Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Coleman, E., et al
International Journal of Transgender Health

ABSTRACT

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8.

Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment.

Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings.

Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health.

Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

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“I bet being trans in The Netherlands is like living in the future”: Could The Netherlands serve as an imperfect “gold standard” comparator for transgender youth research in the United States?

vam der Miesen, A.I.R., et al
International Journal of Transgender Health

ABSTRACT

Background: In available comparative studies, Dutch transgender youth have consistently shown better psychosocial well-being compared to those in other countries. Therefore, the Netherlands (N.L.) could be considered a gold-standard—though imperfect—comparator for transgender youth research. The United States (U.S.) is heterogeneous in its policies and practices impacting transgender youth, and policies are in flux. This study examines similarities and differences between U.S. and Dutch policies, practices, and contexts relevant to the well-being of transgender adolescents.

Methods: A three-stage Delphi procedure was conducted with expert panels in the N.L. and U.S.

Results: This process identified candidate mechanisms driving differences in outcomes for transgender youth between the countries, including: (1) training provided to Dutch students and schools to promote acceptance and understanding of gender diversity; (2) availability of gender specialists for Dutch youth; (3) insurance coverage of broad gender-related services in the N.L., compared to inconsistent coverage in the U.S. and numerous state care bans; and (4) a Dutch public that is largely accepting of gender diversity, with historical roots of acceptance dating back three decades.

Discussion: Study findings indicate intersectional racial inequities remain inadequately addressed in both countries. Primary ongoing needs in each country and novel approaches to improve outcomes are discussed.

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The Dynamic Development of Gender Variability

Fausto-Sterling, A.
Journal of Homosexuality

We diagram and discuss theories of gender identity development espoused by the clinical groups represented in this special issue. We contend that theories of origin relate importantly to clinical practice, and argue that the existing clinical theories are under- developed. Therefore, we develop a dynamic systems framework for gender identity development. Specifically, we suggest that critical aspects of presymbolic gender embodiment occur during infancy as part of the synchronous interplay of caregiver-infant dyads. By 18 months, a transition to symbolic representation and the beginning of an internalization of a sense of gender can be detected and consolidation is quite evident by 3 years of age. We conclude by suggesting empirical studies that could expand and test this framework. With the belief that better, more explicit developmental theory can improve clinical practice, we urge that clinicians take a dynamic developmental view of gender identity formation into account.

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The Transgender Identity Survey:

A Measure of Internalized Transphobia

Bockting, W.O., et al.
LGBT Health

Abstract

Purpose: We describe the development of a measure of internalized transphobia, defined as discomfort with one’s transgender identity as a result of internalizing society’s normative gender expectations.

Methods: An item pool was created based on responses from a small clinical sample (N= 12) to an open-ended questionnaire. Expert judges reviewed the items, resulting in a 60-item instrument for empirical testing. We conducted exploratory factor analysis (EFA) by using a community sample of 430 transgender individuals (aged 18– 72, mean [M]= 37.4, standard deviation [SD]= 12.0), and confirmatory factor analysis (CFA) by using an online sample of 903 transgender individuals (aged 18–66, M= 31.6, SD= 11.1). Construct validity was examined by using correlations with instruments assessing related constructs administered to the online sample.

Results: EFA resulted in a 52-item instrument with four subscales: Pride, Passing, Alienation, and Shame. CFA, after removal of half of the items, retained the four-factor structure. The final 26-item scale showed excellent internal consistency (0.90) and test–retest reliability (0.93). The factors showed a pattern of association with crossgender identity, gender ideology, outness, felt stigma, self-esteem, and psychological distress consistent with moderate-to-good construct validity.

Conclusion: Internalized transphobia can be conceptualized as four inter-related dimensions: pride in transgender identity (reverse scored), investment in passing as a cisgender person, alienation from other transgender people, and shame. The Transgender Identity Survey reliably assesses this construct, useful in research to understand the impact of minority stress on transgender people’s health. It can also be used in clinical practice to assess internalized transphobia at intake and follow-up.

Keywords: identity, internalized transphobia, measure, minority stress, stigma, transgender

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Adult Development and Quality of Life of Transgender and Gender Nonconforming People

Bockting, W.O., et al.
Curr Opin Endocrinol Diabetes Obes.

Abstract

Purpose of review — Research on the health of transgender and gender nonconforming people has been limited with most of the work focusing on transition-related care and HIV. This review summarizes research to date on the overall development and quality of life of transgender and gender nonconforming adults, and makes recommendations for future research.

Recent findings — Pervasive stigma and discrimination attached to gender nonconformity affect the health of transgender people across the lifespan, particularly when it comes to mental health and wellbeing. Despite the related challenges, transgender and gender nonconforming people may develop resilience over time. Social support and affirmation of gender identity play herein a critical role. While there is a growing awareness of diversity in gender identity and expression among this population, a comprehensive understanding of biopsychosocial development beyond the gender binary and beyond transition is lacking.

Summary — Greater visibility of transgender people in society has revealed the need to understand and promote their health and quality of life broadly, including but not limited to gender dysphoria and HIV. This means addressing their needs in context of their families and communities, sexual and reproductive health, and successful aging. Research is needed to better understand what factors are associated with resilience and how it can be effectively promoted.

Keywords Transgender; gender identity; lifespan development; quality of life

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Transgender identity: Development, management and affirmation

Doyle, D.M.
ScienceDirect

Abstract

In this review, I discuss recent research on transgender identity development, management and affirmation, situating key topics within a social feedback model of transgender identity. This model foregrounds the dynamic interplay between internal and external influences on transgender identity. Furthermore, issues of intersectionality are highlighted throughout and located within broader socio-political contexts. Collectively, research on topics such as gender euphoria, passing, identity affirmation and social transitions, among others, points to the pivotal role of supportive social relationships and social environments in the healthy development and expression of transgender identities. Future work should prioritize longitudinal studies with careful and rigorous assessment of identity related constructs in order to further examine these and other topics.

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Stability After Legal Gender Change Among Adults With Gender Dysphoria

Kristen D. Clark
Jama Network Open

Abstract

Importance The number of people seeking treatment for gender dysphoria (GD) has risen in recent decades, yet data remain limited for understanding cases of detransition (ie, the reversal of social, medical, or legal transition). Legal gender change in national registers poses an opportunity to examine legal gender reversals, which may reflect an aspect of the detransition process, while also informing an understanding of the stability after a legal gender change.

Objective To determine the probability of obtaining a legal gender change and its stability over time among people diagnosed with GD in Sweden during a 10-year study period.

Design, Setting, and Participants In this population cohort study using data from Swedish national registers from January 1, 2013, to December 31, 2023, individuals who received their first International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis code for GD during the study period were included. While participants may have received a GD ICD-10 code as youths, legal gender changes only occurred for adults (aged 18 years) based on legal requirements during the time of data collection.

Exposure Gender dysphoria.

Main Outcome and Measures Legal gender change and its stability, that is, absence of legal gender reversal, as reported in the registry. Kaplan-Meier survival analysis was used to determine the probability of legal gender change and its stability during a 10-year study period. + Supplemental content Author affiliations and article information are listed at the end of this article.

Results A total of 7293 people with a GD diagnosis were included (36 025 person-years). Approximately one-third of the sample (n = 2467) obtained a legal gender change during the study period. The probability of legal gender change at 10 years following diagnosis was 58.3% (95% CI, 56.2%-60.4%). Twenty-one cases of legal gender reversal were identified. The probability of legal gender stability at 10 years following the initial change was 97.7% (95% CI, 96.3%-99.2%), with no differences by sex assigned at birth for either outcome.

Conclusions and Relevance In this cohort study using national population registry data, a significant proportion of participants with GD in Sweden obtained legal gender change within 10 years of follow-up. Despite significant growth of the population with GD, the probability of legal gender stability during the 10-year study period was high, at almost 98%. These results highlight that legal gender reversal was an infrequent occurrence in a national sample. Key Points Question What is the probability that the changed legal gender among people with gender dysphoria (GD) will remain stable over time? Findings In this national cohort study, 7293 people with GD had a 58% probability of obtaining a legal gender change over time and an almost 98% probability that the legal gender remained stable. No differences based on sex assigned at birth or age were observed. Meaning These findings suggest that among the most recent cohort of people who have sought treatment for GD and legally changed their gender, there is a low risk for legal gender reversal.

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Transgender people: health at the margins of society

Sam Winter, Milton Diamond, Jamison Green, Dan Karasic, Terry Reed, Stephen Whittle, Kevan Wylie
School of Public Health, Faculty of Health Sciences, Curtin University, Perth, WA, Australia

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classifi cation of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty

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