Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

INTRODUCTION

CHAPTER 1 Terminology

This chapter will lay the framework for language used in the SOC-8. It offers recommendations for use of terminology. It provides (1) terms and definitions, and (2) best practices for utilizing them. This document is accompanied by a glossary of common terms and language to provide a framework for use and interpretation of the SOC-8. See Appendix B for glossary.

CHAPTER 2 Global Applicability

People who defy cultural boundaries of sex and gender have existed in cultures worldwide since ancient times, sometimes acknowledged in local language terms (Feinberg, 1996). In contrast to the more recent pathologization of gender diversity as an illness, some cultures traditionally celebrated and welcomed this diversity (e.g., Nanda, 2014; Peletz, 2009). Today, the English language umbrella term transgender and gender diverse (TGD) describes a huge variety of gender identities and expressions, and therefore a population with diverse health care experiences and needs. Together, TGD people represent important aspects of human diversity the World Professional Association for Transgender Health (WPATH) asserts should be valued and celebrated. TGD people continue to make vital contributions to the societies in which they live, although often these are unrecognized.

Disturbingly, many TGD people in the modern world experience stigma, prejudice, discrimination, harassment, abuse and violence, resulting in social, economic and legal marginalization, poor mental and physical health, and even death—a process that has been characterized as a stigma-sickness slope (Winter, Diamond et al., 2016). Experiences such as these (and the anticipation or fear of encountering such experiences) leads to what Meyer has described as minority stress (Meyer, 2003; see also Bockting et al., 2013 writing specifically about TGD people), and are associated with poor physical (e.g. Rich et al, 2020) and psychological (e.g., Bränström et al., 2022; Scandurra et al., 2017; Shipherd et al., 2019, Tan et al., 2021) health outcomes.

Violence against TGD people is a particular problem. Seen from a global perspective, it is widespread, diverse in nature (emotional, sexual and physical, e.g., see Mujugira et al., 2021), and involves a range of perpetrators (including State actors). Statistics on murder, the form of violence most extreme in its consequences, are alarming. Worldwide, there were over 4,000 documented killings between January 2008 and September 2021; a statistic widely regarded as flawed by under-reporting (TGEU, 2020).

Since the publication of the Standards of Care Version 7 (SOC-7), there have been dramatic changes in perspectives on TGD people and their health care. Mainstream global medicine no longer classifies TGD identities as a mental disorder. In the Diagnostic and Statistical Manual Version 5 (DSM-5) from the American Psychiatric Association (APA, 2013), the diagnosis of Gender Dysphoria focuses on any distress and discomfort that accompanies being TGD, rather than on the gender identity itself. A text revision (DSM-5-TR) was published in 2022. In the International Classification of Diseases, Version 11 (ICD-11), the diagnostic manual of the World Health Organization (WHO, 2019b), the Gender Incongruence diagnosis is placed in a chapter on sexual health and focuses on the person’s experienced identity and any need for gender-affirming treatment that might stem from that identity. Such developments, involving a depathologization (or more precisely a de-psychopathologization) of transgender identities, are fundamentally important on a number of grounds. In the field of health care, they may have helped support a care model that emphasizes patients’ active participation in decision-making about their own health care, supported by primary health care professionals (HCPs) (Baleige et al., 2021). It is reasonable to suppose these developments may also promote more socially inclusive policies such as legislative reform regarding gender recognition that facilitates a rights-based approach, without imposing requirements for diagnosis, hormone therapy and/or surgery. TGD people who have changed gender markers on key documents enjoy better mental health (e.g., Bauer et al., 2015; Scheim et al., 2020). A more rights-based approach in this area may contribute greatly to the overall health and well-being of TGD people (Arístegui et al., 2017).

Previous editions of the SOC have revealed much of the recorded clinical experience and knowledge in this area is derived from North American and Western European sources. They have focused on gender-affirming health care in high income countries that enjoy relatively well-resourced health care systems (including those with trained mental health providers, endocrinologists, surgeons and other specialists) and where services are often funded publicly or (at least for some patients) through private insurance.

For many countries, health care provision for TGD people is aspirational; with resourcing in this area limited or non-existent, and services often unavailable, inappropriate, difficult to access and/or unaffordable. Few if any HCPs (primary or specialist) may exist. Funding for gender-affirming health care may be absent, with patients often bearing the full costs of whatever health care they access. Health care providers often lack clinical and/or cultural competence in this area. Training for work with these patients may be limited (e.g., Martins et al., 2020). For all these reasons and because of mainstream “Western” medicine’s historical view of TGD people as mentally disordered (a perspective that has only recently changed), TGD people have commonly found themselves disempowered as health care consumers.

Health care providers have found the relevant literature is largely North American and European, which present particular challenges for persons working in health care systems that are especially poorly resourced. Recent initiatives that often involve TGD stakeholders as partners are changing this situation somewhat by providing a body of knowledge about good practice in other regions, including how to provide effective, culturally-competent TGD health care in low- and middle-income countries outside the global north.

Within the field, a wide range of valuable health care resources have been developed in recent years. Dahlen et al (2021) review twelve international clinical practice guidelines; over half those reviewed originate from professional bodies based in North America (e.g., Hembree et al., 2017) or Europe (e.g., T’Sjoen et al., 2020). Three are from WHO (the most recent being WHO, 2016). Nowadays, there are numerous other resources, not on Dahlen et al.’s list, that explicitly draw on expertise from regions outside North America and Europe. Examples can be found in Asia and the Pacific (APTN, 2022; Health Policy Project et al., 2015), the Caribbean (PAHO, 2014), Thailand, Australia (Telfer et al., 2020), Aotearoa New Zealand (Oliphant et al., 2018), and South Africa (Tomson et al., 2021) (see also TRANSIT (UNDP et al., 2016)). These resources have commonly been created through the initiatives of or in partnership with TGD communities locally or internationally. This partnership approach, focused on meeting local needs in culturally safe and competent ways, can also have broad international relevance. Some of these publications may be of particular value to those planning, organizing and delivering services in low-income, low-resource countries. There are likely to be other resources published in languages other than English of which we are unaware.

Globally, TGD identities may be associated with differing conceptual frameworks of sex, gender, and sexuality and exist in widely diverse cultural (and sometimes spiritual) contexts and histories. Considering the complex relationships between social and cultural factors, the law, and the demand for and provisions of gender-affirming health care, the SOC-8 should be interpreted through a lens that is appropriate for and within the context of each HCP’s individual practice while maintaining alignment to the core principles that underscore it (APTN and UNDP, 2012; Health Policy Project et al., 2015; PAHO, 2014).

It is within this context and by drawing broadly on the experiences of TGD people and health care providers internationally that we consider the global applicability of SOC-8 within this chapter. We set out key considerations for HCPs and conclude by recommending core principles and practices fundamental to contemporary health care for TGD people, regardless of where they live or whether there are resources available to those who seek to provide such health care.

Statement 2.1

We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.

Medical necessity is a term common to health care coverage and insurance policies globally. A common definition of medical necessity as used by insurers or insurance companies is “Health care services that a physician and/or health care professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the patient’s illness, injury, or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.” The treating HCP asserts and documents that a proposed treatment is medically necessary for treatment of the condition (American Medical Association, 2016).

Generally, “accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, designated Medical Specialty Societies and/or legitimate Medical Colleges’ recommendations, and the views of physicians and/or HCPs practicing in relevant clinical areas.

Medical necessity is central to payment, subsidy, and/or reimbursement for health care in parts of the world. The treating HCP may assert and document that a given treatment is medically necessary for the prevention or treatment of the condition. If health policies and practices challenge the medical necessity of a treatment, there may be an opportunity to appeal to a governmental agency or other entity for an independent medical review.

It should be recognized gender diversity is common to all human beings and is not pathological. However, gender incongruence that causes clinically significant distress and impairment often requires medically necessary clinical interventions. In many countries, medically necessary gender-affirming care is documented by the treating health professional as treatment for Gender Incongruence (HA60 in ICD-11; WHO, 2019b) and/or as treatment for Gender Dysphoria (F64.0 in DSM-5-TR; APA, 2022).

There is strong evidence demonstrating the benefits in quality of life and well-being of gender-affirming treatments, including endocrine and surgical procedures, properly indicated and performed as outlined by the Standards of Care (Version 8), in TGD people in need of these treatments (e.g., Ainsworth & Spiegel, 2010; Aires et al., 2020; Aldridge et al., 2020; Almazan & Keuroghlian, 2021; Al-Tamimi et al., 2019; Balakrishnan et al., 2020; Baker et al., 2021; Buncamper et al., 2016; Cardoso da Silva et al., 2016; Eftekhar Ardebili, 2020; Javier et al., 2022; Lindqvist et al., 2017; Mullins et al., 2021; Nobili et al., 2018; Owen-Smith et al., 2018; Özkan et al., 2018; T’Sjoen et al., 2019; van de Grift, Elaut et al., 2018; White Hughto & Reisner, Poteat et al., 2016; Wierckx, van Caenegem et al., 2014; Yang, Zhao et al., 2016). Gender-affirming interventions may also include hair removal/transplant procedures, voice therapy/surgery, counseling, and other medical procedures required to effectively affirm an individual’s gender identity and reduce gender incongruence and dysphoria. Additionally, legal name and sex or gender change on identity documents can also be beneficial and, in some jurisdictions, are contingent on medical documentation that patients may call on practitioners to produce.

Gender-affirming interventions are based on decades of clinical experience and research; therefore, they are not considered experimental, cosmetic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria (e.g., Aires et al., 2020; Aldridge et al., 2020; Al-Tamimi et al., 2019; Balakrishnan et al., 2020; Baker et al., 2021; Bertrand et al., 2017; Buncamper et al., 2016; Claes et al., 2018; Eftekhar Ardebili, 2020; Esmonde et al., 2019; Javier et al., 2022; Lindqvist et al., 2017; Lo Russo et al., 2017; Marinkovic & Newfield, 2017; Mullins et al., 2021; Nobili et al., 2018; Olson-Kennedy, Rosenthal et al., 2018; Özkan et al., 2018; Poudrier et al., 2019; T’Sjoen et al., 2019; van de Grift, Elaut et al., 2018; White Hughto & Reisner, Poteat et al., 2016; Wierckx, van Caenegem et al., 2014; Wolter et al., 2015; Wolter et al., 2018).

Consequently, WPATH urges health care systems to provide these medically necessary treatments and eliminate any exclusions from their policy documents and medical guidelines that preclude coverage for any medically necessary procedures or treatments for the health and well-being of TGD individuals. In other words, governments should ensure health care services for TGD people are established, extended or enhanced (as appropriate) as elements in any Universal Health Care, public health, government-subsidized systems, or government-regulated private systems that may exist. Health care systems should ensure ongoing health care, both routine and specialized, is readily accessible and affordable to all citizens on an equitable basis.

Medically necessary gender-affirming interventions are discussed in SOC-8. These include but are not limited to hysterectomy +/- bilateral salpingo-oophorectomy; bilateral mastectomy, chest reconstruction or feminizing mammoplasty, nipple resizing or placement of breast prostheses; genital reconstruction, for example, phalloplasty and metoidioplasty, scrotoplasty, and penile and testicular prostheses, penectomy, orchiectomy, vaginoplasty, and vulvoplasty; hair removal from the face, body, and genital areas for gender affirmation or as part of a preoperative preparation process; gender-affirming facial surgery and body contouring; voice therapy and/or surgery; as well as puberty blocking medication and gender-affirming hormones; counseling or psychotherapeutic treatment as appropriate for the patient and based on a review of the patient’s individual circumstances and needs.

Statement 2.2

We recommend health care professionals and other users of the Standards of Care, Version 8 (SOC-8) apply the recommendations in ways that meet the needs of local transgender and gender diverse communities, by providing culturally sensitive care that recognizes the realities of the countries they are practicing in.

TGD people identify in many different ways worldwide, and those identities exist within a cultural context. In English speaking countries, TGD people variously identify as transsexual, trans, gender nonconforming, gender queer or diverse, nonbinary, or indeed transgender and/or gender diverse, as well as by other identities; including (for many identifying inside the gender binary) male or female. (e.g., James et al., 2016; Strauss et al., 2017; Veale et al., 2019).

Elsewhere, identities include but are not limited to travesti (across much of Latin America), hijra (across much of South Asia), khwaja sira (in Pakistan), achout (in Myanmar), maknyah, paknyah (in Malaysia), waria (Indonesia) kathoey, phuying kham phet, sao praphet song (Thailand), bakla, transpinay, transpinoy (Philippines), fa’afafine (Samoa), mahu (French Polynesia, Hawai’i), leiti (Tonga), fakafifine (Niue), pinapinaaine (Tuvalu and Kiribati), vakasalewalewa (Fiji), palopa (Papua Niugini), brotherboys and sistergirls (Aboriginal and Torres Strait Islander people in Australia), and akava’ine (Cook Islands) (e.g., APTN and UNDP, 2012; Health Policy Project et al., 2015; Kerry, 2014). There are also a large number of two spirit identities across North America (e.g., nadleehi in Navajo (Diné) culture) (Sheppard & Mayo, 2013). The identities to which each of these terms refer are often culturally complex and may exist in a spiritual or religious context. Depending on the cultures and the identities concerned, some may be regarded as so-called “third genders” lying beyond the gender binary (e.g., Graham, 2010; Nanda, 2014; Peletz, 2009). Some TGD identities are less firmly established than others. In many places worldwide, the visibility of transgender men and nonbinary trans masculine identities is relatively recent, with few or no applicable traditional terms in local languages (Health Policy Project et al., 2015). Regardless of where or with whom HCPs work (including those working with ethnic minority persons, migrants and refugees), they need to be aware of the cultural context in which people have grown up and live as well as the consequences for health care.

Worldwide the availability, accessibility, acceptability and quality of health care vary greatly, with resulting inequities within and across countries (OECD, 2019). In some countries, formal health care systems exist alongside established traditional and folk health care systems, with indigenous models of health underpinning the importance of holistic health care (WHO, 2019a). HCPs should be aware of the traditions and realities within which health care is available and provide support that is sensitive to the local needs and identities of TGD people and provide them with culturally competent and safe care.

Statement 2.3

We recommend health care providers understand the impact of social attitudes, laws, economic circumstances, and health systems on the lived experiences of transgender and gender diverse people worldwide.

TGD people’s lived experiences vary greatly, depending on a range of factors, including social, cultural (including spiritual), legal, economic and geographic. When TGD people live in environments that affirm their gender and/or cultural identities, then these experiences can be very positive. Families are particularly important in this regard (e.g., Pariseau et al., 2019; Yadegarfard et al., 2014; Zhou et al., 2021). However, when viewed from a global perspective, the circumstances in which TGD people live are often challenging. They are commonly denied widely accepted rights in international human rights law. These include rights to education, health and protection from medical abuses, work and an adequate standard of living, housing, freedom of movement and expression, privacy, security, life, family, freedom from arbitrary deprivation of liberty, fair trial, treatment with humanity while in detention, and freedom from torture, inhuman or degrading treatment or punishment (International Commission of Jurists, 2007, 2017).

It is widely accepted that denial of rights can impact sexual and gender minority health and well-being (e.g., OHCHR et al., 2016; WHO, 2015). We therefore reaffirm here the importance of the rights listed above for TGD people and note WPATH’s previous rights advocacy, including through numerous policy documents (e.g., WPATH, 2016, 2017, 2019). HCPs can play an important role in rights advocacy, including the right to quality gender-affirming health care that is appropriate, affordable, and accessible.

Across the world, a large number of studies detail the challenges TGD people face in their lives, and the impact on their health and well-being (e.g., Aurat Foundation, 2016; Bhattacharya & Ghosh, 2020; Chumakov et al., 2021; Coleman et al., 2018; Heylens, Elaut et al., 2014; Human Rights Watch, 2014; James et al, 2016; Lee, Operario et al., 2020; Luz et al., 2022; McNeil et al., 2012, 2013; Motmans et al., 2017; Muller et al., 2019; Scandurra et al., 2017; Strauss et al., 2019; Suen et al., 2017; Valashany & Janghorbani, 2019; Veale et al., 2019; Wu et al., 2017). The research shows TGD people often experience stigma and prejudice as well as discrimination and harassment, abuse and violence, or they live in anticipation and fear of such actions. Social values and attitudes hostile to TGD people, often communicated to young people in school curricula (e.g., Olivier & Thurasukam, 2018), are also expressed in family rejection (e.g., Yadegarfard et al., 2014), and perpetuated in laws, policies and practices that limit freedom to express one’s gender identity and sexuality and hinder access to housing, public spaces, education, employment and services (including health care). The end result is TGD people are commonly deprived of a wide range of opportunities available to their cisgender counterparts and are pushed to the margins of society, without family supports. To make matters worse, across much of the world TGD people’s access to legal gender recognition is restricted or non-existent (e.g., ILGA World, 2020a; TGEU, 2021; UNDP and APTN, 2017). In some countries, such barriers nowadays draw on support from “gender-critical theorists” (as critiqued by e.g., Madrigal-Borloz, 2021; Zanghellini, 2020).

Gender identity change efforts (gender reparative or gender conversion programs aimed at making the person cisgender) are widespread, cause harm to TGD people (e.g., APTN, 2020a, 2020b, 2020c, 2021; Bishop, 2019; GIRES et al., 2020; Turban, Beckwith et al., 2020), and (like efforts targeting sexual orientation) are considered unethical (e.g., APS, 2021; Trispiotis and Purshouse, 2021; Various, 2019, 2021). These efforts may be viewed as a form of violence. The UN independent expert on protection against violence and discrimination based on sexual orientation and gender identity has called for a global ban on such practices (Madrigal-Borloz, 2020). An increasing number of jurisdictions are outlawing such work (ILGA World, 2020b).

Inequities arise from a range of factors, including economic considerations and values underpinning the provision of health care systems, particularly with regard to the emphasis placed on public-, private- and self-funding of health care. Lack of access to appropriate and affordable health care can lead to a greater reliance on informal knowledge systems. This includes information about self-administration of hormones, which, in many cases, is undertaken without necessary medical monitoring or supervision (e.g., Do et al., 2018; Liu et al., 2020; Rashid et al., 2022; Reisner et al., 2021; Winter & Doussantousse, 2009).

In some parts of the world, large numbers of transgender women employ silicone as a means of modifying their bodies, drawing on the services of silicone “pumpers” and/or attending pumping “parties”, often within their communities. The immediate results of silicone pumping contrast with significant downstream health risks (e.g., Aguayo-Romero et al., 2015; Bertin et al., 2019; Regmi et al., 2021), particularly where industrial silicone or other injectable substances have been used and where surgical removal may be difficult.

Finally, sexual health outcomes for TGD people are poor. HIV prevalence for transgender women reporting to clinical organizations in metropolitan areas is approximately 19% worldwide, which is 49 times higher than the background prevalence rate in the general population (Baral et al., 2013). Sexual health outcomes for transgender men are also problematic (e.g., Mujugira et al., 2021).

Statement 2.4

We recommend translations of the SOC focus on cross-cultural, conceptual and literal equivalence to ensure alignment with the core principles that underpin the SOC-8.

Much of the research literature on TGD people is produced in high-income and English-speaking countries. global northern perspectives about TGD people (including those related to health care needs and provision) dominate this literature. A May 2021 Scopus database search undertaken by the current authors shows 99% of the literature on transgender health care comes out of Europe, North America, Australia, or New Zealand. Overall, 96% of the literature is in the English language. TGD people of the Global South have received relatively little attention in the English language literature, and the work of those HCPs who interact with them has often gone unrecognized and unpublished or has not been translated into English. Applying resources produced in the global north risks overlooking the relevance and nuance of local knowledge, cultural frameworks and practices, and missed opportunities to learn from the work of others.

When translating the principles set out in the SOC, we recommend following best practice guidelines for language translation to ensure high quality written resources are produced that are culturally and linguistically appropriate to the local situation. It is important translators have knowledge about TGD identities and cultures to check that literal translations are culturally competent and safe for local TGD people. It is also important translation should follow established processes for quality assurance (Centers for Medicare & Medicaid Services, 2010; Sprager & Martinez, 2015)

Statement 2.5

We recommend health care professionals and policymakers always apply the SOC-8 core principles to their work with transgender and gender diverse people to ensure respect for human rights and access to appropriate and competent health care, including:

General principles

• Be empowering and inclusive. Work to reduce stigma and facilitate access to appropriate health care, for all who seek it;

• Respect diversity. Respect all clients and all gender identities. Do not pathologize differences in gender identity or expression;

• Respect universal human rights, including the right to bodily and mental integrity, autonomy, and self-determination; freedom from discrimination and the right to the highest attainable standard of health.

Principles around developing and implementing appropriate services and accessible health care

• Involve TGD people in the development and implementation of services;

• Become aware of social, cultural, economic, and legal factors that might impact the health (and health care needs) of transgender and gender diverse people, as well as the willingness and capacity of the person to access services;

• Provide health care (or refer to knowledgeable colleagues) that affirms gender identities and expressions, including health care that reduces the distress associated with gender dysphoria (if this is present);

• Reject approaches that have the goal or effect of conversion, and avoid providing any direct or indirect support for such approaches or services

Principles around delivering competent services

• Become knowledgeable (get training, where possible) about the health care needs of transgender and gender diverse people, including the benefits and risks of gender-affirming care;

• Match the treatment approach to the specific needs of clients, particularly their goals for gender identity and expression;

• Focus on promoting health and well-being rather than solely the reduction of gender dysphoria, which may or may not be present;

• Commit to harm reduction approaches where appropriate;

• Enable the full and ongoing informed participation of transgender and gender diverse people in decisions about their health and well-being;

• Improve experiences of health services, including those associated with administrative systems and continuity of care.

Principles around working towards improved health through wider community approaches

• Put people in touch with communities and peer support networks;

• Support and advocate for clients within their families and communities (schools, workplaces, and other settings) where appropriate.

We have already cited research detailing the broad range of challenges TGD people may face; social economic and legal obstacles, as well those related to health care access. While overall health care services are diverse across the world (in terms of availability, accessibility, and quality), those services available to TGD people are often inadequate. Numerous reports from diverse regions worldwide show, while TGD people may report positive health care experiences, many others do not (e.g., Callander et al., 2019; Costa, da Rosa Filho et al., 2018; Do et al., 2018; Gourab et al., 2019; Health Policy Project et al., 2015; Liu et al., 2020; Motmans et al., 2017; Muller et al., 2019; PAHO, 2014; Reisner et al., 2021; Strauss et al., 2017; TGEU, 2017). Mainstream health care options often do not meet their needs for general, sexual, or gender-affirming health care. Standard patient management procedures at clinics and hospitals often fail to recognize the gender identities of their TGD patients (including where outside of the binary their patients identify). Patients may be housed in wards that are gender inappropriate for them, putting them at risk of sexual harassment. TGD patients often encounter unsupportive or hostile attitudes from HCPs and ancillary staff and may even be refused service. Of great concern, HCPs in some parts of the world are involved in gender identity change efforts of the sort described earlier in this chapter.

Throughout the world, there are many other barriers to the provision of gender-affirming health care. Health care professionals may often be unwilling to provide the services TGD people seek. In some countries, there may be laws or regulations inhibiting or preventing them from doing so. When general practitioners and other health care providers do not have access to clear guidelines in their own language, they may be deterred from providing services. Even in situations where health care is available, patients may find it is difficult to access because of distance, gatekeeping practices, supply and demand issues that result in long wait lists or cost increases. Indeed, gender-affirming procedures may not be incorporated into a universal health care provision or be covered by private insurance, even though similar procedures may be covered for cisgender patients.

For all these reasons, many TGD people avoid formal health care services whenever they can. Their own communities commonly fill the void, acting as important resources for their members. They provide social and emotional support, often in an otherwise hostile environment. In addition, they often act as reservoirs of shared information about available options for health care, including parallel and informal health care options outside of (and more accessible and affordable than) mainstream medicine. As we saw earlier in this chapter, this often includes sharing of information about silicone and other injectable substances for bodily transformation and about hormones that are self-administered without necessary medical monitoring or supervision. WHO notes TGD individuals who self-administer gender-affirming hormones would benefit from access to evidence-based information, quality products, and sterile injection equipment (WHO, 2021). Access to such information can form part of a broader harm reduction approach (e.g., Idrus & Hyman, 2014).

Putting the important core principles outlined above into practice can improve health care experiences and promote respect for TGD people in all local contexts. This can occur regardless of the realities of a health care system (including the cultural, social, legal, economic context in which health care is provided), the level of provision available, or the TGD people seeking such services.

CHAPTER 3 Population Estimates

In the previous edition of its Standards of Care, Version 7, World Professional Association for Transgender Health (WPATH) identified only a small number of articles attempting to estimate the size of the transgender and gender diverse (TGD) population and characterized the state-of-the-science as “a starting point” requiring further systematic study (Coleman et al., 2012). Since then, the literature on this topic has expanded considerably as evidenced by a number of recent reviews that have sought to synthesize the available evidence (Arcelus et al., 2015; Collin et al., 2016; Goodman et al., 2019; Meier & Labuski, 2013; Zhang et al., 2020).

In reviewing epidemiologic data pertaining to the TGD population, it may be best to avoid the terms “incidence” and “prevalence.” Avoiding these and similar terms may preclude inappropriate pathologizing of TGD people (Adams et al., 2017; Bouman et al., 2017). Moreover, the term “incidence” may not be applicable in this situation because it assumes TGD status has an easily identifiable time of onset, a prerequisite for calculating incidence estimates (Celentano & Szklo, 2019). For all the above reasons, we recommend using the terms “number” and “proportion” to signify the absolute and the relative size of the TGD population.

Perhaps the most important consideration in reviewing this literature is the variable definition applied to the TGD population (Collin et al., 2016; Meier & Labuski, 2013). In clinic-based studies, the data on TGD people are typically limited to individuals who received transgender-related diagnoses or counseling or those who requested or underwent gender-affirming therapy, whereas survey-based research typically relies on a broader, more inclusive definition based on self-reported gender identities.

Another methodological consideration in assessing the size and distribution of the TGD population is the need to understand what constitutes the sampling frame. As noted in recent reviews (Goodman et al., 2019; Zhang et al., 2020), many of the published studies, especially those conducted more than a decade ago, first assessed the number of patients seen at a particular clinical center and then divided that number by an approximated population size. This was unlikely to produce an accurate estimate because the numerator in the calculations is not necessarily included in the denominator, and the true size of the denominator often remains unknown.

With these considerations in mind, it is advisable to focus specifically on recent (published within the last decade) peer-reviewed studies that utilized sound methodology in identifying TGD people within a well-defined sampling frame. For all of the above reasons, the present chapter is focused on studies that met the following inclusion criteria 1) appeared in press in 2009 or later; 2) used a clear definition of TGD status; 3) calculated proportions of TGD people based on a well-defined population denominator; and 4) were peer-reviewed. These types of studies can provide more accurate contemporary estimates.

The available studies can be assigned into three groups 1) those that reported proportions of TGD people among individuals enrolled in large health care systems; 2) those that presented results from population surveys of predominantly adult participants; and 3) those that were based on surveys of youth conducted in schools. Of these three categories, the most informative and methodologically sound studies are summarized below. Additional details about these and other similar studies can be found in recent literature reviews (Goodman et al., 2019; Zhang et al., 2020).

Among studies that estimated the size of the TGD population enrolled in large health care systems, all were conducted in the US, and all relied on information obtained from electronic health records. Four of those health system-based studies relied exclusively on diagnostic codes to ascertain the TGD population; two studies (Blosnich et al., 2013; Kauth et al., 2014) used data from the Veterans Health Affairs system, which provides care to over 9 million people, and two studies (Dragon et al., 2017; Ewald et al., 2019) used claims data from Medicare, the federal health insurance program that primarily covers people 65 years of age or older. The proportions of TGD people reported in these diagnostic code-based studies ranged from approximately 0.02% to 0.03%. Another more recent publication also used Medicare data along with commercial insurance claims to identify TGD people and applied expanded inclusion criteria to supplement diagnostic codes with information on procedures and hormone therapy (Jasuja et al., 2020). Using this methodology, the proportion of TGD people among all persons enrolled in the participating health plans was 0.03%. The sixth health systems-based study (Quinn et al., 2017) was conducted at Kaiser Permanente plans in the states of Georgia and California; these plans provide care to approximately 8 million members enrolled through employers, government programs, or individually. The TGD population in the Kaiser Permanente study was ascertained across all age groups using both diagnostic codes and free-text clinical notes. The proportions of TGD people identified at Kaiser Permanente were higher than the corresponding proportions reported in the Veterans Health Affairs and Medicare studies with the most recent estimates ranging from 0.04 to 0.08%.

In contrast to results from the health system-based studies, findings from surveys that relied on self-reported TGD status produced much higher estimates. Two US studies took advantage of the Behavioral Risk Factor Surveillance Study (BRFSS), which is an annual telephone survey conducted in all 50 states and US territories (Conron et al., 2012; Crissman et al., 2017). The first study used data from the 2007–2009 BRFSS cycles in the state of Massachusetts, and the second study used the 2014 BRFSS data from 19 states and the territory of Guam. Both studies reported that approximately 0.5% of adult participants (at least 18 years of age) responded “Yes” to the question “Do you consider yourself to be transgender?”

An internet-based survey administered to a sample of the Dutch population 15–70 years of age (Kuyper & Wijsen, 2014) asked participants to score the following two questions using a 5-point Likert scale: “Could you indicate to which degree you psychologically experience yourself as a man?” and “Could you indicate to which degree you psychologically experience yourself as a woman?” The respondents were considered “gender ambivalent” if they gave the same score to both statements and “gender incongruent” when they reported a lower score for their sex assigned at birth than for their gender identity. The proportions of participants reporting incongruent and ambivalent gender identity were 1.1% and 4.6%, respectively, for persons who were assigned male at birth (AMAB), and 0.8% and 3.2%, respectively, for persons assigned female at birth (AFAB).

A similarly designed study estimated the proportion of TGD residents in the Flanders region of Belgium using a sample drawn from the country’s National Register (Van Caenegem, Wierckx et al., 2015). Participants were asked to score the following statements: “I feel like a woman” and “I feel like a man” on a 5-point Likert scale. Using the same definitions applied in the Dutch study (Kuyper & Wijsen, 2014), the proportion of gender incongruent individuals was 0.7% for AMAB people and 0.6% for AFAB people. The corresponding estimates for gender ambivalence among AMAB and AFAB people were 2.2% and 1.9%, respectively.

A more recent population-based study evaluated the proportion of TGD people among approximately 50,000 adult residents of Stockholm County, Sweden (Åhs et al., 2018). The numerator was determined by asking participants the following question: “I would like hormones or surgery to be more like someone of a different sex.” Two additional items were designed to identify individuals experiencing gender incongruence: “I feel like someone of a different sex” and “I would like to live as or be treated as someone of a different sex.” The need for either hormone therapy or gender-affirming surgery was reported by 0.5% of participants. Individuals who expressed feeling like someone of a different sex and those who wanted to live as or be treated as a person of another sex constituted 2.3% and 2.8% of the total sample, respectively.

Population-based data outside of North America and Western Europe are less common. One recent study offers valuable data from a large representative survey of 6,000 adults in Brazil (Spizzirri et al., 2021). Gender identity of participants was assessed based on the following three questions 1) “Which of the following options best describes how you currently feel?” (Options: I feel I am a man, I feel I am a woman, and I feel I am neither a man nor a woman); 2) “What is the sex on your birth certificate?” (Options: male, female, and undetermined); and 3) “Which of these situations do you most closely relate to?” (Options: I was born male, but I have felt female since childhood; I was born female, but I have felt male since childhood; I was born male, and I feel comfortable with my body; I was born female, and I feel comfortable with my body). Based on the responses to these three questions, the authors determined 1.9% of the survey respondents were TGD (0.7% defined as transgender, and 1.2% defined as nonbinary).

The literature on the population proportions of TGD youth (persons under 19 years of age) includes several survey studies conducted in schools. A 2012 national cross-sectional survey in New Zealand collected information on TGD identity among high school students (Clark et al., 2014). Among over 8,000 survey participants, 1.2% self-identified as TGD and 2.5% reported they were not sure. Another study of schoolchildren was based on a 2016 survey of 9th and 11th grade students (ages 14–18 years) in the US state of Minnesota (Eisenberg et al., 2017). Of the nearly 81,000 survey respondents, 2.7% reported being TGD. A more recent study (Johns et al., 2019) presented results of the Youth Risk Behavior Survey (YRBS), which is conducted biennially among local, state, and nationally representative samples of US high school students in grades 9–12 (approximate age range 13–19 years). The 2017 YRBS cycle was carried out in 10 states and 9 large urban areas and included the following sequence: “Some people describe themselves as transgender when their sex at birth does not match the way they think or feel about their gender. Are you transgender?” Among nearly 120,000 participants across the 19 sites, 1.8% responded “Yes, I am transgender,” and 1.6% responded “I am not sure if I am transgender.”

Another recently published school-based study in the US presented results of a 2015 survey conducted in Florida and California with the aim of identifying gender diverse children and adolescents in a sample of just over 6,000 students in grades 9–12 (Lowry et al., 2018). “High gender-nonconforming” was used to define AMAB children who reported being very/mostly/somewhat feminine or AFAB children who reported being very/mostly/somewhat masculine. Based on these definitions, the proportions of TGD participants were reported to be 13% among AMAB students, 4% among AFAB students, and 8.4% overall.

Only one study examined the proportion of self-identified TGD children in a younger age group. Shields et al. analyzed the data from a 2011 survey of 2,700 students in grades 6–8 (age range 11–13 years) across 22 San Francisco public middle schools (Shields et al., 2013). Thirty-three children self-identified as TGD based on the question “What is your gender?” where the possible responses were “female, male, or transgender.” The resulting proportion of transgender survey respondents was 1.3%. However, this definition would exclude TGD persons self-identifying as nonbinary and those who do not explicitly identify as transgender.

Taken together, these data indicate among health system-based studies that relied on diagnostic codes or other evidence documented in the medical records (Blosnich et al., 2013; Dragon et al., 2017; Ewald et al., 2019; Kauth et al., 2014; Quinn et al., 2017), the proportions of TGD people reported in recent years (2011–2016) ranged from 0.02% to 0.08%. By contrast, when the TGD status was ascertained based on self-report, the corresponding proportions were orders of magnitude higher and reasonably consistent, if the studies used similar definitions. When the surveys specifically inquired about “transgender” identity, the estimates ranged from 0.3% to 0.5% among adults and from 1.2% to 2.7% in children and adolescents. When the definition was expanded to include broader manifestations of gender diversity, such as gender incongruence or gender ambivalence, the corresponding proportions were higher: 0.5% to 4.5% among adults and 2.5% to 8.4% among children and adolescents.

As reviewed elsewhere (Goodman et al., 2019), another noteworthy observation is the continuous increase in both the size and the composition of the TGD population with upward trends in the proportion of TGD people observed in health care systems, through population-based surveys, as well as in the data on legal gender recognition. The higher estimates observed in more recent literature support some of the previous publications indicating the size of TGD population was likely underestimated in earlier studies (Olyslager & Conway, 2008).

The temporal trends in AMAB to AFAB ratio have also been reported in studies analyzing referrals to clinics as well as data from integrated health systems; this ratio has changed from predominantly AMAB in previous decades to predominantly AFAB in recent years, especially among TGD youth (Aitken et al., 2015; de Graaf, Carmichael et al., 2018; de Graaf, Giovanardi et al. 2018; Steensma et al., 2018; Zhang et al., 2021). The trend towards a greater proportion of TGD people in younger age groups and the age-related differences in the AMAB to AFAB ratio likely represent the “cohort effect,” which reflects sociopolitical advances, changes in referral patterns, increased access to health care and to medical information, less pronounced cultural stigma, and other changes that have a differential impact across generations (Ashley 2019d; Pang et al., 2020; Zhang et al., 2020).

Despite recent improvements in the quality of published studies, an important limitation of the existing literature is the relative paucity of peer-reviewed publications from regions outside of Western Europe or North America. Some of the relevant information on global estimates can be obtained from reports supported by the governments or non-governmental organizations (Fisher et al., 2019; Kasianczuk & Trofymenko, 2020), but these reports may be difficult to systematically identify and evaluate until they appear in peer-reviewed literature. Other barriers to evaluating the global distribution of the TGD populations include inadequate access to demographic data and over-representation of English-language journals in the world literature.

These limitations notwithstanding, the available highest-quality data clearly indicate TGD people represent a sizable and growing proportion of the general population. Based on the credible evidence available to date, this proportion may range from a fraction of a percent to several percentage points depending on the inclusion criteria, age group, and geographic location. Accurate estimates of the proportion, distribution, and composition of the TGD population as well as a projection of resources required to adequately support the health needs of TGD people should rely on systematically collected high-quality data, which are now increasingly available. Continuous and routine collection of these data is needed to decrease variability and minimize over- and under-estimation of the reported results. For example, far more accurate and precise estimates should become available when population censuses begin systematically collecting and reporting data on sex assigned at birth and gender identity, including asexual and nonbinary categories, using the now well-validated two-step method. The first such census-based estimate was released by the national statistical office of Canada. Based on the 2021 census data, 100,815 of 30.5 million Canadians self-identified as transgender or nonbinary; this accounted for 0.33% of the population 15 years of age or older (Statistics Canada, 2022). Consistent with the published literature, the proportions of transgender and nonbinary people were much higher for Generation Z (born between 1997 and 2006, 0.79%) and millennials (born between 1981 and 1996, 0.51%) than for Generation X (born between 1966 and 1980, 0.19%), baby boomers (born between 1946 and 1965, 0.15%), and the Interwar and Greatest Generations (born in 1945 or earlier, 0.12%). While these results represent the highest quality data available to date, it is not clear how the population proportions reported in Canada may compare with those in other countries. The variability in the definitions of what constitutes the TGD population and the differences in data collection methods can be reduced further by improving international collaborations.

CHAPTER 4 Education

This chapter will provide a general review of the literature related to education in transgender and gender diverse (TGD) health care. Recommendations are offered at governmental, nongovernmental, institutional, and provider levels with the goal of increasing access to competent, compassionate health care. In turn, this increased access should improve health outcomes in TGD populations. As this is a novel chapter in the World Professional Association for Transgender Health (WPATH) Standards of Care, the intent is to lay the groundwork for the education area and invite a broader and deeper discussion among educators and health professionals.

Health professionals involved in transgender care encompass a broad range of disciplines. Health professional education varies considerably by country or region in terms of structure, licensure, and policy. Published literature on education in TGD health care is predominantly from North America, Europe, Australia and New Zealand. This chapter does not provide a review of the education literature for each discipline, the needs specific to each discipline (which can be found in the relevant chapters), or the needs specific to each country/region’s health education system. Greater understanding and research are needed on the intersection of health education systems, licensure, and transgender health across the world.

On a global level, TGD health education is imperative if national and international health disparities are to be addressed. Cultural competency related to TGD communities continues to be lacking. The World Bank Group (2018) reports widespread discrimination, harassment, violence, and abuse affecting TGD people. They also report TGD people face the highest rates of violence and discrimination (World Bank Group, 2018). Although many higher income countries have national antidiscrimination laws with gender identity as a protected characteristic, discrimination in the workplace, in education, and in health care remains problematic (World Bank Group, 2018).

Across disciplines, curricula at all levels—undergraduate, graduate, residency, or continuing education—historically have ignored TGD cultural or clinical education. The Joint Commission (US) has recommended health care organizations “provide educational programs and forums that support the unique needs of the LGBT community” and “offer educational opportunities that address LGBT health issues” (The Joint Commission, 2011). However, this is not enforced.

On an individual level, several questions need answers. What type of education interventions can most effectively address transphobia and lead to long-standing changes in attitudes? What interventions translate into increasing the number of care providers in this area as well as the number of TGD people receiving care? Does clinical exposure increase the confidence of providers over time? What educational interventions lead to improved health outcomes in the TGD population and, if so, when and how did these interventions accomplish this? Although health professions have begun to incorporate TGD health into education using a variety of modalities and at varying levels of training, efforts differ by health profession and are neither systemic nor systematic in nature (e.g., Brennan et al., 2012; Chinn, 2013; Eliason et al., 2010; Lim et al., 2015; Obedin-Maliver et al., 2011; Rondahl, 2009).

Attaining cultural humility with the full appreciation of the intersectionality of humanity is an ultimate educational goal. That said, this initial call for education is focused on building the foundation in cultural awareness and cultural competency that is currently weak or non-existent in much of the world.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Recommendation 4.1

We recommend all personnel working in governmental, nongovernmental, and private agencies receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity and respect.

Article 1 of the United Nations Universal Declaration of Human Rights states, “All human beings are born free and equal in dignity and rights” (United Nations, 1948). Only recently has this fundamental statement included the recognition that TGD rights are human rights (UNOCHR, 2018). Globally, training at all levels about TGD communities continues to be lacking. As recently as 2002, only 3% of Fortune 500 companies had antidiscrimination protection for TGD employees, and none offered insurance coverage for gender-affirming health care^. (Human Rights Campaign Foundation, 2017). By 2022, 91% of Fortune 500 companies included gender identity in US non-discrimination policies, and 66% offered TGD-inclusive insurance coverage. However, only 72% provide any form of lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) cultural knowledge training for their workforce (Human Rights Campaign Foundation, 2022). This lack of understanding fosters discrimination across the board. Taken together, these inconsistencies negatively affect the health of individuals and communities and exacerbate the health disparities and inequities they face. In Britain, only 28% of TGD workers felt the senior leadership were committed to TGD equality; only 21% of TGD employees would consider reporting transphobic harassment in the workplace (Stonewall, 2018). For those who are openly TGD, 34% were excluded by their co-workers, 35% were abused by customers, 24% were denied promotion due to their gender identity, and 11% were fired (Stonewall, 2018). In southeastern Europe, the World Bank stated there is widespread discrimination, harassment, violence, and abuse, and TGD people in that region faced the highest rates of violence and discrimination (World Bank Group, 2018). Often the discrimination went unreported with 60% of individuals not filing a report because of a lack of faith the complaint would be addressed, a fear of further discrimination or ridicule, and a reluctance to be outed (World Bank Group, 2018). Although many countries in the region have national antidiscrimination laws with gender identity as a protected characteristic, discrimination in the workplace, in education, and in health care remains problematic (World Bank Group, 2018). It is the responsibility of the governmental, nongovernmental, and private agencies in these countries with anti-discrimination laws to ensure the rights of the TGD population. They are, therefore, obligated to find ways in which discrimination and stigma can be decreased. One of these is through education. Local cultures that foster anti-TGD attitudes are often a barrier to this needed education. Although cultural competency trainings have led to equivocal results, Shepherd (2019) recommends that providing cultural knowledge training that prioritizes local cultural issues and focuses on the values of openness, non-judgment, and responsiveness may lead to the desired results. Implementing cultural knowledge training requires a leadership willing to prioritize the training and to dedicate the time, money, and human capital to delivering initial and ongoing training.

Recommendation 4.2

We recommend all members of the health care workforce receive cultural-knowledge training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education.

Across disciplines, curricula at all levels—undergraduate, graduate, residency, or continuing education—historically have ignored TGD cultural or clinical education. Factors contributing to this lack of inclusion include lack of faculty knowledge, experience, comfort with the subject matter, faculty bias, limited space within the existing curriculum, and lack of guidance on how to integrate the topics (McDowell & Bower, 2016). Research into the lack of and the need for such education does not specifically address TGD health concerns. Rather, the existing literature subsumes TGD health education within the broader discussion of the lack of LGBTQ-focused cultural and clinical-competency training. As an example, nursing baccalaureate programs included only an average of 2.12 hours of instruction on LGBTQ health (Lim et al., 2015). A fair assumption is that the amount of time devoted to TGD-specific health issues constituted only a fraction of this time.

Within the broader context of LGBTQ competency, the lack of TGD cultural- and clinical-competency training is a long-known shortfall of health care education (Aldridge et al., 2021). In the US, the Department of Health and Human Services’ Healthy People 2020, (United States Department of Health and Human Services (2013, April 10)), the National Academy of Medicine (The Institute of Medicine, 2011), and the Joint Commission (The Joint Commission, 2011) all recognized lack of education negatively impacts the ability of LGBTQ people, including TGD individuals, to obtain appropriate, medically necessary care. The UK’s House of Commons Women and Equalities Committee found lack of education contributed to TGD health disparities in the National Health Service (House of Commons Women and Equalities Committee, 2015, December 8). The lack of TGD health care education has been identified in the US (Obedin-Maliver et al., 2011), UK (Tollemache et al., 2021), South Africa (de Vries et al., 2020; Taylor et al., 2018; Wilson et al., 2014), Canada (Bauer et al., 2014), Australia (Riggs & Bartholomaeus, 2016), Sweden, Spain, Serbia, Poland (Burgwal et al., 2021), and Pakistan (Martins et al., 2020) among other countries.

In addition to developing curriculum, Shepherd (2022) states both clinical and organizational components are necessary to improve clinical encounters and consumer satisfaction. On an organizational level, it must be feasible as well as locally and practically oriented (Shepherd, 2022). On an individual level, in addition to knowledge training, health care professionals are better served employing generic traits that focus on the values of openness, non-judgment, and responsiveness (Shepherd, 2018).

Recommendation 4.3.

We recommend institutions involved in the training of health professionals develop competencies and learning objectives for transgender and gender diverse health within each of the competency areas for their specialty.

Each health profession has its own educational institutions, administrative, and licensing bodies, which vary by country and specialization within the profession. No major health professional organizations, educational institutions, or licensing bodies appear to require training in TGD health. While these organizations increasingly recommend including LGBTQ intersex health, rarely do they specify competencies, skills, or learning objectives for working with TGD people within their specialty. Published material on health professional education in TGD health is focused primarily on nursing, medicine, and mental health and is predominantly from North America, Europe, Australia, and New Zealand. An increased understanding of transgender health and medical/health professional education systems and requirements globally is essential.

Despite the increasing visibility of TGD people, access to knowledgeable and culturally- competent health professionals remain an overwhelming need around the world (James et al., 2016; Lerner et al., 2020; Müller, 2017). Lack of knowledgeable providers is a major barrier to gender-affirming care for transgender persons (Puckett et al., 2018; Safer et al., 2016) and contributes to large health disparities (Giffort & Underman, 2016; Reisman et al., 2019). The lack of adequate professional education in TGD health is a global problem (Do & Nguyen, 2020; Martins et al., 2020; Parameshwaran et al., 2017) that occurs at all levels of training (Dubin et al., 2018) and traverses health disciplines (Glick et al., 2020; Gunjawate et al., 2020; Johnson & Federman, 2014) and medical specialties (Fung et al., 2020; Korpaisarn and Safer, 2018).

Challenges remain as studies to date have small sample sizes, involve one-time training, include multiple disciplines at multiple career levels, focus on short-term outcomes, and often cover all LGBTQI topics rather than TGD-specific ones that are usually acquired post-licensure and are not the focus of most currently studied educational interventions (Dubin et al., 2018).

To successfully implement the recommendations, institutions may need to consider developing 1) systemic and systematic approaches to developing and implementing competencies for each health discipline across the professional lifespan; 2) standardized assessments for learners, with input from the TGD community; and 3) allotment of curricular resources, including trained faculty, as well as time in accordance with clear, consensual learning objectives (Dubin et al., 2018; Pratt-Chapman, 2020). In addition, evaluations of these interventions should not only focus on outcomes but also strive to understand how, when, and why these outcomes are occurring (Allen et al., 2021).

CHAPTER 5 Assessment of Adults

This chapter provides guidance for the assessment of transgender and gender diverse (TGD) adults who are requesting medically necessary gender-affirming medical and/or surgical treatments (GAMSTs) to better align their body with their gender identity (see medically necessary statement in Chapter 2—Global Applicability, Statement 2.1).

TGD adults are people at or above the age of majority in their country, who have some form of gender diversity. The developmental elements of the adolescent chapter, including the importance of parental/caregiver involvement, may be relevant for the care of young adults too, even if they are above the age of majority.

This chapter includes all forms of gender identities and transitions including, but not limited to, male, female, gender diverse, nonbinary, agender, and eunuch. The population of TGD adults is heterogeneous and will vary according to their clinical need, biological, psychological, and social situations, as well as their access to health care. As such, any assessment for GAMSTs will need to be adapted to the scientific, clinical, and community knowledge base of the presenting gender identity as well as local circumstances. This chapter recognizes individuals may experience different local levels of clinical or regulatory oversight when the state or others are providing health care.

An individual’s gender identity is an internal identification and experience. The role of the assessor is to assess for the presence of gender incongruence and identify any co-existing mental health concerns, to offer information about GAMSTs, to support the TGD person in considering the effects/risks of GAMSTs, and to assess if the TGD person has the capacity to understand the treatment being offered and if the treatment is likely to be of benefit. The assessor can also assist a TGD person to consider choices that could improve their GAMST outcomes. The GAMST assessment approach described in this chapter recognizes the lived experience and self-knowledge of the TGD person and the clinical knowledge of the assessing health care professional (HCP). Consequently, with this approach, the decision to move forward with GAMSTs is shared between the TGD person and the assessing HCP, with both playing a key part in collaborative decision-making.

Some systems use a model of care for TGD adults seeking GAMSTs that prioritizes the TGD adult as the decision maker with the HCP acting as an advisor, barring serious contraindications. These models are used when considering hormone therapy rather than surgery and are often called “informed consent” models (Deutsch, 2011, 2016a). Many such models utilize an abbreviated assessment that focuses primarily on the ability of a TGD person to grant informed consent and to utilize information about GAMSTs to inform their medical decision-making. There is significant variability in such models across jurisdictions, systems, and HCPs (Deutsch, 2011; Morenz et al., 2020). Informed consent models have been used for some time for hormone prescription in many local settings.

This chapter is intended to offer flexible global guidance that must be adapted to local circumstances. HCPs will need to determine which assessment approaches best meet the needs in their local settings. The evaluation of these approaches is best undertaken in collaboration with TGD people.

Since TGD people represent a diverse array of gender identities and expressions and have differing needs for GAMSTs, no single assessment process will fit every person or every situation. Some TGD people may need a comparatively brief assessment process for GAMSTs. For TGD adults with a complex presentation or for those who are requesting less common treatments or treatments with limited research evidence, more comprehensive assessments with different members of a multidisciplinary team will be required. Assessments may be in person or through telehealth. While psychometric assessment tools have been used in some instances, they are not a required part of the assessment for GAMSTs. Counseling or psychotherapy can be helpful when requested by a TGD person. However, counseling or psychotherapy specifically focused on their TGD identity is not a requirement for the assessment or initiation of GAMSTs. Genital exams are not a prerequisite for initiation of GAMTs and should be performed only when clinically indicated.

GAMSTs can be delivered in diverse settings. Settings will depend on available health care systems within each country and may include nationalized/public health care, private sector settings, community health care settings, and charitable institutions. Local and regional circumstances may therefore influence the availability of health care. Regardless of the setting, health care offered to TGD people should be of the highest possible quality. World Professional Organization for Transgender Health (WPATH) advocates for assessment and treatment to be readily available. Access to assessment and treatment for TGD people seeking GAMSTs is critical given the clear medical necessity of these interventions and the profound benefits they offer to TGD people (Aldridge et al., 2020; Byne et al., 2012). The guidance in this chapter will need to be adapted according to local, as well as individual, clinical, and social circumstances.

The statements below are based on significant background literature, including literature demonstrating the strong positive impact of access to GAMSTs; available empirical evidence; a favorable risk-benefit ratio; and consensus of professional best practice. The empirical evidence base for the assessment of TGD adults is limited. It primarily includes an assessment approach that uses specific criteria that are examined by an HCP in close cooperation with a TGD adult and does not include randomized controlled trials or long-term longitudinal research (Olsen-Kennedy et al., 2016). This is understandable given the complexity and ethical considerations of allocating patients in need of care to different assessment groups and the lack of funding for research and other resources to assess long-term outcomes of assessment approaches.

The creation of this guidance has been a complex undertaking. The criteria in this chapter have been significantly revised from SOC-7 to reduce requirements and unnecessary barriers to care. It is hoped that future research will explore the effectiveness of this model as well as evolving assessment models for hormone therapy and for surgery that will allow continued improvements to be made.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 5.1.

We recommend health care professional assessing transgender and gender diverse adults for gender-affirming treatments:

Statement 5.1.a

Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.

TGD people, as with all other people seeking health care, should have the highest quality of care accessible that is commensurate with the quality of care provided to all people utilizing health services (The Yogyakarta Principles, 2017). As this will vary around the globe, the nature of the professional completing an assessment for GAMSTs will vary according to the nature of health care in the local setting as well as the regulatory requirements set by licensing and registration boards. It is important the health care provided includes an assessment conducted by a competent, statutorily regulated HCP who has the competence to identify gender incongruence and conditions that can be mistaken for gender incongruence and who can support the TGD person throughout the assessment process (RCGP, 2019). Assessors must be able to refer to HCPs licensed to provide GAMSTs.

HCPs should have at a minimum a masters-level qualification in a clinical field related to transgender health or equivalent further clinical training and be statutorily regulated; examples include a mental health professional (MHP), general medical practitioner, nurse, or other qualified HCP. In some settings, statutorily regulated HCPs with lower levels of qualification may practice under the clinical supervision of a qualified HCP who takes ultimate clinical responsibility for the quality and accuracy of the completed GAMST assessment. For additional information see Chapter 4—Education.

Accessing a competent, statutorily regulated, HCP with expertise in GAMST assessment can sometimes be difficult. Consequently, ensuring continuity of care and minimizing gaps in accessible care or significantly delayed care (e.g., a long waiting list) may require that a statutorily regulated HCP without expertise provide care and support the assessment of a TGD person for GAMSTs. Avoiding unnecessary delays in care is critically important. However, TGD people should be supported to access care with an experienced HCP as soon as possible (RCGP, 2019).

Established practice requires the competence to identify and diagnose gender incongruence (Hembree et al., 2017; Reed et al., 2016; T'Sjoen et al., 2020) and the ability to identify differentials or conditions that may be mistaken as gender incongruence (Byne et al., 2018; Dhejne et al., 2016; Hembree et al., 2017). Established practice also strongly emphasizes the need for ongoing continuing education in the assessment and provision of care of TGD people (American Psychological Association, 2015; T'Sjoen et al., 2020). For more information see Chapter 4—Education.

Statement 5.1.b

For countries requiring a diagnosis for access to care, the health care professional should be competent using the latest edition of the World Health Organization's International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilize the latest ICD as soon as practicable.

In some countries, a diagnosis of gender incongruence may be necessary to access GAMSTs (as described below). HCPs assessing TGD people in those countries should be competent to diagnose gender incongruence using the most current classification system necessary for TGD people to access GAMSTs. The ICD-11 (WHO, 2019a) is a classification system that focuses on the TGD person’s experienced identity and any need for GAMSTs and does not consider a TGD identity to be a mental illness.

Statement 5.1.c

Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.

Gender diversity is a natural variation in people and is not inherently pathological (American Psychological Association, 2015). However, assessment is best provided by an HCP who possesses some expertise in mental health in order to identify conditions that can be mistaken for gender incongruence. Such conditions are rare and, when present, are often psychological in nature (Byne et al., 2012; Byne et al., 2018; Hembree et al., 2017).

The need to include an HCP with some expertise in mental health does not require the inclusion of a psychologist, psychiatrist, or social worker in each assessment. Instead, a general medical practitioner, nurse, or other qualified HCP could also fulfill this requirement if they have sufficient expertise to identify gender incongruence, recognize mental health concerns, distinguish between these concerns and gender dysphoria, incongruence, and diversity, assist a TGD person in care planning and preparation for GAMSTs, and refer to a mental health professional (MHP), if needed. As discussed in greater depth in the mental health chapter, MHPs have an important role to play in the care of TGD people. For example, the prejudice and discrimination experienced by some TGD people (Robles et al., 2016) can lead to depression, anxiety, or worsening of other mental health conditions. In such cases, an MHP can diagnose, clarify, and treat mental health conditions. MHPs and HCPs with expertise in mental health are well-placed to assess for GAMSTs, as well as to support TGD people who require or request mental health input or support during their transition. For additional information see Chapter 18—Mental Health.

Statement 5.1.d

Are able to assess capacity to consent for treatment.

An assessment for GAMSTs must include an examination of the TGD person’s ability to consent to the proposed treatment. Consent requires the cognitive capacity to understand the risks and benefits of a treatment and the potential negative and positive outcomes. It also requires the ability to retain that information for the purposes of making the decision (using aids as necessary) as well as the cognitive ability to use that understanding to make an informed decision (American Medical Association, 2021; Applebaum, 2007).

Some TGD individuals will have the capacity to grant consent immediately during the assessment. Some TGD individuals may need a longer process to be able to consent through ongoing discussion and the practice of medical decision-making skills. The presence of psychiatric illness or mental health symptoms do not pose a barrier to GAMSTs unless the psychiatric illness or mental health symptoms affect the TGD person’s capacity to consent to the specific treatment being requested or affect their ability to receive treatment. This is especially important because GAMSTs have been found to reduce mental health symptomatology for TGD people (Aldridge et al., 2020).

Health care systems can consider GAMSTs for individuals who may not be able to directly consent if an appropriate legal guardian or regulator-approved independent decision maker with the power to determine health care treatment grants consent and confirms the proposed treatment is in alignment with the TGD individual’s needs and wishes.

Statement 5.1.e

Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity. For supporting text, see Statement 5.1.f.

Statement 5.1.f

Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.

As in any other area of clinical practice, it is vital HCPs who are providing assessment for the initiation of GAMSTs are knowledgeable and experienced in the health care of TGD people. If this is not possible in the local context, the HCP providing the assessment should work closely with an HCP who is knowledgeable and experienced. As part of their clinical practice, HCPs should commit to ongoing training in TGD health care, become a member of relevant professional bodies, attend relevant professional meetings, workshops or seminars, consult with an HCP with relevant experience, and/or engage with the TGD community. This is particularly important in TGD health care as it is a relatively new field, and the knowledge and terminology are constantly changing (American Psychological Association, 2015; Thorne, Yip et al., 2019). Consequently, keeping up to date in the areas of TGD health is vital for anyone involved in an assessment for GAMSTs.

Statement 5.2

We suggest health care professionals assessing transgender and gender diverse adults seeking gender-affirming treatment liaise with professionals from different disciplines within the field of transgender health for consultation and referral, if required.

If required and if possible, assessment for GAMST should be conducted by a multidisciplinary team (Costa, Rosa-e-Silva et al., 2018; Hembree et al., 2017; Karasic & Fraser, 2018; T'Sjoen et al., 2020) with team members who have timely and adequate contact with one another. This could include an MHP, an endocrinologist, a primary care provider, a surgeon, a voice and communication specialist, TGD peer navigator, and others. In some cases, a multidisciplinary team may not be required; however, should a multidisciplinary team be needed, it is critical HCPs be able to access colleagues from different disciplines in a timely manner to complete the GAMST assessment and best support the needs of the TGD person. It is also critical TGD people be supported with follow-up appointments with any HCP who was involved during the assessment for GAMSTs, prior to, during, and after the initiation of gender-affirming treatments.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (all should be met):

Statement 5.3

We recommend health care professionals assessing transgender and gender diverse adults for gender-affirming medical and surgical treatment:

Statement 5.3.a

Only recommend gender-affirming medical treatment requested by a TGD person when the experience of gender incongruence is marked and sustained.

To access GAMSTs, a TGD person’s gender incongruence must be marked and sustained. This can include a need for GAMSTs and a desire to be accepted as a person of the experienced gender. Consequently, a consideration of the nature, length and consistency of gender incongruence is important. This can include such factors as a change of name and identity documents, telling others about one’s gender, health care documentation, or changes in gender expression. However, marked and sustained gender incongruence can exist in the absence of disclosure to others by the TGD person (Brumbaugh-Johnson & Hull, 2019; Saeed et al., 2018; Sequeira et al., 2020). An abrupt or superficial change in gender identity or lack of persistence is insufficient to initiate gender- affirming treatments, and further assessment is recommended. In such circumstances, ongoing assessment is helpful to ensure the consistency and persistence of gender incongruence before GAMSTs are initiated.

While marked and sustained gender incongruence should be present, it is not necessary for TGD people to experience severe levels of distress regarding their gender identity to access gender- affirming treatments. In fact, access to gender-affirming treatment can act as a prophylactic measure to prevent distress (Becker et al., 2018; Giovanardi et al., 2021; Nieder et al., 2021; Nobili et al., 2018; Robles et al., 2016). A TGD adult can have sustained gender incongruence without significant distress and still benefit from GAMSTs.

Established clinical practice examines the persistence of gender incongruence when considering the initiation of GAMSTs (Chen & Loshak, 2020). In a review of 200 clinical notes, Jones, Brewin et al. (2017) identified the importance of the “stability of gender identity” when planning care. Providing GAMSTs to TGD people with persistent gender incongruence has been associated with low rates of patient regret and high rates of patient satisfaction (Becker et al., 2018; El-Hadi et al., 2018; Staples et al., 2020; Wiepjes et al., 2018). However, while the ICD 11 (WHO, 2019a) requires the presence of marked and persistent gender incongruence for a diagnosis of gender incongruence to be made, there is little specific evidence concerning the length of persistence required for treatment in adults. HCPs involved in an assessment of a TGD person for GAMSTs are encouraged to give due consideration to the life stage, history, and current circumstances of the adult being assessed.

Statement 5.3.b

Ensure fulfillment of diagnostic criteria prior to initiating gender-affirming treatments in regions where a diagnosis is necessary to access health care.

A diagnosis of gender incongruence may be necessary in some regions to access transition-related care. When a diagnosis is necessary to access GAMSTs, the assessment for GAMSTs will involve determining and assigning a diagnosis. In these instances, HCPs should have competence using the latest International Classification of Diseases and Related Health Problems (ICD) (WHO, 2019a). In regions where a diagnosis is necessary to access health care, a diagnosis of HA60 Gender Incongruence of Adolescence or Adulthood should be determined prior to gender-affirming interventions. Gender-affirming interventions secondary to a diagnosis of HA6Z Gender Incongruence, Unspecified may be considered in the context of a more comprehensive assessment by the multidisciplinary team.

There is evidence the use of rigid assessment tools for “transition readiness” may reduce access to care and are not always in the best interest of the TGD person (MacKinnon et al., 2020). Therefore, in situations where the assignment of a diagnosis is mandatory to access care, the process should be approached with trust and transparency between the HCP and the TGD individual requesting GAMST, with the needs of the TGD individual in mind. Indeed, high quality relationships between TGD people and their HCPs are associated with lower emotional distress and better outcomes (Kattari et al., 2016). Because many TGD people fear HCPs will erroneously conflate transgender identity with mental illness (Ellis et al., 2015), a diagnostic assessment should be undertaken with sensitivity to facilitate the best relationship between the provider and the TGD individual.

Statement 5.3.c

Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments.

In rare cases, TGD individuals might have a condition that may be mistaken for gender incongruence or may have another reason for seeking treatment aside from the alleviation of gender incongruence. In these cases, and when there is ambiguity regarding the diagnosis of gender incongruence, a more detailed and comprehensive assessment is important. For example, further assessment might be required to determine if gender incongruence persists outside of an acute psychotic episode. If gender incongruence persists after an acute psychotic episode resolves, GAMSTs may be considered as long as the TGD person has the capacity to consent to and undergo the specific treatment. If gender incongruence does not persist and only occurs during such an episode, treatment should not be considered. It is important such circumstances be identified and excluded prior to the initiation of GAMSTs (Byne et al., 2012, 2018; Hembree et al., 2017). It is important to understand, however, TGD people may present with gender incongruence and with a mental health condition, autistic spectrum disorder, or other neurodiversity (Glidden et al., 2016). Indeed, some mental health conditions, such as anxiety (Bouman et al., 2017), depression (Heylens, Elaut et al., 2014; Witcomb et al., 2018), and self-harm (Arcelus et al., 2016; Claes et al., 2015) are more prevalent in TGD people who have not accessed GAMSTs. Recent longitudinal studies suggest mental health symptoms experienced by TGD people tend to improve following GAMSTs (Aldridge et al., 2020; Heylens, Verroken et al., 2014; White Hughto & Reisner, 2016). There is no evidence to suggest a benefit of withholding GAMSTs from TGD people who have gender incongruence simply on the basis that they have a mental health or neurodevelopmental condition. For more information see Chapter 18—Mental Health.

Statement 5.3.d

Ensure any mental health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.

Like their cisgender counterparts, TGD people may have mental health problems. Treatment for mental health problems can and should occur in conjunction with GAMSTs when medical transition is needed. It is vital gender-affirming care is not impeded unless, in some extremely rare cases, there is robust evidence that doing so is necessary to prevent significant decompensation with a risk of harm to self or others. In those cases, it is also important to consider the risks delaying GAMSTs poses to a TGD person’s mental and physical health (Byne et al., 2018).

In general, social and medical transition of TDG people are both associated with a reduction in mental health problems (Aldridge et al., 2020; Bouman et al., 2017; Durwood et al., 2017; Glynn et al., 2016; Hughto & Reisner, 2016; Wilson et al., 2015; Witcomb et al., 2018). Unfortunately, the loss of social support and the physical and financial stress that can be associated with the initiation of GAMSTs may exacerbate pre-existing mental health problems and warrant additional support from the treating HCP (Budge et al., 2013; Yang, Wang et al., 2016). An assessment of mental health symptoms can improve transition outcomes, particularly when the assessment is used to facilitate access to psychological and social support during transition (Byne et al., 2012). A delay of transition in rare circumstances may be considered if, for example, the TGD person is unable to engage with the process of transition or would be unable to manage aftercare following surgery, even with support. Where a delay in GAMST as a last resort has been found to be necessary, the HCP should offer resources and support to improve mental health and facilitate re-engagement with the GAMST process as soon as practicable. It should be noted access to medical transition for TGD people facilitates social transition and improves safety in public (Rood et al., 2017). In turn, the degree to which TGD people’s appearance conforms to their gender identity is the best predictor of quality of life and mental health outcomes following medical transition (Austin & Goodman, 2017). Delaying access to GAMSTs due to the presence of mental health problems may exacerbate symptoms (Owen-Smith et al., 2018) and damage rapport; consequently, this should be done only when all other avenues have been exhausted.

Statement 5.3.e

Ensure any physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.

In rare cases, GAMSTs, such as hormonal and surgical interventions, may have iatrogenic consequences or may exacerbate pre-existing physical health conditions (Hembree et al., 2017). In these instances, care should be taken, whenever possible, to manage pre-existing physical health conditions while initiating (if appropriate) or continuing gender-affirming treatments. Any interruptions in treatment should be as brief as possible and with treatment re-initiated as soon as practicable. Limited data and inconsistent findings suggest an association between cardiovascular and metabolic risks and hormone therapy in TGD adults (Getahun, 2018; Iwamoto, Defreyne et al., 2019; Iwamoto et al., 2021; Spanos et al., 2020). Because of the possible harm related to long-term treatment and the probable benefits expected from the preventive measures applied before and during hormone treatment, a careful assessment of physical health conditions prior to initiation of treatment is important. Some specific conditions, such as a history of hormone-sensitive cancer, may require further assessment and management that may preclude hormone treatment (Center of Excellence for Transgender Health, 2016; Hembree et al., 2017).

Similar concerns may be present for TGD adults who wish to access surgical interventions. Each gender-affirming surgical intervention has specific risks and potentially unfavorable consequences (Bryson & Honig, 2019; Nassiri et al., 2020; Remington et al., 2018). However, intervention-specific risks associated with the presence of specific physical conditions have not been well researched. Thus, the kinds of medical concerns raised by TGD people during the assessment are typically no different from those of any other surgical candidate.

Taking into consideration the mental and physical health disparities (Brown & Jones, 2016) and barriers to health care (Safer et al., 2016) experienced by TGD people, the assessment of physical conditions by HCPs should not be limited to a history of medical interventions. If the TGD person has physical health conditions, it is important these conditions are managed while initiating or continuing GAMSTs whenever possible. Any interruption in treatment should be made with a view toward re-initiating treatment as soon as practicable. It is also important HCPs develop a treatment strategy for managing physical conditions that facilitates health and promotes consistent adherence to a treatment plan.

Statement 5.3.f

Assess the capacity to consent for the specific gender-affirming treatments prior to the initiation of this treatment.

The practice of informed consent to treatment is central to the provision of health care. Informed consent is couched in the ethical principle that recipients of health care should understand the health care they receive and any potential consequences that could result. The importance of informed consent is embedded in many legislative and regulatory practices that guide HCPs around the world (Jefford & Moore, 2008). It is not possible to know all the potential consequences of a health care treatment; instead, considering what would be “reasonable” to expect is often used as a minimum criterion for consent (Jefford & Moore, 2008; Spatz et al., 2016) and remains the case with GAMSTs. Being able to consent to a health care procedure or clinical intervention requires several complex cognitive processes. Consent requires the cognitive capacity to understand the risks and benefits of a treatment and the potential negative and positive outcomes in addition to the ability to retain that information for the purposes of making the decision (using aids as necessary) and the cognitive ability to use that understanding to make an informed decision (American Medical Association, 2021; Applebaum, 2007). It is vital the TGD person and the assessing HCP consider a priori the nature of the treatment sought and the potential positive and negative effects it may have on the biological, psychological, and social domains of the TGD person’s life.

It is important to recognize mental illness, in particular symptoms of cognitive impairment or psychosis, can impact a person’s ability to grant consent for GAMSTs (Hostiuc et al., 2018). However, the presence of such symptoms does not necessarily equate to an inability to give consent because many people with significant mental health symptoms are able to understand the risks and benefits of treatment enough to make an informed decision (Carpenter et al., 2000). Instead, it is important a careful assessment is carried out that examines each TGD person’s ability to comprehend the nature of the specific GAMST being considered, consider treatment options, including risks and benefits, appreciate the potential short- and long-term consequences of the decision, and communicate their choice in order to receive the treatment (Grootens-Wiegers et al., 2017).

There may be instances in which an individual lacks the capacity to consent to health care, such as during an acute episode of psychosis or in situations where an individual has long-term cognitive impairment. However, limits to capacity to consent to treatment should not prevent individuals from receiving appropriate GAMSTs. For some, understanding the risks and benefits may require the use of repeated explanations in jargon-free language over time or the use of diagrams to facilitate explanation and aid comprehension. A comprehensive and thorough assessment undertaken by the multidisciplinary health care team can further inform this process. For others, an alternative decision maker, such as a legal guardian or regulator-approved, independent decision maker may need to be appointed. These situations need to be considered on a case-by-case basis with the aim of ensuring the most affirmative and least restrictive health care is provided to the individual. Also see Chapter 11—Institutional Environments.

Statement 5.3.g

Assess the capacity of the gender diverse and transgender adult to understand the effect of gender-affirming treatment on reproduction and explore reproductive options with the individual prior to the initiation of gender-affirming treatment.

As gender-affirming medical interventions often affect reproductive capacity, HCPs should ensure a TGD person is aware of the implications for reproduction of the treatments and is familiar with gamete storage and assistive reproductive options. Gender-affirming hormone treatments have been shown to impact reproductive functions and fertility, although the consequences are heterogenous for people of all birth-assigned sexes (Adeleye et al., 2019; Jindarak et al., 2018; Taub et al., 2020). There may be individual differences and fluctuations in these effects on TGD adults. It is therefore essential that HCPs inform a TGD person about the possible impact of the treatment on their reproductive potential during the assessment and as part of the evaluation of the person’s capacity to consent for GAMSTs. Reproductive options should be considered and discussed prior to the initiation of gender-affirming treatments. Because the literature is unclear about the possibility of conception while on hormone therapy, information about the necessity of using contraception to avoid unwanted pregnancy and the different methods of contraception available may need to be provided (Light et al., 2014; Schubert & Carey,2020).

Cross-sectional studies in clinical and nonclinical samples from different populations consistently report TGD adults express parental desire and wish to pursue fertility preservation with varying rates that are related to age, gender, and the duration of gender-affirming hormone treatment (Auer et al., 2018; De Sutter et al., 2002; Defreyne, Van Schuvlenbergh et al., 2020; Wierckx, Stuyver et al., 2012). In a small sample, provision of fertility information was found to have an influence on decision-making related to the use of fertility preservation (Chen et al., 2019). Although there was no comparison made between groups who did and did not receive fertility counseling, high fertility preservation rates occurred following comprehensive fertility counseling among transgender individuals (Amir et al., 2020). Further, one study suggested consultation with a specialist reduced regret related to the decision about whether to pursue fertility preservation procedures (Vyas et al., 2021). For more information see Chapter 16—Reproductive Health.

Statement 5.4

We suggest, as part of the assessment for gender-affirming hormonal or surgical treatment, professionals who have competencies in the assessment of transgender and gender diverse people wishing gender-related medical treatment consider the role of social transition together with the individual.

Social transition can be extremely beneficial to many TGD people although not all TGD people are able to socially transition or wish to socially transition (Bränström & Pachankis, 2021; Koehler et al., 2018; Nieder, Eyssel et al., 2020). Consequently, some TGD people seek gender-affirming interventions after social transition, some before, some during, and some in the absence of social transition.

Social transition and gender identity disclosure can improve the mental health of a TGD person seeking gender-affirming interventions (Hughto et al., 2020; McDowell et al., 2019). In addition, chest and facial surgeries prior to hormone therapy can facilitate social transition (Altman, 2012; Davis & Colton Meier, 2014; Olson-Kennedy, Warus et al. 2018; Van Boerum et al., 2019). As part of the assessment process, HCPs should discuss which social role is most comfortable for the TGD person, if a social transition is planned, and the timing for any planned social transition (Barker & Wylie, 2008). It is imperative during the assessment process, HCPs are respectful of the wide diversity of gendered social roles, including nonbinary as well as binary identities and presentations, which vary according to cultural, local community, and individual understandings.

Not everyone who requests GAMSTs will wish to or be able to socially transition. Little is known about TGD people who do not socially transition before, during, or after medical treatment, as this has not been systematically studied. The most frequent reasons that have been identified for avoiding social transition are fear of being abandoned by family or friends, fearing economic loss (Bradford et al., 2013), and being discriminated against and stigmatized (Langenderfer-Magruder et al., 2016; McDowell et al., 2019; White Hughto et al., 2015). However, some people do not pursue social transition because they feel hormonal or surgical treatments offer enough subjective improvement to reduce gender dysphoria.

If there is no clear plan for social transition or if social transition is unwanted, additional assessment is important to determine the specific nature and advisability of the treatment request, especially if surgical treatment is requested. Additional assessment can offer the TGD person an opportunity to consider the possible effects of not socially transitioning while still obtaining GAMSTs. Given the lack of data on health outcomes for TGD people who do not socially transition (Evans et al., 2021; Levine, 2009; Turban, Loo et al., 2021), GAMSTs should be approached cautiously in such circumstances.

Statement 5.5

We recommend transgender and gender diverse adults who fulfill the criteria for gender-affirming medical and surgical treatment require a single opinion for the initiation of this treatment from a professional who has competencies in the assessment of transgender and gender diverse people wishing gender-related medical and surgical treatment.

Previous versions of the SOC guidelines have required TGD individuals to be assessed for GAMSTs by two qualified HCPs. It was believed having two independent opinions was best practice as it ensured safety for both TGD people and HCPs. For example, it was assumed that seeing two HCPs offered assuredness for both TGD people and their assessing HCPs when pursuing irreversible medical interventions.

However, the limited research in the area indicates two opinions are largely unnecessary. For example, Jones, Brewin et al. (2017) reviewed the case notes of experienced HCPs working within a state-funded gender service and found there was an overwhelming correlation between both opinions—arguably making one of them redundant. Further, Bouman et al. (2014) determined the requirement for two independent assessors reflected paternalism in health care services and raised a potential breach of the autonomy of TGD individuals. The authors posited when clients are adequately prepared and assessed under the care of a multidisciplinary team, a second independent assessment is unnecessary.

Consequently, if written documentation or a letter is required to recommend gender-affirming medical and surgical treatment (GAMST), TGD people seeking treatments including hormones, and genital, chest, facial and other gender-affirming surgeries require a single written opinion/signature from an HCP competent to independently assess and diagnose (Bouman et al., 2014; Yuan et al, 2021). Further written opinions/signatures may be requested where there is a specific clinical need.

Statement 5.6

We suggest health care professionals assessing transgender and gender diverse people seeking gonadectomy consider a minimum of 6 months of hormone therapy as appropriate to the TGD person’s gender goals before the TGD person undergoes irreversible surgical intervention (unless hormones are not clinically indicated for the individual).

The Endocrine Society Clinical Practice Guidelines advise a period of consistent hormone treatment prior to genital surgery (Hembree et al., 2017). While there was limited supportive research, this recommendation was considered to be good clinical practice as it allows a more reversible experience prior to the irreversible experience of surgery. For example, there can be changes in sexual desire after genital surgery that removes the testicles (Lawrence, 2005; Wierckx, Van de Peer et al., 2014). In this context, reversible testosterone suppression can offer a TGD person a period of time to experience the absence of testosterone and decide if this feels right for them. It should be noted the effects of reduced estrogen on a TGD person’s sexual desire and functioning following an oophorectomy is less well documented.

Surgery that removes gonads is an irreversible procedure that leads to loss of fertility and loss of the effects of endogenous sex steroids. Both effects must be discussed as a component of the assessment process. For additional information see Chapter 16—Reproductive Health. Of course, hormones are not clinically indicated for TGD adults who do not want them or in cases where they are contraindicated due to health reasons. For more information see Chapter 13—Surgery and Postoperative Care.

Statement 5.7

We recommend health care professionals assessing adults who wish to detransition and seek gender-related hormone intervention, surgical intervention, or both, utilize a comprehensive multidisciplinary assessment that will include additional viewpoints from experienced health care professionals in transgender health and that considers, together with the individual, the role of social transition as part of the assessment process.

Many TGD adults may consider a range of identities and elements of gender presentation while they are exploring their gender identity and are considering transition options. Accordingly, people may spend some time in a gender identity or presentation before they discover it does not feel comfortable and later adapt it or shift to an earlier identity or presentation (Turban, King et al., 2021). Some TGD adults may also experience a change in gender identity over time so that their needs for medical treatment evolve. This is a healthy and reasonable process for determining the most comfortable and congruent way of living, which is informed by the person’s gender identity and the context of their life. This process of identity exploration should not necessarily be equated with regret, confusion, or poor decision-making because a TGD adult’s gender identity may change without devaluing previous transition decisions (MacKinnon et al., 2021; Turban, Loo et al., 2021). TGD adults should be assisted in this exploration and any other changes in their identity (Expósito-Campos, 2021). While exploration continues, gender-affirming treatments that are irreversible should be avoided until clarity about long-term goals and outcomes is achieved.

The decision to detransition appears to be rare (Defreyne, Motmans et al., 2017; Hadje-Moussa et al., 2019; Wiepjes et al., 2018). Estimates of the number of people who detransition due to a change in identity are likely to be overinflated due to research blending different cohorts (Expósito-Campos, 2021). For example, detransition research cohorts often include TGD adults who chose to detransition because of a change in their identity as well as TGD adults who chose to detransition without a change in identity. While little research has been conducted to systematically examine variables that correlate with a TGD adult’s decision to halt a transition process or to detransition, a recent study found the vast majority of TGD people who opted to detransition did so due to external factors, such as stigma and lack of social support and not because of changes in gender identity (Turban, King et al., 2021). TGD adults who have not experienced a change in identity may choose to halt transition or to detransition because of oppression, violence, and social/relational conflict, surgical complications, health concerns, physical contraindications, a lack of resources, or dissatisfaction with the results (Expósito-Campos, 2021). In such cases, MHPs are well placed to assist the TGD person with these challenges.

While the choice to detransition is proportionally rare, it is expected an overall increase in the number of adults who identify as TGD would result in an increase in the absolute number of people seeking to halt or reverse a transition. However, while the absolute numbers may increase, the percentage of people seeking to halt or reverse permanent physical changes should remain static and low. The existence of these rare requests must not be used as a justification to interrupt critical, medically necessary care, including hormone and surgical treatments, for the vast majority of TGD adults.

Due to the limited research in this area, clinical guidance is based primarily on individual case studies and the expert opinion of HCPs working with TGD adults (Expósito-Campos, 2021; Richards & Barrett, 2020). Accordingly, if a TGD adult has undergone permanent physical changes and seeks to undo them, the assessing HCP should be a member of a comprehensive multidisciplinary assessment team. A multidisciplinary team allows for the contribution of additional viewpoints from HCPs experienced in transgender health. In collaboration with the TGD adult, the multidisciplinary team is encouraged to thoroughly understand the motivations for the original treatment and for the decision to detransition. Any concerns with the previous physical changes should be carefully explored and a significant effort made to ensure similar concerns are not replicated by the reversal.

To ensure the greatest likelihood of satisfaction and comfort with a reversal of permanent physical changes, the TGD adult and the multidisciplinary team should explore the role of social transition in the assessment and in preparation for the reversal. In such instances, it is highly likely a prolonged period of living in role will be necessary before further physical changes are recommended. HCPs should support the TGD adult through any social changes, as well as any feelings of failure, shame, depression, or guilt in deciding to make such a change. In addition, people should be supported in coping with any prejudice or social difficulties they may have experienced that could have led to a decision to detransition or that may have resulted from such a decision. It is also important to help the person remain engaged with health care throughout the process (Narayan et al., 2021).

While available research shows consistent positive outcomes for the majority of TGD adults who choose to transition (Aldridge et al., 2020; Byne et al., 2012; Gorin-Lazard et al., 2012; Owen-Smith et al., 2018; White Hughto & Reisner, 2016), some TGD adults may decompensate or experience a worsened condition following transition. Little research has been conducted to systematically examine variables that correlate with poor or worsened biological, psychological, or social conditions following transition (Hall et al., 2021; Littman, 2021); however, this occurrence appears to be rare (Hall et al., 2021; Wiepjes et al., 2018). In cases where people decompensate after physical or social transition and then remain in a poorer biological, psychological, or social state than they were in prior to transition, serious consideration should be given as to whether transition is helpful at this time, for this person, or both. In cases where treatment is no longer supported, assistance should be arranged to support the person to manage the process of stopping treatment and to manage any concomitant difficulties (Narayan et al., 2021).

It is vital that people who detransition, for any reason, be supported. It should be remembered, however, this is a rare occurrence and the literature shows consistently positive outcomes for the vast majority of TGD adults who transition to a gender that is comfortable for them, including those who receive GAMSTs (Byne et al., 2012; Green & Fleming, 1990; Lawrence, 2003; Motmans et al., 2012; Van de Grift, Elaut et al., 2018).

CHAPTER 6 Adolescents

CHAPTER 7 Children

These Standards of Care pertain to prepubescent gender diverse children and are based on research, ethical principles, and accumulated expert knowledge. The principles underlying these standards include the following 1) childhood gender diversity is an expected aspect of general human development (Endocrine Society and Pediatric Endocrine Society, 2020; Telfer et al., 2018); 2) childhood gender diversity is not a pathology or mental health disorder (Endocrine Society and Pediatric Endocrine Society, 2020; Oliphant et al., 2018; Telfer et al., 2018); 3) diverse gender expressions in children cannot always be assumed to reflect a transgender identity or gender incongruence (Ehrensaft, 2016; Ehrensaft, 2018; Rael et al., 2019); 4) guidance from mental health professionals (MHPs) with expertise in gender care for children can be helpful in supporting positive adaptation as well as discernment of gender-related needs over time (APA, 2015; Ehrensaft, 2018; Telfer et al., 2018); 5) conversion therapies for gender diversity in children (i.e., any “therapeutic” attempts to compel a gender diverse child through words, actions, or both to identify with, or behave in accordance with, the gender associated with the sex assigned at birth are harmful and we repudiate their use (APA, 2021; Ashley, 2019b, Paré, 2020; SAMHSA, 2015; Telfer et al., 2018; UN Human Rights Council, 2020).

Throughout the text, the term “health care professional” (HCP) is used broadly to refer to professionals working with gender diverse children. Unlike pubescent youth and adults, prepubescent gender diverse children are not eligible to access medical intervention (Pediatric Endocrine Society, 2020); therefore, when professional input is sought, it is most likely to be from an HCP specialized in psychosocial supports and gender development. Thus, this chapter is uniquely focused on developmentally appropriate psychosocial practices, although other HCPs, such as pediatricians and family practice HCPs may also find these standards useful as they engage in professional work with gender diverse children and their families.

This chapter employs the term “gender diverse” given that gender trajectories in prepubescent children cannot be predicted and may evolve over time (Steensma, Kreukels et al., 2013). At the same time, this chapter recognizes some children will remain stable in a gender identity they articulate early in life that is discrepant from the sex assigned at birth (Olson et al., 2022). The term, “gender diverse” includes transgender binary and nonbinary children, as well as gender diverse children who will ultimately not identify as transgender later in life. Terminology is inherently culturally bound and evolves over time. Thus, it is possible terms used here may become outdated and we will find better descriptors.

This chapter describes aspects of medical necessary care intended to promote the well-being and gender-related needs of children (see medically necessary statement in the Global Applicability chapter, Statement 2.1). This chapter advocates everyone employs these standards, to the extent possible. There may be situations or locations in which the recommended resources are not fully available. HCPs/teams lacking resources need to work toward meeting these standards. However, if unavoidable limitations preclude components of these recommendations, this should not hinder providing the best services currently available. In those locations where some but not all recommended services exist, choosing not to implement potentially beneficial care services risks harm to a child (Murchison et al., 2016; Telfer et al., 2018; Riggs et al., 2020). Overall, it is imperative to prioritize a child’s best interests.

A vast empirical psychological literature indicates early childhood experiences frequently set the stage for lifelong patterns of risk and/or resilience and contribute to a trajectory of development more or less conducive to well-being and a positive quality of life (Anda et al., 2010; Masten & Cicchetti, 2010; Shonkoff & Garner, 2012). The available research indicates, in general, gender diverse youth are at greater risk for experiencing psychological difficulties (Ristori & Steensma, 2016) than age- matched cisgender peers as a result of encountering destructive experiences, including trauma and maltreatment stemming from gender diversity-related rejection and other harsh, non-accepting interactions (Barrow & Apostle, 2018; Giovanardi et al., 2018; Gower, Rider, Brown et al., 2018; Grossman & D’Augelli, 2006; Hendricks & Testa, 2012; Reisner, Greytak et al., 2015; Roberts et al., 2014; Tishelman & Neumann-Mascis, 2018). Further, literature indicates prepubescent children who are well accepted in their gender diverse identities are generally well-adjusted (Malpas et al., 2018; Olson et al., 2016). Assessment and treatment of children typically emphasizes an ecological approach, recognizing children need to be safe and nurtured in each setting they frequent (Belsky, 1993; Bronfenbrenner, 1979; Kaufman & Tishelman, 2018; Lynch & Cicchetti, 1998; Tishelman et al., 2010; Zielinski & Bradshaw, 2006). Thus, the perspective of this chapter draws on basic psychological literature and knowledge of the unique risks to gender diverse children and emphasizes the integration of an ecological approach to understanding their needs and to facilitating positive mental health in all gender care. This perspective prioritizes fostering well-being and quality of life for a child throughout their development. Additionally, this chapter also embraces the viewpoint, supported by the substantial psychological research cited above, that psychosocial gender-affirming care (Hidalgo et al., 2013) for prepubescent children offers a window of opportunity to promote a trajectory of well-being that will sustain them over time and during the transition to adolescence. This approach potentially can mitigate some of the common mental health risks faced by transgender and gender diverse (TGD) teens, as frequently described in literature (Chen et al., 2021; Edwards-Leeper et al., 2017; Haas et al., 2011; Leibowitz & de Vries, 2016; Reisner, Bradford et al., 2015; Reisner, Greytak et al., 2015).

Developmental research has focused on understanding various aspects of gender development in the earliest years of childhood based on a general population of prepubescent children. This research has typically relied on the assumption that child research participants are cisgender (Olezeski et al., 2020) and has reported gender identity stability is established in the preschool years for the general population of children, most of whom are likely not gender diverse (Kohlberg, 1966; Steensma, Kreukels et al., 2013). Recently, developmental research has demonstrated gender diversity can be observed and identified in young prepubescent children (Fast & Olson, 2018; Olson & Gülgöz, 2018; Robles et al., 2016). Nonetheless, empirical study in this area is limited, and at this time there are no psychometrically sound assessment measures capable of reliably and/or fully ascertaining a prepubescent child’s self-understanding of their own gender and/or gender-related needs and preferences (Bloom et al., 2021). Therefore, this chapter emphasizes the importance of a nuanced and individualized clinical approach to gender assessment, consistent with the recommendations from various guidelines and literature (Berg & Edwards-Leeper, 2018; de Vries & Cohen-Kettenis, 2012; Ehrensaft, 2018; Steensma & Wensing-Kruger, 2019). Research and clinical experience have indicated gender diversity in prepubescent children may, for some, be fluid; there are no reliable means of predicting an individual child’s gender evolution (Edwards-Leeper et al., 2016; Ehrensaft, 2018; Steensma, Kreukels et al., 2013), and the gender-related needs for a particular child may vary over the course of their childhood.

It is important to understand the meaning of the term “assessment” (sometimes used synonymously with the term “evaluation”). There are multiple contexts for assessment (Krishnamurthy et al., 2004) including rapid assessments that take place during an immediate crisis (e.g., safety assessment when a child may be suicidal) and focused assessments when a family may have a circumscribed question, often in the context of a relatively brief consultation (Berg & Edwards-Leeper, 2018). The term assessment is also often used in reference to “diagnostic assessment,” which can also be called an “intake” and is for the purpose of determining whether there is an issue that is diagnosable and/or could benefit from a therapeutic process. This chapter focus on comprehensive assessments, useful for understanding a child and family’s needs and goals (APA, 2015; de Vries & Cohen-Kettenis, 2012; Srinath et al., 2019; Steensma & Wensing-Kruger, 2019). This type of psychosocial assessment is not necessary for all gender diverse children, but may be requested for a number of reasons. Assessments may present a useful opportunity to start a process of support for a gender diverse child and their family, with the understanding that gender diverse children benefit when their family dynamics include acceptance of their gender diversity and parenting guidance when requested. Comprehensive assessments are appropriate when solicited by a family requesting a full understanding of the child’s gender and mental health needs in the context of gender diversity.

In these circumstances, family member mental health issues, family dynamics, and social and cultural contexts, all of which impact a gender diverse child, should be taken into consideration (Barrow & Apostle, 2018; Brown & Mar, 2018; Cohen-Kettenis et al., 2003; Hendricks & Testa, 2012; Kaufman & Tishelman, 2018; Ristori & Steensma, 2016; Tishelman & Neumann-Mascis, 2018). This is further elaborated upon in the text below.

It is important HCPs working with gender diverse children strive to understand the child and the family’s various aspects of identity and experience: racial, ethnic, immigrant/refugee status, religious, geographic, and socio-economic, for example, and be respectful and sensitive to cultural context in clinical interactions (Telfer et al., 2018). Many factors may be relevant to culture and gender, including religious beliefs, gender-related expectations, and the degree to which gender diversity is accepted (Oliphant et al., 2018). Intersections between gender diversity, sociocultural diversity, and minority statuses can be sources of strength, social stress, or both (Brown & Mar, 2018; Oliphant et al., 2018; Riggs & Treharne, 2016).

Each child, family member, and family dynamic is unique and potentially encompasses multiple cultures and belief patterns. Thus, HCPs of all disciplines should avoid stereotyping based on preconceived ideas that may be incorrect or biased (e.g., that a family who belongs to a religious organization that is opposed to appreciating gender diversity will necessarily be unsupportive of their child’s gender diversity) (Brown & Mar, 2018). Instead, it is essential to approach each family openly and understand each family member and family pattern as distinct.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 7.1

We recommend the health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess general knowledge of gender diversity across the life span.

HCPs working with gender diverse children should acquire and maintain the necessary training and credentials relevant to the scope of their role as professionals. This includes licensure, certification, or both by appropriate national and/or regional accrediting bodies. We recognize the specifics of credentialing and regulation of professionals vary globally. Importantly, basic licensure, certification, or both may be insufficient in and of itself to ensure competency working with gender diverse children, as HCPs specifically require in-depth training and supervised experience in childhood gender development and gender diversity to provide appropriate care.

Statement 7. 2

We recommend health care professionals working with gender diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum.

HCPs should receive training and supervised expertise in general child and family mental health across the developmental spectrum from toddlerhood through adolescence, including evidence-based assessment and intervention approaches. Gender diversity is not a mental health disorder; however, as cited above, we know mental health can be adversely impacted for gender diverse children (e.g., through gender minority stress) (Hendricks & Testa, 2012) that may benefit from exploration and support; therefore, mental health expertise is highly recommended. Working with children is a complex endeavor, involving an understanding of a child’s developmental needs at various ages, the ability to comprehend the forces impacting a child’s well-being both inside and outside the family (Kaufman & Tishelman, 2018), and an ability to fully assess when a child is unhappy or experiencing significant mental health difficulties, related or unrelated to gender. Research has indicated high levels of adverse experiences and trauma in the gender diverse community of children, including susceptibility to rejection or even maltreatment (APA, 2015; Barrow & Apostle, 2018; Giovanardi et al., 2018; Reisner, Greytak et al., 2015; Roberts et al., 2012; Tishelman & Neumann-Mascis, 2018). HCPs need to be cognizant of the potential for adverse experiences and be able to initiate effective interventions to prevent harm and promote positive well-being.

Statement 7.3

We recommend health care professionals working with gender diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children.

The experience of gender diversity in autistic children as well as in children with other forms of neurodivergence may present extra clinical complexities (de Vries et al., 2010; Strang, Meagher et al., 2018). For example, autistic children may find it difficult to self-advocate for their gender-related needs and may communicate in highly individualistic ways (Kuvalanka et al., 2018; Strang, Powers et al., 2018). They may have varied interpretations of gender-related experiences given common differences in communication and thinking style. Because of the unique needs of gender diverse neurodivergent children, they may be at high risk for being misunderstood (i.e., for their communications to be misinterpreted). Therefore, professionals providing support to these children can best serve them by receiving training and developing expertise in autism and related neurodevelopmental presentations and/or collaborating with autism specialists (Strang, Meagher et al., 2018). Such training is especially relevant as research has documented higher rates of autism among gender diverse youth than in the general population (de Vries et al., 2010; Hisle-Gorman et al., 2019; Shumer et al., 2015).

Statement 7.4

We recommend health care professionals working with gender diverse children engage in continuing education related to gender diverse children and families.

Continuing professional development regarding gender diverse children and families may be acquired through various means, including through readings (journal articles, books, websites associated with gender knowledgeable organizations), attending on-line and in person trainings, and joining peer supervision/consultation groups (Bartholomaeus et al., 2021).

Continuing education includes 1) maintaining up-to-date knowledge of available and relevant research on gender development and gender diversity in prepubescent children and gender diversity across the life span; 2) maintaining current knowledge regarding best practices for assessment, support, and treatment approaches with gender diverse children and families. This is a relatively new area of practice and health care professionals need to adapt as new information emerges through research and other avenues (Bartholomaeus et al., 2021).

Statement 7.5

We recommend health care professionals conducting an assessment with gender diverse children access and integrate information from multiple sources as part of the assessment.

A comprehensive assessment, when requested by a family and/or an HCP can be useful for developing intervention recommendations, as needed, to benefit the well-being of the child and other family members. Such an assessment can be beneficial in a variety of situations when a child and/or their family/guardians, in coordination with providers, feel some type of intervention would be helpful. Neither assessments nor interventions should ever be used as a means of covertly or overtly discouraging a child’s gender diverse expressions or identity. Instead, with appropriately trained providers, assessment can be an effective means of better understanding how to support a child and their family without privileging any particular gender identity or expression. An assessment can be especially important for some children and their families by collaborating to promote a child’s gender health, well-being, and self-fulfillment.

A comprehensive assessment can facilitate the formation of an individualized plan to assist a gender diverse prepubescent children and family members (de Vries & Cohen-Kettenis, 2012; Malpas et al., 2018; Steensma & Wensing-Kruger, 2019; Telfer et al., 2018; Tishelman & Kaufman, 2018). In such an assessment, integrating information from multiple sources is important to 1) best understand the child’s gender needs and make recommendations; and 2) identify areas of child, family/caregiver, and community strengths and supports specific to the child’s gender status and development as well as risks and concerns for the child, their family/caregivers and environment. Multiple informants for both evaluation and support/intervention planning purposes may include the child, parents/caregivers, extended family members, siblings, school personnel, HCPs, the community, broader cultural and legal contexts and other sources as indicated (Berg & Edwards-Leeper, 2018; Srinath, 2019).

An HCP conducting an assessment of gender diverse children needs to explore gender-related issues but must also take a broad view of the child and the environment, consistent with the ecological model described above (Bronfenbrenner, 1979) to fully understand the factors impacting a child’s well-being and areas of gender support and risk (Berg & Edwards-Leeper, 2018; Hendricks & Testa, 2012; Kaufman & Tishelman, 2018; Tishelman & Neumann-Mascis, 2018). This includes understanding the strengths and challenges experienced by the child/family and that are present in the environment. We advise HCPs conducting an assessment with gender diverse children to consider incorporating multiple assessment domains, depending on the child and the family’s needs and circumstances. Although some of the latter listed domains below do not directly address the child’s gender (see items 7–12 below), they need to be accounted for in a gender assessment, as indicated by clinical judgment, to understand the complex web of factors that may be affecting the child’s well-being in an integrated fashion, including gender health, consistent with evaluation best practices a (APA, 2015; Berg & Edwards-Leeper, 2018; Malpas et al., 2018) and develop a multi-pronged intervention when needed.

Summarizing from relevant research and clinical expertise, assessment domains often include 1) a child’s asserted gender identity and gender expression, currently and historically; 2) evidence of dysphoria, gender incongruence, or both; 3) strengths and challenges related to the child, family, peer and others’ beliefs and attitudes about gender diversity, acceptance and support for child; 4) child and family experiences of gender minority stress and rejection, hostility, or both due to the child’s gender diversity; 5) level of support related to gender diversity in social contexts (e.g., school, faith community, extended family); 6) evaluation of conflict regarding the child’s gender and/or parental/caregiver/sibling concerning behavior related to the child’s gender diversity; 7) child mental health, communication and/or cognitive strengths and challenges, neurodivergence, and/or behavioral challenges causing significant functional difficulty; 8) relevant medical and developmental history; 9) areas that may pose risks (e.g., exposure to domestic and/or community violence, any form of child maltreatment; history of trauma; safety and/or victimization with peers or in any other setting; suicidality); 10) co-occurring significant family stressors, such as chronic or terminal illness, homelessness or poverty; 11) parent/caregiver and/or sibling mental health and/or behavioral challenges causing significant functional difficulty; and 12) child’s and family’s strengths and challenges.

A thorough assessment incorporating multiple forms of information gathering is helpful for understanding the needs, strengths, protective factors, and risks for a specific child and family across environments (e.g., home/school). Methods of information gathering often include 1) interviews with the child, family members and others (e.g., teachers), structured and unstructured; 2) caregiver and child completed standardized measures related to gender; general child well-being; child cognitive and communication skills and developmental disorders/disabilities; support and acceptance by parent/caregiver, sibling, extended family and peers; parental stress; history of childhood adversities; and/or other issues as appropriate (APA, 2020; Berg & Edwards-Leeper, 2018; Kaufman & Tishelman, 2018; Srinath, 2019).

Depending on the family characteristics, the developmental profile of the child, or both, methods of information gathering also may also benefit from including the following 1) child and/or family observation, structured and unstructured; and 2) structured and visually supported assessment techniques (worksheets; self-portraits; family drawings, etc.) (Berg & Edwards-Leeper, 2018).

Statement 7.6

We recommend that health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning and language skills.

Given the complexities of assessing young children who, unlike adults, are in the process of development across a range of domains (cognitive, social, emotional, physiological), it is important to consider the developmental status of a child and gear assessment modalities and interactions to the individualized abilities of the child. This includes tailoring the assessment to a child’s developmental stage and abilities (preschoolers, school age, early puberty prior to adolescence), including using language and assessment approaches that prioritize a child's comfort, language skills, and means of self-expression (Berg & Edwards-Leeper, 2018; Srinath, 2019). For example, relevant developmental factors, such as neurocognitive differences (e.g., autism spectrum conditions), and receptive and expressive language skills should be considered in conducting the assessment. Health care professionals may need to consult with specialists for guidance in cases in which they do not possess the specialized skills themselves (Strang et al., 2021).

Statement 7.7

We recommend health care professionals conducting an assessment with gender diverse children consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s).

HCPs conducting an assessment with gender diverse children and families need to account for developmental, emotional, and environmental factors that may constrain a child’s, caregiver’s, sibling or other’s report or influence their belief systems related to gender (Riggs & Bartholomaeus, 2018). As with all child psychological assessments, environmental and family/caregiver reactions (e.g., punishment), and/or cognitive and social factors may influence a child’s comfort and/or ability to directly discuss certain factors, including gender identity and related issues (Srinath, 2019). Similarly, family members may feel constrained in freely expressing their concerns and ideas depending on family conflicts or dynamics and/or other influences (e.g., cultural/religious; extended family pressure) (Riggs & Bartholomaeus, 2018).

Statement 7.8

We recommend health care professionals consider consultation, psychotherapy, or both for a gender diverse child and family/caregivers when families and health care professionals believe this would benefit the well-being and development of a child and/or family.

The goal of psychotherapy should never be aimed at modifying a child's gender identity (APA, 2021; Ashley, 2019b; Paré, 2020; SAMHSA, 2015; UN Human Rights Council, 2020), either covertly or overtly. Not all gender diverse children or their families need input from MHPs as gender diversity is not a mental health disorder (Pediatric Endocrine Society, 2020; Telfer et al., 2018). Nevertheless, it is often appropriate and helpful to seek psychotherapy when there is distress or concerns are expressed by parents to improve psychosocial health and prevent further distress (APA, 2015). Some of the common reasons for considering psychotherapy for a gender diverse child and family include the following 1) A child is demonstrating significant conflicts, confusion, stress or distress about their gender identity or needs a protected space to explore their gender (Ehrensaft, 2018; Spivey and Edwards-Leeper, 2019); 2) A child is experiencing external pressure to express their gender in a way that conflicts with their self-knowledge, desires, and beliefs (APA, 2015); 3) A child is struggling with mental health concerns, related to or independent of their gender (Barrow & Apostle, 2018); 4) A child would benefit from strengthening their resilience in the face of negative environmental responses to their gender identity or presentation (Craig & Auston, 2018; Malpas et al., 2018); 5) A child may be experiencing mental health and/or environmental concerns, including family system problems that can be misinterpreted as gender congruence or incongruence (Berg & Edwards-Leeper, 2018); and 6) A child expresses a desire to meet with an MHP to get gender-related support. In these situations, the psychotherapy will focus on supporting the child with the understanding that the child’s parent(s)/caregiver(s) and potentially other family members will be included as necessary (APA, 2015; Ehrensaft, 2018; McLaughlin & Sharp, 2018). Unless contraindicated, it is extremely helpful for parents/guardians to participate in some capacity in the psychotherapy process involving prepubescent children as family factors are often central to a child’s well-being. Although relatively unexplored in research involving gender diverse children, it may be important to attend to the relationship between siblings and the gender diverse child (Pariseau et al., 2019; Parker & Davis-McCabe, 2021).

HCPs should employ interventions tailor-made to the individual needs of the child that are designed to 1) foster protective social and emotional coping skills to promote resilience in the face of potential negative reactions to the child’s gender identity, expressions, or both (Craig & Austin, 2016; Malpas et al., 2018; Spencer, Berg et al., 2021); 2) collaboratively problem-solve social challenges to reduce gender minority stress (Barrow & Apostle, 2018; Tishelman & Neumann-Mascis, 2018); 3) strengthen environmental supports for the child and/or members of the immediate and extended family (Kaufman & Tishelman, 2018); and 4) provide the child an opportunity to further understand their internal gender experiences (APA, 2015; Barrow& Apostle, 2018; Ehrensaft, 2018; Malpas et al., 2018; McLaughlin & Sharp, 2018). It is helpful for HCPs to develop a relationship with a gender diverse child and family that can endure over time as needed. This enables the child/family to establish a long-term trusting relationship throughout childhood whereby the HCP can offer support and guidance as a child matures and as potentially different challenges or needs emerge for the child/family (Spencer, Berg et al., 2021; Murchison et al., 2016). In addition to the above and within the limits of available resources, when a child is neurodivergent, an HCP who has the skill set to address both neurodevelopmental differences and gender is most appropriate (Strang et al., 2021).

As outlined in the literature, there are numerous reasons parents/caregivers, siblings, and extended family members of a prepubescent child may find it useful to seek psychotherapy for themselves (Ehrensaft, 2018; Malpas et al., 2018; McLaughlin & Sharp, 2018). As summarized below, some of these common catalysts for seeking such treatment occur when one or more family members 1) desire education around gender development (Spivey & Edwards-Leeper, 2019); 2) are experiencing significant confusion or stress about the child’s gender identity, expression, or both (Ashley, 2019c; Ehrensaft, 2018); 3) need guidance related to emotional and behavioral concerns regarding the gender diverse child (Barrow & Apostle, 2018; 4) need support to promote affirming environments outside of the home (e.g., school, sports, camps) (Kaufman & Tishelman, 2018); 5) are seeking assistance to make informed decisions about social transition, including how to do so in a way that is optimal for a child’s gender development and health (Lev & Wolf-Gould, 2018); 6) are seeking guidance for dealing with condemnation from others, including political entities and accompanying legislation, regarding their support for their gender diverse child (negative reactions directed toward parents/caregivers can sometimes include rejection and/or harassment/abuse from the social environment arising from affirming decisions (Hidalgo & Chen, 2019); 7) are seeking to process their own emotional reactions and needs about their child’s gender identity, including grief about their child’s gender diversity and/or potential fears or anxieties for their child’s current and future well-being (Pullen Sansfaçon et al., 2019); and 8) are emotionally distressed and/or in conflict with other family members regarding the child’s gender diversity (as needed, HCPs can provide separate sessions for parents/caregivers, siblings and extended family members for support, guidance, and/or psychoeducation) (McLaughlin & Sharp, 2018; Pullen Sansfaçon et al., 2019; Spivey & Edwards-Leeper, 2019).

Statement 7.9

We recommend health care professionals offering consultation, psychotherapy, or both to gender diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being.

Consistent with the ecological model described above and, as appropriate, based on individual/family circumstances, it can be extremely helpful for HCPs to prioritize coordination with important others (e.g., teachers, coaches, religious leaders) in a child’s life to promote emotional and physical safety across settings (e.g., school settings, sports and other recreational activities, faith-based involvement) (Kaufman & Tishelman, 2018). Therapeutic and/or support groups are often recommended as a valuable resource for families/caregivers and/or gender diverse children themselves (Coolhart, 2018; Horton et al., 2021; Malpas et al., 2018; Murchison et al., 2016).

Statement 7.10

We recommend HCPs offering consultation, psychotherapy, or both to gender diverse children and families/caregivers provide both parties with age appropriate psycho-education about gender development.

Parents/caregivers and their gender diverse child should have the opportunity to develop knowledge regarding ways in which families/caregivers can best support their child to maximize resilience, self-awareness, and functioning (APA, 2015; Ehrensaft, 2018; Malpas, 2018; Spivey & Edwards-Leeper, 2019). It is neither possible nor is it the role of the HCP to predict with certainty the child’s ultimate gender identity; instead, the HCP’s task is to provide a safe space for the child’s identity to develop and evolve over time without attempts to prioritize any particular developmental trajectory with regard to gender (APA, 2015; Spivey & Edwards-Leeper, 2019). Gender diverse children and early adolescents have different needs and experiences than older adolescents, socially and physiologically, and those differences should be reflected in the individualized approach HCPs provide to each child/family (Keo-Meir & Ehrensaft, 2018; Spencer, Berg et al., 2021).

Parents/caregivers and their children should also have the opportunity to develop knowledge about gender development and gender literacy through age-appropriate psychoeducation (Berg & Edwards-Leeper, 2018; Rider, Vencill et al., 2019; Spencer, Berg et al., 2021). Gender literacy involves understanding the distinctions between sex designated at birth, gender identity, and gender expression, including the ways in which these three factors uniquely come together for a child (Berg & Edwards-Leeper, 2018; Rider, Vencill et al., 2019; Spencer, Berg et al., 2021). As a child gains gender literacy, they begin to understand their body parts do not necessarily define their gender identity and/or their gender expression (Berg & Edwards-Leeper, 2018; Rider, Vencill et al., 2019; Spencer, Berg et al., 2021). Gender literacy also involves learning to identify messages and experiences related to gender within society. As a child gains gender literacy, they may view their developing gender identity and gender expression more positively, promoting resilience and self-esteem, and diminishing risk of shame in the face of negative messages from the environment. Gaining gender literacy through psychoeducation may also be important for siblings and/or extended family members who are important to the child (Rider, Vencill et al., 2019; Spencer, Berg et al., 2021).

Statement 7.11

We recommend health care professionals provide information to gender diverse children and their families/caregivers as the child approaches puberty about potential gender-affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation.

As a child matures and approaches puberty, HCPs should prioritize working with children and their parents/caregivers to integrate psychoeducation about puberty, engage in shared decision-making about potential gender-affirming medical interventions, and discuss fertility-related and other reproductive health implications of medical treatments (Nahata, Quinn et al., 2018; Spencer, Berg et al., 2021). Although only limited empirical research exists to evaluate such interventions, expert consensus and developmental psychological literature generally support the notion that open communication with children about their bodies and preparation for physiological changes of puberty, combined with gender-affirming acceptance, will promote resilience and help to foster positive sexuality as a child matures into adolescence (Spencer, Berg et al., 2019). All these discussions may be extended (e.g., starting earlier) to include neurodivergent children, to ensure there is enough time for reflection and understanding, especially as choices regarding future gender- affirming medical care potentially arise (Strang, Jarin et al., 2018). These discussions could include the following topics:

• Review of body parts and their different functions;

• The ways in which a child’s body may change over time with and without medical intervention;

• The impact of medical interventions on later sexual functioning and fertility;

• The impact of puberty suppression on potential later medical interventions;

• Acknowledgment of the current lack of clinical data in certain areas related to the impacts of puberty suppression;

• The importance of appropriate sex education prior to puberty.

These discussions should employ developmentally appropriate language and teaching styles, and be geared to the specific needs of each individual child (Spencer, Berg et al., 2021).

Statement 7.12

We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity.

Gender social transition refers to a process by which a child is acknowledged by others and has the opportunity to live publicly, either in all situations or in certain situations, in the gender identity they affirm and has no singular set of parameters or actions (Ehrensaft et al., 2018).

Gender social transition has often been conceived in the past as binary—a girl transitions to a boy, a boy to a girl. The concept has expanded to include children who shift to a nonbinary or individually shaped iteration of gender identity (Chew et al., 2020; Clark et al., 2018). Newer research indicates the social transition process may serve a protective function for some prepubescent children and serve to foster positive mental health and well-being (Durwood et al., 2017; Gibson et al., 2021; Olson et al., 2016). Thus, recognition that a child’s gender may be fluid and develop over time (Edwards-Leeper et al., 2016; Ehrensaft, 2018; Steensma, Kreukels et al., 2013) is not sufficient justification to negate or deter social transition for a prepubescent child when it would be beneficial. Gender identity evolution may continue even after a partial or complete social transition process has taken place (Ashley, 2019e; Edwards-Leeper et al., 2018; Ehrensaft, 2020; Ehrensaft et al., 2018; Spivey & Edwards-Leeper, 2019). Although empirical data remains limited, existing research has indicated children who are most assertive about their gender diversity are most likely to persist in a diverse gender identity across time, including children who socially transition prior to puberty (Olson et al., 2022; Rae et al., 2019; Steensma, McGuire et al., 2013). Thus, when considering a social transition, we suggest parents/caregivers and HCPs pay particular attention to children who consistently and often persistently articulate a gender identity that does not match the sex designated at birth. This includes those children who may explicitly request or desire a social acknowledgement of the gender that better matches the child's articulated gender identity and/or children who exhibit distress when their gender as they know it is experienced as incongruent with the sex designated at birth (Rae et al., 2019; Steensma, Kreukels et al., 2013).

Although there is a dearth of empirical literature regarding best practices related to the social transition process, clinical literature and expertise provides the following guidance that prioritizes a child’s best interests (Ashley, 2019e; Ehrensaft, 2018; Ehrensaft et al, 2018; Murchison et al., 2016; Telfer et al., 2018): 1) social transition should originate from the child and reflect the child’s wishes in the process of making the decision to initiate a social transition process; 2) an HCP may assist exploring the advantages/benefits, plus potential challenges of social transition; 3) social transition may best occur in all or in specific contexts/settings only (e.g., school, home); and 4) a child may or may not choose to disclose to others that they have socially transitioned, or may designate, typically with the help of their parents/caregivers, a select group of people with whom they share the information.

In summary, social transition, when it takes place, is likely to best serve a child’s well-being when it takes place thoughtfully and individually for each child. A child’s social transition (and gender as well) may evolve over time and is not necessarily static, but best reflects the cross-section of the child’s established self-knowledge of their present gender identity and desired actions to express that identity (Ehrensaft et al., 2018).

A social transition process can include one or more of a number of different actions consistent with a child’s affirmed gender (Ehrensaft et al., 2018), including:

• Name change;

• Pronoun change;

• Change in sex/gender markers (e.g., birth certificate; identification cards; passport; school and medical documentation; etc.);

• Participation in gender-segregated programs (e.g., sports teams; recreational clubs and camps; schools; etc.);

• Bathroom and locker room use;

• Personal expression (e.g., hair style; clothing choice; etc.);

• Communication of affirmed gender to others (e.g., social media; classroom or school announcements; letters to extended families or social contacts; etc.).

Statement 7.13

We recommend health care professionals and parents/caregivers support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition.

It is important children who have engaged in social transition be afforded the same opportunities as other children to continue considering meanings and expressions of gender throughout their childhood years (Ashley 2019e; Spencer, Berg et al., 2021). Some research has found children may experience gender fluidity or even detransition after an initial social transition. Research has not been conclusive about when in the life span such detransition is most likely to occur, or what percentage of youth will eventually experience gender fluidity and/or a desire to detransition—due to gender evolution, or potentially other reasons (e.g., safety concerns; gender minority stress) (Olson et al., 2022; Steensma, Kreukels et al., 2013). A recent research report indicates in the US, detransition occurs with only a small percentage of youth five years after a binary social transition (Olson et al., 2022); further follow-up of these young people would be helpful. Replication of these findings is important as well since this study was conducted with a limited and self-selected participant pool in the US and thus may not be applicable to all gender diverse children. In summary, we have limited ability to know in advance the ways in which a child’s gender identity and expressions may evolve over time and whether or why detransition may take place for some. In addition, not all gender diverse children wish to explore their gender (Telfer et al., 2018). Cisgender children are not expected to undertake this exploration, and therefore attempts to force this with a gender diverse child, if not indicated or welcomed, can be experienced as pathologizing, intrusive and/or cisnormative (Ansara & Hegarty, 2012; Bartholomaeus et al., 2021; Oliphant et al., 2018).

Statement 7.14

We recommend health care professionals discuss the potential benefits and risks of a social transition with families who are considering it.

Social transition in prepubescent children consists of a variety of choices, can occur as a process over time, is individualized based on both a child’s wishes and other psychosocial considerations (Ehrensaft, 2018), and is a decision for which possible benefits and challenges should be weighted and discussed.

A social transition may have potential benefits as outlined in clinical literature (e.g., Ehrensaft et al., 2018) and supported by research (Fast & Olson, 2018; Rae et al., 2019). These include facilitating gender congruence while reducing gender dysphoria and enhancing psychosocial adjustment and well-being (Ehrensaft et al., 2018). Studies have indicated socially transitioned gender diverse children largely mirror the mental health characteristics of age matched cisgender siblings and peers (Durwood et al., 2017). These findings differ markedly from the mental health challenges consistently noted in prior research with gender diverse children and adolescents (Barrow & Apostle, 2018) and suggest the impact of social transition may be positive. Additionally, social transition for children typically can only take place with the support and acceptance of parents/caregivers, which has also been demonstrated to facilitate well-being in gender diverse children (Durwood et al., 2021; Malpas et al., 2018; Pariseau et al., 2019), although other forms of support, such as school-based support, have also been identified as important (Durwood et al., 2021; Turban, King et al., 2021). HCPs should discuss the potential benefits of a social transition with children and families in situations in which 1) there is a consistent, stable articulation of a gender identity that is incongruent with the sex assigned at birth (Fast & Olson, 2018). This should be differentiated from gender diverse expressions/behaviors/interests (e.g., playing with toys, expressing oneself through clothing or appearance choices, and/or engaging in activities socially defined and typically associated with the other gender in a binary model of gender) (Ehrensaft, 2018; Ehrensaft et al., 2018); 2) the child is expressing a strong desire or need to transition to the gender they have articulated as being their authentic gender (Ehrensaft et al., 2018; Fast & Olson, 2018; Rae et al., 2019); and 3) the child will be emotionally and physically safe during and following transition (Brown & Mar, 2018). Prejudice and discrimination should be considerations, especially in localities where acceptance of gender diversity is limited or prohibited (Brown & Mar, 2018; Hendricks & Testa, 2012; Turban, King et al., 2021). Of note, there can also be possible risks to a gender diverse child who does not socially transition, including 1) being ostracized or bullied for being perceived as not conforming to prescribed community gender roles and/or socially expected patterns of behavior; and 2) living with the internal stress or distress that the gender they know themselves to be is incongruent with the gender they are being asked to present to the world.

To promote gender health, the HCP should discuss the potential challenges of a social transition. One concern often expressed relates to fear that a child will preclude considering the possible evolution of their gender identity as they mature or be reluctant to initiate another gender transition even if they no longer feel their social transition matches their current gender identity (Edwards-Leeper et al., 2016; Ristori & Steensma, 2016). Although limited, recent research has found some parents/caregivers of children who have socially transitioned may discuss with their children the option of new gender iterations (for example, reverting to an earlier expression of gender) and are comfortable about this possibility (Olson et al., 2019). Another often identified social transition concern is that a child may suffer negative sequelae if they revert to the former gender identity that matches their sex designated at birth (Chen et al., 2018; Edwards-Leeper et al., 2019; Steensma & Cohen-Kettenis, 2011). From this point of view, parents/caregivers should be aware of the potential developmental effect of a social transition on a child.

HCPs should provide guidance to parents/caregivers and supports to a child when a social gender transition is being considered or taking place by 1) providing consultation, assessment, and gender supports when needed and sought by the parents/caregivers; 2) aiding family members, as needed, to understand the child’s desires for a social transition and the family members’ own feelings about the child’s expressed desires; 3) exploring with, and learning from, the parents/caregivers whether and how they believe a social transition would benefit their child both now and in their ongoing development; 4) providing guidance when parents/caregivers are not in agreement about a social transition and offering the opportunity to work together toward a consistent understanding of their child’s gender status and needs; 5) providing guidance about safe and supportive ways to disclose their child’s social transition to others and to facilitate their child transitioning in their various social environments (e.g., schools, extended family); 6) facilitating communication, when desired by the child, with peers about gender and social transition as well as fortifying positive peer relationships; 7) providing guidance when social transition may not be socially accepted or safe, either everywhere or in specific situations, or when a child has reservations about initiating a transition despite their wish to do so; there may be multiple reasons for reservations, including fears and anxieties; 8) working collaboratively with family members and MHPs to facilitate a social transition in a way that is optimal for the child's unfolding gender development, overall well-being, and physical and emotional safety; and 9) providing psychoeducation about the many different trajectories the child’s gender may take over time, leaving pathways open to future iterations of gender for the child, and emphasizing there is no need to predict an individual child’s gender identity in the future (Malpas et al., 2018).

All of these tasks incorporate enhancing the quality of communication between the child and family members and providing an opportunity for the child to be heard and listened to by all family members involved. These relational processes in turn facilitate the parents/caregivers’ success in making informed decisions about the advisability and/or parameters of a social transition for their child (Malpas et al., 2018).

One role of HCPs is to provide guidance and support in situations in which children and parents/caregivers wish to proceed with a social transition but conclude that the social environment would not be accepting of those choices, by 1) helping parents/caregivers define and extend safe spaces in which the child can express their authentic gender freely; 2) discussing with parents/caregivers ways to advocate that increase the likelihood of the social environment being supportive in the future, if this is a realistic goal; 3) intervening as needed to help the child/family with any associated distress and/or shame brought about by the continued suppression of authentic gender identity and the need for secrecy; and 4) building both the child’s and the family’s resilience, instilling the understanding that if the social environment is having difficulty accepting a child’s social transition and affirmed gender identity, it is not because of some shortcoming in the child but because of insufficient gender literacy in the social environment (Ehrensaft et al., 2018).

Statement 7.15

We suggest health care professionals consider working collaboratively with other professionals and organizations to promote the well-being of gender diverse children and minimize the adversities they may face.

All children have the right to be supported and respected in their gender identities (Human Rights Campaign, 2018; Paré, 2020; SAMHSA, 2015). As noted above, gender diverse children are a particularly vulnerable group (Barrow & Apostle, 2018; Cohen-Kettenis et al., 2003; Giovanardi et al., 2018; Gower, Rider, Coleman et al., 2018; Grossman & D’Augelli, 2007; Hendricks & Testa, 2012; Reisner, Greytak et al., 2015; Ristori & Steensma, 2016; Roberts et al., 2012; Tishelman & Neumann-Mascis, 2018). The responsibilities of HCPs as advocates encompass acknowledging social determinants of health are critical for marginalized minorities (Barrow & Mar, 2018; Hendricks & Testa, 2012). Advocacy is taken up by all HCPs in the form of child and family support (APA, 2015; Malpas et al., 2018). Some HCPs may be called on to move beyond their individual offices or programs to advocate for gender diverse children in the larger community, often in partnership with stakeholders, including parents/caregivers, allies, and youth (Kaufman & Tishelman, 2018; Lopez et al., 2017; Vanderburgh, 2009). These efforts may be instrumental in enhancing children’s gender health and promoting their civil rights (Lopez et al., 2017).

HCP’s voices may be essential in schools, in parliamentary bodies, in courts of law, and in the media (Kuvalanka et al., 2019; Lopez et al., 2017; Whyatt-Sames, 2017; Vanderburgh, 2009). In addition, HCPs may have a more generalized advocacy role in acknowledging and addressing the frequent intentional or unintentional negating of the experience of gender diverse children that may be transmitted or communicated by adults, peers, and in media (Rafferty et al., 2018). Professionals who possess the skill sets and find themselves in appropriate situations can provide clear de-pathologizing statements on the needs and rights of gender diverse children and on the damage caused by discriminatory and transphobic rules, laws, and norms (Rafferty et al., 2018).

CHAPTER 8 Nonbinary

Nonbinary is used as an umbrella term referring to individuals who experience their gender as outside of the gender binary. The term nonbinary is predominantly but not exclusively associated with global north contexts and may sometimes be used to describe indigenous and non-Western genders. The term nonbinary includes people whose genders are comprised of more than one gender identity simultaneously or at different times (e.g., bigender), who do not have a gender identity or have a neutral gender identity (e.g., agender or neutrois), have gender identities that encompass or blend elements of other genders (e.g., polygender, demiboy, demigirl), and/or who have a gender that changes over time (e.g., genderfluid) (Kuper et al., 2014; Richards et al., 2016; Richards et al., 2017; Vincent, 2019). Nonbinary people may identify to varying degrees with binary-associated genders, e.g., nonbinary man/woman, or with multiple gender terms, e.g., nonbinary and genderfluid (James et al., 2016; Kuper et al., 2012). Nonbinary also functions as a gender identity in its own right (Vincent, 2020). It is important to acknowledge this is not an exhaustive list, the same identities can have different meanings for different people, and the use of terms can vary over time and by location.

Genderqueer, first used in the 1990s, is an identity category somewhat older than nonbinary—which first emerged in approximately the late 2000s (Nestle et al., 2002; Wilchins, 1995). Genderqueer may sometimes be used synonymously with nonbinary or may communicate a specific consciously politicized dimension to a person’s gender. While transgender is used in many cultural contexts as an umbrella term inclusive of nonbinary people, not all nonbinary people consider themselves to be transgender for a range of reasons, including because they consider being transgender to be exclusively within the gender binary or because they do not feel “trans enough” to describe themselves as transgender (Garrison, 2018). Some nonbinary people are unsure or ambivalent about whether they would describe themselves as transgender (Darwin, 2020; Vincent, 2019).

In the context of the English language, nonbinary people may use the pronouns they/them/theirs, or neopronouns which include e/em/eir, ze/zir/hir, er/ers/erself among others (Moser & Devereux, 2019; Vincent, 2018). Some nonbinary people use a combination of pronouns (either deliberately mixing usage, allowing free choice, or changing with social context), or prefer to avoid gendered pronouns entirely, instead using their name. Additionally, some nonbinary people use she/her/hers, or he/him/his, sometimes or exclusively, whilst in some regions in the world descriptive language for nonbinary people does not (yet) exist. In contexts outside of English, a wide range of culturally specific linguistic adaptations and evolutions can be observed (Attig, 2022; Kirey-Sitnikova, 2021; Zimman, 2020). Also of note, some languages use one pronoun that is not associated with sex or gender while others gender all nouns. These variations in language are likely to influence nonbinary people’s experience of gender and how they interact with others.

Recent studies suggest nonbinary people comprise roughly 25% to over 50% of the larger transgender population, with samples of youth reporting the highest percentage of nonbinary people (Burgwal et al., 2019; James et al., 2016; Watson, 2020). In recent studies of transgender adults, nonbinary people tend to be younger than transgender men and transgender women and in studies of both youth and adults, nonbinary people are more likely to have been assigned female at birth (AFAB). However, these findings should be interpreted with caution as there are likely a number of complex, sociocultural factors influencing the quality, representativeness, and accuracy of this data (Burgwal et al., 2019; James et al., 2016; Watson, 2020; Wilson & Meyer, 2021) (see also Chapter 3—Population Estimates).

CHAPTER 9 Eunuchs

Among the many people who benefit from gender-affirming medical care, those who identify as eunuchs are among the least visible. The 8th version of the Standards of Care (SOC) includes a discussion of eunuch individuals because of their unique presentation and their need for medically necessary gender-affirming care (see Chapter 2—Global Applicability, Statement 2.1).

Eunuch individuals are those assigned male at birth (AMAB) and wish to eliminate masculine physical features, masculine genitals, or genital functioning. They also include those whose testicles have been surgically removed or rendered nonfunctional by chemical or physical means and who identify as eunuch. This identity-based definition for those who embrace the term eunuch does not include others, such as men who have been treated for advanced prostate cancer and reject the designation of eunuch. We focus here on those who identify as eunuchs as part of the gender diverse umbrella.

As with other gender diverse individuals, eunuchs may also seek castration to better align their bodies with their gender identity. As such, eunuch individuals are gender nonconforming individuals who have needs requiring medically necessary gender-affirming care (Brett et al., 2007; Johnson et al., 2007; Roberts et al., 2008).

Eunuch individuals identify their gender identities in various ways. Many eunuch individuals see their status as eunuch as their distinct gender identity with no other gender or transgender affiliation. The focus of this chapter is on the treatment and care for those who identify as eunuchs. Health care professionals (HCPs) will encounter eunuchs requesting hormonal interventions, castration, or both to become eunuchs. These individuals may also benefit from a eunuch community because of the identification—with or without actual castration.

While there is a 4000-year history of eunuchs in society, the greatest wealth of information about contemporary eunuch-identified people is found within the large online peer-support community that congregates on sites such as the Eunuch Archive (www.eunuch.org), which was established in 1998. The moderators of this site attempt to maintain both medical and historical accuracy in its discussion forums, although there is certainly misinformation as well. According to the website, as of January 2022, there have been over 130,000 registered members from various parts of the world and frequently over 90% of those reading the site are “guests” rather than members. The website lists over 23,000 threads and nearly 220,000 posts. For example, two threads giving instructions for self-castration by injection of different toxins directly into the testicles have about 2,500 posts each, and each has been read well over one million times. Beginning in 2001, there have been 20 annual international gatherings of the Eunuch Archive community in Minneapolis in addition to many regional gatherings elsewhere. While the topic of castration is of interest to the great majority of people who participate in the discussions, it is a minority of the membership who seriously seek or have undergone castration. Many former Eunuch Archive members have achieved their goals and no longer participate.

Because of misconceptions and prejudice about historic eunuchs, the invisibility of contemporary eunuchs, and the social stigma that affects all gender and sexual minorities, few eunuch individuals come out publicly as eunuch and many will tell no one and will share only with like-minded people in an online community or are known as such only to close family and friends (Wassersug & Lieberman, 2010). The stereotypes of eunuchs are often highly negative (Lieberman 2018), and eunuchs may suffer the same minority stress as other stigmatized groups (Wassersug & Lieberman, 2010). Research into minority stress affecting gender diverse people should therefore include eunuchs.

The current set of recommendations is directed at professionals working with individuals who identify as eunuchs (Johnson & Wassersug, 2016; Vale et al., 2010) requesting medically necessary gender-affirming medical and/or surgical treatments (GAMSTs). Although not a specific diagnostic category in the ICD or DSM, eunuch is a useful construct as it speaks to the specifics of eunuch experience while also connecting it to the experience of gender incongruence more broadly. Eunuch individuals will present themselves clinically in various ways. They wish for a body that is compatible with their eunuch identity—a body that does not have fully functional male genitalia. Some other eunuch individuals feel acute discomfort with their male genitals and need to have them removed to feel comfortable in their bodies (Johnson et al., 2007; Roberts et al., 2008). Others are indifferent to having male external genitalia as long as they are only physically present and do not function to produce androgens and male secondary sexual features (Brett et al., 2007). Hormonal means may be used to suppress the production of androgens, although orchiectomy provides a permanent solution for those not wishing genital functioning (Wibowo et al., 2016). Some eunuch individuals desire lower testosterone levels achieved with orchiectomy, but many will elect some form of hormone replacement to prevent adverse effects associated with hypogonadism. Most who elect hormone therapy choose either a full or partial replacement dose of testosterone. A smaller number elect estrogen.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 9.1.

We recommend health care professionals and other users of the Standards of Care, Version 8 guidelines should apply the recommendations in ways that meet the needs of eunuch individuals.

Eunuch individuals are part of the population of gender diverse people who experience gender incongruence and may also seek gender-affirming care. Like other transgender and gender diverse (TGD) individuals, eunuchs require access to affirming care to gain comfort with their gendered self. Each section of the SOC addresses the needs of diverse individuals, and eunuchs can be included within that group. They may have commonality with some nonbinary individuals in that social transition may not be a desired option, and hormone therapy may not play the same role as it might in a social transition or transition within the binary (Wassersug & Lieberman, 2010).

Like other gender diverse individuals, eunuch individuals may be aware of their identity in childhood or adolescence. Due to the lack of research into the treatment of children who may identify as eunuchs, we refrain from making specific suggestions.

Eunuch individuals may seek medical or surgical care (hormone suppression, orchiectomy, and, in some cases, penectomy) to achieve physical, psychological, or sexual changes (Wassersug & Johnson, 2007). It is important all patients, including both eunuchs and those seeking castration, establish and maintain a relationship with an HCP that is built upon trust and mutual understanding. Given a lack of awareness of eunuchs within the general medical community and the fear among many individuals seeking castration they will not be accepted, many do not receive appropriate primary care and screening tests (Jäggi et al., 2018). Increased awareness and education among medical providers will help address the need to be informed about the need to include eunuchs in discussions of gender diversity (Deutsch, 2016a). It goes without saying that eunuchs require and deserve the same primary care services as the general population. The topic of screening tests for cancers, such as prostate and breast, is an important area for discussion as the risks of hormone-related cancers are likely different among male-assigned people whose testosterone and estrogen levels are not in the male range. Due to a lack of studies looking at the prevalence and incidence of hormone-related cancers in the eunuch population, there is no evidence to guide how often to screen for hormone-related cancers with prostate exams, PSA measurements, mammograms, etcetera.

The large literature on prostate cancer patients who have been medically or surgically castrated provides information about some of the effects of post-pubertal castration (such as potential osteoporosis, depression, or metabolic syndrome), but voluntary eunuchs may interpret the results very differently from those castrated for medical reasons. Chemical or surgical castration may be experienced as a source of distress to cis men with prostate cancer, while the same treatment may be affirming and a source of comfort for eunuch individuals. Similarly, transmasculine people who have a mastectomy to gain comfort with their bodies experience that surgery differently from ciswomen who undergo mastectomy to treat breast cancer (Koçan & Gürsoy, 2016; van de Grift et al., 2016). The prostate cancer information is well summarized by Wassersug et al. (2021) who provide references that explore the large literature on the subject. Such information on the effects of castration should be made available to those seeking castration.

Following an assessment as per the SOC-8, medical options requested by the patient can be considered and prescribed, if appropriate. These options can be tailored to the individual to create a plan that reflects their specific needs and preferences. The number and type of interventions applied and the order in which these take place may differ from person to person. These options are consistent with both the assessment and surgery chapters of the SOC-8. Treatment options for eunuchs to consider include:

• Hormone suppression to explore the effects of androgen deficiency for eunuch individuals wishing to become asexual, nonsexual, or androgynous;

• Orchiectomy to stop testicular production of testosterone;

• Orchiectomy with or without penectomy to alter their body to match their self-image;

• Orchiectomy followed by hormone replacement with testosterone or estrogen.

Per statement 5.6 in Chapter 5—Assessment of Adults, eunuch individuals seeking gonadectomy consider a minimum of 6 months of hormone therapy as appropriate to the TGD person’s gender goals before the TGD person undergoes irreversible surgical intervention (unless hormones are not clinically indicated for the individual).

Statement 9.2.

We recommend health care professionals consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.

The same assessment process recommended in the SOC-8 ought to apply to eunuchs (see Chapter 5—Assessment of Adults). The Eunuch Archive has a large number of posts from individuals finding great difficulty in seeking medical providers who will perform castration surgery. There are a large number of eunuch individuals who have performed self-surgery or have had surgery performed by people who are not credentialed medical providers (Johnson & Irwig, 2014). There are also clinical reports of eunuch individuals who have self-castrated and accounts of patients who have misled medical providers to obtain castration (Hermann & Thorstenson, 2015; Mukhopadhyay & Chowdhury, 2009). There is no doubt when members of this population are denied access to quality medical treatment, they will take actions that may cause them great harm, such as bleeding and infection that may require hospital admission (Hay, 2021; Jackowich et al., 2014; Johnson & Irwig, 2014). Because of these serious problems and harm caused through self-surgery, surgery by unqualified practitioners or the unsupervised use of medications that affect hormones, it is important health care providers create a welcoming environment and consider various treatment options after careful assessment to avoid the problems that lack of access to treatment and withholding treatment will cause.

When desired, castration can be achieved either chemically or surgically. For some, chemical castration can be an appropriate trial prior to undergoing surgical castration to determine how the individual feels when hypogonadal (Vale et al., 2010). Chemical castration is usually reversible if the medications are discontinued (Wassersug et al., 2021). The most common types of medications used to lower testosterone levels are antiandrogens and estrogen.

The two most commonly used antiandrogens, cyproterone acetate and spironolactone, are oral. Estrogen is sometimes prescribed for prostate cancer patients to lower serum testosterone levels via negative feedback at the hypothalamus and pituitary gland. Estrogens and antiandrogens may not fully suppress testosterone levels into the female or castrate range, and oral estrogens increase the risk of venous thromboembolism. Although not commonly used due to cost, gonadotropin releasing hormone (GnRH) agonists are a very effective method for suppressing the production of sex steroids and fertility (Hembree et al., 2017). When selecting a medication, we advise using those which have been studied in multiple transgender populations (i.e., estrogen, cyproterone acetate, GnRH agonists) rather than medications with little to no peer-reviewed scientific studies (i.e., bicalutamide, rectal progesterone, etc.) (Angus et al., 2021; Butler et al., 2017; Efstathiou et al., 2019; Tosun et al., 2019).

Many eunuch individuals pursue hormone replacement therapy following castration as they do not desire the complete suppression of hormone levels and consequent problems, such as the increased risk of osteoporosis. The two main options for replacement of sex steroids are testosterone and estrogen that may be used in full or partial replacement doses. The majority elect testosterone as they present as male and are not interested in feminization. A minority elect estrogen at a high enough dose to prevent osteoporosis, but low enough avoid most feminization. They may identify as nonbinary, agender, or other (Johnson et al., 2007; Johnson & Wassersug, 2016).

Although studies on hormone replacement therapy in eunuchs are lacking, findings from cisgender men treated for prostate cancer can be informative regarding the effects of hormone therapy. In a randomized controlled trial of 1,694 cisgender men treated for locally advanced or metastatic prostate cancer, one group received a GnRH agonist and the other received transdermal estrogen (Langley et al., 2021). Cisgender men who received the GnRH agonist developed signs and symptoms of both androgen and estrogen deficiency, whereas men who received the estrogen patch only developed androgen-depleting symptoms. Both groups had high rates of sexual side effects (91%), and weight gain was similar among the groups. Compared with cisgender men receiving the GnRH agonist, cisgender men treated with estrogen patches had a higher self-reported quality of life, lower rates of hot flushes (35% vs. 86%), and higher rates of gynecomastia (86% vs. 38%). Metabolically, cisgender men receiving estrogen patches had favorable changes with a lower mean fasting glucose, fasting total cholesterol, systolic and diastolic blood pressure. Conversely, cisgender men receiving the GnRH agonist experienced the opposite effects. Based on this study, eunuchs may consider a low dose of transdermal estrogen therapy to avoid adverse estrogen-depleting effects, which include hot flashes, fatigue, metabolic effects, and loss of bone mineral density (Hembree et al., 2017; Langley et al., 2021). For further information see Chapter 12—Hormone Therapy.

Statement 9.3.

We recommend health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them.

A frequent topic on the discussion boards of the Eunuch Archive is the difficulty of finding practitioners who are able to understand their needs. Eunuchs and those seeking castration usually are less visible than other gender minorities (Wassersug & Lieberman, 2010). Due to stigma and fear of rejection by the medical community, they may not voluntarily disclose their identity and desires to their medical or mental health providers. In some environments, medical providers may not be aware eunuchs exist and may not even know they have treated eunuch-identified patients.

The SOC section on assessment is applicable to eunuch individuals. Like other gender diverse individuals, those seeking castration can engage in an informed consent process in which qualified providers conduct assessments to ensure individuals are capable of providing informed consent prior to medical interventions and to ensure a mental health problem is not the etiology of the desire. As with other sexual and gender minorities, working with eunuchs requires an understanding that they are a diverse population, and that each person is eunuch in their own way (Johnson et al., 2007). The person seeking services benefits from the professional’s accepting stance, open inquiry, suspension of judgment, and flexible expectations, combined with professional competency and expertise.

To provide appropriate treatment, providers must establish trust and respect by creating an inclusive environment for eunuch-identified people. For eunuch-identified individuals, the ideal intake form would ask the assigned sex and identified gender and offer multiple gender options, including “eunuch” and “other.” Individuals may identify with more than one option and should be able to select more than one.

HCPs may be involved in the assessment, psychotherapy (if desired), preparation, and follow-up for medical and surgical gender-affirming interventions. They may also provide support for partners and families. Eunuch-identified individuals who want the support of a qualified mental health provider will benefit from a therapist who meets the experience and criteria set out in Chapter 4—Education.

While some individuals seeking or considering castration come to counseling or therapy because they want emotional support or help with decision-making, many come to providers for an assessment in preparation for specific medical interventions (Vale et al., 2010).

Statement 9.4.

We suggest health care professionals providing care to eunuch individuals include sexuality education and counseling.

Several research studies have contributed to our knowledge of contemporary eunuch-identified people and have explored demographic characteristics and sexuality (Handy et al., 2015; Vale et al., 2013; Wibowo et al., 2012, 2016). Medical and MHPs should assume eunuchs are sexual people capable of sexual activity, pleasure, and relationships, unless they report otherwise (Wibowo et al., 2021). Research has shown there is great diversity among eunuchs regarding the level of desire, type of preferred physical or sexual contact, and nature of preferred relationships (Brett et al., 2007; Johnson et al., 2007; Roberts et al., 2008). While some enjoy active sex lives with or without romantic relationships, others identify as asexual or aromantic and are relieved by the loss of libido achieved through surgical or chemical castration (Brett et al., 2007). Each person is different, and one’s genital status does not determine sexual or romantic attraction (Walton et al., 2016; Yule et al., 2015).

Regardless of the type of chemical suppression or surgery a person has undergone, they may be capable of sexual pleasure and sexual activity. Contrary to popular belief, eunuchs are not necessarily asexual or nonsexual (Aucoin & Wassersug, 2006). Safe sex education is necessary for all people who engage in sexual activity that could involve an exchange of body fluids. See Chapter 17—Sexual Health for information regarding sex education and safe sex options for people with diverse genders and sexualities. In addition, fertility preservation should be discussed when considering medical interventions that might impact the possibilities for future parenthood. For more considerations see Chapter 16—Reproductive Health.

CHAPTER 10 Intersex

The Standards of Care, Version 7 included a chapter on the applicability of the standards to people with physical intersexuality who become gender-dysphoric and/or change their gender because they differ from transgender individuals without intersexuality in phenomenological presentation, life trajectories, prevalence, etiology, and stigma risks. The current chapter provides an update and adds recommendations on the medically necessary clinical approach to the management of individuals with intersexuality in general (see medical necessity statement in Chapter 2—Global Applicability, Statement 2.1). Because a newborn with an atypical sexual differentiation may already present with clinical challenges, including the need for family education and support from early on, the decision-making on gender assignment, subsequent clinical gender management, components of which—especially genital surgery—may be controversial, and a later risk of gender dysphoria development and gender change that is markedly increased (Sandberg & Gardner, 2022).

CHAPTER 11 Institutional Environments

This chapter addresses care for transgender and gender diverse (TGD) individuals who reside in institutions. By definition, institutions are facilities or establishments in which people live and receive care in a congregate or large group setting, where individuals may or may not have freedom of movement, individual consent, or agency. Carceral facilities (correctional facilities, immigration detention centers, jails, juvenile detention centers) and noncarceral facilities (long-term care facilities, in-patient psychiatric facilities, domiciliaries, hospice/palliative care, assisted living facilities) are residential institutions where health care access for transgender persons may be provided. Much of the evidence in support of proper care of TGD persons comes from carceral settings. However, the recommendations put forth here apply to all institutions that house TGD individuals, both carceral and noncarceral (Porter et al., 2016). All of the recommendations of the Standards of Care apply equally to people living in both types of institutions. People should have access to these medically necessary treatments irrespective of their housing situation within an institution (Brown, 2009). Care for an institutionalized person must consider the individual does not have the access that non-institutionalized persons have to securing care on their own. For that reason, institutionalized persons must be supported in being able to receive the Standards of Care established by the World Professional Association for Transgender Health (WPATH).

TGD residents in carceral facilities report the lack of access to medically necessary transgender-specific health care (see Chapter 2—Global Applicability, Statement 2.1), which is ranked as their number one concern while incarcerated (Brown, 2014; Emmer et al., 2011). The systemic racial inequities inherent in many carceral environments (Sawyer, 2020), racial disparities in health outcomes (Nowotny et al., 2017), and the overrepresentation of TGD people of color in some facilities (Reisner et al., 2014) punctuate a need for facility leadership to attend to transitional care access issues. Controlled studies show clinically significant health and mental health disparities for justice-involved transgender people compared to matched groups of transgender people who have not been incarcerated or jailed (Brown and Jones, 2015). Too often the agencies, structures, and personnel that provide care are lacking in knowledge, training, and capacity to care for gender diverse people (Clark et al., 2017). Discrimination against TGD residents in palliative care settings, including hospice, is common, and the needs of TGD patients or their surrogates have been ignored in these settings (Stein et al., 2020). This is one reason why lesbian, gay, bisexual and transgender (LGBT) patients may choose to hide their sexual and/or gender identity when they enter a nursing home, despite the fact that prior to their admission to the facility they had been living publicly as a LGBT-identified person (Carroll, 2017; Serafin et al., 2013).

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable. The majority of the available literature related to institutions focuses on those who are incarcerated in jails, prisons, or other carceral environments. Literature about other institutional types were also considered and referenced where available. We hope future investigations will address this relative lack of data from noncarceral institutions. The recommendations summarized above are generalizable to a variety of institutional settings that have characteristics in common, including extended periods of stay, loss of or limited agency, and reliance on institutional staff for some or all of the basic necessities of life.

Statement 11.1

We recommend health care professionals responsible for providing gender-affirming care to individuals residing in institutions (or associated with institutions or agencies) recognize the entire list of recommendations of the SOC-8, apply equally to TGD people living in institutions.

Just as people living in institutions require and deserve mental and medical health care in general and in specialty areas, we recognize TGD people are in these institutions and thus need care specific to TGD concerns. We recommend the application of the Standards of Care (SOC) to people living in institutions as basic principles of health care and ethics (Beauchamp & Childress, 2019; Pope & Vasquez, 2016). Additionally, numerous courts have long upheld the need to provide TGD-informed care based in the WPATH SOC to people living in institutions as well (e.g., Koselik v. Massachusetts, 2002; Edmo v. Idaho Department of Corrections, 2020). Agencies that provide staffing for long-term, in-home services should also be aware of the applicability of the Standards of Care.

Statement 11.2

We suggest institutions provide all staff with training on gender diversity.

Because TGD care affects a small percentage of the population, it requires specialized training as outlined in this SOC Version 8. While the level of training will vary based on the staff member’s role within the institutional setting, all staff will need training in addressing residents appropriately while other clinical staff may need more intensive training and/or consultation. These training recommendations also apply to agencies that supply staffing for in-home, long-term care. Misgendering institutionalized residents, not allowing for gender appropriate clothing, shower facilities, or housing, and not using chosen names communicates a lack of respect for TGD residents who may experience repeated indignities as emotionally traumatic, depressing, and anxiety-producing. By providing all institutional staff with training on gender diversity and basic competence in transgender-related health care issues, these harms can be prevented (Hafford-Letchfield et al., 2017). Surveys indicate individuals working with incarcerated individuals as well as in workers in noncarceral settings like palliative care have significant knowledge gaps (Stein et al., 2020; White et al., 2016). Hafford-Letchfied et al. (2017) showed benefit to training residential long-term care staff when such training began with “recognizing LBGT issues” and existed in “care homes”. If the assigned health care providers lack the expertise to assess and/or treat gender diverse persons under their charge, outside consultation should be sought from professionals with expertise in the provision of gender-affirming health care (Brömdal et al., 2019; Sevelius and Jenness, 2017).

Statement 11.3

We recommend medical professionals charged with prescribing and monitoring hormones for TGD individuals living in institutions who need gender-affirming hormone therapy do so without undue delay and in accordance with the SOC-8.

TGD persons may be admitted to institutions in need of evaluation for gender-affirming hormonal care or may develop this need after they have resided in an institutional setting for varying degrees of time. It is not uncommon for TGD persons to be denied access to hormonal care for months or years after making such needs known or to be undertreated and poorly monitored, delaying the necessary titration of medications for safety and efficacy (Keohane, 2018; Kosilek v. Massachusetts, 2002; Monroe v. Baldwin et al., 2019). This can result in significant negative mental health outcomes to include depression, anxiety, suicidality, and surgical self-treatment risks (Brown, 2010). As with all medically necessary health care, access to gender-affirming hormone therapies should be provided in a timely fashion when indicated for a TGD resident, in both carceral and noncarceral institutional environments. Medical professionals shall appropriately titrate hormones based on laboratory results and clinical outcomes to ensure results are within the range of recommended standards within the field of endocrinology. Such labs shall be taken at a frequency so as not to delay appropriate titration.

TGD elderly people living in long-term care facilities have unique needs (Boyd, 2019; Caroll, 2017; Porter, 2016). When elderly individuals request hormonal treatment, while physicians should assess pre-existing conditions, rarely do such conditions absolutely contraindicate administering hormones in this population (Ettner, 2013). People with gender incongruence in institutions may also have coexisting mental health conditions (Brown and Jones, 2015; Cole et al., 1997). These conditions should be evaluated and treated appropriately as part of the overall assessment. Persons receiving hormones must be closely medically monitored to avoid potential drug interactions and polypharmacy (Hembree et al., 2017).

TGD persons who enter an institution on an appropriate regimen of gender-affirming hormone therapy should be continued on the same or similar therapies and monitored according to the SOC Version 8. A “freeze frame” approach is inappropriate and dangerous (Kosilek v. Massachusetts, 2002). A “freeze frame” approach is the outmoded practice of denying hormones to people who are not already on them or keeping TGD persons on the same dose of hormones throughout their institutionalization that they were receiving upon admission, even if that dose was an initiation (low) dose. TGD persons who are deemed appropriate for de novo gender-affirming hormone therapy should be started on such therapy just as they would be outside of an institution (Adams v. Federal Bureau of Prisons, No. 09-10272 [D. MO June 7, 2010]; Brown 2009). The consequences of abrupt withdrawal of hormones or lack of initiation of hormone therapy when medically necessary include a significant likelihood of negative outcomes (Brown, 2010; Sundstrom and Fields v. Frank, 2011), such as surgical self-treatment by autocastration, depressed mood, increased gender dysphoria, and/or suicidality (Brown, 2010; Maruri, 2011).

If an individual in an institution does receive gender-affirming hormones and/or surgeries, decisions regarding housing in sex-segregated facilities may need to be reassessed for the safety and well-being of the TGD person (Ministry of Justice [UK], 2016).

Statement 11.4

We recommend staff and professionals charged with providing health care to TGD individuals living in institutions recommend and support gender-affirming surgical treatments in accordance with SOC-8, when sought by the individual, without undue delay.

TGD people with gender dysphoria should have an appropriate treatment plan to provide medically necessary surgical treatments that contain similar elements provided to persons who reside outside institutions (Adams v. Federal Bureau of Prisons, No. 09-10272 [D. MO June 7, 2010]; Brown 2009; Edmo v. Idaho Department of Corrections, 2020). The consequences of denial or lack of access to gender- affirming surgeries for residents of institutions who cannot access such care outside of their institutions may be serious, including substantial worsening of gender dysphoria symptoms, depression, anxiety, suicidality, and the possibility of surgical self-treatment (e.g., autocastration or autopenectomy; Brown, 2010; Edmo v. Idaho Department of Corrections, 2020; Maruri, 2011). It is not uncommon for residents of institutions to be denied access to evaluation for gender-affirming surgery as well as denial of the treatment itself, even when medically necessary (Kosilek v. Massachusetts/Dennehy, 2012; Edmo v. Idaho Department of Corrections, 2020). The denial of medically necessary evaluations for and the provision of gender-affirming surgical treatments and necessary aftercare is inappropriate and inconsistent with these Standards of Care.

Statement 11.5

We recommend administrators, health care professionals, and all others working in institutions charged with the responsibility of caring for TGD individuals allow those individuals who request appropriate clothing and grooming items to obtain such items concordant with their gender expression.

Gender expression refers to people having hairstyles, grooming products, clothing, names, and pronouns associated with their gender identity in their culture and/or community (American Psychological Association, 2015; Hembree et al., 2017). Gender expression is the norm among most people within a culture or a community. Social transition is the process of TGD persons beginning and continuing to express their gender identity in ways that are authentic and socially perceptible. Often, social transition involves behavior and public presentation differing from what is usually expected for people assigned a given legal gender marker at birth. A gender marker is the legal label for a person’s sex that is typically assigned or designated at birth on official documents (American Psychological Association, 2015). This is most commonly recorded as male or female but also intersex or “X” in some nations and jurisdictions. TGD individuals need the same rights to gender expression afforded cisgender people living both outside and inside institutional settings. Staff acceptance of social transition also sets a tone of respect and affirmation that may enhance respect and affirmation with others residing in the institution, thereby increasing safety and reducing some aspects of gender incongruence.

Research indicates social transition and congruent gender expression have a significant beneficial effect on the mental health of TGD people (Bockting & Coleman, 2007; Boedecker, 2018; Devor, 2004; Glynn et al., 2016; Russell et al., 2018). To allow for expressing gender identity, these recommendations include being allowed to wear gender congruent clothing and hairstyles, to obtain and use gender-appropriate hygiene and grooming products, to be addressed by a chosen name or legal last name (even if unable to change the assigned name legally yet), and to be addressed by a pronoun consistent with one’s identity. These elements of gender expression and social transition, individually or collectively as indicated by the individual’s needs, reduce gender dysphoria/incongruence, depression, anxiety, self-harm ideation and behavior, suicidal ideation and attempts (Russell et al., 2018). Furthermore, these elements of congruent gender expression enhance well-being and functioning (Glynn et al., 2016).

Statement 11.6

We recommend all institutional staff address TGD individuals by their chosen names and pronouns at all times.

Given that an increasing percentage of people openly identify as gender diverse, there is a need to develop and implement practices and policies that meet the needs of these people irrespective of where they live (McCauley et al., 2017). For example, institutions should utilize medical and administrative records systems for their residents that track gender markers consistent with gender identity and not solely sex assigned at birth. In developing these recommendations, there was recognition that gender expansiveness can challenge some institutional norms where TGD people live. However, all institutions have the responsibility to provide for the safety and well-being of all persons living therein (Australia, 2015; Corrective Services New South Wales, 2015; Edmo v. Idaho Department of Corrections, 2020; Kosilek v. Massachusetts, 2002; NCCHC, 2015). Sevelius and colleagues (2020) demonstrated correct pronoun usage is gender-affirming for transgender women and correlates with positive mental health and HIV-related health outcomes. If a resident of an institution has legally changed names, the institutional records should be changed to reflect those changes.

Statement 11.7

We recommend institutional administrators, health care professionals, and other officials responsible for making housing decisions for TGD residents consider the individual’s housing preference, gender identity and expression, and safety considerations, rather than solely their anatomy or sex assignment at birth.

The separation of people based on sex assigned at birth, a policy almost universally implemented in institutional settings (Brown and McDuffie, 2009; Routh et al., 2017), can create an inherently dangerous environment (Ledesma & Ford, 2020). Gender diverse people are extremely vulnerable to stigmatization, victimization, neglect, violence, and sexual abuse (Banbury, 2004; Beck, 2014; Jenness and Fenstermaker, 2016; Malkin & DeJong, 2018; Oparah, 2012; Stein et al., 2020). This systemic sex-segregated rigidity often fails to keep TGD people safe and may impede access to gender-affirming health care (Stohr, 2015). As a result, institutions should follow procedures that routinely evaluate the housing needs and preferences of TGD inmates (e.g., Federal Bureau of Prisons, 2016). Likewise, the Prison Rape Elimination Act specifically cites TGD individuals as a vulnerable population and directs prisons nationwide in the US to consider the housing preferences of these inmates (Bureau of Justice Assistance, 2017).

Statement 11.8

We recommend institutional personnel establish housing policies that ensure the safety of transgender and gender diverse residents without segregating or isolating these individuals.

Assigning placement for a TGD resident solely on the basis of their genital anatomy or sex assigned at birth is misguided and places people at risk for physical and/or psychological harm (Scott, 2013; Simopoulos & Khin, 2014; Yona & Katri, 2020). It is well established within carceral settings, transgender individuals are far more likely than other prisoners to be sexually harassed, assaulted, or both (James et al., 2016; Jenness & Fenstermaker, 2016; Malkin & DeJong, 2019). While placement decisions need to address security concerns, shared decision-making that includes the input of the individual should be made on a case-by-case basis (Federal Bureau of Prisons, 2016; Jenness and Smyth, 2011). Some transgender women prefer to reside in a male facility while others feel safer in a female facility. Given the range of gender identities, expression and transition status is so heterogeneous among gender diverse people, keeping residents safe requires flexible decision-making processes (Yona & Katri, 2020). One of the fears older LBGT individuals have living in long-term care is mistreatment by roommates (Jablonski et al., 2013). Consequently, housing in nursing homes and assisted living facilities should consider assigning rooms to elders based on their self-identified gender without regard to birth assignment or surgical history and in collaboration with the TGD patient.

Solitary confinement, sometimes referred to as administrative segregation in carceral facilities, refers to physical isolation of individuals during which they are confined in their cells for approximately twenty-three hours each day. The use of isolation is employed in some carceral facilities as a disciplinary measure as well as a means of protecting prisoners who are considered a risk to themselves or others or who are at risk of sexual assault by other inmates. However, isolating prisoners for safety concerns, if necessary, should be brief, as isolation can cause severe psychological harm and gross disturbances of functioning (Ahalt et al., 2017; Scharff Smith, 2006). National prison standards organizations as well as The United Nations consider isolation longer than 15 days to be torture (NCCHC, 2016; United Nations, 2015).

Statement 11.9

We recommend institutional personnel allow transgender and gender diverse residents the private use of shower and toilet facilities, upon request.

The necessity and importance of privacy is universal irrespective of gender identity. TGD individuals report avoiding public restrooms, limiting the amount they eat and drink so as not to have to use a public facility, often leading to urinary tract infections and kidney-related problems (James et al., 2016). TGD individuals in institutions are often deprived of privacy in bathroom and shower use, which can result in psychological harm and/or physical and sexual abuse (Bartels and Lynch, 2017; Brown, 2014; Cook-Daniels, 2016; Mann, 2006). Similarly, in carceral environments, pat downs, strip searches and body cavity searches should be conducted by staff members of the same sex with the understanding this may not be possible in extreme emergencies. The incidental viewing of searches by other employees should be avoided (Bureau of Justice Assistance, 2017). Private use of shower and toilet facilities for incarcerated transgender people is also required by some laws, including for instance the United States’ federal Prison Rape Elimination Act in the US.

The population of aging/older TGD persons who need to be served by institutions is increasing (Carroll, 2017; Witten & Eyler, 2016). Many long-term care and other facilities catering to the needs of the aging need to take into consideration the needs of their non-cisgender residents (Ettner, 2016; Ettner & Wiley, 2016). Surveys of HCPs working with elders in hospice and palliative care settings as well as other long-term care facilities report patients who identify as TGD often do not get their basic needs met, are discriminated against in their medical care access, or are physically and/or emotionally abused (Stein et al., 2020) A survey of retirement and residential care providers in Australia found little experience with or understanding of the issues facing this population. Indeed, many elderly TGD residents admitted to concealing their gender identity, bowing to the fear of insensitive treatment or frank discrimination (Cartwright et al., 2012; Cook-Daniels, 2016; Grant et al., 2012; Horner et al., 2012; Orel & Fruhauf, 2015).

CHAPTER 12 Hormone Therapy

Transgender and gender diverse (TGD) persons may require medically necessary gender-affirming hormone therapy (GAHT) to achieve changes consistent with their embodiment goals, gender identity, or both (see medically necessary statement in Chapter 2—Global Applicability, Statement 2.1). This chapter describes hormone therapy recommendations for TGD adults and adolescents. Please refer to Chapter 5—Assessment of Adults and Chapter 6—Adolescents for the assessment criteria related to initiation of hormone therapy for adults and adolescents, respectively. A summary of the recommendations and assessment criteria can be found in Appendix D.

Ever since the first World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) was published in 1979 and in subsequent updates of the SOC, including SOC version 7, GAHT has been accepted as medically necessary (Coleman et al., 2012). WPATH endorsed the Endocrine Society’s guidelines for GAHT for TGD persons in 2009 and 2017 (Hembree et al., 2009; Hembree et al., 2017). The European Society for Sexual Medicine has also published a position statement on hormone management in adolescent and adult TGD people (T’Sjoen et al., 2020). When provided under medical supervision, GAHT in adults is safe (Tangpricha & den Heijer, 2017; Safer & Tangpricha, 2019). However, there are some potential long-term risks, and careful monitoring and screening are required to reduce adverse events (Hembree et al., 2017; Rosenthal, 2021).

In general, the goal is to target serum levels of the sex steroids to match the levels associated with the individual’s gender identity, although optimal target ranges have not been established (Hembree et al., 2017). Health care professionals (HCPs) can use serum testosterone and/or estradiol levels to monitor most sex steroid treatments. However, conjugated estrogens or synthetic estrogen use cannot be monitored. The assumption that the estrone/estradiol ratio should be monitored was not supported in a recent cohort study as there was no relationship between estrone concentration and change in body fat or breast development seen in a European cohort of 212 adult transgender women during a 1-year follow-up of hormone treatment (Tebbens et al., 2021). This study demonstrated higher estrone concentrations or higher estrone/estradiol ratios are not associated with antagonistic effects on feminization (fat percentage and breast development) (Tebbens et al., 2021). Thus, monitoring of the estrone to estradiol ratio is not supported by the current published evidence. Previously used conjugated estrogens have been abandoned in favor of bioidentical estrogens. Even if several studies have shown a significantly greater risk of thromboembolic and cardiovascular complications with the use of oral conjugated estrogens compared with oral estradiol in postmenopausal women, no randomized controlled trials have taken place, either in postmenopausal women or in transgender people undergoing estrogen treatment (Smith et al., 2014).

The approach to GAHT differs and depends on the developmental stage of the individual at the time of initiation of hormone therapy as well as their treatment goals. Hormone therapy is not recommended for children who have not begun endogenous puberty. In eligible youth (as per Chapter 6—Adolescents) who have reached the early stages of puberty, the focus is usually to delay further pubertal progression with gonadotropin releasing hormone agonists (GnRHas) until an appropriate time when GAHT can be introduced. In these cases, pubertal suppression is considered medically necessary. Eligible adults may initiate GAHT if they fulfill the criteria as per Chapter 5—Assessment for Adults. In addition, health care providers should discuss fertility goals and fertility preservation procedures prior to initiating GAHT. See Chapter 16—Reproductive Health.

GAHT with feminine embodiment goals typically consists of estrogen and an androgen-lowering medication (Hembree et al., 2017). Although there are anecdotal reports of progesterone use for breast development and mood management, there is currently insufficient evidence the potential benefits of progesterone administration outweigh the potential risks (Iwamoto, T’Sjoen et al., 2019). Masculinizing GAHT typically consists of testosterone. Both WPATH and the Endocrine Society recommend monitoring levels of sex hormones. While GAHT is customized to meet the individual needs of the TGD person, typically hormone levels are maintained at a concentration sufficient to support good bone health and are not supraphysiologic (Hembree et al., 2017; Rosen et al., 2019).

In most cases, GAHT is maintained throughout life. It is not known if doses of GAHT should be reduced in older TGD people. Discontinuation of hormone therapy may result in bone loss in TGD individuals and will definitely do so in individuals whose gonads have been removed (Wiepjes et al., 2020). Routine primary care should also be performed (see Chapter 15—Primary Care). Epidemiology studies have reported an increased incidence of cardiovascular disease and venous thromboembolism (VTE) in TGD people receiving estrogen, most notably in older people and with different preparations of GAHT (Irwig, 2018; Maraka et al., 2017). TGD individuals treated with testosterone may also have increased adverse cardiovascular risks and events, such as increased myocardial infarction, blood pressure, decreased HDL-cholesterol, and excess weight (Alzahrani et al., 2019; Irwig, 2018; Kyinn et al., 2021). Health care professionals (HCPs) should discuss lifestyle and pharmacologic therapy with patients who are at the highest risk of developing cardiovascular disease (see Chapter 15—Primary Care). Polycythemia is another disorder that may present in TGD people taking testosterone (Antun et al., 2020). Therefore, it is important to continuously monitor for the development of conditions that can be exacerbated by GAHT throughout life (Hembree et al., 2017).

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

CHAPTER 13 Surgery and Postoperative Care

Medically necessary gender-affirmation surgery (GAS) refers to a constellation of procedures designed to align a person’s body with their gender identity (see Chapter 2—Global Applicability for medical necessity, Statement 2.1). This chapter describes surgery and postoperative care recommendations for TGD adults and adolescents. Please refer to Chapter 5—Assessment of Adults and Chapter 6—Adolescents for the assessment criteria related to surgery for adults and adolescents, respectively. A summary of the recommendations and assessment criteria can be found in Appendix D.

Recognizing the diverse and heterogeneous community of individuals who identify as transgender and gender diverse (TGD), gender-affirming surgical interventions may be categorized along a spectrum of procedures for individuals assigned male at birth (AMAB) and assigned female at birth (AFAB).

In appropriately selected TGD individuals, the current literature supports the benefits of GAS. While complications following GAS occur, many are either minor or can be treated with local care on an outpatient basis (Canner et al., 2018; Gaither et al., 2018; Morrison et al., 2016). In addition, complication rates are consistent with those of similar procedures performed for different diagnoses (i.e., non-gender-affirming procedures).

In individuals AFAB, gender-affirming chest surgery or “top surgery” (i.e. “subcutaneous mastectomy”) has been studied in prospective (Agarwal et al., 2018; Frederick et al., 2017; Top & Balta, 2017; van de Grift, Elaut et al., 2017; van de Grift et al., 2016), retrospective (Bertrand et al., 2017; Claes et al., 2018; Esmonde et al., 2019; Lo Russo et al., 2017; Marinkovic & Newfield, 2017; Poudrier et al., 2019; Wolter et al., 2015; Wolter et al., 2018), and cross-sectional cohort studies (Olson-Kennedy, Warus et al., 2018; Owen-Smith et al., 2018; van de Grift, Elaut et al., 2018; van de Grift, Elfering et al., 2018). The efficacy of top surgery has been demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance. Additionally, rates of regret remain very low, varying from 0 to 4%. While the effect of top surgery on additional outcome measures such as depression, anxiety, and sexual function also demonstrated a benefit, the studies were of insufficient strength to draw definitive conclusions. Although further investigation is needed to draw more robust conclusions, the evidence demonstrates top surgery to be a safe and effective intervention.

In individuals AMAB, fewer studies have been published regarding gender-affirming breast surgery (“breast augmentation”) and include 2 prospective (Weigert et al., 2013; Zavlin et al., 2018), 1 retrospective cohort (Fakin et al., 2019), and 3 cross-sectional cohort studies (Kanhai et al., 2000; Owen-Smith et al., 2018; van de Grift, Elaut et al., 2018). All the studies reported a consistent and direct improvement in patient satisfaction, including general satisfaction, body image satisfaction, and body image following surgery. Owen-Smith et al. (2018) demonstrated a positive trend toward improvement in both depression and anxiety scores with increasing levels of gender-affirming interventions. However, there was no statistical comparison between individuals who underwent top surgery and any other group.

Gender-affirming vaginoplasty is one of the most frequently reported gender-affirming surgical interventions; 8 prospective (Buncamper et al., 2017; Cardoso da Silva et al., 2016; Kanhai, 2016; Manero Vazquez et al., 2018; Papadopulos, Zavlin et al., 2017; Tavakkoli Tabassi et al., 2015; Wei et al., 2018; Zavlin et al., 2018), 15 retrospective cohort (Bouman, van der Sluis et al., 2016; Buncamper et al., 2015; Hess et al., 2016; Jiang et al., 2018; LeBreton et al., 2017; Manrique et al., 2018; Massie et al., 2018; Morrison et al., 2015; Papadopulos, Lelle et al., 2017; Raigosa et al., 2015; Salgado et al., 2018; Seyed-Forootan et al., 2018; Sigurjonsson et al., 2017; Simonsen et al., 2016; Thalaivirithan et al., 2018), and 3 cross-sectional cohort studies have recently been reported (Castellano et al., 2015; Owen-Smith et al., 2018; van de Grift, Elaut et al., 2018).

Although different assessment measurements were used, the results from all studies consistently reported both a high level of patient satisfaction (78–100%) as well as satisfaction with sexual function (75–100%). This was especially evident when using more recent surgical techniques. Gender-affirming vaginoplasty was also associated with a low rate of complications and a low incidence of regret (0–8%).

Recent literature reflects the increased clinical interest in metoidioplasty and phalloplasty as reflected by 3 prospective cohort (Garaffa et al., 2010; Stojanovic et al., 2017; Vukadinovic et al., 2014), 6 retrospective cohort (Cohanzad, 2016; Garcia et al., 2014; Simonsen et al., 2016; van de Grift, Pigot et al., 2017; van der Sluis et al., 2017; Zhang et al., 2015), and 4 cross-sectional studies (Castellano et al., 2015; Owen-Smith et al., 2018; van de Grift, Elaut et al., 2018; Wierckx, Van Caenegem et al., 2011), which reviewed the risks and benefits of these procedures.

In terms of urinary function, between 75 and 100% of study participants were able to void while standing. In terms of sexual function, between 77 and 95% of study participants reported satisfaction with their sexual function. Most of these studies report high overall levels of postoperative satisfaction (range 83–100%), with higher rates of satisfaction in studies involving newer surgical techniques. Two prospective and two retrospective cohort studies specifically assessed regret following surgery and found no transgender men experienced regret. While study limitations were identified, the reported results were consistent and direct.

In recent years, facial GAS (FGAS) has received increased attention, and current literature supports its benefits. Eight recent publications include 1 prospective cohort (Morrison et al., 2020), 5 retrospective cohort (Bellinga et al., 2017; Capitán et al., 2014; Noureai et al., 2007; Raffaini et al., 2016; Simon et al., 2022), and 2 cross-sectional studies (Ainsworth & Spiegel, 2010; van de Grift, Elaut et al., 2018). All 8 studies clearly demonstrated individuals were very satisfied with their surgical results (between 72% and 100% of individuals). Additionally, individuals were significantly more satisfied with the appearance of their face compared with individuals who had not undergone surgery. One prospective, international, multicenter, cohort study found facial GAS significantly improves both mid- and long-term quality of life (Morrison et al., 2020). The results were direct and consistent, but somewhat imprecise because of certain study limitations. While gender-affirming facial surgery for AFAB individuals is an emerging field, current limited data points toward equal benefits in select patients. Future studies are recommended.

Additional procedures and/or interventions such as hair removal (prior to facial and/or genital surgery) may be required as part of the preoperative process. See Chapter 15—Primary Care. Furthermore, consultation with pelvic floor physical therapy may be important (or required) both before and after surgery.

Representative surgical interventions include (for complete list, see appendix E and the end of this chapter):

AMAB: facial feminization surgery (including chondrolaryngoplasty/vocal cord surgery), gender-affirming breast surgery, body contouring procedures, orchiectomy, vagino/vulvoplasty (with/without depth), aesthetic procedures, and procedures designed to prepare individuals for surgery (i.e., hair removal).

AFAB: facial masculinization surgery, gender-affirming chest surgery, hysterectomy/oophorectomy, metoidioplasty (including placement of testicular prosthesis), phalloplasty (including placement of testicular/penile prostheses), body contouring procedures, aesthetic procedures, and procedures designed to prepare individuals for surgery (i.e., hair removal).

It is important surgeons understand the indication(s) and the timing for GAS. This is especially important when caring for adolescents (see Chapter 6—Adolescents).

It is important the surgeon and the patient participate in a shared decision-making approach that includes 1) a multidisciplinary approach; 2) an understanding of the patient’s goals and expectations; 3) a discussion regarding the surgical options and associated risks and benefits; and 4) an informed plan for aftercare (see Chapter 5—Assessment for Adults). These recommendations are designed to facilitate an individualized approach to care.

Appropriate aftercare is essential for optimizing outcomes (Buncamper et al., 2015; Lawrence, 2003), and it is important patients are informed about postoperative needs (including local wound care, activity restrictions, time off from work or school, etc.). In addition, it is important the surgeon is available to provide and facilitate postoperative care, refer to specialty services, or both as needed. This may include the need for ongoing support (i.e., both from the caregiver as well as the primary care provider, mental health professionals (MHPs), or both), as well as the need for routine primary care (i.e., breast/chest cancer screening, urologic/gynecologic care, etc.).

With the increase both in public interest and in the number of gender-affirming surgical procedures (Canner et al., 2018; Ross, 2017; Shen et al., 2019), additional training, tracking of outcomes, and continuing medical education for surgeons are necessary (Schechter et al., 2017).

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 13.1

We recommend surgeons who perform gender-affirming surgical procedures have the following credentials:

1. Training and documented supervision in gender-affirming procedures;

2. Maintenance of an active practice in gender-affirming surgical procedures;

3. Knowledge about gender diverse identities and expressions;

4. Continuing education in the field of gender-affirmation surgery;

5. Tracking of surgical outcomes.

Surgeons offering GAS may have a variety of surgical specialty training and backgrounds. The most common surgical specialties include plastic surgery, urology, gynecology, otolaryngology and oro-maxillofacial surgery (Jazayeri et al., 2021). Consistent with other surgical domains, we recommend only surgeons who are certified or eligible to be certified by their respective national professional boards offer GAS. Furthermore, it is recommended surgeons offering care for TGD people have received documented training in gender-affirming procedures and principles of gender-affirming care (Schechter et al., 2017; Schechter & Schechter, 2019). The latter includes, but is not limited, to knowledge about gender diverse identities and expressions, and how those affect patient goals, expectations, and outcomes. It is important surgeons offering GAS be familiar with the available procedures and can provide informed consent. If surgeons do not offer a requested procedure, they may offer a referral for a second opinion. Surgeons offering GAS are expected to participate in continuing education activities in the field of GAS (i.e., meetings, conferences, seminars, etc.) to maintain current knowledge. We further recommend surgical outcomes be tracked and communicated to the patients as part of the informed consent (Schechter et al., 2017).

In addition, hospitals, institutions, and physician offices that offer GAS need to be knowledgeable regarding cultural competencies (i.e., language, terminology, etc.). This may require ongoing and regular staff education.

Statement 13.2

We recommend surgeons assess transgender and gender diverse people for risk factors associated with breast cancer prior to breast augmentation or mastectomy.

Prior to breast augmentation or mastectomy, individuals need to be informed about and assessed for breast cancer risk factors, including genetic mutations (i.e., BRCA1, BRCA2), family history, age, radiation, exposure to estrogen, and the amount of breast tissue anticipated to remain after surgery (Brown, Lourenco et al., 2021; Brown & Jones, 2015; Colebunders et al., 2014; Gooren et al., 2013; Salibian et al., 2021; Weyers et al., 2010). Breast cancer screening balances the identification of cancer with the selection of appropriate imaging, tests, and procedures. Currently, evidence-based screening guidelines specific for TGD individuals do not exist (Salibian et al., 2021), however, recent guidelines have been proposed by the American College of Radiology (Brown, Lourenco et al., 2021). Because the risk of cancer in individuals seeking gender-affirming breast augmentation or mastectomy is similar to that in the general population (even in the setting of hormone use), existing cancer screening guidelines need to be followed (Brown & Jones, 2015; Gooren et al., 2013; Salibian et al., 2021; Weyers et al., 2010). Professionals need to be familiar with updates to these guidelines as they are subject to change. Individuals who undergo gender-affirming surgery of the chest should have ongoing breast cancer surveillance, which should be overseen by their primary care providers.

Statement 13.3

We recommend surgeons inform transgender and gender diverse people undergoing gender-affirming surgical procedures about aftercare requirements, travel and accommodations, and the importance of postoperative follow-up during the preoperative process.

Details about the timing, technique, and duration of the aftercare requirements are shared with patients in the preoperative period such that appropriate planning may be undertaken. This includes a discussion regarding the anticipated staging of surgical procedures (and associated travel requirements). Given the small number of surgeons who specialize in GAS, it is common for patients to travel for their procedures. Prior to surgery, surgeons should provide patients with a postoperative follow-up schedule. The surgeon should discuss the duration of the patient’s travel dates, the anticipated inpatient versus outpatient stay, and the potential need for flexibility in travel arrangements (especially if complications occur). Given the complexity and cost of travel and lodging, changes in the care plan should be shared with the patient as early as possible. Surgeons should facilitate continuity of care with a local provider upon returning home.

Aftercare and postsurgical follow-up are important. Gender-affirming surgical procedures often have specific aftercare requirements, such as postsurgery resources (stable, safe housing; resources for travel and follow-up care), instructions in health-positive habits (e.g., personal hygiene, healthy living, prevention of urinary tract infections (UTIs) and sexually-transmitted infections (STIs) (Wierckx, Van Caenegem et al., 2011)), postsurgery precautions or limitations on activities of daily life (e.g., bathing, physical activity, exercise, nutritional guidance, resumption of sexual activity) (Capitán et al., 2020), postsurgery resumption of medications (i.e., anticoagulants, hormones, etc.), and detailed postsurgery self-care activities (e.g., postvaginoplasty dilation and douching regimens, activation of a penile prosthesis, strategies to optimize postphalloplasty urination, recommendations for hair transplant care) (Capitán et al., 2017; Falcone et al., 2018; Garcia, 2018; Hoebeke et al., 2005). Some aspects of postsurgery self-care activities may be introduced prior to surgery and are reinforced after surgery (Falcone et al., 2018). As issues such as wound disruptions, difficulty with dilation, and UTIs may occur (Dy et al., 2019), the follow-up period provides an opportunity to intervene, mitigate, and prevent complications (Buncamper et al., 2016; Garcia, 2021).

Statement 13.4

We recommend surgeons confirm reproductive options have been discussed prior to gonadectomy in transgender and gender diverse people.

Infertility is often a consequence of both gender-affirming hormone therapy (temporary) and GAS (permanent), and fertility preservation is discussed prior to medical interventions, surgical interventions, or both (Defreyne, van Schuylenbergh et al., 2020; Jahromi et al., 2021; Jones et al., 2021). Surgical interventions that alter reproductive anatomy or function may limit future reproductive options to varying degrees (Nahata et al., 2019). It is thus critical to discuss infertility risk and fertility preservation (FP) options with transgender individuals and their families prior to initiating any of these interventions and on an ongoing basis thereafter (Hembree et al., 2017).

For specific recommendations regarding reproductive options, see Chapter 16—Reproductive Health.

Statement 13.5

We suggest surgeons consider offering gonadectomy to eligible* transgender and gender diverse adults when there is evidence they have tolerated a minimum of 6 months of hormone therapy (unless hormone replacement therapy or gonadal suppression is not clinically indicated or the procedure is inconsistent with the patient's desires, goals, or expressions of individual gender identity). For supporting text, see Statement 13.6.

Statement 13.6

We suggest health care professionals consider gender-affirming genital procedures in eligible* transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result unless hormone therapy is either not desired or is medically contraindicated).

GAHT leads to anatomical, physiological, and psychological changes. The onset of the anatomic effects (e.g., clitoral growth, vaginal mucosal atrophy) may begin early after the initiation of therapy, and the peak effect is expected at 1–2 years (T'Sjoen et al., 2019). Depending upon the surgical result required, a period of hormone treatment may be required (e.g., sufficient clitoral virilization prior to metoidioplasty/phalloplasty) or preferred for psychological reasons, anatomical reasons, or both (breast growth and skin expansion prior to breast augmentation, softening of skin and changes in facial fat distribution prior to facial GAS) (de Blok et al., 2021).

For individuals who are not taking hormones prior to surgical interventions, it is important surgeons review the impact of this on the proposed surgery.

For individuals undergoing gonadectomy who are not taking hormones, a plan for hormone replacement can be developed with their prescribing professional prior to surgery.

Statement 13.7

We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.

Substantial evidence (i.e., observational studies (Monstrey et al., 2001; Stojanovic et al., 2017), literature reviews and expert opinions (Esteva de Antonio et al., 2013; Frey et al., 2017; Hadj-Moussa et al., 2019; Pan & Honig, 2018), established guidelines (Byne et al., 2018; Chen, Fuqua et al., 2016; Hembree et al., 2017; Karasic & Fraser, 2018; Klein, Paradise et al., 2018; Weissler et al., 2018), and a thematic content analysis (Gerritse et al., 2018), support the importance of a multidisciplinary (i.e., medical, mental health, and surgery) approach to transgender health care.

A multidisciplinary approach is especially important in managing mental health issues if these are experienced by a TGD person undergoing GAS (de Freitas et al., 2020; Dhejne et al., 2016; van der Miesen et al., 2016). In addition, primary care providers and medical specialists can help support decisions regarding the timing of surgery, surgical outcomes and expectations, perioperative hormone management, and optimization of medical conditions (Elamin et al., 2010; Hembree et al., 2017).

For specific recommendations regarding presurgical assessment in adolescents, see Chapter 6—Adolescents.

Statement 13.8

We recommend surgeons consult a comprehensive, multidisciplinary team of professionals in the field of transgender health when eligible* transgender and gender diverse people request individually customized (previously termed “non-standard”) surgeries as part of a gender-affirming surgical intervention.

Gender identities may present along a spectrum, and the expression of a person’s identity may vary quite widely amongst individuals (Beek et al., 2015; Koehler et al., 2018). While the overall goal of a particular procedure usually includes reduction of gender dysphoria (van de Grift, Elaut et al., 2017) or achieving gender congruence, gender diverse presentations may lead to individually customized surgical requests some may consider “non-standard” (Beek et al., 2015; Bizic et al., 2018). Individually customized surgical requests can be defined as 1) a procedure that alters an individual’s gender expression without necessarily aiming to express an alternative, binary gender; 2) the “non-standard” combination of well-established procedures; or 3) both.

This is designed to help counsel and inform the patient as well as to ensure their goals can be achieved. The patient and their surgeon need to work together to ensure the patient’s expectations are realistic and achievable, and the proposed interventions are safe and technically feasible. The patient and their surgical team need to engage in a shared decision-making process (Cavanaugh et al., 2016). This informed consent process needs to address the irreversibility of some procedures, the newer nature of some procedures, and the limited information available about the long-term outcomes of some procedures.

Statement 13.9

We suggest surgeons caring for transgender men and gender diverse people who have undergone metoidioplasty/phalloplasty encourage lifelong urological follow-up.

Postoperative complications following metoidioplasty/phalloplasty comprise the urinary tract and sexual function (Kang et al., 2019; Monstrey et al., 2009; Santucci, 2018; Schardein et al., 2019). Reported urethral complications (related to urethral lengthening) include urethral strictures 35–58%, urethral fistulae 15–70% (Monstrey et al., 2009; Santucci, 2018; Schardein et al., 2019), diverticulae, mucocele due to vaginal remnant, and hair growth within the neourethra (Berli et al., 2021; Veerman et al., 2020). Complications related to sexual function include limited to absent tactile and/or erogenous sensation, difficulties with orgasm function, and complications with penile prosthetics (Kang et al., 2019; Santucci, 2018). Penile prosthesis-related complications are estimated to involve infection (incidence 8–12%), malfunction, urethral erosion, skin extrusion, and dislocation of its bone fixation (Falcone et al., 2018; Kang et al., 2019; Morrison et al., 2016). Although most urethral and prosthetic complications occur in the immediate and intermediate postoperative period, complications can occur at any time. Early detection may reduce morbidity (e.g., urethral strictures resulting in fistulae, pending erosion of a penile prosthetic leading to infection and requiring total explant) (Blecher et al., 2019).

Routine follow-up to assess for early evidence of urethral stricture (or other urinary issues) includes bladder ultrasound measurement of postvoid residual volume (to screen for and stage neourethral stricture), fluoroscopic urethrography (to identify and stage neourethral strictures, fistulae, and diverticulae), and cystourethroscopy to examine the urethra and bladder. TGD men may also have routine urologic issues that need not be related to gender transition (urinary calculi, hematuria, and genitourinary malignancies; fertility preservation) (Sterling & Garcia, 2020a, 2020b).

Statement 13.10

We recommend surgeons caring for transgender women and gender diverse people who have undergone vaginoplasty encourage follow-up with their primary surgeon, primary care physician, or gynecologist.

Vaginoplasty is a safe procedure (Hontscharuk, Alba, Hamidian Jahromi et al., 2021). While complications may occur, most are self-limited or can be treated with minor interventions (Hontscharuk, Alba, Hamidian Jahromi et al., 2021). Minor complications include issues such as the formation of granulation tissue, intravaginal hair growth, delayed wound healing or wound disruption (or both), aesthetic concerns, and introital stenosis (Ferrando, 2020; Kloer et al., 2021). While these complications are usually self-limited, they may impact patient well-being after surgery. Additionally, these issues may go either undiagnosed or may be misdiagnosed if patients are not able to access care provided by professionals with expertise in the field of transgender health. We recommend patients be followed by their primary surgeon in person and at regular intervals—for example at two weeks, three months, six months, and one year after surgery—although more follow-up may be indicated for some individuals.

Additional gynecologic care is conducted throughout the TGD person’s lifetime and can be managed in many settings. A speculum exam to check for granulation tissue, hair, and lesions can be performed by the primary care provider, gynecologist, or GAS surgeon and may be necessary outside of the immediate postoperative period (Grimstad, McLaren et al., 2021; Suchak et al., 2015; van der Sluis et al., 2020). After confirmation by laboratory testing, UTIs, STIs, and other fluctuations in the vaginal microbiome may be treated following relevant guidelines formulated for cisgender populations (Hooton, 2012; Sherrard et al., 2018). Manual prostate checks are performed based on relevant guidelines formulated for cisgender populations via the vaginal canal, as the prostate is located on the anterior wall of the vagina (Carter et al., 2013).

Other complications include issues such as stenosis of the neovaginal canal, rectovaginal fistulae, and inflammation (intestinal vaginoplasty) (Bustos et al., 2021). These require a combination of nonsurgical and surgical treatment with consultation and possible referral back to the primary surgeon with other surgical consultants (i.e., colorectal surgeon), if required. In addition, as pelvic floor dysfunction may affect 30–40% of patients both prior to and following vaginoplasty, the availability of pelvic floor physical therapists is an important adjunct in the postoperative period (Jiang et al., 2019).

Statement 13.11

We recommend patients who regret their gender-related surgical intervention be managed by an expert multidisciplinary team.

The percentage of individuals who regret their GAS is very low (between 0.3% and 3.8%) (De Cuypere & Vercruysse, 2009; Defreyne, Motmans et al., 2017; Hadj-Moussa et al., 2019; Hadj-Moussa, Agarwal et al., 2018; Hadj-Moussa, Ohl et al., 2018; Landén et al., 1998; Narayan et al., 2021; van de Grift, Elaut et al., 2018; Wiepjes et al., 2018). The highest incidence of regret was reported at a time when surgical techniques were less refined, the role of multidisciplinary care was less established, and the Standards of Care did not exist or were not widely known (Landén et al., 1998). Regret can be temporarily or permanent and may be classified as (Narayan et al., 2021) social regret (caused by difficulties in familial, religious, social, or professional life), medical regret (due to long-term medical complications, disappointment in surgical results or inadequate preoperative decision-making), and true gender-related regret (mostly based on patient experienced misdiagnosis, insufficient exploration of gender identity, or both). This classification is in accordance with previously discussed positive and negative predictive factors (De Cuypere & Vercruysse, 2009; Gils & Brewaeys, 2007; Pfäfflin & Junge, 1998).

A multidisciplinary team can help identify the etiology of regret as well as the temporal stability of the surgical request (Narayan et al., 2021). Following this evaluation and in consideration of the individual’s circumstances, medical and/or surgical interventions with the intent of either continuing transition or performing surgical procedures to return anatomy to that of the sex assigned at birth may be indicated. For further information see Chapter 5—Assessment of Adults.

*For eligibility criteria for adolescents and adults, please refer to the Assessment for Adults and Adolescent chapters and Appendix D

GENDER-AFFIRMING SURGICAL PROCEDURES

As the field’s understanding of the many facets of gender incongruence expands, and as technology develops which allows for additional treatments, it is imperative to understand this list is not intended to be exhaustive. This is particularly important given the often lengthy time periods between updates to the SOC, during which evolutions in understanding and treatment modalities may occur.

CHAPTER 14 Voice and Communication

Human beings engage in communication practices not only to exchange ideas about the outside world, but also to present themselves as sociocultural beings and to negotiate forms of address, referral and treatment by others that allow them to feel safe and respected (Azul et al., 2022). The human voice is widely regarded as one of the key modalities that contributes to the communication of gender as one of the dimensions of human diversity. However, other aspects and ways of communicating (e.g., articulation, word choice, gesture, listener perceptions and attributions) need to be considered as well (Azul, 2015; Azul & Hancock, 2020). Throughout this chapter “voice and communication” is used as a phrase encompassing the meaning-making practices in which each of the participants of a social encounter engage according to their own needs, wishes, identifications, and capacities.

While a binary understanding of gender has dominated the research literature in this area, the approach recommended in this chapter implies a broadly inclusive view of gender identification (e.g., trans feminine, trans masculine, gender fluid, nonbinary, genderqueer, agender) and the understanding that gender does not exist in isolation, but intersects with other aspects of human diversity (e.g., First Nation status, ethnicity/race, sexuality, dis/ability, faith/religion/spirituality). The recommendations in this chapter apply to all transgender and gender diverse (TGD) people who are seeking professional voice and communication support, including children, adolescents, younger and older adults, and people who wish to transition or detransition, irrespective of their intervention choices.

Not every TGD person experiences challenges with or wants professional support for their voice and communication, but those who do often encounter barriers in accessing care. Although the percentages vary by country and TGD subpopulation, the statistics support the concern TGD people are not able to access voice and communication services when and how they desire (Eyssel et al., 2017; James et al., 2016; Oğuz et al., 2021; Södersten et al., 2015; Veale et al., 2019). In these studies, the percentage of TGD people wishing to receive voice and communication training or voice surgery is generally higher than the percentage of people who have undergone these interventions. With few exceptions, access to voice training is usually greater than access to voice surgery. Groups of TGD people who are further marginalized in their societies, such as TGD people of marginalized race/ethnicity, experience discrimination and limited access to care at even greater rates (James et al., 2016; Xavier et al., 2005).

Cost, not knowing where to access services, and services not being available are amongst the most common barriers cited by research participants. According to studies in the US (Hancock & Downs, 2021; Kennedy & Thibeault, 2020), Turkey (Oğuz et al., 2021), and Aotearoa/New Zealand (Veale et al., 2019), lack of accurate information about options for voice and communication services among TGD people is a significant and ubiquitous barrier to care. Notably, in Sweden, all TGD people are offered support for their voice and communication when a diagnosis of gender incongruence is made (Södersten et al., 2015). Additionally, cultural responsiveness of providers is only slowly improving (Hancock & Haskin, 2015; Jakomin et al., 2020; Matthews et al., 2020; Sawyer et al., 2014). Hancock and Downs (2021) have conducted preliminary work to identify specific barriers to voice and communication services and develop effective means for eliminating them.

This chapter is intended to provide guidance for health care professionals (HCPs) to support and foster well-being in all TGD people who are experiencing challenges or distress regarding their own voice and communication practices and/or regarding responses and attributions they receive from others (Azul et al., 2022).

A number of different approaches TGD people can use to modify their voice and communication, either individually or in combination include self-initiated change, which may be supported by resources TGD people use to guide their voice use and communication practice; behavioral change supported by voice and communication specialists (hereafter referred to as “voice and communication training”); and change as a result of androgen hormonal treatment and/or laryngeal surgery. The currently existing research evidence does not include self-initiated change, but is focused on the latter three approaches.

A “voice and communication specialist” is someone who has knowledge regarding the ongoing and dynamic agency of speaker and listener practices, relevant professional interventions including behavioral, hormonal, and surgical, and relevant processes related to biophysiology, sociocultural meaning-making, and external material forces (Azul & Hancock, 2020). This specialist is capable of conducting appropriate assessments to inform the TGD person’s choice and support the exploration of goals and intervention options by providing guidance in a culturally responsive, person-centered approach. This specialist has knowledge and skills in behavioral voice and communication intervention approaches.

Practices amenable to behavioral change include: speaking and singing voice, mindfulness, relaxation, respiration, pitch and pitch range, voice quality, resonance/timbre, loudness, projection, facial expression, gesture, posture, movement, introducing self to others, describing identifications and requesting culturally responsive treatment and forms of address by others, assertive and resilient responses to misattributions, practicing implementation of voice use and communication practices with different people and in different everyday settings (e.g., Hancock & Siegfriedt, 2020; Mills & Stoneham, 2017).

Voice and communication services are offered as part of a complete and coordinated approach to health, including support for medical, psychological, and social needs (Södersten et al., 2015); however, there are no prerequisites (e.g., hormone use, pursuit of surgeries, or duration living in a gender role). The overall purposes of voice and communication support for TGD people are:

• To educate clients about the factors that influence functional voice and communication practices and the communication of the speaker’s identity (speaker, listener, professional practices, external material, biophysiological, and sociocultural factors);

• To enable clients to communicate their sense of sociocultural belonging (e.g., in terms of gender) in everyday encounters in a manner that matches the client’s desired self-presentation and to develop, maintain and habituate voices, vocal qualities, and communication practices that support the clients’ goals in a manner that does not harm the voice production mechanism;

• To provide training in functional voice production for clients who present with restrictions of voice function (e.g., as a result of overextending their voice production mechanism);

• To support clients with developing the capacity to assertively negotiate desired forms of address and referral from others (e.g., names, pronouns, titles) and to respond to misattributions in a skillful manner that contributes to increasing and maintaining the client’s well-being;

• To support clients to develop the problem-solving skills needed to manage anxiety, stress, and dysphoria in collaboration with mental health providers; and to navigate barriers to practice or real-life use of one’s preferred voice and communication.

• To provide, or refer clients to, supportive resources that facilitate developing voice and communication skills, vocal awareness, and well-being.

• To refer clients to, or collaborate with, other specialists such as mental health practitioners, laryngeal surgeons, and endocrinologists, who may be more equipped to meet the specific needs of that client. This may be especially relevant in cases where clients face unique challenges due to multiple barriers to their health and well-being or when the client wishes to pursue laryngeal surgery or hormone therapy.

Two types of laryngeal surgeries are relevant for TGD populations: those for raising voice pitch (e.g., glottoplasty with retro-displacement of the anterior commissure, cricothyroid approximation (CTA), feminization laryngoplasty, laser-assisted voice adjustment (LAVA)) (Anderson, 2007; Anderson, 2014; Brown, 2000; Casado, 2017; Geneid, 2015; Gross, 1999; Kelly et al., 2018; Kanagalingam, 2005; Kim, 2017; Kim, 2020; Kocak, 2010; Kunachak, 2000; Mastronikolis, 2013; Mastronikolis et al., 2013; Matai, 2003; Meister, 2017; Mora, 2018; Neumann, 2004; Nuyen et al., 2022; Orloff, 2006; Pickuth, 2000; Remacle, 2011; Thomas & MacMillan, 2013; Tschan, 2016; Van Borsel, 2008; Wagner, 2003; Wendler, 1990; Yang, 2002) and for lowering voice pitch (e.g., thyroplasty type III, vocal fold injection augmentation) (Bultynck et al, 2020; Isshiki et al., 1983; Kojima, et al. 2008; Webb et al., 2021). Reported acoustic benefits of pitch-raising surgery include increased voice pitch (average frequency (f_o)) and increased Min f_o(the lowest frequency in physiological voice range). TGD people’s self-rating ratings show general satisfaction with voice postsurgery, although individuals who are interested in more comprehensive changes to vocal self-presentation may need to engage in behavioral interventions with a voice and communication specialist in addition to laryngeal surgery (Brown, Chang et al. 2021; Kelly et al., 2018; Nuyen et al., 2022). Potential harms of pitch-raising surgery can be assessed and addressed in voice training by a voice and communication specialist. Reported harms of pitch-raising surgery include voice problems such as dysphonia, weak voice, restricted speaking voice range especially upper range (lowered Max f_o, in the physiological voice range), hoarseness, vocal instability, and lowering of frequency values over time (Kelly et al., 2018; Song & Jiang, 2017), although the rate of these outcomes is inconsistent.

Research on pitch-lowering surgeries is limited. However, studies including eight TGD people who elected to undergo thyroplasty type III after continued dissatisfaction with hormonal treatment (Bultynck et al., 2020) and one person who received injection augmentation after testosterone therapy and voice training (Webb et al., 2020), reported statistically significant lowering of fundamental frequency, perceived as pitch.

Estrogen treatment in TGD people has not been associated with measurable voice changes (Mészáros et al., 2005), while testosterone treatment in TGD people has been found to result in both desired and undesired changes in gender- and function-related aspects of voice production (Azul, 2015; Azul et al., 2017, 2018, 2020; Azul & Neuschaefer-Rube, 2019; Cosyns et al., 2014; Damrose, 2008; Deuster, Di Vicenzo et al., 2016; Deuster, Matulat et al. 2016; Hancock et al., 2017; Irwig et al., 2017; Nygren et al., 2016; Van Borsel et al., 2000; Yanagi et al., 2015; Ziegler et al., 2018). Desired changes associated with testosterone treatment include lowered voice pitch, increased male attributions to voice, and increased satisfaction with voice. Reported dissatisfaction with testosterone treatment include lack of or insufficient lowering of voice pitch, dysphonia, weak voice, restricted singing pitch range, and vocal instability. These areas can be assessed and addressed in voice training by a voice and communication specialist.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 14.1.

We recommend voice and communication specialists assess current and desired vocal and communication function of transgender and gender diverse people and develop appropriate intervention plans for those dissatisfied with their voice and communication.

Voice and communication specialists may assess satisfaction with the presentation of sociocultural positionings in communicative encounters, including gender and other intersecting identifications, taking into consideration that these may or may not be static over time; attributions received from others, and how these relate to the individual’s identifications, wishes, and well-being; ratings of voice and speech naturalness; and voice and communication function in relation to vocal demands. Assessments may vary in nature (e.g., client-reported outcome measures, perceptual, acoustic, aerodynamic, endoscopic) according to their purpose (Davies et al., 2015; Leyns et al., 2021; Oates & Dacakis, 1983). For example, laryngeal visualization is used when individuals present with a concomitant voice problem, (e.g., muscle tension dysphonia) (Palmer et al., 2011) or experience voice difficulties, which may or may not be secondary to medical gender-affirming interventions of androgen therapy or laryngeal surgery (Azul et al., 2017).

Voice and communication specialists inform intervention-seeking TGD people who are dissatisfied with their voice and communication about available interventions that support TGD people with their voice, communication, and well-being. The nature of each option, including potential outcomes and permanence, is presented objectively to provide the TGD person respect and autonomy in decision-making. Appropriate intervention plans are individualized and feasible and should be inclusive of any professional services available. Goals may evolve over the course of the support period as the TGD person explores modifications to voice and communication, assesses their satisfaction with achieved change and refines their goals.

Statement 14.2.

We recommend voice and communication specialists working with transgender and gender diverse people receive specific education to develop expertise in supporting vocal functioning, communication, and well-being in this population.

Academic and licensing credentials of voice and communication specialists (e.g., speech-language pathologists, speech therapists, singing voice teachers, voice coaches) vary by location but typically do not specify criteria for working with specific populations. Standard curricula in formal education for these professions often do not include specific or adequate training for working with TGD populations (Jakomin et al., 2020; Matthews et al., 2020). General knowledge and skills related to the vocal mechanism and interpersonal communication are foundational but insufficient for conducting culturally responsive, person-centered care for TGD people that is effective, efficient, inclusive, and accessible (Hancock, 2017; Russell & Abrams, 2019).

Professionals in this area should receive comprehensive education that invites them to develop self-awareness, cultural humility, and cultural responsiveness in order to be respectful of and attentive to gender diversity and other aspects of a client’s identifications that can take a variety of forms and imply a range of different support needs (Azul, 2015; Azul et al., 2022). Client preferences for use of names, formal forms of address, gender entry, and pronouns need to be respected in all communication with and about the client (including medical records, reports, emails). Education also needs to inform the setting up of a training space or clinic and administrative practices that are designed to be welcoming to TGD people and allow TGD people to feel safe and respected when raising concerns or issues with the voice and communication support team.

Voice and communication specialists working with TGD people will need working knowledge of applicable intervention principles, mechanisms, and effectiveness, competence in teaching and modeling voice and communication modification skills, and a basic understanding of transgender health, including hormonal and surgical treatments and trans-specific psychosocial issues. Education needs to include methodologies and practices that have been developed within TGD communities and shown to be effective and should ideally be presented by or in collaboration with TGD people with lived experience of voice and communication support.

Statement 14.3.

We recommend health care professionals in transgender health working with transgender and gender diverse people who are dissatisfied with their voice or communication consider offering a referral to voice and communication specialists for voice-related support, assessment, and training.

A voice and communication specialist is well positioned to provide information and guidance to the TGD person expressing dissatisfaction with their voice or communication when available. There is evidence voice and communication specialists provide support in such a way that a client’s satisfaction with voice and communication can be achieved, thereby reducing gender dysphoria and improving communication-related quality of life (Azul, 2016; Block, 2017; Deuster, Di Vincenzo et al., 2016; Hancock, 2017; Hancock et al., 2011; Hardy et al., 2013; Kelly et al., 2018; McNamara, 2007; McNeill et al., 2008; Owen & Hancock, 2010; Pasricha et al., 2008; Söderpalm et al., 2004; Watt et al., 2018).

There is empirical evidence that behavioral voice support for TGD AMAB people is effective with regard to achieving the targeted voice changes (Oates, 2019). Seven studies prior to 2020 provide empirical evidence for the effectiveness of voice training, although it is somewhat weak (Carew et al., 2007; Dacakis, 2000; Gelfer & Tice, 2013; Hancock et al., 2011;Hancock & Garabedian, 2013; McNeill et al., 2008; Mészáros et al., 2005). Voice training methods across these seven studies were similar and indicated voice training can be effective at increasing average fundamental frequency (average pitch), fundamental frequency range (pitch range), satisfaction with voice, self-perception and listener perception of vocal femininity, voice-related quality of life, and social and vocational participation. Weaknesses of the identified studies include lack of randomized controlled trials evaluating voice training, small sample sizes, inadequate long-term follow-up, and lack of control of confounding variables. In 2021, another systematic review of the effects of behavioral speech training for AMAB people reached similar conclusions (Leyns et al., 2021).

Until recently, there was almost no research exploring the effectiveness of voice training with TGD AFAB people. There is, however, some promising, although weak evidence of effectiveness from a case study (Buckley et al., 2020) and one uncontrolled prospective study of group voice training (Mills et al., 2019).

Statement 14.4.

We recommend health care professionals working with transgender and gender diverse people who are considering undergoing voice surgery consider offering a referral to a voice and communication specialist who can provide pre- and/or postoperative support.

This statement does not intend to require TGD people receive presurgical voice training. Rather, it is recommended that every available support be offered to provide individualized informational counseling critical to person-centered care. The recommendation is for the TGD person’s consideration to be informed as necessary by individualized informational counseling based on voice assessment, trial voice training, and discussion of expected voice outcomes and risks of surgery with a voice and communication specialist.

For most types of laryngeal surgery, voice training is recommended both prior to surgery to ensure preparation of the vocal mechanism for the surgical intervention and postsurgery to ensure a return to functional voice production (Branski et al., 2006; Park et al., 2021). For pitch-raising surgery in particular, another reason a trial of voice training is recommended is because there are indications certain measures improve with training but not with pitch-raising surgery (e.g., factors relevant to intonation and naturalness, such as maximum f0 pitch in speech range; Kelly et al., 2018).

The number and quality of research studies evaluating pitch-lowering surgeries are currently insufficient, particularly with regard to comparing outcomes with and without other interventions (i.e., testosterone) (Bultynck et al., 2020). There are more techniques and studies of pitch-raising surgeries, but the quality of the evidence is still low. Outcomes from pitch-raising surgeries have been compared to outcomes from having no surgery (Anderson, 2007, 2014; Brown et al., 2000; Geneid et al., 2015; Gross, 1999; Kim, 2017; Kocak et al., 2010; Kunachak et al., 2000; Matai et al., 2003; Meister et al., 2017; Neumann & Welzel, 2004; Orloff et al., 2006; Pickuth et al., 2000; Remacle et al., 2011; Thomas & Macmillan, 2013; Tschan et al., 2016; Van Borsel et al., 2008; Yang et al., 2002), another type of surgical technique (Mora, 2018), voice training alone (Kanagalingam, 2005; Mastronikolis, 2013; Wagner, 2003) and surgery in conjunction with voice training (Casado, 2017; Kelly et al., 2018).

In the 11 studies reporting whether participants had voice training prior to pitch-raising surgery, most participants had prior voice training, but remained dissatisfied with voice and sought surgical intervention. Thus, most studies of surgical outcomes reflect the combined effects of voice training and surgical intervention. Attributes predicting which clients will pursue surgery after training are unknown.

Statement 14.5.

We recommend health care professionals in transgender health inform transgender and gender diverse people commencing testosterone therapy of the potential and variable effects of this treatment on voice and communication.

The research on the effects of androgen treatment on voice and communication of TGD people points to diverse and unpredictable effects on individual clients. While a number of studies have revealed effects on voice that matched TGD people’s expectations and wishes, there is high quality evidence demonstrating TGD people are not always satisfied with the vocal outcomes of testosterone therapy, and many experience difficulties such as inadequate pitch lowering, compromised voice quality, vocal loudness, vocal endurance, pitch range, and flexibility (Azul, 2015, 2016, 2017, 2018; Cosyns et al., 2014; Nygren et al., 2016; Ziegler et al., 2018). A recent meta-analysis of 19 studies examining the effects of at least 1 year of testosterone therapy estimated 21% of participants did not achieve cisgender male normative frequencies, 21% of participants reported incomplete voice-gender congruence and voice problems, and 16% were not completely satisfied with their voice (Ziegler, 2018).

For people who wish to be treated with androgens, accurate informational counseling prior to commencing treatment should enable the development of realistic expectations to avoid disappointment regarding the permanent impact of hormone treatment on voice and communication. In addition, TGD people who do not have access to or do not wish to be treated with testosterone, but want to change their voice and those who are dissatisfied with the outcomes of testosterone treatment can be advised by a voice and communication specialist of alternative and additional support options (e.g., behavioral voice and communication training; pitch-lowering surgery).

CHAPTER 15 Primary Care

Primary care is the broadest of health care disciplines and is defined as the “provision of integrated, accessible health care services by health care professionals who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” (Institute of Medicine, 1996).

Primary care providers (PCPs) encompass a wide range of health care professionals (HCPs) who deliver this care, including general and family medical practitioners, nurse practitioners, advanced practice nurses, physician associates/assistants, and internists. PCPs are represented by a variety of educational backgrounds, training, and specialties. Given the type of degree and the nature of the specialty, the scope of practice varies, and not all providers may be trained or qualified to directly provide the full breadth of transgender health care, such as mental health, genital/pelvic care, or postoperative care, following gender-affirming procedures. Physicians and other providers receive little education in transgender and gender-diverse (TGD) health at any time during their training (Dubin et al., 2018), and thus most skills are currently acquired in practice, either informally or through brief continuing education opportunities, see also Chapter 4—Education. However, if providers are competent to deliver similar care for cisgender patients, they should develop competency in caring for TGD patients. The competencies outlined below are all to be understood as being within the provider’s scope of licensure and practice. However, all PCPs should be able to manage the comprehensive health of TGD patients either directly or by appropriate referral to other HCPs, including other specialists, for evaluation and treatment. There is no evidence competency in caring for TGD patients can only be achieved through a formal or certification process. In explicitly stating recommended competencies, however, PCP’s and TGD persons across all settings can share a standard set of expectations of the knowledge, skills, and cultural competence required for the care of TGD persons.

Due to the unique medical, surgical, and social conditions faced by TGD people, PCPs need distinct competencies in the care of TGD persons, apart from what is expected of all PCP’s who may otherwise care for a diverse population that includes ethnic, racial, or sexual minorities. Professional bodies from a range of generalist disciplines have issued position statements and guidelines specific to the care of TGD people (American College of Obstetricians and Gynecology, 2021; Italian Society of Gender, Identity and Health (SIGIS); the Italian Society of Andrology and Sexual Medicine (SIAMS); the Italian Society of Endocrinology (SIE), 2021; Polish Sexological Society, 2021; the Southern African HIV Clinicians’ Society, 2021). Wylie et al. (2016) state “For the most part, the general health and well-being of transgender people should be attended to within the primary care setting, without differentiation from services offered to cisgender (non-transgender) people for physical, psychological, and sexual health issues. Specific care for gender transition is also possible in primary care.” There are many examples of these services being provided safely and effectively outside of specialist care in diverse cities such as Toronto and Vancouver in Canada, New York and Boston in the US, and in Sydney, Australia, (Radix & Eisfeld, 2014; Reisner, Radix et al., 2016; Spanos et al., 2021).

CHAPTER 16 Reproductive Health

All humans, including transgender individuals, have the reproductive right to decide whether or not to have children (United Nations Population Fund, 2014). Medically necessary gender-affirming hormonal treatments (GAHTs) and surgical interventions (see medically necessary statement in Chapter 2—Global Applicability, Statement 2.1) that alter reproductive anatomy or function may limit future reproductive options to varying degrees (Hembree et al., 2017; Nahata et al., 2019). It is thus critical to discuss infertility risk and fertility preservation (FP) options with transgender individuals and their families prior to initiating any of these treatments and to continue these conversations on an ongoing basis thereafter (Hembree et al., 2017). Established FP options, such as embryo, oocyte, and sperm cryopreservation, may be available for postpubertal transgender individuals (Nahata et al., 2019). Research protocols for ovarian and testicular tissue cryopreservation have also been developed and studied (Borgström et al., 2020; Nahata et al., 2019; Rodriguez-Wallberg, et al., 2019). Whereas the use of embryos, mature oocytes, and sperm have all proven to be efficacious when employed within clinical treatments, cryopreserved gonadal tissues would require either future retransplantation aimed at obtaining fully functional gametes or the application of laboratory methods for culture, which are still under development in basic science research settings. Of note, recent American Society for Reproductive Medicine guidelines have lifted the experimental label on ovarian tissue cryopreservation, but evidence remains limited in prepubertal children (Practice Committee of the American Society for Reproductive Medicine, 2019).

Individualized care should be provided in the context of each person’s parenthood goals. Some research suggests transgender and gender diverse (TGD) people may be less likely to desire genetically related children or children at all when compared with cisgender peers (Defreyne, van Schuvlenbergh et al., 2020; Russell et al., 2016; von Doussa et al., 2015). Yet, several other studies have shown many TGD individuals 1) desire genetically related children; 2) regret missed opportunities for FP; and 3) are willing to delay or interrupt hormone therapy to preserve fertility and/or conceive (Armuand, Dhejne et al., 2017; Auer et al., 2018; De Sutter et al., 2002; Defreyne, van Schuylenbergh et al., 2020; Tornello & Bos, 2017).

Many barriers to FP have been reported, such as cost (which is exacerbated when insurance coverage is lacking), urgency to start treatment, inability to make future-oriented decisions, inadequate provider knowledge/provider biases that affect offering FP, and difficulties accessing FP (Baram et al., 2019; Defreyne, van Schuylenbergh et al., 2020). Additionally, transgender individuals may have worsening dysphoria due to various steps in the FP process that are inseparably connected with the gender assigned at birth (Armuand, Dhejne, et al., 2017; Baram et al., 2019). When available, a multidisciplinary team approach, where both medical and mental health providers collaborate with gender-affirming fertility specialists, can help overcome some of these barriers (Tishelman et al., 2019). TGD individuals should be educated about the distinction between fertility (utilizing one’s own gametes/reproductive tissues) and pregnancy. In addition to fertility considerations, efforts to ensure equitable high-quality care for all forms of family planning and building throughout the full reproductive continuum must be maintained. This includes procreative options such as perinatal care, pregnancy, delivery, and postpartum care, as well as family planning and contraceptive options to prevent unplanned pregnancies, and pregnancy termination if sanctioned (Bonnington et al., 2020; Cipres et al., 2017; Krempasky et al., 2020; Light et al., 2018; Moseson, Fix et al., 2020). TGD people who wish to carry a pregnancy should undergo standard of care preconception care and prenatal counseling and should receive counseling about breast/chest feeding in environments supportive of people with diverse gender identities and experiences (MacDonald et al., 2016; Obedin-Maliver & Makadon, 2016).

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 16.1

We recommend health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about:

1. Known effects of hormone therapies/surgeries on future fertility;

2. Potential effects of therapies that are not well studied and are of unknown reversibility;

3. Fertility preservation (FP) options (both established and experimental;

4. Psychosocial implications of infertility.

TGD individuals assigned female at birth

GAHT may negatively impact future reproductive capacity (Hembree et al., 2017). Based on current evidence in transgender men and gender diverse people assigned female at birth, these risks are as follows:

Gonadotropin-releasing hormone agonists (GnRHas) may be used for pubertal suppression to prevent further pubertal progression until adolescents are ready for masculinizing treatment. GnRHas may also be used for menstrual suppression. GnRHas impact the maturation of gametes but do not cause permanent damage to gonadal function. Thus, if GnRHas are discontinued, oocyte maturation would be expected to resume.

There are few studies detailing the effects of testosterone therapy on reproductive function in transgender men (Moravek et al., 2020). Restoration of normal ovarian function with oocyte maturation after testosterone interruption has been demonstrated in transgender men who have achieved natural conception. A retrospective study on oocyte cryopreservation showed no differences in the total number of oocytes retrieved or in the number of mature oocytes between transgender men and age- and BMI-matched cisgender women (Adeleye et al., 2018, 2019). The first results have recently been published evaluating live birth rates after controlled ovarian stimulation in transgender men compared with cisgender women (Leung et al., 2019). Testosterone was discontinued prior to ovarian stimulation. Overall, the results concerning the influence of testosterone on reproductive organs and their function appear to be reassuring. However, there have been no prospective studies to date evaluating the effect of long-term hormone therapy on fertility (i.e., started in adolescence) or in those treated with GnRHas in early puberty followed by testosterone therapy. It is important to take into consideration that required medications and procedures for cryopreserving oocytes (a pelvic examination, vaginal ultrasound monitoring, and oocyte retrievals) may lead to increasing gender dysphoria in transgender men (Armuand, Dhejne et al., 2017).

Surgical interventions among transgender men will have obvious implications for reproductive capacity. If patients desire a hysterectomy, the option should be offered of preserving the ovaries to retain the possibility of having a genetically related child. Alternatively, if the ovaries are removed either separately or concurrently with the hysterectomy, egg freezing should be offered prior to surgery and/or ovarian tissue cryopreservation can be done at the time of oophorectomy. Although this procedure is no longer considered experimental, many transgender men may desire in vitro maturation of primordial follicles, which is still investigational. Studies evaluating oocyte function have shown oocytes isolated from transgender men with testosterone exposure at the time of oophorectomy can be matured in vitro to develop normal metaphase II meiotic spindle structure (De Roo et al., 2017; Lierman et al., 2017).

TGD individuals assigned male at birth

Based on current evidence in transgender women and gender diverse people assigned male at birth (AMAB), the influence of medical treatment is as follows:

GnRHas inhibit spermatogenesis. Data suggest discontinuation of treatment results in a re-initiation of spermatogenesis, although this may take at least 3 months and most likely longer (Bertelloni et al., 2000). Furthermore, the psychological burden of re-exposure to testosterone should be considered.

Anti-androgens and estrogens result in an impaired sperm production (de Nie et al., 2020; Jindarak et al., 2018; Kent et al., 2018). Spermatogenesis might resume after discontinuation of prolonged treatment with anti-androgens and estrogens, but data are limited (Adeleye et al., 2019; Alford et al., 2020; Schneider et al., 2017). Testicular volumes diminish under the influence of gender-affirming hormone treatment (Matoso et al., 2018). Semen quality in transgender women may also be negatively affected by specific life-style factors, such as a low frequency of masturbation, wearing the genitals tight against the body (e.g., with use of tight undergarments for tucking) (Jung & Schuppe, 2007; Mieusset et al., 1985, 1987; Rodriguez-Wallberg, Häljestig et al., 2021).

Statement 16.2

We recommend health care professionals refer transgender and gender diverse people interested in fertility preservation to providers with expertise in fertility preservation for further discussion.

Research shows many transgender adults desire biological children (De Sutter et al., 2002; Defreyne, van Schuylenbergh et al., 2020; Wierckx, Van Caenegem et al., 2012), yet FP rates remain widely variable, particularly in youth (< 5%–40%) (Brik et al., 2019; Chen et al., 2017; Chiniara et al., 2019; Nahata et al., 2017; Segev-Becker et al., 2020). In a recent survey, many youth acknowledged their feelings about having a biological child might change in the future (Strang, Jarin et al., 2018). Non-elective sterilization is a violation of human rights (Ethics Committee of the American Society for Reproductive Medicine, 2015; Equality and Human Rights Commission, 2021; Meyer III et al., 2001) and due to advances in social attitudes, fertility medicine, and affirmative transgender health care, opportunities for biological parenthood during transition should be supported for transgender people. Due to the influence clinical opinion may have on transgender or nonbinary people’s FP and on parenting decisions, FP options should be explored by health care providers alongside options such as fostering, adoption, coparenting, and other parenting alternatives (Bartholomaeus & Riggs, 2019). Transgender patients who have been offered this type of discussion and have been given the choice to undergo procedures for FP have reported the experience to be an overall positive one (Armuand, Dhejne et al., 2017; De Sutter et al., 2002; James-Abra et al., 2015).

In other patient populations, fertility referrals and formal fertility programs have been shown to increase FP rates and improve patient satisfaction (Kelvin et al., 2016; Klosky, Anderson et al., 2017; Klosky, Wang et al., 2017; Shnorhavorian et al., 2012) Physician attitudes have been investigated, and recent studies indicate both an awareness and a desire to provide fertility-related information to children and their families (Armuand et al., 2020). However, barriers have also been identified, including lack of knowledge, comfort, and resources (Armuand, Nilsson et al., 2017; Frederick et al., 2018). Thus, the need for appropriate training of health care providers has been highlighted, with emphasis placed on fertility counseling and offering FP options to all at-risk individuals in an unbiased way (Armuand, Nilsson et al., 2017). Parents’ recommendations have also been shown to significantly influence FP rates in adolescent and young adult males with cancer (Klosky, Flynn et al., 2017). While there are clear clinical differences in these populations, these findings can help inform best practices for fertility counseling and FP referrals for transgender individuals.

Statement 16.3

We recommend transgender care teams partner with local reproductive specialists and facilities to provide specific and timely information and fertility preservation services prior to offering medical and surgical interventions that may impact fertility.

Cryopreservation of sperm and oocytes are established FP techniques and can be offered to pubertal, late pubertal, and adult birth assigned males and birth assigned females, respectively, preferably prior to the initiation of GAHT (Hembree et al., 2017; Practice Committee of the American Society for Reproductive Medicine, 2019). Cryopreservation of embryos can be offered to adult (post-pubertal) TGD people who wish to have a child and have an available partner. The future use of cryopreserved gametes is also dependent on the gametes and reproductive organs of the future partner (Fischer, 2021; Maxwell et al., 2017)

Although semen parameters have been shown to be compromised when FP is performed after initiation of GAH medication (Adeleye et al., 2019), one small study showed when the treatment was discontinued, semen parameters were comparable to those in TGD patients who had never undergone GAH treatment. With regard to ovarian stimulation, oocyte vitrification yield and subsequent use of the oocytes in in-vitro fertilization (IVF), there is no reason to anticipate a different outcome in assisted reproductive technology (ART) treatments for TGD patients than that obtained in cisgender patients undergoing ART—other than individual confounding factors related to (in)fertility—when gametes are banked prior to any medical treatment (Adeleye et al., 2019). The use of oocytes in ART treatment resulted in similarly successful outcomes in TGD compared with controlled, matched cisgender patients (Adeleye et al., 2019; Leung et al., 2019; Maxwell et al., 2017).

Although these are established options, few pubertal, late pubertal or adult TGD people undergo FP (Nahata et al., 2017), and many experience challenges while undergoing FP interventions. Not only is access and cost of these methods a barrier (particularly in regions without insurance coverage), but these procedures are often physically and emotionally uncomfortable, and many express concerns about postponing the transitioning process (Chen et al., 2017; De Sutter et al., 2002; Nahata et al., 2017; Wierckx, Stuyver et al., 2012). Especially for the birth assigned females, the invasiveness of endovaginal ultrasound follow-up of the ovarian stimulation and oocyte retrieval procedures (and associated psychological distress) have been cited as a barrier (Armuand, Dhejne et al., 2017; Chen et al., 2017). There is also the concern young adults going through transitioning may not have a clear vision of parenting and are therefore likely to decline the opportunity to use FP at that time—while as adults, they may have different opinions about parenthood (Cauffman & Steinberg, 2000). The reduction of gender dysphoria during transitioning could also influence the decision-making process surrounding FP (Nahata et al., 2017). Based on research showing TGD youths’ fertility perspectives may change over time (Nahata et al., 2019; Strang, Jarin et al., 2018), FP options should be discussed on an ongoing basis.

Statement 16.4

We recommend health care professionals counsel pre- or early-pubertal transgender and gender diverse youth seeking gender-affirming therapy and their families that currently evidence-based/established fertility preservation options are limited.

For prepubertal and early-pubertal children, FP options are limited to the storage of gonadal tissue. Although this option is available for TGD children in the same way that it is available for cisgender prepubertal and early-pubertal oncological patients, there is no literature describing the utilization of this approach in the transgender population. Ovarian tissue autotransplantation has resulted in over 130 live births in cisgender women. Most of these patients conceived naturally without ART (Donnez & Dolmans, 2015; Jadoul et al., 2017), and the majority stored their ovarian tissue either as adults or during puberty. Although the recent American Society for Reproductive Medicine guideline has lifted the experimental label from ovarian tissue cryopreservation (Practice Committee of the American Society for Reproductive Medicine, 2019), there are very few case reports describing a successful pregnancy in a woman following the transplantation of ovarian tissue cryopreserved before puberty. Demeestere et al. (2015) and Rodriguez-Wallberg, Milenkovic et al. (2021) described cases of successful pregnancies following transplantation of tissue procured at the age of 14, and recently Matthews et al. (2018) described the case of a girl diagnosed with thalassemia who had ovarian tissue stored at the age of 9 and transplantation 14 years late. She subsequently conceived through IVF and delivered a healthy baby.

Currently, the only future clinical application for storing ovarian tissue is autotransplantation, which might be undesirable in a transgender man (due to the potentially undesirable effects of estrogen). A laboratory procedure that would make it possible to mature oocytes in vitro starting with ovarian tissue would be the ideal future application of stored ovarian tissue for transgender people, but this technique is currently only being investigated and optimized in basic science research settings (Ladanyi et al., 2017; Oktay et al., 2010).

Prepubertal procurement of testicular tissue has been documented as a low-risk procedure (Borgström et al., 2020; Ming et al., 2018). Some authors have also described this approach as a theoretical option in transgender people (De Roo et al., 2016; Martinez et al., 2017; Nahata, Curci et al., 2018). However, there are no reports in the literature describing the clinical or investigational utilization of this FP option for TGD patients. Moreover, the viability of the clinical application of autotransplantation of testicular tissue remains unknown in humans, and in vitro maturation techniques are still in the realm of basic science research. Thus, specialists currently consider this technique experimental (Picton et al., 2015). The possibility of storing gonadal tissue should be discussed prior to any genital surgery that would result in sterilization, although the probability of being able to use this tissue must be clearly addressed.

Statement 16.5

We recommend transgender and gender diverse people with a uterus who wish to carry a pregnancy undergo preconception care and prenatal counseling regarding the use and cessation of gender-affirming hormones, pregnancy care, labor and delivery, chest/breast feeding supportive services, and postpartum support according to local standards of care in a gender-affirming way.

Most transgender men and gender diverse people (AFAB) retain their uterus and ovaries and thus can conceive and carry a pregnancy even after long-term testosterone use (Light et al., 2014). Many transgender men desire children (Light et al., 2018; Wierckx, van Caenegem et al., 2012) and are willing to carry a pregnancy (Moseson, Fix, Hastings et al., 2021; Moseson, Fix, Ragosta et al., 2021). ART has expanded the opportunity for many transgender men to conceive and fulfill their family planning wishes (De Roo et al., 2017; Ellis et al., 2015; Maxwell et al., 2017). Some transgender men report psychological isolation, dysphoria related to the gravid uterus and chest changes, and depression (Charter, 2018; Ellis et al., 2015; Hoffkling et al., 2017; Obedin-Maliver & Makadon, 2016). Conversely, other studies have reported some positive experiences during pregnancy as well (Fischer, 2021; Light et al., 2014). Mental health providers should be involved to provide support, and counseling should be provided addressing when to stop and when to resume gender-affirming hormones, what options are available for the mode of delivery and for chest/breast feeding (Hoffkling et al., 2017). Finally, system-level and interpersonal-level interventions should be implemented to ensure person-centered reproductive health care for all people (Hahn et al., 2019; Hoffkling et al., 2017; Moseson, Zazanis et al., 2020; Snowden et al., 2018).

Given the potential harmful effects of testosterone on the developing embryo, discontinuing testosterone or masculinizing hormone therapy prior to conception and during the entire pregnancy is recommended. However, the optimal time for both the discontinuation of testosterone prior to pregnancy and its resumption after pregnancy is unknown. Since stopping gender-affirming hormones may cause distress and exacerbate dysphoria in transgender men, when and how to stop this therapy should be discussed during prenatal counseling (Hahn et al., 2019). Because information about the duration of testosterone exposure and the risk of teratogenicity is lacking, testosterone use should be discontinued prior to attempting pregnancy and before stopping contraception. Moreover, there is limited information regarding health outcomes of infants born to transgender men. Small case series attempting to evaluate this question have revealed no adverse physical or psychosocial differences between infants born to transgender men and infants in the general population (Chiland et al., 2013).

Chest/Breast feeding

In the limited studies evaluating lactation and chest/breast feeding, the majority of transgender men and TGD individuals AFAB who chose to chest/breast feed postpartum were successful, with research suggesting induction of lactation is in part dependent on preconception counseling and experienced lactation nursing support (MacDonald et al., 2016; Wolfe-Roubatis & Spatz, 2015). Specifically, transgender men and TGD people who use testosterone should be informed 1) although quantities are small, testosterone does pass through chest/breast milk; and 2) the impact on the developing neonate/child is unknown, and therefore gender-affirming testosterone use is not recommended during lactation but may be resumed after discontinuation of chest/breast feeding (Glaser et al., 2009). Transgender men and other TGD individuals AFAB should be made aware some patients who carry a pregnancy may experience undesired chest growth and/or lactation even after chest reconstruction and should therefore be supported if they desire to suppress lactation (MacDonald et al., 2016).

There is limited information concerning lactation in transgender women as well as other TGD AMAB but many also express the desire to chest/breast feed. While there is a case report of a transgender woman successfully lactating and chest/breast feeding her infant after hormonal support using a combination of estrogen, progesterone, domperidone, and breast pumping (Reisman & Goldstein, 2018), the nutritional and immunological profile of chest/breast milk under these conditions has not been studied. Therefore, patients need to be informed about the risks and benefits of this approach to child feeding (Reisman & Goldstein, 2018).

Statement 16.6

We recommend medical providers discuss contraception methods with transgender and gender diverse people who engage in sexual activity that can result in pregnancy.

Many TGD individuals may retain reproductive capacity, and they (if they retain a uterus, ovaries, and tubes) or their sexual partners (for sperm producing individuals) may experience unplanned pregnancies (James et al., 2016; Light et al., 2014; Moseson, Fix et al., 2020). Therefore, intentional family planning counseling, including contraception and abortion conducted in gender-expansive ways is needed (Klein, Berry-Bibee et al., 2018; Obedin-Maliver, 2015; Stroumsa & Wu, 2018). TGD people AFAB may not use contraception due to an erroneous assumption that testosterone is a reliable form of contraception (Abern & Maguire, 2018; Ingraham et al., 2018; Jones, Wood et al., 2017; Potter et al., 2015). However, based on current understanding, testosterone should not be considered a reliable form of contraception because of its incomplete suppression of the hypothalamic-pituitary-adrenal axis (Krempasky et al., 2020). Furthermore, pregnancies have occurred while individuals are amenorrheic due to testosterone use, which may outlast active periods of administration (Light et al., 2014). Pregnancy can also occur in TGD people after long-term testosterone use (at least up to 10 years), although the effect on oocytes and baseline fertility is still unknown (Light et al., 2014).

TGD people AFAB may use a variety of contraceptive methods (Abern & Maguire, 2018; Bentsianov et al., 2018; Bonnington et al., 2020; Chrisler et al., 2016; Cipres et al., 2017; Jones, Wood et al., 2017; Krempasky et al., 2020; Light et al., 2018).These methods may be used explicitly for pregnancy prevention, menstrual suppression, abnormal bleeding, or other gynecological needs (Bonnington et al., 2020; Chrisler et al., 2016; Krempasky et al., 2020; Schwartz et al., 2019). Contraceptive research gaps within this population are profound. No studies have examined how the use of exogenous androgens (e.g., testosterone) may modify the efficacy or safety profile of hormonal contraceptive methods (e.g., combined estrogen and progestin hormonal contraceptives, progestin-only based contraceptives) or non-hormonal and barrier contraceptive methods (e.g., internal and external condoms, non-hormonal intrauterine devices, diaphragms, sponges, etc.).

Gender diverse individuals who currently have a penis and testicles may engage in sexual activity with individuals who have a uterus, ovaries, and tubes of any gender. Gender diverse people who have a penis and testicles can produce sperm even while on gender-affirming hormones (i.e., estrogen), and although semen parameters are diminished among those who are currently using or who have previously used gender-affirming hormones, azoospermia is not complete and sperm activity is not totally suppressed (Adeleye et al., 2019; Jindarak et al., 2018; Kent et al., 2018). Therefore, contraception needs to be considered if pregnancy is to be avoided in penis-in-vagina sexual activity between a person with a uterus, ovaries, and tubes and one with a penis and testicles, irrespective of the use of gender-affirming hormones by either partner. Currently, contraceptive methods available for use by the sperm-producing partner are primarily mechanical barriers (i.e., external condoms, internal condoms), permanent sterilization (i.e., vasectomy), and gender-affirming surgery (e.g., orchiectomy, which also results in sterilization). Contraceptive counseling that considers sperm producing, egg producing, and gestating partners (as relevant) is recommended.

Statement 16.7

We recommend providers who offer pregnancy termination services ensure procedural approaches are gender-affirming and serve transgender people and those of diverse genders.

Unplanned pregnancies and abortions have been reported among TGD individuals with a uterus (Abern & Maguire, 2018; Light et al., 2014; Light et al., 2018; Moseson, Fix et al., 2020) and documented through surveys of abortion-providing facilities (Jones et al., 2020). However, the population-based epidemiology of abortion provision and the experiences and preferences of TGD individuals AFAB undergoing abortion still represents a critical gap in research (Fix et al., 2020; Moseson, Fix et al., 2020; Moseson, Lunn et al., 2020). Nonetheless, given that pregnancy capacity exists among many TGD people and pregnancies may not always be planned or desired, access to safe, legal, and gender-affirming pregnancy medical and surgical termination services is necessary.

CHAPTER 17 Sexual Health

Sexual health has a profound impact on physical and psychological well-being, regardless of one’s sex, gender, or sexual orientation. However, stigma about sex, gender and sexual orientation influences individual's opportunities to live out their sexuality and to receive appropriate sexual health care. Specifically, in most societies, cisnormativity and heteronormativity lead to the assumption that all people are cisgender and heterosexual (Bauer et al., 2009), and that this combination is superior to all other genders and sexual orientations (Nieder, Güldenring et al., 2020; Rider, Vencill et al., 2019). Hetero-cis-normativity negates the complexity of gender, sexual orientation, and sexuality and disregards diversity and fluidity. This is all the more important since sexual identities, orientations, and practices of transgender and gender diverse (TGD) people are characterized by an enormous diversity (Galupo et al., 2016; Jessen et al., 2021; Thurston & Allan, 2018; T'Sjoen et al., 2020). Likewise, a strong cross-cultural tendency toward allonormativity—the assumption that all people experience sexual attraction or interest in sexual activity—negates the diverse experiences of TGD people, especially those who locate themselves on the asexual spectrum (McInroy et al., 2021; Mollet, 2021; Rothblum et al., 2020).

The World Health Organization (WHO, 2010) emphasizes sexual health depends on respect for the sexual rights of all people, including the right to express diverse sexualities and to be treated respectfully, safely, and with freedom from discrimination and violence. Sexual health discourses have focused on agency and body autonomy, which include consent, sexual pleasure, sexual satisfaction, partnerships, and family life (Cornwall & Jolly, 2006; Lindley et al., 2021). In light of this, the WHO defines sexual health as “a state of physical, emotional, mental, and social well-being in relation to sexuality and not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled” (WHO, 2006, p. 5). This includes individuals on the asexual spectrum, who may not experience sexual attraction to others but may still choose to be sexual at times (e.g., via self-stimulation) and/or experience interest in forming and building romantic relationships (de Oliveira et al., 2021).

Scientific attention to the sexual experiences and behaviors of TGD people has grown in recent years (Gieles et al., 2022; Holmberg et al., 2019; Klein & Gorzalka, 2009; Kloer et al., 2021; Mattawanon et al., 2021; Stephenson et al., 2017; Tirapegui et al., 2020; Thurston & Allan, 2018). This expansion within the literature reflects a sex-positive framework (Harden, 2014), a framework that recognizes both the positive aspects such as sexual pleasure (Laan et al., 2021) and potential risks associated with sexuality (Goldhammer et al., 2022; Mujugira et al., 2021). Studies of TGD people's sexuality, however, often lack validated measures, an appropriate control group, or a prospective design (Holmberg et al., 2019). Additionally, most focus exclusively on sexual functioning (Kennis et al., 2022), and thus neglecting sexual satisfaction and broader operationalizations of sexual pleasure beyond functioning. The effects of current TGD-related medical treatments on sexuality are heterogeneous (Özer et al., 2022; T'Sjoen et al., 2020), and there has been little research on the sexuality of TGD adolescents (Bungener et al., 2017; Maheux et al., 2021; Ristori et al., 2021; Stübler & Becker-Hebly, 2019; Warwick et al., 2022). While sex-positive approaches to counseling and treatment for sexual difficulties experienced by TGD individuals have been proposed (Fielding, 2021; Jacobson et al., 2019; Richards, 2021), to date there is insufficient research on the effectiveness of such interventions. Focusing on the promotion of sexual health, the World Association for Sexual Health (WAS) asserts the importance of sexual pleasure and considers self-determination, consent, safety, privacy, confidence, and the ability to communicate and negotiate sexual relations as major facilitators (Kismödi et al., 2017). WAS asserts sexual pleasure is integral to sexual rights and human rights (Kismödi et al., 2017). To contribute to the sexual health of TGD people, health care professionals (HCPs) need both transgender-related expertise and sensitivity (Nieder, Güldenring et al., 2020). With the goal of improving sexual health care for TGD people to an ethically-sound, evidence-based and high-quality level, HCPs must provide their health services with the same care (i.e., with transgender-related expertise), respect (i.e., with transgender-related sensitivity), and investment in sexual pleasure and sexual satisfaction as they provide for cisgender people (Holmberg et al., 2019).

In many societies, nonconforming gender expressions can elicit strong (emotional) reactions, including in HCPs. Thus, when initiating a health-related contact or establishing a therapeutic relationship, a nonjudgmental, open and welcoming manner is most likely ensured when HCPs reflect on their emotional, cognitive, and interactional reactions to the person (Nieder, Güldenring et al., 2020). In addition, transgender-related expertise refers to identifying the impact the TGD person’s intersectional identities and experiences of marginalization and stigma may have had on their whole self (Rider, Vencill et al., 2019). To adequately address the specific physical, psychological, and social conditions of TGD people, HCPs must be aware these conditions are generally overlooked due to hetero-cis-normativity, lack of knowledge, and lack of skills (Rees et al., 2021). It is also important to consider cultural norms in relation to sexuality. For example, in some African cultures, the idea of sex as taboo restricts the number of acceptable terms to be used when taking a sexual history (Netshandama et al., 2017). Culturally respectful language can facilitate talking openly about one's sexual history and reduce ambiguity or shame (Duby et al., 2016). In addition, HCPs must be sensitive to the history of (mis)use of sexual identity and orientation as a gatekeeping function to exclude transgender people from gender-affirming health care (Nieder & Richter-Appelt, 2011; Richards et al., 2014). The following recommendations aim to improve sexual health care for TGD people.

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 17.1

We recommend health care professionals who provide care to transgender and gender diverse people acquire the knowledge and skills to address sexual health issues (relevant to their care provision).

It is important HCPs addressing the sexual health of TGD people be familiar with commonly used terminology (see Chapter 1—Terminology) and invite those seeking care to explain terms with which the provider may not be familiar. In this context, it is also important HCPs (are prepared to) take a sexual history and offer treatment (according to their competencies) in a gender-affirming way with a sex-positive approach (Centers for Disease Control, 2020; Tomson et al., 2021). However, HCP’s should apply greater importance to the terminology that the TGD person uses for their own body over more traditionally accepted or used medical terminology (Wesp, 2016). When talking about sexual practices, it is advisable to focus on body parts (e.g., “Do you have sex with people with a penis, people with a vagina, or both?”; ACON, 2022) and what role they play in their sexuality (e.g., “During Sex, do any parts of your body enter your partners body, such as their genitals, anus, or mouth?”; ACON, 2022).

Statement 17.2

We recommend health care professionals who provide care to transgender and gender diverse people discuss the impact of gender-affirming treatments on sexual function, pleasure, and satisfaction.

To achieve gender-affirming care, it is crucial HCPs providing transition-related medical interventions be sufficiently informed about the possible effects on sexual function, pleasure, and satisfaction (T'Sjoen et al., 2020). Since clinical data indicate that TGD people score significantly lower in sexual pleasure compared to cisgender individuals, this is even more important (Gieles et al., 2022). If the HCP cannot provide information about the effects of their treatment on sexual function, pleasure, and satisfaction, they are at least expected to refer the individual to someone qualified to do so. If the sexuality-related effects of their treatment are unknown, HCPs should inform their patients accordingly. As introduced above, the sexuality of TGD people often challenges heteronormative views. Nevertheless, there is a large amount of literature (e.g., Bauer, 2018; Laube et al., 2020; Hamm & Nieder, 2021; Stephenson et al., 2017) highlighting the spectrum character of sexuality that does not fit into expectations of what male and female sexuality entails (neither cis- nor transgender), let alone that of gender diverse people (e.g., nonbinary, agender, genderqueer). Thus, these aspects should be carefully considered by HCPs as cisnormativity, heteronormativity, and transition-related medical interventions, all have a strong impact on sexual health.

Sexual pleasure has been well documented as a factor in improving sexual, mental, and physical health outcomes (Anderson, 2013). Next to sexual function, HCPs providing sexual health care must address sexual pleasure and satisfaction as a key factor within sexual health. Historically sexual health care has been disease focused, and this is particularly true for research and clinical practice in working with TGD patients. Although competent sexual health care regarding HIV and STIs is necessary, integration of valuing sexual pleasure of TGD patients is also necessary. Calls for integrating sexual pleasure as a focal point in STI prevention education and interventions rest on the understanding that pleasure is a motivator of behavior (Philpott et al., 2006). TGD people are concerned about their sexual pleasure and need HCPs who are knowledgeable about the diversity of sexual practices and anatomical functioning particular to TGD health care.

Statement 17.3

We recommend health care professionals who provide care to transgender and gender diverse people offer the possibility of including the partner(s) in sexuality-related care, if appropriate.

When appropriate and relevant to clinical concerns, inclusion of a sexual and/or romantic partner(s) in sexual health care decision-making can increase TGD patients’ sexual well-being and satisfaction outcomes (Kleinplatz, 2012). TGD people may choose a range of transition-related medical interventions, and these interventions may have mixed results in shifting experiences of anatomical dysphoria (Bauer & Hammond, 2015). When discussing the impact of medical interventions on sexual functioning, pleasure, and satisfaction, inclusion of partner(s) can increase knowledge of potential changes and encourage communication between partners (Dierckx et al., 2019). Because the process of transitioning is often not a completely solitary endeavor, the inclusion of sexual and/or romantic partners in transition-related health care can facilitate the process of “co-transitioning” (Lindley et al., 2020; Siboni et al., 2022; Theron & Collier, 2013) and can also support sexual growth and adjustment both in the individual as well as in the relationship. Social and psychological barriers to sexual functioning and pleasure, including experiences of gender dysphoria, stigmatization, lack of sexual and relationship role models, and limited skills, can have negative impacts on overall sexual health (Kerckhof et al., 2019). Supportive, gender-affirming sexual communication between partners improves sexual satisfaction outcomes for TGD people (Stephenson et al., 2017; Wierckx, Elaut et al., 2011).

Inclusion of sexual and/or romantic partners offers an additional opportunity to set realistic expectations, disseminate helpful and accurate information, and facilitate gender-affirming positive communication related to sexual health. Ultimately, however, it is important to recognize individual choices related to gender health and transition are the patients to make, not a partner’s decision. It is important the inclusion of partners in sexual health-related care occur only when appropriate and as desired by patients. Contraindications might include interpersonal dynamics that are abusive or violent, in which case patient safety overrides partner involvement. Finally, it is critical HCPs treat all people in an affirming and inclusive manner, including sexual and romantic partners. This means, for example, monitoring and addressing assumptions and potential biases about the gender or sexual orientation of a patient’s partner(s) or a patient’s relationship structure.

Statement 17.4

We recommend health care professionals counsel transgender and gender diverse people about the potential impact of stigma and trauma on sexual risk behavior, sexual avoidance, and sexual functioning.

The TGD community is disproportionately impacted by stigma, discrimination, and violence (de Vries et al., 2020; European Union Agency for Fundamental Rights, 2020; McLachlan, 2019). These experiences are often traumatic in nature (Burnes et al., 2016; Mizock & Lewis, 2008) and can create barriers to sexual health, functioning, and pleasure (Bauer & Hammond, 2015). For example, stigmatizing narratives about transgender sexualities can increase dysphoria and sexual shame, increasing potential avoidance of the sexual communication needed for safety and optimizing pleasure (Stephenson et al., 2017). Research demonstrates stigma, a history of sexual violence, and body image concerns can negatively impact sexual self-esteem and agency, for example the ability to assert what is pleasurable or to negotiate condom use (Clements-Nolle et al., 2008; Dharma et al., 2019). Additionally, gender dysphoria can be exacerbated by past trauma experiences and ongoing trauma-related symptoms (Giovanardi et al., 2018). It may be difficult for some TGD individuals to engage sexually using the genitals with which they were born, and they may choose to avoid such stimulation altogether, disrupting arousal and/or orgasmic processes (Anzani et al., 2021; Bauer & Hammond, 2015; Iantaffi & Bockting, 2011) or result in complex feelings about orgasm (Chadwick et al., 2019). HCPs providing gender-affirming counseling and interventions must be knowledgeable about the spectrum of sexual orientations and identities (including asexual identities and practices) to avoid assumptions based in heteronormative, cisnormative, allonormative modes of behavior or satisfaction while also affirming the potential impacts of stigma and trauma on sexual health and pleasure (Nieder, Güldenring et al., 2020). Some level of disconnect or dissociation may at times be present, particularly in the case of acute trauma symptoms (Colizzi et al., 2015). It is important HCPs be aware of these potential impacts on sexual health, functioning, pleasure, and satisfaction, so they may refer patients as needed to trauma-informed sexual counselors, mental health providers, or both, who may be of further assistance and may also normalize and validate TGD patients exploring multiple diverse pathways of healing and accessing sexual pleasure.

Statement 17.5

We recommend any health care professional who offers care that may impact sexual health provide information, ask about the expectation of the transgender and gender diverse individual, and assess their level of understanding of possible changes.

Transition-related care can affect sexual function, pleasure, and satisfaction, both in positive and negative ways (Holmberg et al., 2018; Kerckhof et al., 2019; Thurston & Allan, 2018; Tirapegui et al., 2020). On the positive side, gender-affirming care can help TGD people improve their sexual functioning and increase their sexual pleasure and satisfaction (Kloer et al., 2021; Özer et al., 2022; T'Sjoen et al., 2020). On the negative side, however, data indicate problematic sexual health outcomes due to hormonal and surgical treatments (Holmberg et al., 2018; Kerckhof et al., 2019, Stephenson et al., 2017; Weyers et al., 2009). Transition-related hormones may affect mood, sexual desire, the ability to have an erection and ejaculation, and genital tissue health, which in turn can impact sexual function, pleasure and sexual self-expression (Defreyne, Elaut et al., 2020; Garcia & Zaliznyak, 2020; Kerckhof et al., 2019; Klein & Gorzalka, 2009; Wierckx, Elaut et al., 2014). TGD people who wish to use their original genital anatomy for penetrative sex may benefit from medications that address sexual health side effects of hormone therapy, such as erectile dysfunction, medications for TGD persons taking estrogen or antiandrogens, and topical estrogen and/or moisturizers for TGD persons experiencing vaginal atrophy or dryness due to testosterone therapy.

Sexual desire, arousal, and function may also be affected by the use of psychotropic drugs (Montejo et al., 2015). As some TGD people are prescribed medication to treat depression (Heylens, Elaut et al., 2014), anxiety (Millet et al., 2017) or other mental health concerns (Dhejne et al., 2016), their potential side effects on sexual health should be considered.

Many gender-affirming surgeries can have significant effects on erogenous sensation, sexual desire and arousal as well as sexual function and pleasure. The impact of these changes for patients may be mixed (Holmberg et al., 2018). Chest surgeries (breast reduction, mastectomy, and breast augmentation) and body contouring surgeries, for example, may offer desired changes in form and appearance thereby reducing psychological distress that can disrupt sexual functioning but may adversely affect erogenous sensation (Bekeny et al., 2020; Claes et al., 2018; Rochlin et al., 2020). Genital surgeries in particular can potentially affect sexual function and pleasure in adverse ways, although they are likely to be experienced positively as the patient’s body becomes more aligned with their gender, potentially opening new avenues for sexual pleasure and satisfaction (Hess et al., 2018; Holmberg et al., 2018; Kerckhof et al., 2019).

There are numerous examples of this in the extant literature:

• Surgery may result in a decrease, a total loss, or a possible increase in erogenous stimulation and/or experienced sensation compared with the patient’s presurgery anatomy (Garcia, 2018; Sigurjónsson et al., 2017).

• A particular surgical option may be associated with specific limitations to sexual function that may manifest immediately, in the future, or at both timepoints, and which patients should consider before finalizing their choice when considering different surgical options (Frey et al., 2016; Garcia, 2018; Isaacson et al., 2017).

• Postsurgical complications can adversely affect sexual function by either decreasing the quality of sexual function (e.g., discomfort or pain with sexual activity) or by precluding satisfactory intercourse (Kerckhof et al., 2019; Schardein et al., 2019).

In general, satisfaction with any medical treatment is heavily influenced by the patient’s expectations (Padilla et al., 2019). Furthermore, when patients have unrealistic expectations before treatment, they are much more likely to be dissatisfied with the outcome, their care, and with their HCP (Padilla et al., 2019). Therefore, it is important to both provide patients with adequate information about their treatment options and to understand and consider what is important to the patient with regard to outcomes (Garcia, 2021). Finally, it is important the HCP ensure patients understand the potential adverse effects of a treatment on their sexual function and pleasure so that a well-informed decision can be made. This is relevant for both meeting the standard of informed consent (i.e., discussion and understanding) and for providing an opportunity to offer further clarification to patients and, if desired, to their partners (Glaser et al., 2020).

Statement 17.6

We recommend health care professionals who provide care to transgender and gender diverse people counsel adolescents and adults regarding prevention of sexually transmitted infections.

The WHO (2015) recommends HCPs implement brief sexuality-related communication in primary care for all adolescents and adults. Therefore, TGD persons who are sexually active or considering sexual activity may benefit from sexuality-related communication or counseling for the purpose of HIV/STI prevention. These conversations are particularly important as TGD persons are disproportionately impacted by human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) relative to cisgender persons (Baral et al., 2013; Becasen et al., 2018; Poteat et al., 2016). However, few data are available for non-HIV STIs, such as chlamydia, gonorrhea, syphilis, viral hepatitis, and herpes simplex virus (Tomson et al., 2021). The United Nations Joint Programme on HIV/AIDS estimates transgender women are 12 times more likely than other adults to be living with HIV (UNAIDS, 2019). A meta-analysis estimated a pooled global HIV prevalence of 19% among transgender women who have sex with men (Baral et al., 2013). HIV/STI risk is concentrated among TGD subgroups at the confluence of multiple biological, psychological, interpersonal, and structural vulnerabilities. In particular, transfeminine persons who have sex with cisgender men, belong to minoritized racial/ethnic groups, live in poverty, and engage in survival sex work are at elevated HIV/STI risk (Becasen et al., 2018; Poteat et al., 2015; Poteat et al., 2016). Less is known about HIV/STI risk among transgender men or gender diverse persons AFAB. Small studies in high-income countries indicate a laboratory-confirmed HIV prevalence of 0-4% among transmasculine people (Becasen et al., 2018; Reisner & Murchison, 2016). Almost no research has been conducted with transmasculine people who have sex with cisgender men in high-HIV-prevalence countries. Despite limited epidemiologic data, transmasculine persons who have sex with cisgender men frequently report HIV/STI risk related to receptive vaginal and/or anal sex (Golub et al., 2019; Reisner et al., 2019; Scheim et al., 2017) and may be more susceptible to HIV acquisition from vaginal intercourse than (pre-menopausal) cisgender women due to hormone-related vaginal atrophy.

HCPs will need to supplement general guidelines by developing the knowledge and skills needed for discussing sexual health issues with TGD people, such as the use of gender-affirming language (see Statement 17.1 in this chapter). It is critical HCPs avoid assumptions about HIV/STI risk based solely on a patient’s gender identity or anatomy. For example, many transgender people are not sexually active, and TGD persons may use prosthetics or toys for sex. To provide appropriate prevention counseling, HCPs should inquire about the specific sexual activities TGD people engage in, and the body parts (or prosthetics) involved in those activities (ACON, 2022). Well-prepared HCPs (including, but not limited to mental health providers) may also engage in in-depth counseling with their patients to address the underlying drivers of HIV/STI risk (see Statement 17.3 in this chapter).

In all cases, HCPs should be sensitive to the collective and individual histories of TGD people (e.g., stereotypes and stigma about trans sexualities and gender dysphoria) and should explain to patients the reasons for sexuality-related inquiries and the voluntary nature of such inquiries. In discussing HIV/STI prevention, HCPs should refer to the full range of prevention options including barrier methods, post-exposure prophylaxis, pre-exposure prophylaxis, and HIV treatment to prevent onwards transmission (WHO, 2021). Trans-specific considerations for pre-exposure prophylaxis are addressed in Statement 17.8.

Statement 17.7

We recommend health care professionals who provide care to transgender and gender diverse people follow local and World Health Organization guidelines for human immunodeficiency virus/sexual transmitted infections (HIV/STIs) screening, prevention, and treatment.

Like cisgender patients, TGD adolescents and adults should be offered screening for HIV/STIs in accordance with existing guidelines and based on their individual risk of HIV/STI acquisition, considering anatomy and behavior rather than gender identity alone. Where local or national guidelines are unavailable, WHO (2019a) offers global recommendations; more frequent screening is recommended for transgender people who have sex with cisgender men as a key population affected by HIV.

Gender-affirming genital surgeries and surgical techniques have implications for STI risks and screening needs, as outlined in recent guidelines from the US Centers for Disease Control (Workowski et al., 2021). For instance, transfeminine persons who have had penile inversion vaginoplasty using only penile and scrotal skin to line the vaginal canal are likely at lower risk of urogenital Chlamydia trachomatis (C. trachomatis) and Neisseria gonorrhoeae (N. gonorrhoeae), but newer surgical techniques that employ buccal or urethral mucosa or peritoneum flaps could in theory increase susceptibility to bacterial STIs relative to the use of penile/scrotal skin alone (Van Gerwen et al., 2021). Routine STI screening of the neovagina (if exposed) is recommended for all transfeminine persons who have had vaginoplasty (Workowski et al., 2021). For transmasculine persons who have had metoidioplasty with urethral lengthening, but not vaginectomy, testing for bacterial urogenital STIs should include a cervical swab because infections may not be detected in urine (Workowski et al., 2021).

Further, it is important for HCPs to offer testing at multiple anatomical sites as STIs in transgender patients are often extragenital (Hiransuthikul et al., 2019; Pitasi et al., 2019). Consistent with WHO (2020) recommendations, self-collection of samples for STI testing should be offered as an option, particularly if patients are uncomfortable or unwilling to undergo provider-collected sampling due to gender dysphoria, trauma histories, or both. Where relevant, integration of HIV/STI testing with regular serology used to monitor hormone therapy may better facilitate access to care (Reisner, Radix et al., 2016; Scheim & Travers, 2017).

Statement 17.8

We recommend health care professionals who provide care to transgender and gender diverse people address concerns about potential interactions between antiretroviral medications and hormones.

For TGD adolescents and adults at substantial risk of HIV infection (generally defined as an ongoing serodiscordant relationship or condomless sex outside of a mutually monogamous relationship with a known HIV-negative partner; WHO, 2017), pre-exposure prophylaxis (PrEP) is an important HIV prevention option (Golub et al., 2019; Sevelius et al., 2016; WHO, 2021). To encourage uptake of PrEP, in 2021 the US Centers for Disease Control recommended all sexually active adolescents and adults be informed about PrEP and offered it if requested (CDC, 2021). For treatment among people living with HIV, transgender-specific guidelines are available in some settings (e.g., Panel on Antiretroviral Guidelines for Adults and Adolescents, 2019).

For both HIV prevention and treatment, there are antiretroviral dosing and administration considerations specific to TGD persons. For oral PrEP, only daily dosing is currently recommended for TGD persons as studies demonstrating the effectiveness of event-driven PrEP with emtricitabine/tenofovir disoproxil fumarate (TDF) have been limited to cisgender men (WHO, 2019c). In addition, while emtricitabine/tenofovir alafenamide (TAF) is a new oral PrEP option, as of early 2022 it is not recommended for people at risk of HIV acquisition through receptive vaginal sex due to a lack of evidence (CDC, 2021). Finally, long-acting injectable formulations of both PrEP and HIV treatment are increasingly available (e.g., cabotegravir for PrEP), and while they are recommended for all patients who might benefit from injectable options, indicated injection sites (i.e., the gluteal muscle) may be unsuitable for individuals who have used soft tissue fillers (Rael et al., 2020).

There is little evidence supporting the occurrence of drug-drug interactions between gender-affirming hormones and PrEP medications. A few small studies, primarily relying on self-reported PrEP use, have shown reduced PrEP drug concentrations in transgender women undergoing hormone therapy, although concentrations remained in the protective range (Yager & Anderson, 2020). A subsequent drug-drug interaction study using directly observed PrEP therapy failed to detect an impact of hormone therapy on PrEP drug concentrations in transgender women and found transgender women and men taking hormone therapy achieved high levels of protection against HIV infection (Grant et al., 2020). Most importantly, for many TGD people, no impact of PrEP on hormone concentrations has been detected. With regard to HIV treatment, specific antiretroviral medications may impact hormone concentrations; however, these can be managed by selecting alternative agents, monitoring and adjusting hormone dosing, or both (Cirrincione et al., 2020) as detailed in guidelines from the US Department of Health and Human Services (Panel on Antiretroviral Guidelines for Adults and Adolescents, 2019). Nevertheless, concerns about drug-drug interactions, particularly interactions that may limit hormone concentrations, represent a barrier to the implementation and adherence to antiretroviral therapy for HIV prevention or treatment (Radix et al., 2020; Sevelius et al., 2016). Therefore, it is advisable for HCPs to proactively address such concerns with those who are candidates for PrEP or HIV treatment. Integration of PrEP or HIV treatment with hormone therapy may further reduce barriers to implementation and adherence (Reisner, Radix et al., 2016). Integration may be achieved through colocation or through coordination with an HIV specialist if the primary care provider does not have the necessary expertise. Some TGD persons may benefit from standalone PrEP or sexual health services that provide greater privacy and flexibility, and thus differentiated service delivery models are needed (Wilson et al., 2021).

CHAPTER 18 Mental Health

This chapter is intended to provide guidance to health care professionals (HCPs) and mental health professionals (MHPs) who offer mental health care to transgender and gender diverse (TGD) adults. It is not meant to be a substitute for chapters on the assessment or evaluation of people for hormonal or surgical interventions. Many TGD people will not require therapy or other forms of mental health care as part of their transition, while others may benefit from the support of mental health providers and systems (Dhejne et al., 2016).

Some studies have shown a higher prevalence of depression (Witcomb et al., 2018), anxiety (Bouman et al., 2017), and suicidality (Arcelus et al., 2016; Bränström & Pachankis, 2022; Davey et al., 2016; Dhejne, 2011; Herman et al., 2019) among TGD people (Jones et al., 2019; Thorne, Witcomb et al., 2019) than in the general population, particularly in those requiring medically necessary gender-affirming medical treatment (see medically necessary statement in Chapter 2—Global Applicability, Statement 2.1). However, transgender identity is not a mental illness, and these elevated rates have been linked to complex trauma, societal stigma, violence, and discrimination (Nuttbrock et al., 2014; Peterson et al., 2021). In addition, psychiatric symptoms lessen with appropriate gender-affirming medical and surgical care (Aldridge et al., 2020; Almazan and Keuroghlian; 2021; Bauer et al., 2015; Grannis et al., 2021) and with interventions that lessen discrimination and minority stress (Bauer et al., 2015; Heylens, Verroken et al., 2014; McDowell et al., 2020).

Mental health treatment needs to be provided by staff and implemented through the use of systems that respect patient autonomy and recognize gender diversity. MHPs working with transgender people should use active listening as a method to encourage exploration in individuals who are uncertain about their gender identity. Rather than impose their own narratives or preconceptions, MHPs should assist their clients in determining their own paths. While many transgender people require medical or surgical interventions or seek mental health care, others do not (Margulies et al., 2021). Therefore, findings from research involving clinical populations should not be extrapolated to the entire transgender population.

Addressing mental illness and substance use disorders is important but should not be a barrier to transition-related care. Rather, these interventions to address mental health and substance use disorders can facilitate successful outcomes from transition-related care, which can improve quality of life (Nobili et al., 2018).

All the statements in this chapter have been recommended based on a thorough review of evidence, an assessment of the benefits and harms, values and preferences of providers and patients, and resource use and feasibility. In some cases, we recognize evidence is limited and/or services may not be accessible or desirable.

Statement 18.1

We recommend mental health professionals address mental health symptoms that interfere with a person’s capacity to consent to gender-affirming treatment before gender-affirming treatment is initiated.

Because patients generally are assumed to be capable of providing consent for care, whether the presence of cognitive impairment, psychosis, or other mental illness impairs the ability to give informed consent is subject to individual examination (Applebaum, 2007). Informed consent is central to the provision of health care. The health care provider must educate the patient about the risks, benefits, and alternatives to any care that is offered so the patient can make an informed, voluntary choice (Berg et al., 2001). Both the primary care provider or endocrinologist prescribing hormones and the surgeon performing surgery must obtain informed consent. Similarly, MHPs obtain informed consent for mental health treatment and may consult on a patient’s capacity to give informed consent when this is in question. Psychiatric illness and substance use disorders, in particular cognitive impairment and psychosis, may impair an individual’s ability to understand the risks and benefits of the treatment (Hostiuc et al., 2018). Conversely, a patient may also have significant mental illness, yet still be able to understand the risks and benefits of a particular treatment (Carpenter et al., 2000). Multidisciplinary communication is important in challenging cases, and expert consultation should be utilized as needed (Karasic & Fraser, 2018). For many patients, difficulty understanding the risks and benefits of a particular treatment can be overcome with time and careful explanation. For some patients, treatment of the underlying condition that is interfering with the capacity to give informed consent—for example treating an underlying psychosis—will allow the patient to gain the capacity to consent to the required treatment. However, mental health symptoms such as anxiety or depressive symptoms that do not affect the capacity to give consent should not be a barrier for gender-affirming medical treatment, particularly as this treatment has been found to reduce mental health symptomatology (Aldridge et al., 2020).

Statement 18.2

We recommend mental health professionals offer care and support to transgender and gender diverse people to address mental health symptoms that interfere with a person’s capacity to participate in essential perioperative care before gender-affirmation surgery.

The inability to adequately participate in perioperative care due to mental illness or substance use should not be viewed as an obstacle to needed transition care, but should be seen as an indication mental health care and social support be provided (Karasic, 2020). Mental illness and substance use disorders may impair the ability of the patient to participate in perioperative care (Barnhill, 2014). Visits to health care providers, wound care, and other aftercare procedures (e.g., dilation after vaginoplasty) may be necessary for a good outcome. A patient with a substance use disorder might have difficulty keeping necessary appointments to the primary care provider and the surgeon. A patient with psychosis or severe depression might neglect their wound or not be attentive to infection or signs of dehiscence (Lee, Marsh et al., 2016). Active mental illness is associated with a greater need for further acute medical and surgical care after the initial surgery (Wimalawansa et al., 2014).

In these cases, treatment of the mental illness or substance use disorder may assist in achieving successful outcomes. Arranging more support for the patient from family and friends or a home health care worker may help the patient participate sufficiently in perioperative care for surgery to proceed. The benefits of mental health treatments that may delay surgery should be weighed against the risks of delaying surgery and should include an assessment of the impact on the patients’ mental health delays may cause in addressing gender dysphoria (Byne et al., 2018).

Statement 18.3

We recommend when significant mental health symptoms or substance abuse exists, mental health professionals assess the potential negative impact mental health symptoms may have on outcomes based on the nature of the specific gender-affirming surgical procedure.

Gender-affirming surgical procedures vary in terms of their impact on the patient. Some procedures require a greater ability to follow preoperative planning as well as engage in peri- and postoperative care to achieve the best outcomes (Tollinche et al., 2018). Mental health symptoms can influence a patient’s ability to participate in the planning and perioperative care necessary for any surgical procedure (Paredes et al., 2020). The mental health assessment can provide an opportunity to develop strategies to address the potential negative impact mental health symptoms may have on outcomes and to plan support for the patient’s ability to participate in the planning and care. Gender-affirming surgical procedures have been shown to relieve symptoms of gender dysphoria and improve mental health (Owen-Smith et al., 2018; van de Grift, Elaut et al., 2017). These benefits are weighed against the risks of each procedure when the patient and provider are deciding whether to proceed with the treatment. HCPs can assist TGD people in reviewing preplanning and perioperative care instructions for each surgical procedure (Karasic, 2020). Provider and patient can collaboratively determine the necessary support or resources needed to assist with keeping appointments for perioperative care, obtaining necessary supplies, addressing financial issues, and handling other preoperative coordination and planning. In addition, issues surrounding appearance-related and functional expectations, including the impact of these various factors on gender dysphoria, can be explored.

Statement 18.4

We recommend health care professionals assess the need for psychosocial and practical support of transgender and gender diverse people in the perioperative period surrounding gender-affirmation surgery.

Regardless of specialty, all HCPs have a responsibility to support patients in accessing medically necessary care. When HCPs are working with TGD people as they prepare for gender-affirming surgical procedures, they should assess the levels of psychosocial and practical support required (Deutsch, 2016b). Assessment is the first step in recognizing where additional support may be needed and enhancing the ability to work collaboratively with the individual to successfully navigate the pre-, peri-, and postsurgical periods (Tollinche et al., 2018). In the perioperative period, it is important to help patients optimize functioning, secure stable housing, when possible, build social and family supports by assessing their unique situation, plan ways of responding to medical complications, navigate the potential impact on work/income, and overcome additional hurdles some patients may encounter, such as coping with electrolysis and tobacco cessation (Berli et al., 2017). In a complex medical system, not all patients will be able to independently navigate the procedures required to obtain care, and HCPs and peer navigators can support patients through this process (Deutsch, 2016a).

Statement 18.5

We recommend health care professionals counsel and assist transgender and gender diverse people in becoming abstinent from tobacco/nicotine prior to gender-affirmation surgery.

Transgender populations have higher rates of tobacco and nicotine use (Kidd et al., 2018). However, many are unaware of the well-documented smoking-associated health risks (Bryant et al., 2014). Tobacco consumption increases the risk of developing health problems (e.g., thrombosis) in individuals receiving gender-affirming hormone treatment, particularly estrogens (Chipkin & Kim, 2017).

Tobacco use has been associated with worse outcomes in plastic surgery, including overall complications, tissue necrosis, and the need for surgical revision (Coon et al., 2013). Smoking also increases the risk for postoperative infection (Kaoutzanis et al., 2019). Tobacco use has been shown to affect the healing process following any surgery, including gender-related surgeries (e.g., chest reconstructive surgery, genital surgery) (Pluvy, Garrido et al., 2015). Tobacco users have a higher risk of cutaneous necrosis, delayed wound healing, and scarring disorders due to hypoxia and tissue ischemia (Pluvy, Panouilleres et al., 2015). In view of this, surgeons recommend stopping the use of tobacco/nicotine prior to gender-affirmation surgery and abstaining from smoking up to several weeks postoperatively until the wound has completely healed (Matei & Danino, 2015). Despite the risks, cessation may be difficult. Tobacco smoking and nicotine use is addictive and is also used as a coping mechanism (Matei et al., 2015). HCPs who see patients longitudinally before surgery, including mental health and primary care providers, should address the use of tobacco/nicotine with individuals in their care, and either assist TGD people in accessing smoking cessation programs or provide treatment directly (e.g., varenicline or bupropion).

Statement 18.6

We recommend health care professionals maintain existing hormone treatment if a transgender and gender diverse individual requires admission to a psychiatric or medical inpatient unit, unless contraindicated.

TGD people entering inpatient psychiatric, substance use treatment, or medical units should be maintained on their current hormone regimens. There is an absence of evidence supporting routine cessation of hormones prior to medical or psychiatric admissions. Rarely, a newly admitted patient may be diagnosed with a medical complication necessitating suspension of hormone treatment, for example an acute venous thromboembolism (Deutsch, 2016a). There is no strong evidence for routinely stopping hormone treatment prior to surgery, and the risks and benefits for each individual patient should be assessed before doing so (Boskey et al., 2018).

Hormone treatment has been shown to improve quality of life and to decrease depression and anxiety (Aldridge et al., 2020; Nguyen et al., 2018; Nobili et al., 2018; Owen-Smith et al., 2018, Rowniak et al., 2019). Access to gender-affirming medical treatment is associated with a substantial reduction in the risk of suicide attempt (Bauer et al., 2015). Halting a patient’s regularly prescribed hormones denies the patient of these salutary effects, and therefore may be counter to the goals of hospitalization.

Some providers may be unaware of the low risk of harm and the high potential benefit of continuing transition-related treatment in the inpatient setting. A study of US and Canadian medical schools revealed that students received an average of 5 hours of LGBT-related course content over their entire four years of education (Obedin-Maliver et al., 2011). According to a survey of Emergency Medicine physicians, who are often responsible for making quick decisions about medications as patients are being admitted, while 88% reported caring for transgender patients, only 17.5% had received any formal training about this population (Chisolm-Straker et al., 2018). As education about transgender topics increases, more providers will become aware of the importance of maintaining transgender patients on their hormone regimens during hospitalization.

Statement 18.7

We recommend health care professionals ensure if transgender and gender diverse people need inpatient or residential mental health, substance abuse, or medical care, all staff use the correct name and pronouns (as provided by the patient), as well as provide access to bathroom and sleeping arrangements that are aligned with the person's gender identity.

Many TGD patients encounter discrimination in a wide range of health settings, including hospitals, mental health treatment settings, and drug treatment programs (Grant et al., 2011). When health systems fail to accommodate TGD individuals, they reinforce the longstanding societal exclusion many have experienced (Karasic, 2016). Experiences of discrimination in health settings lead to avoidance of needed health care due to anticipated discrimination (Kcomt et al., 2020).

The experience of discrimination experienced by TGD individuals is predictive of suicidal ideation (Rood et al., 2015; Williams et al., 2021). Gender minority stress associated with rejection and nonaffirmation has also been associated with suicidality (Testa et al., 2017). Denial of access to gender appropriate bathrooms has been associated with increased suicidality (Seelman, 2016). However, the use of chosen names for TGD people has been associated with lower depression and suicidality (Russell et al., 2018). Structural as well as internalized transphobia must be addressed to reduce the incidence of suicide attempts in TGD people (Brumer et al., 2015). To successfully provide care, health settings must minimize the harm done to patients because of transphobia by respecting and accommodating TGD identities.

Statement 18.8

We recommend mental health professionals encourage, support, and empower transgender and gender diverse people to develop and maintain social support systems, including peers, friends, and families.

While minority stress and the direct effects of discriminatory societal discrimination can be harmful to the mental health of TGD people, strong social support can help lessen this harm (Trujillo et al., 2017). TGD children often internalize rejection from family and peers as well as the transphobia that surrounds them (Amodeo et al., 2015). Furthermore, exposure to transphobic abuse may be impactful across a person’s lifespan and may be particularly acute during the adolescent years (Nuttbrock et al., 2010).

The development of affirming social support is protective of mental health. Social support can act as a buffer against the adverse mental health consequences of violence, stigma, and discrimination (Bockting et al., 2013), can assist in navigating health systems (Jackson Levin et al., 2020), and can contribute to psychological resilience in TGD people (Bariola et al., 2015; Başar and Öz, 2016). Diverse sources of social support, especially LGBTQ + peers and family, have been found to be associated with better mental health outcomes, well-being, and quality of life (Bariola et al., 2015; Başar et al., 2016; Kuper, Adams et al., 2018; Puckett et al., 2019). Social support has been proposed to facilitate the development of coping mechanisms and lead to positive emotional experiences throughout the transition process (Budge et al., 2013).

HCPs can support patients in developing social support systems that allow them to be recognized and accepted as their authentic identity and help them cope with symptoms of gender dysphoria. Interpersonal problems and lack of social support have been associated with a greater incidence of mental health difficulties in TGD people (Bouman, Davey et al., 2016; Davey et al., 2015) and have been shown to be an outcome predictor of gender-affirming medical treatment (Aldridge et al., 2020). Therefore, HCPs should encourage, support, and empower TGD people to develop and maintain social support systems. These experiences can foster the development of interpersonal skills and help with coping with societal discrimination, potentially reducing suicidality and improving mental health (Pflum et al., 2015).

Statement 18.9

We recommend health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people.

Psychotherapy has a long history of being used in clinical work with TGD people (Fraser, 2009b). The aims, requirements, methods and principles of psychotherapy have been an evolving component of the Standards of Care from the initial versions (Fraser, 2009a). At present, psychotherapeutic assistance and counseling with adult TGD people may be sought to address common psychological concerns related to coping with gender dysphoria and may also help some individuals with the coming-out process (Hunt, 2014). Psychological interventions, including psychotherapy, offer effective tools and provide context for the individual, such as exploring gender identity and its expression, enhancing self-acceptance and hope, and improving resilience in hostile and disabling environments (Matsuno and Israel, 2018). Psychotherapy is an established alternative therapeutic approach for addressing mental health symptoms that may be revealed during the initial assessment or later during the follow-up for gender-affirming medical interventions. Recent research shows, although mental health symptoms are reduced following gender-affirming medical treatment, levels of anxiety remain high (Aldridge et al., 2020) suggesting psychological therapy can play a role in helping individuals suffering from anxiety symptoms following gender-affirming treatment.

In recent years, the uses and potential benefits of specific psychotherapeutic modalities have been reported (Austin et al., 2017; Budge, 2013; Budge et al., 2021; Embaye, 2006; Fraser, 2009b; Heck et al., 2015). Specific models of psychotherapy have been proposed for adult transgender and nonbinary individuals (Matsuno & Israel, 2018). However, more empiric data is needed on the comparative benefits of different psychotherapeutic models (Catelan et al., 2017). Psychotherapy can be experienced by transgender persons as a fearful as well as a beneficial experience (Applegarth & Nuttall, 2016) and presents challenges to the therapist and to alliance formation when it is associated with gatekeeping for medical interventions (Budge, 2015).

Experience suggests many transgender and nonbinary individuals decide to undergo gender- affirming medical treatment with little or no use of psychotherapy (Spanos et al., 2021). Although various modalities of psychotherapy may be beneficial for different reasons before, during, and after gender-affirming medical treatments and varying rates of desire for psychotherapy have been reported during different stages of transition (Mayer et al., 2019), a requirement for psychotherapy for initiating gender-affirming medical procedures has not been shown to be beneficial and may be a harmful barrier to care for those who do not need this type of treatment or who lack access to it.

Statement 18.10

We recommend “reparative” and “conversion” therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered.

The use of “reparative” or “conversion” therapy or gender identity “change” efforts is opposed by many major medical and mental health organizations across the world, including the World Psychiatric Association, Pan American Health Organization, American Psychiatric and American Psychological Associations, Royal College of Psychiatrists, and British Psychological Society. Many states in the US have instituted bans on practicing conversion therapy with minors. Gender identity change efforts refers to interventions by MHPs or others that attempt to change gender identity or expression to be more in line with those typically associated with the person’s sex assigned at birth (American Psychological Association, 2021).

Advocates of “conversion therapy” have suggested it could potentially allow a person to fit better into their social world. They also point out some clients specifically ask for help changing their gender identities or expressions and therapists should be allowed to help clients achieve their goals. However, “conversion therapy” has not been shown to be effective (APA, 2009; Przeworski et al., 2020). In addition, there are numerous potential harms. In retrospective studies, a history of having undergone conversion therapy is linked to increased levels of depression, substance abuse, suicidal thoughts, and suicide attempts, as well as lower educational attainment and less weekly income (Ryan et al., 2020; Salway et al., 2020; Turban, Beckwith et al., 2020). In 2021, the American Psychological Association resolutions states that “scientific evidence and clinical experience indicate that GICEs [gender identity change efforts] put individuals at significant risk of harm” (APA, 2021).

While there are barriers to ending gender identity “change” efforts, education about the lack of benefit and the potential harm of these practices may lead to fewer providers offering “conversion therapy” and fewer individuals and families choosing this option.

Conflict of Interest

Conflict of interests were reviewed as part of the selection process for committee members and at the end of the process before publication. No conflicts of interest were deemed significant or consequential.

Ethical Approval

This manuscript does not contain any studies with human participants performed by any of the authors.

Funding

This project was partly funded from a grant of the Tawani Foundation. Most of the expenses went to pay the Evidence-based Practice Center of Johns Hopkins University for their work. Editors and reference checkers were paid nominal fees. Committee members were not paid for their contributions. Some travel expenses for committee chairs were covered by the World Professional Association for Transgender Health (WPATH). WPATH staff and other internal expenses were covered by the Association’s budget.