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| SOC | 6th version | 7th version |
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| Title | Standards of Care for gender identity disorders | Standards of Care for the Health of transsexual, transgender, and gender nonconforming people |
| Organization preparing the SOC | Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders (HBIGDA) | World Professional Association for Transgender Health (WPATH), formerly HBIGDA |
| Date of publication | February 2001 | Approved on September 14, 2011 |
| Number of pages | 22 | 120 |
| References | Absent | Present |
| Based on | Clinical consensus | Clinical consensus and scientific references |
| View of relation between gender dysphoric persons and health personal | Health personal evaluate and treat a disorder | Health personal assist persons to better well-being and his/her harm reduction |
| Diagnosis or not | Diagnosis | Everyone with gender concerns does not have a diagnosis |
| View of diagnosis and evaluation and treatment | Five elements of clinical work: diagnostic assessment, psychotherapy or real-life experience, hormonal therapy, and surgical therapy | Different options of treatment |
| Tasks of the mental health professional | (1) to accurately diagnose the individual’s gender disorder
(2) to accurately diagnose and treat any psychiatric comorbidity
(3) to counsel about the range of treatment options
(4) to engage in psychotherapy
(5) to ascertain eligibility and readiness for hormone and surgical therapy
(6) to make formal recommendation to medical and surgical colleagues
(7) to document their patient’s relevant history in a letter of recommendation
(8) to be a colleague in a team of professionals with interest in gender identity disorders
(9) to educate family members, employers, and so forth about gender identity disorders
(10) to be available for followup | (1) to assess the clients’ gender dysphoria, the impact of stigma attached, and the support from the surrounding. The assessment may result in: no diagnosis, a diagnosis related to gender dysphoria, and/or in other diagnoses (the evaluation could also be done by a nonmental health professional if this person has appropriate training in assessing gender dysphoria)
(2) to provide information regarding options for gender identity and expression, and possible medical treatment
(3) to assess, diagnose, and discuss treatment options for coexisting mental health concerns
(4) if applicable, assess eligibility, prepare, and refer for hormone therapy
(5) if applicable, assess eligibility, prepare, and refer for surgery
(6) to educate and advocate on behalf of the clients within their community and assist clients with making changes in identity documents
(7) to provide information and referral for peer support |
| Psychotherapy prior to hormone treatment or surgery | Requirement if the patient did not experience three months of real life | Not a requirement |
| Real life | “Real-life experience” required for hormone and surgical treatment | “Living in an identity congruent gender role” required for genital surgery |
| One letter from the mental health professional required for instituting hormone therapy and breast surgery | The content of the letter is specified | The content of the letters is specified |
| Two letters from the mental health professional are generally required for genital surgery | The content of the letter is specified | The content of the letters is specified |
| Eligibility criteria for hormone therapy for adults | 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) | Persistent, well-documented gender dysphoria; capacity to make a fully informed decision and to consent for treatment; age of majority in a given country (if younger, follow specific SOC guidelines); if significant medical or mental health concerns are present, they must be reasonably well controlled |
| Readiness criteria for hormone therapy for adults | The patient has had further consolidation of gender identity during the real-life experience or psychotherapy; the patient has made some progresses in mastering other identified problems leading to improving or continuing stable mental health; the patient is likely to take hormones in a responsible manner | No differences between readiness and eligibility |
| Responsibilities of the hormone-prescribing physician | (1) hormones should not be prescribed before an adequate psychological and medical assessment
(2) to review the likely effects and side effects of the hormone treatment | (1) perform an evaluation of the patient’s physical transition goals, health history, physical examination, risk assessment, and relevant laboratory tests
(2) discuss with patients the expected effects of feminizing/masculinizing medication and the possible adverse health effects including reduction in fertility
(3) confirm that the patients have the capacity to understand the risks and benefits of treatment and are capable of making an informed decision about medical care
(4) provide ongoing medical motoring, including regular physical and laboratory examination to monitor hormone effectiveness and side effects
(5) communicate as needed with a patient’s primary care provider, mental health professional, and surgeon
(6) if needed, provide patients with a brief statement indicating that they are under medical supervision and care including feminizing/masculinizing hormone therapy |
| Can hormones be given to those who do not want surgery or a real-life experience? | Yes | Yes |
| Effects of hormone therapy on adults | Described | Larger amount of information is given, with detailed time course |
| Potential negative medical side effects | Described | Larger and detailed amount of information is given |
| The prescribing physician’s responsibilities | Present | Present, more emphasized |
| Criteria for puberty suppressing hormones | Not present | Present |
| Hormones doses, misuse of hormones, and potential benefits of hormones | Present | Present, harm reduction is recommended |
| Clinical situation for hormonal therapy and risk assessment | Not present | Present |
| Information about hormones regimen | Limited | Larger amount of information given, all with references |
| Reproductive options | Limited | Larger amount of information given |
| Voice and communication therapy | Not present | Large amount of information given |
| Sex reassignment surgery | Proven to be effective, medically indicated | Proven to be effective, medically indicated |
| Ethical questions | Professional should feel comfortable about altering anatomically normal structures
The resistance against performing on the ethical bases of “above all do not harm” should be respected | Professional should feel comfortable about altering anatomically normal structures
The resistance against performing on the ethical bases of “above all do not harm” should be respected |
| HIV, HBV, and HCV | “Unethical” to deny treatment to HIV+, HBV+, HCV+, and so forth, patients | “Unethical” to deny treatment to HIV+, HBV+, HCV+, and so forth, patients |
| Surgeon’s relationship with physician-prescribing hormones and mental health professional | They should work as a team. Surgeon should personally communicate with at least one of the mental health professionals to verify the authenticity of their letters | Close work relationship, working as a team |
| Informed consent | The medical records should contain written informed consent for the particular surgery to be performed | Larger amount of information is presented about the informed consent |
| Breast surgery | Minimal information given. No exact indication of timing between beginning of hormonal therapy, real-life experience and mastectomy. Mastectomy can be performed at the same time patients begin hormones. Augmentation mammoplasty may be performed 18 months after the beginning of the hormone treatment | Mastectomy to be performed preferably after ample time of living in the desired gender role, and after 1 year of testosterone treatment; however, hormone therapy does not constitute a prerequisite. It is suggested to perform augmentation mammoplasty after 1 year of hormone therapy |
| Criteria for hysterectomy and ovariectomy in FTM and orchidectomy in MTF | Not present | Persistent, well-documented gender dysphoria; capacity to make a fully informed decision and to consent for treatment; age of majority in a given country (if younger, follow specific SOC guidelines); if significant medical or mental health concerns are present, they must be reasonably well controlled; 12 continuous months of hormone therapy (unless the patient as a medical contraindication) |
| Genital surgery: eligibility criteria | Legal age of majority. Usually 12 months of continuous hormonal therapy for those without a medical contraindication 12 months of successful continuous full-time real-life experience
Regular participation in psychotherapy, if required by the mental health professional
Knowledge of cost, lengths of hospitalizations, likely complications, postsurgical rehabilitation requirements
Awareness of different competent surgeons | Persistent, well-documented gender dysphoria; capacity to make a fully informed decision and to consent for treatment; age of majority in a given country (if younger, follow specific SOC guidelines); if significant medical or mental health concerns are present, they must be reasonably well controlled; 12 continuous months of hormone therapy (unless the patient as a medical contra-indication); 12 continuous months of living in a gender role that is congruent with their gender identity |
| | No difference between eligibility and readiness |
| Genital surgery: readiness criteria | 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, and suicidal tendencies | |
| No genital surgery possible without meeting the eligibility criteria | |
| Conditions under which surgery may occur | Written documentation that a comprehensive evaluation has occurred, and that the person has met the eligibility and readiness criteria
Mental health professional, surgeon, and patient share responsibility of the decision to make irreversible change to the body | Provision of the information in writing, with illustrations, different techniques available, advantages, disadvantages, limits, risks, complications, informed consent, and so forth.
Mental health professional and surgeon share responsibility of the decision to make irreversible change to the body |
| Requirements for the surgeon performing genital reconstruction | The surgeon should be urologist, gynecologist, plastic surgeon, or general surgeon. Board certified by a nationally known association | More emphasis on the fact that the gender surgeon/team should be able to offer several techniques
More emphasis on the patient choice for the surgical technique |
| Other surgeries | Reduction thyroid chondroplasty, liposuction, rhinoplasty, facial bone reduction, face-lift, and blepharoplasty do not require letters of recommendation from mental health professionals. Voice modification surgery to be performed as last procedure, after that all other surgeries requiring general anesthesia with intubation are completed | Reduction thyroid chondroplasty, liposuction, rhinoplasty, facial bone reduction, face-lift, and blepharoplasty do not require letters of recommendation from mental health professionals |
| Competency of voice, communication specialists | Not present | Present |
| Information regarding phalloplasty | Patient should be clearly informed about limits of surgery, complications, stages of surgery, revision surgery
Further technical developments of surgery are necessary
Ideally, surgeons should be knowledgeable about more than one surgical technique for genital reconstruction so that they, in consultation with patients, can choose the ideal technique for each individual. Alternatively, if a surgeon is skilled in a single technique, referral to another skilled appropriate surgeon should be offered | Patient should be clearly informed about limits of surgery, complications, stages of surgery, revision surgery
Pictures of successful and unsuccessful cases should be shown to the patients
Ideally, surgeons should be knowledgeable about more than one surgical technique for genital reconstruction so that they, in consultation with patients, can choose the ideal technique for each individual. Alternatively, if a surgeon is skilled in a single technique, referral to another skilled appropriate surgeon should be offered |
| Urogenital care | Not present | Present |
| Posttransition followup | Followups recommended for both surgery, hormone treatments, and psychotherapy | Same as for 6th version |
| Life-long preventive and primary care | Not present | Present |
| Applicability of SOC to people with disorder of sex development | Not present | Present |
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