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

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

 

The World Professional Association for Transgender Health
Abstract [Full Text] PDF

 

 

Abstract

 

Table of Contents
I. Purpose and Use of the Standards of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
II. Global Applicability of the Standards of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
III. The Difference between Gender Nonconformity and Gender Dysphoria . . . . . . . . . . . . . . 4
IV. Epidemiologic Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
V. Overview of Therapeutic Approaches for Gender Dysphoria. . . . . . . . . . . . . . . . . . . . . . . . 8
VI. Assessment and Treatment of Children and Adolescents with Gender Dysphoria . . . . . 10
VII. Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
VIII. Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
IX. Reproductive Health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
X. Voice and Communication Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
XI. Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . 54
XII. Postoperative Care and Follow-Up. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
XIII. Lifelong Preventive and Primary Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
XIV. Applicability of the Standards of Care to People Living in Institutional Environments . . . 67
XV. Applicability of the Standards of Care to People With Disorders of Sex Development . . . 69
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Appendices:
A. Glossary. 95
B. Overview of Medical Risks of Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
C. Summary of Criteria for Hormone Therapy and Surgeries. . . . . . . . . . . . . . . . . . . . . . . . 104
D. Evidence for Clinical Outcomes of Therapeutic Approaches. . . . . . . . . . . . . . . . . . . . . . 107
E. Development Process for the Standards of Care, Version 7. 109

1
The Standards of Care
7th Version
World Professional Association for Transgender Health
I
Purpose and Use of the Standards of Care
The World Professional Association for Transgender Health (WPATH)1 is an international,
multidisciplinary, professional association whose mission is to promote evidence-based care,
education, research, advocacy, public policy, and respect for transgender health. The vision of
WPATH is to bring together diverse professionals dedicated to developing best practices and
supportive policies worldwide that promote health, research, education, respect, dignity, and
equality for transsexual, transgender, and gender nonconforming people in all cultural settings.
One of the main functions of WPATH is to promote the highest standards of health care for
individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual,
Transgender, and Gender Nonconforming People. The SOC are based on the best available science
and expert professional consensus.2 Most of the research and experience in this field comes from
a North American and Western European perspective; thus, adaptations of the SOC to other parts
of the world are necessary. Suggestions for ways of thinking about cultural relativity and cultural
competence are included in this version of the SOC.

The overall goal of the SOC is to 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. While this is primarily a document for health professionals, the SOC may also be
used by individuals, their families, and social institutions to understand how they can assist with
promoting optimal health for members of this diverse population.

WPATH recognizes that health is dependent upon not only good clinical care but also social and
political climates that provide and ensure social tolerance, equality, and the full rights of citizenship.
Health is promoted through public policies and legal reforms that promote tolerance and equity

1 Formerly the Harry Benjamin International Gender Dysphoria Association
2 Standards of Care (SOC), Version 7 represents a significant departure from previous versions. Changes in this version are based
upon significant cultural shifts, advances in clinical knowledge, and appreciation of the many health care issues that can arise for
transsexual, transgender, and gender nonconforming people beyond hormone therapy and surgery (Coleman, 2009a, b, c, d).
2

The Standards of Care
7th Version
World Professional Association for Transgender Health
for gender and sexual diversity and that eliminate prejudice, discrimination, and stigma.

WPATH is committed to advocacy for these changes in public policies and legal reforms.

The Standards of Care Are Flexible Clinical Guidelines

The SOC are intended to be flexible in order to meet the diverse health care needs of transsexual,
transgender, and gender nonconforming people. While flexible, they offer standards for promoting
optimal health care and guiding the treatment of people experiencing gender dysphoria – broadly
defined as discomfort or distress that is caused by a discrepancy between a person’s gender
identity and that person’s sex assigned at birth (and the associated gender role and/or primary and
secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b).

As for all previous versions of the SOC, the criteria put forth in this document for hormone therapy
and surgical treatments for gender dysphoria are clinical guidelines; individual health professionals
and programs may modify them. Clinical departures from the SOC may come about because of a
patient’s unique anatomic, social, or psychological situation; an experienced health professional’s
evolving method of handling a common situation; a research protocol; lack of resources in various
parts of the world; or the need for specific harm reduction strategies. These departures should
be recognized as such, explained to the patient, and documented through informed consent for
quality patient care and legal protection. This documentation is also valuable for the accumulation
of new data, which can be retrospectively examined to allow for health care – and the SOC – to
evolve.

The SOC articulate standards of care but also acknowledge the role of making informed choices
and the value of harm reduction approaches. In addition, this version of the SOC recognizes and
validates various expressions of gender that may not necessitate psychological, hormonal, or surgical
treatments. Some patients who present for care will have made significant self-directed progress
towards gender role changes, transition, or other resolutions regarding their gender identity or
gender dysphoria. Other patients 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.

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Citation: WPATH