Difference between revisions of "Summary of SOC version 8"

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18.9- We recommend health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people.<br>
 
18.9- We recommend health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people.<br>
 
18.10- We recommend “reparative” and “conversion” therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered.<br>
 
18.10- We recommend “reparative” and “conversion” therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered.<br>
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{{EN|Social support is probably the most important part of mental health that doesn't involve identification and resolving of non-gender identity issues. Likewise if the client is facing housing or food insecurity, having free access to HCP's is going to have limited value. The role of so-called gatekeeping being reduced is appreciated, but old guidelines die hard in countries that require a trans person to go to university hospital in order for national healthcare scheme to cover services available.}}
  
 
==Footnotes==
 
==Footnotes==
 
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Revision as of 12:57, 20 September 2022

  • Editor's Note: Due to the nature of creating a consolidated version of the Standards of Care, some editorial liberties have been utilized to describe the content.


CHAPTER 1 Terminology

1.1- We recommend health care professionals use culturally relevant language (including terms to describe transgender and gender diverse people) when applying the standards of Care in different global settings.
1.2- We recommend health care professionals use language in health care settings that uphold the principles of safety, dignity, and respect.
1.3- We recommend health care professionals discuss with transgender and gender diverse people what language or terminology they prefer.

  • Editor's Note: While the term "gender incongruence" might be the most accurate way to describe the mind-body disconnect, this does not translate very well to non-english languages; thus local terms are preferred because the client population may better understand them. This doesn't address issues of healthcare literacy but that's an issue not exclusive to gender and sexual minorities.

CHAPTER 2 Global Applicability

2.1- We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.
2.2- We recommend health care professionals and other users of the Standards of Care, Version 8 (SOC-8) apply the recommendations in ways that meet the needs of local transgender and gender diverse communities, by providing culturally sensitive care that recognizes the realities of the countries they are practicing in.
2.3- We recommend health care providers understand the impact of social attitudes, laws, economic circumstances, and health systems on the lived experiences of transgender and gender diverse people worldwide.
2.4- We recommend translations of the SOC focus on cross-cultural, conceptual, and literal equivalence to ensure alignment with the core principles that underpin the SOC-8.
2.5- We recommend health care professionals and policymakers always apply the SOC-8 core principles to their work with transgender and gender diverse people to ensure respect for human rights and access to appropriate and competent health care, including:

General principles

  • Be empowering and inclusive. Work to reduce stigma and facilitate access to appropriate health care for all who seek it;
  • Respect diversity. Respect all clients and all gender identities. Do not pathologize differences in gender identity or expression;
  • Respect universal human rights including the right to bodily and mental integrity, autonomy and self-determination; freedom from discrimination, and the right to the highest attainable standard of health.

Principles around developing and implementing appropriate services and accessible health care

  • Involve transgender and gender diverse people in the development and implementation of services;
  • Become aware of social, cultural, economic, and legal factors that might impact the health (and health care needs) of transgender and gender diverse people, as well as the willingness and the capacity of the person to access services;
  • Provide health care (or refer to knowledgeable colleagues) that affirms gender identities and expressions, including health care that reduces the distress associated with gender dysphoria (if this is present);
  • Reject approaches that have the goal or effect of conversion and avoid providing any direct or indirect support for such approaches or services.

Principles around delivering competent services

  • Become knowledgeable (get training, where possible) about the health care needs of transgender and gender diverse people, including the benefits and risks of gender-affirming care;
  • Match the treatment approach to the specific needs of clients, particularly their goals for gender identity and expression;
  • Focus on promoting health and well-being rather than solely the reduction of gender dysphoria, which may or may not be present;
  • Commit to harm reduction approaches where appropriate;
  • Enable the full and ongoing informed participation of transgender and gender diverse people in decisions about their health and well-being;
  • Improve experiences of health services including those related to administrative systems and continuity of care.

Principles around working towards improved health through wider community approaches

  • Put people in touch with communities and peer support networks;
  • Support and advocate for clients within their families and communities (schools, workplaces, and other settings) where appropriate.
  • Editor's Note: While a vast improvement towards acknowledging that not everyone is in NA/West Europe, SOC 8 falls short on advocating for access to healthcare services in general (given parts of the world which have limitations in ability to operate a clinic - due to laws that are hostile against women and minority populations). The topic of 3rd party payers (insurance) or national healthcare scheme also avoids that the SOC is not a legally binding document in terms of ensuring that services that contribute to quality of life are covered at all (or if the client will need to pay cash).

CHAPTER 3 Population Estimates

Summary of reported proportions of TGD people in the general population
Health systems-based studies: 0.02–0.1%
Survey-based studies of adults: 0.3–0.5% (transgender), 0.3–4.5% (all TGD)
Survey-based studies of children and adolescents: 1.2–2.7% (transgender), 2.5–8.4% (all TGD)

  • Editor's Note: Studies will likely always be inaccurate because of the varying degree of openness to admitting for some degree of change to the physical body or gender expression. Likewise, the minority of the minority who regrets their choice to undergo permanent interventions will be difficult to put into numbers due to the nature of politically motivated anti-trans people and groups.

CHAPTER 4 Education

4.1- We recommend all personnel working in governmental, nongovernmental, and private agencies receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity and respect.
4.2- We recommend all members of the health care workforce receive cultural-awareness training focused on treating transgender and gender diverse individuals with dignity during orientation and as part of annual or continuing education.
4.3- We recommend institutions involved in the training of health professionals develop competencies and learning objectives for transgender and gender diverse health within each of the competency areas for their specialty.

  • Editor's Note: This section feels like it needs the most attention due to differing populations when referring to "education" as a general topic. Professional (HCP) training is best addressed with UpToDate or a PIE (Problem, Intervention, Evaluation) based encounter checklist, while mental health and social services are going to lean more on socioeconomic and diversity training. Government sector and corporate training is going to depend heavily on local attitudes and beliefs about gender and sexual minorities. Educating community members through the *mere-exposure effect* can help reduce hostilities although increasing the number of LGBT advocates is best done through other means [1]

CHAPTER 5 Assessment of Adults

5.1- We recommend health care professionals assessing transgender and gender diverse adults for physical treatments:
5.1.a- Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
5.1.b- For countries requiring a diagnosis for access to care, the health care professional should be competent using the latest edition of the World Health Organization's International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilize the latest ICD as soon as practicable.
5.1.c- Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
5.1.d- Are able to assess capacity to consent for treatment.
5.1.e- Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
5.1.f- Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
5.2- We suggest health care professionals assessing transgender and gender diverse adults seeking gender-affirming treatment liaise with professionals from different disciplines within the field of transgender health for consultation and referral, if required.

  • Editor's Note: This list for HCP's feels like it was written by Captain Obvious in that the provider needs to be professionally trained, and can document the informed consent process in the legal sense of the term, rather than the community meaning of unfettered access to medical interventions. The topic of identifying and managing co-morbid conditions is a potential choke point to delivering healthcare services where a patient may be referred to psych services inappropriately, with the unspoken understanding that the majority of mental health practitioners cannot legally manage their client's psych meds, not less prescribe new drugs or order labs to monitor drug effects.

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (all should be met): 5.3- We recommend health care professionals assessing transgender and gender diverse adults for gender-affirming medical and surgical treatment:
5.3.a- Only recommend gender-affirming medical treatment requested by a TGD person when the experience of gender incongruence is marked and sustained.
5.3.b- Ensure fulfillment of diagnostic criteria prior to initiating gender-affirming treatments in regions where a diagnosis is necessary to access health care.
5.3.c- Identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments.
5.3.d- Ensure that any mental health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.
5.3.e- Ensure any physical health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment.
5.3.f- Assess the capacity to consent for the specific physical treatment prior to the initiation of this treatment.
5.3.g- Assess the capacity of the gender diverse and transgender adult to understand the effect of gender-affirming treatment on reproduction and explore reproductive options with the individual prior to the initiation of gender-affirming treatment.
5.4- We suggest, as part of the assessment for gender-affirming hormonal or surgical treatment, professionals who have competencies in the assessment of transgender and gender diverse people wishing gender-related medical treatment consider the role of social transition together with the individual.
5.5- We recommend transgender and gender diverse adults who fulfill the criteria for gender-affirming medical and surgical treatment require a single opinion for the initiation of this treatment from a professional who has competencies in the assessment of transgender and gender diverse people wishing gender-related medical and surgical treatment.
5.6- We suggest health care professionals assessing transgender and gender diverse people seeking gonadectomy consider a minimum of 6 months of hormone therapy as appropriate to the TGD person’s gender goals before the TGD person undergoes irreversible surgical intervention (unless hormones are not clinically indicated for the individual).
5.7- We recommend health care professionals assessing adults who wish to detransition and seek gender-related hormone intervention, surgical intervention, or both, utilize a comprehensive multidisciplinary assessment that will include additional viewpoints from experienced health care professional in transgender health and that considers, together with the individual, the role of social transition as part of the assessment process.

  • Editor's Note: The elimination of a second referral letter for surgical transition options is a significant improvement due to the lack of evidence regarding second opinions. SOC 8 however, does not state if the "opinion"/referral letter will need to be worded to explicitly recommend medical intervention, as is the case with a famous American surgeon's current requirement to take new patients. The reduction of time on HRT before genital surgery may warrant more study to confirm positive effect. This is likely not going to have a perfect solution as less time might increase the regret rate from clients who have unrealistic body image or long term goals, but more time will alienate clients who might benefit from getting medical interventions done sooner than later. Finally, the subject of detransition is a touchy one because of anti-trans lobbying exaggerating the effect of surgical intervention while neglecting the role that lack of social support has on clients who revert to assigned at birth gender.

CHAPTER 6 Adolescents

6.1- We recommend health care professionals working with gender diverse adolescents:
6.1.a- Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
6.1.b- Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
6.1.c- Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
6.1.d- Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
6.1.e- Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.
6.2- We recommend health care professionals working with gender diverse adolescents facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favored.
6.3- We recommend health care professionals working with gender diverse adolescents undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, and that this be accomplished in a collaborative and supportive manner.
6.4- We recommend health care professionals work with families, schools, and other relevant settings to promote acceptance of gender diverse expressions of behavior and identities of the adolescent.
6.5- We recommend against offering reparative and conversion therapy aimed at trying to change a person’s gender and lived gender expression to become more congruent with the sex assigned at birth.
6.6- We suggest health care professionals provide transgender and gender diverse adolescents with health education on chest binding and genital tucking, including a review of the benefits and risks.
6.7- We recommend providers consider prescribing menstrual suppression agents for adolescents experiencing gender incongruence who may not desire testosterone therapy, who desire but have not yet begun testosterone therapy, or in conjunction with testosterone therapy for breakthrough bleeding.
6.8- We recommend health care professionals maintain an ongoing relationship with the gender diverse and transgender adolescent and any relevant caregivers to support the adolescent in their decision-making throughout the duration of puberty suppression treatment, hormonal treatment, and gender- related surgery until the transition is made to adult care.
6.9- We recommend health care professionals involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for gender diverse and transgender adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care.
6.10- We recommend health care professionals working with transgender and gender diverse adolescents requesting gender-affirming medical or surgical treatments inform them, prior to initiating treatment, of the reproductive effects including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development.
6.11- We recommend when gender-affirming medical or surgical treatments are indicated for adolescents, health care professionals working with transgender and gender diverse adolescents involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible.

  • Editor's Note: The above guidelines are another good improvement over the previous SOC. While the suggestion of hormone and surgical intervention is a step forward, the role of puberty suppression as a diagnosis aid should be encouraged in cases where the client (teenager) mental health history (documentation) is unknown. This may conflict with local practice beliefs that prevent trans youth from obtaining permanent interventions until they are age of independent medical decisions. The cost of preserving reproductive options might also deter some clients. Specifically mentioning autism spectrum is problematic due to the issues present in the population that may negatively impact an encounter (bias by provider, or the client who threatens self harm to obtain hormone therapy) [2]

The following recommendations are made regarding the requirements for gender-affirming medical and surgical treatment (All of them must be met):

6.12- We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when:
6.12.a- The adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access health care. In countries that have not implemented the latest ICD, other taxonomies may be used although efforts should be undertaken to utilize the latest ICD as soon as practicable.
6.12.b- The experience of gender diversity/incongruence is marked and sustained over time.
6.12.c- The adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment.
6.12.d- The adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.
6.12.e- The adolescent has been informed of the reproductive effects, including the potential loss of fertility and the available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development.
6.12.f- The adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated.
6.12.g- The adolescent had at least 12 months of gender-affirming hormone therapy or longer, if required, to achieve the desired surgical result for gender-affirming procedures, including breast augmentation, orchiectomy, vaginoplasty, hysterectomy, phalloplasty, metoidioplasty, and facial surgery as part of gender-affirming treatment unless hormone therapy is either not desired or is medically contraindicated.

  • Editor's Note: The last two statements are likely err on the side of caution. Prolonged puberty suppression (more than 2 years before start of cross-sex hormone therapy) is not likely to contribute to positive outcomes the same way as holding on surgical intervention will to ensure that the client is well aware of the effect to their adult life. Addressing this necessitates effective interdiscipline communication in order to have a rough timeline of the client's progress towards self understanding (and to know if treatment should be accelerated, or delayed to address issues that threaten well being).

CHAPTER 7 Children

7.1- We recommend health care professionals working with gender diverse children receive training and have expertise in gender development and gender diversity in children and possess a general knowledge of gender diversity across the life span.
7.2- We recommend health care professionals working with gender diverse children receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum.
7.3- We recommend health care professionals working with gender diverse children receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children.
7.4- We recommend health care professionals working with gender diverse children engage in continuing education related to gender diverse children and families.
7.5- We recommend health care professionals conducting an assessment with gender diverse children access and integrate information from multiple sources as part of the assessment.
7.6- We recommend health care professionals conducting an assessment with gender diverse children consider relevant developmental factors, neurocognitive functioning, and language skills.
7.7- We recommend health care professionals conducting an assessment with gender diverse children consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s).
7.8- We recommend health care professionals consider consultation, psychotherapy, or both for a gender diverse child and family/caregivers when families and health care professionals believe this would benefit the well-being and development of a child and/or family.
7.9- We recommend health care professionals offering consultation, psychotherapy, or both to gender diverse children and families/caregivers work with other settings and individuals important to the child to promote the child's resilience and emotional well-being.
7.10- We recommend health care professionals offering consultation, psychotherapy, or both to gender diverse children and families/caregivers provide both parties with age-appropriate psychoeducation about gender development.
7.11- We recommend that health care professionals provide information to gender diverse children and their families/caregivers as the child approaches puberty about potential gender affirming medical interventions, the effects of these treatments on future fertility, and options for fertility preservation.
7.12- We recommend parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity.
7.13- We recommend health care professionals and parents/caregivers support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition.
7.14- We recommend the health care professionals discuss the potential benefits and risks of a social transition with families who are considering it.
7.15- We suggest health care professionals consider working collaboratively with other professionals and organizations to promote the well-being of gender diverse children and minimize the adversities they may face.

  • Editor's Note: All solid recommendations given pre-teen trans youth interventions will not involve medical therapies. Exploring the client's identity and developing the language skills to communicate their mental state and body image is the groundwork to figuring out if presentation/social changes are good enough or if the child will progress medically. The biggest barrier to services (without regard to future interventions) is likely to be the parent/guardian themselves either refusing to accept that their child is trans spectrum, questioning, or gender non-conforming; or being overly permissive (and not encouraging the child to understand themselves). The costs associated with healthcare services in this population are less an issue than access to properly trained HCP's.

CHAPTER 8 Nonbinary

8.1- We recommend health care professionals provide nonbinary people with individualized assessment and treatment that affirms their experience of gender.
8.2- We recommend health care professionals consider gender-affirming medical interventions (hormonal treatment or surgery) for nonbinary people in the absence of “social gender transition.”
8.3- We recommend health care professionals consider gender-affirming surgical interventions in the absence of hormonal treatment, unless hormone therapy is required to achieve the desired surgical result.
8.4- We recommend health care professionals provide information to nonbinary people about the effects of hormonal therapies/surgery on future fertility and discuss the options for fertility preservation prior to starting hormonal treatment or undergoing surgery.

  • Editor's Note: Nonbinary and gender non-conforming clients should not require different treatment from a male/female identified client. Social attitudes about the nature of gender identity can influence the ability for the client to understand their own needs, assuming there are words (in the spoken or written language) they can use to describe their sense of self. Access to HCP services in general may be the biggest issue.

CHAPTER 9 Eunuchs

9.1- We recommend health care professionals and other users of the Standards of Care 8th guidelines should apply the recommendations in ways that meet the needs of eunuch individuals
9.2- We recommend health care professionals should consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones.
9.3- We recommend health care professionals who are assessing eunuch individuals for treatment have demonstrated competency in assessing them.
9.4- We suggest health care professionals providing care to eunuch individuals include sexuality education and counseling.

  • Editor's Note: This could be a copy paste of guidelines to help nonbinary people but will be more influenced by social and religious beliefs. Gender-null or similar terms for rejecting the body may not translate very well in societies that already question the validity of self reported gender identity. In that case access to HCP will be the least of their problems.

CHAPTER 10 Intersex

10.1- We suggest a multidisciplinary team, knowledgeable in diversity of gender identity and expression as well as in intersexuality, provide care to individuals with intersexuality and their families.
10.2- We recommend health care professionals providing care for transgender youth and adults seek training and education in the aspects of intersex care relevant to their professional discipline.
10.3- We suggest health care professionals educate and counsel families of children with intersexuality from the time of diagnosis onward about the child’s specific intersex condition and its psychosocial implications.
10.4- We suggest both providers and parents engage children/individuals with intersexuality in ongoing, developmentally appropriate communications about their intersex condition and its psychosocial implications.
10.5- We suggest health care professionals and parents support children/individuals with intersexuality in exploring their gender identity throughout their life.
10.6- We suggest health care professionals promote well-being and minimize the potential stigma of having an intersex condition by working collaboratively with both medical and non-medical individuals/organizations.
10.7- We suggest health care professionals refer children/individuals with intersexuality and their families to mental-health providers as well as peer and other psychosocial supports as indicated.
10.8- We recommend health care professionals counsel individuals with intersexuality and their families about puberty suppression and/or hormonal treatment options within the context of the individual's gender identity, age, and unique medical circumstances.
10.9- We suggest health care professionals counsel parents and children with intersexuality (when cognitively sufficiently developed) to delay gender-affirming genital surgery, gonadal surgery, or both, so as to optimize the children’s self-determination and ability to participate in the decision based on informed consent.
10.10- We suggest only surgeons experienced in intersex genital or gonadal surgery operate on individuals with intersexuality.
10.11- We recommend health care professionals who are prescribing or referring for hormonal therapies/surgeries counsel individuals with intersexuality and fertility potential and their families about a) known effects of hormonal therapies/surgery on future fertility; b) potential effects of therapies that are not well studied and are of unknown reversibility; c) fertility preservation options; and d) psychosocial implications of infertility.
10.12- We suggest health care professionals caring for individuals with intersexuality and congenital infertility introduce them and their families, early and gradually, to the various alternative options of parenthood.

  • Editor's Note: It feels like it should not need be stated that forced gender assignment shortly after live birth (in an infant presenting with a disorder of sexual development or ambiguous genitalia) should not be performed. Comorbid conditions such as bladder exstrophy should be corrected but conditions like streak gonads should be monitored. Social pressure to conform (to gender binary) is likely the biggest non-medical issue.

CHAPTER 11 Institutional Environments

11.1- We recommend health care professionals responsible for providing gender-affirming care to individuals residing in institutions (or associated with institutions or agencies) recognize the entire list of recommendations of the SOC-8 apply equally to people living in institutions.
11.2- We suggest institutions provide all staff with training on gender diversity.
11.3- We recommend medical professionals charged with prescribing and monitoring hormones for TGD individuals living in institutions who need gender-affirming hormone therapy do so without undue delay and in accordance with the SOC-8.
11.4- We recommend staff and professionals charged with providing health care to TGD individuals living in institutions recommend and support gender-affirming surgical treatments in accordance with the SOC-8 when sought by the individual, without undue delay.
11.5- We recommend administrators, health care professionals, and all others working in institutions charged with the responsibility of caring for TGD individuals allow those individuals who request appropriate clothing and grooming items to obtain such items concordant with their gender expression.
11.6- We recommend all institutional staff address TGD individuals by their chosen names and pronouns at all times.
11.7- We recommend institutional administrators, health care professionals, and other officials responsible for making housing decisions for TGD residents consider the individual’s housing preference, gender identity and expression, and safety considerations rather than solely their anatomy or sex assignment at birth.
11.8- We recommend institutional personnel establish housing policies that ensure the safety of TGD residents without segregating or isolating these individuals.
11.9- We recommend institutional personnel allow TGD residents the private use of shower and toilet facilities upon request.

  • Editor's Note: Access to mental health services in order to start transition while incarcerated or otherwise as a ward of the state is going to depend on the state's policy. Needless to say if they ration healthcare to staffing issues, providing a trans inmate with private toilet/bathing facilities without resorting to placing them in seg is going to be difficult.

CHAPTER 12 Hormone Therapy

12.1- We recommend health care professionals begin pubertal hormone suppression in eligible* transgender and gender diverse adolescents after they first exhibit physical changes of puberty (Tanner stage 2).
12.2- We recommend health care professionals use gonadotropin releasing hormone (GnRH) agonists to suppress endogenous sex hormones in eligible* transgender and gender diverse people for whom puberty blocking is indicated.
12.3- We suggest health care professionals prescribe progestins (oral or injectable depot) for pubertal suspension in eligible* transgender and gender diverse youth when GnRH agonists are either not available or are cost prohibitive.
12.4- We suggest health care professionals prescribe GnRH agonists for suppression of sex steroids without concomitant sex steroid hormone replacement in eligible* transgender and gender diverse adolescents seeking such intervention and who are well into or have completed pubertal development (past Tanner stage 3) but are either unsure about or do not want to begin sex steroid hormone therapy.
12.5- We recommend health care professionals prescribe sex hormone treatment regimens as part of gender-affirming treatment for eligible* transgender and gender diverse adolescents who are at least Tanner stage 2, with parental/guardian involvement unless their involvement is determined to be harmful or unnecessary to the adolescent.
12.6- We recommend health care professionals measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at levels appropriate for the treatment goals of transgender and gender diverse people according to the Tanner stage.
12.7- We recommend health care professionals prescribe progestogens or a GnRH agonist for eligible* transgender and gender diverse adolescents with a uterus to reduce dysphoria caused by their menstrual cycle when gender-affirming testosterone use is not yet indicated.
12.8- We recommend health care providers involve professionals from multiple disciplines who are experts in transgender health and in the management of the care required for transgender and gender diverse adolescents.
12.9- We recommend health care professionals institute regular clinical evaluations for physical changes and potential adverse reactions to sex steroid hormones, including laboratory monitoring of sex steroid hormones every 3 months during the first year of hormone therapy or with dose changes until stable adult dosing is reached followed by clinical and laboratory testing once or twice a year once an adult maintenance dose is attained.

  • Editor's Note: For AMAB clients, more estrogen does not mean more better if the body produces SHBG in response to orally administered hormones. Suppression of androgens is more effective [3].

12.10- We recommend health care professionals inform and counsel all individuals seeking gender-affirming medical treatment about the options available for fertility preservation prior to initiating puberty suppression and prior to treating with hormone therapy.
12.11- We recommend health care professionals evaluate and address medical conditions that can be exacerbated by lowered endogenous sex hormone concentrations and treatment with exogenous sex hormones before beginning treatment for transgender and gender diverse people.
12.12- We recommend health care professionals educate transgender and gender diverse people undergoing gender-affirming treatment about the onset and time course of the physical changes induced by sex hormonal treatment.
12.13- We recommend health care professionals not prescribe ethinyl estradiol for transgender and gender diverse people as part of a gender-affirming hormonal treatment.
12.14- We suggest health care professionals prescribe transdermal estrogen for eligible* transgender and gender diverse people at higher risk of developing venous thromboembolism based on age > 45 years or a previous history of venous thromboembolism, when gender-affirming estrogen treatment is recommended.
12.15- We suggest health care professionals not prescribe conjugated estrogens in transgender and gender diverse people when estradiol is available as a component of gender-affirming hormonal treatment.
12.16- We recommend health care professionals prescribe testosterone-lowering medications (either cyproterone acetate, spironolactone, or GnRH agonists) for eligible* transgender and gender diverse people with testes who are taking estrogen as part of a hormonal treatment plan if the individual’s goal is to approximate circulating sex hormone concentrations in cisgender women.
12.17- We recommend health care professionals monitor hematocrit (or hemoglobin) in transgender and gender diverse people treated with testosterone.
12.18- We suggest health care professionals collaborate with surgeons regarding hormone use before and after gender-affirmation surgery.
12.19- We suggest health care professionals counsel transgender and gender diverse people about the various options available for gender-affirmation surgery unless surgery is not indicated or is medically contraindicated.
12.20- We recommend health care professionals initiate and continue gender-affirming hormone therapy for eligible* transgender and gender diverse people who require this treatment due to demonstrated improvement in psychosocial functioning and quality of life.
12.21- We recommend health care professionals maintain existing hormone therapy if the transgender and gender diverse individual's mental health deteriorates and assess the reason for the deterioration, unless contraindicated.

  • Editor's Note: The big take away is to continue hormone therapy before genital surgery unless there's documented risk of a thrombosis related event. After all, it's not like one can tell cis-women to turn their ovaries off before elective surgery. This is likely dependent on access to safe hormone options especially in populations who are at risk of self medicating with birth control pills.

CHAPTER 13 Surgery and Postoperative Care

13.1- We recommend surgeons who perform gender-affirming surgical procedures have the following credentials:
13.1.a- Training and documented supervision in gender-affirming procedures;
13.1.b- Maintenance of an active practice in gender-affirming surgical procedures;
13.1.c- Knowledge about gender diverse identities and expressions;
13.1.d- Continuing education in the field of gender-affirmation surgery
13.1.e- Tracking of surgical outcomes.
13.2- We recommend surgeons assess transgender and gender diverse people for risk factors associated with breast cancer prior to breast augmentation or mastectomy.
13.3- We recommend surgeons inform transgender and gender diverse people undergoing gender-affirming surgical procedures about aftercare requirements, travel and accommodations, and the importance of postoperative follow-up during the preoperative process.
13.4- We recommend surgeons confirm reproductive options have been discussed prior to gonadectomy in transgender and gender diverse people.
13.5- We suggest surgeons consider offering gonadectomy to eligible* transgender and gender diverse adults when there is evidence they have tolerated a minimum of 6 months of hormone therapy (unless hormone replacement therapy or gonadal suppression is not clinically indicated or the procedure is inconsistent with the patient's desires, goals, or expressions of individual gender identity).
13.6- We suggest health care professionals consider gender-affirming genital procedures for eligible* transgender and gender diverse adults seeking these interventions when there is evidence the individual has been stable on their current treatment regime (which may include at least 6 months of hormone treatment or a longer period if required to achieve the desired surgical result, unless hormone therapy is either not desired or is medically contraindicated).
13.7- We recommend surgeons consider gender-affirming surgical interventions for eligible* transgender and gender diverse adolescents when there is evidence a multidisciplinary approach that includes mental health and medical professionals has been involved in the decision-making process.
13.8- We recommend surgeons consult a comprehensive, multidisciplinary team of professionals in the field of transgender health when eligible* transgender and gender diverse people request individually customized (previously termed “non-standard”) surgeries as part of a gender-affirming surgical intervention.
13.9- We suggest surgeons caring for transgender men and gender diverse people who have undergone metoidioplasty/phalloplasty encourage lifelong urological follow-up.
13.10- We recommend surgeons caring for transgender women and gender diverse people who have undergone vaginoplasty encourage follow-up with their primary surgeon, primary care physician, or gynecologist.
13.11- We recommend patients who regret their gender-related surgical intervention be managed by an expert multidisciplinary team.

  • Editor's Note: This chapter feels like it focuses too much on maintaining medical bureaucracy in which the process goes from mental health referral to PCP to specialist to mental health (again) to surgeon, rather than effectively communicate findings of prior encounters. The need for local followup visits goes hand in hand with access to transition services in general, especially in HCP specialties that may be depended on for non-complex monitoring. The state of surgical options for AFAB clients needs a great deal of development, notably in the case of the use of algorithms for determining appropriate chest surgery (given the volume of material to remove); and to advance genital surgery by restarting attempts to create lab grown analogs to erectile tissue and bucks fascia (in the construction of a functional penis).

CHAPTER 14 Voice and Communication

14.1- We recommend voice and communication specialists assess current and desired vocal and communication function of transgender and gender diverse people and develop appropriate intervention plans for those dissatisfied with their voice and communication.
14.2- We recommend voice and communication specialists working with transgender and gender diverse people receive specific education to develop expertise in supporting vocal functioning, communication, and well-being in this population.
14.3- We recommend health care professionals in transgender health working with transgender and gender diverse people who are dissatisfied with their voice or communication consider offering a referral to voice and communication specialists for voice-related support, assessment, and training.
14.4- We recommend health care professionals consider working with transgender and gender diverse people who are considering undergoing voice surgery consider offering a referral to a voice and communication specialist who can provide pre- and/or postoperative support.
14.5- We recommend health care professionals in transgender health inform transgender and gender diverse people commencing testosterone therapy of the potential and variable effects of this treatment on voice and communication.

  • Editor's Note: Recommendations regarding voice altering interventions are limited because of the general lack of availability of voice pathology services in order to avoid surgical intervention for AMAB persons (along with difficulty of accessing surgical options). AFAB people are more likely to need assistance in using their testosterone changed voice than interventions to reduce the pitch/tone further.

CHAPTER 15 Primary Care

15.1- We recommend health care professionals obtain a detailed medical history from transgender and gender diverse people that includes past and present use of hormones, gonadal surgeries, as well as the presence of traditional cardiovascular and cerebrovascular risk factors with the aim of providing regular cardiovascular risk assessment according to established, locally used guidelines.
15.2- We recommend health care professionals assess and manage cardiovascular health in transgender and gender diverse people using a tailored risk factor assessment and cardiovascular/cerebrovascular management methods.
15.3- We recommend health care professionals tailor sex-based risk calculators used for assessing medical conditions to the needs of transgender and gender diverse people, taking into consideration the length of hormone use, dosing, serum hormone levels, current age, and the age at which hormone therapy was initiated.
15.4- We recommend health care professionals counsel transgender and gender diverse people about their tobacco use and advise tobacco/nicotine abstinence prior to gender-affirming surgery.
15.5- We recommend health care professionals discuss and address aging-related psychological, medical, and social concerns with transgender and gender diverse people.
15.6- We recommend health care professionals follow local breast cancer screening guidelines developed for cisgender women in their care of transgender and gender diverse people who have received estrogens, taking into consideration the length of time of hormone use, dosing, current age, and the age at which hormones were initiated.
15.7- We recommend health care professionals follow local breast cancer screening guidelines developed for cisgender women in their care of transgender and gender diverse people with breasts from natal puberty who have not had gender-affirming chest surgery.
15.8- We recommend health care professionals apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of transgender and gender diverse people who have the same risks.
15.9- We recommend against routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer for transgender and gender diverse people undergoing testosterone treatment and who have an otherwise average risk of malignancy.
15.10- We recommend health care professionals offer cervical cancer screening to transgender and gender diverse people who currently have or previously had a cervix following local guidelines for cisgender women.
15.11- We recommend health care professionals counsel transgender and gender diverse people that the use of antiretroviral medications is not a contraindication to gender-affirming hormone therapy.
15.12- We recommend health care professionals obtain a detailed medical history from transgender and gender diverse people that includes past and present use of hormones, gonadal surgeries as well as the presence of traditional osteoporosis risk factors to assess the optimal age and necessity for osteoporosis screening.
15.13- We recommend health care professionals discuss bone health with transgender and gender diverse people including the need for active weight bearing exercise, healthy diet, calcium, and vitamin D supplementation.
15.14- We recommend health care professionals offer transgender and gender diverse people referrals for hair removal from the face, body, and genital areas for gender-affirmation or as part of a preoperative preparation process.

  • Editor's Note: All good stuff. Affordability/access to permanent facial hair removal services is an obstacle to many trans people given 3rd party payers/insurance is likely to treat it as cosmetic/non covered unless explicitly required for surgical prep.

CHAPTER 16 Reproductive Health

16.1- We recommend health care professionals who are treating transgender and gender diverse people and prescribing or referring patients for hormone therapies/surgeries advise their patients about:
16.1.a- Known effects of hormone therapies/surgery on future fertility;
16.1.b- Potential effects of therapies that are not well studied and are of unknown reversibility;
16.1.c- Fertility preservation (FP) options (both established and experimental);
16.1.d- Psychosocial implications of infertility.
16.2- We recommend health care professionals refer transgender and gender diverse people interested in fertility preservation to providers with expertise in fertility preservation for further discussion.
16.3- We recommend transgender care teams partner with local reproductive specialists and facilities to provide specific and timely information and fertility preservation services prior to offering medical and surgical interventions that may impact fertility.
16.4- We recommend health care professionals counsel pre- or early-pubertal transgender and gender diverse youth seeking gender-affirming therapy and their families that currently evidence-based/established fertility preservation options are limited.
16.5- We recommend transgender and gender diverse people with a uterus who wish to carry a pregnancy undergo preconception care, prenatal counseling regarding use and cessation of gender-affirming hormones, pregnancy care, labor and delivery, chest/breast feeding supportive services, and postpartum support according to local standards of care in a gender-affirming way.
16.6. We recommend medical providers discuss contraception methods with transgender and gender diverse people who engage in sexual activity that can result in pregnancy.
16.7. We recommend providers who offer pregnancy termination services ensure procedural options are gender-affirming and serve transgender people and those of diverse genders.

  • Editor's Note: The ethics of reproductive health is a well known issue regardless of the client having a transition history. Given that gender confirming surgery usually results in permanent infertility, the options for genetically related children are very strongly dependent on the client's current situation with their partner. This is especially true when a surrogate with a uterus is needed for the pregnancy process. We would like to think that giving the option for birth control for trans people who do NOT want pregnancy to result is a given, but sexual health may be a taboo subject depending on the society (especially to treat sexually transmitted infections, or to offer HPV vaccine).

CHAPTER 17 Sexual Health

17.1- We recommend health care professionals who provide care to transgender and gender diverse people acquire the knowledge and skills needed to address sexual health issues (relevant to their care provision).
17.2- We recommend health care professionals who provide care to transgender and gender diverse people discuss the impact of gender-affirming treatments on sexual function, pleasure, and satisfaction.
17.3- We recommend health care professionals who provide care to transgender and gender diverse people offer the possibility of including the partner(s) in sexuality-related care, if appropriate.
17.4- We recommend health care professionals counsel transgender and gender diverse people about the potential impact of stigma and trauma on sexual risk behavior, sexual avoidance, and sexual functioning.
17.5- We recommend any health care professional who offers care that may impact sexual health provide information, ask about the expectations of the transgender and gender diverse individual and assess their level of understanding of possible changes.
17.6.-We recommend health care professionals who provide care to transgender and gender diverse people counsel adolescents and adults regarding prevention of sexually transmitted infections.
17.7- We recommend health care professionals who provide care to transgender and gender diverse people follow local and World Health Organization guidelines for human immunodeficiency virus/sexual transmitted infections (HIV/STIs) screening, prevention, and treatment.
17.8- We recommend health care professionals who provide care to transgender and gender diverse people address concerns about potential interactions between antiretroviral medications and hormones.

CHAPTER 18 Mental Health

18.1- We recommend mental health professionals address mental health symptoms that interfere with a person’s capacity to consent to gender-affirming treatment before gender-affirming treatment is initiated.
18.2- We recommend mental health professionals offer care and support to transgender and gender diverse people to address mental health symptoms that interfere with a person’s capacity to participate in essential perioperative care before gender-affirmation surgery.
18.3- We recommend when significant mental health symptoms or substance abuse exists, mental health professionals assess the potential negative impact that mental health symptoms may have on outcomes based on the nature of the specific gender-affirming surgical procedure.
18.4- We recommend health care professionals assess the need for psychosocial and practical support of transgender and gender diverse people in the perioperative period surrounding gender- affirmation surgery.
18.5- We recommend health care professionals counsel and assist transgender and gender diverse people in becoming abstinent from tobacco/nicotine prior to gender-affirmation surgery.
18.6- We recommend health care professionals maintain existing hormone treatment if a transgender and gender diverse individual requires admission to a psychiatric or medical inpatient unit, unless contraindicated.
18.7- We recommend health care professionals ensure if transgender and gender diverse people need in-patient or residential mental health, substance abuse or medical care, all staff use the correct name and pronouns (as provided by the patient), as well as provide access to bathroom and sleeping arrangements that are aligned with the person's gender identity.
18.8- We recommend mental health professionals encourage, support, and empower transgender and gender diverse people to develop and maintain social support systems, including peers, friends, and families.
18.9- We recommend health care professionals should not make it mandatory for transgender and gender diverse people to undergo psychotherapy prior to the initiation of gender-affirming treatment, while acknowledging psychotherapy may be helpful for some transgender and gender diverse people.
18.10- We recommend “reparative” and “conversion” therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered.

  • Editor's Note: Social support is probably the most important part of mental health that doesn't involve identification and resolving of non-gender identity issues. Likewise if the client is facing housing or food insecurity, having free access to HCP's is going to have limited value. The role of so-called gatekeeping being reduced is appreciated, but old guidelines die hard in countries that require a trans person to go to university hospital in order for national healthcare scheme to cover services available.

Footnotes