International Journal of Transgenderism
ISSN: 1553-2739 (Print) 1434-4599 (Online) Journal homepage: https://www.tandfonline.com/loi/wijt20
Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7
E. Coleman , W. Bockting , M. Botzer , P. Cohen-Kettenis , G. DeCuypere , J. Feldman , L. Fraser , J. Green , G. Knudson , W. J. Meyer , S. Monstrey , R. K. Adler , G. R. Brown , A. H. Devor , R. Ehrbar , R. Ettner , E. Eyler , R. Garofalo , D. H. Karasic , A. I. Lev , G. Mayer , H. Meyer-Bahlburg , B. P. Hall , F. Pfaefflin , K. Rachlin , B. Robinson , L. S. Schechter , V. Tangpricha , M. van Trotsenburg , A. Vitale , S. Winter , S. Whittle , K. R. Wylie & K. Zucker
To cite this article: E. Coleman , W. Bockting , M. Botzer , P. Cohen-Kettenis , G. DeCuypere , J. Feldman , L. Fraser , J. Green , G. Knudson , W. J. Meyer , S. Monstrey , R. K. Adler , G. R. Brown , A. H. Devor , R. Ehrbar , R. Ettner , E. Eyler , R. Garofalo , D. H. Karasic , A. I. Lev , G. Mayer , H. Meyer-Bahlburg , B. P. Hall , F. Pfaefflin , K. Rachlin , B. Robinson , L. S. Schechter , V. Tangpricha , M. van Trotsenburg , A. Vitale , S. Winter , S. Whittle , K. R. Wylie & K. Zucker (2012) Standards of Care for the Health of Transsexual, Transgender, and Gender- Nonconforming People, Version 7, International Journal of Transgenderism, 13:4, 165-232, DOI: 10.1080/15532739.2011.700873 To link to this article: https://doi.org/10.1080/15532739.2011.700873
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Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=wijt21 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: [email protected]
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I. PURPOSE AND USE OF THE counseling, psychotherapy), and hormonal and STANDARDS OF CARE surgical treatments. While this is primarily a document for health professionals, the SOC The World Professional Association for may also be used by individuals, their families, Transgender Health (WPATH)1 is an interna- and social institutions to understand how they tional, multidisciplinary, professional associa- can assist with promoting optimal health for tion whose mission is to promote evidence- members of this diverse population. based care, education, research, advocacy, public WPATH recognizes that health is dependent policy, and respect in transsexual and transgen- upon not only good clinical care but also social der health. The vision of WPATH is a world and political climates that provide and ensure so- wherein transsexual, transgender, and gender- cial tolerance, equality, and the full rights of citi- nonconforming people benefit from access to zenship. Health is promoted through public poli- evidence-based health care, social services, jus- cies and legal reforms that promote tolerance and tice, and equality. equity for gender and sexual diversity and that One of the main functions of WPATH is to eliminate prejudice, discrimination, and stigma. promote the highest standards of health care for WPATH is committed to advocacy for these individuals through the articulation of Standards changes in public policies and legal reforms. of Care (SOC) for the Health of Transsexual, Transgender, and Gender-Nonconforming Peo- The Standards of Care Are Flexible ple.TheSOC are based on the best available Clinical Guidelines science and expert professional consensus.2 Most of the research and experience in this The SOC are intended to be flexible in order field comes from a North American and Western to meet the diverse health care needs of trans- European perspective; thus, adaptations of the sexual, transgender, and gender-nonconforming SOC to other parts of the world are necessary. people. While flexible, they offer standards Suggestions for ways of thinking about cultural for promoting optimal health care and guiding relativity and cultural competence are included the treatment of people experiencing gender in this version of the SOC. dysphoria—broadly defined as discomfort or The overall goal of the SOC is to pro- distress that is caused by a discrepancy between vide clinical guidance for health professionals a person’s gender identity and that person’s sex to assist transsexual, transgender, and gender- assigned at birth (and the associated gender role nonconforming people with safe and effective and/or primary and secondary sex character- pathways to achieving lasting personal comfort istics) (Fisk, 1974; Knudson, De Cuypere, & with their gendered selves, in order to maximize Bockting, 2010b). their overall health, psychological well-being, As in all previous versions of the SOC,the and self-fulfillment. This assistance may include criteria put forth in this document for hormone primary care, gynecologic and urologic care, therapy and surgical treatments for gender dys- reproductive options, voice and communication phoria are clinical guidelines; individual health therapy, mental health services (e.g., assessment, professionals and programs may modify them. Clinical departures from the SOC may come about because of a patient’s unique anatomic, so- 1Formerly the Harry Benjamin International cial, or psychological situation; an experienced Gender Dysphoria Association. health professional’s evolving method of han- 2The Standards of Care (SOC), Version 7, repre- dling a common situation; a research protocol; sents a significant departure from previous versions. lack of resources in various parts of the world; Changes in this version are based upon significant or the need for specific harm-reduction strate- cultural shifts, advances in clinical knowledge, and gies. These departures should be recognized as appreciation of the many health care issues that can arise for transsexual, transgender, and gender- such, explained to the patient, and documented nonconforming people beyond hormone therapy and through informed consent for quality patient care surgery (Coleman, 2009a, 2009b, 2009c, 2009d). and legal protection. This documentation is also Coleman et al. 167 valuable for the accumulation of new data, which initiate a change in their gender expression can be retrospectively examined to allow for and physical characteristics while in their teens health care—and the SOC—to evolve. or even earlier. Many grow up and live in The SOC articulate standards of care but a social, cultural, and even linguistic context also acknowledge the role of making informed quite unlike that of Western cultures. Yet almost choices and the value of harm-reduction ap- all experience prejudice (Peletz, 2006; Winter, proaches. In addition, this version of the SOC 2009). In many cultures, social stigma towards recognizes and validates various expressions of gender nonconformity is widespread and gender gender that may not necessitate psychological, roles are highly prescriptive (Winter et al., 2009). hormonal, or surgical treatments. Some patients Gender-nonconforming people in these settings who present for care will have made signifi- are forced to be hidden and, therefore, may lack cant self-directed progress towards gender role opportunities for adequate health care (Winter, changes, transition, or other resolutions regard- 2009). ing their gender identity or gender dysphoria. The SOC are not intended to limit efforts Other patients will require more intensive ser- to provide the best available care to all in- vices. Health professionals can use the SOC to dividuals. Health professionals throughout the help patients consider the full range of health world—even in areas with limited resources services open to them, in accordance with their and training opportunities—can apply the many clinical needs and goals for gender expression. core principles that undergird the SOC. These principles include the following: Exhibit re- spect for patients with nonconforming gender II. GLOBAL APPLICABILITY OF THE identities (do not pathologize differences in STANDARDS OF CARE gender identity or expression); provide care (or refer to knowledgeable colleagues) that While the SOC are intended for worldwide affirms patients’ gender identities and reduces use, WPATH acknowledges that much of the the distress of gender dysphoria, when present; recorded clinical experience and knowledge in become knowledgeable about the health care this area of health care is derived from North needs of transsexual, transgender, and gender- American and Western European sources. From nonconforming people, including the benefits place to place, both across and within nations, and risks of treatment options for gender dys- there are differences in all of the following: phoria; match the treatment approach to the social attitudes towards transsexual, transgender, specific needs of patients, particularly their goals and gender-nonconforming people; construc- for gender expression and need for relief from tions of gender roles and identities; language gender dysphoria; facilitate access to appropriate used to describe different gender identities; care; seek patients’ informed consent before epidemiology of gender dysphoria; access to and providing treatment; offer continuity of care; and cost of treatment; therapies offered; number and be prepared to support and advocate for patients type of professionals who provide care; and legal within their families and communities (schools, and policy issues related to this area of health workplaces, and other settings). care (Winter, 2009). Terminology is culturally and time-dependent It is impossible for the SOC to reflect all of and is rapidly evolving. It is important to use these differences. In applying these standards respectful language in different places and times, to other cultural contexts, health professionals and among different people. As the SOC are must be sensitive to these differences and translated into other languages, great care must adapt the SOC according to local realities. be taken to ensure that the meanings of terms are For example, in a number of cultures, gender- accurately translated. Terminology in English nonconforming people are found in such num- may not be easily translated into other languages, bersandlivinginsuchwaysastomakethem and vice versa. Some languages do not have highly socially visible (Peletz, 2006). In settings equivalent words to describe the various terms such as these, it is common for people to within this document; hence, translators should 168 INTERNATIONAL JOURNAL OF TRANSGENDERISM be cognizant of the underlying goals of treatment of Medicine, 2011). Gender dysphoria refers to and articulate culturally applicable guidance for discomfort or distress that is caused by a discrep- reaching those goals. ancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex III. THE DIFFERENCE BETWEEN characteristics) (Fisk, 1974; Knudson, De GENDER NONCONFORMITY Cuypere, & Bockting, 2010b). Only some AND GENDER DYSPHORIA gender-nonconforming people experience gender dysphoria at some point in their lives. Being Transsexual, Transgender, Treatment is available to assist people with or Gender Nonconforming Is a Matter such distress to explore their gender identity and find a gender role that is comfortable for of Diversity, Not Pathology them (Bockting & Goldberg, 2006). Treatment is WPATH released a statement in May 2010 individualized: What helps one person alleviate urging the de-psychopathologization of gender gender dysphoria might be very different from nonconformity worldwide (WPATH Board of what helps another person. This process may Directors, 2010). This statement noted that “the or may not involve a change in gender expres- expression of gender characteristics, including sion or body modifications. Medical treatment identities, that are not stereotypically associated options include, for example, feminization or with one’s assigned sex at birth is a common masculinization of the body through hormone and culturally diverse human phenomenon [that] therapy and/or surgery, which are effective in should not be judged as inherently pathological alleviating gender dysphoria and are medically or negative.” necessary for many people. Gender identities Unfortunately, there is a stigma attached to and expressions are diverse, and hormones and gender nonconformity in many societies around surgery are just two of many options available the world. Such stigma can lead to prejudice to assist people with achieving comfort with self and discrimination, resulting in “minority stress” and identity. (I. H. Meyer, 2003). Minority stress is unique Gender dysphoria can in large part be alle- (additive to general stressors experienced by viated through treatment (Murad et al., 2010). all people), socially based, and chronic, and Hence, while transsexual, transgender, and may make transsexual, transgender, and gender- gender-nonconforming people may experience nonconforming individuals more vulnerable to gender dysphoria at some points in their lives, developing mental health problems such as many individuals who receive treatment will find anxiety and depression (Institute of Medicine, a gender role and expression that is comfortable 2011). In addition to prejudice and discrimina- for them, even if these differ from those asso- tion in society at large, stigma can contribute ciated with their sex assigned at birth, or from to abuse and neglect in one’s relationships with prevailing gender norms and expectations. peers and family members, which in turn can lead to psychological distress. However, these Diagnoses Related to Gender Dysphoria symptoms are socially induced and are not inherent to being transsexual, transgender, or Some people experience gender dysphoria gender-nonconforming. at such a level that the distress meets criteria for a formal diagnosis that might be classi- Gender Nonconformity Is Not the Same fied as a mental disorder. Such a diagnosis as Gender Dysphoria is not a license for stigmatization or for the deprivation of civil and human rights. Existing Gender nonconformity refers to the extent classification systems such as the Diagnostic to which a person’s gender identity, role, Statistical Manual of Mental Disorders (DSM) or expression differs from the cultural norms (American Psychiatric Association, 2000) and prescribed for people of a particular sex (Institute the International Classification of Diseases Coleman et al. 169
(ICD) (World Health Organization, 2007) define that cultural differences from one country to hundreds of mental disorders that vary in onset, another would alter both the behavioral ex- duration, pathogenesis, functional disability, and pressions of different gender identities and the treatability. All of these systems attempt to extent to which gender dysphoria—distinct from classify clusters of symptoms and conditions, one’s gender identity—is actually occurring in a not the individuals themselves. A disorder is a population. While in most countries, crossing description of something with which a person normative gender boundaries generates moral might struggle, not a description of the person censure rather than compassion, there are exam- or the person’s identity. ples in certain cultures of gender-nonconforming Thus, transsexual, transgender, and gender- behaviors (e.g., in spiritual leaders) that are less nonconforming individuals are not inherently stigmatized and even revered (Besnier, 1994; disordered. Rather, the distress of gender dys- Bolin, 1988; Chinas,˜ 1995; Coleman, Colgan, & phoria, when present, is the concern that might Gooren, 1992; Costa & Matzner, 2007; Jackson be diagnosable and for which various treatment & Sullivan, 1999; Nanda, 1998; Taywaditep, options are available. The existence of a diagno- Coleman, & Dumronggittigule, 1997). sis for such dysphoria often facilitates access to For various reasons, researchers who have health care and can guide further research into studied incidence and prevalence have tended effective treatments. to focus on the most easily counted subgroup of Research is leading to new diagnostic nomen- gender-nonconforming individuals: transsexual clatures, and terms are changing in both the DSM individuals who experience gender dysphoria (Cohen-Kettenis & Pfafflin,¨ 2010; Knudson, De and who present for gender-transition-related Cuypere, & Bockting, 2010b; Meyer-Bahlburg, care at specialist gender clinics (Zucker & 2010; Zucker, 2010) and the ICD. For this Lawrence, 2009). Most studies have been con- reason, familiar terms are employed in the ducted in European countries such as Sweden SOC and definitions are provided for terms that (Walinder,˚ 1968, 1971), the United Kingdom may be emerging. Health professionals should (Hoenig & Kenna, 1974), the Netherlands refer to the most current diagnostic criteria and (Bakker, Van Kesteren, Gooren, & Bezemer, appropriate codes to apply in their practice areas. 1993; Eklund, Gooren, & Bezemer, 1988; van Kesteren, Gooren, & Megens, 1996), Germany (Weitze & Osburg, 1996), and Belgium (De IV. EPIDEMIOLOGIC Cuypere et al., 2007). One was conducted in CONSIDERATIONS Singapore (Tsoi, 1988). De Cuypere and colleagues (2007) reviewed Formal epidemiologic studies on the 3 4 such studies, as well as conducted their own. incidence and prevalence of transsexual- Together, those studies span 39 years. Leaving ism specifically or transgender and gender- aside two outlier findings from Pauly in 1965 nonconforming identities in general have not and Tsoi in 1988, ten studies involving eight been conducted, and efforts to achieve realistic countries remain. The prevalence figures re- estimates are fraught with enormous difficul- ported in these ten studies range from 1:11,900 to ties (Institute of Medicine, 2011; Zucker & 1:45,000 for male-to-female individuals (MtF) Lawrence, 2009). Even if epidemiologic studies and 1:30,400 to 1:200,000 for female-to-male established that a similar proportion of trans- (FtM) individuals. Some scholars have sug- sexual, transgender, or gender-nonconforming gested that the prevalence is much higher, people existed all over the world, it is likely depending on the methodology used in the research (e.g., Olyslager & Conway, 2007). Direct comparisons across studies are impos- 3Incidence—the number of new cases arising in a given period (e.g., a year). sible, as each differed in their data collection 4Prevalence—the number of individuals having methods and in their criteria for documenting a 4035 condition, divided by the number of people in a person as transsexual (e.g., whether or not the general population. a person had undergone genital reconstruction, 170 INTERNATIONAL JOURNAL OF TRANSGENDERISM versus had initiated hormone therapy, versus had Overall, the existing data should be consid- come to the clinic seeking medically supervised ered a starting point, and health care would transition services). The trend appears to be benefit from more rigorous epidemiologic study towards higher prevalence rates in the more in different locations worldwide. recent studies, possibly indicating increasing numbers of people seeking clinical care. Support for this interpretation comes from research by V. OVERVIEW OF THERAPEUTIC Reed and colleagues (2009), who reported a APPROACHES FOR GENDER doubling of the numbers of people accessing DYSPHORIA care at gender clinics in the United Kingdom every five or six years. Similarly, Zucker and Advancements in the Knowledge and colleagues (2008) reported a four- to five-fold Treatment of Gender Dysphoria increase in child and adolescent referrals to their Toronto, Canada, clinic over a 30-year period. In the second half of the 20th century, The numbers yielded by studies such as these awareness of the phenomenon of gender can be considered minimum estimates at best. dysphoria increased when health professionals The published figures are mostly derived from began to provide assistance to alleviate gender clinics where patients met criteria for severe dysphoria by supporting changes in primary and gender dysphoria and had access to health care secondary sex characteristics through hormone at those clinics. These estimates do not take into therapy and surgery, along with a change in account that treatments offered in a particular gender role. Although Harry Benjamin already clinic setting might not be perceived as afford- acknowledged a spectrum of gender noncon- able, useful, or acceptable by all self-identified formity (Benjamin, 1966), the initial clinical gender dysphoric individuals in a given area. By approach largely focused on identifying who was counting only those people who present at clinics an appropriate candidate for sex reassignment to for a specific type of treatment, an unspecified facilitate a physical change from male to female number of gender dysphoric individuals are or female to male as completely as possible (e.g., overlooked. Green & Fleming, 1990; Hastings, 1974). This Other clinical observations (not yet firmly approach was extensively evaluated and proved supported by systematic study) support the to be highly effective. Satisfaction rates across likelihood of a higher prevalence of gender studies ranged from 87% of MtF patients to dysphoria: (i) Previously unrecognized gender 97% of FtM patients (Green & Fleming, 1990), dysphoria is occasionally diagnosed when pa- and regrets were extremely rare (1%–1.5% tients are seen with anxiety, depression, conduct of MtF patients and < 1% of FtM patients; disorder, substance abuse, dissociative identity Pfafflin,¨ 1993). Indeed, hormone therapy and disorders, borderline personality disorder, sex- surgery have been found to be medically ual disorders, and disorders of sex develop- necessary to alleviate gender dysphoria in many ment (Cole, O’Boyle, Emory, & Meyer, 1997). people (American Medical Association, 2008; (ii) Some cross-dressers, drag queens/kings or Anton, 2009; World Professional Association female/male impersonators, and gay and les- for Transgender Health, 2008). bian individuals may be experiencing gender As the field matured, health professionals dysphoria (Bullough & Bullough, 1993). (iii) recognized that while many individuals need The intensity of some people’s gender dysphoria both hormone therapy and surgery to alleviate fluctuates below and above a clinical thresh- their gender dysphoria, others need only one of old (Docter, 1988). (iv) Gender nonconformity these treatment options and some need neither among FtM individuals tends to be relatively in- (Bockting & Goldberg, 2006; Bockting, 2008; visible in many cultures, particularly to Western Lev, 2004). Often with the help of psychother- health professionals and researchers who have apy, some individuals integrate their trans- conducted most of the studies on which the or cross-gender feelings into the gender role current estimates of prevalence and incidence they were assigned at birth and do not feel the are based (Winter, 2009). need to feminize or masculinize their body. For Coleman et al. 171 others, changes in gender role and expression Options for Psychological and Medical are sufficient to alleviate gender dysphoria. Treatment of Gender Dysphoria Some patients may need hormones, a possible change in gender role, but not surgery; others For individuals seeking care for gender may need a change in gender role along with dysphoria, a variety of therapeutic options surgery but not hormones. In other words, can be considered. The number and type of treatment for gender dysphoria has become interventions applied and the order in which more individualized. these take place may differ from person to person As a generation of transsexual, transgender, (e.g., Bockting, Knudson, & Goldberg, 2006; and gender-nonconforming individuals has Bolin, 1994; Rachlin, 1999; Rachlin, Green, & come of age—many of whom have benefitted Lombardi, 2008; Rachlin, Hansbury, & Pardo, from different therapeutic approaches—they 2010). Treatment options include the following: have become more visible as a community and • demonstrated considerable diversity in their Changes in gender expression and role gender identities, roles, and expressions. Some (which may involve living part time or full individuals describe themselves not as gender- time in another gender role, consistent with one’s gender identity); nonconforming but as unambiguously cross- • sexed (i.e., as a member of the other sex; Bockt- Hormone therapy to feminize or masculin- ize the body; ing, 2008). Other individuals affirm their unique • gender identity and no longer consider them- Surgery to change primary and/or sec- selves to be either male or female (Bornstein, ondary sex characteristics (e.g., breasts/ 1994; Kimberly, 1997; Stone, 1991; Warren, chest, external and/or internal genitalia, facial features, body contouring); 1993). Instead, they may describe their gender • identity in specific terms such as transgender, Psychotherapy (individual, couple, family, bigender, or genderqueer, affirming their unique or group) for purposes such as explor- experiences that may transcend a male/female ing gender identity, role, and expression; binary understanding of gender (Bockting, addressing the negative impact of gender 2008; Ekins & King, 2006; Nestle, Wilchins, & dysphoria and stigma on mental health; Howell, 2002). They may not experience their alleviating internalized transphobia; en- process of identity affirmation as a “transition,” hancing social and peer support; improving because they never fully embraced the gender body image; or promoting resilience. role they were assigned at birth or because Options for Social Support and Changes they actualize their gender identity, role, and in Gender Expression expression in a way that does not involve a change from one gender role to another. For In addition (or as an alternative) to the example, some youth identifying as genderqueer psychological- and medical-treatment options have always experienced their gender identity described above, other options can be considered and role as such (genderqueer). Greater public to help alleviate gender dysphoria, for example: visibility and awareness of gender diversity (Feinberg, 1996) have further expanded options • In person and online peer support re- for people with gender dysphoria to actualize an sources, groups, or community organi- identity and find a gender role and expression zations that provide avenues for social that are comfortable for them. support and advocacy; Health professionals can assist gender dys- • In person and online support resources for phoric individuals with affirming their gender families and friends; identity, exploring different options for expres- • Voice and communication therapy to help sion of that identity, and making decisions about individuals develop verbal and nonverbal medical treatment options for alleviating gender communication skills that facilitate com- dysphoria. fort with their gender identity; 172 INTERNATIONAL JOURNAL OF TRANSGENDERISM
• Hair removal through electrolysis, laser 1984). Newer studies, also including girls, treatment, or waxing; showed a 12%–27% persistence rate of gender • Breast binding or padding, genital tucking dysphoria into adulthood (Drummond, Bradley, or penile prostheses, padding of hips or Peterson-Badali, & Zucker, 2008; Wallien & buttocks; Cohen-Kettenis, 2008). • Changes in name and gender marker on In contrast, the persistence of gender dyspho- identity documents. ria into adulthood appears to be much higher for adolescents. No formal prospective studies exist. However, in a follow-up study of 70 adolescents VI. ASSESSMENT AND TREATMENT who were diagnosed with gender dysphoria and OF CHILDREN AND ADOLESCENTS given puberty-suppressing hormones, all con- WITH GENDER DYSPHORIA tinued with actual sex reassignment, beginning with feminizing/masculinizing hormone therapy There are a number of differences in the phe- (de Vries, Steensma, Doreleijers, & Cohen- nomenology, developmental course, and treat- Kettenis, 2010). ment approaches for gender dysphoria in chil- Another difference between gender dysphoric dren, adolescents, and adults. In children and children and adolescents is in the sex ratios adolescents, a rapid and dramatic developmental for each age group. In clinically referred, process (physical, psychological, and sexual) gender dysphoric children under age 12, the is involved and there is greater fluidity and male/female ratio ranges from 6:1 to 3:1 (Zucker, variability in outcomes, particularly in prepu- 2004). In clinically referred, gender dysphoric bertal children. Accordingly, this section of the adolescents older than age 12, the male/female SOC offers specific clinical guidelines for the ratio is close to 1:1 (Cohen-Kettenis & Pfafflin,¨ assessment and treatment of gender dysphoric 2003). children and adolescents. As discussed in section IV and by Zucker and Lawrence (2009), formal epidemiologic studies Differences Between Children and on gender dysphoria—in children, adolescents, Adolescents with Gender Dysphoria and adults—are lacking. Additional research is needed to refine estimates of its preva- An important difference between gender lence and persistence in different populations dysphoric children and adolescents is in the worldwide. proportion for whom dysphoria persists into adulthood. Gender dysphoria during childhood Phenomenology in Children does not inevitably continue into adulthood.5 Rather, in follow-up studies of prepubertal Children as young as age two may show children (mainly boys) who were referred to features that could indicate gender dysphoria. clinics for assessment of gender dysphoria, the They may express a wish to be of the other dysphoria persisted into adulthood for only sex and be unhappy about their physical sex 6%–23% of children (Cohen-Kettenis, 2001; characteristics and functions. In addition, they Zucker & Bradley, 1995). Boys in these studies may prefer clothes, toys, and games that are com- were more likely to identify as gay in adulthood monly associated with the other sex and prefer than as transgender (Green, 1987; Money & playing with other-sex peers. There appears to be Russo, 1979; Zucker & Bradley, 1995; Zuger, heterogeneity in these features: Some children demonstrate extremely gender-nonconforming behavior and wishes, accompanied by persistent 5Gender-nonconforming behaviors in children and severe discomfort with their primary sex may continue into adulthood, but such behaviors are characteristics. In other children, these char- not necessarily indicative of gender dysphoria and a acteristics are less intense or only partially need for treatment. As described in section III, gender dysphoria is not synonymous with diversity in gender present (Cohen-Kettenis et al., 2006; Knudson, expression. De Cuypere, & Bockting, 2010a). Coleman et al. 173
It is relatively common for gender dysphoric first Tanner stages—differs among countries and children to have coexisting internalizing disor- centers. Not all clinics offer puberty suppression. ders such as anxiety and depression (Cohen- If such treatment is offered, the pubertal stage Kettenis, Owen, Kaijser, Bradley, & Zucker, at which adolescents are allowed to start varies 2003; Wallien, Swaab, & Cohen-Kettenis, 2007; from Tanner stage 2 to stage 4 (Delemarre-van Zucker, Owen, Bradley, & Ameeriar, 2002). de Waal & Cohen-Kettenis, 2006; Zucker et al., The prevalence of autism spectrum disorders 2012). The percentages of treated adolescents seems to be higher in clinically referred, gender are likely influenced by the organization dysphoric children than in the general popu- of health care, insurance aspects, cultural lation (de Vries, Noens, Cohen-Kettenis, van differences, opinions of health professionals, Berckelaer-Onnes, & Doreleijers, 2010). and diagnostic procedures offered in different settings. Phenomenology in Adolescents Inexperienced clinicians may mistake indica- tions of gender dysphoria for delusions. Phe- In most children, gender dysphoria will dis- nomenologically, there is a qualitative difference appear before, or early in, puberty. However, between the presentation of gender dysphoria in some children these feelings will intensify and the presentation of delusions or other psy- and body aversion will develop or increase as chotic symptoms. The vast majority of children they become adolescents and their secondary sex and adolescents with gender dysphoria are not characteristics develop (Cohen-Kettenis, 2001; suffering from underlying severe psychiatric Cohen-Kettenis & Pfafflin,¨ 2003; Drummond illness such as psychotic disorders (Steensma, et al., 2008; Wallien & Cohen-Kettenis, 2008; Biemond, de Boer, & Cohen-Kettenis, published Zucker & Bradley, 1995). Data from one study online ahead of print January 7, 2011). suggest that more extreme gender nonconfor- It is more common for adolescents with gen- mity in childhood is associated with persistence der dysphoria to have coexisting internalizing of gender dysphoria into late adolescence and disorders such as anxiety and depression, and/or early adulthood (Wallien & Cohen-Kettenis, externalizing disorders such as oppositional 2008). Yet many adolescents and adults pre- defiant disorder (de Vries et al., 2010). As in senting with gender dysphoria do not report children, there seems to be a higher prevalence of a history of childhood gender-nonconforming autistic spectrum disorders in clinically referred, behaviors (Docter, 1988; Landen,´ Walinder,˚ gender dysphoric adolescents than in the general & Lundstrom,¨ 1998). Therefore, it may come adolescent population (de Vries et al., 2010). as a surprise to others (parents, other family members, friends, and community members) Competency of Mental Health when a youth’s gender dysphoria first becomes Professionals Working with Children evident in adolescence. or Adolescents with Gender Dysphoria Adolescents who experience their primary and/or secondary sex characteristics and their The following are recommended minimum sex assigned at birth as inconsistent with their credentials for mental health professionals who gender identity may be intensely distressed assess, refer, and offer therapy to children and about it. Many, but not all, gender dysphoric adolescents presenting with gender dysphoria: adolescents have a strong wish for hormones and surgery. Increasing numbers of adolescents 1. Meet the competency requirements for have already started living in their desired gender mental health professionals working with role upon entering high school (Cohen-Kettenis adults, as outlined in section VII; &Pfafflin,¨ 2003). 2. Trained in childhood and adolescent devel- Among adolescents who are referred to opmental psychopathology; gender identity clinics, the number considered 3. Competent in diagnosing and treating the eligible for early medical treatment—starting ordinary problems of children and adoles- with GnRH analogues to suppress puberty in the cents. 174 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Roles of Mental Health Professionals support, such as support groups for parents Working with Children and Adolescents of gender-nonconforming and transgender with Gender Dysphoria children (Gold & MacNish, 2011; Pleak, 1999; Rosenberg, 2002). The roles of mental health professionals working with gender dysphoric children and Assessment and psychosocial interventions for adolescents may include the following: children and adolescents are often provided within a multidisciplinary gender identity 1. Directly assess gender dysphoria in chil- specialty service. If such a multidisciplinary dren and adolescents (see general guide- service is not available, a mental health profes- lines for assessment, below). sional should provide consultation and liaison 2. Provide family counseling and support- arrangements with a pediatric endocrinologist ive psychotherapy to assist children and for the purpose of assessment, education, and adolescents with exploring their gender involvement in any decisions about physical identity, alleviating distress related to their interventions. gender dysphoria, and ameliorating any other psychosocial difficulties. Psychological Assessment of Children 3. Assess and treat any coexisting mental and Adolescents health concerns of children or adolescents (or refer to another mental health pro- When assessing children and adolescents who fessional for treatment). Such concerns present with gender dysphoria, mental health should be addressed as part of the overall professionals should broadly conform to the treatment plan. following guidelines: 4. Refer adolescents for additional physical interventions (such as puberty-suppressing 1. Mental health professionals should not hormones) to alleviate gender dysphoria. dismiss or express a negative attitude The referral should include documentation towards nonconforming gender identities of an assessment of gender dysphoria and or indications of gender dysphoria. Rather, mental health, the adolescent’s eligibility they should acknowledge the presenting for physical interventions (outlined be- concerns of children, adolescents, and their low), the mental health professional’s rel- families; offer a thorough assessment for evant expertise, and any other information gender dysphoria and any coexisting men- pertinent to the youth’s health and referral tal health concerns; and educate clients and for specific treatments. their families about therapeutic options, 5. Educate and advocate on behalf of gender if needed. Acceptance, and alleviation of dysphoric children, adolescents, and their secrecy, can bring considerable relief to families in their community (e.g., day care gender dysphoric children/adolescents and centers, schools, camps, other organiza- their families. tions). This is particularly important in 2. Assessment of gender dysphoria and men- light of evidence that children and adoles- tal health should explore the nature and cents who do not conform to socially pre- characteristics of a child’s or adolescent’s scribed gender norms may experience ha- gender identity. A psychodiagnostic and rassment in school (Grossman, D’Augelli, psychiatric assessment—covering the ar- Howell, & Hubbard, 2006; Grossman, eas of emotional functioning, peer and D’Augelli, & Salter, 2006; Sausa, 2005), other social relationships, and intellectual putting them at risk for social isolation, functioning/school achievement—should depression, and other negative sequelae be performed. Assessment should include (Nuttbrock et al., 2010). an evaluation of the strengths and weak- 6. Provide children, youth, and their families nesses of family functioning. Emotional with information and referral for peer and behavioral problems are relatively Coleman et al. 175
common, and unresolved issues in a child’s de Waal, 2006; Di Ceglie & Thummel,¨ or youth’s environment may be present (de 2006; Hill, Menvielle, Sica, & Johnson, Vries, Doreleijers, Steensma, & Cohen- 2010; Malpas, 2011; Menvielle & Tuerk, Kettenis, 2011; Di Ceglie & Thummel,¨ 2002; Rosenberg, 2002; Vanderburgh, 2006; Wallien et al., 2007). 2009; Zucker, 2006). 3. For adolescents, the assessment phase Treatment aimed at trying to change a should also be used to inform youth and person’s gender identity and expression to their families about the possibilities and become more congruent with sex assigned limitations of different treatments. This at birth has been attempted in the past is necessary for informed consent and without success (Gelder & Marks, 1969; also important for assessment. The way Greenson, 1964), particularly in the long that adolescents respond to information term (Cohen-Kettenis & Kuiper, 1984; about the reality of sex reassignment Pauly, 1965). Such treatment is no longer can be diagnostically informative. Correct considered ethical. information may alter a youth’s desire 3. Families should be supported in managing for certain treatment, if the desire was uncertainty and anxiety about their child’s based on unrealistic expectations of its or adolescent’s psychosexual outcomes possibilities. and in helping youth to develop a positive self-concept. Psychological and Social Interventions for 4. Mental health professionals should not im- Children and Adolescents pose a binary view of gender. They should give ample room for clients to explore When supporting and treating children and different options for gender expression. adolescents with gender dysphoria, health pro- Hormonal or surgical interventions are fessionals should broadly conform to the follow- appropriate for some adolescents but not ing guidelines: for others. 5. Clients and their families should be sup- 1. Mental health professionals should help ported in making difficult decisions re- families to have an accepting and nurturing garding the extent to which clients are response to the concerns of their gender allowed to express a gender role that is dysphoric child or adolescent. Families consistent with their gender identity, as play an important role in the psychological well as the timing of changes in gender health and well-being of youth (Brill & role and possible social transition. For Pepper, 2008; Lev, 2004). This also applies example, a client might attend school while to peers and mentors from the community, undergoing social transition only partly who can be another source of social (e.g., by wearing clothing and having a support. hairstyle that reflects gender identity) or 2. Psychotherapy should focus on reducing completely (e.g., by also using a name and a child’s or adolescent’s distress pronouns congruent with gender identity). related to the gender dysphoria and Difficult issues include whether and when on ameliorating any other psychosocial to inform other people of the client’s difficulties. For youth pursuing sex situation, and how others in their lives reassignment, psychotherapy may focus might respond. on supporting them before, during, and 6. Health professionals should support clients after reassignment. Formal evaluations of and their families as educators and advo- different psychotherapeutic approaches cates in their interactions with community for this situation have not been published, members and authorities such as teachers, but several counseling methods have school boards, and courts. been described (Cohen-Kettenis, 2006; de 7. Mental health professionals should strive Vries, Cohen-Kettenis, & Delemarre-van to maintain a therapeutic relationship with 176 INTERNATIONAL JOURNAL OF TRANSGENDERISM
gender-nonconforming children/adoles- compromises (e.g., only when on vacation). It cents and their families throughout any is also important that parents explicitly let the subsequent social changes or physical child know that there is a way back. interventions. This ensures that decisions Regardless of a family’s decisions regarding about gender expression and the treatment transition (timing, extent), professionals should of gender dysphoria are thoughtfully counsel and support them as they work through and recurrently considered. The same the options and implications. If parents do not reasoning applies if a child or adolescent allow their young child to make a gender-role has already socially changed gender role transition, they may need counseling to assist prior to being seen by a mental health them with meeting their child’s needs in a professional. sensitive and nurturing way, ensuring that the child has ample possibilities to explore gender Social Transition in Early Childhood feelings and behavior in a safe environment. If parents do allow their young child to make a Some children state that they want to make gender-role transition, they may need counseling a social transition to a different gender role to facilitate a positive experience for their long before puberty. For some children, this may child. For example, they may need support in reflect an expression of their gender identity. For using correct pronouns, maintaining a safe and others, this could be motivated by other forces. supportive environment for their transitioning Families vary in the extent to which they allow child (e.g., in school, peer group settings), and their young children to make a social transition communicating with other people in their child’s to another gender role. Social transitions in early life. In either case, as a child nears puberty, childhood do occur within some families with further assessment may be needed as options early success. This is a controversial issue, and for physical interventions become relevant. divergent views are held by health professionals. The current evidence base is insufficient to Physical Interventions for Adolescents predict the long-term outcomes of completing a gender role transition during early childhood. Before any physical interventions are consid- Outcomes research with children who completed ered for adolescents, extensive exploration of early social transitions would greatly inform psychological, family, and social issues should future clinical recommendations. be undertaken, as outlined above. The duration Mental health professionals can help families of this exploration may vary considerably de- to make decisions regarding the timing and pro- pending on the complexity of the situation. cess of any gender-role changes for their young Physical interventions should be addressed in children. They should provide information and the context of adolescent development. Some help parents to weigh the potential benefits and identity beliefs in adolescents may become challenges of particular choices. Relevant in firmly held and strongly expressed, giving a this respect are the previously described rela- false impression of irreversibility. An adoles- tively low persistence rates of childhood gender cent’s shift towards gender conformity can occur dysphoria (Drummond et al., 2008; Wallien & primarily to please the parents and may not Cohen-Kettenis, 2008). A change back to the persist or reflect a permanent change in gender original gender role can be highly distressing dysphoria (Hembree et al., 2009; Steensma et al., and even result in postponement of this second published online ahead of print January 7, 2011). social transition on the child’s part (Steensma Physical interventions for adolescents fall & Cohen-Kettenis, 2011). For reasons such as into three categories or stages (Hembree et al., these, parents may want to present this role 2009): change as an exploration of living in another gender role rather than an irreversible situation. 1. Fully reversible interventions. These in- Mental health professionals can assist parents volve the use of GnRH analogues to sup- in identifying potential in-between solutions or press estrogen or testosterone production Coleman et al. 177
and consequently delay the physical formity and other developmental issues and (ii) changes of puberty. Alternative treat- their use may facilitate transition by preventing ment options include progestins (most the development of sex characteristics that are commonly medroxyprogesterone) or other difficult or impossible to reverse if adolescents medications (such as spironolactone) that continue on to pursue sex reassignment. decrease the effects of androgens secreted Puberty suppression may continue for a few by the testicles of adolescents who are years, at which time a decision is made to either not receiving GnRH analogues. Continu- discontinue all hormone therapy or transition to ous oral contraceptives (or depot medrox- a feminizing/masculinizing hormone regimen. yprogesterone) may be used to suppress Pubertal suppression does not inevitably lead to menses. social transition or to sex reassignment. 2. Partially reversible interventions. These include hormone therapy to masculinize or Criteria for Puberty-Suppressing Hormones feminize the body. Some hormone-induced changes may need reconstructive surgery In order for adolescents to receive puberty- to reverse the effect (e.g., gynaecomastia suppressing hormones, the following minimum caused by estrogens), while other changes criteria must be met: are not reversible (e.g., deepening of the voice caused by testosterone). 1. The adolescent has demonstrated a long- 3. Irreversible interventions. These are surgi- lasting and intense pattern of gender non- cal procedures. conformity or gender dysphoria (whether suppressed or expressed); A staged process is recommended to keep op- 2. Gender dysphoria emerged or worsened tions open through the first two stages. Moving with the onset of puberty; from one stage to another should not occur until 3. Any coexisting psychological, medical, there has been adequate time for adolescents and or social problems that could interfere their parents to assimilate fully the effects of with treatment (e.g., that may compromise earlier interventions. treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start Fully Reversible Interventions treatment; Adolescents may be eligible for 4. The adolescent has given informed consent puberty-suppressing hormones as soon as and, particularly when the adolescent has pubertal changes have begun. In order for not reached the age of medical consent, adolescents and their parents to make an the parents or other caretakers or guardians informed decision about pubertal delay, it is have consented to the treatment and are recommended that adolescents experience the involved in supporting the adolescent onset of puberty to at least Tanner Stage 2. Some throughout the treatment process. children may arrive at this stage at very young ages (e.g., 9 years of age). Studies evaluating Regimens, Monitoring, and Risks for Pu- this approach have only included children who berty Suppression were at least 12 years of age (Cohen-Kettenis, Schagen, Steensma, de Vries, & Delemarre-van For puberty suppression, adolescents with de Waal, 2011; de Vries, Steensma et al., 2010; male genitalia should be treated with GnRH Delemarre-van de Waal, van Weissenbruch, & analogues, which stop luteinizing hormone se- Cohen Kettenis, 2004; Delemarre-van de Waal cretion and therefore testosterone secretion. & Cohen-Kettenis, 2006). Alternatively, they may be treated with pro- Two goals justify intervention with puberty- gestins (such as medroxyprogesterone) or with suppressing hormones: (i) their use gives adoles- other medications that block testosterone se- cents more time to explore their gender noncon- cretion and/or neutralize testosterone action. 178 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Adolescents with female genitalia should be with parental consent. In many countries, 16- treated with GnRH analogues, which stop the year-olds are legal adults for medical decision- production of estrogens and progesterone. Al- making and do not require parental consent. Ide- ternatively, they may be treated with progestins ally, treatment decisions should be made among (such as medroxyprogesterone). Continuous oral the adolescent, the family, and the treatment contraceptives (or depot medroxyprogesterone) team. may be used to suppress menses. In both groups Regimens for hormone therapy in gender of adolescents, use of GnRH analogues is the dysphoric adolescents differ substantially from preferred treatment (Hembree et al., 2009), but those used in adults (Hembree et al., 2009). their high cost is prohibitive for some patients. The hormone regimens for youth are adapted to During pubertal suppression, an adoles- account for the somatic, emotional, and mental cent’s physical development should be care- development that occurs throughout adolescence fully monitored—preferably by a pediatric (Hembree et al., 2009). endocrinologist—so that any necessary inter- ventions can occur (e.g., to establish an adequate Irreversible Interventions gender appropriate height, to improve iatrogenic low bone mineral density) (Hembree et al., Genital surgery should not be carried out until 2009). (i) patients reach the legal age of majority to Early use of puberty-suppressing hormones give consent for medical procedures in a given may avert negative social and emotional con- country and (ii) patients have lived continuously sequences of gender dysphoria more effectively for at least 12 months in the gender role that than their later use would. Intervention in early is congruent with their gender identity. The age adolescence should be managed with pediatric threshold should be seen as a minimum criterion endocrinological advice, when available. Ado- and not an indication in and of itself for active lescents with male genitalia who start GnRH intervention. analogues early in puberty should be informed Chest surgery in FtM patients could be carried that this could result in insufficient penile tissue out earlier, preferably after ample time of living for penile inversion vaginoplasty techniques in the desired gender role and after one year of (alternative techniques, such as the use of a skin testosterone treatment. The intent of this sug- graft or colon tissue, are available). gested sequence is to give adolescents sufficient Neither puberty suppression nor allowing opportunity to experience and socially adjust in puberty to occur is a neutral act. On the one hand, a more masculine gender role, before under- functioning in later life can be compromised by going irreversible surgery. However, different the development of irreversible secondary sex approaches may be more suitable, depending characteristics during puberty and by years spent on an adolescent’s specific clinical situation and experiencing intense gender dysphoria. On the goals for gender identity expression. other hand, there are concerns about negative physical side effects of GnRH analogue use (e.g., Risks of Withholding Medical Treatment on bone development and height). Although the for Adolescents very first results of this approach (as assessed for adolescents followed over 10 years) are promis- Refusing timely medical interventions for ing (Cohen-Kettenis et al., 2011; Delemarre-van adolescents might prolong gender dysphoria and de Waal & Cohen-Kettenis, 2006), the long-term contribute to an appearance that could provoke effects can only be determined when the earliest- abuse and stigmatization. As the level of gender- treated patients reach the appropriate age. related abuse is strongly associated with the degree of psychiatric distress during adolescence Partially Reversible Interventions (Nuttbrock et al., 2010), withholding puberty- suppression and subsequent feminizing or mas- Adolescents may be eligible to begin feminiz- culinizing hormone therapy is not a neutral ing/masculinizing hormone therapy, preferably option for adolescents. Coleman et al. 179
VII. MENTAL HEALTH 3. Ability to recognize and diagnose co- existing mental health concerns and to Transsexual, transgender, and gender- distinguish these from gender dysphoria. nonconforming people might seek the assistance 4. Documented supervised training and com- of a mental health professional for any number petence in psychotherapy or counseling. of reasons. Regardless of a person’s reason for 5. Knowledge about gender-nonconforming seeking care, mental health professionals should identities and expressions, and the assess- have familiarity with gender nonconformity, ment and treatment of gender dysphoria. act with appropriate cultural competence, and 6. Continuing education in the assess- exhibit sensitivity in providing care. ment and treatment of gender dyspho- This section of the SOC focuses on the role ria. This may include attending relevant of mental health professionals in the care of professional meetings, workshops, or sem- adults seeking help for gender dysphoria and inars; obtaining supervision from a mental related concerns. Professionals working with health professional with relevant experi- gender dysphoric children, adolescents, and their ence; or participating in research related to families should consult section VI. gender nonconformity and gender dyspho- ria.
Competency of Mental Health In addition to the minimum credentials above, it Professionals Working with Adults is recommended that mental health professionals Who Present with Gender Dysphoria develop and maintain cultural competence to fa- cilitate their work with transsexual, transgender, The training of mental health professionals and gender-nonconforming clients. This may competent to work with gender dysphoric adults involve, for example, becoming knowledgeable rests upon basic general clinical competence about current community, advocacy, and public in the assessment, diagnosis, and treatment of policy issues relevant to these clients and their mental health concerns. Clinical training may families. Additionally, knowledge about sexual- occur within any discipline that prepares mental ity, sexual health concerns, and the assessment health professionals for clinical practice, such and treatment of sexual disorders is preferred. as psychology, psychiatry, social work, mental Mental health professionals who are new to health counseling, marriage and family therapy, the field (irrespective of their level of training nursing, or family medicine with specific train- and other experience) should work under the ing in behavioral health and counseling. The fol- supervision of a mental health professional with lowing are recommended minimum credentials established competence in the assessment and for mental health professionals who work with treatment of gender dysphoria. adults presenting with gender dysphoria: Tasks of Mental Health Professionals 1. A master’s degree or its equivalent in Working with Adults Who Present a clinical behavioral science field. This with Gender Dysphoria degree, or a more advanced one, should be granted by an institution accredited by the Mental health professionals may serve trans- appropriate national or regional accredit- sexual, transgender, and gender-nonconforming ing board. The mental health professional individuals and their families in many ways, should have documented credentials from depending on a client’s needs. For example, a relevant licensing board or equivalent for mental health professionals may serve as a that country. psychotherapist, counselor, or family therapist, 2. Competence in using the Diagnostic Sta- or as a diagnostician/assessor, advocate, or tistical Manual of Mental Disorders and/or educator. the International Classification of Dis- Mental health professionals should deter- eases for diagnostic purposes. mine a client’s reasons for seeking professional 180 INTERNATIONAL JOURNAL OF TRANSGENDERISM assistance. For example, a client may be present- the prescribing hormone-therapy provider or a ing for any combination of the following health member of that provider’s health care team. care services: psychotherapeutic assistance to explore gender identity and expression or to 2. Provide Information Regarding Options facilitate a coming-out process; assessment and for Gender Identity and Expression and referral for feminizing/masculinizing medical Possible Medical Interventions interventions; psychological support for family members (partners, children, extended family); An important task of mental health pro- psychotherapy unrelated to gender concerns; or fessionals is to educate clients regarding the other professional services. diversity of gender identities and expressions Below are general guidelines for common and the various options available to alleviate tasks that mental health professionals may fulfill gender dysphoria. Mental health professionals in working with adults who present with gender then may facilitate a process (or refer elsewhere) dysphoria. in which clients explore these various options, with the goals of finding a comfortable gender role and expression and becoming prepared to Tasks Related to Assessment and Referral make a fully informed decision about available 1. Assess Gender Dysphoria medical interventions, if needed. This process may include referral for individual, family, and Mental health professionals assess clients’ group therapy and/or to community resources gender dysphoria in the context of an evaluation and avenues for peer support. The professional of their psychosocial adjustment (Bockting et al., and the client discuss the implications, both 2006; Lev, 2004, 2009). The evaluation includes, short- and long-term, of any changes in gender at a minimum, assessment of gender identity role and use of medical interventions. These and gender dysphoria, history and development implications can be psychological, social, phys- of gender dysphoric feelings, the impact of ical, sexual, occupational, financial, and legal stigma attached to gender nonconformity on (Bockting et al., 2006; Lev, 2004). mental health, and the availability of support This task is also best conducted by a from family, friends, and peers (for example, qualified mental health professional, but may in-person or online contact with other trans- be conducted by another health professional sexual, transgender, or gender-nonconforming with appropriate training in behavioral health individuals or groups). The evaluation may result and with sufficient knowledge about gender- in no diagnosis, in a formal diagnosis related nonconforming identities and expressions and to gender dysphoria, and/or in other diagnoses about possible medical interventions for gen- that describe aspects of the client’s health and der dysphoria, particularly when functioning psychosocial adjustment. The role of mental as part of a multidisciplinary specialty team health professionals includes making reasonably that provides access to feminizing/masculinizing sure that the gender dysphoria is not secondary hormone therapy. to, or better accounted for, by other diagnoses. Mental health professionals with the com- 3. Assess, Diagnose, and Discuss Treat- petencies described above (hereafter called “a ment Options for Coexisting Mental Health qualified mental health professional”) are best Concerns prepared to conduct this assessment of gender dysphoria. However, this task may instead be Clients presenting with gender dysphoria may conducted by another type of health professional struggle with a range of mental health concerns who has appropriate training in behavioral (Gomez-Gil,´ Trilla, Salamero, Godas,´ & Valdes,´ health and is competent in the assessment of 2009; Murad et al., 2010) whether related or gender dysphoria, particularly when functioning unrelated to what is often a long history of as part of a multidisciplinary specialty team gender dysphoria and/or chronic minority stress. that provides access to feminizing/masculinizing Possible concerns include anxiety, depression, hormone therapy. This professional may be self-harm, a history of abuse and neglect, Coleman et al. 181 compulsivity, substance abuse, sexual concerns, therapy (outlined in section VIII and Appendix personality disorders, eating disorders, psy- C). Mental health professionals can help clients chotic disorders, and autistic spectrum disorders who are considering hormone therapy to be (Bockting et al., 2006; Nuttbrock et al., 2010; both psychologically prepared (e.g., client has Robinow, 2009). Mental health professionals made a fully informed decision with clear and should screen for these and other mental health realistic expectations; is ready to receive the concerns and incorporate the identified concerns service in line with the overall treatment plan; into the overall treatment plan. These concerns has included family and community as appro- can be significant sources of distress and, if priate) and practically prepared (e.g., has been left untreated, can complicate the process of evaluated by a physician to rule out or address gender identity exploration and resolution of medical contraindications to hormone use; has gender dysphoria (Bockting et al., 2006; Fraser, considered the psychosocial implications). If 2009a; Lev, 2009). Addressing these concerns clients are of childbearing age, reproductive can greatly facilitate the resolution of gender options (section IX) should be explored before dysphoria, possible changes in gender role, the initiating hormone therapy. making of informed decisions about medical in- It is important for mental health professionals terventions, and improvements in quality of life. to recognize that decisions about hormones Some clients may benefit from psychotropic are first and foremost a client’s decisions—as medications to alleviate symptoms or treat co- are all decisions regarding health care. How- existing mental health concerns. Mental health ever, mental health professionals have a re- professionals are expected to recognize this and sponsibility to encourage, guide, and assist either provide pharmacotherapy or refer to a clients with making fully informed decisions colleague who is qualified to do so. The presence and becoming adequately prepared. To best of coexisting mental health concerns does not support their clients’ decisions, mental health necessarily preclude possible changes in gender professionals need to have functioning work- role or access to feminizing/masculinizing hor- ing relationships with their clients and suffi- mones or surgery; rather, these concerns need cient information about them. Clients should to be optimally managed prior to, or concurrent receive prompt and attentive evaluation, with with, treatment of gender dysphoria. In addition, the goal of alleviating their gender dysphoria clients should be assessed for their ability to and providing them with appropriate medical provide educated and informed consent for services. medical treatments. Referral for feminizing/masculinizing hor- Qualified mental health professionals are mone therapy. People may approach a special- specifically trained to assess, diagnose, and treat ized provider in any discipline to pursue feminiz- (or refer to treatment for) these coexisting men- ing/masculinizing hormone therapy. However, tal health concerns. Other health professionals transgender health care is an interdisciplinary with appropriate training in behavioral health, field, and coordination of care and referral particularly when functioning as part of a mul- among a client’s overall care team is recom- tidisciplinary specialty team providing access mended. to feminizing/masculinizing hormone therapy, Hormone therapy can be initiated with a may also screen for mental health concerns and, referral from a qualified mental health profes- if indicated, provide referral for comprehensive sional. Alternatively, a health professional who assessment and treatment by a qualified mental is appropriately trained in behavioral health and health professional. competent in the assessment of gender dysphoria may assess eligibility of, prepare, and refer the 4. If Applicable, Assess Eligibility, Prepare, patient for hormone therapy, particularly in the and Refer for Hormone Therapy absence of significant coexisting mental health concerns and when working in the context The SOC provide criteria to guide decisions of a multidisciplinary specialty team. The regarding feminizing/masculinizing hormone referring health professional should provide 182 INTERNATIONAL JOURNAL OF TRANSGENDERISM documentation—in the chart and/or referral appropriate) and practically prepared (e.g., has letter—of the patient’s personal and treatment made an informed choice about a surgeon to history, progress, and eligibility. Health perform the procedure; has arranged aftercare). professionals who recommend hormone therapy If clients are of childbearing age, reproductive share the ethical and legal responsibility for that options (section IX) should be explored before decision with the physician who provides the undergoing genital surgery. service. The SOC do not state criteria for other surgical The recommended content of the referral procedures, such as feminizing or masculinizing letter for feminizing/masculinizing hormone facial surgery; however, mental health profes- therapy is as follows: sionals can play an important role in helping their clients to make fully informed decisions about 1. The client’s general identifying character- the timing and implications of such procedures istics; in the context of the overall coming-out or 2. Results of the client’s psychosocial assess- transition process. ment, including any diagnoses; It is important for mental health professionals 3. The duration of the referring health pro- to recognize that decisions about surgery are fessional’s relationship with the client, in- first and foremost a client’s decisions—as are cluding the type of evaluation and therapy all decisions regarding health care. However, or counseling to date; mental health professionals have a responsibility 4. An explanation that the criteria for hor- to encourage, guide, and assist clients with mone therapy have been met and a brief making fully informed decisions and becom- description of the clinical rationale for ing adequately prepared. To best support their supporting the client’s request for hormone clients’ decisions, mental health professionals therapy; need to have functioning working relationships 5. A statement that informed consent has with their clients and sufficient information been obtained from the patient; about them. Clients should receive prompt and 6. A statement that the referring health pro- attentive evaluation, with the goal of alleviating fessional is available for coordination of their gender dysphoria and providing them with care and welcomes a phone call to establish appropriate medical services. this. Referral for surgery. Surgical treatments for gender dysphoria can be initiated by a refer- For providers working within a multidisciplinary ral (one or two, depending on the type of specialty team, a letter may not be necessary; surgery) from a qualified mental health profes- rather, the assessment and recommendation can sional. The mental health professional provides be documented in the patient’s chart. documentation—in the chart and/or referral letter—of the patient’s personal and treatment 5. If Applicable, Assess Eligibility, Prepare, history, progress, and eligibility. Mental health and Refer for Surgery professionals who recommend surgery share the ethical and legal responsibility for that decision The SOC also provide criteria to guide with the surgeon. decisions regarding breast/chest surgery and genital surgery (outlined in section XI and • One referral from a qualified mental health Appendix C). Mental health professionals can professional is needed for breast/chest help clients who are considering surgery to surgery (e.g., mastectomy, chest recon- be both psychologically prepared (e.g., client struction, or augmentation mammoplasty). has made a fully informed decision with clear • Two referrals—from qualified mental and realistic expectations; is ready to receive health professionals who have indepen- the service in line with the overall treatment dently assessed the patient—are needed plan; has included family and community as for genital surgery (i.e., hysterectomy/ Coleman et al. 183
salpingo-oophorectomy, orchiectomy, progress and obtain peer consultation from other genital reconstructive surgeries). If professionals (both in mental health care and the first referral is from the patient’s other health disciplines) who are competent psychotherapist, the second referral in the assessment and treatment of gender should be from a person who has only had dysphoria. The relationship among professionals an evaluative role with the patient. Two involved in a client’s health care should remain separate letters, or one letter signed by collaborative, with coordination and clinical both (e.g., if practicing within the same dialogue taking place as needed. Open and clinic) may be sent. Each referral letter, consistent communication may be necessary however, is expected to cover the same for consultation, referral, and management of topics in the areas outlined below. postoperative concerns. • No letter is required for hysterectomy/ salpingo-oophorectomy or orchiectomy to be performed for reasons unrelated to Tasks Related to Psychotherapy gender dysphoria or due to other diagnoses. Psychotherapy Is Not an Absolute Require- The recommended content of the referral letters ment for Hormone Therapy and Surgery for surgery is as follows: A mental health screening and/or assessment as outlined above is needed for referral to 1. The client’s general identifying character- hormonal and surgical treatments for gen- istics; der dysphoria. In contrast, psychotherapy— 2. Results of the client’s psychosocial assess- although highly recommended—is not a require- ment, including any diagnoses; ment. 3. The duration of the mental health profes- The SOC do not recommend a minimum num- sional’s relationship with the client, includ- ber of psychotherapy sessions prior to hormone ing the type of evaluation and therapy or therapy or surgery. The reasons for this are multi- counseling to date; faceted (Lev, 2009). First, a minimum number of 4. An explanation that the criteria for surgery sessions tends to be construed as a hurdle, which have been met, and a brief description of discourages the genuine opportunity for personal the clinical rationale for supporting the growth. Second, mental health professionals can patient’s request for surgery; offer important support to clients throughout 5. A statement that informed consent has all phases of exploration of gender identity, been obtained from the patient; gender expression, and possible transition—not 6. A statement that the mental health profes- just prior to any possible medical interventions. sional is available for coordination of care Third, clients and their psychotherapists differ in and welcomes a phone call to establish their abilities to attain similar goals in a specified this. time period. For providers working within a multidisci- plinary specialty team, a letter may not be neces- Goals of Psychotherapy for Adults sary, rather, the assessment and recommendation with Gender Concerns can be documented in the patient’s chart. The general goal of psychotherapy is to find ways to maximize a person’s overall psycho- Relationship of Mental Health logical well-being, quality of life, and self- Professionals with Hormone-Prescribing fulfillment. Psychotherapy is not intended to Physicians, Surgeons, and Other Health alter a person’s gender identity; rather, psy- Professionals chotherapy can help an individual to explore gender concerns and find ways to alleviate gen- It is ideal for mental health professionals der dysphoria, if present (Bockting et al., 2006; to perform their work and periodically discuss Bockting & Coleman, 2007; Fraser, 2009a; Lev, 184 INTERNATIONAL JOURNAL OF TRANSGENDERISM
2004). Typically, the overarching treatment goal challenging—often more so than the physical is to help transsexual, transgender, and gender- aspects. Because changing gender role can have nonconforming individuals achieve long-term profound personal and social consequences, the comfort in their gender identity expression, decision to do so should include an awareness with realistic chances for success in their re- of what the familial, interpersonal, educational, lationships, education, and work. For additional vocational, economic, and legal challenges are details, see Fraser (Fraser, 2009c). likely to be, so that people can function success- Therapy may consist of individual, cou- fully in their gender role. ple, family, or group psychotherapy, the lat- Many transsexual, transgender, and gender- ter being particularly important to foster peer nonconforming people will present for care support. without ever having been related to, or accepted in, the gender role that is most congruent Psychotherapy for Transsexual, Transgen- with their gender identity. Mental health pro- der, and Gender-Nonconforming Clients, fessionals can help these clients to explore and Including Counseling and Support for anticipate the implications of changes in gender Changes in Gender Role role, and to pace the process of implementing these changes. Psychotherapy can provide a Finding a comfortable gender role is, first and space for clients to begin to express themselves foremost, a psychosocial process. Psychother- in ways that are congruent with their gender apy can be invaluable in assisting transsexual, identity and, for some clients, overcome fears transgender, and gender-nonconforming indi- about changes in gender expression. Calculated viduals with all of the following: (i) clarifying risks can be taken outside of therapy to gain and exploring gender identity and role, (ii) experience and build confidence in the new addressing the impact of stigma and minority role. Assistance with coming out to family and stress on one’s mental health and human de- community (friends, school, workplace) can be velopment, and (iii) facilitating a coming-out provided. process (Bockting & Coleman, 2007; Devor, Other transsexual, transgender, and gender- 2004; Lev, 2004), which for some individuals nonconforming individuals will present for care may include changes in gender role expression already having acquired experience (minimal, and the use of feminizing/masculinizing medical moderate, or extensive) living in a gender role interventions. that differs from that associated with their Mental health professionals can provide sup- birth-assigned sex. Mental health professionals port and promote interpersonal skills and re- can help these clients to identify and work silience in individuals and their families as they through potential challenges and foster optimal navigate a world that often is ill-prepared to adjustment as they continue to express changes accommodate and respect transgender, trans- in their gender role. sexual, and gender-nonconforming people. Psy- chotherapy can also aid in alleviating any Family Therapy or Support for Family coexisting mental health concerns (e.g., anxi- Members ety, depression) identified during screening and assessment. Decisions about changes in gender role and For transsexual, transgender, and gender- medical interventions for gender dysphoria have nonconforming individuals who plan to change implications for, not only clients, but also their gender roles permanently and make a social families (Emerson & Rosenfeld, 1996; Fraser, gender role transition, mental health profes- 2009a; Lev, 2004). Mental health profession- sionals can facilitate the development of an als can assist clients with making thoughtful individualized plan with specific goals and decisions about communicating with family timelines. While the experience of changing members and others about their gender identity one’s gender role differs from person to person, and treatment decisions. Family therapy may the social aspects of the experience are usually include work with spouses or partners, as well Coleman et al. 185 as with children and other members of a client’s most recent literature pertaining to this rapidly extended family. evolving medium. A more thorough description Clients may also request assistance with their of the potential uses, processes, and ethical relationships and sexual health. For example, concerns related to e-therapy has been published they may want to explore their sexuality and (Fraser, 2009b). intimacy-related concerns. Family therapy might be offered as part of the client’s individual therapy and, if clinically Other Tasks of the Mental Health appropriate, by the same provider. Alternatively, Professionals referrals can be made to other therapists with Educate and Advocate on Behalf of Clients relevant expertise for working with family mem- Within Their Community (Schools, Work- bers or to sources of peer support (e.g., in person or offline support networks of partners places, Other Organizations) and Assist or families). Clients with Making Changes in Identity Documents Follow-Up Care Throughout Life Transsexual, transgender, and gender- Mental health professionals may work with nonconforming people may face challenges in clients and their families at many stages of their their professional, educational, and other types lives. Psychotherapy may be helpful at different of settings as they actualize their gender identity times and for various issues throughout the life and expression (Lev, 2004, 2009). Mental health cycle. professionals can play an important role by educating people in these settings regarding E-therapy, Online Counseling, or Distance gender nonconformity and by advocating on Counseling behalf of their clients (Currah, Juang, & Minter, 2006; Currah & Minter, 2000). This role may Online or e-therapy has been shown to be involve consultation with school counselors, particularly useful for people who have difficulty teachers, and administrators, human resources accessing competent in-person psychothera- staff, personnel managers and employers, peutic treatment and who may experience and representatives from other organizations isolation and stigma (Derrig-Palumbo & Zeine, and institutions. In addition, health providers 2005; Fenichel et al., 2004; Fraser, 2009b). may be called upon to support changes in a By extrapolation, e-therapy may be a useful client’s name and/or gender marker on identity modality for psychotherapy with transsexual, documents such as passports, driver’s licenses, transgender, and gender-nonconforming people. birth certificates, and diplomas. E-therapy offers opportunities for potentially enhanced, expanded, creative, and tailored delivery of services; however, as a developing Provide Information and Referral for Peer modality it may also carry unexpected risk. Support Telemedicine guidelines are clear in some disciplines in some parts of the United States For some transsexual, transgender, and (Fraser, 2009b; Maheu, Pulier, Wilhelm, gender-nonconforming people, an experience in McMenamin, & Brown-Connolly, 2005) but not peer support groups may be more instructive all; the international situation is even less well regarding options for gender expression than defined (Maheu et al., 2005). Until sufficient anything individual psychotherapy could offer evidence-based data on this use of e-therapy is (Rachlin, 2002). Both experiences are poten- available, caution in its use is advised. tially valuable, and all people exploring gender Mental health professionals engaging in e- issues should be encouraged to participate in therapy are advised to stay current with their community activities, if possible. Resources for particular licensing board, professional associ- peer support and information should be made ation, and country’s regulations, as well as the available. 186 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Culture and Its Ramifications for Issues of Access to Care Assessment and Psychotherapy Qualified mental health professionals are not Health professionals work in enormously universally available; thus, access to quality care different environments across the world. Forms might be limited. WPATH aims to improve ac- of distress that cause people to seek professional cess and provides regular continuing education assistance in any culture are understood and opportunities to train professionals from vari- classified by people in terms that are products ous disciplines to provide quality, transgender- of their own cultures (Frank & Frank, 1993). specific health care. Providing mental health care Cultural settings also largely determine how from a distance through the use of technology such conditions are understood by mental health may be one way to improve access (Fraser, professionals. Cultural differences related to 2009b). gender identity and expression can affect pa- In many places around the world, access to tients, mental health professionals, and accepted health care for transsexual, transgender, and psychotherapy practice. WPATH recognizes that gender-nonconforming people is also limited by the SOC have grown out of a Western tradition a lack of health insurance or other means to and may need to be adapted depending on the pay for needed care. WPATH urges health in- cultural context. surance companies and other third-party payers to cover the medically necessary treatments to alleviate gender dysphoria (American Medical Ethical Guidelines Related to Mental Association, 2008; Anton, 2009; World Pro- Health Care fessional Association for Transgender Health, 2008). Mental health professionals need to be cer- When faced with a client who is unable to ac- tified or licensed to practice in a given coun- cess services, referral to available peer-support try according to that country’s professional resources (offline and online) is recommended. regulations (Fraser, 2009b; Pope & Vasquez, Finally, harm-reduction approaches might be 2011). Professionals must adhere to the ethical indicated to assist clients with making healthy codes of their professional licensing or certifying decisions to improve their lives. organizations in all of their work with trans- sexual, transgender, and gender-nonconforming clients. VIII. HORMONE THERAPY Treatment aimed at trying to change a per- son’s gender identity and lived gender ex- Medical Necessity of Hormone Therapy pression to become more congruent with sex assigned at birth has been attempted in the past Feminizing/masculinizing hormone therapy (Gelder & Marks, 1969; Greenson, 1964), yet —the administration of exogenous endocrine without success, particularly in the long-term agents to induce feminizing or masculinizing (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). changes—is a medically necessary intervention Such treatment is no longer considered ethical. for many transsexual, transgender, and gender- If mental health professionals are uncom- nonconforming individuals with gender dyspho- fortable with, or inexperienced in, working ria (Newfield, Hart, Dibble, & Kohler, 2006; with transsexual, transgender, and gender- Pfafflin¨ & Junge, 1998). Some people seek nonconforming individuals and their families, maximum feminization/ masculinization, while they should refer clients to a competent provider others experience relief with an androgynous or, at minimum, consult with an expert peer. If presentation resulting from hormonal minimiza- no local practitioners are available, consultation tion of existing secondary sex characteristics may be done via telehealth methods, assuming (Factor & Rothblum, 2008). Evidence for the local requirements for distance consultation are psychosocial outcomes of hormone therapy is met. summarized in Appendix D. Coleman et al. 187
Hormone therapy must be individualized an alternative to illicit or unsupervised hormone based on a patient’s goals, the risk/benefit ratio use or to patients who have already established of medications, the presence of other medical themselves in their affirmed gender and who conditions, and consideration of social and have a history of prior hormone use. It is economic issues. Hormone therapy can provide unethical to deny availability of or eligibility for significant comfort to patients who do not wish hormone therapy solely on the basis of blood to make a social gender role transition or undergo seropositivity for blood-borne infections such as surgery, or who are unable to do so (Meyer, HIV or hepatitis B or C. 2009). Hormone therapy is a recommended In rare cases, hormone therapy may be criterion for some, but not all, surgical treat- contraindicated due to serious individual health ments for gender dysphoria (see section XI and conditions. Health professionals should assist Appendix C). these patients with accessing nonhormonal inter- ventions for gender dysphoria. A qualified men- Criteria for Hormone Therapy tal health professional familiar with the patient is an excellent resource in these circumstances. Initiation of hormone therapy may be un- dertaken after a psychosocial assessment has Informed Consent been conducted and informed consent has been Feminizing/masculinizing hormone therapy obtained by a qualified health professional, as may lead to irreversible physical changes. Thus, outlined in section VII of the SOC. A referral hormone therapy should be provided only to is required from the mental health professional those who are legally able to provide informed who performed the assessment, unless the as- consent. This includes people who have been sessment was done by a hormone provider who declared by a court to be emancipated minors, is also qualified in this area. incarcerated people, and cognitively impaired The criteria for hormone therapy are as fol- people who are considered competent to partic- lows: ipate in their medical decisions (Bockting et al., 2006). Providers should document in the medical 1. Persistent, well-documented gender dys- record that comprehensive information has been phoria; provided and understood about all relevant 2. Capacity to make a fully informed decision aspects of the hormone therapy, including both and to consent for treatment; possible benefits and risks and the impact on 3. Age of majority in a given country (if reproductive capacity. younger, follow the SOC outlined in sec- tion VI); Relationship Between the Standards 4. If significant medical or mental health con- of Care and Informed Consent Model cerns are present, they must be reasonably Protocols well-controlled. A number of community health centers in As noted in section VII of the SOC,the the United States have developed protocols for presence of coexisting mental health concerns providing hormone therapy based on an ap- does not necessarily preclude access to fem- proach that has become known as the Informed inizing/masculinizing hormones; rather, these Consent Model (Callen Lorde Community concerns need to be managed prior to, or Health Center, 2000, 2011; Fenway Community concurrent with, treatment of gender dysphoria. Health Transgender Health Program, 2007; Tom In selected circumstances, it can be accept- Waddell Health Center, 2006). These protocols able practice to provide hormones to patients are consistent with the guidelines presented in who have not fulfilled these criteria. Examples the WPATH Standards of Care, Version 7.The include facilitating the provision of monitored SOC are flexible clinical guidelines; they allow therapy using hormones of known quality as for tailoring of interventions to the needs of the 188 INTERNATIONAL JOURNAL OF TRANSGENDERISM individual receiving services and for tailoring of Physical Effects of Hormone Therapy protocols to the approach and setting in which these services are provided (Ehrbar & Gorton, Feminizing/masculinizing hormone therapy 2010). will induce physical changes that are more Obtaining informed consent for hormone congruent with a patient’s gender identity. therapy is an important task of providers to ensure that patients understand the psycholog- • In FtM patients, the following physical ical and physical benefits and risks of hormone changes are expected to occur: deep- therapy, as well as its psychosocial implications. ened voice, clitoral enlargement (variable), Providers prescribing the hormones or health growth in facial and body hair, cessation professionals recommending the hormones of menses, atrophy of breast tissue, and should have the knowledge and experience to decreased percentage of body fat compared assess gender dysphoria. They should inform to muscle mass. individuals of the particular benefits, limitations, • In MtF patients, the following physical and risks of hormones, given the patient’s changes are expected to occur: breast age, previous experience with hormones, and growth (variable), decreased erectile func- concurrent physical or mental health concerns. tion, decreased testicular size, and in- Screening for and addressing acute or current creased percentage of body fat compared mental health concerns is an important part of the to muscle mass. informed consent process. This may be done by a mental health professional or by an appropriately Most physical changes, whether feminizing trained prescribing provider (see section VII or masculinizing, occur over the course of two of the SOC). The same provider or another years. The amount of physical change and the appropriately trained member of the health care exact timeline of effects can be highly variable. team (e.g., a nurse) can address the psychosocial Tables 1a and 1b outline the approximate time implications of taking hormones when necessary course of these physical changes. (e.g., the impact of masculinization/feminization on how one is perceived and its potential impact on relationships with family, friends, and TABLE 1a. Effects and Expected Time Course coworkers). If indicated, these providers will of Masculinizing Hormonesa make referrals for psychotherapy and for the assessment and treatment of coexisting mental Expected Expected maximum health concerns such as anxiety or depression. Effect onsetb effectb The difference between the Informed Consent Skin oiliness/acne 1–6 months 1–2 years Model and SOC, Version 7, is that the SOC Facial/body hair 3–6 months 3–5 years puts greater emphasis on the important role that growth mental health professionals can play in alleviat- Scalp hair loss >12 monthsc Variable d ing gender dysphoria and facilitating changes in Increased muscle 6–12 months 2–5 years mass/strength gender role and psychosocial adjustment. This Body fat 3–6 months 2–5 years may include a comprehensive mental health redistribution assessment and psychotherapy, when indicated. Cessation of 2–6 months n/a In the Informed Consent Model, the focus is menses Clitoral 3–6 months 1–2 years on obtaining informed consent as the threshold enlargement for the initiation of hormone therapy in a Vaginal atrophy 3–6 months 1–2 years multidisciplinary, harm-reduction environment. Deepened voice 3–12 months 1–2 years
Less emphasis is placed on the provision of a Adapted with permission from Hembree et al. (2009). Copyright mental health care until the patient requests it, 2009, The Endocrine Society. unless significant mental health concerns are b Estimates represent published and unpublished clinical observa- tions. identified that would need to be addressed before c Highly dependent on age and inheritance; may be minimal. hormone prescription. d Significantly dependent on amount of exercise. Coleman et al. 189
TABLE 1b. Effects and Expected Time Course of Feminizing Hormonesa
Expected maximum Effect Expected onsetb effect b
Body fat redistribution 3–6 months 2–5 years Decreased muscle mass/strength 3–6 months 1–2 yearsc 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 6–12 months > 3 yearsd and facial hair 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- categorized as follows: (i) likely increased risk pends in part on the dose, route of administration, with hormone therapy, (ii) possibly increased and medications used, which are selected in ac- risk with hormone therapy, or (iii) inconclusive cordance with a patient’s specific medical goals or no increased risk. Items in the last category (e.g., changes in gender-role expression, plans include those that may present risk but for for sex reassignment) and medical risk profile. which the evidence is so minimal that no clear There is no current evidence that response to conclusion can be reached. hormone therapy—with the possible exception Additional detail about these risks can be of voice deepening in FtM persons—can be found in Appendix B, which is based on reliably predicted based on age, body habitus, two comprehensive, evidence-based literature ethnicity, or family appearance. All other factors reviews of masculinizing/feminizing hormone being equal, there is no evidence to suggest that therapy (Feldman & Safer, 2009; Hembree any medically approved type or method of ad- et al., 2009), along with a large cohort study ministering hormones is more effective than any (Asscheman et al., 2011). These reviews can other in producing the desired physical changes. serve as detailed references for providers, along with other widely recognized, published clinical Risks of Hormone Therapy materials (Dahl, Feldman, Goldberg, & Jaberi, 2006; Ettner, Monstrey, & Eyler, 2007). All medical interventions carry risks. The likelihood of a serious adverse event is depen- Competency of Hormone-Prescribing dent on numerous factors: the medication itself, Physicians, Relationship with Other dose, route of administration, and a patient’s Health Professionals clinical characteristics (age, comorbidities, fam- ily history, health habits). It is thus impossible Feminizing/masculinizing hormone therapy to predict whether a given adverse effect will is best undertaken in the context of a complete happen in an individual patient. approach to health care that includes comprehen- The risks associated with feminizing/ sive primary care and a coordinated approach to masculinizing hormone therapy for the trans- psychosocial issues (Feldman & Safer, 2009). sexual, transgender, and gender-nonconforming While psychotherapy or ongoing counseling population as a whole are summarized in Table is not required for the initiation of hormone 2. Based on the level of evidence, risks are therapy, if a therapist is involved, then regular 190 INTERNATIONAL JOURNAL OF TRANSGENDERISM
TABLE 2. Risks Associated with Hormone Therapy
Risk level Feminizing hormones Masculinizing hormones
Likely increased risk • Venous thromboembolic diseasea • Polycythemia • Gallstones • Weight gain • Elevated liver enzymes • Acne • Weight gain • Androgenic alopecia (balding) • Hypertriglyceridemia • Sleep apnea
Likely increased risk with presence of • Cardiovascular disease additional risk factorsb
Possible increased risk • Hypertension • Elevated liver enzymes • Hyperprolactinemia or prolactinoma • Hyperlipidemia
Possible increased risk with presence • Type2diabetesa • Destabilization of certain of additional risk factors b psychiatric disordersc • Cardiovascular disease • Hypertension • Type 2 diabetes No increased risk or inconclusive • Breast cancer • Loss of bone density • Breast cancer • Cervical cancer • Ovarian cancer • Uterine cancer
Note. Bolded items are clinically significant. a Risk is greater with oral estrogen administration than with transdermal estrogen administration. b Additional risk factors include age. c Includes bipolar, schizoaffective, and other disorders that may include manic or psychotic symptoms. This adverse event appears to be associated with higher doses or supraphysiologic blood levels of testosterone. communication among health professionals is where dedicated gender teams or specialized advised (with the patient’s consent) to ensure physicians are not available. that the transition process is going well, both Given the multidisciplinary needs of trans- physically and psychosocially. sexual, transgender, and gender-nonconforming With appropriate training, feminiz- people seeking hormone therapy, as well as the ing/masculinizing hormone therapy can be difficulties associated with fragmentation of care managed by a variety of providers, including in general (World Health Organization, 2008), nurse practitioners, physician assistants, and WPATH strongly encourages the increased train- primary care physicians (Dahl et al., 2006). ing and involvement of primary care providers Medical visits relating to hormone maintenance in the area of feminizing/masculinizing hor- provide an opportunity to deliver broader mone therapy. If hormones are prescribed by care to a population that is often medically a specialist, there should be close communica- underserved (Clements, Wilkinson, Kitano, & tion with the patient’s primary care provider. Marx, 1999; Feldman, 2007; Xavier, 2000). Conversely, an experienced hormone provider Many of the screening tasks and management or endocrinologist should be involved if the of comorbidities associated with long-term primary care physician has no experience with hormone use, such as cardiovascular risk factors this type of hormone therapy or if the patient has and cancer screening, fall more uniformly a preexisting metabolic or endocrine disorder within the scope of primary care rather than that could be affected by endocrine therapy. specialist care (American Academy of Family While formal training programs in transgen- Physicians, 2005; Eyler, 2007; World Health der medicine do not yet exist, hormone providers Organization, 2008), particularly in locations have a responsibility to obtain appropriate Coleman et al. 191 knowledge and experience in this field. Clini- phases of hormone treatment, a patient cians can increase their experience and comfort may wish to carry this statement at all times in providing feminizing/masculinizing hormone to help prevent difficulties with the police therapy by comanaging care or consulting with and other authorities. a more experienced provider, or by providing more limited types of hormone therapy before Depending on the clinical situation for providing progressing to initiation of hormone therapy. hormones (see below), some of these respon- Because this field of medicine is evolving, clin- sibilities are less relevant. Thus, the degree of icians should become familiar and keep current counseling, physical examinations, and labora- with the medical literature and discuss emerging tory evaluations should be individualized to a issues with colleagues. Such discussions might patient’s needs. occur through networks established by WPATH and other national/local organizations. Clinical Situations for Hormone Therapy There are circumstances in which clinicians Responsibilities of Hormone-Prescribing may be called upon to provide hormones without Physicians necessarily initiating or maintaining long-term feminizing/masculinizing hormone therapy. By In general, clinicians who prescribe hormone acknowledging these different clinical situations therapy should engage in the following tasks: (see below, from least to highest level of com- plexity), it may be possible to involve clinicians 1. Perform an initial evaluation that includes in feminizing/masculinizing hormone therapy discussion of a patient’s physical transition who might not otherwise feel able to offer this goals, health history, physical examina- treatment. tion, risk assessment, and relevant labo- ratory tests. 1. Bridging 2. Discuss with patients the expected effects of feminizing/masculinizing medications Whether prescribed by another clinician or and the possible adverse health effects. obtained through other means (e.g., purchased These effects can include a reduction in over the Internet), patients may present for fertility (Feldman & Safer, 2009; Hembree care already on hormone therapy. Clinicians et al., 2009). Therefore, reproductive op- can provide a limited (1–6 month) prescription tions should be discussed with patients be- for hormones while helping patients find a fore starting hormone therapy (see section provider who can prescribe long-term hormone IX). therapy. Providers should assess a patient’s 3. Confirm that patients have the capacity current regimen for safety and drug interactions to understand the risks and benefits of and substitute safer medications or doses when treatment and are capable of making an indicated (Dahl et al., 2006; Feldman & Safer, informed decision about medical care. 2009). If hormones were previously prescribed, 4. Provide ongoing medical monitoring, in- medical records should be requested (with the cluding regular physical and laboratory patient’s permission) to obtain the results of examination to monitor hormone effective- baseline examinations and laboratory tests and ness and side effects. any adverse events. Hormone providers should 5. Communicate as needed with a patient’s also communicate with any mental health pro- primary care provider, mental health pro- fessional who is currently involved in a patient’s fessional, and surgeon. care. If a patient has never had a psychosocial 6. If needed, provide patients with a brief assessment as recommended by the SOC (see written statement indicating that they are section VII), clinicians should refer the patient under medical supervision and care that in- to a qualified mental health professional if ap- cludes feminizing/masculinizing hormone propriate and feasible (Feldman & Safer, 2009). therapy. Particularly during the early Providers who prescribe bridging hormones 192 INTERNATIONAL JOURNAL OF TRANSGENDERISM need to work with patients to establish limits hormone regimens have been published (Dahl as to the duration of bridging therapy. et al., 2006; Hembree et al., 2009; Moore et al., 2003), there are no published reports 2. Hormone Therapy Following Gonad of randomized clinical trials comparing safety Removal and efficacy. Despite this variation, a reasonable framework for initial risk assessment and on- Hormone replacement with estrogen or going monitoring of hormone therapy can be testosterone is usually continued lifelong after an constructed, based on the efficacy and safety oophorectomy or orchiectomy, unless medical evidence presented above. contraindications arise. Because hormone doses are often decreased after these surgeries (Basson, 2001; Levy, Crown, & Reid, 2003; Moore, Risk Assessment and Modification for Wisniewski, & Dobs, 2003) and only adjusted Initiating Hormone Therapy for age and comorbid health concerns, hormone management in this situation is quite similar The initial evaluation for hormone therapy to hormone replacement in any hypogonadal assesses a patient’s clinical goals and risk factors patient. for hormone-related adverse events. During the risk assessment, the patient and clinician should 3. Hormone Maintenance Prior to Gonad develop a plan for reducing risks wherever Removal possible, either prior to initiating therapy or as part of ongoing harm reduction. Once patients have achieved maximal fem- All assessments should include a thorough inizing/masculinizing benefits from hormones physical exam, including weight, height, and (typically two or more years), they remain on blood pressure. The need for breast, genital, a maintenance dose. The maintenance dose is and rectal exams, which are sensitive issues then adjusted for changes in health conditions, for most transsexual, transgender, and gender- aging, or other considerations such as lifestyle nonconforming patients, should be based on changes (Dahl et al., 2006). When a patient individual risks and preventive health care needs on maintenance hormones presents for care, (Feldman & Goldberg, 2006; Feldman, 2007). the provider should assess the patient’s current regimen for safety and drug interactions and Preventive Care substitute safer medications or doses when indicated. The patient should continue to be Hormone providers should address preventive monitored by physical examinations and labo- health care with patients, particularly if a patient ratory testing on a regular basis, as outlined in does not have a primary care provider. Depend- the literature (Feldman & Safer, 2009; Hembree ing on a patient’s age and risk profile, there et al., 2009). The dose and form of hormones may be appropriate screening tests or exams for should be revisited regularly with any changes in conditions affected by hormone therapy. Ideally, the patient’s health status and available evidence these screening tests should be carried out prior on the potential long-term risks of hormones (see to the start of hormone therapy. Hormone Regimens,below). Risk Assessment and Modification for 4. Initiating Hormonal Feminization/ Feminizing Hormone Therapy (MtF) Masculinization There are no absolute contraindications to This clinical situation requires the greatest feminizing therapy per se, but absolute con- commitment in terms of provider time and ex- traindications exist for the different feminizing pertise. Hormone therapy must be individualized agents, particularly estrogen. These include based on a patient’s goals, the risk/benefit ratio previous venous thrombotic events related to an of medications, the presence of other medical underlying hypercoagulable condition, history conditions, and consideration of social and of estrogen-sensitive neoplasm, and end-stage economic issues. Although a wide variety of chronic liver disease (Gharib et al., 2005). Coleman et al. 193
Other medical conditions, as noted in Table 2 1997). While there is no evidence that PCOS and Appendix B, can be exacerbated by estrogen is related to the development of a transsexual, or androgen blockade and, therefore, should transgender, or gender-nonconforming identity, be evaluated and reasonably well controlled PCOS is associated with increased risk of prior to starting hormone therapy (Feldman diabetes, cardiac disease, high blood pressure, & Safer, 2009; Hembree et al., 2009. Dhejne and ovarian and endometrial cancers (Cattrall et al., 2011). Clinicians should particularly & Healy, 2004). Signs and symptoms of PCOS attend to tobacco use, as it is associated with should be evaluated prior to initiating testos- increased risk of venous thrombosis, which is terone therapy, as testosterone may affect many further increased with estrogen use. Consulta- of these conditions. Testosterone can affect the tion with a cardiologist may be advisable for developing fetus (Physicians’ Desk Reference, patients with known cardio- or cerebrovascular 2010), and patients at risk of becoming pregnant disease. require highly effective birth control. Baseline laboratory values are important to Baseline laboratory values are important to both assess initial risk and evaluate possible both assess initial risk and evaluate possible future adverse events. Initial labs should be future adverse events. Initial labs should be based on the risks of feminizing hormone based on the risks of masculinizing hormone therapy outlined in Table 2, as well as individual therapy outlined in Table 2, as well as individual patient risk factors, including family history. patient risk factors, including family history. Suggested initial lab panels have been published Suggested initial lab panels have been published (Feldman & Safer, 2009; Hembree et al., 2009). (Feldman & Safer, 2009; Hembree et al., 2009). These can be modified for patients or health care These can be modified for patients or health care systems with limited resources and in otherwise systems with limited resources and in otherwise healthy patients. healthy patients.
Risk Assessment and Modification for Masculinizing Hormone Therapy (FtM) Clinical Monitoring During Hormone Therapy for Efficacy and Adverse Events Absolute contraindications to testosterone therapy include pregnancy, unstable coronary The purpose of clinical monitoring during artery disease, and untreated polycythemia with hormone use is to assess the degree of feminiza- a hematocrit of 55% or higher (Carnegie, 2004). tion/masculinization and the possible presence Because the aromatization of testosterone to of adverse effects of medication. However, as estrogen may increase risk in patients with a with the monitoring of any long-term med- history of breast or other estrogen-dependent ication, monitoring should take place in the cancers (Moore et al., 2003), consultation with context of comprehensive health care. Sug- an oncologist may be indicated prior to hormone gested clinical monitoring protocols have been use. Comorbid conditions likely to be exacer- published (Feldman & Safer, 2009; Hembree bated by testosterone use should be evaluated et al., 2009). Patients with comorbid medical and treated, ideally prior to starting hormone conditions may need to be monitored more therapy (Feldman & Safer, 2009; Hembree frequently. Healthy patients in geographically et al., 2009). Consultation with a cardiologist remote or resource-poor areas may be able to may be advisable for patients with known use alternative strategies, such as telehealth, or cardio- or cerebrovascular disease (Dhejne et al., cooperation with local providers such as nurses 2011). and physician assistants. In the absence of other An increased prevalence of polycystic ovarian indications, health professionals may prioritize syndrome (PCOS) has been noted among FtM monitoring for those risks that are either likely patients even in the absence of testosterone use to be increased by hormone therapy or possibly (Baba et al., 2007; Balen, Schachter, Mont- increased by hormone therapy but clinically gomery, Reid, & Jacobs, 1993; Bosinski et al., serious in nature. 194 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Efficacy and Risk Monitoring During Femi- Monitoring for adverse events should in- nizing Hormone Therapy (MtF) clude both clinical and laboratory evaluation. Follow-up should include careful assessment The best assessment of hormone efficacy for signs and symptoms of excessive weight is clinical response: Is a patient developing a gain, acne, uterine break-through bleeding, and feminized body while minimizing masculine cardiovascular impairment, as well as psychi- characteristics consistent with that patient’s atric symptoms in at-risk patients. Physical gender goals? In order to more rapidly predict examinations should include measurement of the hormone dosages that will achieve clinical blood pressure, weight, pulse, and skin, as well response, one can measure testosterone levels as and heart and lung exams (Feldman & Safer, for suppression below the upper limit of the 2009). Laboratory monitoring should be based normal female range and estradiol levels within on the risks of hormone therapy described above, a premenopausal female range but well below a patient’s individual comorbidities and risk supraphysiologic levels (Feldman & Safer, 2009; factors, and the specific hormone regimen itself. Hembree et al., 2009). Specific lab monitoring protocols have been Monitoring for adverse events should in- published (Feldman & Safer, 2009; Hembree clude both clinical and laboratory evaluation. et al., 2009). Follow-up should include careful assessment for signs of cardiovascular impairment and venous Hormone Regimens thromboembolism (VTE) through measurement of blood pressure, weight, and pulse; heart and To date, no controlled clinical trials of lung exams; and examination of the extremi- any feminizing/masculinizing hormone regimen ties for peripheral edema, localized swelling, have been conducted to evaluate safety or effi- or pain (Feldman & Safer, 2009). Laboratory cacy in producing physical transition. As a result, monitoring should be based on the risks of wide variation in doses and types of hormones hormone therapy described above, a patient’s have been published in the medical literature individual comorbidities and risk factors, and (Moore et al., 2003; Tangpricha et al., 2003; the specific hormone regimen itself. Specific van Kesteren, Asscheman, Megens, & Gooren, lab-monitoring protocols have been published 1997). In addition, access to particular medica- (Feldman & Safer, 2009; Hembree et al., 2009). tions may be limited by a patient’s geographical location and/or social or economic situations. Efficacy and Risk Monitoring During For these reasons, WPATH does not describe Masculinizing Hormone Therapy (FtM) or endorse a particular feminizing/masculinizing hormone regimen. Rather, the medication The best assessment of hormone efficacy classes and routes of administration used in most is clinical response: Is a patient developing a published regimens are broadly reviewed. masculinized body while minimizing feminine As outlined above, there are demonstrated characteristics consistent with that patient’s gen- safety differences in individual elements of vari- der goals? Clinicians can achieve a good clinical ous regimens. The Endocrine Society Guidelines response with the least likelihood of adverse (Hembree et al., 2009) and Feldman and Safer events by maintaining testosterone levels within (2009) provide specific guidance regarding the the normal male range while avoiding supra- types of hormones and suggested dosing to physiological levels (Dahl et al., 2006; Hembree maintain levels within physiologic ranges for a et al., 2009). For patients using intramuscular patient’s desired gender expression (based on (IM) testosterone cypionate or enanthate, some goals of full feminization/masculinization). It is clinicians check trough levels while others prefer strongly recommended that hormone providers midcycle levels (Dahl et al., 2006; Hembree regularly review the literature for new informa- et al., 2009; Tangpricha, Turner, Malabanan, & tion and use those medications that safely meet Holick, 2001; Tangpricha, Ducharme, Barber, & individual patient needs with available local Chipkin, 2003). resources. Coleman et al. 195
Regimens for Feminizing Hormone Therapy block the gonadtropin-releasing hormone (MtF) receptor, thus blocking the release of fol- licle stimulating hormone and luteinizing Estrogen. Use of oral estrogen, and hormone. This leads to highly effective specifically ethinyl estradiol, appears to increase gonadal blockade. However, these medi- the risk of VTE. Because of this safety concern, cations are expensive and only available as ethinyl estradiol is not recommended for femi- injectables or implants. nizing hormone therapy. Transdermal estrogen is • 5-alpha reductase inhibitors (finasteride recommended for those patients with risk factors and dutasteride) block the conversion of for VTE. The risk of adverse events increases testosterone to the more active agent, 5- with higher doses, particularly doses resulting in alpha-dihydrotestosterone. These medica- supraphysiologic levels (Hembree et al., 2009). tions have beneficial effects on scalp hair Patients with comorbid conditions that can be loss, body hair growth, sebaceous glands, affected by estrogen should avoid oral estrogen and skin consistency. if possible and be started at lower levels. Some patients may not be able to safely use the levels Cyproterone and spironolactone are the most of estrogen needed to get the desired results. This commonly used anti-androgens and are likely possibility needs to be discussed with patients the most cost-effective. well in advance of starting hormone therapy. Progestins. With the exception of cypro- Androgen-reducing medications (“anti- terone, the inclusion of progestins in feminizing androgens”). A combination of estrogen and hormone therapy is controversial (Oriel, 2000). “anti-androgens” is the most commonly studied Because progestins play a role in mammary regimen for feminization. Androgen-reducing development on a cellular level, some clinicians medications, from a variety of classes of drugs, believe that these agents are necessary for full have the effect of reducing either endogenous breast development (Basson & Prior, 1998; testosterone levels or testosterone activity and, Oriel, 2000). However, a clinical comparison thus, diminishing masculine characteristics of feminization regimens with and without such as body hair. They minimize the dosage progestins found that the addition of progestins of estrogen needed to suppress testosterone neither enhanced breast growth nor lowered thereby reducing the risks associated with serum levels of free testosterone (Meyer et al., high-dose exogenous estrogen (Prior, Vigna, 1986). There are concerns regarding potential Watson, Diewold, & Robinow, 1986; Prior, adverse effects of progestins, including depres- Vigna, & Watson, 1989). sion, weight gain, and lipid changes (Meyer Common anti-androgens include the follow- et al., 1986; Tangpricha et al., 2003). Pro- ing: gestins (especially medroxyprogesterone) are also suspected to increase breast cancer risk and • Spironolactone, an antihypertensive agent, cardiovascular risk in women (Rossouw et al., directly inhibits testosterone secretion and 2002). Micronized progesterone may be better androgen binding to the androgen receptor. tolerated and have a more favorable impact on Blood pressure and electrolytes need to the lipid profile than medroxyprogesterone does be monitored because of the potential for (de Lignieres,` 1999; Fitzpatrick, Pace, & Wiita, hyperkalemia. 2000). • Cyproterone acetate is a progestational compound with anti-androgenic proper- Regimens for Masculinizing Hormone ties. This medication is not approved in Therapy (FtM) the United States because of concerns over potential hepatotoxicity, but it is widely Testosterone. Testosterone generally can be used elsewhere (De Cuypere et al., 2005). given orally, transdermally, or parenterally • GnRH agonists (e.g., goserelin, busere- (IM), although buccal and implantable prepa- lin, triptorelin) are neurohormones that rations are also available. Oral testosterone 196 INTERNATIONAL JOURNAL OF TRANSGENDERISM undecanoate, available outside the United States, than government-agency-approved bioidentical results in lower serum testosterone levels than hormones (Sood, Shuster, Smith, Vincent, & nonoral preparations and has limited efficacy Jatoi, 2011). Therefore, it has been advised by in suppressing menses (Feldman, 2005, April; the North American Menopause Society (2010) Moore et al., 2003). Because intramuscular and others to assume that, whether the hormone testosterone cypionate or enanthate are often is from a compounding pharmacy or not, if the administered every 2–4 weeks, some patients active ingredients are similar, it should have a may notice cyclic variation in effects (e.g., similar side-effect profile. WPATH concurs with fatigue and irritability at the end of the injec- this assessment. tion cycle, aggression or expansive mood at the beginning of the injection cycle), as well as more time outside the normal physiologic IX. REPRODUCTIVE HEALTH levels (Dhejne et al., 2011; Jockenhovel,¨ 2004). This may be mitigated by using a lower but Many transgender, transsexual, and gender- more frequent dosage schedule or by using nonconforming people will want to have chil- a daily transdermal preparation (Dobs et al., dren. Because feminizing/masculinizing hor- 1999; Jockenhovel,¨ 2004; Nieschlag et al., mone therapy limits fertility (Darney, 2008; 2004). Intramuscular testosterone undecanoate Zhang, Gu, Wang, Cui, & Bremner, 1999), (not currently available in the United States) it is desirable for patients to make decisions maintains stable, physiologic testosterone levels concerning fertility before starting hormone over approximately 12 weeks and has been effec- therapy or undergoing surgery to remove/alter tive in both the setting of hypogonadism and in their reproductive organs. Cases are known FtM individuals (Mueller, Kiesewetter, Binder, of people who received hormone therapy and Beckmann, & Dittrich, 2007; Zitzmann, Saad, & genital surgery and later regretted their inability Nieschlag, 2006). There is evidence that trans- to parent genetically related children (De Sutter, dermal and intramuscular testosterone achieve Kira, Verschoor, & Hotimsky, 2002). similar masculinizing results, although the time- Health care professionals—including mental frame may be somewhat slower with transdermal health professionals recommending hormone preparations (Feldman, 2005, April). Especially therapy or surgery, hormone-prescribing as patients age, the goal is to use the lowest physicians, and surgeons—should discuss dose needed to maintain the desired clinical reproductive options with patients prior to result, with appropriate precautions being made initiation of these medical treatments for gender to maintain bone density. dysphoria. These discussions should occur even Other agents. Progestins, most commonly if patients are not interested in these issues medroxyprogesterone, can be used for a short at the time of treatment, which may be more period of time to assist with menstrual cessation common for younger patients (De Sutter, 2009). early in hormone therapy. GnRH agonists can Early discussions are desirable, but not always be used similarly, as well as for refractory uter- possible. If an individual has not had complete ine bleeding in patients without an underlying sex reassignment surgery, it may be possible to gynecological abnormality. stop hormones long enough for natal hormones to recover, allowing the production of mature Bioidentical and Compounded Hormones gametes (Payer, Meyer, & Walker, 1979; Van den Broecke, Van der Elst, Liu, Hovatta, & As discussion surrounding the use of bioiden- Dhont, 2001). tical hormones in postmenopausal hormone Besides debate and opinion papers, very replacement has heightened, interest has also few research papers have been published on increased in the use of similar compounds the reproductive health issues of individuals in feminizing/masculinizing hormone therapy. receiving different medical treatments for gender There is no evidence that custom compounded dysphoria. Another group who faces the need bioidentical hormones are safer or more effective to preserve reproductive function in light of Coleman et al. 197 loss or damage to their gonads are people with blockers or cross-gender hormones. At this time malignancies that require removal of reproduc- there is no technique for preserving function tive organs or use of damaging radiation or from the gonads of these individuals. chemotherapy. Lessons learned from that group can be applied to people treated for gender dysphoria. X. VOICE AND COMMUNICATION MtF patients, especially those who have not THERAPY already reproduced, should be informed about sperm-preservation options and encouraged to Communication, both verbal and nonverbal, consider banking their sperm prior to hormone is an important aspect of human behavior and therapy. In a study examining testes that were gender expression. Transsexual, transgender, exposed to high-dose estrogen (Payer et al., and gender-nonconforming people might seek 1979), findings suggest that stopping estrogen the assistance of a voice and communica- may allow the testes to recover. In an article tion specialist to develop vocal characteristics reporting on the opinions of MtF individuals (e.g., pitch, intonation, resonance, speech rate, towards sperm freezing (De Sutter et al., 2002), phrasing patterns) and nonverbal communica- the vast majority of 121 survey respondents felt tion patterns (e.g., gestures, posture/movement, that the availability of freezing sperm should facial expressions) that facilitate comfort with be discussed and offered by the medical world. their gender identity. Voice and communication Sperm should be collected before hormone ther- therapy may help to alleviate gender dysphoria apy or after stopping the therapy until the sperm and be a positive and motivating step towards count rises again. Cryopreservation should be achieving one’s goals for gender role expression. discussed even if there is poor semen quality. In adults with azoospermia, a testicular biopsy Competency of Voice and Communication with subsequent cryopreservation of biopsied Specialists Working with Transsexual, material for sperm is possible, but may not be Transgender, and Gender-Nonconforming successful. Clients Reproductive options for FtM patients might include oocyte (egg) or embryo freezing. The Specialists may include speech-language frozen gametes and embryo could later be used pathologists, speech therapists, and speech- with a surrogate woman to carry to pregnancy. voice clinicians. In most countries the Studies of women with polycystic ovarian dis- professional association for speech-language ease suggest that the ovary can recover in part pathologists requires specific qualifications and from the effects of high testosterone levels credentials for membership. In some countries (Hunter & Sterrett, 2000). Stopping the testos- the government regulates practice through terone briefly might allow for ovaries to recover licensing, certification, or registration processes enough to release eggs; success likely depends (American Speech-Language-Hearing Associ- on the patient’s age and duration of testosterone ation, 2011; Canadian Association of Speech- treatment. While not systematically studied, Language Pathologists and Audiologists; Royal some FtM individuals are doing exactly that, College of Speech & Language Therapists, and some have been able to become pregnant United Kingdom; Speech Pathology Australia). and deliver children (More, 1998). The following are recommended minimum Patients should be advised that these tech- credentials for voice and communication spe- niques are not available everywhere and can cialists working with transsexual, transgender, be very costly. Transsexual, transgender, and and gender-nonconforming clients: gender-nonconforming people should not be refused reproductive options for any reason. 1. Specialized training and competence in the A special group of individuals are prepubertal assessment and development of commu- or pubertal adolescents who will never develop nication skills in transsexual, transgender, reproductive function in their natal sex due to and gender-nonconforming clients. 198 INTERNATIONAL JOURNAL OF TRANSGENDERISM
2. A basic understanding of transgen- Association of Speech-Language Pathologists der health, including hormonal and and Audiologists; Royal College of Speech & surgical treatments for feminization/ Language Therapists, United Kingdom; Speech masculinization and trans-specific psy- Pathology Australia). chosocial issues as outlined in the SOC, Individuals may choose the communication and familiarity with basic sensitivity pro- behaviors that they wish to acquire in accordance tocols such as the use of preferred gender with their gender identity. These decisions are pronoun and name (Canadian Association also informed and supported by the knowledge of Speech-Language Pathologists and Au- of the voice and communication specialist and diologists; Royal College of Speech & by the assessment data for a specific client Language Therapists, United Kingdom; (Hancock, Krissinger, & Owen, 2010). Assess- Speech Pathology Australia). ment includes a client’s self-evaluation and 3. Continuing education in the assessment a specialist’s evaluation of voice, resonance, and development of communication skills articulation, spoken language, and nonverbal in transsexual, transgender, and gender- communication (Adler et al., 2006; Hancock nonconforming clients. This may include et al., 2010). attendance at professional meetings, work- Voice-and-communication treatment plans shops, or seminars; participation in re- are developed by considering the available search related to gender-identity issues; research evidence, the clinical knowledge and independent study; or mentoring from an experience of the specialist, and the client’s own experienced, certified clinician. goals and values (American Speech-Language- Hearing Association, 2011; Canadian Associa- Other professionals such as vocal coaches, the- tion of Speech-Language Pathologists and Audi- ater professionals, singing teachers, and move- ologists; Royal College of Speech & Language ment experts may play a valuable adjunct role. Therapists, United Kingdom; Speech Pathology Such professionals will ideally have experience Australia). Targets of treatment typically include working with, or be actively collaborating with, pitch, intonation, loudness and stress patterns, speech-language pathologists. voice quality, resonance, articulation, speech rate and phrasing, language, and nonverbal Assessment and Treatment Considerations communication (Adler et al., 2006; Davies & Goldberg, 2006; de Bruin, Coerts, & Greven, The overall purpose of voice and commu- 2000; Gelfer, 1999; McNeill, 2006; Oates & nication therapy is to help clients adapt their Dacakis, 1983). Treatment may involve individ- voice and communication in a way that is both ual and/or group sessions. The frequency and safe and authentic, resulting in communication duration of treatment will vary according to patterns that clients feel are congruent with a client’s needs. Existing protocols for voice- their gender identity and that reflect their sense and-communication treatment can be considered of self (Adler, Hirsch, & Mordaunt, 2006). in developing an individualized therapy plan It is essential that voice and communication (Carew, Dacakis, & Oates, 2007; Dacakis, 2000; specialists be sensitive to individual commu- Davies & Goldberg, 2006; Gelfer, 1999; Mc- nication preferences. Communication—style, Neill, Wilson, Clark, & Deakin, 2008; Mount & voice, choice of language, etc.—is personal. Salmon, 1988). Individuals should not be counseled to adopt Feminizing or masculinizing the voice in- behaviors with which they are not comfortable volves nonhabitual use of the voice production or which do not feel authentic. Specialists can mechanism. Prevention measures are necessary best serve their clients by taking the time to to avoid the possibility of vocal misuse and long- understand a person’s gender concerns and goals term vocal damage. All voice and communica- for gender-role expression (American Speech- tion therapy services should therefore include a Language-Hearing Association, 2011; Canadian vocal health component (Adler et al., 2006). Coleman et al. 199
Vocal Health Considerations After Voice on postoperative outcomes such as subjective Feminization Surgery well-being, cosmesis, and sexual function (De Cuypere et al., 2005; Gijs & Brewaeys, 2007; As noted in section XI, some transsexual, Klein & Gorzalka, 2009; Pfafflin¨ & Junge, transgender, and gender-nonconforming people 1998). Additional information on the outcomes will undergo voice feminization surgery. (Voice of surgical treatments are summarized in deepening can be achieved through masculiniz- Appendix D. ing hormone therapy, but feminizing hormones do not have an impact on the adult MtF voice.) Ethical Questions Regarding Sex There are varying degrees of satisfaction, safety, Reassignment Surgery and long-term improvement in patients who have had such surgery. It is recommended that individ- In ordinary surgical practice, pathological uals undergoing voice feminization surgery also tissues are removed to restore disturbed func- consult a voice and communication specialist tions, or alterations are made to body features to maximize the surgical outcome, help protect to improve a patient’s self image. Some people, vocal health, and learn nonpitch related aspects including some health professionals, object on of communication. Voice surgery procedures ethical grounds to surgery as a treatment for should include follow-up sessions with a voice gender dysphoria, because these conditions are and communication specialist who is licensed thought not to apply. and/or credentialed by the board responsible for It is important that health professionals car- speech therapists/speech-language pathologists ing for patients with gender dysphoria feel in that country (Kanagalingam et al., 2005; comfortable about altering anatomically normal Neumann & Welzel, 2004). structures. In order to understand how surgery can alleviate the psychological discomfort and XI. SURGERY distress of individuals with gender dysphoria, professionals need to listen to these patients Sex Reassignment Surgery Is Effective discuss their symptoms, dilemmas, and life his- and Medically Necessary tories. The resistance against performing surgery on the ethical basis of “above all do no harm” Surgery—particularly genital surgery—is of- should be respected, discussed, and met with ten the last and the most considered step the opportunity to learn from patients them- in the treatment process for gender dyspho- selves about the psychological distress of having ria. While many transsexual, transgender, and gender dysphoria and the potential for harm gender-nonconforming individuals find comfort caused by denying access to appropriate treat- with their gender identity, role, and expression ments. without surgery, for many others surgery is Genital and breast/chest surgical treatments essential and medically necessary to alleviate for gender dysphoria are not merely another set their gender dysphoria (Hage & Karim, 2000). of elective procedures. Typical elective proce- For the latter group, relief from gender dysphoria dures involve only a private mutually consent- cannot be achieved without modification of their ing contract between a patient and a surgeon. primary and/or secondary sex characteristics to Genital and breast/chest surgeries as medically establish greater congruence with their gender necessary treatments for gender dysphoria are identity. Moreover, surgery can help patients feel to be undertaken only after assessment of the more at ease in the presence of sex partners or patient by qualified mental health professionals, in venues such as physicians’ offices, swimming as outlined in section VII of the SOC. These pools, or health clubs. In some settings, surgery surgeries may be performed once there is written might reduce risk of harm in the event of arrest documentation that this assessment has occurred or search by police or other authorities. and that the person has met the criteria for Follow-up studies have shown an undeniable a specific surgical treatment. By following beneficial effect of sex reassignment surgery this procedure, mental health professionals, 200 INTERNATIONAL JOURNAL OF TRANSGENDERISM surgeons, and patients share responsibility for of their own patients, including both suc- the decision to make irreversible changes to the cessful and unsuccessful outcomes; body. • The inherent risks and possible complica- It is unethical to deny availability or eligibility tions of the various techniques; surgeons for sex reassignment surgeries solely on the should inform patients of their own compli- basis of blood seropositivity for blood-borne cation rates with respect to each procedure. infections such as HIV or hepatitis C or B. These discussions are the core of the informed- Relationship of Surgeons with Mental consent process, which is both an ethical and Health Professionals, Hormone- legal requirement for any surgical procedure. Prescribing Physicians (if Applicable), Ensuring that patients have a realistic expec- and Patients (Informed Consent) tation of outcomes is important in achieving a result that will alleviate their gender dysphoria. The role of a surgeon in the treatment of All of this information should be provided to gender dysphoria is not that of a mere technician. patients in writing, in a language in which they Rather, conscientious surgeons will have insight are fluent, and in graphic illustrations. Patients into each patient’s history and the rationale that should receive the information in advance (pos- led to the referral for surgery. To that end, sibly via the Internet) and given ample time to surgeons must talk at length with their patients review it carefully. The elements of informed and have close working relationships with other consent should always be discussed face-to-face health professionals who have been actively prior to the surgical intervention. Questions can involved in their clinical care. then be answered and written informed consent Consultation is readily accomplished when a can be provided by the patient. Because these surgeon practices as part of an interdisciplinary surgeries are irreversible, care should be taken health care team. In the absence of this, a to ensure that patients have sufficient time to surgeon must be confident that the referring absorb information fully before they are asked mental health professional(s), and if applicable to provide informed consent. A minimum of the physician who prescribes hormones, is/are 24 hours is suggested. competent in the assessment and treatment of Surgeons should provide immediate aftercare gender dysphoria, because the surgeon is relying and consultation with other physicians serving heavily on his/her/their expertise. the patient in the future. Patients should work Once a surgeon is satisfied that the criteria with their surgeon to develop an adequate for specific surgeries have been met (as outlined aftercare plan for the surgery. below), surgical treatment should be consid- ered and a preoperative surgical consultation Overview of Surgical Procedures for the should take place. During this consultation, the Treatment of Patients with Gender procedure and postoperative course should be Dysphoria extensively discussed with the patient. Surgeons are responsible for discussing all of the following For the Male-to-Female (MtF) Patient, with patients seeking surgical treatments for Surgical Procedures May Include the gender dysphoria: Following: • The different surgical techniques available 1. Breast/chest surgery: augmentation mam- (with referral to colleagues who provide moplasty (implants/lipofilling); alternative options); 2. Genital surgery: penectomy, orchiectomy, • The advantages and disadvantages of each vaginoplasty, clitoroplasty, vulvoplasty; technique; 3. Nongenital, nonbreast surgical interven- • The limitations of a procedure to achieve tions: facial feminization surgery, lipo- “ideal” results; surgeons should provide a suction, lipofilling, voice surgery, thyroid full range of before-and-after photographs cartilage reduction, gluteal augmentation Coleman et al. 201
(implants/lipofilling), hair reconstruction, vaginoplasty as an intervention to end lifelong and various aesthetic procedures. suffering, for certain patients an intervention like a reduction rhinoplasty can have a radical and For the Female-to-Male (FtM) Patient, Sur- permanent effect on their quality of life and, gical Procedures May Include the Follow- therefore, is much more medically necessary ing: than for somebody without gender dysphoria. 1. Breast/chest surgery: subcutaneous mas- Criteria for Surgeries tectomy, creation of a male chest; 2. Genital surgery: hysterectomy/salpingo- As for all of the SOC, the criteria for initiation oophorectomy, reconstruction of the fixed of surgical treatments for gender dysphoria part of the urethra, which can be com- were developed to promote optimal patient care. bined with a metoidioplasty or with a While the SOC allow for an individualized phalloplasty (employing a pedicled or free approach to best meet a patient’s health care vascularized flap), vaginectomy, scroto- needs, a criterion for all breast/chest and genital plasty, and implantation of erection and/or surgeries is documentation of persistent gender testicular prostheses; dysphoria by a qualified mental health profes- 3. Nongenital, nonbreast surgical interven- sional. For some surgeries, additional criteria tions: voice surgery (rare), liposuction, include preparation and treatment consisting of lipofilling, pectoral implants, and various feminizing/masculinizing hormone therapy and aesthetic procedures. one year of continuous living in a gender role that is congruent with one’s gender identity. Reconstructive Versus Aesthetic Surgery These criteria are outlined below. Based on the available evidence and expert clinical The question of whether sex reassignment consensus, different recommendations are made surgery should be considered “aesthetic” surgery for different surgeries. or “reconstructive” surgery is pertinent not only The SOC do not specify an order in which from a philosophical point of view, but also from different surgeries should occur. The number a financial point of view. Aesthetic or cosmetic and sequence of surgical procedures may vary surgery is mostly regarded as not medically nec- from patient to patient, according to their clinical essary and therefore is typically paid for entirely needs. by the patient. In contrast, reconstructive proce- dures are considered medically necessary—with Criteria for Breast/Chest Surgery (One unquestionable therapeutic results—and thus Referral) paid for partially or entirely by national health systems or insurance companies. Criteria for mastectomy and creation of a Unfortunately, in the field of plastic and male chest in FtM patients: reconstructive surgery (both in general and specifically for gender-related surgeries), there 1. Persistent, well-documented gender dys- is no clear distinction between what is purely phoria; reconstructive and what is purely cosmetic. Most 2. Capacity to make a fully informed decision plastic surgery procedures actually are a mixture and to consent for treatment; of both reconstructive and cosmetic components. 3. Age of majority in a given country (if While most professionals agree that genital younger, follow the SOC for children and surgery and mastectomy cannot be considered adolescents); purely cosmetic, opinions diverge as to what 4. If significant medical or mental health con- degree other surgical procedures (e.g., breast cerns are present, they must be reasonably augmentation, facial feminization surgery) can well controlled. be considered purely reconstructive. Although it may be much easier to see a phalloplasty or a Hormone therapy is not a prerequisite. 202 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Criteria for breast augmentation (im- These criteria do not apply to patients who are plants/lipofilling) in MtF patients: having these procedures for medical indications other than gender dysphoria. 1. Persistent, well-documented gender dys- phoria; Criteria for metoidioplasty or phalloplasty 2. Capacity to make a fully informed decision in FtM patients and for vaginoplasty in MtF and to consent for treatment; patients: 3. Age of majority in a given country (if younger, follow the SOC for children and 1. Persistent, well-documented gender dys- adolescents); phoria; 4. If significant medical or mental health con- 2. Capacity to make a fully informed decision cerns are present, they must be reasonably and to consent for treatment; well controlled. 3. Age of majority in a given country; 4. If significant medical or mental health Although not an explicit criterion, it is recom- concerns are present, they must be well mended that MtF patients undergo feminizing controlled; hormone therapy (minimum 12 months) prior to 5. 12 continuous months of hormone therapy breast augmentation surgery. The purpose is to as appropriate to the patient’s gender maximize breast growth in order to obtain better goals (unless hormones are not clinically surgical (aesthetic) results. indicated for the individual). 6. 12 continuous months of living in a gender role that is congruent with the patient’s identity. Criteria for Genital Surgery (Two Referrals) Although not an explicit criterion, it is recom- The criteria for genital surgery are specific to mended that these patients also have regular the type of surgery being requested. visits with a mental health or other medical professional. Criteria for hysterectomy and salpingo- oophorectomy in FtM patients and for orchiec- Rationale for a preoperative, 12-month tomy in MtF patients: experience of living in an identity-congruent gender role. The criterion noted above for some 1. Persistent, well-documented gender dys- types of genital surgeries—i.e., that patients phoria; engage in 12 continuous months of living in a 2. Capacity to make a fully informed decision gender role that is congruent with their gender and to give consent for treatment; identity—is based on expert clinical consensus 3. Age of majority in a given country; that this experience provides ample opportunity 4. If significant medical or mental health for patients to experience and socially adjust concerns are present, they must be well in their desired gender role, before undergoing controlled. irreversible surgery. As noted in section VII, 5. 12 continuous months of hormone therapy the social aspects of changing one’s gender role as appropriate to the patient’s gender are usually challenging—often more so than the goals (unless hormones are not clinically physical aspects. Changing gender role can have indicated for the individual). profound personal and social consequences, and the decision to do so should include an awareness The aim of hormone therapy prior to gonadec- of what the familial, interpersonal, educational, tomy is primarily to introduce a period of vocational, economic, and legal challenges reversible estrogen or testosterone suppression, are likely to be, so that people can function before the patient undergoes irreversible surgical successfully in their gender role. Support from intervention. a qualified mental health professional and from Coleman et al. 203 peers can be invaluable in ensuring a successful cologists, plastic surgeons, or general surgeons, gender role adaptation (Bockting, 2008). and board-certified as such by the relevant The duration of 12 months allows for a range national and/or regional association. Surgeons of different life experiences and events that may should have specialized competence in genital occur throughout the year (e.g., family events, reconstructive techniques as indicated by docu- holidays, vacations, season-specific work or mented supervised training with a more experi- school experiences). During this time, patients enced surgeon. Even experienced surgeons must should present consistently, on a day-to-day be willing to have their surgical skills reviewed basis and across all settings of life, in their by their peers. An official audit of surgical desired gender role. This includes coming out outcomes and publication of these results would to partners, family, friends, and community be greatly reassuring to both referring health members (e.g., at school, work, other settings). professionals and patients. Surgeons should reg- Health professionals should clearly document ularly attend professional meetings where new a patient’s experience in the gender role in techniques are presented. The Internet is often the medical chart, including the start date of effectively used by patients to share information living full-time for those who are preparing for on their experience with surgeons and their genital surgery. In some situations, if needed, teams. health professionals may request verification Ideally, surgeons should be knowledgeable that this criterion has been fulfilled: They may about more than one surgical technique for gen- communicate with individuals who have related ital reconstruction so that they, in consultation to the patient in an identity-congruent gender with patients, can choose the ideal technique for role or request documentation of a legal name each individual. Alternatively, if a surgeon is and/or gender-marker change, if applicable. skilled in a single technique and this procedure is either not suitable for or desired by a patient, Surgery for People with Psychotic the surgeon should inform the patient about Conditions and Other Serious Mental other procedures and offer referral to another Illnesses appropriately skilled surgeon. When patients with gender dysphoria are also Breast/Chest Surgery Techniques and diagnosed with severe psychiatric disorders and Complications impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, Although breast/chest appearance is an im- borderline personality disorder), an effort must portant secondary sex characteristic, breast pres- be made to improve these conditions with ence or size is not involved in the legal definitions psychotropic medications and/or psychother- of sex and gender and is not necessary for apy before surgery is contemplated (Dhejne reproduction. The performance of breast/chest et al., 2011). Reevaluation by a mental health operations for treatment of gender dysphoria professional qualified to assess and manage should be considered with the same care as psychotic conditions should be conducted prior beginning hormone therapy, as both produce to surgery, describing the patient’s mental status relatively irreversible changes to the body. and readiness for surgery. It is preferable that this For the MtF patient, a breast augmentation mental health professional be familiar with the (sometimes called “chest reconstruction”) is not patient. No surgery should be performed while different from the procedure in a natal female a patient is actively psychotic (De Cuypere & patient. It is usually performed through implan- Vercruysse, 2009). tation of breast prostheses and occasionally with the lipofilling technique. Infections and capsular Competency of Surgeons Performing fibrosis are rare complications of augmentation Breast/Chest or Genital Surgery mammoplasty in MtF patients (Kanhai, Hage, Karim, & Mulder, 1999). Physicians who perform surgical treatments For the FtM patient, a mastectomy or “male for gender dysphoria should be urologists, gyne- chest contouring” procedure is available. For 204 INTERNATIONAL JOURNAL OF TRANSGENDERISM many FtM patients, this is the only surgery of surgery and frequent technical difficulties, undertaken. When the amount of breast tissue which may require additional operations. Even removed requires skin removal, a scar will metoidioplasty, which in theory is a one-stage result and the patient should be so informed. procedure for construction of a microphallus, Complications of subcutaneous mastectomy can often requires more than one operation. The include nipple necrosis, contour irregularities, objective of standing micturition with this tech- and unsightly scarring (Monstrey et al., 2008). nique can not always be ensured (Monstrey et al., 2009). Genital Surgery Techniques and Complications of phalloplasty in FtMs may Complications include frequent urinary tract stenoses and fistu- las, and occasionally necrosis of the neophallus. Genital surgical procedures for the MtF Metoidioplasty results in a micropenis, without patient may include orchiectomy, penectomy, the capacity for standing urination. Phalloplasty, vaginoplasty, clitoroplasty, and labiaplasty. using a pedicled or a free vascularized flap, is a Techniques include penile skin inversion, pedi- lengthy, multi-stage procedure with significant cled colosigmoid transplant, and free skin grafts morbidity that includes frequent urinary com- to line the neovagina. Sexual sensation is an plications and unavoidable donor site scarring. important objective in vaginoplasty, along with For this reason, many FtM patients never un- creation of a functional vagina and acceptable dergo genital surgery other than hysterectomy cosmesis. and salpingo-oophorectomy (Hage & De Graaf, Surgical complications of MtF genital surgery 1993). may include complete or partial necrosis of the Even patients who develop severe surgical vagina and labia, fistulas from the bladder or complications seldom regret having undergone bowel into the vagina, stenosis of the urethra, and surgery. The importance of surgery can be vaginas that are either too short or too small for appreciated by the repeated finding that quality coitus. While the surgical techniques for creating of surgical results is one of the best predictors a neovagina are functionally and aesthetically of the overall outcome of sex reassignment excellent, anorgasmia following the procedure (Lawrence, 2006). has been reported, and a second stage labiaplasty may be needed for cosmesis (Klein & Gorzalka, 2009; Lawrence, 2006). Other Surgeries Genital surgical procedures for FtM pa- tients may include hysterectomy, salpingo- Other surgeries for assisting in body feminiza- oophorectomy, vaginectomy, metoidioplasty, tion include reduction thyroid chondroplasty scrotoplasty, urethroplasty, placement of testic- (reduction of the Adam’s apple), voice modifica- ular prostheses, and phalloplasty. For patients tion surgery, suction-assisted lipoplasty (contour without former abdominal surgery, the laparo- modeling) of the waist, rhinoplasty (nose correc- scopic technique for hysterectomy and salpingo- tion), facial bone reduction, face-lift, and ble- oophorectomy is recommended to avoid a lower- pharoplasty (rejuvenation of the eyelid). Other abdominal scar. Vaginal access may be difficult surgeries for assisting in body masculinization as most patients are nulliparous and have often include liposuction, lipofilling, and pectoral not experienced penetrative intercourse. Current implants. Voice surgery to obtain a deeper operative techniques for phalloplasty are varied. voice is rare but may be recommended in some The choice of techniques may be restricted by cases, such as when hormone therapy has been anatomical or surgical considerations and by a ineffective. client’s financial considerations. If the objectives Although these surgeries do not require of phalloplasty are a neophallus of good ap- referral by mental health professionals, such pearance, standing micturition, sexual sensation, professionals can play an important role in and/or coital ability, patients should be clearly assisting clients in making a fully informed informed that there are several separate stages decision about the timing and implications of Coleman et al. 205 such procedures in the context of the social XIII. LIFELONG PREVENTIVE transition. AND PRIMARY CARE Although most of these procedures are gener- ally labeled “purely aesthetic,” these same oper- Transsexual, transgender, and gender- ations in an individual with severe gender dys- nonconforming people need health care phoria can be considered medically necessary, throughout their lives. For example, to avoid depending on the unique clinical situation of a the negative secondary effects of having a given patient’s condition and life situation. This gonadectomy at a relatively young age and/or ambiguity reflects reality in clinical situations, receiving long-term, high-dose hormone and allows for individual decisions as to the need therapy, patients need thorough medical care and desirability of these procedures. by providers experienced in primary care and transgender health. If one provider is not able to provide all services, ongoing communication among providers is essential. XII. POSTOPERATIVE CARE Primary care and health maintenance issues AND FOLLOW-UP should be addressed before, during, and after any possible changes in gender role and medical in- Long-term postoperative care and follow-up terventions to alleviate gender dysphoria. While after surgical treatments for gender dysphoria hormone providers and surgeons play important are associated with good surgical and psychoso- roles in preventive care, every transsexual, cial outcomes (Monstrey et al., 2009). Follow-up transgender, and gender-nonconforming person is important to a patient’s subsequent physical should partner with a primary care provider for and mental health and to a surgeon’s knowledge overall health care needs (Feldman, 2007). about the benefits and limitations of surgery. Surgeons who operate on patients coming from long distances should include personal follow- General Preventive Health Care up in their care plan and attempt to ensure affordable local long-term aftercare in their Screening guidelines developed for the gen- patients’ geographic region. eral population are appropriate for organ systems Postoperative patients may sometimes ex- that are unlikely to be affected by feminiz- clude themselves from follow-up by specialty ing/masculinizing hormone therapy. However, providers, including the hormone-prescribing in areas such as cardiovascular risk factors, physician (for patients receiving hormones), not osteoporosis, and some cancers (breast, cervical, recognizing that these providers are often best ovarian, uterine, and prostate), such general able to prevent, diagnose, and treat medical guidelines may either over- or underestimate the conditions that are unique to hormonally and sur- cost-effectiveness of screening individuals who gically treated patients. The need for follow-up are receiving hormone therapy. equally extends to mental health professionals, Several resources provide detailed protocols who may have spent a longer period of time for the primary care of patients undergoing with the patient than any other professional and feminizing/masculinizing hormone therapy, in- therefore are in an excellent position to assist in cluding therapy that is provided after sex re- any postoperative adjustment difficulties. Health assignment surgeries (Center of Excellence for professionals should stress the importance of Transgender Health, UCSF, 2011; Feldman & postoperative follow-up care with their patients Goldberg, 2006; Feldman, 2007; Gorton, Buth, and offer continuity of care. & Spade, 2005). Clinicians should consult their Postoperative patients should undergo regular national evidence-based guidelines and discuss medical screening according to recommended screening with their patients in light of the guidelines for their age. This is discussed more effects of hormone therapy on their baseline in the next section. risk. 206 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Cancer Screening the shortened urethra. In addition, these patients may suffer from functional disorders of the Cancer screening of organ systems lower urinary tract; such disorders may be that are associated with sex can present caused by damage of the autonomous nerve particular medical and psychosocial challenges supply of the bladder floor during dissection for transsexual, transgender, and gender- between the rectum and the bladder, and by a nonconforming patients and their health change of the position of the bladder itself. A care providers. In the absence of large-scale dysfunctional bladder (e.g., overactive bladder, prospective studies, providers are unlikely stress or urge urinary incontinence) may occur to have enough evidence to determine the after sex reassignment surgery (Hoebeke et al., appropriate type and frequency of cancer 2005; Kuhn, Hiltebrand, & Birkhauser, 2007). screenings for this population. Over-screening Most FtM patients do not undergo vaginec- results in higher health care costs, high false tomy (colpectomy). For patients who take positive rates, and often unnecessary exposure to masculinizing hormones, despite considerable radiation and/or diagnostic interventions such as conversion of testosterone to estrogens, atrophic biopsies. Under-screening results in diagnostic changes of the vaginal lining can be observed delay for potentially treatable cancers. Patients regularly and may lead to pruritus or burn- may find cancer screening gender affirming ing. Examination can be both physically and (such as mammograms for MtF patients) or both emotionally painful, but lack of treatment can physically and emotionally painful (such as Pap seriously aggravate the situation. Gynecologists smears offer continuity of care for FtM patients). treating the genital complaints of FtM patients should be aware of the sensitivity that patients Urogenital Care with a male gender identity and masculine gender expression might have around having Gynecologic care may be necessary for trans- genitals typically associated with the female sex. sexual, transgender, and gender-nonconforming people of both sexes. For FtM patients, such care is needed predominantly for individuals who have not had genital surgery. For MtF patients, XIV. APPLICABILITY OF THE such care is needed after genital surgery. While STANDARDS OF CARE TO PEOPLE many surgeons counsel patients regarding post- LIVING IN INSTITUTIONAL operative urogenital care, primary care clinicians ENVIRONMENTS and gynecologists should also be familiar with the special genital concerns of this population. The SOC in their entirety apply to all trans- All MtF patients should receive counseling sexual, transgender, and gender-nonconforming regarding genital hygiene, sexuality, and pre- people, irrespective of their housing situation. vention of sexually transmitted infections; those People should not be discriminated against in who have had genital surgery should also be their access to appropriate health care based counseled on the need for regular vaginal dila- on where they live, including institutional envi- tion or penetrative intercourse in order to main- ronments such as prisons or long-/intermediate- tain vaginal depth and width (van Trotsenburg, term health care facilities (Brown, 2009). Health 2009). Due to the anatomy of the male pelvis, the care for transsexual, transgender, and gender- axis and the dimensions of the neovagina differ nonconforming people living in an institutional substantially from those of a biologic vagina. environment should mirror that which would be This anatomic difference can affect intercourse available to them if they were living in a nonin- if not understood by MtF patients and their stitutional setting within the same community. partners (van Trotsenburg, 2009). All elements of assessment and treatment as Lower-urinary-tract infections occur fre- described in the SOC can be provided to people quently in MtF patients who have had surgery living in institutions (Brown, 2009). Access to because of the reconstructive requirements of these medically necessary treatments should not Coleman et al. 207 be denied on the basis of institutionalization or ward, or pod on the sole basis of the appearance housing arrangements. If the in-house expertise of the external genitalia may not be appropriate of health professionals in the direct or indirect and may place the individual at risk for victim- employ of the institution does not exist to assess ization (Brown, 2009). and/or treat people with gender dysphoria, it is Institutions where transsexual, transgender, appropriate to obtain outside consultation from and gender-nonconforming people reside and professionals who are knowledgeable about this receive health care should monitor for a tolerant specialized area of health care. and positive climate to ensure that residents are People with gender dysphoria in institutions not under attack by staff or other residents. may also have coexisting mental health condi- tions (Cole et al., 1997). These conditions should be evaluated and treated appropriately. XV. APPLICABILITY OF THE People who enter an institution on an ap- STANDARDS OF CARE TO PEOPLE propriate regimen of hormone therapy should WITH DISORDERS OF SEX be continued on the same, or similar, therapies and monitored according to the SOC. A “freeze DEVELOPMENT frame” approach is not considered appropriate Terminology care in most situations (Kosilek v. Massachusetts Department of Corrections/Maloney,C.A.No. The term disorder of sex development (DSD) 92-12820-MLW, 2002). People with gender dys- refers to a somatic condition of atypical de- phoria who are deemed appropriate for hormone velopment of the reproductive tract (Hughes, therapy (following the SOC) should be started Houk, Ahmed, Lee, & LWPES/ESPE Consensus on such therapy. The consequences of abrupt Group, 2006). DSDs include the condition withdrawal of hormones or lack of initiation that used to be called intersexuality. Although of hormone therapy when medically necessary the terminology was changed to DSD during include a high likelihood of negative outcomes an international consensus conference in 2005 such as surgical self-treatment by autocastration, (Hughes et al., 2006), disagreement about lan- depressed mood, dysphoria, and/or suicidality guage use remains. Some people object strongly (Brown, 2010). to the “disorder” label, preferring instead to Reasonable accommodations to the institu- view these congenital conditions as a matter tional environment can be made in the delivery of diversity (Diamond, 2009) and to continue of care consistent with the SOC, if such ac- using the terms intersex or intersexuality.Inthe commodations do not jeopardize the delivery SOC, WPATH uses the term DSD in an objective of medically necessary care to people with and value-free manner, with the goal of ensuring gender dysphoria. An example of a reasonable that health professionals recognize this medical accommodation is the use of injectable hor- term and use it to access relevant literature as mones, if not medically contraindicated, in an the field progresses. WPATH remains open to environment where diversion of oral prepara- new terminology that will further illuminate tions is highly likely (Brown, 2009). Denial the experience of members of this diverse of needed changes in gender role or access to population and lead to improvements in health treatments, including sex reassignment surgery, care access and delivery. on the basis of residence in an institution are not reasonable accommodations under the SOC Rationale for Addition to the SOC (Brown, 2010). Housing and shower/bathroom facilities Previously, individuals with a DSD who also for transsexual, transgender, and gender- met the DSM-IV-TR’s behavioral criteria for nonconforming people living in institutions Gender Identity Disorder (American Psychiatric should take into account their gender identity Association, 2000) were excluded from that and role, physical status, dignity, and personal general diagnosis. Instead, they were catego- safety. Placement in a single-sex housing unit, rized as having a “Gender Identity Disorder-Not 208 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Otherwise Specified.” They were also excluded The type of DSD and severity of the con- from the WPATH Standards of Care. dition has significant implications for deci- The current proposal for DSM-5 sions about a patient’s initial sex assignment, (www.dsm5.org) is to replace the term subsequent genital surgery, and other medical gender identity disorder with gender dysphoria. and psychosocial care (Meyer-Bahlburg, 2009). Moreover, the proposed changes to the DSM For instance, the degree of prenatal androgen consider gender dysphoric people with a DSD exposure in individuals with a DSD has been to have a subtype of gender dysphoria. This correlated with the degree of masculinization proposed categorization—which explicitly of gender-related behavior (that is, gender differentiates between gender dysphoric role and expression); however, the correlation individuals with and without a DSD—is is only moderate, and considerable behavioral justified: In people with a DSD, gender variability remains unaccounted for by prenatal dysphoria differs in its phenomenological androgen exposure (Jurgensen et al., 2007; presentation, epidemiology, life trajectories, Meyer-Bahlburg, Dolezal, Baker, Ehrhardt, & and etiology (Meyer-Bahlburg, 2009). New, 2006). Notably, a similar correlation of Adults with a DSD and gender dysphoria prenatal hormone exposure with gender iden- have increasingly come to the attention of health tity has not been demonstrated (e.g., Meyer- professionals. Accordingly, a brief discussion of Bahlburg, Dolezal, et al., 2004). This is un- their care is included in this version of the SOC. derlined by the fact that people with the same (core) gender identity can vary widely in the Health History Considerations degree of masculinization of their gender-related behavior. Health professionals assisting patients with both a DSD and gender dysphoria need to be Assessment and Treatment of Gender aware that the medical context in which such Dysphoria in People with Disorders of Sex patients have grown up is typically very different Development from that of people without a DSD. Some people are recognized as having a Very rarely are individuals with a DSD DSD through the observation of gender-atypical identified as having gender dysphoria before a genitals at birth. (Increasingly this observation DSD diagnosis has been made. Even so, a DSD is made during the prenatal period by way diagnosis is typically apparent with an appro- of imaging procedures such as ultrasound.) priate history and basic physical exam—both These infants then undergo extensive medical of which are part of a medical evaluation diagnostic procedures. After consultation among for the appropriateness of hormone therapy the family and health professionals—during or surgical interventions for gender dysphoria. which the specific diagnosis, physical and Mental health professionals should ask their hormonal findings, and feedback from long- clients presenting with gender dysphoria to have term outcome studies (Cohen-Kettenis, 2005; a physical exam, particularly if they are not Dessens, Slijper, & Drop, 2005; Jurgensen, currently seeing a primary care (or other health Hiort, Holterhus, & Thyen, 2007; Mazur, 2005; care) provider. Meyer-Bahlburg, 2005; Stikkelbroeck et al., Most people with a DSD who are born with 2003; Wisniewski, Migeon, Malouf, & Gearhart, genital ambiguity do not develop gender dyspho- 2004) are considered—the newborn is assigned ria (e.g., Meyer-Bahlburg, Dolezal, et al., 2004; a sex, either male or female. Wisniewski et al., 2004). However, some people Other individuals with a DSD come to the with a DSD will develop chronic gender dys- attention of health professionals around the age phoria and even undergo a change in their birth- of puberty through the observation of atypical assigned sex and/or their gender role (Meyer- development of secondary sex characteristics. Bahlburg, 2005; Wilson, 1999; Zucker, 1999). This observation also leads to a specific medical If there are persistent and strong indications that evaluation. gender dysphoria is present, a comprehensive Coleman et al. 209 evaluation by clinicians skilled in the assessment ries may include a great variety of inborn genetic, and treatment of gender dysphoria is essential, endocrine, and somatic atypicalities, as well as irrespective of the patient’s age. Detailed various hormonal, surgical, and other medical recommendations have been published for treatments. For this reason, many additional conducting such an assessment and for making issues need to be considered in the psychosocial treatment decisions to address gender dysphoria and medical care of such patients, regardless of in the context of a DSD (Meyer-Bahlburg, the presence of gender dysphoria. Consideration 2011). Only after thorough assessment should of these issues is beyond what can be covered steps be taken in the direction of changing a in the SOC. The interested reader is referred patient’s birth-assigned sex or gender role. to existing publications (e.g., Cohen-Kettenis Clinicians assisting these patients with treat- &Pfafflin,¨ 2003; Meyer-Bahlburg, 2002, 2008). ment options to alleviate gender dysphoria may Some families and patients also find it useful to profit from the insights gained from providing consult or work with community support groups. care to patients without a DSD (Cohen-Kettenis, There is a very substantial medical literature 2010). However, certain criteria for treatment on the medical management of patients with a (e.g., age, duration of experience with living DSD. Much of this literature has been produced in the desired gender role) are usually not by high-level specialists in pediatric endocrinol- routinely applied to people with a DSD; rather, ogy and urology, with input from specialized the criteria are interpreted in light of a patient’s mental health professionals, especially in the specific situation (Meyer-Bahlburg, 2011). In the area of gender. Recent international consensus context of a DSD, changes in birth-assigned conferences have addressed evidence-based care sex and gender role have been made at any guidelines (including issues of gender and of age between early-elementary-school age and genital surgery) for DSD in general (Hughes middle adulthood. Even genital surgery may be et al., 2006) and specifically for Congenital performed much earlier in these patients than Adrenal Hyperplasia (Joint LWPES/ESPE CAH in gender dysphoric individuals without a DSD Working Group et al., 2002; Speiser et al., 2010). if the surgery is well justified by the diagnosis, Others have addressed the research needs for by the evidence-based gender-identity prognosis DSD in general (Meyer-Bahlburg & Blizzard, for the given syndrome and syndrome severity, 2004) and for selected syndromes such as 46, and by the patient’s wishes. XXY (Simpson et al., 2003). One reason for these treatment differences is that genital surgery in individuals with a DSD is quite common in infancy and adolescence. REFERENCES Infertility may already be present due to either early gonadal failure or to gonadectomy because Abramowitz, S. I. (1986). Psychosocial outcomes of sex of a malignancy risk. Even so, it is advisable for reassignment surgery. Journal of Consulting and Clin- patients with a DSD to undergo a full social ical Psychology, 54(2), 183–189. doi:10.1037/0022- transition to another gender role only if there 006X.54.2.183 ACOG Committee of Gynecologic Practice. (2005). is a long-standing history of gender-atypical Committee opinion #322: Compounded bioidentical behavior, and if gender dysphoria and/or the hormones. Obstetrics & Gynecology, 106(5), 139– desire to change one’s gender role has been 140. strong and persistent for a considerable period Adler, R. K., Hirsch, S., & Mordaunt, M. (2006). Voice and of time. Six months is the time period of full communication therapy for the transgender/transsexual symptom expression required for the application client: A comprehensive clinical guide. San Diego, CA: of the gender dysphoria diagnosis proposed for Plural Pub. DSM-5 (Meyer-Bahlburg, 2011). American Academy of Family Physicians. (2005). Defi- nition of family medicine. Retrieved from http://www. aafp.org/online/en/home/policy/policies/f/fammeddef. Additional Resources html American Medical Association. (2008). Resolution 122 The gender-relevant medical histories of peo- (A-08). Retrieved from http://www.ama-assn.org/ama1/ ple with a DSD are often complex. Their histo- pub/upload/mm/471/122.doc 210 INTERNATIONAL JOURNAL OF TRANSGENDERISM
American Psychiatric Association. (2000). Diagnostic and Eyler (Eds.), Principles of transgender medicine and statistical manual of mental disorders DSM-IV-TR (4th surgery (pp. 185–208). New York, NY: Haworth Press. ed., text rev.). Washington, DC: Author. Bockting, W. O., & Goldberg, J. M. (2006). Guidelines for American Speech-Language-Hearing Association. (2011). transgender care [Special issue]. International Journal Scope of practice. Retrieved from www.asha.org of Transgenderism, 9(3/4). Anton, B. S. (2009). Proceedings of the American Psy- Bockting, W. O., Knudson, G., & Goldberg, J. M. (2006). chological Association for the legislative year 2008: Counseling and mental health care for transgender Minutes of the annual meeting of the council of adults and loved ones. International Journal of Trans- representatives, February 22–24, 2008, Washington, genderism, 9(3/4), 35–82. doi:10.1300/J485v09n03 03 DC, and August 13 and 17, 2008, Boston, MA, and Bolin, A. (1988). In search of Eve (pp. 189–192). New minutes of the February, June, August, and December York, NY: Bergin & Garvey. 2008 meetings of the board of directors. American Bolin, A. (1994). Transcending and transgendering: Male- Psychologist, 64, 372–453. doi:10.1037/a0015932 to-female transsexuals, dichotomy and diversity. In G. Asscheman, H., Giltay, E. J., Megens, J. A. J., de Ronde, Herdt (Ed.), Third sex, third gender: Beyond sexual W., van Trotsenburg, M. A. A., & Gooren, L. J. G. dimorphism in culture and history (pp. 447–486). New (2011). A long-term follow-up study of mortality in York, NY: Zone Books. transsexuals receiving treatment with cross-sex hor- Bornstein, K. (1994). Gender outlaw: On men, women, and mones. European Journal of Endocrinology, 164(4), the rest of us. New York, NY: Routledge. 635–642. doi:10.1530/EJE-10-1038 Bosinski, H. A. G., Peter, M., Bonatz, G., Arndt, R., Baba, T., Endo, T., Honnma, H., Kitajima, Y., Hayashi, Heidenreich, M., Sippell, W. G., & Wille, R. (1997). A T., Ikeda, H., ...Saito, T. (2007). Association between higher rate of hyperandrogenic disorders in female-to- polycystic ovary syndrome and female-to-male trans- male transsexuals. Psychoneuroendocrinology, 22(5), sexuality. Human Reproduction, 22(4), 1011–1016. 361–380. doi:10.1016/S0306-4530(97)00033-4 doi:10.1093/humrep/del474 Brill, S. A., & Pepper, R. (2008). The transgender child: A Bakker, A., Van Kesteren, P. J., Gooren, L. J., & Bezemer, handbook for families and professionals.Berkeley,CA: P. D. (1993). The prevalence of transsexualism in the Cleis Press. Netherlands. Acta Psychiatrica Scandinavica, 87(4), Brown, G. R. (2009). Recommended revisions to 237–238. doi:10.1111/j.1600-0447.1993.tb03364.x The World Professional Association for Transgender Balen, A. H., Schachter, M. E., Montgomery, D., Reid, Health’s Standards of Care section on medical care for R. W., & Jacobs, H. S. (1993). Polycystic ovaries incarcerated persons with gender identity disorder. In- are a common finding in untreated female to male ternational Journal of Transgenderism, 11(2), 133–139. transsexuals. Clinical Endocrinology, 38(3), 325–329. doi:10.1080/15532730903008073 doi:10.1111/j.1365-2265.1993.tb01013.x Brown, G. R. (2010). Autocastration and autopenectomy Basson, R. (2001). Towards optimal hormonal treatment as surgical self-treatment in incarcerated persons with of male to female gender identity disorder. Journal of gender identity disorder. International Journal of Trans- Sexual and Reproductive Medicine, 1(1), 45–51. genderism, 12(1), 31–39. doi:10.1080/1553273100 Basson, R., & Prior, J. C. (1998). Hormonal therapy 3688970 of gender dysphoria: The male-to-female transsexual. Bullough, V.L., & Bullough, B. (1993). Cross dressing, sex, In D. Denny (Ed.), Current concepts in transgender and gender. Philadelphia: University of Pennsylvania identity (pp. 277–296). New York, NY: Garland. Press. Benjamin, H. (1966). The transsexual phenomenon.New Callen Lorde Community Health Center. (2000). York, NY: Julian Press. Transgender health program protocols. Retrieved from Besnier, N. (1994). Polynesian gender liminality through http://www.callen-lorde.org/documents/TG Protocol time and space. In G. Herdt (Ed.), Third sex, third Request Form2.pdf gender: Beyond sexual dimorphism in culture and Callen Lorde Community Health Center. (2011). history (pp. 285–328). New York, NY: Zone Books. Transgender health program protocols. Retrieved from Bockting, W. O. (1999). From construction to context: http://www.callen-lorde.org/documents/TG Protocol Gender through the eyes of the transgendered. Siecus Request Form2.pdf Report, 28(1), 3–7. Canadian Association of Speech-Language Pathologists Bockting, W. O. (2008). Psychotherapy and the real- and Audiologists. (n.d.). CASLPA clinical certification life experience: From gender dichotomy to gender program. Retrieved from http://www.caslpa.ca/ diversity. Sexologies, 17(4), 211–224. doi:10.1016/j. Carew, L., Dacakis, G., & Oates, J. (2007). The effec- sexol.2008.08.001 tiveness of oral resonance therapy on the perception Bockting, W. O., & Coleman, E. (2007). Developmental of femininity of voice in male-to-female transsexuals. stages of the transgender coming out process: Toward Journal of Voice, 21(5), 591–603. doi:10.1016/j.jvoice. an integrated identity. In R. Ettner, S. Monstrey, & A. 2006.05.005 Coleman et al. 211
Carnegie, C. (2004). Diagnosis of hypogonadism: Clinical Cohen-Kettenis, P.T., Schagen, S. E. E., Steensma, T. D., de assessments and laboratory tests. Reviews in Urology, Vries, A. L. C., & Delemarre-van de Waal, H. A. (2011). 6(Suppl 6), S3–8. Puberty suppression in a gender-dysphoric adolescent: Cattrall, F. R., & Healy, D. L. (2004). Long-term A 22-year follow-up. Archives of Sexual Behavior, metabolic, cardiovascular and neoplastic risks with 40(4), 843–847. doi:0.1007/s10508-011-9758-9 polycystic ovary syndrome. Best Practice & Research Cohen-Kettenis, P. T., Wallien, M., Johnson, L. L., Owen- Clinical Obstetrics & Gynaecology, 18(5), 803–812. Anderson, A. F. H., Bradley, S. J., & Zucker, K. J. doi:10.1016/j.bpobgyn.2004.05.005 (2006). A parent-report gender identity questionnaire Center of Excellence for Transgender Health, UCSF. for children: A cross-national, cross-clinic comparative (2011). Primary care protocol for transgender analysis. Clinical Child Psychology and Psychiatry, health care. Retrieved from http://transhealth.ucsf.edu/ 11(3), 397–405. doi:10.1177/1359104506059135 trans?page = protocol-00-00 Cole, C. M., O’Boyle, M., Emory, L. E., & Meyer, W. Chinas,˜ B. (1995). Isthmus Zapotec attitudes to- J., III. (1997). Comorbidity of gender dysphoria and ward sex and gender anomalies. In S. O. Mur- other major psychiatric diagnoses. Archives of Sexual ray (Ed.), Latin American male homosexualities (pp. Behavior, 26(1), 13–26. 293–302). Albuquerque: University of New Mexico Coleman, E. (2009a). Toward version 7 of the World Press. Professional Association for Transgender Health’s Clements, K., Wilkinson, W., Kitano, K., & Marx, R. Standards of Care. International Journal of Transgen- (1999). HIV prevention and health service needs of the derism, 11(1), 1–7. doi:10.1080/15532730902799912 transgender community in San Francisco. International Coleman, E. (2009b). Toward version 7 of the World Journal of Transgenderism, 3(1), 2–17. Professional Association for Transgender Health’s Stan- Cohen-Kettenis, P. T. (2001). Gender identity disorder in dards of Care: Hormonal and surgical approaches to DSM? Journal of the American Academy of Child & treatment. International Journal of Transgenderism, Adolescent Psychiatry, 40(4), 391–391. doi:10.1097/ 11(3), 141–145. doi:10.1080/15532730903383740 00004583-200104000-00006 Coleman, E. (2009c). Toward version 7 of the World Cohen-Kettenis, P. T. (2005). Gender change in 46,XY Professional Association for Transgender Health’s Stan- persons with 5α-reductase-2 deficiency and 17β- dards of Care: Medical and therapeutic approaches hydroxysteroid dehydrogenase-3 deficiency. Archives of to treatment. International Journal of Transgenderism, Sexual Behavior, 34(4), 399–410. doi:10.1007/s10508- 11(4), 215–219. doi:10.1080/15532730903439450 005-4339-4 Coleman, E. (2009d). Toward version 7 of the World Profes- Cohen-Kettenis, P. T. (2006). Gender identity disorders. sional Association for Transgender Health’s Standards In C. Gillberg, R. Harrington, & H. C. Steinhausen of Care: Psychological assessment and approaches to (Eds.), A clinician’s handbook of child and adolescent treatment. International Journal of Transgenderism, psychiatry (pp. 695–725). New York, NY: Cambridge 11(2), 69–73. doi:10.1080/15532730903008008 University Press. Coleman, E., Colgan, P., & Gooren, L. (1992). Male cross- Cohen-Kettenis, P. T. (2010). Psychosocial and psychosex- gender behavior in Myanmar (Burma): A description ual aspects of disorders of sex development. Best Prac- of the acault. Archives of Sexual Behavior, 21(3), 313– tice & Research Clinical Endocrinology & Metabolism, 321. 24(2), 325–334. doi:10.1016/j.beem.2009.11.005 Costa, L. M., & Matzner, A. (2007). Male bodies, women’s Cohen-Kettenis, P. T., & Kuiper, A. J. (1984). Transseksu- souls: Personal narratives of Thailand’s transgendered aliteit en psychotherapie.´ T`ıjdschrift Voor Psychothera- youth. Binghamton, NY: Haworth Press. pie, 10, 153–166. Currah, P., Juang, R. M., & Minter, S. (2006). Transgender Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, rights. Minneapolis, MN: University of Minnesota S. J., & Zucker, K. J. (2003). Demographic charac- Press. teristics, social competence, and behavior problems Currah, P., & Minter, S. (2000). Unprincipled exclusions: in children with gender identity disorder: A cross- The struggle to achieve judicial and legislative equality national, cross-clinic comparative analysis. Journal of for transgender people. William and Mary Journal of Abnormal Child Psychology, 31(1), 41–53. doi:10. Women and Law, 7, 37–60. 1023/A:1021769215342 Dacakis, G. (2000). Long-term maintenance of fundamen- Cohen-Kettenis, P. T., & Pfafflin,¨ F. (2003). Transgen- tal frequency increases in male-to-female transsexuals. derism and intersexuality in childhood and adoles- Journal of Voice, 14(4), 549–556. doi:10.1016/S0892- cence: Making choices. Thousand Oaks, CA: Sage. 1997(00)80010-7 Cohen-Kettenis, P. T., & Pfafflin,¨ F. (2010). The DSM Dahl, M., Feldman, J. L., Goldberg, J. M., & Jaberi, diagnostic criteria for gender identity disorder in A. (2006). Physical aspects of transgender endocrine adolescents and adults. Archives of Sexual Behavior, therapy. International Journal of Transgenderism, 9(3), 39(2), 499–513. doi:10.1007/s10508-009-9562-y 111–134. doi:10.1300/J485v09n03 06 212 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Darney, P. D. (2008). Hormonal contraception. In H. M. Retrieved from http://www.wpath.org/journal/www. Kronenberg, S. Melmer, K. S. Polonsky, & P. R. Larsen iiav.nl/ezines/web/IJT/97- (Eds.), Williams textbook of endocrinology (11th ed., 03/numbers/symposion/ijtvo06no03 02.htm pp. 615–644). Philadelphia, PA: Saunders. Devor, A. H. (2004). Witnessing and mirroring: A fourteen Davies, S., & Goldberg, J. M. (2006). Clinical aspects stage model. Journal of Gay and Lesbian Psychother- of transgender speech feminization and masculiniza- apy, 8(1/2), 41–67. tion. International Journal of Transgenderism, 9(3-4), de Vries, A. L. C., Cohen-Kettenis, P. T., & Delemarre- 167–196. doi:10.1300/J485v09n03 08 van de Waal, H. A. (2006). Clinical management de Bruin, M. D., Coerts, M. J., & Greven, A. J. (2000). of gender dysphoria in adolescents. International Speech therapy in the management of male-to-female Journal of Transgenderism, 9(3-4), 83–94. doi:10. transsexuals. Folia Phoniatrica Et Logopaedica, 52(5), 1300/J485v09n03 04 220–227. de Vries, A. L. C., Doreleijers, T. A. H., Steensma, De Cuypere, G., T’Sjoen, G., Beerten, R., Selvaggi, G., T. D., & Cohen-Kettenis, P. T. (2011). Psychi- De Sutter, P., Hoebeke, P., ... Rubens, R. (2005). atric comorbidity in gender dysphoric adolescents. Sexual and physical health after sex reassignment Journal of Child Psychology and Psychiatry. Ad- surgery. Archives of Sexual Behavior, 34(6), 679–690. vance online publication. doi:10.1111/j.1469-7610. doi:10.1007/s10508-005-7926-5 2011.02426.x De Cuypere, G., Van Hemelrijck, M., Michel, A., de Vries, A. L. C., Noens, I. L. J., Cohen-Kettenis, P. T., van Carael, B., Heylens, G., Rubens, R., ... Monstrey, S. Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). (2007). Prevalence and demography of transsexualism Autism spectrum disorders in gender dysphoric children in Belgium. European Psychiatry, 22(3), 137–141. and adolescents. Journal of Autism and Developmental doi:10.1016/j.eurpsy.2006.10.002 Disorders, 40(8), 930–936. doi:10.1007/s10803-010- De Cuypere, G., & Vercruysse, H. (2009). Eligibility 0935-9 and readiness criteria for sex reassignment surgery: de Vries, A. L. C., Steensma, T. D., Doreleijers, T. Recommendations for revision of the WPATH standards A. H., & Cohen-Kettenis, P. T. (2010). Puberty sup- of care. International Journal of Transgenderism, 11(3), pression in adolescents with gender identity disorder: 194–205. doi:10.1080/15532730903383781 A prospective follow-up study. Journal of Sexual Delemarre-van de Waal, H. A., & Cohen-Kettenis, P. Medicine. Advance online publication. doi:10.1111/ T. (2006). Clinical management of gender identity j.1743-6109.2010.01943.x disorder in adolescents: A protocol on psychologi- Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. cal and paediatric endocrinology aspects. European L. V., Langstrom, N., & Landen, M. (2011). Long- Journal of Endocrinology, 155(Suppl 1), S131–S137. term follow-up of transsexual persons undergoing doi:10.1530/eje.1.02231 sex reassignment surgery: Cohort study in Sweden. Delemarre-van de Waal, H. A., van Weissenbruch, M. M., PloS ONE, 6(2), 1–8. doi:10.1371/journal.pone.00 & Cohen Kettenis, P. T. (2004). Management of puberty 16885 in transsexual boys and girls. Hormone Research in Pae- Diamond, M. (2009). Human intersexuality: Difference or diatrics, 62(Suppl 2), 75–75. doi:10.1159/000081145 disorder? Archives of Sexual Behavior, 38(2), 172–172. de Lignieres,` B. (1999). Oral micronized pro- doi:10.1007/s10508-008-9438-6 gesterone. Clinical Therapeutics, 21(1), 41–60. Di Ceglie, D., & Thummel,¨ E. C. (2006). An experience of doi:10.1016/S0149-2918(00)88267-3 group work with parents of children and adolescents Derrig-Palumbo, K., & Zeine, F. (2005). Online therapy: A with gender identity disorder. Clinical Child Psy- therapist’s guide to expanding your practice.NewYork, chology and Psychiatry, 11(3), 387–396. doi:10.1177/ NY: W.W. Norton. 1359104506064983 Dessens, A. B., Slijper, F. M. E., & Drop, S. L. S. (2005). Dobs, A. S., Meikle, A. W., Arver, S., Sanders, S. W., Gender dysphoria and gender change in chromosomal Caramelli, K. E., & Mazer, N. A. (1999). Pharmacoki- females with congenital adrenal hyperplasia. Archives of netics, efficacy, and safety of a permeation-enhanced Sexual Behavior, 34(4), 389–397. doi:10.1007/s10508- testosterone transdermal system in comparison with 005-4338-5 bi-weekly injections of testosterone enanthate for the De Sutter, P. (2009). Reproductive options for transpeople: treatment of hypogonadal men. Journal of Clinical Recommendations for revision of the WPATH’s stan- Endocrinology & Metabolism, 84(10), 3469–3478. dards of care. International Journal of Transgenderism, doi:10.1210/jc.84.10.3469 11(3), 183–185. doi:10.1080/15532730903383765 Docter, R. F. (1988). Transvestites and transsexuals: De Sutter, P., Kira, K., Verschoor, A., & Hotimsky, Toward a theory of cross-gender behavior.NewYork, A. (2002). The desire to have children and the NY: Plenum Press. preservation of fertility in transsexual women: A Drummond, K. D., Bradley, S. J., Peterson-Badali, M., & survey. International Journal of Transgenderism, 6(3). Zucker, K. J. (2008). A follow-up study of girls with Coleman et al. 213
gender identity disorder. Developmental Psychology, Myths and realities of online clinical work, obser- 44(1), 34–45. doi:10.1037/0012-1649.44.1.34 vations on the phenomena of online behavior, ex- Ehrbar, R. D., & Gorton, R. N. (2010). Exploring provider perience, and therapeutic relationships. A 3rd-year treatment models in interpreting the standards of report from ISMHO’s clinical case study group.Re- care. International Journal of Transgenderism, 12(4), trieved from https://www.ismho.org/myths n realities. 198–210. doi:10.1080/15532739.2010.544235 asp Ekins, R., & King, D. (2006). The transgender phe- Fenway Community Health Transgender Health Program. nomenon. Thousand Oaks, CA: Sage. (2007). Protocol for hormone therapy. Retrieved from Eklund, P. L., Gooren, L. J., & Bezemer, P. D. (1988). http://www.fenwayhealth.org/site/DocServer/Fenway Prevalence of transsexualism in the Netherlands. British Protocols.pdf?docID = 2181 Journal of Psychiatry, 152(5), 638–640. Fisk, N. M. (1974). Editorial: Gender dysphoria Eldh, J., Berg, A., & Gustafsson, M. (1997). Long-term syndrome—the conceptualization that liberalizes in- follow up after sex reassignment surgery. Scandinavian dications for total gender reorientation and im- Journal of Plastic and Reconstructive Surgery and Hand plies a broadly based multi-dimensional rehabilita- Surgery, 31(1), 39–45. tive regimen. Western Journal of Medicine, 120(5), Emerson, S., & Rosenfeld, C. (1996). Stages of ad- 386–391. justment in family members of transgender individ- Fitzpatrick, L. A., Pace, C., & Wiita, B. (2000). Comparison uals. Journal of Family Psychotherapy, 7(3), 1–12. of regimens containing oral micronized progesterone doi:10.1300/J085V07N03 01 or medroxyprogesterone acetate on quality of life Emory, L. E., Cole, C. M., Avery, E., Meyer, O., & in postmenopausal women: A cross-sectional survey. Meyer I, W. J. (2003, September). Client’s view of Journal of Women’s Health & Gender-Based Medicine, gender identity: Life, treatment status and outcome. 9(4), 381–387. Paper presented at the 18th Biennial Harry Benjamin Frank, J. D., & Frank, J. B. (1993). Persuasion and Symposium, Gent, Belgium. healing: A comparative study of psychotherapy (3rd Ettner, R., Monstrey, S., & Eyler, A. (Eds.) (2007). Princi- ed.). Baltimore, MD: Johns Hopkins University Press. ples of transgender medicine and surgery. Binghamton, Fraser, L. (2009a). Depth psychotherapy with trans- NY: Haworth Press. gender people. Sexual and Relationship Ther- Eyler, A. E. (2007). Primary medical care of the gender- apy, 24(2), 126–142. doi:10.1080/1468199090300 variant patient. In R. Ettner, S. Monstrey, & E. Eyler 3878 (Eds.), Principles of transgender medicine and surgery Fraser, L. (2009b). Etherapy: Ethical and clinical con- (pp. 15–32). Binghamton, NY: Haworth Press. siderations for version 7 of the World Professional Factor, R. J., & Rothblum, E. (2008). Exploring gender Association for Transgender Health’s Standards of identity and community among three groups of trans- Care. International Journal of Transgenderism, 11(4), gender individuals in the United States: MTFs, FTMs, 247–263. doi:10.1080/15532730903439492 and genderqueers. Health Sociology Review, 17(3), Fraser, L. (2009c). Psychotherapy in the World Profes- 235–253. sional Association for Transgender Health’s Standards Feinberg, L. (1996). Transgender warriors: Making history of Care: Background and recommendations. Interna- from Joan of Arc to Dennis Rodman. Boston, MA: tional Journal of Transgenderism, 11(2), 110–126. Beacon Press. doi:10.1080/15532730903008057 Feldman, J. (2005, April). Masculinizing hormone therapy Garaffa, G., Christopher, N. A., & Ralph, D. J. with testosterone 1% topical gel. Paper presented at (2010). Total phallic reconstruction in female-to- the 19th Biennial Symposium of the Harry Benjamin male transsexuals. European Urology, 57(4), 715–722. International Gender Dysphoria Association, Bologna, doi:10.1016/j.eururo.2009.05.018 Italy. Gelder, M. G., & Marks, I. M. (1969). Aversion treatment Feldman, J. (2007). Preventive care of the transgendered intransvestismandtranssexualism.InR.Green&J. patient. In R. Ettner, S. Monstrey, & E. Eyler (Eds.), Money (Eds.), Transsexualism and sex reassignment Principles of transgender surgery and medicine (pp. (pp. 383–413). Baltimore, MD: Johns Hopkins Univer- 33–72). Binghamton, NY: Haworth Press. sity Press. Feldman, J., & Goldberg, J. (2006). Transgender primary Gelfer, M. P.(1999). Voicetreatment for the male-to-female medical care. International Journal of Transgenderism, transgendered client. American Journal of Speech- 9(3), 3–34. doi:10.1300/J485v09n03 02 Language Pathology, 8(3), 201–208. Feldman, J., & Safer, J. (2009). Hormone therapy in adults: Gharib, S., Bigby, J., Chapin, M., Ginsburg, E., Johnson, P., Suggested revisions to the sixth version of the standards Manson, J., & Solomon, C. (2005). Menopause: A guide of care. International Journal of Transgenderism, 11(3), to management. Boston, MA: Brigham and Women’s 146–182. doi:10.1080/15532730903383757 Hospital. Fenichel, M., Suler, J., Barak, A., Zelvin, E., Jones, Gijs, L., & Brewaeys, A. (2007). Surgical treatment of G., Munro, K., ... Walker-Schmucker, W. (2004). gender dysphoria in adults and adolescents: Recent 214 INTERNATIONAL JOURNAL OF TRANSGENDERISM
developments, effectiveness, and challenges. Annual Hembree, W. C., Cohen-Kettenis, P., Delemarre-van de Review of Sex Research, 18, 178–224. Waal, H. A., Gooren, L. J., Meyer, W. J., III, Spack, Gold, M., & MacNish, M. (2011). Adjustment and re- N. P., ... Montori, V. M. (2009). Endocrine treatment siliency following disclosure of transgender identity of transsexual persons: An Endocrine Society clinical in families of adolescents and young adults: Themes practice guideline. Journal of Clinical Endocrinology and clinical implications. Washington, DC: American & Metabolism, 94(9), 3132–3154. doi:10.1210/jc.2009- Family Therapy Academy. 0345 Gomez-Gil,´ E., Trilla, A., Salamero, M., Godas,´ T., Hill, D. B., Menvielle, E., Sica, K. M., & Johnson, &Valdes,´ M. (2009). Sociodemographic, clinical, A. (2010). An affirmative intervention for families and psychiatric characteristics of transsexuals from with gender-variant children: Parental ratings of child Spain. Archives of Sexual Behavior, 38(3), 378–392. mental health and gender. Journal of Sex and Mari- doi:10.1007/s10508-007-9307-8 tal Therapy, 36(1), 6–23. doi:10.1080/0092623090337 Gooren, L. (2005). Hormone treatment of the adult 5560 transsexual patient. Hormone Research in Paediatrics, Hoebeke, P., Selvaggi, G., Ceulemans, P., De Cuypere, G. 64(Suppl 2), 31–36. doi:10.1159/000087751 D., T’Sjoen, G., Weyers, S., ... Monstrey, S. (2005). Gorton, R. N., Buth, J., & Spade, D. (2005). Medical Impact of sex reassignment surgery on lower urinary therapy and health maintenance for transgender men: tract function. European Urology, 47(3), 398–402. A guide for health care providers. San Francisco, CA: doi:10.1016/j.eururo.2004.10.008 Lyon-Martin Women’s Health Services. Hoenig, J., & Kenna, J. C. (1974). The prevalence of Green, R. (1987). The “sissy boy syndrome” and the transsexualism in England and Wales. British Journal of development of homosexuality. New Haven, CT: Yale Psychiatry, 124(579), 181–190. doi:10.1192/bjp.124.2. University Press. 181 Green, R., & Fleming, D. (1990). Transsexual surgery Hughes, I. A., Houk, C. P., Ahmed, S. F., Lee, P. A., follow-up: Status in the 1990s. Annual Review of Sex & LWPES/ESPE Consensus Group. (2006). Consen- Research, 1(1), 163–174. sus statement on management of intersex disorders. Greenson, R. R. (1964). On homosexuality and gender Archives of Disease in Childhood, 91(7), 554–563. identity. International Journal of Psycho-Analysis, 45, doi:10.1136/adc.2006.098319 217–219. Hunter, M. H., & Sterrett, J. J. (2000). Polycystic ovary Grossman, A. H., D’Augelli, A. R., Howell, T. J., & syndrome: It’s not just infertility. American Family Hubbard, S. (2006). Parent’s reactions to transgender Physician, 62(5), 1079–1095. youth’s gender-nonconforming expression and identity. Institute of Medicine. (2011). The health of lesbian, Journal of Gay & Lesbian Social Services, 18(1), 3–16. gay, bisexual, and transgender people: Building a doi:10.1300/J041v18n01 02 foundation for better understanding. Washington, DC: Grossman, A. H., D’Augelli, A. R., & Salter, N. P. (2006). National Academies Press. Male-to-female transgender youth: Gender expression Jackson, P. A., & Sullivan, G. (Eds.). (1999). Lady boys, milestones, gender atypicality, victimization, and par- tom boys, rent boys: Male and female homosexualities ents’ responses. Journal of GLBT Family Studies, 2(1), in contemporary Thailand. Binghamton, NY: Haworth 71–92. Press. Grumbach, M. M., Hughes, I. A., & Conte, F. A. (2003). Jockenhovel,¨ F. (2004). Testosterone therapy-what, when Disorders of sex differentiation. In P. R. Larsen, H. and to whom? The Aging Male, 7(4), 319–324. M. Kronenberg, S. Melmed, & K. S. Polonsky (Eds.), doi:10.1080/13685530400016557 Williams textbook of endocrinology (10th ed., pp. Johansson, A., Sundbom, E., Hojerback,¨ T., & Bodlund, 842–1002). Philadelphia, PA: Saunders. O. (2010). A five-year follow-up study of Swedish Hage, J. J., & De Graaf, F. H. (1993). Addressing the adults with gender identity disorder. Archives of Sexual ideal requirements by free flap phalloplasty: Some Behavior, 39(6), 1429–1437. doi:10.1007/s10508-009- reflections on refinements of technique. Microsurgery, 9551-1 14(9), 592–598. doi:10.1002/micr.1920140910 Joint LWPES/ESPE CAH Working Group, Clayton, P. E., Hage, J. J., & Karim, R. B. (2000). Ought GIDNOS get Miller, W. L., Oberfield, S. E., Ritzen, E. M., Sippell, nought? Treatment options for nontranssexual gender W. G., & Speiser, P. W. (2002). Consensus state- dysphoria. Plastic and Reconstructive Surgery, 105(3), ment on 21-hydroxylase deficiency from the Lawson 1222–1227. Wilkins Pediatric Endocrine Society and the European Hancock, A. B., Krissinger, J., & Owen, K. (2010). Society for Pediatric Endocrinology. Journal of Clin- Voice perceptions and quality of life of transgender ical Endocrinology & Metabolism, 87(9), 4048–4053. people. Journal of Voice. Advance online publication doi:10.1210/jc.2002-020611 doi:10.1016/j.jvoice.2010.07.013 Jurgensen, M., Hiort, O., Holterhus, P. M., & Thyen, U. Hastings, D. W. (1974). Postsurgical adjustment of male (2007). Gender role behavior in children with XY kary- transsexual patients. Clinics in Plastic Surgery, 1(2), otype and disorders of sex development. Hormones and 335–344. Coleman et al. 215
Behavior, 51(3), 443–453. doi:0.1016/j.yhbeh.2007.01. signment surgery. Archives of Sexual Behavior, 32(4), 001 299–315. doi:10.1023/A:1024086814364 Kanagalingam, J., Georgalas, C., Wood, G. R., Ahluwalia, Lawrence, A. A. (2006). Patient-reported complications S., Sandhu, G., & Cheesman, A. D. (2005). Cricothyroid and functional outcomes of male-to-female sex reas- approximation and subluxation in 21 male-to-female signment surgery. Archives of Sexual Behavior, 35(6), transsexuals. The Laryngoscope, 115(4), 611–618. 717–727. doi:10.1007/s10508-006-9104-9 doi:10.1097/01.mlg.0000161357.12826.33 Lev, A. I. (2004). Transgender emergence: Therapeutic Kanhai, R. C. J., Hage, J. J., Karim, R. B., & Mulder, guidelines for working with gender-variant people J. W. (1999). Exceptional presenting conditions and and their families. Binghamton, NY: Haworth Clinical outcome of augmentation mammaplasty in male-to- Practice Press. female transsexuals. Annals of Plastic Surgery, 43(5), Lev, A. I. (2009). The ten tasks of the mental health 476–483. provider: Recommendations for revision of the World Kimberly, S. (1997). I am transsexual—hear me roar. Professional Association for Transgender Health’s Minnesota Law & Politics, June, 21–49. Standards of Care. International Journal of Trans- Klein, C., & Gorzalka, B. B. (2009). Sexual functioning genderism, 11(2), 74–99. doi:10.1080/1553273090300 in transsexuals following hormone therapy and gen- 8032 ital surgery: A review (CME). The Journal of Sex- Levy, A., Crown, A., & Reid, R. (2003). Endocrine inter- ual Medicine, 6(11), 2922–2939. doi:10.1111/j.1743- vention for transsexuals. Clinical Endocrinology, 59(4), 6109.2009.01370.x 409–418. doi:10.1046/j.1365-2265.2003.01821.x Knudson, G., De Cuypere, G., & Bockting, W. (2010a). MacLaughlin, D. T., & Donahoe, P. K. (2004). Sex Process toward consensus on recommendations for revi- determination and differentiation. New England Journal sion of the DSM diagnoses of gender identity disorders of Medicine, 350(4), 367–378. by the World Professional Association for Transgender Maheu, M. M., Pulier, M. L., Wilhelm, F. H., McMe- Health. International Journal of Transgenderism, 12(2), namin, J. P., & Brown-Connolly, N. E. (2005). The 54–59. doi:10.1080/15532739.2010.509213 mental health professional and the new technologies: Knudson, G., De Cuypere, G., & Bockting, W. (2010b). A handbook for practice today. Mahwah, NJ: Lawrence Recommendations for revision of the DSM diagnoses Erlbaum. of gender identity disorders: Consensus statement of Malpas, J. (2011). Between pink and blue: A multi- the World Professional Association for Transgender dimensional family approach to gender nonconforming Health. International Journal of Transgenderism, 12(2), children and their families. Family Process, 50(4), 115–118. doi:10.1080/15532739.2010.509215 453–470. doi:10.1111/j.1545-5300.2011.01371.x Kosilek v. Massachusetts Department of Correc- Mazur, T. (2005). Gender dysphoria and gender change tions/Maloney, C.A. No. 92-12820-MLW (U.S. Federal in androgen insensitivity or micropenis. Archives of District Court, Boston, MA, 2002). Sexual Behavior, 34(4), 411–421. doi:10.1007/s10508- Krege, S., Bex, A., Lummen,¨ G., & Rubben,¨ H. (2001). 005-4341-x Male-to-female transsexualism: A technique, results McNeill, E. J. M. (2006). Management of the transgender and long-term follow-up in 66 patients. British Jour- voice. The Journal of Laryngology & Otology, 120(07), nal of Urology, 88(4), 396–402. doi:10.1046/j.1464- 521–523. doi:10.1017/S0022215106001174 410X.2001.02323.x McNeill, E. J. M., Wilson, J. A., Clark, S., & Kuhn, A., Bodmer, C., Stadlmayr, W., Kuhn, P., Mueller, Deakin, J. (2008). Perception of voice in the trans- M. D., & Birkhauser,¨ M. (2009). Quality of life gender client. Journal of Voice, 22(6), 727–733. 15 years after sex reassignment surgery for trans- doi:10.1016/j.jvoice.2006.12.010 sexualism. Fertility and Sterility, 92(5), 1685–1689. Menvielle, E. J., & Tuerk, C. (2002). A support group for doi:10.1016/j.fertnstert.2008.08.126 parents of gender-nonconforming boys. Journal of the Kuhn, A., Hiltebrand, R., & Birkhauser, M. (2007). American Academy of Child & Adolescent Psychiatry, Do transsexuals have micturition disorders? Euro- 41(8), 1010–1013. doi:10.1097/00004583-200208000- pean Journal of Obstetrics & Gynecology and Re- 00021 productive Biology, 131(2), 226–230. doi:10.1016/j. Meyer, I. H. (2003). Prejudice as stress: Conceptual and ejogrb.2006.03.019 measurement problems. American Journal of Public Landen,´ M., Walinder,˚ J., & Lundstrom,¨ B. (1998). Health, 93(2), 262–265. Clinical characteristics of a total cohort of female and Meyer, J. K., & Reter, D. J. (1979). Sex reassignment: male applicants for sex reassignment: A descriptive Follow-up. Archives of General Psychiatry, 36(9), study. Acta Psychiatrica Scandinavica, 97(3), 189–194. 1010–1015. doi:10.1111/j.1600-0447.1998.tb09986.x Meyer, W. J., III. (2009). World Professional Association Lawrence, A. A. (2003). Factors associated with satis- for Transgender Health’s standards of care requirements faction or regret following male-to-female sex reas- of hormone therapy for adults with gender identity 216 INTERNATIONAL JOURNAL OF TRANSGENDERISM
disorder. International Journal of Transgenderism, Money, J., & Ehrhardt, A. A. (1972). Man and woman, 11(2), 127–132. doi:10.1007/15532730903008065 boy and girl. Baltimore, MD: Johns Hopkins University Meyer, W. J., III, Webb, A., Stuart, C. A., Finkelstein, J. Press. W., Lawrence, B., & Walker, P. A. (1986). Physical Money, J., & Russo, A. J. (1979). Homosexual outcome of and hormonal evaluation of transsexual patients: A discordant gender identity/role in childhood: Longitu- longitudinal study. Archives of Sexual Behavior, 15(2), dinal follow-up. Journal of Pediatric Psychology, 4(1), 121–138. doi:10.1007/BF01542220 29–41. doi:10.1093/jpepsy/4.1.29 Meyer-Bahlburg, H. F. L. (2002). Gender assignment Monstrey, S., Hoebeke, P., Selvaggi, G., Ceulemans, P., Van and reassignment in intersexuality: Controversies, data, Landuyt, K., Blondeel, P., ... De Cuypere, G. (2009). and guidelines for research. Advances in Experimental Penile reconstruction: Is the radial forearm flap really Medicine and Biology, 511, 199–223. doi:10.1007/978- the standard technique? Plastic and Reconstructive 1-4615-0621-8 12 Surgery, 124(2), 510–518. Meyer-Bahlburg, H. F. L. (2005). Gender identity out- Monstrey, S., Selvaggi, G., Ceulemans, P., Van Landuyt, come in female-raised 46,XY persons with penile K., Bowman, C., Blondeel, P., ... De Cuypere, G. agenesis, cloacal exstrophy of the bladder, or penile (2008). Chest-wall contouring surgery in female-to- ablation. Archives of Sexual Behavior, 34(4), 423–438. male transsexuals: A new algorithm. Plastic and Recon- doi:10.1007/s10508-005-4342-9 structive Surgery, 121(3), 849–859. doi:10.1097/01.prs. Meyer-Bahlburg, H. F. L. (2008). Treatment guidelines 0000299921.15447.b2 for children with disorders of sex development. Neu- Moore, E., Wisniewski, A., & Dobs, A. (2003). En- ropsychiatrie de l’Enfance et de l’Adolescence, 56(6), docrine treatment of transsexual people: A review of 345–349. doi:10.1016/j.neurenf.2008.06.002. treatment regimens, outcomes, and adverse effects. Meyer-Bahlburg, H. F. L. (2009). Variants of gender Journal of Clinical Endocrinology & Metabolism, differentiation in somatic disorders of sex develop- 88(8), 3467–3473. doi:10.1210/jc.2002-021967 ment. International Journal of Transgenderism, 11(4), More, S. D. (1998). The pregnant man—an oxy- 226–237. doi:10.1080/15532730903439476 moron? Journal of Gender Studies, 7(3), 319–328. Meyer-Bahlburg, H. F. L. (2010). From mental disorder doi:10.1080/09589236.1998.9960725 to iatrogenic hypogonadism: Dilemmas in conceptu- Mount, K. H., & Salmon, S. J. (1988). Changing the alizing gender identity variants as psychiatric condi- vocal characteristics of a postoperative transsexual tions. Archives of Sexual Behavior, 39(2), 461–476. patient: A longitudinal study. Journal of Communi- doi:10.1007/s10508-009-9532-4 cation Disorders, 21(3), 229–238. doi:10.1016/0021- Meyer-Bahlburg, H. F. L. (2011). Gender monitoring 9924(88)90031-7 and gender reassignment of children and adolescents Mueller, A., Kiesewetter, F., Binder, H., Beckmann, M. with a somatic disorder of sex development. Child & W., & Dittrich, R. (2007). Long-term administration Adolescent Psychiatric Clinics of North America, 20(4), of testosterone undecanoate every 3 months for testos- 639–649. doi: 10.1016/j.ch.2011.07.002. terone supplementation in female-to-male transsexuals. Meyer-Bahlburg, H. F. L., & Blizzard, R. M. (2004). Con- Journal of Clinical Endocrinology & Metabolism, ference proceedings: Research on intersex—Summary 92(9), 3470–3475. doi:10.1210/jc.2007-0746 of a planning workshop. The Endocrinologist, 14(2), Murad, M. H., Elamin, M. B., Garcia, M. Z., Mullan, R. 59–69. doi:10.1097/01.ten.0000123701.61007.4e J., Murad, A., Erwin, P. J., & Montori, V. M. (2010). Meyer-Bahlburg, H. F. L., Dolezal, C., Baker, S. W., Hormonal therapy and sex reassignment: A system- Carlson, A. D., Obeid, J. S., & New, M. I. (2004). Pre- atic review and meta-analysis of quality of life and natal androgenization affects gender-related behavior psychosocial outcomes. Clinical Endocrinology, 72(2), but not gender identity in 5–12-year-old girls with con- 214–231. doi:10.1111/j.1365-2265.2009.03625.x genital adrenal hyperplasia. Archives of Sexual Behav- Nanda, S. (1998). Neither man nor woman: The hijras of ior, 33(2), 97–104. doi:10.1023/B:ASEB.0000014324. India. Belmont, CA: Wadsworth. 25718.51 Nestle, J., Wilchins, R. A., & Howell, C. (2002). Gen- Meyer-Bahlburg, H. F. L., Dolezal, C., Baker, S. W., derqueer: Voices from beyond the sexual binary.Los Ehrhardt, A. A., & New, M. I. (2006). Gender devel- Angeles, CA: Alyson. opment in women with congenital adrenal hyperplasia Neumann, K., & Welzel, C. (2004). The importance of as a function of disorder severity. Archives of Sexual voice in male-to-female transsexualism. Journal of Behavior, 35(6), 667–684. doi:10.1007/s10508-006- Voice, 18(1), 153–167. 9068-9 Newfield, E., Hart, S., Dibble, S., & Kohler, L. (2006). Meyer-Bahlburg, H. F. L., Migeon, C. J., Berkovitz, G. D., Female-to-male transgender quality of life. Quality of Gearhart, J. P., Dolezal, C., & Wisniewski, A. B. (2004). Life Research, 15(9), 1447–1457. doi:10.1007/s11136- Attitudes of adult 46,XY intersex persons to clinical 006-0002-3 management policies. The Journal of Urology, 171(4), Nieschlag, E., Behre, H. M., Bouchard, P., Corrales, J. J., 1615–1619. doi:10.1097/01.ju.0000117761.94734.b7 Jones,T.H.,Stalla,G.K.,... Wu, F. C. W. (2004). Coleman et al. 217
Testosterone replacement therapy: Current trends and In M. Rottnek (Ed.), Sissies and tomboys: Gender future directions. Human Reproduction Update, 10(5), nonconformity and homosexual childhood (pp. 34–51). 409–419. doi:10.1093/humupd/dmh035 New York: New York University Press. North American Menopause Society. (2010). Estrogen Pope, K. S., & Vasquez, M. J. (2011). Ethics in psy- and progestogen use in postmenopausal women: chotherapy and counseling: A practical guide (4th ed.). 2010 position statement. Menopause, 17(2), 242–255. Hoboken, NJ: John Wiley. doi:10.1097/gme.0b013e3181d0f6b9 Prior, J. C., Vigna, Y. M., & Watson, D. (1989). Nuttbrock, L., Hwahng, S., Bockting, W., Rosen- Spironolactone with physiological female steroids blum, A., Mason, M., Macri, M., & Becker, J. for presurgical therapy of male-to-female (2010). Psychiatric impact of gender-related abuse transsexualism. Archives of Sexual Behavior, 18(1), across the life course of male-to-female transgen- 49–57. doi:10.1007/BF01579291 der persons. Journal of Sex Research, 47(1), 12–23. Prior, J. C., Vigna, Y. M., Watson, D., Diewold, P., & doi:10.1080/00224490903062258 Robinow, O. (1986). Spironolactone in the presurgical Oates, J. M., & Dacakis, G. (1983). Speech pathology therapy of male to female transsexuals: Philosophy and considerations in the management of transsexualism—a experience of the Vancouver Gender Dysphoria Clinic. review. International Journal of Language & Journal of Sex Information & Education Council of Communication Disorders, 18(3), 139–151. doi:10. Canada, 1, 1–7. 3109/13682828309012237 Rachlin, K. (1999). Factors which influence individual’s de- Olyslager, F., & Conway, L. (2007, September). On the cal- cisions when considering female-to-male genital recon- culation of the prevalence of transsexualism. Paper pre- structive surgery. International Journal of Transgen- sented at the World Professional Association for Trans- derism, 3(3). Retrieved from http://www.WPATH.org gender Health 20th International Symposium, Chicago, Rachlin, K. (2002). Transgendered individuals’ IL. Retrieved from http://www.changelingaspects.com/ experiences of psychotherapy. International Journal PDF/2007-09-06-Prevalence of Transsexualism.pdf of Transgenderism, 6(1). Retrieved from http://www. Oriel, K. A. (2000). Clinical update: Medical care of trans- wpath.org/journal/www.iiav.nl/ezines/web/IJT/97-03/ sexual patients. Journal of the Gay and Lesbian Medical numbers/symposion/ijtvo06no01 03.htm. Association, 4(4), 185–194. doi:1090-7173/00/1200- Rachlin, K., Green, J., & Lombardi, E. (2008). Utilization 0185$18.00/1 of health care among female-to-male transgender indi- Pauly, I. B. (1965). Male psychosexual inversion: Trans- viduals in the United States. Journal of Homosexuality, sexualism: A review of 100 cases. Archives of General 54(3), 243–258. doi:10.1080/00918360801982124 Psychiatry, 13(2), 172–181. Rachlin, K., Hansbury, G., & Pardo, S. T. (2010). Hys- Pauly, I. B. (1981). Outcome of sex reassignment terectomy and oophorectomy experiences of female- surgery for transsexuals. Australian and New Zealand to-male transgender individuals. International Jour- Journal of Psychiatry, 15(1), 45–51. doi:10.3109/ nal of Transgenderism, 12(3), 155–166. doi:10. 00048678109159409 1080/15532739.2010.514220 Payer, A. F., Meyer, W. J., III, & Walker, P. A. (1979). Reed, B., Rhodes, S., Schofield, P. & Wylie, K. The ultrastructural response of human leydig cells (2009). Gender variance in the UK: Prevalence, to exogenous estrogens. Andrologia, 11(6), 423–436. incidence, growth and geographic distribution.Re- doi:10.1111/j.1439-0272.1979.tb02232.x trieved from http://www.gires.org.uk/assets/Medpro- Peletz, M. G. (2006). Transgenderism and gender pluralism Assets/GenderVarianceUK-report.pdf in southeast Asia since early modern times. Current Rehman, J., Lazer, S., Benet, A. E., Schaefer, L. C., & Anthropology, 47(2), 309–340. doi:10.1086/498947 Melman, A. (1999). The reported sex and surgery satis- Pfafflin,¨ F. (1993). Regrets after sex reassignment surgery. factions of 28 postoperative male-to-female transsexual Journal of Psychology & Human Sexuality, 5(4), 69–85. patients. Archives of Sexual Behavior, 28(1), 71–89. Pfafflin,¨ F., & Junge, A. (1998). Sex reassignment. doi:10.1023/A:1018745706354 Thirty years of international follow-up studies after Robinow, O. (2009). Paraphilia and transgenderism: sex reassignment surgery: A comprehensive review, A connection with Asperger’s disorder? Sex- 1961–1991. International Journal of Transgenderism. ual and Relationship Therapy, 24(2), 143–151. Retrieved from http://web.archive.org/web/2007050 doi:10.1080/14681990902951358 3090247/http://www.symposion.com/ijt/pfaefflin/1000. Rosenberg, M. (2002). Children with gender identity htm issues and their parents in individual and group Physicians’ desk reference (61st ed.). (2007). Montvale, treatment. Journal of the American Academy of NJ: PDR. Child and Adolescent Psychiatry, 41(5), 619–621. Physicians’ desk reference (65th ed.). (2010). Montvale, doi:10.1097/00004583-200205000-00020 NJ: PDR. Rossouw, J. E., Anderson, G. L., Prentice, R. L., Pleak, R. R. (1999). Ethical issues in diagnosing and LaCroix, A. Z., Kooperberg, C., Stefanick, M. L., treating gender-dysphoric children and adolescents. ... Johnson, K. C. (2002). Risks and benefits of 218 INTERNATIONAL JOURNAL OF TRANSGENDERISM
estrogen plus progestin in healthy postmenopausal and satisfaction in adult female patients. Journal of women: Principal results from the women’s health ini- Pediatric and Adolescent Gynecology, 16(5), 289–296. tiative randomized controlled trial. JAMA: The Journal doi:10.1016/S1083-3188(03)00155-4 of the American Medical Association, 288(3), 321– Stoller, R. J. (1964). A contribution to the study of gender 333. identity. International Journal of Psychoanalysis, 45, Royal College of Speech & Language Therapists, United 220–226. Kingdom. Retrieved from http://www.rcslt.org/ Stone, S. (1991). The empire strikes back: A posttransexual Ruble, D. N., Martin, C. L., & Berenbaum, S. A. (2006). manifesto. In J. Epstein, & K. Straub (Eds.), Body Gender development. In N. Eisenberg, W. Damon & R. guards: The cultural politics of gender ambiguity (pp. M. Lerner (Eds.), Handbook of child psychology (6th 280–304). London, UK: Routledge. ed., pp. 858–932). Hoboken, NJ: John Wiley. Tangpricha, V., Ducharme, S. H., Barber, T. W., & Chipkin, Sausa, L. A. (2005). Translating research into practice: S. R. (2003). Endocrinologic treatment of gender Trans youth recommendations for improving school identity disorders. Endocrine Practice, 9(1), 12–21. systems. Journal of Gay & Lesbian Issues in Education, Tangpricha, V., Turner, A., Malabanan, A., & Holick, M. 3(1), 15–28. doi:10.1300/J367v03n01 04 (2001). Effects of testosterone therapy on bone mineral Simpson, J. L., de la Cruz, F., Swerdloff, R. S., Samango- density in the FTM patient. International Journal of Sprouse, C., Skakkebaek, N. E., Graham, J. M. Transgenderism, 5(4). J., ... Willard, H. F. (2003). Klinefelter syndrome: Taywaditep, K. J., Coleman, E., & Dumronggittigule, P. Expanding the phenotype and identifying new re- (1997). Thailand (Muang Thai). In R. Francoeur (Ed.), search directions. Genetics in Medicine, 5(6), 460–468. International encyclopedia of sexuality.NewYork,NY: doi:10.1097/01.GIM.0000095626.54201.D0 Continuum. Smith,Y.L.S.,VanGoozen,S.H.M.,Kuiper,A.J., Thole, Z., Manso, G., Salgueiro, E., Revuelta, P., & & Cohen-Kettenis, P. T. (2005). Sex reassignment: Hidalgo, A. (2004). Hepatotoxicity induced by an- Outcomes and predictors of treatment for adolescent tiandrogens: A review of the literature. Urologia and adult transsexuals. Psychological Medicine, 35(1), Internationalis, 73(4), 289–295. doi:10.1159/00008 89–99. doi:10.1017/S0033291704002776 1585 Sood, R., Shuster, L., Smith, R., Vincent, A., & Ja- Tom Waddell Health Center. (2006). Protocols for hor- toi, A. (2011). Counseling postmenopausal women monal reassignment of gender. Retrieved from http:// about bioidentical hormones: Ten discussion points www.sfdph.org/dph/comupg/oservices/medSvs/hlthCt for practicing physicians. Journal of the American rs/TransGendprotocols122006.pdf Board of Family Practice, 24(2), 202–210. doi:10. Tsoi, W. F. (1988). The prevalence of transsexualism 3122/jabfm.2011.02.100194 in Singapore. Acta Psychiatrica Scandinavica, 78(4), Speech Pathology Australia. Retrieved from 501–504. doi:10.1111/j.1600-0447.1988.tb06373.x http://www.speechpathologyaustralia.org.au/ Van den Broecke, R., Van der Elst, J., Liu, J., Hovatta, O., Speiser, P. W., Azziz, R., Baskin, L. S., Ghizzoni, L., & Dhont, M. (2001). The female-to-male transsexual Hensle, T. W., Merke, D. P., ...Oberfield, S. E. (2010). patient: A source of human ovarian cortical tissue Congenital adrenal hyperplasia due to steroid 21- for experimental use. Human Reproduction, 16(1), hydroxylase deficiency: An endocrine society clinical 145–147. doi:10.1093/humrep/16.1.145 practice guideline. Journal of Clinical Endocrinology Vanderburgh, R. (2009). Appropriate therapeutic care & Metabolism, 95(9), 4133–4160. doi:10.1210/jc.2009- for families with prepubescent transgender/gender- 2631 dissonant children. Child and Adolescent Social Work Steensma, T. D., Biemond, R., de Boer, F., & Journal, 26(2), 135–154. doi:10.1007/s10560-008- Cohen-Kettenis, P. T. (2011). Desisting and per- 0158-5 sisting gender dysphoria after childhood: A qual- van Kesteren, P. J. M., Asscheman, H., Megens, J. A. itative follow-up study. Clinical Child Psychology J., & Gooren, L. J. G. (1997). Mortality and mor- and Psychiatry. Advance online publication. doi:10. bidity in transsexual subjects treated with cross-sex 1177/1359104510378303 hormones. Clinical Endocrinology, 47(3), 337–343. Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Gen- doi:10.1046/j.1365-2265.1997.2601068.x der transitioning before puberty? Archives of Sexual van Kesteren, P. J. M., Gooren, L. J., & Megens, Behavior, 40(4), 649–650. doi:10.1007/s10508-011- J. A. (1996). An epidemiological and demographic 9752-2 study of transsexuals in the Netherlands. Archives of Stikkelbroeck, N. M. M. L., Beerendonk, C., Willemsen, Sexual Behavior, 25(6), 589–600. doi:10.1007/BF0243 W. N. P., Schreuders-Bais, C. A., Feitz, W. F. J., 7841 Rieu,P.N.M.A.,... Otten, B. J. (2003). The van Trotsenburg, M. A. A. (2009). Gynecological as- long term outcome of feminizing genital surgery for pects of transgender healthcare. International Jour- congenital adrenal hyperplasia: Anatomical, functional nal of Transgenderism, 11(4), 238–246. doi:10.1080/ and cosmetic outcomes, psychosexual development, 15532730903439484 Coleman et al. 219
Vilain, E. (2000). Genetics of sexual development. Annual of treatment, sex reassignment, and insurance coverage Review of Sex Research, 11, 1–25. in the U.S.A. Retrieved from http://www.wpath. Walinder,˚ J. (1968). Transsexualism: Definition, preva- org/documents/Med%20Nec%20on%202008%20Letter lence and sex distribution. Acta Psychiatrica Scandi- head.pdf navica, 43(S203), 255–257. WPATH Board of Directors. (2010). De- Walinder,˚ J. (1971). Incidence and sex ratio of transsex- psychopathologisation statement released May 26, ualism in Sweden. The British Journal of Psychiatry, 2010. Retrieved from http://wpath.org/announcements 119(549), 195–196. detail.cfm?pk announcement = 17 Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Xavier, J. M. (2000). The Washington, D.C. transgender Psychosexual outcome of gender-dysphoric children. needs assessment survey: Final report for phase two. Journal of the American Academy of Child & Washington, DC: Administration for HIV/AIDS of Adolescent Psychiatry, 47(12), 1413–1423. doi:10. District of Columbia Government. 1097/CHI.0b013e31818956b9 Zhang, G., Gu, Y., Wang, X., Cui, Y., & Bremner, Wallien, M. S. C., Swaab, H., & Cohen-Kettenis, P. T. W. J. (1999). A clinical trial of injectable testos- (2007). Psychiatric comorbidity among children with terone undecanoate as a potential male contracep- gender identity disorder. Journal of the American tive in normal Chinese men. Journal of Clinical Academy of Child & Adolescent Psychiatry, 46(10), Endocrinology & Metabolism, 84(10), 3642–3647. 1307–1314. doi:10.1097/chi.0b013e3181373848 doi:10.1210/jc.84.10.3642 Warren, B. E. (1993). Transsexuality, identity and empow- Zitzmann, M., Saad, F., & Nieschlag, E. (2006, April). erment. A view from the frontlines. SIECUS Report, Long term experience of more than 8 years with a February/March, 14–16. novel formulation of testosterone undecanoate (nebido) Weitze, C., & Osburg, S. (1996). Transsexualism in Ger- in substitution therapy of hypogonadal men. Paper many: Empirical data on epidemiology and application presented at European Congress of Endocrinology, of the German Transsexuals’ Act during its first ten Glasgow, UK. years. Archives of Sexual Behavior, 25(4), 409–425. Zucker, K. J. (1999). Intersexuality and gender identity Wilson, J. D. (1999). The role of androgens in male gender differentiation. Annual Review of Sex Research, 10(1), role behavior. Endocrine Reviews, 20(5), 726–737. 1–69. doi:10.1210/er.20.5.726 Zucker, K. J. (2004). Gender identity develop- Winter, S. (2009). Cultural considerations for the World ment and issues. Child and Adolescent Psychi- Professional Association for Transgender Health’s atric Clinics of North America, 13(3), 551–568. standards of care: The Asian perspective. Inter- doi:10.1016/j.chc.2004.02.006 national Journal of Transgenderism, 11(1), 19–41. Zucker, K. J. (2006). “I’m half-boy, half-girl”: Play doi:10.1080/15532730902799938 psychotherapy and parent counseling for gender identity Winter, S., Chalungsooth, P., Teh, Y. K., Rojanalert, disorder.InR.L.Spitzer,M.B.First,J.B.W.Williams, N., Maneerat, K., Wong, Y. W., ... Macapagal, R. & M. Gibbons (Eds.), DSM-IV-TR casebook, volume 2 A. (2009). Transpeople, transprejudice and patholo- (pp. 321–334). Arlington, VA: American Psychiatric. gization: A seven–country factor analytic study. In- Zucker, K. J. (2010). The DSM diagnostic criteria for ternational Journal of Sexual Health, 21(2), 96–118. gender identity disorder in children. Archives of Sexual doi:10.1080/19317610902922537 Behavior, 39(2), 477–498. doi:10.1007/s10508-009- Wisniewski, A. B., Migeon, C. J., Malouf, M. A., 9540-4 & Gearhart, J. P. (2004). Psychosexual outcome in Zucker, K. J., & Bradley, S. J. (1995). Gender identity women affected by congenital adrenal hyperplasia disorder and psychosexual problems in children and due to 21-hydroxylase deficiency. The Journal of adolescents. New York, NY: Guilford Press. Urology, 171(6, Part 1), 2497–2501. doi:10.1097/ Zucker, K. J., Bradley, S. J., Owen-Anderson, A., Kibble- 01.ju.0000125269.91938.f7 white, S. J., & Cantor, J. M. (2008). Is gender identity World Health Organization. (2007). International classi- disorder in adolescents coming out of the closet? fication of diseases and related health problems-10th Journal of Sex & Marital Therapy, 34(4), 287–290. revision. Geneva, Switzerland: World Health Organiza- doi:10.1080/00926230802096192 tion. Zucker, K. J., Bradley, S. J., Owen-Anderson, A., Kibble- World Health Organization. (2008). The world health white, S. J., Wood, H., Singh, D., & Choi, K. (2012). report 2008: Primary health care—now more than ever. Demographics, behavior problems, and psychosexual Geneva, Switzerland: World Health Organization. characteristics of adolescents with gender identity World Professional Association for Transgender Health, disorder or transvestic fetishism. Journal of Sex & Inc. (2008). WPATH clarification on medical necessity Marital Therapy, 38(2), 151–189. 220 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Zucker, K. J., & Lawrence, A. A. (2009). Epi- comparative analysis of demographic characteristics demiology of gender identity disorder: Recommen- and behavioral problems. Clinical Child Psychology dations for the standards of care of the World and Psychiatry, 7(3), 398–411. Professional Association for Transgender Health. In- Zuger, B. (1984). Early effeminate behavior in boys: ternational Journal of Transgenderism, 11(1), 8–18. Outcome and significance for homosexuality. Jour- doi:10.1080/15532730902799946 nal of Nervous and Mental Disease, 172(2), 90– Zucker, K. J., Owen, A., Bradley, S. J., & Ameeriar, L. 97. (2002). Gender–dysphoric children and adolescents: A Coleman et al. 221
APPENDIX A: GLOSSARY patient according to a physician’s specifications. Government-drug-agency approval is not possi- Terminology in the area of health care ble for each compounded product made for an for transsexual, transgender, and gender- individual consumer. nonconforming people is rapidly evolving; new terms are being introduced, and the defini- Cross-dressing (transvestism): Wearing cloth- tions of existing terms are changing. Thus, ing and adopting a gender role presentation that, there is often misunderstanding, debate, or in a given culture, is more typical of the other disagreement about language in this field. Terms sex. that may be unfamiliar or that have specific meanings in the SOC are defined below for Disorders of sex development (DSD): Congeni- the purpose of this document only. Others may tal conditions in which the development of chro- adopt these definitions, but WPATH acknowl- mosomal, gonadal, or anatomic sex is atypical. edges that these terms may be defined differ- Some people strongly object to the “disorder” ently in different cultures, communities, and label and instead view these conditions as a contexts. matter of diversity (Diamond, 2009), preferring WPATH also acknowledges that many terms the terms intersex and intersexuality. used in relation to this population are not ideal. For example, the terms transsexual and Female-to-male (FtM): Adjective to describe transvestite—and, some would argue, the more individuals assigned female at birth who are recent term transgender—have been applied changing or who have changed their body and/or to people in an objectifying fashion. Yet such gender role from birth-assigned female to a more terms have been more or less adopted by many masculine body or role. people who are making their best effort to make themselves understood. By continuing to use Gender dysphoria: Distress that is caused by these terms, WPATH intends only to ensure that a discrepancy between a person’s gender iden- concepts and processes are comprehensible, in tity and that person’s sex assigned at birth order to facilitate the delivery of quality health (and the associated gender role and/or primary care to transsexual, transgender, and gender- and secondary sex characteristics) (Fisk, 1974; nonconforming people. WPATH remains open Knudson, De Cuypere, & Bockting, 2010b). to new terminology that will further illuminate the experience of members of this diverse Gender identity: A person’s intrinsic sense population and lead to improvements in health of being male (a boy or a man), female (a care access and delivery. girl or a woman), or an alternative gender (e.g., boygirl, girlboy, transgender, genderqueer, Bioidentical hormones: Hormones that are eunuch) (Bockting, 1999; Stoller, 1964). structurally identical to those found in the human body (ACOG Committee of Gynecologic Prac- Gender identity disorder: Formal diagnosis tice, 2005). The hormones used in bioidentical set forth by the Diagnostic Statistical Man- hormone therapy (BHT) are generally derived ual of Mental Disorders, 4th Edition, Text from plant sources and are structurally similar to Rev. (DSM IV-TR) (American Psychiatric As- endogenous human hormones, but they need to sociation, 2000). Gender identity disorder is be commercially processed to become bioiden- characterized by a strong and persistent cross- tical. gender identification and a persistent discomfort with one’s sex or sense of inappropriateness Bioidentical compounded hormone therapy in the gender role of that sex, causing clini- (BCHT): Use of hormones that are prepared, cally significant distress or impairment in so- mixed, assembled, packaged, or labeled as a cial, occupational, or other important areas of drug by a pharmacist and custom-made for a functioning. 222 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Gender-nonconforming: Adjective to describe genitalia, chromosomal and hormonal sex) are individuals whose gender identity, role, or ex- considered in order to assign sex (Grumbach, pression differs from what is normative for their Hughes, & Conte, 2003; MacLaughlin & Don- assigned sex in a given culture and historical ahoe, 2004; Money & Ehrhardt, 1972; Vilain, period. 2000). For most people, gender identity and expression are consistent with their sex assigned Gender role or expression: Characteristics in at birth; for transsexual, transgender, and gender- personality, appearance, and behavior that in a nonconforming individuals, gender identity or given culture and historical period are designated expression differ from their sex assigned at as masculine or feminine (that is, more typical of birth. the male or female social role) (Ruble, Martin, & Berenbaum, 2006). While most individuals Sex reassignment surgery (gender affirmation present socially in clearly masculine or feminine surgery): Surgery to change primary and/or gender roles, some people present in an alterna- secondary sex characteristics to affirm a person’s tive gender role such as genderqueer or specifi- gender identity. Sex reassignment surgery can cally transgender. All people tend to incorporate be an important part of medically necessary both masculine and feminine characteristics in treatment to alleviate gender dysphoria. their gender expression in varying ways and to varying degrees (Bockting, 2008). Transgender: Adjective to describe a diverse group of individuals who cross or transcend Genderqueer: Identity label that may be used culturally defined categories of gender. The by individuals whose gender identity and/or role gender identity of transgender people differs to does not conform to a binary understanding of varying degrees from the sex they were assigned gender as limited to the categories of man or at birth (Bockting, 1999). woman, male or female (Bockting, 2008). Transition: Period of time when individuals Internalized transphobia: Discomfort with change from the gender role associated with one’s own transgender feelings or identity as their sex assigned at birth to a different gender a result of internalizing society’s normative role. For many people, this involves learning gender expectations. how to live socially in another gender role; for others this means finding a gender role and Male-to-female (MtF): Adjective to describe expression that is most comfortable for them. individuals assigned male at birth who are Transition may or may not include feminiza- changing or who have changed their body and/or tion or masculinization of the body through gender role from birth-assigned male to a more hormones or other medical procedures. The feminine body or role. nature and duration of transition is variable and individualized. Natural hormones: Hormones that are derived from natural sources such as plants or animals. Transsexual: Adjective (often applied by the Natural hormones may or may not be bioidenti- medical profession) to describe individuals who cal. seek to change or who have changed their primary and/or secondary sex characteristics Sex: Sex is assigned at birth as male or female, through femininizing or masculinizing medical usually based on the appearance of the exter- interventions (hormones and/or surgery), typi- nal genitalia. When the external genitalia are cally accompanied by a permanent change in ambiguous, other components of sex (internal gender role. Coleman et al. 223
APPENDIX B: OVERVIEW OF • In general, clinical evidence suggests that MEDICAL RISKS OF HORMONE MtF patients with preexisting lipid disor- THERAPY ders may benefit from the use of transder- mal rather than oral estrogen. The risks outlined below are based on two comprehensive, evidence-based literature Liver/gallbladder reviews of masculinizing/feminizing hormone • therapy (Feldman & Safer, 2009; Hembree Estrogen and cyproterone acetate use may et al., 2009), along with a large cohort study be associated with transient liver-enzyme (Asscheman et al., 2011). These reviews can elevations and, rarely, clinical hepatotoxi- city. serve as detailed references for providers, along • with other widely recognized, published clinical Estrogen use increases the risk of materials (e.g., Dahl et al., 2006; Ettner et al., cholelithiasis (gall stones) and subsequent 2007). cholecystectomy.
Risks of Feminizing Hormone Therapy Possible Increased Risk (MTF) Type 2 diabetes mellitus Likely Increased Risk • Feminizing hormone therapy, particularly Venous thromboembolic disease estrogen, may increase the risk of type 2 diabetes, particularly among patients with • Estrogen use increases the risk of venous a family history of diabetes or other risk thromboembolic events (VTE), particu- factors for this disease. larly in patients who are over age 40, smokers, highly sedentary, obese, and who have underlying thrombophilic disorders. Hypertension • This risk is increased with the additional • Estrogen use may increase blood pressure, use of third generation progestins. • but the effect on incidence of overt hyper- This risk is decreased with use of the tension is unknown. transdermal (versus oral) route of estradiol • Spironolactone reduces blood pressure and administration, which is recommended for is recommended for at-risk or hypertensive patients at higher risk of VTE. patients desiring feminization. Cardiovascular, cerebrovascular disease Prolactinoma • Estrogen use increases the risk of cardio- • vascular events in patients over age 50 with Estrogen use increases the risk of hyper- underlying cardiovascular risk factors. Ad- prolactinemia among MtF patients in the ditional progestin use may increase this first year of treatment, but this risk is risk. unlikely thereafter. • High-dose estrogen use may promote the Lipids clinical appearance of preexisting but clin- ically unapparent prolactinoma. • Oral estrogen use may markedly increase triglycerides in patients, increasing the risk Inconclusive or No Increased Risk of pancreatitis and cardiovascular events. • Different routes of administration will have Items in this category include those that different metabolic effects on levels of may present risk, but for which the evidence HDL cholesterol, LDL cholesterol, and is so minimal that no clear conclusion can be lipoprotein(a). reached. 224 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Breast cancer approved for use (Dahl et al., 2006; Moore et al., 2003; Tangpricha et al., 2003). Spironolactone • MtF persons who have taken feminizing has a long history of use in treating hypertension hormones do experience breast cancer, but and congestive heart failure. Its common side it is unknown how their degree of risk effects include hyperkalemia, dizziness, and compares to that of persons born with gastrointestinal symptoms (Physicians’ Desk female genitalia. Reference, 2007). • Longer duration of feminizing hormone exposure (i.e., number of years taking Risks of Masculinizing Hormone Therapy estrogen preparations), family history of (FtM) breast cancer, obesity (BMI >35), and the use of progestins likely influence the level Likely Increased Risk of risk. Polycythemia
Other Side Effects of Feminizing Therapy • Masculinizing hormone therapy involving testosterone or other androgenic steroids The following effects may be considered mi- increases the risk of polycythemia (hemat- nor or even desired, depending on the patient, but ocrit > 50%), particularly in patients with are clearly associated with feminizing hormone other risk factors. therapy. • Transdermal administration and adaptation of dosage may reduce this risk. Fertility and sexual function Weight gain/visceral fat • Feminizing hormone therapy may impair fertility. • Masculinizing hormone therapy can result • Feminizing hormone therapy may decrease in modest weight gain, with an increase in libido. visceral fat. • Feminizing hormone therapy reduces noc- turnal erections, with variable impact on Possible Increased Risk sexually stimulated erections. Lipids Risks of Anti-androgen Medications • Testosterone therapy decreases HDL, but Feminizing hormone regimens often include variably affects LDL and triglycerides. a variety of agents that affect testosterone • Supraphysiologic (beyond normal male production or action. These include GnRH ago- range) serum levels of testosterone, often nists, progestins (including cyproterone acetate), found with extended intramuscular dosing, spironolactone, and 5-alpha reductase inhibitors. may worsen lipid profiles, whereas trans- An extensive discussion of the specific risks of dermal administration appears to be more these agents is beyond the scope of the SOC. lipid neutral. However, both spironolactone and cyproterone • Patients with underlying polycystic ovar- acetate are widely used and deserve some ian syndrome or dyslipidemia may be at comment. increased risk of worsening dyslipidemia Cyproterone acetate is a progestational com- with testosterone therapy. pound with anti-androgenic properties (Gooren, 2005; Levy et al., 2003). Although widely used Liver in Europe, it is not approved for use in the United States because of concerns about hepatotoxicity • Transient elevations in liver enzymes may (Thole, Manso, Salgueiro, Revuelta, & Hidalgo, occur with testosterone therapy. 2004). Spironolactone is commonly used as an • Hepatic dysfunction and malignancies anti-androgen in feminizing hormone therapy, have been noted with oral methyltestos- particularly in regions where cyproterone is not terone. However, methyltestosterone is no Coleman et al. 225
longer available in most countries and polycystic ovarian syndrome, may be at should no longer be used. increased risk.
Psychiatric Type 2 diabetes mellitus
• Masculinizing therapy involving testos- • Testosterone therapy does not appear to terone or other androgenic steroids may increase the risk of type 2 diabetes among increase the risk of hypomanic, manic, FtM patients overall, unless other risk or psychotic symptoms in patients with factors are present. underlying psychiatric disorders that in- • Testosterone therapy may further increase clude such symptoms. This adverse event the risk of type 2 diabetes in patients appears to be associated with higher doses with other risk factors, such as significant or supraphysiologic blood levels of testos- weight gain, family history, and polycystic terone. ovarian syndrome. There are no data that suggest or show an increase in risk in those Inconclusive or No Increased Risk with risk factors for dyslipidemia. Items in this category include those that may present risk, but for which the evidence is so Breast cancer minimal that no clear conclusion can be reached. • Testosterone therapy in FtM patients does Osteoporosis not increase the risk of breast cancer.
• Testosterone therapy maintains or in- Cervical cancer creases bone mineral density among FtM patients prior to oophorectomy, at least in • Testosterone therapy in FtM patients does the first three years of treatment. not increase the risk of cervical cancer, • There is an increased risk of bone den- although it may increase the risk of mini- sity loss after oophorectomy, particularly mally abnormal Pap smears due to atrophic if testosterone therapy is interrupted or changes. insufficient. This includes patients utilizing solely oral testosterone. Ovarian cancer Cardiovascular • Analogous to persons born with female • Masculinizing hormone therapy at normal genitalia with elevated androgen levels, physiologic doses does not appear to in- testosterone therapy in FtM patients may crease the risk of cardiovascular events increase the risk of ovarian cancer, al- among healthy patients. though evidence is limited. • Masculinizing hormone therapy may in- crease the risk of cardiovascular disease Endometrial (uterine) cancer in patients with underlying risks factors. • Testosterone therapy in FtM patients may Hypertension increase the risk of endometrial cancer, although evidence is limited. • Masculinizing hormone therapy at normal physiologic doses may increase blood pres- Other Side Effects of Masculinizing Therapy sure but does not appear to increase the risk of hypertension. The following effects may be considered • Patients with risk factors for hypertension, minor or even desired, depending on the patient, such as weight gain, family history, or but are clearly associated with masculinization. 226 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Fertility and sexual function • Testosterone therapy induces clitoral en- largement and increases libido. • Testosterone therapy in FtM patients re- duces fertility, although the degree and Acne, androgenic alopecia. Acne and varying reversibility are unknown. degrees of male pattern hair loss (androgenic • Testosterone therapy can induce permanent alopecia) are common side effects of masculin- anatomic changes in the developing em- izing hormone therapy. bryo or fetus. Coleman et al. 227
APPENDIX C: SUMMARY OF 3. Age of majority in a given country (if CRITERIA FOR HORMONE THERAPY younger, follow the SOC for children and AND SURGERIES adolescents); 4. If significant medical or mental health con- As for all previous versions of the SOC,the cerns are present, they must be reasonably criteria put forth in the SOC for hormone therapy well controlled. and surgical treatments for gender dysphoria are clinical guidelines; individual health profession- Hormone therapy is not a prerequisite. als and programs may modify them. Clinical departures from the SOC may come about because of a patient’s unique anatomic, social, or Breast Augmentation (Implants/Lipofilling) psychological situation; an experienced health in MtF Patients professional’s evolving method of handling a 1. Persistent, well-documented gender dys- common situation; a research protocol; lack phoria; of resources in various parts of the world; 2. Capacity to make a fully informed decision or the need for specific harm-reduction strate- and to give consent for treatment; gies. These departures should be recognized as 3. Age of majority in a given country (if such, explained to the patient, and documented younger, follow the SOC for children and through informed consent for quality patient care adolescents); and legal protection. This documentation is also 4. If significant medical or mental health con- valuable to accumulate new data, which can cerns are present, they must be reasonably be retrospectively examined to allow for health well controlled. care—and the SOC—to evolve.
Criteria for Feminizing/Masculinizing Although not an explicit criterion, it is recom- mended that MtF patients undergo feminizing Hormone Therapy (One Referral or Chart hormone therapy (minimum 12 months) prior to Documentation of Psychosocial breast augmentation surgery. The purpose is to Assessment) maximize breast growth in order to obtain better surgical (aesthetic) results. 1. Persistent, well-documented gender dys- phoria; 2. Capacity to make a fully informed decision Criteria for Genital Surgery (Two and to give consent for treatment; Referrals) 3. Age of majority in a given country (if younger, follow the SOC for children and Hysterectomy and Salpingo-oophorectomy adolescents); in FtM Patients and Orchiectomy in MtF 4. If significant medical or mental concerns Patients are present, they must be reasonably well controlled. 1. Persistent, well-documented gender dys- phoria; Criteria for Breast/Chest Surgery (One 2. Capacity to make a fully informed decision Referral) and to give consent for treatment; 3. Age of majority in a given country; Mastectomy and Creation of a Male Chest 4. If significant medical or mental health in FtM Patients concerns are present, they must be well controlled; 1. Persistent, well-documented gender dys- 5. 12 continuous months of hormone therapy phoria; as appropriate to the patient’s gender 2. Capacity to make a fully informed decision goals (unless hormones are not clinically and to give consent for treatment; indicated for the individual). 228 INTERNATIONAL JOURNAL OF TRANSGENDERISM
The aim of hormone therapy prior to go- 5. 12 continuous months of hormone therapy nadectomy is primarily to introduce a period of as appropriate to the patient’s gender reversible estrogen or testosterone suppression, goals (unless hormones are not clinically before a patient undergoes irreversible surgical indicated for the individual); intervention. 6. 12 continuous months of living in a gender These criteria do not apply to patients who role that is congruent with their gender are having these surgical procedures for medical identity. indications other than gender dysphoria. Although not an explicit criterion, it is rec- ommended that these patients also have regular Metoidioplasty or Phalloplasty in FtM Pa- visits with a mental health or other medical tients and Vaginoplasty in MtF Patients professional. The criterion noted above for some types 1. Persistent, well-documented gender dys- of genital surgeries—that is, that patients en- phoria; gage in 12 continuous months of living in a 2. Capacity to make a fully informed decision gender role that is congruent with their gender and to give consent for treatment; identity—is based on expert clinical consensus 3. Age of majority in a given country; that this experience provides ample opportunity 4. If significant medical or mental health for patients to experience and socially adjust concerns are present, they must be well in their desired gender role, before undergoing controlled; irreversible surgery. Coleman et al. 229
APPENDIX D: EVIDENCE FOR Care. The findings of Rehman and colleagues CLINICAL OUTCOMES OF (1999) and Krege and colleagues (2001) are THERAPEUTIC APPROACHES typical of this body of work; none of the patients in these studies regretted having had surgery, and One of the real supports for any new therapy most reported being satisfied with the cosmetic is an outcome analysis. Because of the contro- and functional results of the surgery. Even versial nature of sex reassignment surgery, this patients who develop severe surgical complica- type of analysis has been very important. Almost tions seldom regret having undergone surgery. all of the outcome studies in this area have been Quality of surgical results is one of the best retrospective. predictors of the overall outcome of sex reas- One of the first studies to examine the post- signment (Lawrence, 2003). The vast majority treatment psychosocial outcomes of transsexual of follow-up studies have shown an undeniable patients was done in 1979 at Johns Hopkins beneficial effect of sex reassignment surgery University School of Medicine and Hospital on postoperative outcomes such as subjective (USA) (J. K. Meyer & Reter, 1979). This study well being, cosmesis, and sexual function (De focused on patients’ occupational, educational, Cuypere et al., 2005; Garaffa, Christopher, & marital, and domiciliary stability. The results Ralph, 2010; Klein & Gorzalka, 2009), although revealed several significant changes with treat- the specific magnitude of benefit is uncertain ment. These changes were not seen as positive; from the currently available evidence. One study rather, they showed that many individuals who (Emory, Cole, Avery, Meyer, & Meyer, 2003) had entered the treatment program were no better even showed improvement in patient income. off or were worse off in many measures after One troubling report (Newfield et al., 2006) participation in the program. These findings documented lower scores on quality of life resulted in closure of the treatment program (measured with the SF-36) for FtM patients than at that hospital/medical school (Abramowitz, for the general population. A weakness of that 1986). study is that it recruited its 384 participants by a Subsequently, a significant number of health general email rather than a systematic approach, professionals called for a standard for eligi- and the degree and type of treatment was not bility for sex reassignment surgery. This led recorded. Study participants who were taking to the formulation of the original Standards testosterone had typically been doing so for less of Care of the Harry Benjamin International than 5 years. Reported quality of life was higher Gender Dysphoria Association (now WPATH)in for patients who had undergone breast/chest 1979. surgery than for those who had not (p < .001). In 1981, Pauly published results from a large (A similar analysis was not done for genital retrospective study of people who had undergone surgery). In other work, Kuhn and colleagues sex reassignment surgery. Participants in that (2009) used the King’s Health Questionnaire study had much better outcomes: Among 83 to assess the quality of life of 55 transsexual FtM patients, 80.7% had a satisfactory outcome patients at 15 years after surgery. Scores were (i.e., patient self report of “improved social compared to those of 20 healthy female control and emotional adjustment”), 6.0% unsatisfac- patients who had undergone abdominal/pelvic tory. Among 283 MtF patients, 71.4% had a surgery in the past. Quality of life scores for satisfactory outcome, 8.1% unsatisfactory. This transsexual patients were the same or better study included patients who were treated before than those of control patients for some sub- the publication and use of the Standards of Care. scales (emotions, sleep, incontinence, symptom Since the Standards of Care have been in severity, and role limitation), but worse in other place, there has been a steady increase in pa- domains (general health, physical limitation, and tient satisfaction and decrease in dissatisfaction personal limitation). with the outcome of sex reassignment surgery. Two long-term observational studies, both Studies conducted after 1996 focused on patients retrospective, compared the mortality and psy- who were treated according to the Standards of chiatric morbidity of transsexual adults to those 230 INTERNATIONAL JOURNAL OF TRANSGENDERISM of general population samples (Asscheman et al., those before 1986; this reflects significant im- 2011; Dhejne et al., 2011). An analysis of data provement in surgical complications (Eldh et al., from the Swedish National Board of Health 1997). Most patients have reported improved and Welfare information registry found that psychosocial outcomes, ranging between 87% individuals who had received sex reassignment for MtF patients and 97% for FtM patients surgery (191 MtF and 133 FtM) had significantly (Green & Fleming, 1990). Similar improve- higher rates of mortality, suicide, suicidal behav- ments were found in a Swedish study in which ior, and psychiatric morbidity than those for a “almost all patients were satisfied with sex nontranssexual control group matched on age, reassignment at 5 years, and 86% were assessed immigrant status, prior psychiatric morbidity, by clinicians at follow-up as stable or improved and birth sex (Dhejne et al., 2011). Similarly, a in global functioning” (Johansson, Sundbom, study in the Netherlands reported a higher total Hojerback,¨ & Bodlund, 2010). Weaknesses of mortality rate, including incidence of suicide, in these earlier studies are their retrospective de- both pre- and postsurgery transsexual patients sign and use of different criteria to evaluate (966 MtF and 365 FtM) than in the general outcomes. population of that country (Asscheman et al., A prospective study conducted in the Nether- 2011). Neither of these studies questioned the lands evaluated 325 consecutive adult and efficacy of sex reassignment; indeed, both lacked adolescent subjects seeking sex reassignment an adequate comparison group of transsexuals (Smith, Van Goozen, Kuiper, & Cohen-Kettenis, who either did not receive treatment or who 2005). Patients who underwent sex reassignment received treatment other than genital surgery. therapy (both hormonal and surgical interven- Moreover, transexual people in these studies tion) showed improvements in their mean gender were treated as far back as the 1970’s. However, dysphoria scores, measured by the Utrecht Gen- these findings do emphasize the need to have der Dysphoria Scale. Scores for body dissatisfac- good long-term psychological and psychiatric tion and psychological function also improved care available for this population. More studies in most categories. Fewer than 2% of patients are needed that focus on the outcomes of current expressed regret after therapy. This is the largest assessment and treatment approaches for gender prospective study to affirm the results from retro- dysphoria. spective studies that a combination of hormone It is difficult to determine the effectiveness of therapy and surgery improves gender dysphoria hormones alone in the relief of gender dysphoria. and other areas of psychosocial functioning. Most studies evaluating the effectiveness of There is a need for further research on the effects masculinizing/feminizing hormone therapy on of hormone therapy without surgery, and without gender dysphoria have been conducted with the goal of maximum physical feminization or patients who have also undergone sex reas- masculinization. signment surgery. Favorable effects of therapies Overall, studies have been reporting a steady that included both hormones and surgery were improvement in outcomes as the field becomes reported in a comprehensive review of over 2000 more advanced. Outcome research has mainly patients in 79 studies (mostly observational) focused on the outcome of sex reassignment conducted between 1961 and 1991 (Eldh, Berg, surgery. In current practice there is a range of & Gustafsson, 1997; Gijs & Brewaeys, 2007; identity, role, and physical adaptations that could Murad et al., 2010; Pfafflin¨ & Junge, 1998). use additional follow-up or outcome research Patients operated on after 1986 did better than (Institute of Medicine, 2011). Coleman et al. 231
APPENDIX E: DEVELOPMENT articles and additional recommendations that PROCESS FOR THE STANDARDS OF emanated from the online discussion—and (2) CARE, VERSION 7 create a survey to solicit further input on these potential revisions. From the survey results, the The process of developing Standards of Care, Writing Group was able to discern where these Version 7, began when an initial SOC “work experts stood in terms of areas of agreement and group” was established in 2006. Members were areas in need of more discussion and debate. The invited to examine specific sections of SOC, technical writer then (3) created a very rough first Version 6 . For each section, they were asked draft of SOC, Version 7, for the Writing Group to review the relevant literature, identify areas to consider and build on. where research was lacking and needed, and The Writing Group met on March 4 and 5, recommend potential revisions to the SOC as 2011, in a face-to-face expert consultation meet- warranted by new evidence. Invited papers were ing. They reviewed all recommended changes submitted by the following authors: Aaron De- and debated and came to consensus on various vor, Walter Bockting, George Brown, Michael controversial areas. Decisions were made based Brownstein, Peggy Cohen-Kettenis, Griet De- on the best available science and expert con- Cuypere, Petra De Sutter, Jamie Feldman, Lin sensus. These decisions were incorporated into Fraser, Arlene Istar Lev, Stephen Levine, Walter the draft, and additional sections were written Meyer, Heino Meyer-Bahlburg, Stan Monstrey, by the Writing Group with the assistance of the Loren Schechter, Mick van Trotsenburg, Sam technical writer. Winter, and Ken Zucker. Some of these authors The draft that emerged from the consulta- chose to add coauthors to assist them in their tion meeting was then circulated among the task. Writing Group and finalized with the help of Initial drafts of these papers were due June 1, the technical writer. Once this initial draft was 2007. Most were completed by September 2007, finalized it was circulated among the broader with the rest completed by the end of 2007. SOC Revision Committee and the International These manuscripts were then submitted to the Advisory Group. Discussion was opened up International Journal of Transgenderism (IJT). on the Google website and a conference call Each underwent the regular IJT peer review was held to resolve issues. Feedback from process. The final papers were published in these groups was considered by the Writing Volume 11 (1–4) in 2009, making them available Group, who then made further revisions. Two for discussion and debate. additional drafts were created and posted on the After these articles were published, an SOC Google website for consideration by the broader Revision Committee was established by the SOC Revision Committee and the International WPATH Board of Directors in 2010. The Advisory Group. Upon completion of these Revision Committee was first charged with three iterations of review and revision, the final debating and discussing the IJT background document was presented to the WPATH Board of papers through a Google website. A subgroup Directors for approval. The Board of Directors of the Revision Committee was appointed by the approved this version on September 14, 2011. Board of Directors to serve as the Writing Group. This group was charged with preparing the first draft of SOC, Version 7, and continuing to work Funding on revisions for consideration by the broader Revision Committee. The Board also appointed The Standards of Care revision process was an International Advisory Group of transsexual, made possible through a generous grant from transgender, and gender-nonconforming indi- the Tawani Foundation and a gift from an viduals to give input on the revision. anonymous donor. These funds supported the A technical writer was hired to (1) review all following: of the recommendations for revision—both the original recommendations as outlined in the IJT 1. Costs of a professional technical writer; 232 INTERNATIONAL JOURNAL OF TRANSGENDERISM
2. Process of soliciting international input Blaine Paxton Hall, MHS-CL, PA-C (USA) on proposed changes from gender identity Friedmann Pfafflin,¨ MD, PhD (Germany) professionals and the transgender commu- Katherine Rachlin, PhD (USA) nity; Bean Robinson, PhD (USA) 3. Working meeting of the Writing Group; Loren Schechter, MD (USA) 4. Process of gathering additional feedback Vin Tangpricha, MD, PhD (USA) and arriving at final expert consensus from Mick van Trotsenburg, MD (Netherlands) the professional and transgender commu- Anne Vitale, PhD (USA) nities, the Standards of Care, Version 7, Sam Winter, PhD (Hong Kong) Revision Committee, and WPATH Board Stephen Whittle, OBE (UK) of Directors; Kevan Wylie, MB, MD (UK) 5. Costs of printing and distributing Stan- Ken Zucker, PhD (Canada) dards of Care, Version 7, and posting a free downloadable copy on the WPATH International Advisory Group Selection website; Committee 6. Plenary session to launch the Standards of Care, Version 7, at the 2011 WPATH Walter Bockting, PhD (USA) Biennial Symposium in Atlanta, Georgia, Marsha Botzer, MA (USA) USA. Aaron Devor, PhD (Canada) Randall Ehrbar, PsyD (USA) Members of the Standards of Care Evan Eyler, MD (USA) Revision Committee† Jamison Green, PhD, MFA (USA) Blaine Paxton Hall, MHS-CL, PA (USA) Eli Coleman, PhD (USA)∗—Committee chair Richard Adler, PhD (USA) International Advisory Group Walter Bockting, PhD (USA)∗ ∗ Marsha Botzer, MA (USA) Tamara Adrian, LGBT Rights Venezuela George Brown, MD (USA) (Venezuela) ∗ Peggy Cohen-Kettenis, PhD (Netherlands) Craig Andrews, FTM Australia (Australia) ∗ Griet DeCuypere, MD (Belgium) Christine Burns, MBE, Plain Sense Ltd (UK) Aaron Devor, PhD (Canada) Naomi Fontanos, Society for Transsexual Randall Ehrbar, PsyD (USA) Women’s Rights in the Phillipines (Phillipines) Randi Ettner, PhD (USA) Tone Marie Hansen, Harry Benjamin Re- Evan Eyler, MD (USA) source Center (Norway) ∗ Jamie Feldman, MD, PhD (USA) Rupert Raj, Shelbourne Health Center ∗ Lin Fraser, EdD (USA) (Canada) Rob Garofalo, MD, MPH (USA) Masae Torai, FTM Japan (Japan) ∗ Jamison Green, PhD, MFA (USA) Kelley Winters, GID Reform Advocates Dan Karasic, MD (USA) (USA) Gail Knudson, MD (Canada)∗ Arlene Istar Lev, LCSW-R (USA) Technical Writer Gal Mayer, MD (USA) WalterMeyer,MD(USA)∗ Anne Marie Weber-Main, PhD (USA) Heino Meyer-Bahlburg, Dr. rer.nat. (USA) Editorial Assistance Stan Monstrey, MD, PhD (Belgium)∗ Heidi Fall (USA) ∗Writing Group member †All members of the Standards of Care, Version 7, Revision Committee donated their time to work on this revision.