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Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

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Abstract

The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.
International Journal of Transgenderism, 13:165–232, 2011
Copyright
C
World Professional Association for Transgender Health
ISSN: 1553-2739 print / 1434-4599 online
DOI: 10.1080/15532739.2011.700873
Standards of Care for the Health of Transsexual,
Transgender, and Gender-Nonconforming People, Version 7
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,
Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R.,
Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I.,
Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B.,
Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S.,
Wylie, K. R., & Zucker, K.
ABSTRACT. The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender
Nonconforming People is a publication of the World Professional Association for Transgender Health
(WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to
assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to
achieving lasting personal comfort with their gendered selves, in order to maximize their overall health,
psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic
and urologic care, reproductive options, voice and communication therapy, mental health services (e.g.,
assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based
on the best available science and expert professional consensus. Because most of the research and
experience in this field comes from a North American and Western European perspective, adaptations
of the SOC to other parts of the world are necessary. The SOC articulate standards of care while
acknowledging the role of making informed choices and the value of harm reduction approaches. In
addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or
distress that is caused by a discrepancy between persons gender identity and that persons sex assigned
at birth (and the associated gender role and/or primary and secondary sex characteristics) has become
more individualized. Some individuals who present for care will have made significant self-directed
progress towards gender role changes or other resolutions regarding their gender identity or gender
dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC
to help patients consider the full range of health services open to them, in accordance with their clinical
needs and goals for gender expression.
KEYWORDS. Transexual, transgender, gender dysphoria, Standards of Care
This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous
revisions were in 1980, 1981, 1990, 1998, and 2001.
Address correspondence to Eli Coleman, PhD, Program in Human Sexuality, University of Minnesota
Medical School, 1300 South 2nd Street, Suite 180, Minneapolis, MN 55454. E-mail: colem001@umn.edu
165
166 INTERNATIONAL JOURNAL OF TRANSGENDERISM
I. PURPOSE AND USE OF THE
STANDARDS OF CARE
The World Professional Association for
Transgender Health (WPATH)
1
is an interna-
tional, multidisciplinary, professional associa-
tion whose mission is to promote evidence-
based care, education, research, advocacy, public
policy, and respect in transsexual and transgen-
der health. The vision of WPATH is a world
wherein transsexual, transgender, and gender-
nonconforming people benefit from access to
evidence-based health care, social services, jus-
tice, and equality.
One of the main functions of WPATH is to
promote the highest standards of health care for
individuals through the articulation of Standards
of Care (SOC) for the Health of Transsexual,
Transgender, and Gender-Nonconforming Peo-
ple.TheSOC are based on the best available
science and expert professional consensus.
2
Most of the research and experience in this
field comes from a North American and Western
European perspective; thus, adaptations of the
SOC to other parts of the world are necessary.
Suggestions for ways of thinking about cultural
relativity and cultural competence are included
in this version of the SOC.
The overall goal of the SOC is to pro-
vide clinical guidance for health professionals
to assist transsexual, transgender, and gender-
nonconforming people with safe and effective
pathways to achieving lasting personal comfort
with their gendered selves, in order to maximize
their overall health, psychological well-being,
and self-fulfillment. This assistance may include
primary care, gynecologic and urologic care,
reproductive options, voice and communication
therapy, mental health services (e.g., assessment,
1
Formerly the Harry Benjamin International
Gender Dysphoria Association.
2
The Standards of Care (SOC), Version 7, repre-
sents a significant departure from previous versions.
Changes in this version are based upon significant
cultural shifts, advances in clinical knowledge, and
appreciation of the many health care issues that
can arise for transsexual, transgender, and gender-
nonconforming people beyond hormone therapy and
surgery (Coleman, 2009a, 2009b, 2009c, 2009d).
counseling, psychotherapy), and hormonal and
surgical treatments. While this is primarily a
document for health professionals, the SOC
may also be used by individuals, their families,
and social institutions to understand how they
can assist with promoting optimal health for
members of this diverse population.
WPATH recognizes that health is dependent
upon not only good clinical care but also social
and political climates that provide and ensure so-
cial tolerance, equality, and the full rights of citi-
zenship. Health is promoted through public poli-
cies and legal reforms that promote tolerance and
equity for gender and sexual diversity and that
eliminate prejudice, discrimination, and stigma.
WPATH is committed to advocacy for these
changes in public policies and legal reforms.
The Standards of Care Are Flexible
Clinical Guidelines
The SOC are intended to be flexible in order
to meet the diverse health care needs of trans-
sexual, transgender, and gender-nonconforming
people. While flexible, they offer standards
for promoting optimal health care and guiding
the treatment of people experiencing gender
dysphoria—broadly defined as discomfort or
distress that is caused by a discrepancy between
a person’s gender identity and that person’s sex
assigned at birth (and the associated gender role
and/or primary and secondary sex character-
istics) (Fisk, 1974; Knudson, De Cuypere, &
Bockting, 2010b).
As in all previous versions of the SOC,the
criteria put forth in this document for hormone
therapy and surgical treatments for gender dys-
phoria are clinical guidelines; individual health
professionals and programs may modify them.
Clinical departures from the SOC may come
about because of a patient’s unique anatomic, so-
cial, or psychological situation; an experienced
health professional’s evolving method of han-
dling a common situation; a research protocol;
lack of resources in various parts of the world;
or the need for specific harm-reduction strate-
gies. These departures should be recognized as
such, explained to the patient, and documented
through informed consent for quality patient care
and legal protection. This documentation is also
Coleman et al. 167
valuable for the accumulation of new data, which
can be retrospectively examined to allow for
health care—and the SOC—to evolve.
The SOC articulate standards of care but
also acknowledge the role of making informed
choices and the value of harm-reduction ap-
proaches. In addition, this version of the SOC
recognizes and validates various expressions of
gender that may not necessitate psychological,
hormonal, or surgical treatments. Some patients
who present for care will have made signifi-
cant self-directed progress towards gender role
changes, transition, or other resolutions regard-
ing their gender identity or gender dysphoria.
Other patients will require more intensive ser-
vices. Health professionals can use the SOC to
help patients consider the full range of health
services open to them, in accordance with their
clinical needs and goals for gender expression.
II. GLOBAL APPLICABILITY OF THE
STANDARDS OF CARE
While the SOC are intended for worldwide
use, WPATH acknowledges that much of the
recorded clinical experience and knowledge in
this area of health care is derived from North
American and Western European sources. From
place to place, both across and within nations,
there are differences in all of the following:
social attitudes towards transsexual, transgender,
and gender-nonconforming people; construc-
tions of gender roles and identities; language
used to describe different gender identities;
epidemiology of gender dysphoria; access to and
cost of treatment; therapies offered; number and
type of professionals who provide care; and legal
and policy issues related to this area of health
care (Winter, 2009).
It is impossible for the SOC to reflect all of
these differences. In applying these standards
to other cultural contexts, health professionals
must be sensitive to these differences and
adapt the SOC according to local realities.
For example, in a number of cultures, gender-
nonconforming people are found in such num-
bersandlivinginsuchwaysastomakethem
highly socially visible (Peletz, 2006). In settings
such as these, it is common for people to
initiate a change in their gender expression
and physical characteristics while in their teens
or even earlier. Many grow up and live in
a social, cultural, and even linguistic context
quite unlike that of Western cultures. Yet almost
all experience prejudice (Peletz, 2006; Winter,
2009). In many cultures, social stigma towards
gender nonconformity is widespread and gender
roles are highly prescriptive (Winter et al., 2009).
Gender-nonconforming people in these settings
are forced to be hidden and, therefore, may lack
opportunities for adequate health care (Winter,
2009).
The SOC are not intended to limit efforts
to provide the best available care to all in-
dividuals. Health professionals throughout the
world—even in areas with limited resources
and training opportunities—can apply the many
core principles that undergird the SOC. These
principles include the following: Exhibit re-
spect for patients with nonconforming gender
identities (do not pathologize differences in
gender identity or expression); provide care
(or refer to knowledgeable colleagues) that
affirms patients’ gender identities and reduces
the distress of gender dysphoria, when present;
become knowledgeable about the health care
needs of transsexual, transgender, and gender-
nonconforming people, including the benefits
and risks of treatment options for gender dys-
phoria; match the treatment approach to the
specific needs of patients, particularly their goals
for gender expression and need for relief from
gender dysphoria; facilitate access to appropriate
care; seek patients’ informed consent before
providing treatment; offer continuity of care; and
be prepared to support and advocate for patients
within their families and communities (schools,
workplaces, and other settings).
Terminology is culturally and time-dependent
and is rapidly evolving. It is important to use
respectful language in different places and times,
and among different people. As the SOC are
translated into other languages, great care must
be taken to ensure that the meanings of terms are
accurately translated. Terminology in English
may not be easily translated into other languages,
and vice versa. Some languages do not have
equivalent words to describe the various terms
within this document; hence, translators should
168 INTERNATIONAL JOURNAL OF TRANSGENDERISM
be cognizant of the underlying goals of treatment
and articulate culturally applicable guidance for
reaching those goals.
III. THE DIFFERENCE BETWEEN
GENDER NONCONFORMITY
AND GENDER DYSPHORIA
Being Transsexual, Transgender,
or Gender Nonconforming Is a Matter
of Diversity, Not Pathology
WPATH released a statement in May 2010
urging the de-psychopathologization of gender
nonconformity worldwide (WPATH Board of
Directors, 2010). This statement noted that “the
expression of gender characteristics, including
identities, that are not stereotypically associated
with one’s assigned sex at birth is a common
and culturally diverse human phenomenon [that]
should not be judged as inherently pathological
or negative.
Unfortunately, there is a stigma attached to
gender nonconformity in many societies around
the world. Such stigma can lead to prejudice
and discrimination, resulting in “minority stress”
(I. H. Meyer, 2003). Minority stress is unique
(additive to general stressors experienced by
all people), socially based, and chronic, and
may make transsexual, transgender, and gender-
nonconforming individuals more vulnerable to
developing mental health problems such as
anxiety and depression (Institute of Medicine,
2011). In addition to prejudice and discrimina-
tion in society at large, stigma can contribute
to abuse and neglect in one’s relationships with
peers and family members, which in turn can
lead to psychological distress. However, these
symptoms are socially induced and are not
inherent to being transsexual, transgender, or
gender-nonconforming.
Gender Nonconformity Is Not the Same
as Gender Dysphoria
Gender nonconformity refers to the extent
to which a person’s gender identity, role,
or expression differs from the cultural norms
prescribed for people of a particular sex (Institute
of Medicine, 2011). Gender dysphoria refers to
discomfort or distress that is caused by a discrep-
ancy between a person’s gender identity and that
person’s sex assigned at birth (and the associated
gender role and/or primary and secondary sex
characteristics) (Fisk, 1974; Knudson, De
Cuypere, & Bockting, 2010b). Only some
gender-nonconforming people experience
gender dysphoria at some point in their lives.
Treatment is available to assist people with
such distress to explore their gender identity
and find a gender role that is comfortable for
them (Bockting & Goldberg, 2006). Treatment is
individualized: What helps one person alleviate
gender dysphoria might be very different from
what helps another person. This process may
or may not involve a change in gender expres-
sion or body modifications. Medical treatment
options include, for example, feminization or
masculinization of the body through hormone
therapy and/or surgery, which are effective in
alleviating gender dysphoria and are medically
necessary for many people. Gender identities
and expressions are diverse, and hormones and
surgery are just two of many options available
to assist people with achieving comfort with self
and identity.
Gender dysphoria can in large part be alle-
viated through treatment (Murad et al., 2010).
Hence, while transsexual, transgender, and
gender-nonconforming people may experience
gender dysphoria at some points in their lives,
many individuals who receive treatment will find
a gender role and expression that is comfortable
for them, even if these differ from those asso-
ciated with their sex assigned at birth, or from
prevailing gender norms and expectations.
Diagnoses Related to Gender Dysphoria
Some people experience gender dysphoria
at such a level that the distress meets criteria
for a formal diagnosis that might be classi-
fied as a mental disorder. Such a diagnosis
is not a license for stigmatization or for the
deprivation of civil and human rights. Existing
classification systems such as the Diagnostic
Statistical Manual of Mental Disorders (DSM)
(American Psychiatric Association, 2000) and
the International Classification of Diseases
Coleman et al. 169
(ICD) (World Health Organization, 2007) define
hundreds of mental disorders that vary in onset,
duration, pathogenesis, functional disability, and
treatability. All of these systems attempt to
classify clusters of symptoms and conditions,
not the individuals themselves. A disorder is a
description of something with which a person
might struggle, not a description of the person
or the person’s identity.
Thus, transsexual, transgender, and gender-
nonconforming individuals are not inherently
disordered. Rather, the distress of gender dys-
phoria, when present, is the concern that might
be diagnosable and for which various treatment
options are available. The existence of a diagno-
sis for such dysphoria often facilitates access to
health care and can guide further research into
effective treatments.
Research is leading to new diagnostic nomen-
clatures, and terms are changing in both the DSM
(Cohen-Kettenis & Pf
¨
afflin, 2010; Knudson, De
Cuypere, & Bockting, 2010b; Meyer-Bahlburg,
2010; Zucker, 2010) and the ICD. For this
reason, familiar terms are employed in the
SOC and definitions are provided for terms that
may be emerging. Health professionals should
refer to the most current diagnostic criteria and
appropriate codes to apply in their practice areas.
IV. EPIDEMIOLOGIC
CONSIDERATIONS
Formal epidemiologic studies on the
incidence
3
and prevalence
4
of transsexual-
ism specifically or transgender and gender-
nonconforming identities in general have not
been conducted, and efforts to achieve realistic
estimates are fraught with enormous difficul-
ties (Institute of Medicine, 2011; Zucker &
Lawrence, 2009). Even if epidemiologic studies
established that a similar proportion of trans-
sexual, transgender, or gender-nonconforming
people existed all over the world, it is likely
3
Incidence—the number of new cases arising in
a given period (e.g., a year).
4
Prevalence—the number of individuals having
a 4035 condition, divided by the number of people in
the general population.
that cultural differences from one country to
another would alter both the behavioral ex-
pressions of different gender identities and the
extent to which gender dysphoria—distinct from
one’s gender identity—is actually occurring in a
population. While in most countries, crossing
normative gender boundaries generates moral
censure rather than compassion, there are exam-
ples in certain cultures of gender-nonconforming
behaviors (e.g., in spiritual leaders) that are less
stigmatized and even revered (Besnier, 1994;
Bolin, 1988; Chi
˜
nas, 1995; Coleman, Colgan, &
Gooren, 1992; Costa & Matzner, 2007; Jackson
& Sullivan, 1999; Nanda, 1998; Taywaditep,
Coleman, & Dumronggittigule, 1997).
For various reasons, researchers who have
studied incidence and prevalence have tended
to focus on the most easily counted subgroup of
gender-nonconforming individuals: transsexual
individuals who experience gender dysphoria
and who present for gender-transition-related
care at specialist gender clinics (Zucker &
Lawrence, 2009). Most studies have been con-
ducted in European countries such as Sweden
(W
˚
alinder, 1968, 1971), the United Kingdom
(Hoenig & Kenna, 1974), the Netherlands
(Bakker, Van Kesteren, Gooren, & Bezemer,
1993; Eklund, Gooren, & Bezemer, 1988; van
Kesteren, Gooren, & Megens, 1996), Germany
(Weitze & Osburg, 1996), and Belgium (De
Cuypere et al., 2007). One was conducted in
Singapore (Tsoi, 1988).
De Cuypere and colleagues (2007) reviewed
such studies, as well as conducted their own.
Together, those studies span 39 years. Leaving
aside two outlier findings from Pauly in 1965
and Tsoi in 1988, ten studies involving eight
countries remain. The prevalence figures re-
ported in these ten studies range from 1:11,900 to
1:45,000 for male-to-female individuals (MtF)
and 1:30,400 to 1:200,000 for female-to-male
(FtM) individuals. Some scholars have sug-
gested that the prevalence is much higher,
depending on the methodology used in the
research (e.g., Olyslager & Conway, 2007).
Direct comparisons across studies are impos-
sible, as each differed in their data collection
methods and in their criteria for documenting
a person as transsexual (e.g., whether or not
a person had undergone genital reconstruction,
170 INTERNATIONAL JOURNAL OF TRANSGENDERISM
versus had initiated hormone therapy, versus had
come to the clinic seeking medically supervised
transition services). The trend appears to be
towards higher prevalence rates in the more
recent studies, possibly indicating increasing
numbers of people seeking clinical care. Support
for this interpretation comes from research by
Reed and colleagues (2009), who reported a
doubling of the numbers of people accessing
care at gender clinics in the United Kingdom
every five or six years. Similarly, Zucker and
colleagues (2008) reported a four- to five-fold
increase in child and adolescent referrals to their
Toronto, Canada, clinic over a 30-year period.
The numbers yielded by studies such as these
can be considered minimum estimates at best.
The published figures are mostly derived from
clinics where patients met criteria for severe
gender dysphoria and had access to health care
at those clinics. These estimates do not take into
account that treatments offered in a particular
clinic setting might not be perceived as afford-
able, useful, or acceptable by all self-identified
gender dysphoric individuals in a given area. By
counting only those people who present at clinics
for a specific type of treatment, an unspecified
number of gender dysphoric individuals are
overlooked.
Other clinical observations (not yet firmly
supported by systematic study) support the
likelihood of a higher prevalence of gender
dysphoria: (i) Previously unrecognized gender
dysphoria is occasionally diagnosed when pa-
tients are seen with anxiety, depression, conduct
disorder, substance abuse, dissociative identity
disorders, borderline personality disorder, sex-
ual disorders, and disorders of sex develop-
ment (Cole, O’Boyle, Emory, & Meyer, 1997).
(ii) Some cross-dressers, drag queens/kings or
female/male impersonators, and gay and les-
bian individuals may be experiencing gender
dysphoria (Bullough & Bullough, 1993). (iii)
The intensity of some people’s gender dysphoria
fluctuates below and above a clinical thresh-
old (Docter, 1988). (iv) Gender nonconformity
among FtM individuals tends to be relatively in-
visible in many cultures, particularly to Western
health professionals and researchers who have
conducted most of the studies on which the
current estimates of prevalence and incidence
are based (Winter, 2009).
Overall, the existing data should be consid-
ered a starting point, and health care would
benefit from more rigorous epidemiologic study
in different locations worldwide.
V. OVERVIEW OF THERAPEUTIC
APPROACHES FOR GENDER
DYSPHORIA
Advancements in the Knowledge and
Treatment of Gender Dysphoria
In the second half of the 20th century,
awareness of the phenomenon of gender
dysphoria increased when health professionals
began to provide assistance to alleviate gender
dysphoria by supporting changes in primary and
secondary sex characteristics through hormone
therapy and surgery, along with a change in
gender role. Although Harry Benjamin already
acknowledged a spectrum of gender noncon-
formity (Benjamin, 1966), the initial clinical
approach largely focused on identifying who was
an appropriate candidate for sex reassignment to
facilitate a physical change from male to female
or female to male as completely as possible (e.g.,
Green & Fleming, 1990; Hastings, 1974). This
approach was extensively evaluated and proved
to be highly effective. Satisfaction rates across
studies ranged from 87% of MtF patients to
97% of FtM patients (Green & Fleming, 1990),
and regrets were extremely rare (1%–1.5%
of MtF patients and < 1% of FtM patients;
Pf
¨
afflin, 1993). Indeed, hormone therapy and
surgery have been found to be medically
necessary to alleviate gender dysphoria in many
people (American Medical Association, 2008;
Anton, 2009; World Professional Association
for Transgender Health, 2008).
As the field matured, health professionals
recognized that while many individuals need
both hormone therapy and surgery to alleviate
their gender dysphoria, others need only one of
these treatment options and some need neither
(Bockting & Goldberg, 2006; Bockting, 2008;
Lev, 2004). Often with the help of psychother-
apy, some individuals integrate their trans-
or cross-gender feelings into the gender role
they were assigned at birth and do not feel the
need to feminize or masculinize their body. For
Coleman et al. 171
others, changes in gender role and expression
are sufficient to alleviate gender dysphoria.
Some patients may need hormones, a possible
change in gender role, but not surgery; others
may need a change in gender role along with
surgery but not hormones. In other words,
treatment for gender dysphoria has become
more individualized.
As a generation of transsexual, transgender,
and gender-nonconforming individuals has
come of age—many of whom have benefitted
from different therapeutic approaches—they
have become more visible as a community and
demonstrated considerable diversity in their
gender identities, roles, and expressions. Some
individuals describe themselves not as gender-
nonconforming but as unambiguously cross-
sexed (i.e., as a member of the other sex; Bockt-
ing, 2008). Other individuals affirm their unique
gender identity and no longer consider them-
selves to be either male or female (Bornstein,
1994; Kimberly, 1997; Stone, 1991; Warren,
1993). Instead, they may describe their gender
identity in specific terms such as transgender,
bigender, or genderqueer, affirming their unique
experiences that may transcend a male/female
binary understanding of gender (Bockting,
2008; Ekins & King, 2006; Nestle, Wilchins, &
Howell, 2002). They may not experience their
process of identity affirmation as a “transition,
because they never fully embraced the gender
role they were assigned at birth or because
they actualize their gender identity, role, and
expression in a way that does not involve a
change from one gender role to another. For
example, some youth identifying as genderqueer
have always experienced their gender identity
and role as such (genderqueer). Greater public
visibility and awareness of gender diversity
(Feinberg, 1996) have further expanded options
for people with gender dysphoria to actualize an
identity and find a gender role and expression
that are comfortable for them.
Health professionals can assist gender dys-
phoric individuals with affirming their gender
identity, exploring different options for expres-
sion of that identity, and making decisions about
medical treatment options for alleviating gender
dysphoria.
Options for Psychological and Medical
Treatment of Gender Dysphoria
For individuals seeking care for gender
dysphoria, a variety of therapeutic options
can be considered. The number and type of
interventions applied and the order in which
these take place may differ from person to person
(e.g., Bockting, Knudson, & Goldberg, 2006;
Bolin, 1994; Rachlin, 1999; Rachlin, Green, &
Lombardi, 2008; Rachlin, Hansbury, & Pardo,
2010). Treatment options include the following:
Changes in gender expression and role
(which may involve living part time or full
time in another gender role, consistent with
one’s gender identity);
Hormone therapy to feminize or masculin-
ize the body;
Surgery to change primary and/or sec-
ondary sex characteristics (e.g., breasts/
chest, external and/or internal genitalia,
facial features, body contouring);
Psychotherapy (individual, couple, family,
or group) for purposes such as explor-
ing gender identity, role, and expression;
addressing the negative impact of gender
dysphoria and stigma on mental health;
alleviating internalized transphobia; en-
hancing social and peer support; improving
body image; or promoting resilience.
Options for Social Support and Changes
in Gender Expression
In addition (or as an alternative) to the
psychological- and medical-treatment options
described above, other options can be considered
to help alleviate gender dysphoria, for example:
In person and online peer support re-
sources, groups, or community organi-
zations that provide avenues for social
support and advocacy;
In person and online support resources for
families and friends;
Voice and communication therapy to help
individuals develop verbal and nonverbal
communication skills that facilitate com-
fort with their gender identity;
172 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Hair removal through electrolysis, laser
treatment, or waxing;
Breast binding or padding, genital tucking
or penile prostheses, padding of hips or
buttocks;
Changes in name and gender marker on
identity documents.
VI. ASSESSMENT AND TREATMENT
OF CHILDREN AND ADOLESCENTS
WITH GENDER DYSPHORIA
There are a number of differences in the phe-
nomenology, developmental course, and treat-
ment approaches for gender dysphoria in chil-
dren, adolescents, and adults. In children and
adolescents, a rapid and dramatic developmental
process (physical, psychological, and sexual)
is involved and there is greater fluidity and
variability in outcomes, particularly in prepu-
bertal children. Accordingly, this section of the
SOC offers specific clinical guidelines for the
assessment and treatment of gender dysphoric
children and adolescents.
Differences Between Children and
Adolescents with Gender Dysphoria
An important difference between gender
dysphoric children and adolescents is in the
proportion for whom dysphoria persists into
adulthood. Gender dysphoria during childhood
does not inevitably continue into adulthood.
5
Rather, in follow-up studies of prepubertal
children (mainly boys) who were referred to
clinics for assessment of gender dysphoria, the
dysphoria persisted into adulthood for only
6%–23% of children (Cohen-Kettenis, 2001;
Zucker & Bradley, 1995). Boys in these studies
were more likely to identify as gay in adulthood
than as transgender (Green, 1987; Money &
Russo, 1979; Zucker & Bradley, 1995; Zuger,
5
Gender-nonconforming behaviors in children
may continue into adulthood, but such behaviors are
not necessarily indicative of gender dysphoria and a
need for treatment. As described in section III, gender
dysphoria is not synonymous with diversity in gender
expression.
1984). Newer studies, also including girls,
showed a 12%–27% persistence rate of gender
dysphoria into adulthood (Drummond, Bradley,
Peterson-Badali, & Zucker, 2008; Wallien &
Cohen-Kettenis, 2008).
In contrast, the persistence of gender dyspho-
ria into adulthood appears to be much higher for
adolescents. No formal prospective studies exist.
However, in a follow-up study of 70 adolescents
who were diagnosed with gender dysphoria and
given puberty-suppressing hormones, all con-
tinued with actual sex reassignment, beginning
with feminizing/masculinizing hormone therapy
(de Vries, Steensma, Doreleijers, & Cohen-
Kettenis, 2010).
Another difference between gender dysphoric
children and adolescents is in the sex ratios
for each age group. In clinically referred,
gender dysphoric children under age 12, the
male/female ratio ranges from 6:1 to 3:1 (Zucker,
2004). In clinically referred, gender dysphoric
adolescents older than age 12, the male/female
ratio is close to 1:1 (Cohen-Kettenis & Pf
¨
afflin,
2003).
As discussed in section IV and by Zucker and
Lawrence (2009), formal epidemiologic studies
on gender dysphoria—in children, adolescents,
and adults—are lacking. Additional research
is needed to refine estimates of its preva-
lence and persistence in different populations
worldwide.
Phenomenology in Children
Children as young as age two may show
features that could indicate gender dysphoria.
They may express a wish to be of the other
sex and be unhappy about their physical sex
characteristics and functions. In addition, they
may prefer clothes, toys, and games that are com-
monly associated with the other sex and prefer
playing with other-sex peers. There appears to be
heterogeneity in these features: Some children
demonstrate extremely gender-nonconforming
behavior and wishes, accompanied by persistent
and severe discomfort with their primary sex
characteristics. In other children, these char-
acteristics are less intense or only partially
present (Cohen-Kettenis et al., 2006; Knudson,
De Cuypere, & Bockting, 2010a).
Coleman et al. 173
It is relatively common for gender dysphoric
children to have coexisting internalizing disor-
ders such as anxiety and depression (Cohen-
Kettenis, Owen, Kaijser, Bradley, & Zucker,
2003; Wallien, Swaab, & Cohen-Kettenis, 2007;
Zucker, Owen, Bradley, & Ameeriar, 2002).
The prevalence of autism spectrum disorders
seems to be higher in clinically referred, gender
dysphoric children than in the general popu-
lation (de Vries, Noens, Cohen-Kettenis, van
Berckelaer-Onnes, & Doreleijers, 2010).
Phenomenology in Adolescents
In most children, gender dysphoria will dis-
appear before, or early in, puberty. However,
in some children these feelings will intensify
and body aversion will develop or increase as
they become adolescents and their secondary sex
characteristics develop (Cohen-Kettenis, 2001;
Cohen-Kettenis & Pf
¨
afflin, 2003; Drummond
et al., 2008; Wallien & Cohen-Kettenis, 2008;
Zucker & Bradley, 1995). Data from one study
suggest that more extreme gender nonconfor-
mity in childhood is associated with persistence
of gender dysphoria into late adolescence and
early adulthood (Wallien & Cohen-Kettenis,
2008). Yet many adolescents and adults pre-
senting with gender dysphoria do not report
a history of childhood gender-nonconforming
behaviors (Docter, 1988; Land
´
en, W
˚
alinder,
& Lundstr
¨
om, 1998). Therefore, it may come
as a surprise to others (parents, other family
members, friends, and community members)
when a youth’s gender dysphoria first becomes
evident in adolescence.
Adolescents who experience their primary
and/or secondary sex characteristics and their
sex assigned at birth as inconsistent with their
gender identity may be intensely distressed
about it. Many, but not all, gender dysphoric
adolescents have a strong wish for hormones
and surgery. Increasing numbers of adolescents
have already started living in their desired gender
role upon entering high school (Cohen-Kettenis
&Pf
¨
afflin, 2003).
Among adolescents who are referred to
gender identity clinics, the number considered
eligible for early medical treatment—starting
with GnRH analogues to suppress puberty in the
first Tanner stages—differs among countries and
centers. Not all clinics offer puberty suppression.
If such treatment is offered, the pubertal stage
at which adolescents are allowed to start varies
from Tanner stage 2 to stage 4 (Delemarre-van
de Waal & Cohen-Kettenis, 2006; Zucker et al.,
2012). The percentages of treated adolescents
are likely influenced by the organization
of health care, insurance aspects, cultural
differences, opinions of health professionals,
and diagnostic procedures offered in different
settings.
Inexperienced clinicians may mistake indica-
tions of gender dysphoria for delusions. Phe-
nomenologically, there is a qualitative difference
between the presentation of gender dysphoria
and the presentation of delusions or other psy-
chotic symptoms. The vast majority of children
and adolescents with gender dysphoria are not
suffering from underlying severe psychiatric
illness such as psychotic disorders (Steensma,
Biemond, de Boer, & Cohen-Kettenis, published
online ahead of print January 7, 2011).
It is more common for adolescents with gen-
der dysphoria to have coexisting internalizing
disorders such as anxiety and depression, and/or
externalizing disorders such as oppositional
defiant disorder (de Vries et al., 2010). As in
children, there seems to be a higher prevalence of
autistic spectrum disorders in clinically referred,
gender dysphoric adolescents than in the general
adolescent population (de Vries et al., 2010).
Competency of Mental Health
Professionals Working with Children
or Adolescents with Gender Dysphoria
The following are recommended minimum
credentials for mental health professionals who
assess, refer, and offer therapy to children and
adolescents presenting with gender dysphoria:
1. Meet the competency requirements for
mental health professionals working with
adults, as outlined in section VII;
2. Trained in childhood and adolescent devel-
opmental psychopathology;
3. Competent in diagnosing and treating the
ordinary problems of children and adoles-
cents.
174 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Roles of Mental Health Professionals
Working with Children and Adolescents
with Gender Dysphoria
The roles of mental health professionals
working with gender dysphoric children and
adolescents may include the following:
1. Directly assess gender dysphoria in chil-
dren and adolescents (see general guide-
lines for assessment, below).
2. Provide family counseling and support-
ive psychotherapy to assist children and
adolescents with exploring their gender
identity, alleviating distress related to their
gender dysphoria, and ameliorating any
other psychosocial difficulties.
3. Assess and treat any coexisting mental
health concerns of children or adolescents
(or refer to another mental health pro-
fessional for treatment). Such concerns
should be addressed as part of the overall
treatment plan.
4. Refer adolescents for additional physical
interventions (such as puberty-suppressing
hormones) to alleviate gender dysphoria.
The referral should include documentation
of an assessment of gender dysphoria and
mental health, the adolescent’s eligibility
for physical interventions (outlined be-
low), the mental health professional’s rel-
evant expertise, and any other information
pertinent to the youth’s health and referral
for specific treatments.
5. Educate and advocate on behalf of gender
dysphoric children, adolescents, and their
families in their community (e.g., day care
centers, schools, camps, other organiza-
tions). This is particularly important in
light of evidence that children and adoles-
cents who do not conform to socially pre-
scribed gender norms may experience ha-
rassment in school (Grossman, D’Augelli,
Howell, & Hubbard, 2006; Grossman,
D’Augelli, & Salter, 2006; Sausa, 2005),
putting them at risk for social isolation,
depression, and other negative sequelae
(Nuttbrock et al., 2010).
6. Provide children, youth, and their families
with information and referral for peer
support, such as support groups for parents
of gender-nonconforming and transgender
children (Gold & MacNish, 2011; Pleak,
1999; Rosenberg, 2002).
Assessment and psychosocial interventions for
children and adolescents are often provided
within a multidisciplinary gender identity
specialty service. If such a multidisciplinary
service is not available, a mental health profes-
sional should provide consultation and liaison
arrangements with a pediatric endocrinologist
for the purpose of assessment, education, and
involvement in any decisions about physical
interventions.
Psychological Assessment of Children
and Adolescents
When assessing children and adolescents who
present with gender dysphoria, mental health
professionals should broadly conform to the
following guidelines:
1. Mental health professionals should not
dismiss or express a negative attitude
towards nonconforming gender identities
or indications of gender dysphoria. Rather,
they should acknowledge the presenting
concerns of children, adolescents, and their
families; offer a thorough assessment for
gender dysphoria and any coexisting men-
tal health concerns; and educate clients and
their families about therapeutic options,
if needed. Acceptance, and alleviation of
secrecy, can bring considerable relief to
gender dysphoric children/adolescents and
their families.
2. Assessment of gender dysphoria and men-
tal health should explore the nature and
characteristics of a child’s or adolescent’s
gender identity. A psychodiagnostic and
psychiatric assessment—covering the ar-
eas of emotional functioning, peer and
other social relationships, and intellectual
functioning/school achievement—should
be performed. Assessment should include
an evaluation of the strengths and weak-
nesses of family functioning. Emotional
and behavioral problems are relatively
Coleman et al. 175
common, and unresolved issues in a child’s
or youth’s environment may be present (de
Vries, Doreleijers, Steensma, & Cohen-
Kettenis, 2011; Di Ceglie & Th
¨
ummel,
2006; Wallien et al., 2007).
3. For adolescents, the assessment phase
should also be used to inform youth and
their families about the possibilities and
limitations of different treatments. This
is necessary for informed consent and
also important for assessment. The way
that adolescents respond to information
about the reality of sex reassignment
can be diagnostically informative. Correct
information may alter a youth’s desire
for certain treatment, if the desire was
based on unrealistic expectations of its
possibilities.
Psychological and Social Interventions for
Children and Adolescents
When supporting and treating children and
adolescents with gender dysphoria, health pro-
fessionals should broadly conform to the follow-
ing guidelines:
1. Mental health professionals should help
families to have an accepting and nurturing
response to the concerns of their gender
dysphoric child or adolescent. Families
play an important role in the psychological
health and well-being of youth (Brill &
Pepper, 2008; Lev, 2004). This also applies
to peers and mentors from the community,
who can be another source of social
support.
2. Psychotherapy should focus on reducing
a child’s or adolescent’s distress
related to the gender dysphoria and
on ameliorating any other psychosocial
difficulties. For youth pursuing sex
reassignment, psychotherapy may focus
on supporting them before, during, and
after reassignment. Formal evaluations of
different psychotherapeutic approaches
for this situation have not been published,
but several counseling methods have
been described (Cohen-Kettenis, 2006; de
Vries, Cohen-Kettenis, & Delemarre-van
de Waal, 2006; Di Ceglie & Th
¨
ummel,
2006; Hill, Menvielle, Sica, & Johnson,
2010; Malpas, 2011; Menvielle & Tuerk,
2002; Rosenberg, 2002; Vanderburgh,
2009; Zucker, 2006).
Treatment aimed at trying to change a
person’s gender identity and expression to
become more congruent with sex assigned
at birth has been attempted in the past
without success (Gelder & Marks, 1969;
Greenson, 1964), particularly in the long
term (Cohen-Kettenis & Kuiper, 1984;
Pauly, 1965). Such treatment is no longer
considered ethical.
3. Families should be supported in managing
uncertainty and anxiety about their child’s
or adolescent’s psychosexual outcomes
and in helping youth to develop a positive
self-concept.
4. Mental health professionals should not im-
pose a binary view of gender. They should
give ample room for clients to explore
different options for gender expression.
Hormonal or surgical interventions are
appropriate for some adolescents but not
for others.
5. Clients and their families should be sup-
ported in making difficult decisions re-
garding the extent to which clients are
allowed to express a gender role that is
consistent with their gender identity, as
well as the timing of changes in gender
role and possible social transition. For
example, a client might attend school while
undergoing social transition only partly
(e.g., by wearing clothing and having a
hairstyle that reflects gender identity) or
completely (e.g., by also using a name and
pronouns congruent with gender identity).
Difficult issues include whether and when
to inform other people of the client’s
situation, and how others in their lives
might respond.
6. Health professionals should support clients
and their families as educators and advo-
cates in their interactions with community
members and authorities such as teachers,
school boards, and courts.
7. Mental health professionals should strive
to maintain a therapeutic relationship with
176 INTERNATIONAL JOURNAL OF TRANSGENDERISM
gender-nonconforming children/adoles-
cents and their families throughout any
subsequent social changes or physical
interventions. This ensures that decisions
about gender expression and the treatment
of gender dysphoria are thoughtfully
and recurrently considered. The same
reasoning applies if a child or adolescent
has already socially changed gender role
prior to being seen by a mental health
professional.
Social Transition in Early Childhood
Some children state that they want to make
a social transition to a different gender role
long before puberty. For some children, this may
reflect an expression of their gender identity. For
others, this could be motivated by other forces.
Families vary in the extent to which they allow
their young children to make a social transition
to another gender role. Social transitions in early
childhood do occur within some families with
early success. This is a controversial issue, and
divergent views are held by health professionals.
The current evidence base is insufficient to
predict the long-term outcomes of completing
a gender role transition during early childhood.
Outcomes research with children who completed
early social transitions would greatly inform
future clinical recommendations.
Mental health professionals can help families
to make decisions regarding the timing and pro-
cess of any gender-role changes for their young
children. They should provide information and
help parents to weigh the potential benefits and
challenges of particular choices. Relevant in
this respect are the previously described rela-
tively low persistence rates of childhood gender
dysphoria (Drummond et al., 2008; Wallien &
Cohen-Kettenis, 2008). A change back to the
original gender role can be highly distressing
and even result in postponement of this second
social transition on the child’s part (Steensma
& Cohen-Kettenis, 2011). For reasons such as
these, parents may want to present this role
change as an exploration of living in another
gender role rather than an irreversible situation.
Mental health professionals can assist parents
in identifying potential in-between solutions or
compromises (e.g., only when on vacation). It
is also important that parents explicitly let the
child know that there is a way back.
Regardless of a family’s decisions regarding
transition (timing, extent), professionals should
counsel and support them as they work through
the options and implications. If parents do not
allow their young child to make a gender-role
transition, they may need counseling to assist
them with meeting their child’s needs in a
sensitive and nurturing way, ensuring that the
child has ample possibilities to explore gender
feelings and behavior in a safe environment. If
parents do allow their young child to make a
gender-role transition, they may need counseling
to facilitate a positive experience for their
child. For example, they may need support in
using correct pronouns, maintaining a safe and
supportive environment for their transitioning
child (e.g., in school, peer group settings), and
communicating with other people in their child’s
life. In either case, as a child nears puberty,
further assessment may be needed as options
for physical interventions become relevant.
Physical Interventions for Adolescents
Before any physical interventions are consid-
ered for adolescents, extensive exploration of
psychological, family, and social issues should
be undertaken, as outlined above. The duration
of this exploration may vary considerably de-
pending on the complexity of the situation.
Physical interventions should be addressed in
the context of adolescent development. Some
identity beliefs in adolescents may become
firmly held and strongly expressed, giving a
false impression of irreversibility. An adoles-
cent’s shift towards gender conformity can occur
primarily to please the parents and may not
persist or reflect a permanent change in gender
dysphoria (Hembree et al., 2009; Steensma et al.,
published online ahead of print January 7, 2011).
Physical interventions for adolescents fall
into three categories or stages (Hembree et al.,
2009):
1. Fully reversible interventions. These in-
volve the use of GnRH analogues to sup-
press estrogen or testosterone production
Coleman et al. 177
and consequently delay the physical
changes of puberty. Alternative treat-
ment options include progestins (most
commonly medroxyprogesterone) or other
medications (such as spironolactone) that
decrease the effects of androgens secreted
by the testicles of adolescents who are
not receiving GnRH analogues. Continu-
ous oral contraceptives (or depot medrox-
yprogesterone) may be used to suppress
menses.
2. Partially reversible interventions. These
include hormone therapy to masculinize or
feminize the body. Some hormone-induced
changes may need reconstructive surgery
to reverse the effect (e.g., gynaecomastia
caused by estrogens), while other changes
are not reversible (e.g., deepening of the
voice caused by testosterone).
3. Irreversible interventions. These are surgi-
cal procedures.
A staged process is recommended to keep op-
tions open through the first two stages. Moving
from one stage to another should not occur until
there has been adequate time for adolescents and
their parents to assimilate fully the effects of
earlier interventions.
Fully Reversible Interventions
Adolescents may be eligible for
puberty-suppressing hormones as soon as
pubertal changes have begun. In order for
adolescents and their parents to make an
informed decision about pubertal delay, it is
recommended that adolescents experience the
onset of puberty to at least Tanner Stage 2. Some
children may arrive at this stage at very young
ages (e.g., 9 years of age). Studies evaluating
this approach have only included children who
were at least 12 years of age (Cohen-Kettenis,
Schagen, Steensma, de Vries, & Delemarre-van
de Waal, 2011; de Vries, Steensma et al., 2010;
Delemarre-van de Waal, van Weissenbruch, &
Cohen Kettenis, 2004; Delemarre-van de Waal
& Cohen-Kettenis, 2006).
Two goals justify intervention with puberty-
suppressing hormones: (i) their use gives adoles-
cents more time to explore their gender noncon-
formity and other developmental issues and (ii)
their use may facilitate transition by preventing
the development of sex characteristics that are
difficult or impossible to reverse if adolescents
continue on to pursue sex reassignment.
Puberty suppression may continue for a few
years, at which time a decision is made to either
discontinue all hormone therapy or transition to
a feminizing/masculinizing hormone regimen.
Pubertal suppression does not inevitably lead to
social transition or to sex reassignment.
Criteria for Puberty-Suppressing Hormones
In order for adolescents to receive puberty-
suppressing hormones, the following minimum
criteria must be met:
1. The adolescent has demonstrated a long-
lasting and intense pattern of gender non-
conformity or gender dysphoria (whether
suppressed or expressed);
2. Gender dysphoria emerged or worsened
with the onset of puberty;
3. Any coexisting psychological, medical,
or social problems that could interfere
with treatment (e.g., that may compromise
treatment adherence) have been addressed,
such that the adolescent’s situation and
functioning are stable enough to start
treatment;
4. The adolescent has given informed consent
and, particularly when the adolescent has
not reached the age of medical consent,
the parents or other caretakers or guardians
have consented to the treatment and are
involved in supporting the adolescent
throughout the treatment process.
Regimens, Monitoring, and Risks for Pu-
berty Suppression
For puberty suppression, adolescents with
male genitalia should be treated with GnRH
analogues, which stop luteinizing hormone se-
cretion and therefore testosterone secretion.
Alternatively, they may be treated with pro-
gestins (such as medroxyprogesterone) or with
other medications that block testosterone se-
cretion and/or neutralize testosterone action.
178 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Adolescents with female genitalia should be
treated with GnRH analogues, which stop the
production of estrogens and progesterone. Al-
ternatively, they may be treated with progestins
(such as medroxyprogesterone). Continuous oral
contraceptives (or depot medroxyprogesterone)
may be used to suppress menses. In both groups
of adolescents, use of GnRH analogues is the
preferred treatment (Hembree et al., 2009), but
their high cost is prohibitive for some patients.
During pubertal suppression, an adoles-
cent’s physical development should be care-
fully monitored—preferably by a pediatric
endocrinologist—so that any necessary inter-
ventions can occur (e.g., to establish an adequate
gender appropriate height, to improve iatrogenic
low bone mineral density) (Hembree et al.,
2009).
Early use of puberty-suppressing hormones
may avert negative social and emotional con-
sequences of gender dysphoria more effectively
than their later use would. Intervention in early
adolescence should be managed with pediatric
endocrinological advice, when available. Ado-
lescents with male genitalia who start GnRH
analogues early in puberty should be informed
that this could result in insufficient penile tissue
for penile inversion vaginoplasty techniques
(alternative techniques, such as the use of a skin
graft or colon tissue, are available).
Neither puberty suppression nor allowing
puberty to occur is a neutral act. On the one hand,
functioning in later life can be compromised by
the development of irreversible secondary sex
characteristics during puberty and by years spent
experiencing intense gender dysphoria. On the
other hand, there are concerns about negative
physical side effects of GnRH analogue use (e.g.,
on bone development and height). Although the
very first results of this approach (as assessed for
adolescents followed over 10 years) are promis-
ing (Cohen-Kettenis et al., 2011; Delemarre-van
de Waal & Cohen-Kettenis, 2006), the long-term
effects can only be determined when the earliest-
treated patients reach the appropriate age.
Partially Reversible Interventions
Adolescents may be eligible to begin feminiz-
ing/masculinizing hormone therapy, preferably
with parental consent. In many countries, 16-
year-olds are legal adults for medical decision-
making and do not require parental consent. Ide-
ally, treatment decisions should be made among
the adolescent, the family, and the treatment
team.
Regimens for hormone therapy in gender
dysphoric adolescents differ substantially from
those used in adults (Hembree et al., 2009).
The hormone regimens for youth are adapted to
account for the somatic, emotional, and mental
development that occurs throughout adolescence
(Hembree et al., 2009).
Irreversible Interventions
Genital surgery should not be carried out until
(i) patients reach the legal age of majority to
give consent for medical procedures in a given
country and (ii) patients have lived continuously
for at least 12 months in the gender role that
is congruent with their gender identity. The age
threshold should be seen as a minimum criterion
and not an indication in and of itself for active
intervention.
Chest surgery in FtM patients could be carried
out earlier, preferably after ample time of living
in the desired gender role and after one year of
testosterone treatment. The intent of this sug-
gested sequence is to give adolescents sufficient
opportunity to experience and socially adjust in
a more masculine gender role, before under-
going irreversible surgery. However, different
approaches may be more suitable, depending
on an adolescent’s specific clinical situation and
goals for gender identity expression.
Risks of Withholding Medical Treatment
for Adolescents
Refusing timely medical interventions for
adolescents might prolong gender dysphoria and
contribute to an appearance that could provoke
abuse and stigmatization. As the level of gender-
related abuse is strongly associated with the
degree of psychiatric distress during adolescence
(Nuttbrock et al., 2010), withholding puberty-
suppression and subsequent feminizing or mas-
culinizing hormone therapy is not a neutral
option for adolescents.
Coleman et al. 179
VII. MENTAL HEALTH
Transsexual, transgender, and gender-
nonconforming people might seek the assistance
of a mental health professional for any number
of reasons. Regardless of a person’s reason for
seeking care, mental health professionals should
have familiarity with gender nonconformity,
act with appropriate cultural competence, and
exhibit sensitivity in providing care.
This section of the SOC focuses on the role
of mental health professionals in the care of
adults seeking help for gender dysphoria and
related concerns. Professionals working with
gender dysphoric children, adolescents, and their
families should consult section VI.
Competency of Mental Health
Professionals Working with Adults
Who Present with Gender Dysphoria
The training of mental health professionals
competent to work with gender dysphoric adults
rests upon basic general clinical competence
in the assessment, diagnosis, and treatment of
mental health concerns. Clinical training may
occur within any discipline that prepares mental
health professionals for clinical practice, such
as psychology, psychiatry, social work, mental
health counseling, marriage and family therapy,
nursing, or family medicine with specific train-
ing in behavioral health and counseling. The fol-
lowing are recommended minimum credentials
for mental health professionals who work with
adults presenting with gender dysphoria:
1. A master’s degree or its equivalent in
a clinical behavioral science field. This
degree, or a more advanced one, should be
granted by an institution accredited by the
appropriate national or regional accredit-
ing board. The mental health professional
should have documented credentials from
a relevant licensing board or equivalent for
that country.
2. Competence in using the Diagnostic Sta-
tistical Manual of Mental Disorders and/or
the International Classification of Dis-
eases for diagnostic purposes.
3. Ability to recognize and diagnose co-
existing mental health concerns and to
distinguish these from gender dysphoria.
4. Documented supervised training and com-
petence in psychotherapy or counseling.
5. Knowledge about gender-nonconforming
identities and expressions, and the assess-
ment and treatment of gender dysphoria.
6. Continuing education in the assess-
ment and treatment of gender dyspho-
ria. This may include attending relevant
professional meetings, workshops, or sem-
inars; obtaining supervision from a mental
health professional with relevant experi-
ence; or participating in research related to
gender nonconformity and gender dyspho-
ria.
In addition to the minimum credentials above, it
is recommended that mental health professionals
develop and maintain cultural competence to fa-
cilitate their work with transsexual, transgender,
and gender-nonconforming clients. This may
involve, for example, becoming knowledgeable
about current community, advocacy, and public
policy issues relevant to these clients and their
families. Additionally, knowledge about sexual-
ity, sexual health concerns, and the assessment
and treatment of sexual disorders is preferred.
Mental health professionals who are new to
the field (irrespective of their level of training
and other experience) should work under the
supervision of a mental health professional with
established competence in the assessment and
treatment of gender dysphoria.
Tasks of Mental Health Professionals
Working with Adults Who Present
with Gender Dysphoria
Mental health professionals may serve trans-
sexual, transgender, and gender-nonconforming
individuals and their families in many ways,
depending on a client’s needs. For example,
mental health professionals may serve as a
psychotherapist, counselor, or family therapist,
or as a diagnostician/assessor, advocate, or
educator.
Mental health professionals should deter-
mine a client’s reasons for seeking professional
180 INTERNATIONAL JOURNAL OF TRANSGENDERISM
assistance. For example, a client may be present-
ing for any combination of the following health
care services: psychotherapeutic assistance to
explore gender identity and expression or to
facilitate a coming-out process; assessment and
referral for feminizing/masculinizing medical
interventions; psychological support for family
members (partners, children, extended family);
psychotherapy unrelated to gender concerns; or
other professional services.
Below are general guidelines for common
tasks that mental health professionals may fulfill
in working with adults who present with gender
dysphoria.
Tasks Related to Assessment and Referral
1. Assess Gender Dysphoria
Mental health professionals assess clients’
gender dysphoria in the context of an evaluation
of their psychosocial adjustment (Bockting et al.,
2006; Lev, 2004, 2009). The evaluation includes,
at a minimum, assessment of gender identity
and gender dysphoria, history and development
of gender dysphoric feelings, the impact of
stigma attached to gender nonconformity on
mental health, and the availability of support
from family, friends, and peers (for example,
in-person or online contact with other trans-
sexual, transgender, or gender-nonconforming
individuals or groups). The evaluation may result
in no diagnosis, in a formal diagnosis related
to gender dysphoria, and/or in other diagnoses
that describe aspects of the client’s health and
psychosocial adjustment. The role of mental
health professionals includes making reasonably
sure that the gender dysphoria is not secondary
to, or better accounted for, by other diagnoses.
Mental health professionals with the com-
petencies described above (hereafter called “a
qualified mental health professional”) are best
prepared to conduct this assessment of gender
dysphoria. However, this task may instead be
conducted by another type of health professional
who has appropriate training in behavioral
health and is competent in the assessment of
gender dysphoria, particularly when functioning
as part of a multidisciplinary specialty team
that provides access to feminizing/masculinizing
hormone therapy. This professional may be
the prescribing hormone-therapy provider or a
member of that provider’s health care team.
2. Provide Information Regarding Options
for Gender Identity and Expression and
Possible Medical Interventions
An important task of mental health pro-
fessionals is to educate clients regarding the
diversity of gender identities and expressions
and the various options available to alleviate
gender dysphoria. Mental health professionals
then may facilitate a process (or refer elsewhere)
in which clients explore these various options,
with the goals of finding a comfortable gender
role and expression and becoming prepared to
make a fully informed decision about available
medical interventions, if needed. This process
may include referral for individual, family, and
group therapy and/or to community resources
and avenues for peer support. The professional
and the client discuss the implications, both
short- and long-term, of any changes in gender
role and use of medical interventions. These
implications can be psychological, social, phys-
ical, sexual, occupational, financial, and legal
(Bockting et al., 2006; Lev, 2004).
This task is also best conducted by a
qualified mental health professional, but may
be conducted by another health professional
with appropriate training in behavioral health
and with sufficient knowledge about gender-
nonconforming identities and expressions and
about possible medical interventions for gen-
der dysphoria, particularly when functioning
as part of a multidisciplinary specialty team
that provides access to feminizing/masculinizing
hormone therapy.
3. Assess, Diagnose, and Discuss Treat-
ment Options for Coexisting Mental Health
Concerns
Clients presenting with gender dysphoria may
struggle with a range of mental health concerns
(G
´
omez-Gil, Trilla, Salamero, God
´
as, & Vald
´
es,
2009; Murad et al., 2010) whether related or
unrelated to what is often a long history of
gender dysphoria and/or chronic minority stress.
Possible concerns include anxiety, depression,
self-harm, a history of abuse and neglect,
Coleman et al. 181
compulsivity, substance abuse, sexual concerns,
personality disorders, eating disorders, psy-
chotic disorders, and autistic spectrum disorders
(Bockting et al., 2006; Nuttbrock et al., 2010;
Robinow, 2009). Mental health professionals
should screen for these and other mental health
concerns and incorporate the identified concerns
into the overall treatment plan. These concerns
can be significant sources of distress and, if
left untreated, can complicate the process of
gender identity exploration and resolution of
gender dysphoria (Bockting et al., 2006; Fraser,
2009a; Lev, 2009). Addressing these concerns
can greatly facilitate the resolution of gender
dysphoria, possible changes in gender role, the
making of informed decisions about medical in-
terventions, and improvements in quality of life.
Some clients may benefit from psychotropic
medications to alleviate symptoms or treat co-
existing mental health concerns. Mental health
professionals are expected to recognize this and
either provide pharmacotherapy or refer to a
colleague who is qualified to do so. The presence
of coexisting mental health concerns does not
necessarily preclude possible changes in gender
role or access to feminizing/masculinizing hor-
mones or surgery; rather, these concerns need
to be optimally managed prior to, or concurrent
with, treatment of gender dysphoria. In addition,
clients should be assessed for their ability to
provide educated and informed consent for
medical treatments.
Qualified mental health professionals are
specifically trained to assess, diagnose, and treat
(or refer to treatment for) these coexisting men-
tal health concerns. Other health professionals
with appropriate training in behavioral health,
particularly when functioning as part of a mul-
tidisciplinary specialty team providing access
to feminizing/masculinizing hormone therapy,
may also screen for mental health concerns and,
if indicated, provide referral for comprehensive
assessment and treatment by a qualified mental
health professional.
4. If Applicable, Assess Eligibility, Prepare,
and Refer for Hormone Therapy
The SOC provide criteria to guide decisions
regarding feminizing/masculinizing hormone
therapy (outlined in section VIII and Appendix
C). Mental health professionals can help clients
who are considering hormone therapy to be
both psychologically prepared (e.g., client has
made a fully informed decision with clear and
realistic expectations; is ready to receive the
service in line with the overall treatment plan;
has included family and community as appro-
priate) and practically prepared (e.g., has been
evaluated by a physician to rule out or address
medical contraindications to hormone use; has
considered the psychosocial implications). If
clients are of childbearing age, reproductive
options (section IX) should be explored before
initiating hormone therapy.
It is important for mental health professionals
to recognize that decisions about hormones
are first and foremost a client’s decisions—as
are all decisions regarding health care. How-
ever, mental health professionals have a re-
sponsibility to encourage, guide, and assist
clients with making fully informed decisions
and becoming adequately prepared. To best
support their clients’ decisions, mental health
professionals need to have functioning work-
ing relationships with their clients and suffi-
cient information about them. Clients should
receive prompt and attentive evaluation, with
the goal of alleviating their gender dysphoria
and providing them with appropriate medical
services.
Referral for feminizing/masculinizing hor-
mone therapy. People may approach a special-
ized provider in any discipline to pursue feminiz-
ing/masculinizing hormone therapy. However,
transgender health care is an interdisciplinary
field, and coordination of care and referral
among a client’s overall care team is recom-
mended.
Hormone therapy can be initiated with a
referral from a qualified mental health profes-
sional. Alternatively, a health professional who
is appropriately trained in behavioral health and
competent in the assessment of gender dysphoria
may assess eligibility of, prepare, and refer the
patient for hormone therapy, particularly in the
absence of significant coexisting mental health
concerns and when working in the context
of a multidisciplinary specialty team. The
referring health professional should provide
182 INTERNATIONAL JOURNAL OF TRANSGENDERISM
documentation—in the chart and/or referral
letter—of the patient’s personal and treatment
history, progress, and eligibility. Health
professionals who recommend hormone therapy
share the ethical and legal responsibility for that
decision with the physician who provides the
service.
The recommended content of the referral
letter for feminizing/masculinizing hormone
therapy is as follows:
1. The client’s general identifying character-
istics;
2. Results of the client’s psychosocial assess-
ment, including any diagnoses;
3. The duration of the referring health pro-
fessional’s relationship with the client, in-
cluding the type of evaluation and therapy
or counseling to date;
4. An explanation that the criteria for hor-
mone therapy have been met and a brief
description of the clinical rationale for
supporting the client’s request for hormone
therapy;
5. A statement that informed consent has
been obtained from the patient;
6. A statement that the referring health pro-
fessional is available for coordination of
care and welcomes a phone call to establish
this.
For providers working within a multidisciplinary
specialty team, a letter may not be necessary;
rather, the assessment and recommendation can
be documented in the patient’s chart.
5. If Applicable, Assess Eligibility, Prepare,
and Refer for Surgery
The SOC also provide criteria to guide
decisions regarding breast/chest surgery and
genital surgery (outlined in section XI and
Appendix C). Mental health professionals can
help clients who are considering surgery to
be both psychologically prepared (e.g., client
has made a fully informed decision with clear
and realistic expectations; is ready to receive
the service in line with the overall treatment
plan; has included family and community as
appropriate) and practically prepared (e.g., has
made an informed choice about a surgeon to
perform the procedure; has arranged aftercare).
If clients are of childbearing age, reproductive
options (section IX) should be explored before
undergoing genital surgery.
The SOC do not state criteria for other surgical
procedures, such as feminizing or masculinizing
facial surgery; however, mental health profes-
sionals can play an important role in helping their
clients to make fully informed decisions about
the timing and implications of such procedures
in the context of the overall coming-out or
transition process.
It is important for mental health professionals
to recognize that decisions about surgery are
first and foremost a client’s decisions—as are
all decisions regarding health care. However,
mental health professionals have a responsibility
to encourage, guide, and assist clients with
making fully informed decisions and becom-
ing adequately prepared. To best support their
clients’ decisions, mental health professionals
need to have functioning working relationships
with their clients and sufficient information
about them. Clients should receive prompt and
attentive evaluation, with the goal of alleviating
their gender dysphoria and providing them with
appropriate medical services.
Referral for surgery. Surgical treatments for
gender dysphoria can be initiated by a refer-
ral (one or two, depending on the type of
surgery) from a qualified mental health profes-
sional. The mental health professional provides
documentation—in the chart and/or referral
letter—of the patient’s personal and treatment
history, progress, and eligibility. Mental health
professionals who recommend surgery share the
ethical and legal responsibility for that decision
with the surgeon.
One referral from a qualified mental health
professional is needed for breast/chest
surgery (e.g., mastectomy, chest recon-
struction, or augmentation mammoplasty).
Two referrals—from qualified mental
health professionals who have indepen-
dently assessed the patient—are needed
for genital surgery (i.e., hysterectomy/
Coleman et al. 183
salpingo-oophorectomy, orchiectomy,
genital reconstructive surgeries). If
the first referral is from the patient’s
psychotherapist, the second referral
should be from a person who has only had
an evaluative role with the patient. Two
separate letters, or one letter signed by
both (e.g., if practicing within the same
clinic) may be sent. Each referral letter,
however, is expected to cover the same
topics in the areas outlined below.
No letter is required for hysterectomy/
salpingo-oophorectomy or orchiectomy to
be performed for reasons unrelated to
gender dysphoria or due to other diagnoses.
The recommended content of the referral letters
for surgery is as follows:
1. The client’s general identifying character-
istics;
2. Results of the client’s psychosocial assess-
ment, including any diagnoses;
3. The duration of the mental health profes-
sional’s relationship with the client, includ-
ing the type of evaluation and therapy or
counseling to date;
4. An explanation that the criteria for surgery
have been met, and a brief description of
the clinical rationale for supporting the
patient’s request for surgery;
5. A statement that informed consent has
been obtained from the patient;
6. A statement that the mental health profes-
sional is available for coordination of care
and welcomes a phone call to establish
this.
For providers working within a multidisci-
plinary specialty team, a letter may not be neces-
sary, rather, the assessment and recommendation
can be documented in the patient’s chart.
Relationship of Mental Health
Professionals with Hormone-Prescribing
Physicians, Surgeons, and Other Health
Professionals
It is ideal for mental health professionals
to perform their work and periodically discuss
progress and obtain peer consultation from other
professionals (both in mental health care and
other health disciplines) who are competent
in the assessment and treatment of gender
dysphoria. The relationship among professionals
involved in a client’s health care should remain
collaborative, with coordination and clinical
dialogue taking place as needed. Open and
consistent communication may be necessary
for consultation, referral, and management of
postoperative concerns.
Tasks Related to Psychotherapy
Psychotherapy Is Not an Absolute Require-
ment for Hormone Therapy and Surgery
A mental health screening and/or assessment
as outlined above is needed for referral to
hormonal and surgical treatments for gen-
der dysphoria. In contrast, psychotherapy—
although highly recommended—is not a require-
ment.
The SOC do not recommend a minimum num-
ber of psychotherapy sessions prior to hormone
therapy or surgery. The reasons for this are multi-
faceted (Lev, 2009). First, a minimum number of
sessions tends to be construed as a hurdle, which
discourages the genuine opportunity for personal
growth. Second, mental health professionals can
offer important support to clients throughout
all phases of exploration of gender identity,
gender expression, and possible transition—not
just prior to any possible medical interventions.
Third, clients and their psychotherapists differ in
their abilities to attain similar goals in a specified
time period.
Goals of Psychotherapy for Adults
with Gender Concerns
The general goal of psychotherapy is to find
ways to maximize a person’s overall psycho-
logical well-being, quality of life, and self-
fulfillment. Psychotherapy is not intended to
alter a person’s gender identity; rather, psy-
chotherapy can help an individual to explore
gender concerns and find ways to alleviate gen-
der dysphoria, if present (Bockting et al., 2006;
Bockting & Coleman, 2007; Fraser, 2009a; Lev,
184 INTERNATIONAL JOURNAL OF TRANSGENDERISM
2004). Typically, the overarching treatment goal
is to help transsexual, transgender, and gender-
nonconforming individuals achieve long-term
comfort in their gender identity expression,
with realistic chances for success in their re-
lationships, education, and work. For additional
details, see Fraser (Fraser, 2009c).
Therapy may consist of individual, cou-
ple, family, or group psychotherapy, the lat-
ter being particularly important to foster peer
support.
Psychotherapy for Transsexual, Transgen-
der, and Gender-Nonconforming Clients,
Including Counseling and Support for
Changes in Gender Role
Finding a comfortable gender role is, first and
foremost, a psychosocial process. Psychother-
apy can be invaluable in assisting transsexual,
transgender, and gender-nonconforming indi-
viduals with all of the following: (i) clarifying
and exploring gender identity and role, (ii)
addressing the impact of stigma and minority
stress on one’s mental health and human de-
velopment, and (iii) facilitating a coming-out
process (Bockting & Coleman, 2007; Devor,
2004; Lev, 2004), which for some individuals
may include changes in gender role expression
and the use of feminizing/masculinizing medical
interventions.
Mental health professionals can provide sup-
port and promote interpersonal skills and re-
silience in individuals and their families as they
navigate a world that often is ill-prepared to
accommodate and respect transgender, trans-
sexual, and gender-nonconforming people. Psy-
chotherapy can also aid in alleviating any
coexisting mental health concerns (e.g., anxi-
ety, depression) identified during screening and
assessment.
For transsexual, transgender, and gender-
nonconforming individuals who plan to change
gender roles permanently and make a social
gender role transition, mental health profes-
sionals can facilitate the development of an
individualized plan with specific goals and
timelines. While the experience of changing
one’s gender role differs from person to person,
the social aspects of the experience are usually
challenging—often more so than the physical
aspects. Because changing gender role can have
profound personal and social consequences, the
decision to do so should include an awareness
of what the familial, interpersonal, educational,
vocational, economic, and legal challenges are
likely to be, so that people can function success-
fully in their gender role.
Many transsexual, transgender, and gender-
nonconforming people will present for care
without ever having been related to, or accepted
in, the gender role that is most congruent
with their gender identity. Mental health pro-
fessionals can help these clients to explore and
anticipate the implications of changes in gender
role, and to pace the process of implementing
these changes. Psychotherapy can provide a
space for clients to begin to express themselves
in ways that are congruent with their gender
identity and, for some clients, overcome fears
about changes in gender expression. Calculated
risks can be taken outside of therapy to gain
experience and build confidence in the new
role. Assistance with coming out to family and
community (friends, school, workplace) can be
provided.
Other transsexual, transgender, and gender-
nonconforming individuals will present for care
already having acquired experience (minimal,
moderate, or extensive) living in a gender role
that differs from that associated with their
birth-assigned sex. Mental health professionals
can help these clients to identify and work
through potential challenges and foster optimal
adjustment as they continue to express changes
in their gender role.
Family Therapy or Support for Family
Members
Decisions about changes in gender role and
medical interventions for gender dysphoria have
implications for, not only clients, but also their
families (Emerson & Rosenfeld, 1996; Fraser,
2009a; Lev, 2004). Mental health profession-
als can assist clients with making thoughtful
decisions about communicating with family
members and others about their gender identity
and treatment decisions. Family therapy may
include work with spouses or partners, as well
Coleman et al. 185
as with children and other members of a client’s
extended family.
Clients may also request assistance with their
relationships and sexual health. For example,
they may want to explore their sexuality and
intimacy-related concerns.
Family therapy might be offered as part of
the client’s individual therapy and, if clinically
appropriate, by the same provider. Alternatively,
referrals can be made to other therapists with
relevant expertise for working with family mem-
bers or to sources of peer support (e.g., in
person or offline support networks of partners
or families).
Follow-Up Care Throughout Life
Mental health professionals may work with
clients and their families at many stages of their
lives. Psychotherapy may be helpful at different
times and for various issues throughout the life
cycle.
E-therapy, Online Counseling, or Distance
Counseling
Online or e-therapy has been shown to be
particularly useful for people who have difficulty
accessing competent in-person psychothera-
peutic treatment and who may experience
isolation and stigma (Derrig-Palumbo & Zeine,
2005; Fenichel et al., 2004; Fraser, 2009b).
By extrapolation, e-therapy may be a useful
modality for psychotherapy with transsexual,
transgender, and gender-nonconforming people.
E-therapy offers opportunities for potentially
enhanced, expanded, creative, and tailored
delivery of services; however, as a developing
modality it may also carry unexpected risk.
Telemedicine guidelines are clear in some
disciplines in some parts of the United States
(Fraser, 2009b; Maheu, Pulier, Wilhelm,
McMenamin, & Brown-Connolly, 2005) but not
all; the international situation is even less well
defined (Maheu et al., 2005). Until sufficient
evidence-based data on this use of e-therapy is
available, caution in its use is advised.
Mental health professionals engaging in e-
therapy are advised to stay current with their
particular licensing board, professional associ-
ation, and country’s regulations, as well as the
most recent literature pertaining to this rapidly
evolving medium. A more thorough description
of the potential uses, processes, and ethical
concerns related to e-therapy has been published
(Fraser, 2009b).
Other Tasks of the Mental Health
Professionals
Educate and Advocate on Behalf of Clients
Within Their Community (Schools, Work-
places, Other Organizations) and Assist
Clients with Making Changes in Identity
Documents
Transsexual, transgender, and gender-
nonconforming people may face challenges in
their professional, educational, and other types
of settings as they actualize their gender identity
and expression (Lev, 2004, 2009). Mental health
professionals can play an important role by
educating people in these settings regarding
gender nonconformity and by advocating on
behalf of their clients (Currah, Juang, & Minter,
2006; Currah & Minter, 2000). This role may
involve consultation with school counselors,
teachers, and administrators, human resources
staff, personnel managers and employers,
and representatives from other organizations
and institutions. In addition, health providers
may be called upon to support changes in a
client’s name and/or gender marker on identity
documents such as passports, driver’s licenses,
birth certificates, and diplomas.
Provide Information and Referral for Peer
Support
For some transsexual, transgender, and
gender-nonconforming people, an experience in
peer support groups may be more instructive
regarding options for gender expression than
anything individual psychotherapy could offer
(Rachlin, 2002). Both experiences are poten-
tially valuable, and all people exploring gender
issues should be encouraged to participate in
community activities, if possible. Resources for
peer support and information should be made
available.
186 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Culture and Its Ramifications for
Assessment and Psychotherapy
Health professionals work in enormously
different environments across the world. Forms
of distress that cause people to seek professional
assistance in any culture are understood and
classified by people in terms that are products
of their own cultures (Frank & Frank, 1993).
Cultural settings also largely determine how
such conditions are understood by mental health
professionals. Cultural differences related to
gender identity and expression can affect pa-
tients, mental health professionals, and accepted
psychotherapy practice. WPATH recognizes that
the SOC have grown out of a Western tradition
and may need to be adapted depending on the
cultural context.
Ethical Guidelines Related to Mental
Health Care
Mental health professionals need to be cer-
tified or licensed to practice in a given coun-
try according to that country’s professional
regulations (Fraser, 2009b; Pope & Vasquez,
2011). Professionals must adhere to the ethical
codes of their professional licensing or certifying
organizations in all of their work with trans-
sexual, transgender, and gender-nonconforming
clients.
Treatment aimed at trying to change a per-
son’s gender identity and lived gender ex-
pression to become more congruent with sex
assigned at birth has been attempted in the past
(Gelder & Marks, 1969; Greenson, 1964), yet
without success, particularly in the long-term
(Cohen-Kettenis & Kuiper, 1984; Pauly, 1965).
Such treatment is no longer considered ethical.
If mental health professionals are uncom-
fortable with, or inexperienced in, working
with transsexual, transgender, and gender-
nonconforming individuals and their families,
they should refer clients to a competent provider
or, at minimum, consult with an expert peer. If
no local practitioners are available, consultation
may be done via telehealth methods, assuming
local requirements for distance consultation are
met.
Issues of Access to Care
Qualified mental health professionals are not
universally available; thus, access to quality care
might be limited. WPATH aims to improve ac-
cess and provides regular continuing education
opportunities to train professionals from vari-
ous disciplines to provide quality, transgender-
specific health care. Providing mental health care
from a distance through the use of technology
may be one way to improve access (Fraser,
2009b).
In many places around the world, access to
health care for transsexual, transgender, and
gender-nonconforming people is also limited by
a lack of health insurance or other means to
pay for needed care. WPATH urges health in-
surance companies and other third-party payers
to cover the medically necessary treatments to
alleviate gender dysphoria (American Medical
Association, 2008; Anton, 2009; World Pro-
fessional Association for Transgender Health,
2008).
When faced with a client who is unable to ac-
cess services, referral to available peer-support
resources (offline and online) is recommended.
Finally, harm-reduction approaches might be
indicated to assist clients with making healthy
decisions to improve their lives.
VIII. HORMONE THERAPY
Medical Necessity of Hormone Therapy
Feminizing/masculinizing hormone therapy
—the administration of exogenous endocrine
agents to induce feminizing or masculinizing
changes—is a medically necessary intervention
for many transsexual, transgender, and gender-
nonconforming individuals with gender dyspho-
ria (Newfield, Hart, Dibble, & Kohler, 2006;
Pf
¨
afflin & Junge, 1998). Some people seek
maximum feminization/ masculinization, while
others experience relief with an androgynous
presentation resulting from hormonal minimiza-
tion of existing secondary sex characteristics
(Factor & Rothblum, 2008). Evidence for the
psychosocial outcomes of hormone therapy is
summarized in Appendix D.
Coleman et al. 187
Hormone therapy must be individualized
based on a patient’s goals, the risk/benefit ratio
of medications, the presence of other medical
conditions, and consideration of social and
economic issues. Hormone therapy can provide
significant comfort to patients who do not wish
to make a social gender role transition or undergo
surgery, or who are unable to do so (Meyer,
2009). Hormone therapy is a recommended
criterion for some, but not all, surgical treat-
ments for gender dysphoria (see section XI and
Appendix C).
Criteria for Hormone Therapy
Initiation of hormone therapy may be un-
dertaken after a psychosocial assessment has
been conducted and informed consent has been
obtained by a qualified health professional, as
outlined in section VII of the SOC . A referral
is required from the mental health professional
who performed the assessment, unless the as-
sessment was done by a hormone provider who
is also qualified in this area.
The criteria for hormone therapy are as fol-
lows:
1. Persistent, well-documented gender dys-
phoria;
2. Capacity to make a fully informed decision
and to consent for treatment;
3. Age of majority in a given country (if
younger, follow the SOC outlined in sec-
tion VI);
4. If significant medical or mental health con-
cerns are present, they must be reasonably
well-controlled.
As noted in section VII of the SOC,the
presence of coexisting mental health concerns
does not necessarily preclude access to fem-
inizing/masculinizing hormones; rather, these
concerns need to be managed prior to, or
concurrent with, treatment of gender dysphoria.
In selected circumstances, it can be accept-
able practice to provide hormones to patients
who have not fulfilled these criteria. Examples
include facilitating the provision of monitored
therapy using hormones of known quality as
an alternative to illicit or unsupervised hormone
use or to patients who have already established
themselves in their affirmed gender and who
have a history of prior hormone use. It is
unethical to deny availability of or eligibility for
hormone therapy solely on the basis of blood
seropositivity for blood-borne infections such as
HIV or hepatitis B or C.
In rare cases, hormone therapy may be
contraindicated due to serious individual health
conditions. Health professionals should assist
these patients with accessing nonhormonal inter-
ventions for gender dysphoria. A qualified men-
tal health professional familiar with the patient
is an excellent resource in these circumstances.
Informed Consent
Feminizing/masculinizing hormone therapy
may lead to irreversible physical changes. Thus,
hormone therapy should be provided only to
those who are legally able to provide informed
consent. This includes people who have been
declared by a court to be emancipated minors,
incarcerated people, and cognitively impaired
people who are considered competent to partic-
ipate in their medical decisions (Bockting et al.,
2006). Providers should document in the medical
record that comprehensive information has been
provided and understood about all relevant
aspects of the hormone therapy, including both
possible benefits and risks and the impact on
reproductive capacity.
Relationship Between the Standards
of Care and Informed Consent Model
Protocols
A number of community health centers in
the United States have developed protocols for
providing hormone therapy based on an ap-
proach that has become known as the Informed
Consent Model (Callen Lorde Community
Health Center, 2000, 2011; Fenway Community
Health Transgender Health Program, 2007; Tom
Waddell Health Center, 2006). These protocols
are consistent with the guidelines presented in
the WPATH Standards of Care, Version 7.The
SOC are flexible clinical guidelines; they allow
for tailoring of interventions to the needs of the
188 INTERNATIONAL JOURNAL OF TRANSGENDERISM
individual receiving services and for tailoring of
protocols to the approach and setting in which
these services are provided (Ehrbar & Gorton,
2010).
Obtaining informed consent for hormone
therapy is an important task of providers to
ensure that patients understand the psycholog-
ical and physical benefits and risks of hormone
therapy, as well as its psychosocial implications.
Providers prescribing the hormones or health
professionals recommending the hormones
should have the knowledge and experience to
assess gender dysphoria. They should inform
individuals of the particular benefits, limitations,
and risks of hormones, given the patient’s
age, previous experience with hormones, and
concurrent physical or mental health concerns.
Screening for and addressing acute or current
mental health concerns is an important part of the
informed consent process. This may be done by a
mental health professional or by an appropriately
trained prescribing provider (see section VII
of the SOC). The same provider or another
appropriately trained member of the health care
team (e.g., a nurse) can address the psychosocial
implications of taking hormones when necessary
(e.g., the impact of masculinization/feminization
on how one is perceived and its potential
impact on relationships with family, friends, and
coworkers). If indicated, these providers will
make referrals for psychotherapy and for the
assessment and treatment of coexisting mental
health concerns such as anxiety or depression.
The difference between the Informed Consent
Model and SOC, Version 7, is that the SOC
puts greater emphasis on the important role that
mental health professionals can play in alleviat-
ing gender dysphoria and facilitating changes in
gender role and psychosocial adjustment. This
may include a comprehensive mental health
assessment and psychotherapy, when indicated.
In the Informed Consent Model, the focus is
on obtaining informed consent as the threshold
for the initiation of hormone therapy in a
multidisciplinary, harm-reduction environment.
Less emphasis is placed on the provision of
mental health care until the patient requests it,
unless significant mental health concerns are
identified that would need to be addressed before
hormone prescription.
Physical Effects of Hormone Therapy
Feminizing/masculinizing hormone therapy
will induce physical changes that are more
congruent with a patient’s gender identity.
In FtM patients, the following physical
changes are expected to occur: deep-
ened voice, clitoral enlargement (variable),
growth in facial and body hair, cessation
of menses, atrophy of breast tissue, and
decreased percentage of body fat compared
to muscle mass.
In MtF patients, the following physical
changes are expected to occur: breast
growth (variable), decreased erectile func-
tion, decreased testicular size, and in-
creased percentage of body fat compared
to muscle mass.
Most physical changes, whether feminizing
or masculinizing, occur over the course of two
years. The amount of physical change and the
exact timeline of effects can be highly variable.
Tables 1a and 1b outline the approximate time
course of these physical changes.
TABLE 1a. Effects and Expected Time Course
of Masculinizing Hormones
a
Expected Expected maximum
Effect onset
b
effect
b
Skin oiliness/acne 1–6 months 1–2 years
Facial/body hair
growth
3–6 months 3–5 years
Scalp hair loss >12 months
c
Variable
Increased muscle
mass/strength
6–12 months 2–5 years
d
Body fat
redistribution
3–6 months 2–5 years
Cessation of
menses
2–6 months n/a
Clitoral
enlargement
3–6 months 1–2 years
Vaginal atrophy 3–6 months 1–2 years
Deepened voice 3–12 months 1–2 years
a
Adapted with permission from Hembree et al. (2009). Copyright
2009, The Endocrine Society.
b
Estimates represent published and unpublished clinical observa-
tions.
c
Highly dependent on age and inheritance; may be minimal.
d
Significantly dependent on amount of exercise.
Coleman et al. 189
TABLE 1b. Effects and Expected Time Course of Feminizing Hormones
a
Expected maximum
Effect Expected onset
b
effect
b
Body fat redistribution 3–6 months 2–5 years
Decreased muscle mass/strength 3–6 months 1–2 years
c
Softening of skin/decreased oiliness 3–6 months Unknown
Decreased libido 1–3 months 1–2 years
Decreased spontaneous erections 1–3 months 3–6 months
Male sexual dysfunction Variable Variable
Breast growth 3–6 months 2–3 years
Decreased testicular volume 3–6 months 2–3 years
Decreased sperm production Variable Variable
Thinning and slowed growth of body
and facial hair
6–12 months > 3 years
d
Male pattern baldness No regrowth, loss stops 1–3 months 1–2 years
a
Adapted with permission from Hembree et al. (2009). Copyright 2009, The Endocrine Society.
b
Estimates represent published and unpublished clinical observations.
c
Significantly dependent on amount of exercise.
d
Complete removal of male facial and body hair requires electrolysis, laser treatment, or both.
The degree and rate of physical effects de-
pends in part on the dose, route of administration,
and medications used, which are selected in ac-
cordance with a patient’s specific medical goals
(e.g., changes in gender-role expression, plans
for sex reassignment) and medical risk profile.
There is no current evidence that response to
hormone therapy—with the possible exception
of voice deepening in FtM persons—can be
reliably predicted based on age, body habitus,
ethnicity, or family appearance. All other factors
being equal, there is no evidence to suggest that
any medically approved type or method of ad-
ministering hormones is more effective than any
other in producing the desired physical changes.
Risks of Hormone Therapy
All medical interventions carry risks. The
likelihood of a serious adverse event is depen-
dent on numerous factors: the medication itself,
dose, route of administration, and a patient’s
clinical characteristics (age, comorbidities, fam-
ily history, health habits). It is thus impossible
to predict whether a given adverse effect will
happen in an individual patient.
The risks associated with feminizing/
masculinizing hormone therapy for the trans-
sexual, transgender, and gender-nonconforming
population as a whole are summarized in Table
2. Based on the level of evidence, risks are
categorized as follows: (i) likely increased risk
with hormone therapy, (ii) possibly increased
risk with hormone therapy, or (iii) inconclusive
or no increased risk. Items in the last category
include those that may present risk but for
which the evidence is so minimal that no clear
conclusion can be reached.
Additional detail about these risks can be
found in Appendix B, which is based on
two comprehensive, evidence-based literature
reviews of masculinizing/feminizing hormone
therapy (Feldman & Safer, 2009; Hembree
et al., 2009), along with a large cohort study
(Asscheman et al., 2011). These reviews can
serve as detailed references for providers, along
with other widely recognized, published clinical
materials (Dahl, Feldman, Goldberg, & Jaberi,
2006; Ettner, Monstrey, & Eyler, 2007).
Competency of