Gail Knudson

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

ABSTRACT The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts of the world are necessary. The SOC articulate standards of care while acknowledging the role of making informed choices and the value of harm reduction approaches. In addition, this version of the SOC recognizes that treatment for gender dysphoria i.e., discomfort or distress that is caused by a discrepancy between persons gender identity and that persons sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) has become more individualized. Some individuals who present for care will have made significant self-directed progress towards gender role changes or other resolutions regarding their gender identity or gender dysphoria. Other individuals will require more intensive services. Health professionals can use the SOC to help patients consider the full range of health services open to them, in accordance with their clinical needs and goals for gender expression.

Serving transgender people: clinical care considerations and service delivery models in transgender health

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.

Recommendations for Revision of the DSM Diagnoses of Gender Identity Disorders: Consensus Statement of the World Professional Association for Transgender Health

This consensus statement is an executive summary of several papers resulting from a 2009 consensus process comprising nine work groups and 37 members of the World Professional Association for Transgender Health (WPATH). The purpose of this group was to put forth recommendations for the upcoming revision of the DSM with respect to the Gender Identity Disorder diagnoses. The consensus process was collaborative, interdisciplinary, and evidence based. A majority (but not all) of the participants believed that a diagnosis related to Gender Identity Disorder should remain in the DSM, and many advocated changes in name, diagnostic criteria, and placement within the DSM. The proposed name is Gender Dysphoria, and the diagnostic criteria should be distress based. Placement should be outside the chapter on Sexual Disorders and possibly within Psychiatric Disorders Related to a Medical Condition. If there were to be a diagnostic category for childhood, there should also be separate categories for adults and adolescents. A Not Otherwise Specified category should be retained, and Disorders of Sex Development should not be an exclusionary criterion for Gender Dysphoria.

Response of the World Professional Association for Transgender Health to the Proposed DSM 5 Criteria for Gender Incongruence

We would like to begin with expressing our respect for the work of the DSM 5 Work Group on Sexual and Gender Identity Disorders (WGSGID) of the American Psychiatric Association and the Gender Identity Disorders sub-work group, in particular, concerning the proposed changes for the diagnosis and the revised criteria. The proposal is definitely a step in the right direction, addressing several of the primary concerns raised about the diagnosis as currently stated in DSM-IV-TR. We acknowledge, specifically:

Prevalence of Childhood Trauma in a Clinical Population of Transsexual People

ABSTRACT Few studies have focused on the prevalence and extent of childhood trauma in the transsexual population. In our study of 42 transsexual people (34 = natal males, 8 = natal females), 55% (n = 23) reported experiencing an unwanted sexual event before the age of 18, with the average age of initial sexual contact being 13. This sexual event differs from other clinical populations in that the unwanted sexual experiences in this sample were the consequence of adolescents satisfying their curiosity about the gender of the transsexual rather than for their own sexual gratification. Consequently, the sequalae of the unwanted sexual touches in our sample did not lead to sexualised behaviours described in the sexual abuse literature of clinical samples. Our sample also reported being: verbally abused (77%), insulted (81%), embarrassed in front of others (55%), made to feel guilty by their parents (58%) before their fifteenth birthday.

Synergies in health and human rights: a call to action to improve transgender health

2015 was an unprecedented year in the recognition of transgender rights in some high-income countries. However, this recognition in the public domain has yet to translate to a concerted eff ort to support the right to health of transgender people around the world. Transgender people continue to face a range of challenges that deprive them of respect, opportunities, and dignity and have damaging eff ects on their mental and physical health and wellbeing, as shown in the Lancet Series on transgender health. These “situated vulnerabilities”, as they are called in the Series paper by Sari Reisner and colleagues, can prompt or aggravate depression, anxiety, self-harm, and suicidal behaviour among transgender people, which are exacerbated by biological risks, and social and sexual network-level risks, for HIV and other sexually transmitted infections. In their Lancet Series paper, Sam Winter and colleagues write of a “slope leading from stigma to sickness”. Moving forward, these health needs and vulnerabilities can be better addressed through improved understanding of the legal and social policies that promote harms and diminish the potential impact of health programmes. There is also a need for increased knowledge of the optimal content and models of clinical service provision, as highlighted by Kevan Wylie and colleagues’ Series paper, and of the epidemiology of communicable and non-communicable diseases in transgender people globally. Ultimately, action is needed at and across multiple levels and sectors to optimise the provision and uptake of health services for transgender people (panel). Health policies must change to improve the health of transgender people. Transgender people worldwide report problems in accessing appropriate and equitable health care—whether related to gender affi rmation, sexual and reproductive health, or more general health. Steps need to be taken to ensure that national health policies are as inclusive as possible with regard to transgender health care. Such health care, including access to feminising and masculinising hormones, should be funded on the same Synergies in health and human rights: a call to action to improve transgender health

What Surgeons Need to Know About Gender Confirmation Surgery When Providing Care for Transgender Individuals: A Review

Importance In 2014, the US Department of Health and Human Services decided that its 1981 exclusion of transsexual surgical treatments from Medicare coverage was based on outdated, incomplete, and biased science and did not reflect current evidence or standards of care, and the exclusion was therefore lifted. As a direct result of this decision, surgeons nationwide are seeing an increase in consultations for surgical therapy to help transgender and gender-nonconforming individuals. Although some clinicians may have the technical training for such surgical procedures, in many cases, they may not have a full understanding of the complex and comprehensive care required to provide optimal health care for transgender individuals. Observations Gender confirmation surgery is a developing field in the United States and other areas of the world. The World Professional Association for Transgender Health started a global education initiative intended to provide surgeons and other health care professionals with the necessary background knowledge to understand and treat this patient population. This article provides an overview of best practices as set forth in the seventh edition of the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health, including mental health, endocrinology, and surgery for trans women and trans men. Conclusions and Relevance Experts in each aspect of transgender health have summarized the content of the global education initiative in this article. It provides valuable information to surgeons of all disciplines and other health care professionals to help guide the treatment and management of transgender individuals.

Process Toward Consensus on Recommendations for Revision of the DSM Diagnoses of Gender Identity Disorders by the World Professional Association for Transgender Health

The World Professional Association for Transgender Health (WPATH) is recognized as the leading authority in the field of transgender health, through a membership that encompasses experts in this field and transgender community representatives. WPATH therefore is in an excellent position to give input on the DSM 5 section on gender identity disorders. To streamline the ideas of the membership, the authors, all elected officers of the association, organized a consensus-building process beginning January 2009 to arrive at recommendations for removal or reform of the DSM 5 diagnoses. This article describes this process, how the various work groups were formed, and the topics covered in the work group discussions. In addition, this article reports on a face-to-face meeting held with all of the consensus participants and work groups in conjunction with the 2009 biennial conference of WPATH in Oslo, Norway, where a consensus was reached on several issues. The outcome of this face-to-face meeting was subsequently discussed during a plenary session at the conference, which many WPATH members attended. After a description of this process, we introduce the nine articles written by each of the working groups and an executive summary with a set of recommendations for the DSM 5 Work Group on Sexual and Gender Identity Disorders.

Female Sexual Disorders: Assessment, Diagnosis, and Treatment

Sexual health is important to overall health and quality of life. Sexual problems have been associated with relationship problems and may interfere with overall health and they may also be a marker for other undiagnosed comorbid medical conditions. In order for healthcare professionals to manage the sexual health concerns of their patients, it is important for them to understand what constitutes good sexual health. To that end, it is necessary to have a working knowledge of the evolving theoretical models offered to describe a healthy sexual response as well as an understanding of the neurobiology of sexual function. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised lists six primary female sexual disorders: hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder, female orgasmic disorder,dyspareunia, and vaginismus. Despite a growing awareness of the high prevalence of sexual disorders they are not typically identified nor treated. There are a number of reasons why clinicians fail to identify and treat sexual problems including insufficient training in sexual medicine and communication skills, time-constraints, and embarrassment. Treatment for female sexual problems is usually individualized and may include a combination of office-based education and basic counseling, cognitive-behavioral psychotherapy, pharmacotherapy, and treatment of concomitant medical conditions.

Semen characteristics of transwomen referred for sperm banking before sex transition: a case series

Transwomen (TW) can now turn to cryopreserve spermatozoa before gender reassignment (GR). The objective is to assess semen quality of TW and evaluate adequacy for assisted reproduction technology (ART). Pre‐freezing (PF) and post‐thaw (PT) semen parameters of 2 and PF data of 27 TW who were referred for sperm banking in Cleveland Clinic/USA and Ghent Center/Belgium, before GR, were retrospectively analysed. The study period was between February, 2003 and October, 2011. We also evaluated adequacy of 24‐h PT data for ART. PF data of 29 TW, mean age of 28.9 years, showed high incidence of oligozoospermia (27.58%), asthenozoospermia (31%) and teratozoospermia (31%). Mean sperm concentration was 46.9 × 106/ml, mean per cent motility was 42.9 and mean per cent sperm morphology (Krugers) was 7.98. The 24‐h PT data, for 2 TW, showed mean motility 22.4%, mean total motile sperm count 13.7 × 106 and total motile sperm concentration 8.7 × 106/ml. Single patient had used the frozen spermatozoon for intrauterine insemination (IUI) of a surrogate mother resulting in birth of healthy newborn. It is concluded that poor PF and 24‐h PT semen quality is frequently seen among TW. As such, considerable proportion of TW should use more expensive method of ART, for example IVF/ICSI rather than inexpensive IUI.