Transgender health care
Transgender health care includes the prevention, diagnosis and treatment of physical and mental health conditions which affect transgender individuals. A major component of transgender health care is gender-affirming care, the medical aspect of gender transition. Questions implicated in transgender health care include gender variance, sex reassignment therapy, health risks, and access to healthcare for trans people in different countries around the world. Gender-affirming health care can include psychological, medical, physical, and social behavioral care. The purpose of gender-affirming care is to help a transgender individual conform to their desired gender identity.
In the 1920s, physician Magnus Hirschfeld conducted formal studies to understand gender dysphoria and human sexuality and advocated for communities that were marginalized. His research and work provided a new perspective on gender identity, gender expression, and sexuality. This was the first time there was a challenge against societal norms. In addition to his research, Hirschfeld also coined the term transvestite, which in modern terms is known as "transgender". Hirschfeld's work was ended during the Nazi German era when many transgender individuals were arrested and sent to concentration camps.
In 1966 the Johns Hopkins Gender Identity Clinic opened; it was one of the first in the US to provide care for transgender individuals, including hormone replacement therapy, surgery, psychological counseling, and other gender affirmative healthcare. The clinic required patients before a gender affirmation surgery to go through a program called "Real Life Test". The Real Life Test was a program where before a gender affirming surgery the patient was required to live with their desired gender role. In 1979 the clinic was closed by the newly appointed director of psychiatry Paul McHughs.
Medical characterization of gender variance
Gender variance is defined in medical literature as "gender identity, expression, or behavior that falls outside of culturally defined norms associated with a specific gender". For centuries, gender variance was seen by medicine as a pathology. The World Health Organization identified gender dysphoria as a mental disorder in the International Classification of Diseases until 2018. Gender dysphoria was also listed in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, where it was previously called "transsexualism" and "gender identity disorder".In 2018, the ICD-11 included the term "gender incongruence" as "marked and persistent incongruence between an individual's experienced gender and the assigned sex", where gender variant behaviour and preferences do not necessarily imply a medical diagnosis. However, the difference between "gender dysphoria" and "gender incongruence" is not always clear in the medical literature.
Some studies posit that treating gender variance as a medical condition has negative effects on the health of transgender people and claim that assumptions of coexisting psychiatric symptoms should be avoided. Other studies argue that gender incongruence diagnosis may be important and even positive for transgender people at the individual and social level.
As there are various ways of classifying or characterizing those who are either diagnosed or self-affirm as transgender individuals, the literature cannot clearly estimate how prevalent these experiences are within the total population. The results of a recent systematic review highlight the need to standardize the scope and methodology related to data collection of those presenting as transgender.
Mental health assistance
Due to the discrimination they face, trans individuals often present significant mental health disparities. Among them, it is estimated that 32-50% of trans individuals across various countries have attempted suicide, with this high prevalence attributed to factors such as victimization, bullying, violence, social and familial rejection, as well as discrimination in different public sectors. Other than gender dysphoria, trans individuals are also affected by mental health diagnoses, such as major depression and generalized anxiety, at far greater rates than the non-trans population. Whilst gender-affirming care has a positive impact on trans individuals' mental health and may lessen several symptoms, the psychological improvements of such care are often limited by the minority stressors affecting the trans population.Due to these factors, mental health assistance through means such as psychotherapy may play an important role in addressing trans patients' mental health. Mental health assessments and treatment may be conducted prior to the initiation of gender-affirming care as a means of ensuring the patient's informed consent and complementing medical transition. Pyschotherapy as a requirement for the inititation of affirmative medical care today is discouraged by trans health care protocols, as are approaches attempting to change the patient's identity or skew self-exploration towards one particular direction.
Identity exploration
Because the development and consolidation of gender identity is a diverse process among trans adolescents, it is recommended that healthcare professionals offer a respectful environment for clients, especially youth, to explore and express different facets of their identity, including the need for gender-affirming care. It is important that gender exploration is not used to delay gender-affirming care or attempt tracing trans identity to pathologies, as such approaches would be tantamount to conversion practices, which are known for causing significant harm.Gender-affirming care
Various options are available for transgender people to pursue physical transition. There have been options for transitioning for transgender individuals since 1917. Gender-affirming care helps people to change their physical appearance and/or sex characteristics to accord with their gender identity; it includes gender-affirming hormone therapy and gender-affirming surgery. While many transgender people do elect to transition physically, every transgender person has different needs and, as such, there is no required transition plan. Preventive health care is a crucial part of transitioning and a primary care physician is recommended for transgender people who are transitioning.Eligibility
In the 11th version of the International Classification of Diseases, the diagnosis is known as gender incongruence. ICD-11 states that "Gender variant behaviour and preferences alone are not a basis for assigning the diagnosis."The US Diagnostic and Statistical Manual of Mental Disorders names it gender dysphoria. Some people who are validly diagnosed have no desire for all or some parts of hormone replacement therapy, or gender affirming surgery, and/or are not appropriate candidates for such treatment.
The general standards for diagnosing, as well as treating distress caused by gender incongruence or gender dysphoria are outlined in the WPATH Standards of Care for the Health of Transgender and Gender Diverse People. As of February 2023, the most recent version of the standards is Version 8, called SOC8 in short. According to the standards of care, "Gender Dysphoria describes a state of distress or discomfort that may be experienced because a person's gender identity differs from that which is physically and/or socially attributed to their sex assigned at birth... Not all transgender and gender diverse people experience gender dysphoria." Gender nonconformity is not the same as gender dysphoria; nonconformity, according to the standards of care, is not a pathology and does not require medical treatment.
The WPATH Standards of Care in the latest version 8 from February 2023, follow an informed consent model, which is the default approach that most medical professionals administering gender-affirming care follow today.
Informed consent approaches include conversations between the medical provider and person seeking care on the details of risks and outcomes, current understandings of scientific research, and how the provider can best assist the person in making decisions.
Local standards of care exist in many countries, with most local standards being based on the WPATH standards, with some minor exceptions.
Eligibility for different stages of treatment
While a mental health assessment is recommended as standard practice by the WPATH Standards of Care, psychotherapy is not an absolute requirement but is highly recommended.Hormone replacement therapy is to be initiated from a qualified health professional. The general requirements, according to the WPATH standards, include:
- 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 significant medical or mental health concerns are present, they must be reasonably well-controlled.
Eligibility of minors
While the WPATH standards of care generally require the patient to have reached the age of majority, they include a separate section devoted to children and adolescents. Prepubescent children do not have access to medical intervention for gender-affirming therapy. After puberty, some medical intervention is available for adolescents depending on specific criteria for gender incongruence diagnosis, capacity for informed consent, and mental and physical health.According to a study by JAMA Pediatrics published in January 2025, less than 0.1% of adolescents covered by private medical insurance in the US take gender-affirming medication to treat gender dysphoria.