UNDERSTANDING GENDER TRANSITIONS
In exploring gender diversity we must review the current Standards of Care for those who seek medically supported gender transition. The World Professional Association for Transgender Health (WPATH) has offered standards of care for transition services since 1979. Second, the Endocrine Society represents international endocrinologists offering hormone therapy for transition services. Third, The American Psychological Association (APA), is a significant player because transition often requires involvement of mental health providers.
TERMS AND ABBREVIATIONS
To start, we will start with terms to help in the discussion. Please note that the terms used by transgender and gender nonconforming people are as diverse as the community itself. They are also always evolving. Finally, the language of medical literature tends to be updated slowly, lagging far behind the TGNC community discourse.
APA – The American Psychological Association
Cisgender – A term for people whose gender identity generally matches the gender they were assigned at birth.
Gender Identity – A person’s basic internal sense of being a man, woman, and/or another gender (e.g., gender queer, gender fluid).
Gender Expression – Conveyed through appearance (clothing etc.), behaviors, and personality styles. These means of expression are often culturally define as masculine or feminine.
Gender Binary – A classification of gender that recognizes only two distinct, opposite forms: male and female.
Gender Dysphoria – Distress caused by the discrepancy between one’s experienced gender and one’s assigned gender and/or sex characteristics.
Non-Binary – An umbrella term for gender identities that are neither male nor female. This includes gender identities such as genderqueer, gender-fluid, bigender, and agender.
Sex assigned at birth – The sex (male, female, intersex) assigned to a child at birth, most often by a doctor, based on the child’s external anatomy.
TGNC – Transgender and nonconforming.
Transgender – An umbrella term for people whose gender identity does not match sex assigned at birth. Transgender people may identify as female, male, non-binary, etc.
Transition – An individualized process in which transgender people move from living aligned with the sex assigned at birth to living aligned with their gender identity. Each person’s transition path is unique.
Gender diversity – In the last decade, there has been an explosion of TGNC visibility. Correspondingly, there has been an increased social recognition that sex assigned at birth and gender identity do not always align. It also includes a recognition that people do not always experience gender according to a ‘male or female’ gender binary. In other words, society is increasingly recognizing the enormous range of human gender diversity.
Transgender is an umbrella term referring to a heterogeneous group of people whose gender identity does not match the sex assigned at birth. Included in this are people who identify as female or male. The WPATH Standards of Care (SOC) is limited to the treatment of gender dysphoria, and the focus is primarily on transition services. Transition following the WPATH SOC requires a diagnosis of gender dysphoria (GD). The necessity of a GD diagnosis for medical transition is controversial. Those in support argue that receiving a diagnosis is necessary for safe care and for coverage by medical insurance within many healthcare systems. Those opposed are concerned that his medicalization and the gatekeeping role of physicians and mental health providers can create unnecessary barriers or stigma.
CLINICAL PRACTICE GUIDELINES
Historically, medical providers often attempted to change a person’s general identity and gender expression to match sex assigned at birth. Just like attempts to change people’s sexual identities, this approach was unsuccessful and caused enormous harm. Research has thoroughly discredited these “conversion therapies.” As a result, many countries throughout the world are banning them. However, the legislature and educational work is far from done. The development of standards of care and institutional resolutions have been essential in correcting this painful and destructive history.
WORLD PROFESSIONAL ASSOCIATION FOR TRANSGENDER HEALTH STANDARDS OF CARE
SOC TRANSITION PROTOCOL
SOC for adults require well document gender dysphoria and the capacity for fully informed consent. Informed consent is the process in which a medical provider educates a patient about the risk, benefits, and alternatives of a procedure or intervention. The patient must be competent to make a voluntary decision about whether to undergo the procedure or intervention. The SOC transition protocol includes hormone therapy and gender confirmation surgery. These refer to the use of hormones or surgery, respectively, to alter one’s physical characteristics to align with one’s gender identity.
PUBERTY SUPPRESSION IN ADOLESCENTS
SOC for adolescents begins with puberty suppression. “Puberty blockers” works by blocking the hormones testosterone and estrogen that lead to puberty-related secondary sex characteristics. These include breast growth, menstruation, voice-deepening, facial hair, and development of thyroid cartilage (often referred to as an “Adam’s apple”). Puberty suppression does not resolve gender dysphoria. It buys time, keeping potions open for adolescents. Continued development of unwanted secondary sexual characteristics can trigger depression, anxiety, isolation, self-harm, and suicidality. Puberty suppression can greatly reduce the extreme distress that many gender dysphoric adolescents experience.
Puberty suppression has been used safely for decades in children with medical conditions other than GD, including early onset puberty. This process can continue for years and is fully reversible. Spending a year in the desire gender role, as a real-life experience (RLE), is recommended before proceeding with hormone therapy and gender confirmation surgery. However, research strongly indicates that adolescents motivated by severe GD almost always choose to continue with transition.
SOC recommends considerations for adolescents prior to engaging in medical transitioning. One is that one adolescent does not suffer from psychosocial challenges that interfere with assessment or treatment. Another is that they have adequate family or other support. A third is that they have good comprehension of the impact of medical interventions. If they meet these conditions, then they are eligible for puberty suppression, hormone therapy, and gender confirmation surgery at the respective ages of 12, 16, and 18 years. For those who have had the opportunity to use puberty blockers, gender confirmation surgeries are far simpler.
ACCESS TO TRANS-AFFIRMATIVE MEDICAL CARE
Lack of access to trans-affirmative mental and physical healthcare is a common barrier for TGNC people. Untreated GD presents significant risks. Due to pervasive experiences of discrimination and violence in many cultures and societies, gender dysphoric adolescents are already highly vulnerable. They exhibit high rates of mental health concerns, isolation, self-harm, and suicide at the onset of puberty that feels wrong.
Increasingly, access to care is being prioritized over strict adherence to guidelines. WPATH, Endocrine Society, and APA all recognize that flexibility and an emphasis on reducing stigma are important considerations in treatment of TGNC people.
Are you looking to work through gender transition of your own or to better understand someone else’s transition? Working with a LBGTQ-affirmative therapist can help.