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

Overview

This new Guidelines summary aims to provide primary healthcare professionals (HCPs) with guidance to assist transgender and gender-diverse people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves, with the aim of optimising their overall physical health, psychological wellbeing, and self-fulfilment.

For detailed information and for recommendations on global applicability, education, institutional environments, surgery and postoperative care, reproductive health, and sexual health, refer to the full Standards of Care (SOC) document.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Terminology

• In this SOC, the phrase transgender and gender diverse (TGD) is used for convenience as a shorthand for transgender and gender diverse, and intended to be as broad and comprehensive as possible in describing members of the many varied communities globally of people with gender identities or expressions that differ from the gender socially attributed to the sex assigned to them at birth
• This includes people who have culturally specific and/or language-specific experiences, identities, or expressions, and/or that are not based on or encompassed by Western conceptualisations of gender, or the language used to describe it
• Use culturally relevant language (including terms to describe transgender and gender diverse people) when applying the SOC in different global settings
• Use language in healthcare settings that upholds the principles of safety, dignity, and respect
• Discuss with transgender and gender diverse people what language or terminology they prefer.

For recommendations on global applicability and education, refer to the full guideline.

Assessment of Adults

• It is recommended that HCPs assessing TGD adults for gender-affirming treatments:
  • are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution
  • for countries requiring a diagnosis for access to care, the HCP should be competent using the latest edition of the World Health Organization's International Classification of Diseases (ICD) for diagnosis. In countries that have not implemented the latest ICD, other taxonomies may be used; efforts should be undertaken to utilise the latest ICD as soon as practicable
  • are able to identify coexisting mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity
  • are able to assess capacity to consent for treatment
  • have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity
  • undergo continuing education in healthcare relating to gender dysphoria, incongruence, and diversity
• HCPs assessing TGD adults seeking gender-affirming treatment should liaise with professionals from different disciplines within the field of transgender health for consultation and referral, if required
• It is recommended that HCPs assessing TGD adults for gender-affirming medical and surgical treatment:
  • only recommend gender-affirming medical treatment requested by a TGD person when the experience of gender incongruence is marked and sustained
  • ensure fulfilment of diagnostic criteria prior to initiating gender-affirming treatments in regions where a diagnosis is necessary to access healthcare
  • identify and exclude other possible causes of apparent gender incongruence prior to the initiation of gender-affirming treatments
  • ensure any physical and mental health conditions that could negatively impact the outcome of gender-affirming medical treatments are assessed, with risks and benefits discussed, before a decision is made regarding treatment
  • assess the capacity to consent for the specific gender-affirming treatments prior to the initiation of this treatment
  • assess the capacity of the TGD adult to understand the effect of gender-affirming treatment on reproduction and explore reproductive options with the individual prior to the initiation of gender-affirming treatment.

For further recommendations on assessment of adults, refer to the full guideline.

Adolescents

For clarity, this section applies to adolescents from the start of puberty until the legal age of majority (in most cases 18 years); however, there are developmental elements of this section, including the importance of parental/caregiver involvement, that are often relevant for the care of transitional-aged young adults and should be considered appropriately.

• Facilitate the exploration and expression of gender openly and respectfully so that no one particular identity is favoured
• Undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity-related concerns and seek medical/surgical transition-related care, which should be accomplished in a collaborative and supportive manner
• It is recommended 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
• Maintain an ongoing relationship with the TGD adolescent and any relevant caregivers to support the adolescent in their decision making throughout the duration of puberty-suppression treatment, hormonal treatment, and gender-related surgery until the transition is made to adult care
• Involve relevant disciplines, including mental health and medical professionals, to reach a decision about whether puberty suppression, hormone initiation, or gender-related surgery for TGD adolescents are appropriate and remain indicated throughout the course of treatment until the transition is made to adult care
• HCPs working with TGD adolescents requesting gender-affirming medical or surgical treatments should inform them, prior to the initiation of treatment, of the reproductive effects, including the potential loss of fertility and available options to preserve fertility within the context of the youth's stage of pubertal development
• When gender-affirming medical or surgical treatments are indicated for adolescents, HCPs working with TGD adolescents should involve parent(s)/guardian(s) in the assessment and treatment process, unless their involvement is determined to be harmful to the adolescent or not feasible
• Only recommend gender-affirming medical or surgical treatments requested by the patient when:
  • the adolescent meets the diagnostic criteria of gender incongruence as per the ICD-11 in situations where a diagnosis is necessary to access healthcare
  • the experience of gender diversity/incongruence is marked and sustained over time
  • the adolescent demonstrates the emotional and cognitive maturity required to provide informed consent/assent for the treatment
  • the adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and/or gender-affirming medical treatments have been addressed
  • the adolescent has been informed of the reproductive effects, including the potential loss of fertility and available options to preserve fertility, and these have been discussed in the context of the adolescent’s stage of pubertal development
  • the adolescent has reached Tanner stage 2 of puberty for pubertal suppression to be initiated
    • Tanner staging refers to five stages of pubertal development ranging from prepubertal (Tanner stage 1) to post-pubertal, and adult sexual maturity (Tanner stage 5). For assigned females at birth, pubertal onset (for example, gonadarche) is defined by the occurrence of breast budding (Tanner stage 2), and for birth-assigned males, the achievement of a testicular volume of ≥4 ml
  • 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.

 Children

• HCPs working with gender diverse children should:
  • receive training and have expertise in gender development and gender diversity in children, and possess general knowledge of gender diversity across the life span
  • receive theoretical and evidenced-based training and develop expertise in general child and family mental health across the developmental spectrum
  • receive training and develop expertise in autism spectrum disorders and other neurodiversity or collaborate with an expert with relevant expertise when working with autistic/neurodivergent, gender diverse children
  • engage in continuing education related to gender diverse children and families
• HCPs conducting an assessment with gender diverse children should:
  • access and integrate information from multiple sources as part of the assessment
  • consider relevant developmental factors, neurocognitive functioning, and language skills
  • consider factors that may constrain accurate reporting of gender identity/gender expression by the child and/or family/caregiver(s)
• Consider consultation, psychotherapy, or both for a gender-diverse child and family/caregivers when families and HCPs believe this would benefit the wellbeing and development of a child and/or family.

For further recommendations on working with gender-diverse children, refer to the full guideline.

Nonbinary

Nonbinary is used as an umbrella term referring to individuals who experience their gender as outside of the gender binary. The term nonbinary includes people whose genders are comprised of more than one gender identity simultaneously or at different times (for example, bigender), who do not have a gender identity or have a neutral gender identity (for example, agender or neutrois), have gender identities that encompass or blend elements of other genders (for example, polygender, demiboy, demigirl), and/or who have a gender that changes over time.

• Provide nonbinary people with individualised assessment and treatment that affirms their nonbinary experiences of gender
• Consider medical interventions (hormonal treatment or surgery) for nonbinary people in the absence of ‘social gender transition’
• Consider gender-affirming surgical interventions in the absence of hormonal treatment unless hormone therapy is required to achieve the desired surgical result
• Provide information to nonbinary people about the effects of hormonal therapies/surgery on future fertility and discuss the options for fertility preservation prior to starting hormonal treatment or undergoing surgery.

Eunuch Individuals

Eunuch individuals are those assigned male at birth and who wish to eliminate masculine physical features, masculine genitals, or genital functioning. They also include those whose testicles have been surgically removed or rendered nonfunctional by chemical or physical means and who identify as eunuch.

• Consider medical intervention, surgical intervention, or both for eunuch individuals when there is a high risk that withholding treatment will cause individuals harm through self-surgery, surgery by unqualified practitioners, or unsupervised use of medications that affect hormones
• HCPs who are assessing eunuch individuals for treatment should have demonstrated competency in assessing them
• HCPs providing care to eunuch individuals should include sexuality education and counselling.

Intersexuality

In medicine, the term intersex is colloquially applied to individuals with markedly atypical, congenital variations in the reproductive tract. In recent years, intersex has also become an identity label adopted by some individuals with intersex conditions and a subset of (nonintersex) individuals with a nonbinary gender identity.

• A multidisciplinary team, knowledgeable in diversity of gender identity and expression as well as in intersexuality, should provide care to individuals with intersexuality and their families
• HCPs providing care for transgender youth and adults should seek training and education in the aspects of intersex care relevant to their professional discipline
• Educate and counsel families of children with intersexuality from the time of diagnosis onward about the child’s specific intersex condition and its psychosocial implications
• Support children/individuals with intersexuality in exploring their gender identity throughout their life
• Promote wellbeing and minimise the potential stigma of having an intersex condition by working collaboratively with both medical and nonmedical individuals/organisations
• Refer children/individuals with intersexuality and their families to mental health professionals as well as peer and other psychosocial supports as indicated
• Counsel individuals with intersexuality and their families about puberty suppression and/or hormonal treatment options within the context of the individual's gender identity, age, and unique medical circumstances
• Counsel parents and children with intersexuality (when cognitively sufficiently developed) to delay gender-affirming genital surgery, gonadal surgery, or both, to optimise children’s self-determination and ability to participate in the decision based on informed consent
• HCPs who are prescribing or referring for hormonal therapies/surgeries should counsel individuals with intersexuality and fertility potential and their families about:
  • known effects of hormonal therapies/surgery on future fertility
  • potential effects of therapies that are not well studied and are of unknown reversibility
  • fertility preservation options
  • psychosocial implications of infertility
• HCPs caring for individuals with intersexuality and congenital infertility should introduce them and their families, early and gradually, to the various alternative options of parenthood.

For recommendations related to institutional environments, refer to the full guideline.

Hormone Therapy

• Begin pubertal hormone suppression in eligible^[A] TGD adolescents only after they first exhibit physical changes of puberty (Tanner stage 2)
• Use gonadotrophin-releasing hormone (GnRH) agonists to suppress endogenous sex hormones in eligible^[A] TGD people for whom puberty blocking is indicated
• Prescribe progestins (oral or injectable depot) for pubertal suspension in eligible^[A] TGD youth when GnRH agonists are not available or are cost prohibitive
• Prescribe GnRH agonists to suppress sex steroids without concomitant sex steroid hormone replacement in eligible TGD people seeking such intervention who are well into or have completed pubertal development (past Tanner stage 3) but are unsure about or do not wish to begin sex steroid hormone therapy
• Prescribe sex hormone treatment regimens as part of gender-affirming treatment in eligible^[A] TGD adolescents who are at least Tanner stage 2, with parental/guardian involvement unless their involvement is determined to be harmful or unnecessary to the adolescent
• Measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at a level appropriate for the treatment goals of TGD people according to the Tanner stage
• Prescribe progestogens or a GnRH agonist for eligible^[A] TGD adolescents with a uterus to reduce dysphoria caused by their menstrual cycle when gender-affirming testosterone use is not yet indicated
• Involve professionals from multiple disciplines who are experts in transgender health and in the management of the care of TGD adolescents
• Organise regular clinical evaluations for physical changes and potential adverse reactions to sex steroid hormones, including laboratory monitoring of sex steroid hormones every 3 months during the first year of hormone therapy or with dose changes, until a stable adult dosing is reached, followed by clinical and laboratory testing once or twice a year once an adult maintenance dose is attained
• Inform and counsel all individuals seeking gender-affirming medical treatment about options for fertility preservation prior to initiating puberty suppression and prior to administering hormone therapy
• Evaluate and address medical conditions that can be exacerbated by lowered endogenous sex hormone concentrations and treatment with exogenous sex hormones before beginning treatment in TGD people
• Educate TGD people undergoing gender-affirming treatment about the onset and time course of physical changes induced by sex hormone treatment
• Do not prescribe ethinyl oestradiol for TGD people as part of a gender-affirming hormonal treatment
• Prescribe transdermal oestrogen for eligible^[A] TGD people at higher risk of developing venous thromboembolism based on age >45 years or a previous history of venous thromboembolism, when gender-affirming oestrogen treatment is recommended
• Do not prescribe conjugated oestrogens in TGD people when oestradiol is available as part of a gender-affirming hormonal treatment
• Prescribe testosterone-lowering medications (either cyproterone acetate, spironolactone, or GnRH agonists) for eligible^[A] TGD people with testes taking oestrogen as part of a hormonal treatment plan if their individual goal is to approximate levels of circulating sex hormone in cisgender women
• Monitor haematocrit (or haemoglobin) levels in TGD people treated with testosterone
• Collaborate with surgeons regarding hormone use before and after gender-affirmation surgery
• Counsel eligible^[A] TGD people about the various options for gender-affirmation surgery unless surgery is either not indicated or is medically contraindicated
• Initiate and continue gender-affirming hormone therapy for eligible^[A] TGD people who wish this treatment to achieve a demonstrated improvement in psychosocial functioning and quality of life
• Maintain existing hormone therapy if the TGD individual's mental health deteriorates and assess the reason for the deterioration, unless contraindicated.

For recommendations on surgery and postoperative care, refer to the full guideline.

General Primary Care Recommendations

• Obtain a detailed medical history from TGD people, that includes past and present use of hormones and gonadal surgeries, as well as the presence of traditional cardiovascular and cerebrovascular risk factors, with the aim of providing regular cardiovascular risk assessment according to established, locally used guidelines
• Assess and manage cardiovascular health in TGD people using a tailored risk factor assessment and cardiovascular/cerebrovascular management methods
• Tailor sex-based risk calculators used for assessing medical conditions to the needs of TGD people, taking into consideration the length of hormone use, dosing, serum hormone levels, current age, and the age at which hormone therapy was initiated
• Counsel TGD people about their tobacco use and advise tobacco/nicotine abstinence prior to gender-affirming surgery
• Discuss and address ageing-related psychological, medical, and social concerns with TGD people
• Follow local breast cancer screening guidelines developed for cisgender women in their care of TGD people:
  • who have received oestrogens, taking into consideration length of time of hormone use, dosing, current age, and the age at which hormones were initiated
  • with breasts from natal puberty who have not had gender-affirming chest surgery
• Apply the same respective local screening guidelines (including the recommendation not to screen) developed for cisgender women at average and elevated risk for developing ovarian or endometrial cancer in their care of TGD people who have the same risks
• Routine oophorectomy or hysterectomy solely for the purpose of preventing ovarian or uterine cancer is not recommended for TGD people undergoing testosterone treatment and who have an otherwise average risk of malignancy
• Offer cervical cancer screening to TGD people who currently have or previously had a cervix, following local guidelines for cisgender women
• Counsel TGD people that the use of antiretroviral medications is not a contraindication to gender-affirming hormone therapy
• Obtain a detailed medical history from TGD people that includes past and present use of hormones and gonadal surgeries, as well as the presence of traditional osteoporosis risk factors, to assess the optimal age and necessity for osteoporosis screening
• Discuss bone health with TGD people, including the need for active weight-bearing exercise, healthy diet, calcium, and vitamin D supplementation
• Offer TGD people referrals for hair removal from the face, body, and genital areas for gender-affirmation or as part of a preoperative preparation process.

For recommendations on reproductive health and sexual health, refer to the full guideline.

Mental Health

• Address mental health symptoms that interfere with a person’s capacity to consent to gender-affirming treatment before gender-affirming treatment is initiated
• Offer care and support to TGD people to address mental health symptoms that interfere with a person’s capacity to participate in essential perioperative care before gender-affirmation surgery
• When significant mental health symptoms or substance abuse exists, assess the potential negative impact mental health symptoms may have on outcomes based on the nature of the specific gender-affirming surgical procedure
• Maintain existing hormone treatment if a TGD individual requires admission to a psychiatric or medical inpatient unit, unless contraindicated
• HCPs should not make it mandatory for TGD people to undergo psychotherapy prior to the initiation of gender-affirming treatment, although acknowledging that psychotherapy may be helpful for some TGD people
• ‘Reparative’ and ‘conversion’ therapy aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with the sex assigned at birth should not be offered.

Footnote

[A] For eligibility criteria for adolescents and adults, refer to the sections on Assessment for Adults and Adolescents, as well as Appendix D in the full guideline.