goal of maximum physical feminization or
patients who have also undergone sex reas- masculinization.
signment surgery. Favorable effects of therapies Overall, studies have been reporting a steady
that included both hormones and surgery were improvement in outcomes as the field becomes
reported in a comprehensive review of over 2000 more advanced. Outcome research has mainly
patients in 79 studies (mostly observational) focused on the outcome of sex reassignment
conducted between 1961 and 1991 (Eldh, Berg, surgery. In current practice there is a range of
& Gustafsson, 1997; Gijs & Brewaeys, 2007; identity, role, and physical adaptations that could
Murad et al., 2010; Pfäfflin & Junge, 1998). use additional follow-up or outcome research
Patients operated on after 1986 did better than (Institute of Medicine, 2011).
Coleman et al. 231
2. Process of soliciting international input Blaine Paxton Hall, MHS-CL, PA-C (USA)
on proposed changes from gender identity Friedmann Pfäfflin, MD, PhD (Germany)
professionals and the transgender commu- Katherine Rachlin, PhD (USA)
nity; Bean Robinson, PhD (USA)
3. Working meeting of the Writing Group; Loren Schechter, MD (USA)
4. Process of gathering additional feedback Vin Tangpricha, MD, PhD (USA)
and arriving at final expert consensus from Mick van Trotsenburg, MD (Netherlands)
the professional and transgender commu- Anne Vitale, PhD (USA)
nities, the Standards of Care, Version 7, Sam Winter, PhD (Hong Kong)
Revision Committee, and WPATH Board Stephen Whittle, OBE (UK)
of Directors; Kevan Wylie, MB, MD (UK)
5. Costs of printing and distributing Stan- Ken Zucker, PhD (Canada)
dards of Care, Version 7, and posting a
free downloadable copy on the WPATH International Advisory Group Selection
website; Committee
6. Plenary session to launch the Standards
of Care, Version 7, at the 2011 WPATH Walter Bockting, PhD (USA)
Biennial Symposium in Atlanta, Georgia, Marsha Botzer, MA (USA)
USA. Aaron Devor, PhD (Canada)
Randall Ehrbar, PsyD (USA)
Members of the Standards of Care Evan Eyler, MD (USA)
Revision Committee† Jamison Green, PhD, MFA (USA)
Blaine Paxton Hall, MHS-CL, PA (USA)
Eli Coleman, PhD (USA)∗ —Committee chair
Richard Adler, PhD (USA)
International Advisory Group
Walter Bockting, PhD (USA)∗
Marsha Botzer, MA (USA)∗ Tamara Adrian, LGBT Rights Venezuela
George Brown, MD (USA) (Venezuela)
Peggy Cohen-Kettenis, PhD (Netherlands)∗ Craig Andrews, FTM Australia (Australia)
Griet DeCuypere, MD (Belgium)∗ Christine Burns, MBE, Plain Sense Ltd (UK)
Aaron Devor, PhD (Canada) Naomi Fontanos, Society for Transsexual
Randall Ehrbar, PsyD (USA) Women’s Rights in the Phillipines (Phillipines)
Randi Ettner, PhD (USA) Tone Marie Hansen, Harry Benjamin Re-
Evan Eyler, MD (USA) source Center (Norway)
Jamie Feldman, MD, PhD (USA)∗ Rupert Raj, Shelbourne Health Center
Lin Fraser, EdD (USA)∗ (Canada)
Rob Garofalo, MD, MPH (USA) Masae Torai, FTM Japan (Japan)
Jamison Green, PhD, MFA (USA)∗ Kelley Winters, GID Reform Advocates
Dan Karasic, MD (USA) (USA)
Gail Knudson, MD (Canada)∗
Arlene Istar Lev, LCSW-R (USA) Technical Writer
Gal Mayer, MD (USA)
Walter Meyer, MD (USA)∗ Anne Marie Weber-Main, PhD (USA)
Heino Meyer-Bahlburg, Dr. rer.nat. (USA)
Editorial Assistance
Stan Monstrey, MD, PhD (Belgium)∗
Heidi Fall (USA)
∗
Writing Group member
†
All members of the Standards of Care, Version
7, Revision Committee donated their time to work on
this revision.