Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7
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International Journal of Transgenderism, 13:165–232, 2011
Copyright C World Professional Association for Transgender Health
ISSN: 1553-2739 print / 1434-4599 online
DOI: 10.1080/15532739.2011.700873
Standards of Care for the Health of Transsexual,
Transgender, and Gender-Nonconforming People, Version 7
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,
Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R.,
Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., Lev, A. I.,
Mayer, G., Meyer-Bahlburg, H., Hall, B. P., Pfaefflin, F., Rachlin, K., Robinson, B.,
Schechter, L. S., Tangpricha, V., van Trotsenburg, M., Vitale, A., Winter, S., Whittle, S.,
Wylie, K. R., & Zucker, K.
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.
KEYWORDS. Transexual, transgender, gender dysphoria, Standards of Care
This is the seventh version of the Standards of Care. The original SOC were published in 1979. Previous
revisions were in 1980, 1981, 1990, 1998, and 2001.
Address correspondence to Eli Coleman, PhD, Program in Human Sexuality, University of Minnesota
Medical School, 1300 South 2nd Street, Suite 180, Minneapolis, MN 55454. E-mail: colem001@umn.edu
165166 INTERNATIONAL JOURNAL OF TRANSGENDERISM
I. PURPOSE AND USE OF THE counseling, psychotherapy), and hormonal and
STANDARDS OF CARE surgical treatments. While this is primarily a
document for health professionals, the SOC
The World Professional Association for may also be used by individuals, their families,
Transgender Health (WPATH)1 is an interna- and social institutions to understand how they
tional, multidisciplinary, professional associa- can assist with promoting optimal health for
tion whose mission is to promote evidence- members of this diverse population.
based care, education, research, advocacy, public WPATH recognizes that health is dependent
policy, and respect in transsexual and transgen- upon not only good clinical care but also social
der health. The vision of WPATH is a world and political climates that provide and ensure so-
wherein transsexual, transgender, and gender- cial tolerance, equality, and the full rights of citi-
nonconforming people benefit from access to zenship. Health is promoted through public poli-
evidence-based health care, social services, jus- cies and legal reforms that promote tolerance and
tice, and equality. equity for gender and sexual diversity and that
One of the main functions of WPATH is to eliminate prejudice, discrimination, and stigma.
promote the highest standards of health care for WPATH is committed to advocacy for these
individuals through the articulation of Standards changes in public policies and legal reforms.
of Care (SOC) for the Health of Transsexual,
Transgender, and Gender-Nonconforming Peo- The Standards of Care Are Flexible
ple. The SOC are based on the best available Clinical Guidelines
science and expert professional consensus.2
Most of the research and experience in this The SOC are intended to be flexible in order
field comes from a North American and Western to meet the diverse health care needs of trans-
European perspective; thus, adaptations of the sexual, transgender, and gender-nonconforming
SOC to other parts of the world are necessary. people. While flexible, they offer standards
Suggestions for ways of thinking about cultural for promoting optimal health care and guiding
relativity and cultural competence are included the treatment of people experiencing gender
in this version of the SOC. dysphoria—broadly defined as discomfort or
The overall goal of the SOC is to pro- distress that is caused by a discrepancy between
vide clinical guidance for health professionals a person’s gender identity and that person’s sex
to assist transsexual, transgender, and gender- assigned at birth (and the associated gender role
nonconforming people with safe and effective and/or primary and secondary sex character-
pathways to achieving lasting personal comfort istics) (Fisk, 1974; Knudson, De Cuypere, &
with their gendered selves, in order to maximize Bockting, 2010b).
their overall health, psychological well-being, As in all previous versions of the SOC, the
and self-fulfillment. This assistance may include criteria put forth in this document for hormone
primary care, gynecologic and urologic care, therapy and surgical treatments for gender dys-
reproductive options, voice and communication phoria are clinical guidelines; individual health
therapy, mental health services (e.g., assessment, professionals and programs may modify them.
Clinical departures from the SOC may come
about because of a patient’s unique anatomic, so-
1
Formerly the Harry Benjamin International cial, or psychological situation; an experienced
Gender Dysphoria Association. health professional’s evolving method of han-
2
The Standards of Care (SOC), Version 7, repre- dling a common situation; a research protocol;
sents a significant departure from previous versions. lack of resources in various parts of the world;
Changes in this version are based upon significant or the need for specific harm-reduction strate-
cultural shifts, advances in clinical knowledge, and gies. These departures should be recognized as
appreciation of the many health care issues that
can arise for transsexual, transgender, and gender- such, explained to the patient, and documented
nonconforming people beyond hormone therapy and through informed consent for quality patient care
surgery (Coleman, 2009a, 2009b, 2009c, 2009d). and legal protection. This documentation is alsoColeman et al. 167
valuable for the accumulation of new data, which initiate a change in their gender expression
can be retrospectively examined to allow for and physical characteristics while in their teens
health care—and the SOC—to evolve. or even earlier. Many grow up and live in
The SOC articulate standards of care but a social, cultural, and even linguistic context
also acknowledge the role of making informed quite unlike that of Western cultures. Yet almost
choices and the value of harm-reduction ap- all experience prejudice (Peletz, 2006; Winter,
proaches. In addition, this version of the SOC 2009). In many cultures, social stigma towards
recognizes and validates various expressions of gender nonconformity is widespread and gender
gender that may not necessitate psychological, roles are highly prescriptive (Winter et al., 2009).
hormonal, or surgical treatments. Some patients Gender-nonconforming people in these settings
who present for care will have made signifi- are forced to be hidden and, therefore, may lack
cant self-directed progress towards gender role opportunities for adequate health care (Winter,
changes, transition, or other resolutions regard- 2009).
ing their gender identity or gender dysphoria. The SOC are not intended to limit efforts
Other patients will require more intensive ser- to provide the best available care to all in-
vices. Health professionals can use the SOC to dividuals. Health professionals throughout the
help patients consider the full range of health world—even in areas with limited resources
services open to them, in accordance with their and training opportunities—can apply the many
clinical needs and goals for gender expression. core principles that undergird the SOC. These
principles include the following: Exhibit re-
spect for patients with nonconforming gender
II. GLOBAL APPLICABILITY OF THE identities (do not pathologize differences in
STANDARDS OF CARE gender identity or expression); provide care
(or refer to knowledgeable colleagues) that
While the SOC are intended for worldwide affirms patients’ gender identities and reduces
use, WPATH acknowledges that much of the the distress of gender dysphoria, when present;
recorded clinical experience and knowledge in become knowledgeable about the health care
this area of health care is derived from North needs of transsexual, transgender, and gender-
American and Western European sources. From nonconforming people, including the benefits
place to place, both across and within nations, and risks of treatment options for gender dys-
there are differences in all of the following: phoria; match the treatment approach to the
social attitudes towards transsexual, transgender, specific needs of patients, particularly their goals
and gender-nonconforming people; construc- for gender expression and need for relief from
tions of gender roles and identities; language gender dysphoria; facilitate access to appropriate
used to describe different gender identities; care; seek patients’ informed consent before
epidemiology of gender dysphoria; access to and providing treatment; offer continuity of care; and
cost of treatment; therapies offered; number and be prepared to support and advocate for patients
type of professionals who provide care; and legal within their families and communities (schools,
and policy issues related to this area of health workplaces, and other settings).
care (Winter, 2009). Terminology is culturally and time-dependent
It is impossible for the SOC to reflect all of and is rapidly evolving. It is important to use
these differences. In applying these standards respectful language in different places and times,
to other cultural contexts, health professionals and among different people. As the SOC are
must be sensitive to these differences and translated into other languages, great care must
adapt the SOC according to local realities. be taken to ensure that the meanings of terms are
For example, in a number of cultures, gender- accurately translated. Terminology in English
nonconforming people are found in such num- may not be easily translated into other languages,
bers and living in such ways as to make them and vice versa. Some languages do not have
highly socially visible (Peletz, 2006). In settings equivalent words to describe the various terms
such as these, it is common for people to within this document; hence, translators should168 INTERNATIONAL JOURNAL OF TRANSGENDERISM
be cognizant of the underlying goals of treatment of Medicine, 2011). Gender dysphoria refers to
and articulate culturally applicable guidance for discomfort or distress that is caused by a discrep-
reaching those goals. ancy between a person’s gender identity and that
person’s sex assigned at birth (and the associated
gender role and/or primary and secondary sex
III. THE DIFFERENCE BETWEEN characteristics) (Fisk, 1974; Knudson, De
GENDER NONCONFORMITY Cuypere, & Bockting, 2010b). Only some
AND GENDER DYSPHORIA gender-nonconforming people experience
gender dysphoria at some point in their lives.
Being Transsexual, Transgender, Treatment is available to assist people with
or Gender Nonconforming Is a Matter such distress to explore their gender identity
and find a gender role that is comfortable for
of Diversity, Not Pathology them (Bockting & Goldberg, 2006). Treatment is
WPATH released a statement in May 2010 individualized: What helps one person alleviate
urging the de-psychopathologization of gender gender dysphoria might be very different from
nonconformity worldwide (WPATH Board of what helps another person. This process may
Directors, 2010). This statement noted that “the or may not involve a change in gender expres-
expression of gender characteristics, including sion or body modifications. Medical treatment
identities, that are not stereotypically associated options include, for example, feminization or
with one’s assigned sex at birth is a common masculinization of the body through hormone
and culturally diverse human phenomenon [that] therapy and/or surgery, which are effective in
should not be judged as inherently pathological alleviating gender dysphoria and are medically
or negative.” necessary for many people. Gender identities
Unfortunately, there is a stigma attached to and expressions are diverse, and hormones and
gender nonconformity in many societies around surgery are just two of many options available
the world. Such stigma can lead to prejudice to assist people with achieving comfort with self
and discrimination, resulting in “minority stress” and identity.
(I. H. Meyer, 2003). Minority stress is unique Gender dysphoria can in large part be alle-
(additive to general stressors experienced by viated through treatment (Murad et al., 2010).
all people), socially based, and chronic, and Hence, while transsexual, transgender, and
may make transsexual, transgender, and gender- gender-nonconforming people may experience
nonconforming individuals more vulnerable to gender dysphoria at some points in their lives,
developing mental health problems such as many individuals who receive treatment will find
anxiety and depression (Institute of Medicine, a gender role and expression that is comfortable
2011). In addition to prejudice and discrimina- for them, even if these differ from those asso-
tion in society at large, stigma can contribute ciated with their sex assigned at birth, or from
to abuse and neglect in one’s relationships with prevailing gender norms and expectations.
peers and family members, which in turn can
lead to psychological distress. However, these Diagnoses Related to Gender Dysphoria
symptoms are socially induced and are not
inherent to being transsexual, transgender, or Some people experience gender dysphoria
gender-nonconforming. at such a level that the distress meets criteria
for a formal diagnosis that might be classi-
Gender Nonconformity Is Not the Same fied as a mental disorder. Such a diagnosis
as Gender Dysphoria is not a license for stigmatization or for the
deprivation of civil and human rights. Existing
Gender nonconformity refers to the extent classification systems such as the Diagnostic
to which a person’s gender identity, role, Statistical Manual of Mental Disorders (DSM)
or expression differs from the cultural norms (American Psychiatric Association, 2000) and
prescribed for people of a particular sex (Institute the International Classification of DiseasesColeman et al. 169
(ICD) (World Health Organization, 2007) define that cultural differences from one country to
hundreds of mental disorders that vary in onset, another would alter both the behavioral ex-
duration, pathogenesis, functional disability, and pressions of different gender identities and the
treatability. All of these systems attempt to extent to which gender dysphoria—distinct from
classify clusters of symptoms and conditions, one’s gender identity—is actually occurring in a
not the individuals themselves. A disorder is a population. While in most countries, crossing
description of something with which a person normative gender boundaries generates moral
might struggle, not a description of the person censure rather than compassion, there are exam-
or the person’s identity. ples in certain cultures of gender-nonconforming
Thus, transsexual, transgender, and gender- behaviors (e.g., in spiritual leaders) that are less
nonconforming individuals are not inherently stigmatized and even revered (Besnier, 1994;
disordered. Rather, the distress of gender dys- Bolin, 1988; Chiñas, 1995; Coleman, Colgan, &
phoria, when present, is the concern that might Gooren, 1992; Costa & Matzner, 2007; Jackson
be diagnosable and for which various treatment & Sullivan, 1999; Nanda, 1998; Taywaditep,
options are available. The existence of a diagno- Coleman, & Dumronggittigule, 1997).
sis for such dysphoria often facilitates access to For various reasons, researchers who have
health care and can guide further research into studied incidence and prevalence have tended
effective treatments. to focus on the most easily counted subgroup of
Research is leading to new diagnostic nomen- gender-nonconforming individuals: transsexual
clatures, and terms are changing in both the DSM individuals who experience gender dysphoria
(Cohen-Kettenis & Pfäfflin, 2010; Knudson, De and who present for gender-transition-related
Cuypere, & Bockting, 2010b; Meyer-Bahlburg, care at specialist gender clinics (Zucker &
2010; Zucker, 2010) and the ICD. For this Lawrence, 2009). Most studies have been con-
reason, familiar terms are employed in the ducted in European countries such as Sweden
SOC and definitions are provided for terms that (Wålinder, 1968, 1971), the United Kingdom
may be emerging. Health professionals should (Hoenig & Kenna, 1974), the Netherlands
refer to the most current diagnostic criteria and (Bakker, Van Kesteren, Gooren, & Bezemer,
appropriate codes to apply in their practice areas. 1993; Eklund, Gooren, & Bezemer, 1988; van
Kesteren, Gooren, & Megens, 1996), Germany
(Weitze & Osburg, 1996), and Belgium (De
IV. EPIDEMIOLOGIC Cuypere et al., 2007). One was conducted in
CONSIDERATIONS Singapore (Tsoi, 1988).
De Cuypere and colleagues (2007) reviewed
Formal epidemiologic studies on the such studies, as well as conducted their own.
incidence3 and prevalence4 of transsexual- Together, those studies span 39 years. Leaving
ism specifically or transgender and gender- aside two outlier findings from Pauly in 1965
nonconforming identities in general have not and Tsoi in 1988, ten studies involving eight
been conducted, and efforts to achieve realistic countries remain. The prevalence figures re-
estimates are fraught with enormous difficul- ported in these ten studies range from 1:11,900 to
ties (Institute of Medicine, 2011; Zucker & 1:45,000 for male-to-female individuals (MtF)
Lawrence, 2009). Even if epidemiologic studies and 1:30,400 to 1:200,000 for female-to-male
established that a similar proportion of trans- (FtM) individuals. Some scholars have sug-
sexual, transgender, or gender-nonconforming gested that the prevalence is much higher,
people existed all over the world, it is likely depending on the methodology used in the
research (e.g., Olyslager & Conway, 2007).
3 Direct comparisons across studies are impos-
Incidence—the number of new cases arising in
a given period (e.g., a year). sible, as each differed in their data collection
4
Prevalence—the number of individuals having methods and in their criteria for documenting
a 4035 condition, divided by the number of people in a person as transsexual (e.g., whether or not
the general population. a person had undergone genital reconstruction,170 INTERNATIONAL JOURNAL OF TRANSGENDERISM
versus had initiated hormone therapy, versus had Overall, the existing data should be consid-
come to the clinic seeking medically supervised ered a starting point, and health care would
transition services). The trend appears to be benefit from more rigorous epidemiologic study
towards higher prevalence rates in the more in different locations worldwide.
recent studies, possibly indicating increasing
numbers of people seeking clinical care. Support
for this interpretation comes from research by V. OVERVIEW OF THERAPEUTIC
Reed and colleagues (2009), who reported a APPROACHES FOR GENDER
doubling of the numbers of people accessing DYSPHORIA
care at gender clinics in the United Kingdom
every five or six years. Similarly, Zucker and Advancements in the Knowledge and
colleagues (2008) reported a four- to five-fold Treatment of Gender Dysphoria
increase in child and adolescent referrals to their
Toronto, Canada, clinic over a 30-year period. In the second half of the 20th century,
The numbers yielded by studies such as these awareness of the phenomenon of gender
can be considered minimum estimates at best. dysphoria increased when health professionals
The published figures are mostly derived from began to provide assistance to alleviate gender
clinics where patients met criteria for severe dysphoria by supporting changes in primary and
gender dysphoria and had access to health care secondary sex characteristics through hormone
at those clinics. These estimates do not take into therapy and surgery, along with a change in
account that treatments offered in a particular gender role. Although Harry Benjamin already
clinic setting might not be perceived as afford- acknowledged a spectrum of gender noncon-
able, useful, or acceptable by all self-identified formity (Benjamin, 1966), the initial clinical
gender dysphoric individuals in a given area. By approach largely focused on identifying who was
counting only those people who present at clinics an appropriate candidate for sex reassignment to
for a specific type of treatment, an unspecified facilitate a physical change from male to female
number of gender dysphoric individuals are or female to male as completely as possible (e.g.,
overlooked. Green & Fleming, 1990; Hastings, 1974). This
Other clinical observations (not yet firmly approach was extensively evaluated and proved
supported by systematic study) support the to be highly effective. Satisfaction rates across
likelihood of a higher prevalence of gender studies ranged from 87% of MtF patients to
dysphoria: (i) Previously unrecognized gender 97% of FtM patients (Green & Fleming, 1990),
dysphoria is occasionally diagnosed when pa- and regrets were extremely rare (1%–1.5%
tients are seen with anxiety, depression, conduct of MtF patients and < 1% of FtM patients;
disorder, substance abuse, dissociative identity Pfäfflin, 1993). Indeed, hormone therapy and
disorders, borderline personality disorder, sex- surgery have been found to be medically
ual disorders, and disorders of sex develop- necessary to alleviate gender dysphoria in many
ment (Cole, O’Boyle, Emory, & Meyer, 1997). people (American Medical Association, 2008;
(ii) Some cross-dressers, drag queens/kings or Anton, 2009; World Professional Association
female/male impersonators, and gay and les- for Transgender Health, 2008).
bian individuals may be experiencing gender As the field matured, health professionals
dysphoria (Bullough & Bullough, 1993). (iii) recognized that while many individuals need
The intensity of some people’s gender dysphoria both hormone therapy and surgery to alleviate
fluctuates below and above a clinical thresh- their gender dysphoria, others need only one of
old (Docter, 1988). (iv) Gender nonconformity these treatment options and some need neither
among FtM individuals tends to be relatively in- (Bockting & Goldberg, 2006; Bockting, 2008;
visible in many cultures, particularly to Western Lev, 2004). Often with the help of psychother-
health professionals and researchers who have apy, some individuals integrate their trans-
conducted most of the studies on which the or cross-gender feelings into the gender role
current estimates of prevalence and incidence they were assigned at birth and do not feel the
are based (Winter, 2009). need to feminize or masculinize their body. ForColeman et al. 171
others, changes in gender role and expression Options for Psychological and Medical
are sufficient to alleviate gender dysphoria. Treatment of Gender Dysphoria
Some patients may need hormones, a possible
change in gender role, but not surgery; others For individuals seeking care for gender
may need a change in gender role along with dysphoria, a variety of therapeutic options
surgery but not hormones. In other words, can be considered. The number and type of
treatment for gender dysphoria has become interventions applied and the order in which
more individualized. these take place may differ from person to person
As a generation of transsexual, transgender, (e.g., Bockting, Knudson, & Goldberg, 2006;
and gender-nonconforming individuals has Bolin, 1994; Rachlin, 1999; Rachlin, Green, &
come of age—many of whom have benefitted Lombardi, 2008; Rachlin, Hansbury, & Pardo,
from different therapeutic approaches—they 2010). Treatment options include the following:
have become more visible as a community and
demonstrated considerable diversity in their • Changes in gender expression and role
gender identities, roles, and expressions. Some (which may involve living part time or full
individuals describe themselves not as gender- time in another gender role, consistent with
nonconforming but as unambiguously cross- one’s gender identity);
sexed (i.e., as a member of the other sex; Bockt- • Hormone therapy to feminize or masculin-
ing, 2008). Other individuals affirm their unique ize the body;
gender identity and no longer consider them- • Surgery to change primary and/or sec-
selves to be either male or female (Bornstein, ondary sex characteristics (e.g., breasts/
1994; Kimberly, 1997; Stone, 1991; Warren, chest, external and/or internal genitalia,
1993). Instead, they may describe their gender facial features, body contouring);
identity in specific terms such as transgender, • Psychotherapy (individual, couple, family,
bigender, or genderqueer, affirming their unique or group) for purposes such as explor-
experiences that may transcend a male/female ing gender identity, role, and expression;
binary understanding of gender (Bockting, addressing the negative impact of gender
2008; Ekins & King, 2006; Nestle, Wilchins, & dysphoria and stigma on mental health;
Howell, 2002). They may not experience their alleviating internalized transphobia; en-
process of identity affirmation as a “transition,” hancing social and peer support; improving
because they never fully embraced the gender body image; or promoting resilience.
role they were assigned at birth or because Options for Social Support and Changes
they actualize their gender identity, role, and
expression in a way that does not involve a
in Gender Expression
change from one gender role to another. For In addition (or as an alternative) to the
example, some youth identifying as genderqueer psychological- and medical-treatment options
have always experienced their gender identity described above, other options can be considered
and role as such (genderqueer). Greater public to help alleviate gender dysphoria, for example:
visibility and awareness of gender diversity
(Feinberg, 1996) have further expanded options • In person and online peer support re-
for people with gender dysphoria to actualize an sources, groups, or community organi-
identity and find a gender role and expression zations that provide avenues for social
that are comfortable for them. support and advocacy;
Health professionals can assist gender dys- • In person and online support resources for
phoric individuals with affirming their gender families and friends;
identity, exploring different options for expres- • Voice and communication therapy to help
sion of that identity, and making decisions about individuals develop verbal and nonverbal
medical treatment options for alleviating gender communication skills that facilitate com-
dysphoria. fort with their gender identity;172 INTERNATIONAL JOURNAL OF TRANSGENDERISM
• Hair removal through electrolysis, laser 1984). Newer studies, also including girls,
treatment, or waxing; showed a 12%–27% persistence rate of gender
• Breast binding or padding, genital tucking dysphoria into adulthood (Drummond, Bradley,
or penile prostheses, padding of hips or Peterson-Badali, & Zucker, 2008; Wallien &
buttocks; Cohen-Kettenis, 2008).
• Changes in name and gender marker on In contrast, the persistence of gender dyspho-
identity documents. ria into adulthood appears to be much higher for
adolescents. No formal prospective studies exist.
However, in a follow-up study of 70 adolescents
VI. ASSESSMENT AND TREATMENT who were diagnosed with gender dysphoria and
OF CHILDREN AND ADOLESCENTS given puberty-suppressing hormones, all con-
WITH GENDER DYSPHORIA tinued with actual sex reassignment, beginning
with feminizing/masculinizing hormone therapy
There are a number of differences in the phe- (de Vries, Steensma, Doreleijers, & Cohen-
nomenology, developmental course, and treat- Kettenis, 2010).
ment approaches for gender dysphoria in chil- Another difference between gender dysphoric
dren, adolescents, and adults. In children and children and adolescents is in the sex ratios
adolescents, a rapid and dramatic developmental for each age group. In clinically referred,
process (physical, psychological, and sexual) gender dysphoric children under age 12, the
is involved and there is greater fluidity and male/female ratio ranges from 6:1 to 3:1 (Zucker,
variability in outcomes, particularly in prepu- 2004). In clinically referred, gender dysphoric
bertal children. Accordingly, this section of the adolescents older than age 12, the male/female
SOC offers specific clinical guidelines for the ratio is close to 1:1 (Cohen-Kettenis & Pfäfflin,
assessment and treatment of gender dysphoric 2003).
children and adolescents. As discussed in section IV and by Zucker and
Lawrence (2009), formal epidemiologic studies
Differences Between Children and on gender dysphoria—in children, adolescents,
Adolescents with Gender Dysphoria and adults—are lacking. Additional research
is needed to refine estimates of its preva-
An important difference between gender lence and persistence in different populations
dysphoric children and adolescents is in the worldwide.
proportion for whom dysphoria persists into
adulthood. Gender dysphoria during childhood Phenomenology in Children
does not inevitably continue into adulthood.5
Rather, in follow-up studies of prepubertal Children as young as age two may show
children (mainly boys) who were referred to features that could indicate gender dysphoria.
clinics for assessment of gender dysphoria, the They may express a wish to be of the other
dysphoria persisted into adulthood for only sex and be unhappy about their physical sex
6%–23% of children (Cohen-Kettenis, 2001; characteristics and functions. In addition, they
Zucker & Bradley, 1995). Boys in these studies may prefer clothes, toys, and games that are com-
were more likely to identify as gay in adulthood monly associated with the other sex and prefer
than as transgender (Green, 1987; Money & playing with other-sex peers. There appears to be
Russo, 1979; Zucker & Bradley, 1995; Zuger, heterogeneity in these features: Some children
demonstrate extremely gender-nonconforming
behavior and wishes, accompanied by persistent
5 and severe discomfort with their primary sex
Gender-nonconforming behaviors in children
may continue into adulthood, but such behaviors are characteristics. In other children, these char-
not necessarily indicative of gender dysphoria and a acteristics are less intense or only partially
need for treatment. As described in section III, gender
dysphoria is not synonymous with diversity in gender
present (Cohen-Kettenis et al., 2006; Knudson,
expression. De Cuypere, & Bockting, 2010a).Coleman et al. 173
It is relatively common for gender dysphoric first Tanner stages—differs among countries and
children to have coexisting internalizing disor- centers. Not all clinics offer puberty suppression.
ders such as anxiety and depression (Cohen- If such treatment is offered, the pubertal stage
Kettenis, Owen, Kaijser, Bradley, & Zucker, at which adolescents are allowed to start varies
2003; Wallien, Swaab, & Cohen-Kettenis, 2007; from Tanner stage 2 to stage 4 (Delemarre-van
Zucker, Owen, Bradley, & Ameeriar, 2002). de Waal & Cohen-Kettenis, 2006; Zucker et al.,
The prevalence of autism spectrum disorders 2012). The percentages of treated adolescents
seems to be higher in clinically referred, gender are likely influenced by the organization
dysphoric children than in the general popu- of health care, insurance aspects, cultural
lation (de Vries, Noens, Cohen-Kettenis, van differences, opinions of health professionals,
Berckelaer-Onnes, & Doreleijers, 2010). and diagnostic procedures offered in different
settings.
Phenomenology in Adolescents Inexperienced clinicians may mistake indica-
tions of gender dysphoria for delusions. Phe-
In most children, gender dysphoria will dis- nomenologically, there is a qualitative difference
appear before, or early in, puberty. However, between the presentation of gender dysphoria
in some children these feelings will intensify and the presentation of delusions or other psy-
and body aversion will develop or increase as chotic symptoms. The vast majority of children
they become adolescents and their secondary sex and adolescents with gender dysphoria are not
characteristics develop (Cohen-Kettenis, 2001; suffering from underlying severe psychiatric
Cohen-Kettenis & Pfäfflin, 2003; Drummond illness such as psychotic disorders (Steensma,
et al., 2008; Wallien & Cohen-Kettenis, 2008; Biemond, de Boer, & Cohen-Kettenis, published
Zucker & Bradley, 1995). Data from one study online ahead of print January 7, 2011).
suggest that more extreme gender nonconfor- It is more common for adolescents with gen-
mity in childhood is associated with persistence der dysphoria to have coexisting internalizing
of gender dysphoria into late adolescence and disorders such as anxiety and depression, and/or
early adulthood (Wallien & Cohen-Kettenis, externalizing disorders such as oppositional
2008). Yet many adolescents and adults pre- defiant disorder (de Vries et al., 2010). As in
senting with gender dysphoria do not report children, there seems to be a higher prevalence of
a history of childhood gender-nonconforming autistic spectrum disorders in clinically referred,
behaviors (Docter, 1988; Landén, Wålinder, gender dysphoric adolescents than in the general
& Lundström, 1998). Therefore, it may come adolescent population (de Vries et al., 2010).
as a surprise to others (parents, other family
members, friends, and community members) Competency of Mental Health
when a youth’s gender dysphoria first becomes Professionals Working with Children
evident in adolescence. or Adolescents with Gender Dysphoria
Adolescents who experience their primary
and/or secondary sex characteristics and their The following are recommended minimum
sex assigned at birth as inconsistent with their credentials for mental health professionals who
gender identity may be intensely distressed assess, refer, and offer therapy to children and
about it. Many, but not all, gender dysphoric adolescents presenting with gender dysphoria:
adolescents have a strong wish for hormones
and surgery. Increasing numbers of adolescents 1. Meet the competency requirements for
have already started living in their desired gender mental health professionals working with
role upon entering high school (Cohen-Kettenis adults, as outlined in section VII;
& Pfäfflin, 2003). 2. Trained in childhood and adolescent devel-
Among adolescents who are referred to opmental psychopathology;
gender identity clinics, the number considered 3. Competent in diagnosing and treating the
eligible for early medical treatment—starting ordinary problems of children and adoles-
with GnRH analogues to suppress puberty in the cents.174 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Roles of Mental Health Professionals support, such as support groups for parents
Working with Children and Adolescents of gender-nonconforming and transgender
with Gender Dysphoria children (Gold & MacNish, 2011; Pleak,
1999; Rosenberg, 2002).
The roles of mental health professionals
working with gender dysphoric children and Assessment and psychosocial interventions for
adolescents may include the following: children and adolescents are often provided
within a multidisciplinary gender identity
1. Directly assess gender dysphoria in chil- specialty service. If such a multidisciplinary
dren and adolescents (see general guide- service is not available, a mental health profes-
lines for assessment, below). sional should provide consultation and liaison
2. Provide family counseling and support- arrangements with a pediatric endocrinologist
ive psychotherapy to assist children and for the purpose of assessment, education, and
adolescents with exploring their gender involvement in any decisions about physical
identity, alleviating distress related to their interventions.
gender dysphoria, and ameliorating any
other psychosocial difficulties. Psychological Assessment of Children
3. Assess and treat any coexisting mental and Adolescents
health concerns of children or adolescents
(or refer to another mental health pro- When assessing children and adolescents who
fessional for treatment). Such concerns present with gender dysphoria, mental health
should be addressed as part of the overall professionals should broadly conform to the
treatment plan. following guidelines:
4. Refer adolescents for additional physical
interventions (such as puberty-suppressing 1. Mental health professionals should not
hormones) to alleviate gender dysphoria. dismiss or express a negative attitude
The referral should include documentation towards nonconforming gender identities
of an assessment of gender dysphoria and or indications of gender dysphoria. Rather,
mental health, the adolescent’s eligibility they should acknowledge the presenting
for physical interventions (outlined be- concerns of children, adolescents, and their
low), the mental health professional’s rel- families; offer a thorough assessment for
evant expertise, and any other information gender dysphoria and any coexisting men-
pertinent to the youth’s health and referral tal health concerns; and educate clients and
for specific treatments. their families about therapeutic options,
5. Educate and advocate on behalf of gender if needed. Acceptance, and alleviation of
dysphoric children, adolescents, and their secrecy, can bring considerable relief to
families in their community (e.g., day care gender dysphoric children/adolescents and
centers, schools, camps, other organiza- their families.
tions). This is particularly important in 2. Assessment of gender dysphoria and men-
light of evidence that children and adoles- tal health should explore the nature and
cents who do not conform to socially pre- characteristics of a child’s or adolescent’s
scribed gender norms may experience ha- gender identity. A psychodiagnostic and
rassment in school (Grossman, D’Augelli, psychiatric assessment—covering the ar-
Howell, & Hubbard, 2006; Grossman, eas of emotional functioning, peer and
D’Augelli, & Salter, 2006; Sausa, 2005), other social relationships, and intellectual
putting them at risk for social isolation, functioning/school achievement—should
depression, and other negative sequelae be performed. Assessment should include
(Nuttbrock et al., 2010). an evaluation of the strengths and weak-
6. Provide children, youth, and their families nesses of family functioning. Emotional
with information and referral for peer and behavioral problems are relativelyColeman et al. 175
common, and unresolved issues in a child’s de Waal, 2006; Di Ceglie & Thümmel,
or youth’s environment may be present (de 2006; Hill, Menvielle, Sica, & Johnson,
Vries, Doreleijers, Steensma, & Cohen- 2010; Malpas, 2011; Menvielle & Tuerk,
Kettenis, 2011; Di Ceglie & Thümmel, 2002; Rosenberg, 2002; Vanderburgh,
2006; Wallien et al., 2007). 2009; Zucker, 2006).
3. For adolescents, the assessment phase Treatment aimed at trying to change a
should also be used to inform youth and person’s gender identity and expression to
their families about the possibilities and become more congruent with sex assigned
limitations of different treatments. This at birth has been attempted in the past
is necessary for informed consent and without success (Gelder & Marks, 1969;
also important for assessment. The way Greenson, 1964), particularly in the long
that adolescents respond to information term (Cohen-Kettenis & Kuiper, 1984;
about the reality of sex reassignment Pauly, 1965). Such treatment is no longer
can be diagnostically informative. Correct considered ethical.
information may alter a youth’s desire 3. Families should be supported in managing
for certain treatment, if the desire was uncertainty and anxiety about their child’s
based on unrealistic expectations of its or adolescent’s psychosexual outcomes
possibilities. and in helping youth to develop a positive
self-concept.
Psychological and Social Interventions for 4. Mental health professionals should not im-
Children and Adolescents pose a binary view of gender. They should
give ample room for clients to explore
When supporting and treating children and different options for gender expression.
adolescents with gender dysphoria, health pro- Hormonal or surgical interventions are
fessionals should broadly conform to the follow- appropriate for some adolescents but not
ing guidelines: for others.
5. Clients and their families should be sup-
1. Mental health professionals should help ported in making difficult decisions re-
families to have an accepting and nurturing garding the extent to which clients are
response to the concerns of their gender allowed to express a gender role that is
dysphoric child or adolescent. Families consistent with their gender identity, as
play an important role in the psychological well as the timing of changes in gender
health and well-being of youth (Brill & role and possible social transition. For
Pepper, 2008; Lev, 2004). This also applies example, a client might attend school while
to peers and mentors from the community, undergoing social transition only partly
who can be another source of social (e.g., by wearing clothing and having a
support. hairstyle that reflects gender identity) or
2. Psychotherapy should focus on reducing completely (e.g., by also using a name and
a child’s or adolescent’s distress pronouns congruent with gender identity).
related to the gender dysphoria and Difficult issues include whether and when
on ameliorating any other psychosocial to inform other people of the client’s
difficulties. For youth pursuing sex situation, and how others in their lives
reassignment, psychotherapy may focus might respond.
on supporting them before, during, and 6. Health professionals should support clients
after reassignment. Formal evaluations of and their families as educators and advo-
different psychotherapeutic approaches cates in their interactions with community
for this situation have not been published, members and authorities such as teachers,
but several counseling methods have school boards, and courts.
been described (Cohen-Kettenis, 2006; de 7. Mental health professionals should strive
Vries, Cohen-Kettenis, & Delemarre-van to maintain a therapeutic relationship with176 INTERNATIONAL JOURNAL OF TRANSGENDERISM
gender-nonconforming children/adoles- compromises (e.g., only when on vacation). It
cents and their families throughout any is also important that parents explicitly let the
subsequent social changes or physical child know that there is a way back.
interventions. This ensures that decisions Regardless of a family’s decisions regarding
about gender expression and the treatment transition (timing, extent), professionals should
of gender dysphoria are thoughtfully counsel and support them as they work through
and recurrently considered. The same the options and implications. If parents do not
reasoning applies if a child or adolescent allow their young child to make a gender-role
has already socially changed gender role transition, they may need counseling to assist
prior to being seen by a mental health them with meeting their child’s needs in a
professional. sensitive and nurturing way, ensuring that the
child has ample possibilities to explore gender
Social Transition in Early Childhood feelings and behavior in a safe environment. If
parents do allow their young child to make a
Some children state that they want to make gender-role transition, they may need counseling
a social transition to a different gender role to facilitate a positive experience for their
long before puberty. For some children, this may child. For example, they may need support in
reflect an expression of their gender identity. For using correct pronouns, maintaining a safe and
others, this could be motivated by other forces. supportive environment for their transitioning
Families vary in the extent to which they allow child (e.g., in school, peer group settings), and
their young children to make a social transition communicating with other people in their child’s
to another gender role. Social transitions in early life. In either case, as a child nears puberty,
childhood do occur within some families with further assessment may be needed as options
early success. This is a controversial issue, and for physical interventions become relevant.
divergent views are held by health professionals.
The current evidence base is insufficient to Physical Interventions for Adolescents
predict the long-term outcomes of completing
a gender role transition during early childhood. Before any physical interventions are consid-
Outcomes research with children who completed ered for adolescents, extensive exploration of
early social transitions would greatly inform psychological, family, and social issues should
future clinical recommendations. be undertaken, as outlined above. The duration
Mental health professionals can help families of this exploration may vary considerably de-
to make decisions regarding the timing and pro- pending on the complexity of the situation.
cess of any gender-role changes for their young Physical interventions should be addressed in
children. They should provide information and the context of adolescent development. Some
help parents to weigh the potential benefits and identity beliefs in adolescents may become
challenges of particular choices. Relevant in firmly held and strongly expressed, giving a
this respect are the previously described rela- false impression of irreversibility. An adoles-
tively low persistence rates of childhood gender cent’s shift towards gender conformity can occur
dysphoria (Drummond et al., 2008; Wallien & primarily to please the parents and may not
Cohen-Kettenis, 2008). A change back to the persist or reflect a permanent change in gender
original gender role can be highly distressing dysphoria (Hembree et al., 2009; Steensma et al.,
and even result in postponement of this second published online ahead of print January 7, 2011).
social transition on the child’s part (Steensma Physical interventions for adolescents fall
& Cohen-Kettenis, 2011). For reasons such as into three categories or stages (Hembree et al.,
these, parents may want to present this role 2009):
change as an exploration of living in another
gender role rather than an irreversible situation. 1. Fully reversible interventions. These in-
Mental health professionals can assist parents volve the use of GnRH analogues to sup-
in identifying potential in-between solutions or press estrogen or testosterone productionColeman et al. 177
and consequently delay the physical formity and other developmental issues and (ii)
changes of puberty. Alternative treat- their use may facilitate transition by preventing
ment options include progestins (most the development of sex characteristics that are
commonly medroxyprogesterone) or other difficult or impossible to reverse if adolescents
medications (such as spironolactone) that continue on to pursue sex reassignment.
decrease the effects of androgens secreted Puberty suppression may continue for a few
by the testicles of adolescents who are years, at which time a decision is made to either
not receiving GnRH analogues. Continu- discontinue all hormone therapy or transition to
ous oral contraceptives (or depot medrox- a feminizing/masculinizing hormone regimen.
yprogesterone) may be used to suppress Pubertal suppression does not inevitably lead to
menses. social transition or to sex reassignment.
2. Partially reversible interventions. These
include hormone therapy to masculinize or Criteria for Puberty-Suppressing Hormones
feminize the body. Some hormone-induced
changes may need reconstructive surgery In order for adolescents to receive puberty-
to reverse the effect (e.g., gynaecomastia suppressing hormones, the following minimum
caused by estrogens), while other changes criteria must be met:
are not reversible (e.g., deepening of the
voice caused by testosterone). 1. The adolescent has demonstrated a long-
3. Irreversible interventions. These are surgi- lasting and intense pattern of gender non-
cal procedures. conformity or gender dysphoria (whether
suppressed or expressed);
A staged process is recommended to keep op- 2. Gender dysphoria emerged or worsened
tions open through the first two stages. Moving with the onset of puberty;
from one stage to another should not occur until 3. Any coexisting psychological, medical,
there has been adequate time for adolescents and or social problems that could interfere
their parents to assimilate fully the effects of with treatment (e.g., that may compromise
earlier interventions. treatment adherence) have been addressed,
such that the adolescent’s situation and
functioning are stable enough to start
Fully Reversible Interventions treatment;
Adolescents may be eligible for 4. The adolescent has given informed consent
puberty-suppressing hormones as soon as and, particularly when the adolescent has
pubertal changes have begun. In order for not reached the age of medical consent,
adolescents and their parents to make an the parents or other caretakers or guardians
informed decision about pubertal delay, it is have consented to the treatment and are
recommended that adolescents experience the involved in supporting the adolescent
onset of puberty to at least Tanner Stage 2. Some throughout the treatment process.
children may arrive at this stage at very young
ages (e.g., 9 years of age). Studies evaluating Regimens, Monitoring, and Risks for Pu-
this approach have only included children who berty Suppression
were at least 12 years of age (Cohen-Kettenis,
Schagen, Steensma, de Vries, & Delemarre-van For puberty suppression, adolescents with
de Waal, 2011; de Vries, Steensma et al., 2010; male genitalia should be treated with GnRH
Delemarre-van de Waal, van Weissenbruch, & analogues, which stop luteinizing hormone se-
Cohen Kettenis, 2004; Delemarre-van de Waal cretion and therefore testosterone secretion.
& Cohen-Kettenis, 2006). Alternatively, they may be treated with pro-
Two goals justify intervention with puberty- gestins (such as medroxyprogesterone) or with
suppressing hormones: (i) their use gives adoles- other medications that block testosterone se-
cents more time to explore their gender noncon- cretion and/or neutralize testosterone action.178 INTERNATIONAL JOURNAL OF TRANSGENDERISM
Adolescents with female genitalia should be with parental consent. In many countries, 16-
treated with GnRH analogues, which stop the year-olds are legal adults for medical decision-
production of estrogens and progesterone. Al- making and do not require parental consent. Ide-
ternatively, they may be treated with progestins ally, treatment decisions should be made among
(such as medroxyprogesterone). Continuous oral the adolescent, the family, and the treatment
contraceptives (or depot medroxyprogesterone) team.
may be used to suppress menses. In both groups Regimens for hormone therapy in gender
of adolescents, use of GnRH analogues is the dysphoric adolescents differ substantially from
preferred treatment (Hembree et al., 2009), but those used in adults (Hembree et al., 2009).
their high cost is prohibitive for some patients. The hormone regimens for youth are adapted to
During pubertal suppression, an adoles- account for the somatic, emotional, and mental
cent’s physical development should be care- development that occurs throughout adolescence
fully monitored—preferably by a pediatric (Hembree et al., 2009).
endocrinologist—so that any necessary inter-
ventions can occur (e.g., to establish an adequate Irreversible Interventions
gender appropriate height, to improve iatrogenic
low bone mineral density) (Hembree et al., Genital surgery should not be carried out until
2009). (i) patients reach the legal age of majority to
Early use of puberty-suppressing hormones give consent for medical procedures in a given
may avert negative social and emotional con- country and (ii) patients have lived continuously
sequences of gender dysphoria more effectively for at least 12 months in the gender role that
than their later use would. Intervention in early is congruent with their gender identity. The age
adolescence should be managed with pediatric threshold should be seen as a minimum criterion
endocrinological advice, when available. Ado- and not an indication in and of itself for active
lescents with male genitalia who start GnRH intervention.
analogues early in puberty should be informed Chest surgery in FtM patients could be carried
that this could result in insufficient penile tissue out earlier, preferably after ample time of living
for penile inversion vaginoplasty techniques in the desired gender role and after one year of
(alternative techniques, such as the use of a skin testosterone treatment. The intent of this sug-
graft or colon tissue, are available). gested sequence is to give adolescents sufficient
Neither puberty suppression nor allowing opportunity to experience and socially adjust in
puberty to occur is a neutral act. On the one hand, a more masculine gender role, before under-
functioning in later life can be compromised by going irreversible surgery. However, different
the development of irreversible secondary sex approaches may be more suitable, depending
characteristics during puberty and by years spent on an adolescent’s specific clinical situation and
experiencing intense gender dysphoria. On the goals for gender identity expression.
other hand, there are concerns about negative
physical side effects of GnRH analogue use (e.g., Risks of Withholding Medical Treatment
on bone development and height). Although the for Adolescents
very first results of this approach (as assessed for
adolescents followed over 10 years) are promis- Refusing timely medical interventions for
ing (Cohen-Kettenis et al., 2011; Delemarre-van adolescents might prolong gender dysphoria and
de Waal & Cohen-Kettenis, 2006), the long-term contribute to an appearance that could provoke
effects can only be determined when the earliest- abuse and stigmatization. As the level of gender-
treated patients reach the appropriate age. related abuse is strongly associated with the
degree of psychiatric distress during adolescence
Partially Reversible Interventions (Nuttbrock et al., 2010), withholding puberty-
suppression and subsequent feminizing or mas-
Adolescents may be eligible to begin feminiz- culinizing hormone therapy is not a neutral
ing/masculinizing hormone therapy, preferably option for adolescents.Coleman et al. 179
VII. MENTAL HEALTH 3. Ability to recognize and diagnose co-
existing mental health concerns and to
Transsexual, transgender, and gender- distinguish these from gender dysphoria.
nonconforming people might seek the assistance 4. Documented supervised training and com-
of a mental health professional for any number petence in psychotherapy or counseling.
of reasons. Regardless of a person’s reason for 5. Knowledge about gender-nonconforming
seeking care, mental health professionals should identities and expressions, and the assess-
have familiarity with gender nonconformity, ment and treatment of gender dysphoria.
act with appropriate cultural competence, and 6. Continuing education in the assess-
exhibit sensitivity in providing care. ment and treatment of gender dyspho-
This section of the SOC focuses on the role ria. This may include attending relevant
of mental health professionals in the care of professional meetings, workshops, or sem-
adults seeking help for gender dysphoria and inars; obtaining supervision from a mental
related concerns. Professionals working with health professional with relevant experi-
gender dysphoric children, adolescents, and their ence; or participating in research related to
families should consult section VI. gender nonconformity and gender dyspho-
ria.
Competency of Mental Health In addition to the minimum credentials above, it
Professionals Working with Adults is recommended that mental health professionals
Who Present with Gender Dysphoria develop and maintain cultural competence to fa-
cilitate their work with transsexual, transgender,
The training of mental health professionals and gender-nonconforming clients. This may
competent to work with gender dysphoric adults involve, for example, becoming knowledgeable
rests upon basic general clinical competence about current community, advocacy, and public
in the assessment, diagnosis, and treatment of policy issues relevant to these clients and their
mental health concerns. Clinical training may families. Additionally, knowledge about sexual-
occur within any discipline that prepares mental ity, sexual health concerns, and the assessment
health professionals for clinical practice, such and treatment of sexual disorders is preferred.
as psychology, psychiatry, social work, mental Mental health professionals who are new to
health counseling, marriage and family therapy, the field (irrespective of their level of training
nursing, or family medicine with specific train- and other experience) should work under the
ing in behavioral health and counseling. The fol- supervision of a mental health professional with
lowing are recommended minimum credentials established competence in the assessment and
for mental health professionals who work with treatment of gender dysphoria.
adults presenting with gender dysphoria:
Tasks of Mental Health Professionals
1. A master’s degree or its equivalent in Working with Adults Who Present
a clinical behavioral science field. This
with Gender Dysphoria
degree, or a more advanced one, should be
granted by an institution accredited by the Mental health professionals may serve trans-
appropriate national or regional accredit- sexual, transgender, and gender-nonconforming
ing board. The mental health professional individuals and their families in many ways,
should have documented credentials from depending on a client’s needs. For example,
a relevant licensing board or equivalent for mental health professionals may serve as a
that country. psychotherapist, counselor, or family therapist,
2. Competence in using the Diagnostic Sta- or as a diagnostician/assessor, advocate, or
tistical Manual of Mental Disorders and/or educator.
the International Classification of Dis- Mental health professionals should deter-
eases for diagnostic purposes. mine a client’s reasons for seeking professionalYou can also read
