WPATH Standards Of Care (SOC) - Version 6
NOTE: This is a condensed form of the Standards of Care.
It is in your best interest to take the time to download this entire document and read it.
Click here to download full document
WPATH Standards of Care-Highlights
The Harry Benjamin International Gender Dysphoria Association's
Standards Of Care For Gender Identity Disorders, Sixth Version February, 2001
This is the sixth version of the Standards of Care since the original 1979 document.
Previous revisions were in 1980, 1981, 1990, and 1998.
Table of Contents
| I. Introductory Concepts (p. 1) |
| II. Epidemiological Considerations (p. 2) |
| III. Diagnostic Nomenclature (p. 3) |
| IV. The Mental Health Professional (p. 6) |
| V. Assessment and Treatment of Children and Adolescents (p. 8) |
| VI. Psychotherapy with Adults (p. 11) |
| VII. Requirements for Hormone Therapy for Adults (p. 13) |
| VIII. Effects of Hormone Therapy in Adults (p. 14) |
| IX. The Real-life Experience (p. 17) |
| X. Surgery (p. 18) |
| XI. Breast Surgery (p. 19) |
| XII. Genital Surgery (p. 20) |
| XIII. Post-Transition Follow-up (p. 22) |
I. Introductory Concepts
The Purpose of the Standards of Care
The major purpose of the Standards of Care (SOC) is to articulate this international organization's
professional consensus about the psychiatric, psychological, medical,
and surgical management of gender identity disorders.
Professionals may use this document to understand the parameters within which they may
offer assistance to those with these conditions.
Persons with gender identity disorders, their families, and social institutions may use the SOC
to understand the current thinking of professionals. All readers
should be aware of the limitations of knowledge in this area and of the hope that some of the
clinical uncertainties will be resolved in the future through scientific investigation.
II. Epidemiological Considerations
Prevalence. When the gender identity disorders first came to professional attention, clinical
perspectives were largely focused on how to identify candidates for sex reassignment surgery. As
the field matured, professionals recognized that some persons with bona fide gender identity
disorders neither desired nor were candidates for sex reassignment surgery. The earliest
estimates of prevalence for transsexualism in adults were 1 in 37,000 males and 1 in 107,000
females. The most recent prevalence information from the Netherlands for the transsexual end of
the gender identity disorder spectrum is 1 in 11,900 males and 1 in 30,400 females.
Four observations, not yet firmly supported by systematic study, increase the likelihood of an even
higher prevalence:
| 1) Unrecognized gender problems are occasionally diagnosed when patients are seen with anxiety, depression, bipolar disorder, conduct disorder, substance abuse, dissociative identity disorders, borderline personality disorder, other sexual disorders and intersexed conditions. |
| 2) Some nonpatient male transvestites, female impersonators, transgender people, and male and female homosexuals may have a form of gender identity disorder. |
| 3) The intensity of some persons' gender identity disorders fluctuates below and above a clinical threshold. |
| 4) Gender variance among female-bodied individuals tends to be relatively invisible to the culture, particularly to mental health professionals and scientists. |
III. Diagnostic Nomenclature
The Five Elements of Clinical Work. Professional involvement with patients with gender
identity disorders involves any of the following: diagnostic assessment, psychotherapy, real-life
experience, hormone therapy, and surgical therapy. This section provides a background on
diagnostic assessment.
IV. The Mental Health Professional
The Ten Tasks of the Mental Health Professional
Mental health professionals (MHPs) who work with individuals with gender identity disorders
may be regularly called upon to carry out many of these responsibilities:
| 1. To accurately diagnose the individual's gender disorder. |
| 2. To accurately diagnose any co-morbid psychiatric conditions and see to their appropriate treatment. |
| 3. To counsel the individual about the range of treatment options and their implications. |
| 4. To engage in psychotherapy. |
| 5. To ascertain eligibility and readiness for hormone and surgical therapy. |
| 6. To make formal recommendations to medical and surgical colleagues. |
| 7. To document their patient's relevant history in a letter of recommendation. |
| 8. To be a colleague on a team of professionals with an interest in the gender identity disorders. |
| 9. To educate family members, employers, and institutions about gender identity disorders. |
| 10. To be available for follow-up of previously seen gender patients. |
The Mental Health Professional’s Documentation Letter for Hormone Therapy or Surgery
Should Succinctly Specify:
| 1. The patient's general identifying characteristics. |
| 2. The initial and evolving gender, sexual, and other psychiatric diagnoses. |
| 3. The duration of their professional relationship including the type of psychotherapy or evaluation that the patient underwent. |
| 4. The eligibility criteria that have been met and the mental health professional’s rationale for hormone therapy or surgery. |
| 5. The degree to which the patient has followed the Standards of Care to date and the likelihood of future compliance. |
| 6. Whether the author of the report is part of a gender team. |
| 7. That the sender welcomes a phone call to verify the fact that the mental health professional actually wrote the letter as described in this document. The organization and completeness of these letters provide the hormone-prescribing physician and the surgeon an important degree of assurance that mental health professional is knowledgeable and competent concerning gender identity disorders. |
One Letter is Required for Instituting Hormone Therapy or for Breast Surgery
One letter from a mental health professional, including the above seven points, written to the physician who
will be responsible for the patient’s medical treatment, is sufficient for instituting hormone
therapy or for a referral for breast surgery (e.g., mastectomy, chest reconstruction, or
augmentation mammoplasty).
Two Letters are Generally Required for Genital Surgery
| Genital surgery for biologic males may include orchiectomy, penectomy, clitoroplasty,labiaplasty or creation of a neovagina |
| For biologic females it may include hysterectomy, salpingo-oophorectomy, vaginectomy, metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, or creation of a neophallus. |
For biologic females it may include hysterectomy, salpingo-oophorectomy, vaginectomy,
metoidioplasty, scrotoplasty, urethroplasty, placement of testicular prostheses, or creation of a neophallus.
V. Assessment and Treatment of Children and Adolescents
Phenomenology. Gender identity disorders in children and adolescents are different from those
seen in adults, in that a rapid and dramatic developmental process (physical, psychological and
sexual) is involved. Gender identity disorders in children and adolescents are complex
conditions. The young person may experience his or her phenotype sex as inconsistent with his
or her own sense of gender identity. Intense distress is often experienced, particularly in
adolescence, and there are frequently associated emotional and behavioral difficulties. There is
greater fluidity and variability in outcomes, especially in pre-pubertal children.
Only a few gender variant youths become transsexual, although many eventually develop a homosexual
orientation.
Commonly seen features of gender identity conflicts in children and adolescents include
| 1) A stated desire to be the other sex. |
| 2) Cross dressing. |
| 3) Play with games and toys usually associated with the gender with which the child identifies. |
| 4) Avoidance of the clothing. |
| 5) Demeanor and play normally associated with the child’s sex and gender of assignment. |
| 6) Preference for playmates or friends of the sex and gender with which the child identifies. |
| 7) Dislike of bodily sex characteristics and functions. |
Gender identity disorders are more often diagnosed in boys.
VI. Psychotherapy with Adults
A Basic Observation: Many adults with gender identity disorder find comfortable, effective
ways of living that do not involve all the components of the triadic treatment sequence. While
some individuals manage to do this on their own, psychotherapy can be very helpful in bringing
about the discovery and maturational processes that enable self-comfort.
Psychotherapy is Not an Absolute Requirement for Triadic Therapy
Not every adult gender patient requires psychotherapy in order to proceed with hormone therapy, the real-life
experience, hormones, or surgery. Individual programs vary to the extent that they perceive a
need for psychotherapy. When the mental health professional's initial assessment leads to a
recommendation for psychotherapy, the clinician should specify the goals of treatment, and
estimate its frequency and duration.
There is no required minimum number of psychotherapy sessions prior to hormone therapy,
the real-life experience, or surgery, for three reasons:
| 1) Patients differ widely in their abilities to attain similar goals in a specified time. |
| 2) A minimum number of sessions tends to be construed as a hurdle, which discourages the genuine opportunity for personal growth. |
| 3) The mental health professional can be an important support to the patient throughout all phases of gender transition. Individual programs may set eligibility criteria to some minimum number of sessions or months of psychotherapy. |
VII. Requirements for Hormone Therapy for Adults
Reasons for Hormone Therapy
Cross-sex hormonal treatments play an important role in the
anatomical and psychological gender transition process for properly selected adults with gender
identity disorders. Hormones are often medically necessary for successful living in the new
gender. They improve the quality of life and limit psychiatric co-morbidity, which often
accompanies lack of treatment. When physicians administer androgens to biologic females and
estrogens, progesterone, and testosterone-blocking agents to biologic males, patients feel and
appear more like members of their preferred gender.
Eligibility Criteria
The administration of hormones is not to be lightly undertaken because of
their medical and social risks. Three criteria exist.
| 1. Age 18 years; |
| 2. Demonstrable knowledge of what hormones medically can and cannot do and their social benefits and risks; |
| 3. Either: a) A documented real-life experience of at least three months prior to the administration of hormones; or b) A period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months). |
VIII. Effects of Hormone Therapy in Adults
The maximum physical effects of hormones may not be evident until two years of continuous
treatment. Heredity limits the tissue response to hormones and this cannot be overcome by
increasing dosage. The degree of effects actually attained varies from patient to patient.
Desired Effects of Hormones
Biologic males treated with estrogens can realistically expect
treatment to result in: breast growth, some redistribution of body fat to approximate a female
body habitus, decreased upper body strength, softening of skin, decrease in body hair, slowing or
stopping the loss of scalp hair, decreased fertility and testicular size, and less frequent, less firm
erections. Most of these changes are reversible, although breast enlargement will not completely
reverse after discontinuation of treatment.
Biologic females treated with testosterone can expect the following permanent changes: a
deepening of the voice, clitoral enlargement, mild breast atrophy, increased facial and body hair
and male pattern baldness. Reversible changes include increased upper body strength, weight
gain, increased social and sexual interest and arousability, and decreased hip fat.
IX. The Real-Life Experience
The act of fully adopting a new or evolving gender role or gender presentation in everyday life is
known as the real-life experience. The real-life experience is essential to the transition to the
gender role that is congruent with the patient’s gender identity. Since changing one's gender
presentation has immediate profound personal and social consequences, the decision to do so
should be preceded by an awareness of what the familial, vocational, interpersonal, educational,
economic, and legal consequences are likely to be. Professionals have a responsibility to discuss
these predictable consequences with their patients. Change of gender role and presentation can
be an important factor in employment discrimination, divorce, marital problems, and the
restriction or loss of visitation rights with children. These represent external reality issues that
must be confronted for success in the new gender presentation. These consequences may be quite
different from what the patient imagined prior to undertaking the real-life experiences. However,
not all changes are negative.
Parameters of the Real-Life Experience
When clinicians assess the quality of a person's real-life experience in the desired gender,
the following abilities are reviewed:
| 1. To maintain full or part-time employment, |
| 2. To function as a student, |
| 3. To function in community-based volunteer activity. |
| 4. To undertake some combination of items 1-3. |
| 5. To acquire a (legal) gender-identity-appropriate first name. |
| 6. To provide documentation that persons other than the therapist know that the patient functions in the desired gender role. |
X. Surgery
Sex Reassignment is Effective and Medically Indicated in Severe GID
In persons diagnosed with transsexualism or profound GID, sex reassignment surgery,
along with hormone therapy and real-life experience, is a treatment that has proven to be effective.
Such a therapeutic regimen, when prescribed or recommended by qualified practitioners,
is medically indicated and medically necessary.
Sex reassignment is not "experimental," "investigational," "elective,""cosmetic,"
or optional in any meaningful sense. It constitutes very effective and appropriate
treatment for transsexualism or profound GID.
XI. Breast Surgery
Breast augmentation and removal are common operations, easily obtainable by the general
public for a variety of indications. Reasons for these operations range from cosmetic indications
to cancer. Although breast appearance is definitely important as a secondary sex characteristic,
breast size or presence are not involved in the legal definitions of sex and gender and are not
important for reproduction. The performance of breast operations should be considered
with the same reservations as beginning hormonal therapy.
Both produce relatively irreversible changes to the body.
The approach for male-to-female patients is different than for female-to-male patients. For
female-to-male patients, a mastectomy procedure is usually the first surgery performed for
success in gender presentation as a man; and for some patients it is the only surgery undertaken.
When the amount of breast tissue removed requires skin removal, a scar will result and the
patient should be so informed. Female-to-male patients may have surgery at the same time they
begin hormones. For male-to-female patients, augmentation mammoplasty may be performed if
the physician prescribing hormones and the surgeon have documented that breast enlargement
after undergoing hormone treatment for 18 months is not sufficient for comfort in the social
gender role.
XII. Genital Surgery
Eligibility Criteria
These minimum eligibility criteria for various genital surgeries equally
apply to biologic males and females seeking genital surgery. They are:
| 1. Legal age of majority in the patient's nation; |
| 2. Usually 12 months of continuous hormonal therapy for those without a medical contraindication (see below, "Can Surgery Be Performed Without Hormones and the Real-life Experience"); |
| 3. 12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and generally should not be used to fulfill this criterion; |
| 4. If required by the mental health professional, regular responsible participation in psychotherapy throughout the real-life experience at a frequency determined jointly by the patient and the mental health professional. Psychotherapy per se is not an absolute eligibility criterion for surgery; |
| 5. Demonstrable knowledge of the cost, required lengths of hospitalizations, likely complications, and post surgical rehabilitation requirements of various surgical approaches; |
| 6. Awareness of different competent surgeons. |
Readiness Criteria
The readiness criteria include:
| 1. Demonstrable progress in consolidating one’s gender identity; |
| 2. Demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better state of mental health; this implies satisfactory control of problems such as sociopathy, substance abuse, psychosis, suicidality, for instance). |
XIII. Post-Transition Follow-up
Long-term postoperative follow-up is encouraged in that it is one of the factors associated with a
good psychosocial outcome. Follow-up is important to the patient's subsequent anatomic and
medical health and to the surgeon's knowledge about the benefits and limitations of surgery.
Long-term follow-up with the surgeon is recommended in all patients to ensure an optimal
surgical outcome. Surgeons who operate on patients who are coming from long distances should
include personal follow-up in their care plan and attempt to ensure affordable, local, long-term
aftercare in the patient's geographic region. Postoperative patients may also sometimes exclude
themselves from follow-up with the physician prescribing hormones, not recognizing that these
physicians are best able to prevent, diagnose and treat possible long term medical conditions that
are unique to hormonally and surgically treated patients. Postoperative patients should undergo
regular medical screening according to recommended guidelines for their age. The need for
follow-up extends to the mental health professional, who having spent a longer period of time
with the patient than any other professional, is in an excellent position to assist in any post-
operative adjustment difficulties.
NOTE: This is a condensed form of the Standards of Care.
It is in your best interest to take the time to download this entire document and read it.
Click here to download full document
Please email us at info@tmeltzer.com for more information,
or call our office at 1-480-657-7006 or toll-free at 1-866-876-6329.
| BACK TO TOP |
