Standards of Care for the Health of Transgender and Gender Diverse People

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The Standards of Care for the Health of Transgender and Gender Diverse People (SOC) is an international clinical protocol by the World Professional Association for Transgender Health (WPATH) outlining the recommended assessment and treatment for transgender and gender-diverse individuals across the lifespan including social, hormonal, or surgical transition. [1] It often influences clinicians' decisions regarding patients' treatment. While other standards, protocols, and guidelines exist –especially outside the United States –the WPATH SOC is the most widespread protocol used by professionals working with transgender or gender-variant people. [2] [3] [4]

Contents

Version 8 of the WPATH SOC was released online on September 15, 2022. [1] [5]

History and development

Prior to the advent of the first SOC, there was no semblance of consensus on psychiatric, psychological, medical, and surgical requirements or procedures. Before the 1960s, few countries offered safe, legal medical options and many criminalized cross-gender behaviors or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association (now known as the World Professional Association for Transgender Health) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment."

The WPATH SOC are periodically updated and revised. The eighth and latest version was released on September 15, 2022. Previous versions were released in 1979, 1980, 1981, 1990, 1998, 2001, and 2012. [3] [5]

Version 6

The sixth version, [6] titled "The Harry Benjamin International Gender Dysphoria Association's Standards Of Care For Gender Identity Disorders", was published in 2001. It recommends that mental health professionals document a patient's relevant history in a letter, which should be required by medical professionals prior to physical intervention. One letter is required for hormone replacement therapy or either augmentation mammoplasty or male chest reconstruction. Two additional letters are needed for genital surgeries. [7]

The Eligibility Criteria and Readiness Criteria in version 6 give certain very specific minimum requirements as prerequisites to HRT or sex reassignment surgery (SRS). Section Nine covers "The Real-life Experience," during which individuals seeking hormonal and other treatments are expected to begin transitioning publicly to their preferred gender role. Section Twelve, titled "Genital Surgery," deals directly with all concerns about sex reassignment surgery. It includes six "Eligibility Criteria" and two "Readiness Criteria", which are intended to be used by professionals for both diagnosis and guidance before providing patients "letters of recommendation." For this and other reasons, the WPATH SOC 6 was a controversial and often maligned document among patients seeking medical intervention (hormones, and/or surgery), who stated that their legally protected right to proper medical care and treatment was unjustly and unduly withheld or even denied based on the SOC.

The assessment and treatment of children and adolescents was covered in section V of version 6.

Version 7

The seventh version, titled "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People", was published in 2012. Included in the guidelines are sections on purpose and use of the WPATH SOC, the global applicability of the WPATH SOC, the difference between gender nonconformity and gender dysphoria, epidemiology, treatment of children, adolescents and adults, mental health, hormone replacement therapy (masculinizing or feminizing; HRT), reproductive health, voice and communication therapy, sex reassignment surgery, lifelong preventive and primary care, applicability of the WPATH SOC to people living in institutional environments, and applicability of the WPATH SOC to people with disorders of sex development.

The seventh version also includes acknowledgements of the ever-evolving language used to describe and treat transsexual, transgender, and gender non-conforming individuals. There is an emphasis placed on the idea that identifying with these labels does not inherently qualify someone as disordered, and that treatment should be focused on the alleviation of any suffering caused by gender dysphoria. They make a stance against the "deprivation of civil and human rights" on the grounds of someone's gender identity. This version, much like its predecessor requires referrals for surgical procedures based on set criteria, but notes the importance of informed consent and listening to the wishes of the patient. [3]

The seventh version includes a section distinguishing between cases of gender dysphoria and non-conformity for children and adolescents, as well as recommended treatment paths for each. [3]

The seventh version, together with the 2009 guideline from the Endocrine Society guideline influenced a wide range of international guidelines, nearly all of those in a systematic review conducted to inform the Cass Review in 2022. [8] The systematic review concluded that the two international guidelines from WPATH and Endocrine Society lacked "developmental rigour and transparency". [8]

Version 8

The eighth version, titled "Standards of Care for the Health of Transgender and Gender Diverse People", was published in 2022. It gives recommendations for health professionals in eighteen chapters. [1] The guidelines were developed by a multidisciplinary committee of experts, building on previous versions and using the Delphi method. [5]

Version 8 is the first one to include a chapter on adolescent care separate from that on the care of children. [9] This version of the protocol gives no specific age limits for treatments, emphasizing the need to decide individually for each patient. [10] An earlier draft would have required several years of transgender identity before an adolescent could begin treatment. After criticism from transgender advocates, this provision was removed in the final release. Despite the criticism, transgender youths wishing to be treated are still required to undergo a "comprehensive diagnostic assessment". [11] It was also criticized for suggesting that young people may come to believe they are transgender through social influence. [9]

The guidelines became a focus of controversy during the debate over the Scottish government's Gender Recognition Reform Bill in 2022. Opponents of the bill highlighted the chapter on eunuchs, which proposes eunuch be considered a gender identity, and criticised NHS Scotland's association with WPATH. [12]

NHS England in March 2024 updated their guidelines [13] and stated that for children and adolescents they do not follow WPATH 8; whilst other UK bodies such as the General Medical Council continue to link to WPATH 8 as a Useful Link. [14]

Populations

Issues specific to certain demographics, including adults, children, and adolescents, are described in Chapters 5–11.

Adults

Adolescents

In a departure from previous versions, Version 8 draws a conceptual distinction between Adolescents and Children with separate chapters.

Continued care and careful assessment of cognitive maturity by qualified mental health professionals is recommended. In contrast to previous versions, there are no absolute requirements for duration of assessments or age to access gender-affirming treatments; rather, individual psychosocial and physical development should be taken into account.

Additionally, Chapter 12 and 13 and Appendix D contain further recommendations regarding hormone therapy and surgical treatments in adolescents.

Children

Pertaining to prepubescent children only, chapter 7 makes recommendations regarding the support of children and their families throughout gender exploration and potential social transitions.

Non-binary

Non-binary individuals are included for the first time in chapter 8. The guidelines recommend that medical treatment and social support be made available to non-binary people in individualized combinations, for example providing medical interventions without social transition or gender-affirming surgery without hormone therapy. The chapter additionally notes unique experiences of discrimination, minority stress, and difficulty accessing gender-affirming medical treatment among non-binary people, which healthcare providers should take into consideration.

Treatments

Recommendations for treatments, including medical and social aspects of gender transition as well as mental health, as are given in Chapters 12–18.

See also

Related Research Articles

Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth. The term replaced the previous diagnostic label of gender identity disorder (GID) in 2013 with the release of the diagnostic manual DSM-5. The condition was renamed to remove the stigma associated with the term disorder.

Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, although many such treatments are also pursued by cisgender and non-intersex individuals. It is also known as sex reassignment surgery, gender confirmation surgery, and several other names.

The World Professional Association for Transgender Health (WPATH), formerly the Harry Benjamin International Gender Dysphoria Association (HBIGDA), is a professional organization devoted to the understanding and treatment of gender identity and gender dysphoria, and creating standardized treatment for transgender and gender variant people. WPATH was founded in September 1979 by endocrinologist and sexologist Harry Benjamin, with the goal of creating an international community of professionals specializing in treating gender variance.

The following outline is provided as an overview of and topical guide to transgender topics.

<span class="mw-page-title-main">Trans man</span> Man assigned female at birth

A trans man is a man who was assigned female at birth. Trans men have a male gender identity, and many trans men undergo medical and social transition to alter their appearance in a way that aligns with their gender identity or alleviates gender dysphoria.

Gender transition is the process of changing one's gender presentation or sex characteristics to accord with one's internal sense of gender identity – the idea of what it means to be a man or a woman, or to be non-binary, genderqueer, bigender, or pangender, or to be agender (genderless). For transgender and transsexual people, this process commonly involves reassignment therapy, with their gender identity being opposite that of their birth-assigned sex. Transitioning might involve medical treatment, but it does not always involve it. Cross-dressers, drag queens, and drag kings tend not to transition, since their variant gender presentations are generally only adopted temporarily.

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent due to a mismatch between their assigned sex and gender identity. The diagnostic label gender identity disorder in children (GIDC) was used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) until it was renamed gender dysphoria in children in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.

Kenneth J. Zucker is an American-Canadian psychologist and sexologist. He was named editor-in-chief of Archives of Sexual Behavior in 2001. He was psychologist-in-chief at Toronto's Centre for Addiction and Mental Health (CAMH) and head of its Gender Identity Service until December 2015. Zucker is a professor in the departments of psychiatry and psychology at the University of Toronto.

<span class="mw-page-title-main">LGBT people in prison</span> Lesbian, gay, bisexual, transgender and queer people in prison

Lesbian, gay, bisexual, transgender and queer (LGBTQ) people face difficulties in prison such as increased vulnerability to sexual assault, other kinds of violence, and trouble accessing necessary medical care. While much of the available data on LGBTQ inmates comes from the United States, Amnesty International maintains records of known incidents internationally in which LGBTQ prisoners and those perceived to be lesbian, gay, bisexual or transgender have suffered torture, ill-treatment and violence at the hands of fellow inmates as well as prison officials.

<span class="mw-page-title-main">Transsexual</span> People experiencing a gender identity inconsistent with their assigned sex

A transsexual person is someone who experiences a gender identity that is inconsistent with their assigned sex, and desires to permanently transition to the sex or gender with which they identify, usually seeking medical assistance to help them align their body with their identified sex or gender.

<span class="mw-page-title-main">Transgender youth</span> Children and adolescents who are transgender

Transgender youth are children or adolescents who do not identify with the sex they were assigned at birth. Because transgender youth are usually dependent on their parents for care, shelter, financial support, and other needs, they differ in challenges compared to adults. According to the World Professional Association for Transgender Health, the American Psychological Association, and the American Academy of Pediatrics, appropriate care for transgender youth may include supportive mental health care, social transition, and/or puberty blockers, which delay puberty and the development of secondary sex characteristics to allow children more time to explore their gender identity.

Puberty blockers are medicines used to postpone puberty in children. The most commonly used puberty blockers are gonadotropin-releasing hormone (GnRH) agonists, which suppress the natural production of sex hormones, such as androgens and estrogens. In addition to their use in treating precocious puberty, which involves puberty occurring at an unusually early age in children, puberty blockers are also used for transgender children to delay the development of unwanted sex characteristics, so as to allow transgender youth more time to explore their gender identity.

Transgender hormone therapy, also called hormone replacement therapy (HRT) or gender-affirming hormone therapy (GAHT), is a form of hormone therapy in which sex hormones and other hormonal medications are administered to transgender or gender nonconforming individuals for the purpose of more closely aligning their secondary sexual characteristics with their gender identity. This form of hormone therapy is given as one of two types, based on whether the goal of treatment is masculinization or feminization:

The real-life experience (RLE), sometimes called the real-life test (RLT), is a period of time or process in which transgender individuals live full-time in their identified gender role in order to be eligible to receive gender-affirming treatment. The purpose of the RLE has been to confirm that a given transgender person could function successfully as a member of said gender in society, as well as to confirm that they are sure they want to live as said gender for the rest of their life. A documented RLE was previously a requirement of many physicians before prescribing gender-affirming hormone therapy, and a requirement of most surgeons before performing gender-affirming surgery.

Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions, as well as gender-affirming care, for transgender individuals. A major component of transgender health care is gender-affirming care, the medical aspect of gender transition. Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks, and access to healthcare for trans people in different countries around the world.

Transgender rights in Australia have legal protection under federal and state/territory laws, but the requirements for gender recognition vary depending on the jurisdiction. For example, birth certificates, recognised details certificates, and driver licences are regulated by the states and territories, while Medicare and passports are matters for the Commonwealth.

Detransition is the cessation or reversal of a transgender identification or of gender transition, temporarily or permanently, through social, legal, and/or medical means. The term is distinct from the concept of 'regret', and the decision may be based on a shift in gender identity, or other reasons, such as health concerns, social pressure, or discrimination and stigma.

<span class="mw-page-title-main">Genspect</span> Organization opposing transgender rights

Genspect is an international group founded in June 2021 by psychotherapist Stella O'Malley that has been described as gender-critical. Genspect opposes gender-affirming care, as well as social and medical transition for transgender people. Genspect opposes allowing transgender people under 25 years old to transition, and opposes laws that would ban conversion therapy on the basis of gender identity. Genspect also endorses the unproven concept of rapid-onset gender dysphoria (ROGD), which proposes a subclass of gender dysphoria caused by peer influence and social contagion. ROGD has been rejected by major medical organisations due to its lack of evidence and likelihood to cause harm by stigmatizing gender-affirming care.

<span class="mw-page-title-main">Society for Evidence-Based Gender Medicine</span> Organization opposing transgender rights

The Society For Evidence-Based Gender Medicine (SEGM) is a non-profit organization that is known for its opposition to gender-affirming care for transgender youth and for engaging in political lobbying, to limit and remove the rights of transgender youth and adults. The group routinely cites the unproven and discredited conspiracy of rapid-onset gender dysphoria and has falsely claimed that conversion therapy techniques are only practiced on the basis of sexual orientation rather than gender identity. SEGM is often cited in anti-transgender legislation and court cases, sometimes filing court briefs. It is not recognized as a scientific organization by the international medical community.

<span class="mw-page-title-main">Cass Review</span> Review of gender identity services in England

The Independent Review of Gender Identity Services for Children and Young People was commissioned in 2020 by NHS England and NHS Improvement and led by Hilary Cass, a retired consultant paediatrician and former President of the Royal College of Paediatrics and Child Health. It dealt with gender services for children and young people, including those with gender dysphoria and those identifying as transgender.

References

  1. 1 2 3 Coleman, E.; et al. (August 19, 2022). "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8". International Journal of Transgender Health . 23 (Suppl 1): S1–S259. doi: 10.1080/26895269.2022.2100644 . ISSN   2689-5269. PMC   9553112 . PMID   36238954.
  2. ↑ Britt Colebunders; et al. (2015). "New Criteria for Sex Reassignment Surgery: WPATH Standards of Care, Version 7, Revisited". International Journal of Transgenderism . 16 (4): 222–233. doi:10.1080/15532739.2015.1081086. S2CID   74097076.
  3. 1 2 3 4 Coleman, Eli; et al. "Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People". 7. World Professional Association for Transgender Health . Retrieved May 9, 2018.
  4. ↑ Grinberg, Emanuella (June 20, 2018). "What is medically necessary treatment for gender-affirming health care?". CNN . Retrieved July 6, 2018.
  5. 1 2 3 World Professional Association for Transgender Health (September 15, 2022). "World Professional Association for Transgender Health (WPATH) Releases the Standards of Care for the Health of Transgender and Gender Diverse People, Version 8" (PDF) (Press release). Retrieved September 18, 2022.
  6. ↑ Meyer III, Walter; et al. (February 2001). "The Harry Benjamin International Gender Dysphoria Association's Standards Of Care For Gender Identity Disorders, Sixth Version" (PDF). Cpath.ca. Retrieved May 4, 2019.
  7. ↑ "The Mental Health Professional." The World Professional Association for Transgender Health's Standards Of Care For Gender Identity Disorders. 6th ed. 2001.
  8. 1 2 Taylor, Jo; Hall, Ruth; Heathcote, Claire; Hewitt, Catherine Elizabeth; Langton, Trilby; Fraser, Lorna (April 9, 2024). "Clinical guidelines for children and adolescents experiencing gender dysphoria or incongruence: a systematic review of guideline quality (part 1)". Archives of Disease in Childhood. doi:10.1136/archdischild-2023-326499. ISSN   0003-9888. PMID   38594049.
  9. 1 2 Yurcaba, Jo (June 17, 2022). "Trans kids and advocates blame culture war for debate over adolescent health care". NBC News .
  10. ↑ Nainggolan, Lisa (September 16, 2022). "WPATH Removes Age Limits From Transgender Treatment Guidelines". Medscape .
  11. ↑ Bazelon, Emily (June 15, 2022). "The Battle Over Gender Therapy". The New York Times Magazine . Archived from the original on July 1, 2022.
  12. ↑ "NHS apologises for claiming eunuch is a gender identity". LBC. Retrieved November 1, 2022.
  13. ↑ "Puberty Suppressing Hormones (PSH) for children and adolescents who have gender incongruence/dysphoria [URN 1927" (PDF). NHS England- Children and young people’s gender services. March 14, 2024. Retrieved March 25, 2024.
  14. ↑ "Trans healthcare: General Medical Council". General Medical Council.
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