Standards of Care – Sue In Utah

The World Professional Association of Transgender Health (WPATH) is a 501(c)(3) non-profit, interdisciplinary professional and educational organization focused on transgender health. Their members are engaged in clinical and academic research to develop evidence based medicine and work towards the safe and effective treatment for transgender, non-binary, intersex, and gender-nonconforming individuals internationally.

The Standards of Care (SOC) is the guiding document for transgender related healthcare worldwide developed by WPATH and its members. This document has been in existence since 1979. As medicine is always evolving, the WPATH members meet to work on updates to the document based on evidence based science. The SOC version 8 is the current revision.

As the SOC is a substantial document, I am going to extract key lines below and you are obviously free to go to those sections if you wish to read deeper on that context. Many conclusive statements are noted with the appropriate study and the last ~100 pages of the document are a vast collection of evidence based references. Note, I am still in the processing of consuming this document and will add more references as I read further.

Link to the Standards of Care: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

Acronyms used below:
DSM – Diagnostic and Statistical Manual of Mental Disorders
DSD – Differences in Sex Development
GAHT – Gender Affirrning Hormone Treatment
GAMST – Gender-Affirming Medical and Surgical Treatment
GAS – Gender Affirming Surgery
GnRH – Gonadotropin Releasing Hormone
HCP – Health Care Professional
MHP – Mental Health Professionals
PTSD – Post Traumatic Stress Disorder
TGD – Transgender and Gender Diverse

Section	Page	Quoted Statement
Introduction	8	The SOC-8 supports the role of informed decision-making and the value of harm reduction approaches.
Introduction	9	Worldwide, TGD people are sometime forced by family members or religious communities to undergo conversion therapy. WPATH strongly recommends against any use of reparative or con- version therapy (see statements 6.5 and 18.10).
2	19	2.1- We recommend health care systems should provide medically necessary gender-affirming health care for transgender and gender diverse people.
2	19	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)
2	19	Reject approaches that have the goal or effect of conversion and avoid providing any direct or indirect support for such approaches or services.
2	19	Match the treatment approach to the specific needs of clients, particularly their goals for gender identity and expression
2	19	It should be recognized gender diversity is common to all human beings and is not pathological.
2	20	Gender-affirming interventions are based on decades of clinical experience and research; there- fore, they are not considered experimental, cos- metic, or for the mere convenience of a patient. They are safe and effective at reducing gender incongruence and gender dysphoria
2	22	Finally, sexual health outcomes for TGD people are poor. HIV prevalence for transgender women reporting to clinical organizations in metropolitan areas is approximately 19% worldwide, which is 49 times higher than the background prevalence rate in the general population
2	22	Gender identity change efforts (gender repar- ative or gender conversion programs aimed at making the person cisgender) are widespread, cause harm to TGD people and are consid- ered unethical
3	28	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)
5	34	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	37	While marked and sustained gender incongru- ence should be present, it is not necessary for TGD people to experience severe levels of distress regard- ing their gender identity to access gender- affirming treatments. In fact, access to gender-affirming treat- ment can act as a prophylactic measure to prevent distress
5	38-39	Recent longitudinal studies suggest mental health symptoms experienced by TGD people tend to improve following GAMSTs
5	39	It is vital gender-affirming care is not impeded unless, in some extremely rare cases, there is robust evi- dence that doing so is necessary to prevent significant decompensation with a risk of harm to self or others. In those cases, it is also important to consider the risks delaying GAMSTs poses to a TGD person’s mental and physical health
5	42	Previous versions of the SOC guidelines have required TGD individuals to be assessed for GAMSTs by two qualified HCPs. It was believed having two independent opinions was best prac- tice as it ensured safety for both TGD people and HCPs. However, the limited research in the area indi- cates two opinions are largely unnecessary. Consequently, if written documentation or a letter is required to recommend gender-affirming medical and surgical treatment (GAMST), TGD people seeking treatments including hormones, and genital, chest, facial and other gender-affirming surgeries require a single written opinion/signature from an HCP competent to independently assess and diagnose
5	43	The decision to detransition appears to be rare (Defreyne, Motmans et al., 2017; Hadje-Moussa et al., 2019; Wiepjes et al., 2018). Estimates of the number of people who detran- sition due to a change in identity are likely to be overinflated due to research blending differ- ent cohorts (Expósito-Campos, 2021). A recent study found the vast majority of TGD people who opted to detransition did so due to external factors, such as stigma and lack of social support and not because of changes in gender identity (Turban, King et al., 2021).
6	45	Studies from high school samples indicate much higher rates than earlier thought, with reports of up to 1.2% of partici- pants identifying as transgender (Clark et al., 2014) and up to 2.7% or more (e.g., 7–9%) expe- riencing some level of self-reported gender diver- sity (Eisenberg et al., 2017; Kidd et al., 2021; Wang et al., 2020).
6	47	Dutch longitudinal clinical follow-up studies of adolescents with childhood gender dysphoria who received puberty suppression, gender-affirming hormones, or both, found that none of the youth in adulthood regretted the decisions they had taken in adolescence (Cohen-Kettenis & van Goozen, 1997; de Vries et al., 2014).
6	47	One researcher attempted to study and describe a spe- cific form of later-presenting gender diversity expe- rience (Littman, 2018). However, the findings of the study must be considered within the context of significant methodological challenges, including 1) the study surveyed parents and not youth perspectives; and 2) recruitment included parents from community settings in which treatments for gender dysphoria are viewed with scepticism and are criticized. However, these findings have not been rep- licated.
6	49	In a large non-probability sample of transgender-identified adults, Turban et al. (2022) found those who reported access to gender-affirming hormones in adolescence had lower odds of past-year suicidality compared with transgender people accessing gender- affirming hormones in adulthood.
6	49	Two Dutch studies report low rates of adoles- cents (1.9% and 3.5%) choosing to stop puberty suppression (Brik et al., 2019; Wiepjes et al., 2018).
6	50	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	50	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	50	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.
6	54	Russell et al. (2018) found mental health improvement increases with more acceptance and affirmation across more settings (e.g., home, school, work, and friends). Rejection by family, peers, and school staff (e.g., intentionally using the name and pronoun the youth does not identify with, not acknowledging affirmed gender identity, bullying, harassment, verbal and physical abuse, poor relationships, rejection for being TGD, evic- tion) was strongly linked to negative outcomes, such as anxiety, depression, suicidal ideation, sui- cide attempts, and substance use
6	55	Conversion/reparative therapy has been linked to increased anxiety, depression, suicidal ideation, suicide attempts, and health care avoidance
6	60	Importantly, gender histories may be unknown to parent(s)/ caregiver(s) because gender may be internal expe- rience for youth, not known by others unless it is discussed. For this reason, an adolescent’s report of their gender history and experience is central to the assessment process.
6	62	Therefore, the level of reversibility of a gender-affirming medical intervention should be considered along with the sustained duration of a young person’s experience of gender incon- gruence when initiating treatment. However, in this age group of younger adolescents, several years is not always practical nor necessary given the premise of the treatment as a means to buy time while avoiding distress from irreversible pubertal changes. For youth who have experienced a shorter
6	63	Importantly, findings from studies of gender incongruent pubertal/adolescent cohorts, in which participants who have under- gone comprehensive gender evaluation over time, have shown persistent gender incongruence and gender-related need and have received refer- rals for medical gender care, suggest low levels of regret regarding gender-related medical care decisions (de Vries et al., 2014; Wiepjes et al., 2018). Critically, these findings of low regret can only currently be applied to youth who have demonstrated sustained gender incongruence and gender-related needs over time as estab- lished through a comprehensive and iterative assessment
6	64-65	Of note, many transgender adolescents are well-functioning and experience few if any mental health concerns. For example, socially transi- tioned pubertal adolescents who receive medical gender-affirming treatment at specialized gender clinics may experience mental health outcomes equivalent to those of their cisgender peers
6	66	The use of puberty-blocking medications, such as GnRH analogues, is not recommended until children have achieved a minimum of Tanner stage 2 of puberty because the experience of physical puberty may be critical for further gender identity development for some TGD ado- lescents (Steensma et al., 2011). Therefore, puberty blockers should not be implemented in prepubertal gender diverse youth (Waal & Cohen-Kettenis, 2006).
6	68	Chest masculinization surgery can be considered in minors when clinically and developmentally appropriate as determined by a multidisciplinary team experienced in adolescent and gender development.
6	68	GAHT, specifically estrogen, can help with development of breast tissue, and it is recommended youth have a minimum of 12 months of hormone therapy, or longer as is surgically indicated, prior to breast augmentation unless hormone therapy is not clinically indicated or is medically contraindicated.
7	75	Not all gender diverse children or their families need input from MHPs as gender diversity is not a mental health disorder (Pediatric Endocrine Society, 2020; Telfer et al., 2018).
7	78	Thus, when considering a social transition, we suggest parents/caregivers and HCPs pay particular attention to children who consistently and often persistently articulate a gender identity that does not match the sex designated at birth.
8	86	8.2 – We recommend health care professionals consider gender-affirming medical intervention (hormonal treatment surgery) for nonbinary people in the absence of “social gender transition.”
8	86	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.
10	96	Obvious genital atypically (“ambiguous genitalia”) occurs with an estimated frequency ranging from approximately 1:2000 – 1:4500 people. The most inclusive definitions of DSD estimate a prevalence of up to 1.7%.
10	97	10.5 – We suggest health care progressional and parents support children/individuals with intersexuality in exploring their gender identity throughout their life.
10	99	However, the criteria for sex/gender decisions have changed over time. In the second half of the 20th century, the decisions were biased towards female assignment, because feminizing genital surgery was seen as easier and less side-effect prone than masculinizing surgery. Yet, in certain intersex conditions, for instance 46 X/Y 5a-RD-2 deficiency, female sex/gender assignment was found to be associated with high rates of later gender dysphoria and gender change.
10	101	Individuals with intersexuality are reported to experience stigma, feelings of shame, guilt, anger, sadness, and depression.
10	102	A recent online study of a very large sample of POGBTQ youth indicated that LGBTQ youth who categorized themselves as having a physical intersex variation had a rate of mental health problems that was higher than the rate in LGBTQ youth without intersexuality.
10	103	International human rights organizations have increasingly expressed their concerns that surgeries performed before a child can participate meaningfully in decision-making may endanger the child’s human rights to autonomy, self-determination, and an open future.
10	104	People with intersex conditions are also far more likely than the general population to be transgender, to be gender diverse, or to have gender dysphoria.
11	107	Additionally, numerous courts have long upheld the need to provide TGD-informed care based in the WPATH SOC to people living in institutions as well (e.g. Koelik v. Massachusetts, 2002; Edmo v. Idaho Department of Corrections , 2020).
11	108	TGD persons who enter an institution on an appropriate regimen of gender-affirming hormone therapy should be continued on the same or similar therapies and monitored according to the SOC Version 8. A “Freeze frame” approach iOS inappropriate and dangerous.
11	110	The separation of people based on sex assigned at birth, a policy almost universally implemented in institutional settings can create an inherently dangerous environment. Gender diverse people are extremely vulnerable to stigmatization, victimization, neglect, violence, and secular abuse.
11	110	Likewise, the Prison Rape Elimination Act specifically cites TGD individuals as a vulnerable population and directs prisons nationwide in the US to consider the housing preferences of these inmates.
11	111	Private use of shower and toilet facilities for incarcerated transgender people is also required by some laws, including for instance the United States’ federal Prison Rape Elimination Act.
12	112	Ever since the first World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) was published in 1979 and in subsequent updates of the SOC, including version 7, GAHT has been accepted as medically necessary.
12	112	Hormone therapy is not recommended for children who have not begun endogenous puberty.
12	114	In general, the goal of GnRHa administration is TGD adolescents is to prevent further development of the endogenous secondary sex characteristics corresponding to the sex designated at birth. Since this treatment is fully reversible, it is regarded as an extended time for adolescents to explore their gender identity by means of an early social transition.
12	116	GnRHas have been used since 1981 for the treatment of central precocious puberty. The use of GnRHas in individuals with central previous puberty is regarded as both safe and effective, with no known long-term adverse effects.
12	118	In adolescents who pursue GAHT (given this is a partly irreversible treatment), we suggest initiating treatment using a schedule of gradually increasing doses after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and has established the individual possesses the mental capacity to give informed consent.
12	119	Individuals should not be referred to for mental health treatment exclusively not he basis of a transgender identity.
12	128	Hormone therapy has been found to positively impact the mental health and quality of life of TGD youth and adults who embark on this treatment.
12	128	Found a decrease in the odds of lifetime suicidal ideation in adolescents who required pubertal suppression and had access to this treatment compared with those with a similar desire with no such access.
13	130	The efficacy of top surgery has been demonstrated in multiple domains, including a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance. Additionally, rates of regret remain very low varying from 0 to 4%.
13	136	The percentage of individuals who regret their GAS is very low (between 0.3% and 3.8%).
13	131	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.
18	173	However, transgender identity ins not a mental illness, and these elevated rates have been linked to complex trauma, societal stigma, violence, and discrimination. In addition, psychiatric symptoms lessen with a appropriate gender-affirming medical and surgical care.
18	173	Addressing mental illness and substance use disorders is important but should not be a barrier to transition-related care.
18	174	Both the primary care provider or endocrinologist prescribing hormones and the surgeon performing surgery must obtain informed consent.
18	176	There is no strong evidence for routinely stopping hormone treatment prior to surgery, and the risks and benefits for each individual patient should be assessed before doing so.
18	177	However the use of chosen names for YGD people has been associated with lower depression and suicidality.
18	178	In retrospective studies, a history of having undergone conversion therapy is linked to increased levels of depression, substance abuse, suicidal thoughts, and suicide attempts as well as lower educational attainment and less weekly income.