I. Introductory Concepts
The Purpose of the Standards of Care. The major purpose of the Standards
of Care (SOC) is to articulate this international organization's
professional consensus about the psychiatric, psychological, medical, and
surgical management of gender identity disorders. Professionals may use this
document to understand the parameters within which they may offer assistance
to those with these conditions. Persons with gender identity disorders, their
families, and social institutions may use the SOC to understand the current
thinking of professionals. All readers should be aware of the limitations
of knowledge in this area and of the hope that some of the clinical uncertainties
will be resolved in the future through scientific investigation.
The Overarching Treatment Goal. The general goal of psychotherapeutic,
endocrine, or surgical therapy for persons with gender identity disorders
is lasting personal comfort with the gendered self in order to maximize overall
psychological well-being and self-fulfillment.
The Standards of Care Are Clinical Guidelines. The SOC are intended
to provide flexible directions for the treatment of persons with gender identity
disorders. When eligibility requirements are stated they are meant to be
minimum requirements. Individual professionals and organized programs may
modify them. Clinical departures from these guidelines may come about because
of a patient's unique anatomic, social, or psychological situation, an
experienced professional’s evolving method of handling a common situation,
or a research protocol. These departures should be recognized as such, explained
to the patient, and documented both for legal protection and so that the
short and long term results can be retrieved to help the field to evolve.
The Clinical Threshold. A clinical threshold is passed when concerns,
uncertainties, and questions about gender identity persist during a
person’s development, become so intense as to seem to be the most important
aspect of a person's life, or prevent the establishment of a relatively
unconflicted gender identity. The person's struggles are then variously
informally referred to as a gender identity problem, gender dysphoria, a
gender problem, a gender concern, gender distress, gender conflict, or
transsexualism. Such struggles are known to occur from the preschool years
to old age and have many alternate forms. These reflect various degrees of
personal dissatisfaction with sexual identity, sex and gender demarcating
body characteristics, gender roles, gender identity, and the perceptions
of others. When dissatisfied individuals meet specified criteria in one of
two official nomenclatures--the International Classification of Diseases-10
(ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders--Fourth
Edition (DSM-IV)--they are formally designated as suffering from a
gender identity disorder (GID). Some persons with GID exceed another
threshold--they persistently possess a wish for surgical transformation of
their bodies.
Two Primary Populations with GID Exist -- Biological Males and Biological
Females. The sex of a patient always is a significant factor in the
management of GID. Clinicians need to separately consider the biologic, social,
psychological, and economic dilemmas of each sex. All patients, however,
should follow the SOC.
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II. Epidemiological Considerations
Prevalence. When the gender identity disorders first came to professional
attention, clinical perspectives were largely focused on how to identify
candidates for sex reassignment surgery. As the field matured, professionals
recognized that some persons with bona fide gender identity disorders neither
desired nor were candidates for sex reassignment surgery. The earliest estimates
of prevalence for transsexualism in adults were 1 in 37,000 males and 1 in
107,000 females. The most recent prevalence information from the Netherlands
for the transsexual end of the gender identity disorder spectrum is 1 in
11,900 males and 1 in 30,400 females. Four observations, not yet firmly supported
by systematic study, increase the likelihood of an even higher prevalence:
1) unrecognized gender problems are occasionally diagnosed when patients
are seen with anxiety, depression, bipolar disorder, conduct disorder, substance
abuse, dissociative identity disorders, borderline personality disorder,
other sexual disorders and intersexed conditions; 2) some nonpatient male
transvestites, female impersonators, transgender people, and male and female
homosexuals may have a form of gender identity disorder; 3) the intensity
of some persons' gender identity disorders fluctuates below and above a clinical
threshold; 4) gender variance among female-bodied individuals tends to be
relatively invisible to the culture, particularly to mental health professionals
and scientists.
Natural History of Gender Identity Disorders. Ideally, prospective
data about the natural history of gender identity struggles would inform
all treatment decisions. These are lacking, except for the demonstration
that, without therapy, most boys and girls with gender identity disorders
outgrow their wish to change sex and gender. After the diagnosis of GID is
made the therapeutic approach usually includes three elements or phases
(sometimes labeled triadic therapy): a real life experience in the desired
role, hormones of the desired gender, and surgery to change the genitalia
and other sex characteristics. Five less firmly scientifically established
observations prevent clinicians from prescribing the triadic therapy based
on diagnosis alone: 1) some carefully diagnosed persons spontaneously change
their aspirations; 2) others make more comfortable accommodations to their
gender identities without medical interventions; 3) others give up their
wish to follow the triadic sequence during psychotherapy; 4) some gender
identity clinics have an unexplained high drop out rate; and 5) the percentage
of persons who are not benefited from the triadic therapy varies significantly
from study to study. Many persons with GID will desire all three elements
of triadic therapy. Typically, triadic therapy takes place in the order of
hormones = = > real life experience = = > surgery, or sometimes: real
life experience = = > hormones = = > surgery. For some biologic females,
the preferred sequence may be hormones = = > breast surgery = = > real
life experience. However, the diagnosis of GID invites the consideration
of a variety of therapeutic options, only one of which is the complete
therapeutic triad. Clinicians have increasingly become aware that not all
persons with gender identity disorders need or want all three elements of
triadic therapy.
Cultural Differences in Gender Identity Variance throughout the World.
Even if epidemiological studies established that a similar base rate of gender
identity disorders existed all over the world, it is likely that cultural
differences from one country to another would alter the behavioral expressions
of these conditions. Moreover, access to treatment, cost of treatment, the
therapies offered and the social attitudes towards gender variant people
and the professionals who deliver care differ broadly from place to place.
While in most countries, crossing gender boundaries usually generates moral
censure rather than compassion, there are striking examples in certain cultures
of cross-gendered behaviors (e.g., in spiritual leaders) that are not
stigmatized.
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III. Diagnostic Nomenclature
The Five Elements of Clinical Work. Professional involvement with
patients with gender identity disorders involves any of the following: diagnostic
assessment, psychotherapy, real life experience, hormone therapy, and surgical
therapy. This section provides a background on diagnostic assessment.
The Development of a Nomenclature. The term transexxual emerged
into professional and public usage in the 1950s as a means of designating
a person who aspired to or actually lived in the anatomically contrary gender
role, whether or not hormones had been administered or surgery had been
performed. During the 1960s and 1970s, clinicians used the term
true transsexual. The true transsexual was thought to be
a person with a characteristic path of atypical gender identity development
that predicted an improved life from a treatment sequence that culminated
in genital surgery. True transsexuals were thought to have: 1) cross-gender
identifications that were consistently expressed behaviorally in childhood,
adolescence, and adulthood; 2) minimal or no sexual arousal to cross-dressing;
and 3) no heterosexual interest, relative to their anatomic sex. True
transsexuals could be of either sex. True transsexual males were distinguished
from males who arrived at the desire to change sex and gender via a reasonably
masculine behavioral developmental pathway. Belief in the true transsexual
concept for males dissipated when it was realized that such patients were
rarely encountered, and that some of the original true transsexuals had falsified
their histories to make their stories match the earliest theories about the
disorder. The concept of true transsexual females never created diagnostic
uncertainties, largely because patient histories were relatively consistent
and gender variant behaviors such as female cross-dressing remained unseen
by clinicians. The term "gender dysphoria syndrome" was later adopted to
designate the presence of a gender problem in either sex until psychiatry
developed an official nomenclature.
The diagnosis of Transsexualism was introduced in the DSM-III in 1980 for
gender dysphoric individuals who demonstrated at least two years of continuous
interest in transforming the sex of their bodies and their social gender
status. Others with gender dysphoria could be diagnosed as Gender Identity
Disorder of Adolescence or Adulthood, Nontranssexual Type; or Gender Identity
Disorder Not Otherwise Specified (GIDNOS). These diagnostic terms were usually
ignored by the media, which used the term transsexual for any person who
wanted to change his/her sex and gender.
The DSM-IV. In 1994, the DSM-IV committee replaced the diagnosis of
Transsexualism with Gender Identity Disorder. Depending on their age, those
with a strong and persistent cross-gender identification and a persistent
discomfort with their sex or a sense of inappropriateness in the gender role
of that sex, were to be diagnosed as Gender Identity Disorder of Childhood
(302.6), Adolescence, or Adulthood (302.85). For persons who did not meet
these criteria, Gender Identity Disorder Not Otherwise Specified
(GIDNOS)(302.6) was to be used. This category included a variety of individuals,
including those who desired only castration or penectomy without a desire
to develop breasts, those who wished hormone therapy and mastectomy without
genital reconstruction, those with a congenital intersex condition, those
with transient stress-related cross-dressing, and those with considerable
ambivalence about giving up their gender status. Patients diagnosed with
GID and GIDNOS were to be subclassified according to the sexual orientation:
attracted to males; attracted to females; attracted to both; or attracted
to neither. This subclassification was intended to assist in determining,
over time, whether individuals of one sexual orientation or another experienced
better outcomes using particular therapeutic approaches; it was not
intended to guide treatment decisions.
Between the publication of DSM-III and DSM-IV, the term "transgender" began
to be used in various ways. Some employed it to refer to those with unusual
gender identities in a value-free manner – that is, without a connotation
of psychopathology. Some people informally used the term to refer to any
person with any type of gender identity issues. Transgender is not a formal
diagnosis, but many professionals and members of the public found it easier
to use informally than GIDNOS, which is a formal diagnosis.
The ICD-10. The ICD-10 now provides five diagnoses for the gender
identity disorders (F64):
Transsexualism (F64.0) has three criteria:
1. The desire to live and be accepted as a member of the opposite sex, usually
accompanied by the wish to make his or her body as congruent as possible
with the preferred sex through surgery and hormone treatment;
2. The transsexual identity has been present persistently for at least two
years;
3. The disorder is not a symptom of another mental disorder or a chromosomal
abnormality.
Dual-role Transvestism (F64.1) has three criteria:
1. The individual wears clothes of the opposite sex in order to experience
temporary membership in the opposite sex;
2. There is no sexual motivation for the cross-dressing;
3. The individual has no desire for a permanent change to the opposite sex.
Gender Identity Disorder of Childhood (64.2) has separate criteria
for girls and for boys.
For girls:
1. The individual shows persistent and intense distress about being a girl,
and has a stated desire to be a boy (not merely a desire for any perceived
cultural advantages to being a boy) or insists that she is a boy;
2. Either of the following must be present:
-
Persistent marked aversion to normative feminine clothing and insistence
on wearing stereotypical masculine clothing;
-
Persistent repudiation of female anatomical structures, as evidenced by at
least one of the following:
-
An assertion that she has, or will grow, a penis;
-
Rejection of urination in a sitting position;
-
Assertion that she does not want to grow breasts or menstruate.
3. The girl has not yet reached puberty;
4. The disorder must have been present for at least 6 months.
For boys:
1. The individual shows persistent and intense distress about being a boy,
and has a desire to be a girl, or, more rarely, insists that he is a girl.
2. Either of the following must be present:
-
Preoccupation with stereotypic female activities, as shown by a preference
for either cross-dressing or simulating female attire, or by an intense desire
to participate in the games and pastimes of girls and rejection of stereotypical
male toys, games, and activities;
-
Persistent repudiation of male anatomical structures, as evidenced by at
least one of the following repeated assertions:
-
That he will grow up to become a woman (not merely in the role);
-
That his penis or testes are disgusting or will disappear;
-
That it would be better not to have a penis or testes.
3. The boy has not yet reached puberty;
4. The disorder must have been present for at least 6 months.
Other Gender Identity Disorders (F64.8) has no specific criteria.
Gender Identity Disorder, Unspecified has no specific criteria.
Either of the previous two diagnoses could be used for those with an intersexed
condition.
The purpose of the DSM-IV and ICD-10 is to guide treatment and research.
Different professional groups created these nomenclatures through consensus
processes at different times. There is an expectation that the differences
between the systems will be eliminated in the future. At this point, the
specific diagnoses are based more on clinical reasoning than on scientific
investigation.
Are Gender Identity Disorders Mental Disorders? To qualify as a mental
disorder, a behavioral pattern must result in a significant adaptive disadvantage
to the person and cause personal mental suffering. The DSM-IV and ICD-10
have defined hundreds of mental disorders which vary in onset, duration,
pathogenesis, functional disability, and treatability. The designation of
gender identity disorders as mental disorders is not a license for
stigmatization, or for the deprivation of gender patients' civil rights.
The use of a formal diagnosis is often important in offering relief, providing
health insurance coverage, and guiding research to provide more effective
future treatments.
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IV. The Mental Health Professional
The Ten Tasks of the Mental Health Professional. Mental health professionals
(MHPs) who work with individuals with gender identity disorders may be regularly
called upon to carry out many of these responsibilities:
-
To accurately diagnose the individual's gender disorder;
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To accurately diagnose any co-morbid psychiatric conditions and see to their
appropriate treatment;
-
To counsel the individual about the range of treatment options and their
implications;
-
To engage in psychotherapy;
-
To ascertain eligibility and readiness for hormone and surgical therapy;
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To make formal recommendations to medical and surgical colleagues;
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To document their patient's relevant history in a letter of recommendation;
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To be a colleague on a team of professionals with an interest in the gender
identity disorders;
-
To educate family members, employers, and institutions about gender identity
disorders;
-
To be available for follow-up of previously seen gender patients.
The Adult-Specialist. The education of the mental health professional
who specializes in adult gender identity disorders rests upon basic general
clinical competence in diagnosis and treatment of mental or emotional disorders.
Clinical training may occur within any formally credentialing discipline
-- for example, psychology, psychiatry, social work, counseling, or nursing.
The following are the recommended minimal credentials for special competence
with the gender identity disorders:
-
A master's degree or its equivalent in a clinical behavioral science field.
This or a more advanced degree should be granted by an institution accredited
by a recognized national or regional accrediting board. The mental health
professional should have documented credentials from a proper training facility
and a licensing board.
-
Specialized training and competence in the assessment of the DSM-IV/ICD-10
Sexual Disorders (not simply gender identity disorders).
-
Documented supervised training and competence in psychotherapy.
-
Continuing education in the treatment of gender identity disorders, which
may include attendance at professional meetings, workshops, or seminars or
participating in research related to gender identity issues.
The Child-Specialist. The professional who evaluates and offers therapy
for a child or early adolescent with GID should have been trained in childhood
and adolescent developmental psychopathology. The professional should be
competent in diagnosing and treating the ordinary problems of children
and adolescents. These requirements are in addition to the adult-specialist
requirement.
The Differences between Eligibility and Readiness. The SOC provide
recommendations for eligibility requirements for hormones and surgery. Without
first meeting these recommended eligibility requirements, the patient and
the therapist should not request hormones or surgery. An example of an
eligibility requirement is: a person must live full time in the preferred
gender for twelve months prior to genital surgery. To meet this criterion,
the professional needs to document that the real life experience has occurred
for this duration. Meeting readiness criteria -- further consolidation of
the evolving gender identity or improving mental health in the new or confirmed
gender role -- is more complicated, because it rests upon the clinician's
and the patient’s judgment.
The Mental Health Professional's Relationship to the Prescribing Physician
and Surgeon. Mental health professionals who recommend hormonal and surgical
therapy share the legal and ethical responsibility for that decision with
the physician who undertakes the treatment. Hormonal treatment can
often alleviate anxiety and depression in people without the use of additional
psychotropic medications. Some individuals, however, need psychotropic medication
prior to, or concurrent with, taking hormones or having surgery. The mental
health professional is expected to make this assessment, and see that the
appropriate psychotropic medications are offered to the patient. The presence
of psychiatric co-morbidities does not necessarily preclude hormonal
or surgical treatment, but some diagnoses pose difficult treatment dilemmas
and may delay or preclude the use of either treatment.
The Mental Health Professional’s Documentation Letters for Hormone
Therapy or Surgery Should Succinctly Specify:
-
The patient's general identifying characteristics;
-
The initial and evolving gender, sexual, and other psychiatric diagnoses;
-
The duration of their professional relationship including the type of
psychotherapy or evaluation that the patient underwent;
-
The eligibility criteria that have been met and the mental health
professional’s rationale for hormone therapy or surgery;
-
The degree to which the patient has followed the Standards of Care to date
and the likelihood of future compliance;
-
Whether the author of the report is part of a gender team;
-
That the sender welcomes a phone call to verify the fact that the mental
health professional actually wrote the letter as described in this document.
The organization and completeness of these letters provide the
hormone-prescribing physician and the surgeon an important degree of assurance
that mental health professional is knowledgeable and competent concerning
gender identity disorders.
One Letter if Required for Instituting Hormone Therapy, or for Breast
Surgery.
One letter from a mental health professional, including the above seven points,
written to the physician who will be responsible for the patient’s medical
treatment, is sufficient for instituting hormone therapy or for a referral
for breast surgery (e.g., mastectomy, chest reconstruction, or augmentation
mammoplasty).
Two Letters are Generally Required for Genital Surgery.
Genital surgery for biologic males may include orchiectomy, penectomy,
clitoroplasty, labiaplasty or creation of a neovagina; for biologic females
it may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty,
scrotoplasty, urethroplasty, placement of testicular prostheses, or creation
of a neophallus.
It is ideal if mental health professionals conduct their tasks and periodically
report on these processes as part of a team of other mental health professionals
and nonpsychiatric physicians. One letter to the physician performing genital
surgery will generally suffice as long as two mental health professionals
sign it.
More commonly, however, letters of recommendation are from mental health
professionals who work alone without colleagues experienced with gender identity
disorders. Because professionals working independently may not have the benefit
of ongoing professional consultation on gender cases, two letters of
recommendation are required prior to initiating genital surgery. If the first
letter is from a person with a master's degree, the second letter should
be from a psychiatrist or a Ph.D. clinical psychologist, who can be expected
to adequately evaluate co-morbid psychiatric conditions. If the first letter
is from the patient's psychotherapist, the second letter should be from a
person who has only played an evaluative role for the patient. Each letter,
however, is expected to cover the same topics. At least one of the letters
should be an extensive report. The second letter writer, having read the
first letter, may choose to offer a briefer summary and an agreement with
the recommendation.
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V. Assessment and Treatment of Children and
Adolescents
Phenomenology. Gender identity disorders in children and adolescents are
different from those seen in adults, in that a rapid and dramatic developmental
process (physical, psychological and sexual) is involved. Gender identity
disorders in children and adolescents are complex conditions. The young person
may experience his or her phenotype sex as inconsistent with his or her own
sense of gender identity. Intense distress is often experienced, particularly
in adolescence, and there are frequently associated emotional and behavioral
difficulties. There is greater fluidity and variability in outcomes, especially
in pre-pubertal children. Only a few gender variant youths become transsexual,
although many eventually develop a homosexual orientation.
Commonly seen features of gender identity conflicts in children and adolescents
include a stated desire to be the other sex; cross dressing; play with games
and toys usually associated with the gender with which the child identifies;
avoidance of the clothing, demeanor and play normally associated with the
child’s sex and gender of assignment; preference for playmates or friends
of the sex and gender with which the child identifies; and dislike of bodily
sex characteristics and functions. Gender identity disorders are more often
diagnosed in boys.
Phenomenologically, there is a qualitative difference between the way children
and adolescents present their sex and gender predicaments, and the presentation
of delusions or other psychotic symptoms. Delusional beliefs about their
body or gender can occur in psychotic conditions but they can be distinguished
from the phenomenon of a gender identity disorder. Gender identity disorders
in childhood are not equivalent to those in adulthood and the former do not
inevitably lead to the latter. The younger the child the less certain and
perhaps more malleable the outcome.
Psychological and Social Interventions. The task of the child-specialist
mental health professional is to provide assessment and treatment that broadly
conforms to the following guidelines:
-
The professional should recognize and accept the gender identity problem.
Acceptance and removal of secrecy can bring considerable relief.
-
The assessment should explore the nature and characteristics of the child’s
or adolescent’s gender identity. A complete psychodiagnostic and psychiatric
assessment should be performed. A complete assessment should include a family
evaluation, because other emotional and behavioral problems are very common,
and unresolved issues in the child’s environment are often present.
-
Therapy should focus on ameliorating any comorbid problems in the child’s
life, and on reducing distress the child experiences from his or her gender
identity problem and other difficulties. The child and family should be supported
in making difficult decisions regarding the extent to which to allow the
child to assume a gender role consistent with his or her gender identity.
This includes issues of whether to inform others of the child’s situation,
and how others in the child’s life should respond; for example, whether
the child should attend school using a name and clothing opposite to his
or her sex of assignment. They should also be supported in tolerating uncertainty
and anxiety in relation to the child’s gender expression and how best
to manage it. Professional network meetings can be very useful in finding
appropriate solutions to these problems.
Physical Interventions. Before any physical intervention is considered,
extensive exploration of psychological, family and social issues should be
undertaken. Physical interventions should be addressed in the context of
adolescent development. Adolescents’ gender identity development can
rapidly and unexpectedly evolve. An adolescent shift toward gender conformity
can occur primarily to please the family, and may not persist or reflect
a permanent change in gender identity. Identity beliefs in adolescents may
become firmly held and strongly expressed, giving a false impression of
irreversibility; more fluidity may return at a later stage. For these reasons,
irreversible physical interventions should be delayed as long as is clinically
appropriate. Pressure for physical interventions because of an adolescent’s
level of distress can be great and in such circumstances a referral to a
child and adolescent multi-disciplinary specialty service should be considered,
in locations where these exist.
Physical interventions fall into three categories or stages:
-
Fully reversible interventions. These involve the use of LHRH agonists or
medroxyprogesterone to suppress estrogen or testosterone production, and
consequently to delay the physical changes of puberty.
-
Partially reversible interventions. These include hormonal interventions
that masculinize or feminize the body, such as administration of testosterone
to biologic females and estrogen to biologic males. Reversal may involve
surgical intervention.
-
Irreversible interventions. These are surgical procedures.
A staged process is recommended to keep options open through the first two
stages. Moving from one state to another should not occur until there has
been adequate time for the young person and his/her family to assimilate
fully the effects of earlier interventions.
Fully Reversible Interventions. Adolescents may be eligible
for puberty-delaying hormones as soon as pubertal changes have begun. In
order for the adolescent and his or her parents to make an informed decision
about pubertal delay, it is recommended that the adolescent experience the
onset of puberty in his or her biologic sex, at least to Tanner Stage Two.
If for clinical reasons it is thought to be in the patient’s interest
to intervene earlier, this must be managed with pediatric endocrinological
advice and more than one psychiatric opinion.
Two goals justify this intervention: a) to gain time to further explore the
gender identity and other developmental issues in psychotherapy; and b) to
make passing easier if the adolescent continues to pursue sex and gender
change. In order to provide puberty delaying hormones to an adolescent, the
following criteria must be met:
-
throughout childhood the adolescent has demonstrated an intense pattern of
cross-sex and cross-gender identity and aversion to expected gender role
behaviors;
-
sex and gender discomfort has significantly increased with the onset of puberty;
-
the family consents and participates in the therapy.
Biologic males should be treated with LHRH agonists (which stop LH secretion
and therefore testosterone secretion), or with progestins or antiandrogens
(which block testosterone secretion or neutralize testosterone action). Biologic
females should be treated with LHRH agonists or with sufficient progestins
(which stop the production of estrogens and progesterone) to stop menstruation.
Partially Reversible Interventions. Adolescents may be eligible to
begin masculinizing or feminizing hormone therapy as early as age 16, preferably
with parental consent. In many countries 16-year olds are legal adults for
medical decision making, and do not require parental consent.
Mental health professional involvement is an eligibility requirement for
triadic therapy during adolescence. For the implementation of the real life
experience or hormone therapy, the mental health professional should be involved
with the patient and family for a minimum of six months. While the number
of sessions during this six-month period rests upon the clinician’s
judgement, the intent is that hormones and the real life experience be
thoughtfully and recurrently considered over time. In those patients who
have already begun the real life experience prior to being seen, the professional
should work closely with them and their families with the thoughtful recurrent
consideration of what is happening over time.
Irreversible Interventions. Any surgical intervention should not be
carried out prior to adulthood, or prior to a real life experience of at
least two years in the gender role of the sex with which the adolescent
identifies. The threshold of 18 should be seen as an eligibility criterion
and not an indication in itself for active intervention.
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VI. Psychotherapy with Adults
A Basic Observation. Many adults with gender identity disorder find comfortable,
effective ways of living that do not involve all the components of the triadic
treatment sequence. While some individuals manage to do this on their
own, psychotherapy can be very helpful in bringing about the discovery and
maturational processes that enable self-comfort.
Psychotherapy is Not an Absolute Requirement for Triadic Therapy. Not
every adult gender patient requires psychotherapy in order to proceed with
hormone therapy, the real life experience, hormones, or surgery. Individual
programs vary to the extent that they perceive a need for psychotherapy.
When the mental health professional's initial assessment leads to
a recommendation for psychotherapy, the clinician should specify the goals
of treatment, and estimate its frequency and duration. There is no required
minimum number of psychotherapy sessions prior to hormone therapy, the real
life experience, or surgery, for three reasons: 1) patients differ widely
in their abilities to attain similar goals in a specified time; 2) a minimum
number of sessions tends to be construed as a hurdle, which discourages the
genuine opportunity for personal growth; 3) the mental health professional
can be an important support to the patient throughout all phases of gender
transition. Individual programs may set eligibility criteria to some minimum
number of sessions or months of psychotherapy.
The mental health professional who conducts the initial evaluation need not
be the psychotherapist. If members of a gender team do not do psychotherapy,
the psychotherapist should be informed that a letter describing the patient's
therapy might be requested so the patient can proceed with the next
phase of treatment.
Goals of Psychotherapy. Psychotherapy often provides education about
a range of options not previously seriously considered by the patient. It
emphasizes the need to set realistic life goals for work and relationships,
and it seeks to define and alleviate the patient's conflicts that may have
undermined a stable lifestyle.
The Therapeutic Relationship. The establishment of a reliable trusting
relationship with the patient is the first step toward successful work as
a mental health professional. This is usually accomplished by competent
nonjudgmental exploration of the gender issues with the patient during the
initial diagnostic evaluation. Other issues may be better dealt with later,
after the person feels that the clinician is interested in and understands
their gender identity concerns. Ideally, the clinician's work is with the
whole of the person's complexity. The goals of therapy are to help the person
to live more comfortably within a gender identity and to deal effectively
with non-gender issues. The clinician often attempts to facilitate the capacity
to work and to establish or maintain supportive relationships. Even when
these initial goals are attained, mental health professionals should discuss
the likelihood that no educational, psychotherapeutic, medical, or surgical
therapy can permanently eradicate all vestiges of the person's original sex
assignment and previous gendered experience.
Processes of Psychotherapy. Psychotherapy is a series of interactive
communications between a therapist who is knowledgeable about how people
suffer emotionally and how this may be alleviated, and a patient who is
experiencing distress. Typically, psychotherapy consists of regularly held
50-minutes sessions. The psychotherapy sessions initiate a developmental
process. They enable the patient’s history to be appreciated,
current dilemmas to be understood, and unrealistic ideas and maladaptive
behaviors to be identified. Psychotherapy is not intended to cure the gender
identity disorder. Its usual goal is a long-term stable life style with realistic
chances for success in relationships, education, work, and gender identity
expression. Gender distress often intensifies relationship, work, and educational
dilemmas.
The therapist should make clear that it is the patient's right to choose
among many options. The patient can experiment over time with alternative
approaches.
Ideally, psychotherapy is a collaborative effort. The therapist must be certain
that the patient understands the concepts of eligibility and readiness, because
the therapist and patient must cooperate in defining the patient's problems,
and in assessing progress in dealing with them. Collaboration can prevent
a stalemate between a therapist who seems needlessly withholding of a
recommendation, and a patient who seems too profoundly distrusting to freely
share thoughts, feelings, events, and relationships.
Patients may benefit from psychotherapy at every stage of gender evolution.
This includes the post-surgical period, when the anatomic obstacles to gender
comfort have been removed, but the person may continue to feel a lack of
genuine comfort and skill in living in the new gender role.
Options for Gender Adaptation. The activities and processes that are
listed below have, in various combinations, helped people to find more personal
comfort. These adaptations may evolve spontaneously and during
psychotherapy. Finding new gender adaptations does not mean that the person
may not in the future elect to pursue hormone therapy, the real life experience,
or genital surgery.
Activities
Biological Males
-
Cross-dressing: unobtrusively with undergarments; unisexually; or in a feminine
fashion;
-
Changing the body through: hair removal through electrolysis or body waxing;
minor plastic cosmetic surgical procedures;
-
Increasing grooming, wardrobe, and vocal expression skills.
B>Biological Females
-
Cross-dressing: unobtrusively with undergarments, unisexually, or in a masculine
fashion;
-
Changing the body through breast binding, weight lifting, applying theatrical
facial hair;
-
Padding underpants or wearing a penile prosthesis.
Both Genders
-
Learning about transgender phenomena from: support groups and gender networks,
communication with peers via the Internet, studying these Standards of Care,
relevant lay and professional literatures about legal rights pertaining to
work, relationships, and public cross-dressing;
-
Involvement in recreational activities of the desired gender;
-
Episodic cross-gender living.
Processes
-
Acceptance of personal homosexual or bisexual fantasies and behaviors
(orientation) as distinct from gender identity and gender role aspirations;
-
Acceptance of the need to maintain a job, provide for the emotional needs
of children, honor a spousal commitment, or not to distress a family member
as currently having a higher priority than the personal wish for constant
cross-gender expression;
-
Integration of male and female gender awareness into daily living;
-
Identification of the triggers for increased cross-gender yearnings and
effectively attending to them; for instance, developing better self-protective,
self-assertive, and vocational skills to advance at work and resolve
interpersonal struggles to strengthen key relationships.
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VII. Requirements for Hormone Therapy for
Adults
Reasons for Hormone Therapy. Cross-sex hormonal treatments play an important
role in the anatomical and psychological gender transition process for properly
selected adults with gender identity disorders. Hormones are often medically
necessary for successful living in the new gender. They improve the quality
of life and limit psychiatric co-morbidity, which often accompanies lack
of treatment. When physicians administer androgens to biologic females and
estrogens, progesterone, and testosterone-blocking agents to biologic males,
patients feel and appear more like members of their preferred gender.
Eligibility Criteria. The administration of hormones is not to be
lightly undertaken because of their medical and social risks. Three
criteria exist.
-
Age 18 years;
-
Demonstrable knowledge of what hormones medically can and cannot do and their
social benefits and risks;
-
Either:
a. A documented real life experience of at least three months prior to the
administration of hormones; or
b. A period of psychotherapy of a duration specified by the mental health
professional after the initial evaluation (usually a minimum of three months).
In selected circumstances, it can be acceptable to provide hormones to patients
who have not fulfilled criterion 3 – for example, to facilitate the
provision of monitored therapy using hormones of known quality, as an alternative
to black-market or unsupervised hormone use.
Readiness Criteria. Three criteria exist:
-
The patient has had further consolidation of gender identity during the real-life
experience or psychotherapy;
-
The patient has made some progress in mastering other identified problems
leading to improving or continuing stable mental health (this implies
satisfactory control of problems such as sociopathy, substance abuse, psychosis
and suicidality;
-
The patient is likely to take hormones in a responsible manner.
Can Hormones Be Given To Those Who Do Not Want Surgery or a Real-life
Experience? Yes, but after diagnosis and psychotherapy with a qualified
mental health professional following minimal standards listed above. Hormone
therapy can provide significant comfort to gender patients who do not wish
to cross live or undergo surgery, or who are unable to do so. In some patients,
hormone therapy alone may provide sufficient symptomatic relief to obviate
the need for cross living or surgery.
Hormone Therapy and Medical Care for Incarcerated Persons. Persons
who are receiving treatment for gender identity disorders should continue
to receive appropriate treatment following these Standards of Care after
incarceration. For example, those who are receiving psychotherapy and/or
cross-sex hormonal treatments should be allowed to continue this medically
necessary treatment to prevent or limit emotional lability, undesired regression
of hormonally-induced physical effects and the sense of desperation that
may lead to depression, anxiety and suicidality. Prisoners who are subject
to rapid withdrawal of cross-sex hormones are particularly at risk for
psychiatric symptoms and self-injurious behaviors. Medical monitoring of
hormonal treatment as described in these Standards should also be provided.
Housing for transgendered prisoners should take into account their transition
status and their personal safety.
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VIII. Effects of Hormone Therapy in Adults
The maximum physical effects of hormones may not be evident until two years
of continuous treatment. Heredity limits the tissue response to hormones
and this cannot be overcome by increasing dosage. The degree of effects actually
attained varies from patient to patient.
Desired Effects of Hormones. Biologic males treated with estrogens
can realistically expect treatment to result in: breast growth, some
redistribution of body fat to approximate a female body habitus, decreased
upper body strength, softening of skin, decrease in body hair, slowing or
stopping the loss of scalp hair, decreased fertility and testicular size,
and less frequent, less firm erections. Most of these changes are reversible,
although breast enlargement will not completely reverse after discontinuation
of treatment.
Biologic females treated with testosterone can expect the following
permanent changes: a deepening of the voice, clitoral enlargement, mild breast
atrophy, increased facial and body hair and male pattern baldness. Reversible
changes include increased upper body strength, weight gain, increased social
and sexual interest and arousability, and decreased hip fat.
Potential Negative Medical Side Effects. Patients with medical problems
or otherwise at risk for cardiovascular disease may be more likely to experience
serious or fatal consequences of cross-sex hormonal treatments. For example,
cigarette smoking, obesity, advanced age, heart disease, hypertension, clotting
abnormalities, malignancy, and some endocrine abnormalities may increase
side effects and risks for hormonal treatment. Therefore, some patients may
not be able to tolerate cross-sex hormones. However, hormones can provide
health benefits as well as risks. Risk-benefit ratios should be considered
collaboratively by the patient and prescribing physician.
Side effects in biologic males treated with estrogens and progestins may
include increased propensity to blood clotting (venous thrombosis with a
risk of fatal pulmonary embolism), development of benign pituitary prolactinomas,
infertility, weight gain, emotional lability, liver disease, gallston formation,
somnolence, hypertension, and diabetes mellitus.
Side effects in biologic females treated with testosterone may include
infertility, acne, emotional lability, increases in sexual desire, shift
of lipid profiles to male patterns which increase the risk of cardiovascular
disease, and the potential to develop benign and malignant liver tumors and
hepatic dysfunction.
The Prescribing Physician's Responsibilities. Hormones are to be
prescribed by a physician, and should not be administered without adequate
psychological and medical assessment before and during treatment. Patients
who do not understand the eligibility and readiness requirements and who
are unaware of the SOC should be informed of them. This may be a good indication
for a referral to a mental health professional experienced with gender identity
disorders.
The physician providing hormonal treatment and medical monitoring need not
be a specialist in endocrinology, but should become well-versed in the relevant
medical and psychological aspects of treating persons with gender identity
disorders.
After a thorough medical history, physical examination, and laboratory
examination, the physician should again review the likely effects and side
effects of hormone treatment, including the potential for serious,
life-threatening consequences. The patient must have the capacity to appreciate
the risks and benefits of treatment, have his/her questions answered, and
agree to medical monitoring of treatment. The medical record must contain
a written informed consent document reflecting a discussion of the risks
and benefits of hormone therapy.
Physicians have a wide latitude in what hormone preparations they may prescribe
and what routes of administration they may select for individual patients.
Viable options include oral, injectable, and transdermal delivery systems.
The use of transdermal estrogen patches should be considered for males over
40 years of age or those with clotting abnormalities or a history of venous
thrombosis. Transdermal testosterone is useful in females who do not want
to take injections. In the absence of any other medical, surgical, or psychiatric
conditions, basic medical monitoring should include: serial physical examinations
relevant to treatment effects and side effects, vital sign measurements before
and during treatment, weight measurements, and laboratory assessment. Gender
patients, whether on hormones or not, should be screened for pelvic malignancies
as are other persons.
For those receiving estrogens, the minimum laboratory assessment should consist
of a pretreatment free testosterone level, fasting glucose, liver function
tests, and complete blood count with reassessment at 6 and 12 months and
annually thereafter. A pretreatment prolactin level should be obtained and
repeated at 1, 2, and 3 years. If hyperprolactemia does not occur during
this time, no further measurements are necessary. Biologic males undergoing
estrogen treatment should be monitored for breast cancer and encouraged to
engage in routine self-examination. As they age, they should be monitored
for prostatic cancer.
For those receiving androgens, the minimum laboratory assessment should consist
of pretreatment liver function tests and complete blood count with reassessment
at 6 months, 12 months, and yearly thereafter. Yearly palpation of the liver
should be considered. Females who have undergone mastectomies and who have
a family history of breast cancer should be monitored for this disease.
Physicians may provide their patients with a brief written statement indicating
that the person is under medical supervision, which includes cross-sex hormone
therapy. During the early phases of hormone treatment, the patient may be
encouraged to carry this statement at all times to help prevent difficulties
with the police and other authorities.
Reductions in Hormone Doses After Gonadectomy. Estrogen doses
in post-orchiectomy patients can often be reduced by 1/3 to ½ and still
maintain feminization. Reductions in testosterone doses post-oophorectomy
should be considered, taking into account the risks of osteoporosis. Lifelong
maintenance treatment is usually required in all gender patients.
The Misuse of Hormones. Some individuals obtain hormones without
prescription from friends, family members, and pharmacies in other countries.
Medically unmonitored hormone use can expose the person to greater medical
risk. Persons taking medically monitored hormones have been known to take
additional doses of illicitly obtained hormones without their physician's
knowledge. Mental health professionals and prescribing physicians should
make an effort to encourage compliance with recommended dosages, in order
to limit morbidity. It is ethical for physicians to discontinue treatment
of patients who do not comply with prescribed treatment regimens.
Other Potential Benefits of Hormones. Hormonal treatment, when medically
tolerated, should precede any genital surgical interventions. Satisfaction
with the hormone's effects consolidates the person's identity as a member
of the preferred sex and gender and further adds to the conviction to proceed.
Dissatisfaction with hormonal effects may signal ambivalence about proceeding
to surgical interventions. In biologic males, hormones alone often generate
adequate breast development, precluding the need for augmentation mammaplasty.
Some patients who receive hormonal treatment will not desire genital or other
surgical interventions.
The Use of Antiandrogens and Sequential Therapy. Antiandrogens can
be used as adjunctive treatments in biologic males receiving estrogens, though
they are not always necessary to achieve feminization. In some patients,
antiandrogens may more profoundly suppress the production of testosterone,
enabling a lower dose of estrogen to be used when adverse estrogen side effects
are anticipated.
Feminization does not require sequential therapy. Attempts to mimic the menstrual
cycle by prescribing interrupted estrogen therapy or substituting progesterone
for estrogen during part of the month are not necessary to achieve feminization.
Informed Consent. Hormonal treatment should be provided only to those
who are legally able to provide informed consent. This includes persons who
have been declared by a court to be emancipated minors and incarcerated persons
who are considered competent to participate in their medical decisions. For
adolescents, informed consent needs to include the minor patient's assent
and the written informed consent of a parent or legal guardian.
Reproductive Options. Informed consent implies that the patient
understands that hormone administration limits fertility and that the removal
of sexual organs prevents the capacity to reproduce. Cases are known of persons
who have received hormone therapy and sex reassignment surgery who later
regretted their inability to parent genetically related children. The mental
health professional recommending hormone therapy, and the physician prescribing
such therapy, should discuss reproductive options with the patient prior
to starting hormone therapy. Biologic males, especially those who have not
already reproduced, should be informed about sperm preservation options,
and encouraged to consider banking sperm prior to hormone therapy. Biologic
females do not presently have readily available options for gamete preservation,
other than cryopreservation of fertilized embryos. However, they should be
informed about reproductive issues, including this option. As other options
become available, these should be presented.
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IX. The Real-life Experience
The act of fully adopting a new or evolving gender role or gender presentation
in everyday life is known as the real-life experience. The real-life experience
is essential to the transition to the gender role that is congruent with
the patient’s gender identity. Since changing one's gender presentation
has immediate profound personal and social consequences, the decision to
do so should be preceded by an awareness of what the familial, vocational,
interpersonal, educational, economic, and legal consequences are likely to
be. Professionals have a responsibility to discuss these predictable consequences
with their patients. Change of gender role and presentation can be a factor
in employment discrimination, divorce, marital problems, and the restriction
or loss of visitation rights with children. These represent external reality
issues that must be confronted for success in the new gender presentation.
These consequences may be quite different from what the patient imagined
prior to undertaking the real-life experiences. However, not all changes
are negative.
Parameters of the Real-life Experience. When clinicians assess the
quality of a person's real-life experience in the desired gender, the following
abilities are reviewed:
-
To maintain full or part-time employment;
-
To function as a student;
-
To function in community-based volunteer activity;
-
To undertake some combination of items 1-3;
-
To acquire a (legal) gender-identity-appropriate first name;
-
To provide documentation that persons other than the therapist know that
the patient functions in the desired gender role.
Real-life Experience versus Real-life Test. Although
professionals may recommend living in the desired gender, the decision as
to when and how to begin the real-life experience remains the person's
responsibility. Some begin the real-life experience and decide that this
often imagined life direction is not in their best interest. Professionals
sometimes construe the real-life experience as the real-life test of the
ultimate diagnosis. If patients prosper in the preferred gender, they are
confirmed as "transsexual," but if they decided against continuing, they
"must not have been." This reasoning is a confusion of the forces that enable
successful adaptation with the presence of a gender identity disorder. The
real-life experience tests the person's resolve, the capacity to function
in the preferred gender, and the adequacy of social, economic, and psychological
supports. It assists both the patient and the mental health professional
in their judgments about how to proceed. Diagnosis, although always open
for reconsideration, precedes a recommendation for patients to embark on
the real-life experience. When the patient is successful in the real-life
experience, both the mental health professional and the patient gain confidence
about undertaking further steps.
Removal of Beard and other Unwanted Hair for the Male to Female Patient.
Beard density is not significantly slowed by cross-sex hormone
administration. Facial hair removal via electrolysis is a generally safe,
time-consuming process that often facilitates the real-life experience for
biologic males. Side effects include discomfort during and immediately after
the procedure and less frequently hypo- or hyper-pigmentation, scarring,
and folliculitis. Formal medical approval for hair removal is not necessary;
electrolysis may be begun whenever the patient deems it prudent. It is usually
recommended prior to commencing the real-life experience, because the beard
must grow out to visible lengths to be removed. Many patients will require
two years of regular treatments to effectively eradicate their facial hair.
Hair removal by laser is a new alternative approach, but experience with
it is limited.
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X. Surgery
Sex Reassignment is Effective and Medically Indicated in Severe GID. In persons
diagnosed with transsexualism or profound GID, sex reassignment surgery,
along with hormone therapy and real life experience, is a treatment that
has proven to be effective. Such a therapeutic regimen, when prescribed or
recommended by qualified practitioners, is medically indicated and medically
necessary. Sex reassignment is not "experimental," "investigational," "elective,"
"cosmetic," or optional in any meaningful sense. It constitutes very effective
and appropriate treatment for transsexualism or profound GID.
How to Deal with Ethical Questions Concerning Sex Reassignment Surgery.
Many persons, including some medical professionals, object on ethical
grounds to surgery for GID. In ordinary surgical practice, pathological tissues
are removed in order to restore disturbed functions, or alterations are made
to body features to improve the patient’s self image. Among those who
object to sex reassignment surgery, these conditions are not thought to present
when surgery is performed for persons with gender identity disorders. It
is important that professionals dealing with patients with gender identity
disorders feel comfortable about altering anatomically normal structures.
In order to understand how surgery can alleviate the psychological discomfort
of patients diagnosed with gender identity disorders, professionals need
to listen to these patients, discuss their life histories and dilemmas. The
resistance against performing surgery on the ethical basis of "above all
do no harm" should be respected, discussed, and met with the opportunity
to learn from patients themselves about the psychological distress of having
profound gender identity disorder.
It is unethical to deny availability or eligibility for sex reassignment
surgeries or hormone therapy solely on the basis of blood seropositivity
for blood-borne infections such as HIV, or hepatitis B or C, etc.
The Surgeon’s Relationship with the Physician Prescribing Hormones
and the Mental Health Professional. The surgeon is not merely a technician
hired to perform a procedure. The surgeon is part of the team of clinicians
participating in a long-term treatment process. The patient often feels an
immense positive regard for the surgeon, which ideally will enable long-term
follow-up care. Because of his or her responsibility to the patient, the
surgeon must understand the diagnosis that has led to the recommendation
for genital surgery. Surgeons should have a chance to speak at length with
their patients to satisfy themselves that the patient is likely to benefit
from the procedures. Ideally, the surgeon should have a close working
relationship with the other professionals who have been actively involved
in the patient’s psychological and medical care. This is best accomplished
by belonging to an interdisciplinary team of professionals who specialize
in gender identity disorders. Such gender teams do not exist everywhere,
however. At the very least, the surgeon needs to be assured that the mental
health professional and physician prescribing hormones are reputable
professionals with specialized experience with gender identity disorders.
This is often reflected in the quality of the documentation letters. Since
fictitious and falsified letters have occasionally been presented, surgeons
should personally communicate with at least one of the mental health
professionals to verify the authenticity of their letters.
Prior to performing any surgical procedures, the surgeon should have all
medical conditions appropriately monitored and the effects of the hormonal
treatment upon the liver and other organ systems investigated. This can be
done alone or in conjunction with medical colleagues. Since pre-existing
conditions may complicate genital reconstructive surgeries, surgeons must
also be competent in urological diagnosis. The medical record should contain
written informed consent for the particular surgery to be performed.
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XI. Breast Surgery
Breast augmentation and removal are common operations, easily obtainable
by the general public for a variety of indications. Reasons for these operations
range from cosmetic indications to cancer. Although breast appearance is
definitely important as a secondary sex characteristic, breast size or presence
are not involved in the legal definitions of sex and gender and are not important
for reproduction. The performance of breast operations should be considered
with the same reservations as beginning hormonal therapy. Both produce relatively
irreversible changes to the body.
The approach to male-to-female patients is different than for female-to-male
patients. For female-to-male patients, a mastectomy procedure is usually
the first surgery preformed for success in gender presentation as a man;
and for some patients it is the only surgery undertaken. When the amount
of breast tissue removed requires skin removal, a scar will result and the
patient should be so informed. Female-to-male patients may have surgery at
the same time they begin hormones. For male-to-female patients, augmentation
mammoplasty may be performed if the physician prescribing hormones and the
surgeon have documented that breast enlargement after undergoing hormone
treatment for 18 months is not sufficient for comfort in the social gender
role.
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XII. Genital Surgery
Eligibility Criteria. These minimum eligibility criteria for various genital
surgeries equally apply to biologic males and females seeking genital surgery.
They are:
-
Legal age of majority in the patient's nation;
-
Usually 12 months of continuous hormonal therapy for those without a medical
contraindication (see below "Can Surgery Be Provided Without Hormones and
the Real-life Experience");
-
12 months of successful continuous full time real-life experience. Periods
of returning to the original gender may indicate ambivalence about proceeding
and generally should not be used to fulfill this criterion;
-
If required by the mental health professional, regular responsible participation
in psychotherapy throughout the real life experience at a frequency determined
jointly by the patient and the mental health professional. Psychotherapy
per se is not an absolute eligibility criterion for surgery;
-
Demonstrable knowledge of the cost, required lengths of hospitalizations,
likely complications, and post-surgical rehabilitation requirements of various
surgical approaches;
-
Awareness of different competent surgeons.
Readiness Criteria. The readiness criteria include:
-
Demonstrable progress in consolidating one’s gender identity;
-
Demonstrable progress in dealing with work, family, and interpersonal issues
resulting in a significantly better state of mental health; this implies
satisfactory control of problems such as sociopathy, substance abuse, psychosis,
suicidality, for instance).
Can Surgery Be Provided Without Hormones and the Real-life Experience?
Individuals cannot receive genital surgery without meeting the eligibility
criteria. Genital surgery is a treatment for a diagnosed gender identity
disorder, and should undertaken only after careful evaluation. Genital surgery
is not a right that must be granted upon request. The SOC provide for an
individual approach for every patient; but this does not mean that the general
guidelines, which specify treatment consisting of diagnostic evaluation,
possible psychotherapy, hormones, and real life experience, can be
ignored. However, if a person has lived convincingly as a member of the preferred
gender for a long period of time and is assessed to be a psychologically
healthy after a requisite period of psychotherapy, there is no inherent reason
that he or she must take hormones prior to genital surgery.
Conditions under which Surgery May Occur. Genital surgical treatments
for persons with a diagnosis of gender identity disorder are not merely another
set of elective procedures. Typical elective procedures only involve a private
mutually consenting contract between a patient and a surgeon. Genital surgeries
for individuals diagnosed as having GID are to be undertaken only after a
comprehensive evaluation by a qualified mental health professional. Genital
surgery may be performed once written documentation that a comprehensive
evaluation has occurred and that the person has met the eligibility and readiness
criteria. By following this procedure, the mental health professional, the
surgeon and the patient share responsibility of the decision to make irreversible
changes to the body.
Requirements for the Surgeon Performing Genital Reconstruction. The
surgeon should be a urologist, gynecologist, plastic surgeon or general surgeon,
and Board-Certified as such by a nationally known and reputable association.
The surgeon should have specialized competence in genital reconstructive
techniques as indicated by documented supervised training with a more experienced
surgeon. Even experienced surgeons in this field must be willing to have
their therapeutic skills reviewed by their peers. Surgeons should attend
professional meetings where new techniques are presented.
Ideally, the surgeon should be knowledgeable about more than one of the surgical
techniques for genital reconstruction so that he or she, in consultation
with the patient, will be able to choose the ideal technique for the individual
patient. When surgeons are skilled in a single technique, they should so
inform their patients and refer those who do not want or are unsuitable for
this procedure to another surgeon.
Genital Surgery for the Male-to-Female Patient. Genital surgical
procedures may include orchiectomy, penectomy, vaginoplasty, clitoroplasty,
and labiaplasty. These procedures require skilled surgery and postoperative
care. Techniques include penile skin inversion, pedicled rectosigmoid transplant,
or free skin graft to line the neovagina. Sexual sensation is an important
objective in vaginoplasty, along with creation of a functional vagina and
acceptable cosmesis.
Other Surgery for the Male-to-Female Patient. Other surgeries that
may be performed to assist feminization include reduction thyroid chondroplasty,
suction-assisted lipoplasty of the waist, rhinoplasty, facial bone reduction,
face-lift, and blepharoplasty. These do not require letters of recommendation
from mental health professionals.
There are concerns about the safety and effectiveness of voice modification
surgery and more follow-up research should be done prior to widespread use
of this procedure. In order to protect their vocal cords, patients who elect
this procedure should do so after all other surgeries requiring general
anesthesia with intubation are completed.
Genital Surgery for the Female-to-Male Patient. Genital surgical
procedures may include hysterectomy, salpingo-oophorectomy, vaginectomy,
metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses,
and phalloplasty. Current operative techniques for phalloplasty are varied.
The choice of techniques may be restricted by anatomical or surgical
considerations. If the objectives of phalloplasty are a neophallus of good
appearance, standing micturition, sexual sensation, and/or coital ability,
the patient should be clearly informed that there are several separate stages
of surgery and frequent technical difficulties which may require additional
operations. Even metoidioplasty, which in theory is a one-stage procedure
for construction of a microphallus, often requires more than one surgery.
The plethora of techniques for penis construction indicates that further
technical development is necessary.
Other Surgery for the Female-to-Male Patient. Other surgeries that
may be performed to assist masculinization include liposuction to reduce
fat in hips, thighs and buttocks.
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XIII. Post-Transition Follow-up
Long-term postoperative follow-up is encouraged in that it is one of the
factors associated with a good psychosocial outcome. Follow-up is important
to the patient's subsequent anatomic and medical health and to the surgeon's
knowledge about the benefits and limitations of surgery.
Long-term follow-up with the surgeon is recommended in all patients to ensure
an optimal surgical outcome. Surgeons who operate on patients who are coming
from long distances should include personal follow-up in their care plan
and attempt to ensure affordable, local, long-term aftercare in the patient's
geographic region. Postoperative patients may also sometimes exclude themselves
from follow-up with the physician prescribing hormones, not recognizing that
these physicians are best able to prevent, diagnose and treat possible long
term medical conditions that are unique to hormonally and surgically treated
patients. Postoperative patients should undergo regular medical screening
according to recommended guidelines for their age. The need for follow-up
extends to the mental health professional, who having spent a longer period
of time with the patient than any other professional, is in an excellent
position to assist in any post-operative adjustment difficulties.
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