Table 2: Differences between the 6th [20] and the 7th [17] versions of the Standards of Care.

SOC6th version7th version

TitleStandards of Care for gender identity disordersStandards of Care for the Health of transsexual, transgender, and gender nonconforming people
Organization preparing the SOCHarry 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 publicationFebruary 2001Approved on September 14, 2011
Number of pages22120
ReferencesAbsentPresent
Based onClinical consensusClinical consensus and scientific references
View of relation between gender dysphoric persons and health personalHealth personal evaluate and treat a disorderHealth personal assist persons to better well-being and his/her harm reduction
Diagnosis or notDiagnosisEveryone with gender concerns does not have a diagnosis
View of diagnosis and evaluation and treatmentFive elements of clinical work: diagnostic assessment, psychotherapy or real-life experience, hormonal therapy, and surgical therapyDifferent 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 surgeryRequirement if the patient did not experience three months of real lifeNot 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 surgeryThe content of the letter is specifiedThe content of the letters is specified
Two letters from the mental health professional are generally required for genital surgeryThe content of the letter is specifiedThe content of the letters is specified
Eligibility criteria for hormone therapy for adultsAge 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 adultsThe 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 mannerNo 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?YesYes
Effects of hormone therapy on adultsDescribedLarger amount of information is given, with detailed time course
Potential negative medical side effectsDescribedLarger and detailed amount of information is given
The prescribing physician’s responsibilitiesPresentPresent, more emphasized
Criteria for puberty suppressing hormonesNot presentPresent
Hormones doses, misuse of hormones, and potential benefits of hormonesPresentPresent, harm reduction is recommended
Clinical situation for hormonal therapy and risk assessmentNot presentPresent
Information about hormones regimenLimitedLarger amount of information given, all with references
Reproductive optionsLimitedLarger amount of information given
Voice and communication therapyNot presentLarge amount of information given
Sex reassignment surgeryProven to be effective, medically indicatedProven to be effective, medically indicated
Ethical questionsProfessional 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 professionalThey should work as a team. Surgeon should personally communicate with at least one of the mental health professionals to verify the authenticity of their lettersClose work relationship, working as a team
Informed consentThe medical records should contain written informed consent for the particular surgery to be performedLarger amount of information is presented about the informed consent
Breast surgeryMinimal 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 treatmentMastectomy 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 MTFNot presentPersistent, 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 criteriaLegal 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 criteriaDemonstrable 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 occurWritten 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 reconstructionThe surgeon should be urologist, gynecologist, plastic surgeon, or general surgeon. Board certified by a nationally known associationMore 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 surgeriesReduction 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 completedReduction 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 specialistsNot presentPresent
Information regarding phalloplastyPatient 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 careNot presentPresent
Posttransition followupFollowups recommended for both surgery, hormone treatments, and psychotherapySame as for 6th version
Life-long preventive and primary careNot presentPresent
Applicability of SOC to people with disorder of sex developmentNot presentPresent