Expert panel recommends revisions to gender-affirming care guidelines

Reviewed by Emily Henderson, B.Sc.Dec 19 2022

Transgender and gender-diverse (TGD) people often seek social, medical, and surgical gender-affirming care from a variety of healthcare professionals. Individualized care for optimal gender identity confirmation should be the main goal, rather than strict rules to guide interventions, according to an expert panel's commentary in the November issue of Harvard Review of Psychiatry (HRP). The journal is published in the Lippincott portfolio by Wolters Kluwer.

The panel's opinion was prompted by proposed updates to the gender-affirming care guidelines of the World Professional Association for Transgender Health (WPATH). The WPATH is an interdisciplinary professional and educational organization devoted to promoting the health of TGD people in all cultural settings. As part of that mission, WPATH publishes Standards of Care for the Health of Transgender and Gender Diverse People, which are updated regularly to reflect the latest scientific evidence and expert consensus.

Gender-affirming inventions and care promoted in revised guidelines

The next version of these guidelines is scheduled for release in 2023. Accordingly, the Radcliffe Institute for Advanced Study at Harvard University hosted an exploratory seminar that brought together experts from the United States, Mexico, and the United Kingdom to share knowledge and propose revisions to the WPATH update. Christina Macenski, MD, a Child and Adolescent Psychiatry Fellow at Massachusetts General Hospital and Harvard Medical School, hosted the seminar with John A. Fromson, MD, Vice Chair of Community Psychiatry at Brigham and Women's Hospital and Associate Professor of Psychiatry at Harvard Medical School.

As outlined in the HRP column, gender-affirming interventions can be grouped into three major categories:

• Social interventions that allow for a person to live their identified gender through changes in behavior or appearance (e.g., changing their names, pronouns, and aspects of gender expression such as clothing and voice pitch)
• Prescribed hormones (or hormone blockers) that result in changes to secondary sexual characteristics, such as muscle, weight, and hair redistribution
• Surgical interventions that allow for body anatomy to match gender identity

The seminar participants recommend promoting gender-affirming care by:

• Providing patients with a balanced risk–benefit analysis for interventions
• Avoiding the assumption that mental health concerns automatically affect a person's ability to make decisions about gender-affirming interventions
• Taking care of patients with language which reflects the continuum of gender, rather than a gender binary; using words like "needed" rather than "desired" when discussing medical treatments; and being mindful that TGD people do not necessarily have "dysphoria" related to their gender
• Firmly and unequivocally condemning conversion therapy (attempts to change a person's gender identity by force)

Unique needs of TGD adolescents taken into consideration

The authors highlight the need to individualize the sequence of gender-affirming interventions. Some physicians recommend hormone initiation prior to any surgery, but the workgroup does not consider hormone therapy a prerequisite for specific interventions. As stated in their paper, "Some individuals may require surgical intervention . . . without the need or desire for prior hormone treatment (or hormone treatment at all)."

The workgroup also draws attention to the unique needs of TGD adolescents. Gender-affirming care for adolescents can be complicated by requirements for parental consent for many interventions. Some parents are hesitant to support social, medical, or surgical treatment for a variety of reasons, including fear of their child regretting their decision. However, the authors note that detransition rates are very low, even in adolescence. They recommend that requirements for specific interventions should consider the emotional, physical, and developmental stage of the individual patient, rather than be based on an arbitrary age.

The authors conclude that when considered together, their recommendations "represent a more comprehensive way to provide care that promotes justice in gender-affirming treatment."