Puberty Blockers

Lee says:

I’m copying the WPATH-SOC’s guidelines for medical transitioning here.

Puberty Blockers

Adolescents may be eligible for puberty suppressing hormones as soon as pubertal changes have begun. In order for adolescents and their parents to make an informed decision about pubertal delay, it is recommended that adolescents experience the onset of puberty to at least Tanner Stage 2.  

In order for adolescents to receive puberty suppressing hormones, the following minimum criteria must be met:

The adolescent has demonstrated a long-lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed);

Gender dysphoria emerged or worsened with the onset of puberty;

Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;

The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process.

Hormone Replacement Therapy (estrogen or testosterone)

The criteria you have to meet to start hormone therapy is as follows:

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 younger, follow the Standards of Care outlined in section VI);

If significant medical or mental health concerns are present, they must be reasonably well controlled.

The recommended content of the referral letter for feminizing/masculinizing hormone therapy is as follows:

The client’s general identifying characteristics;

Results of the client’s psychosocial assessment, including any diagnoses;

The duration of the referring health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;

An explanation that the criteria for hormone therapy have been met, and a brief description of the clinical rationale for supporting the client’s request for hormone therapy;

A statement about the fact that informed consent has been obtained from the patient;

A statement that the referring health professional is available for coordination of care and welcomes a phone call to establish this.

For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.

Chest Surgery

One referral from a qualified mental health professional is needed for breast/chest surgery 

e.g., mastectomy, chest reconstruction, or augmentation mammoplasty

Criteria for mastectomy and creation of a male chest in FtM patients:

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 younger, follow the SOC for children and adolescents);

If significant medical or mental health concerns are present, they must be reasonably well controlled.

Hormone therapy is not a pre-requisite.

Criteria for breast augmentation (implants/lipofilling) in MtF patients:

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 younger, follow the SOC for children and adolescents);

If significant medical or mental health concerns are present, they must be reasonably well controlled.

Although not an explicit criterion, it is recommended that MtF patients undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

The recommended content of the referral letters for surgery is as follows:

The client’s general identifying characteristics

Results of the client’s psychosocial assessment, including any diagnoses;

The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;

An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;

A statement about the fact that informed consent has been obtained from the patient;

A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.

Genital Surgery

Two referrals – from qualified mental health professionals who have independently assessed the patient – are needed for genital surgery 

i.e., hysterectomy/salpingo-oophorectomy, orchiectomy, genital reconstructive surgeries

If the first referral is from the patient’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the patient. 

Two separate letters, or one letter signed by both (e.g., if practicing within the same clinic) may be sent. 

Each referral letter, however, is expected to cover the same topics in the areas outlined below.

(Note: there’s an open letter to WPATH about genital surgery here you can sign, or reblog a link to it here)

Criteria for hysterectomy and ovariectomy in FtM patients and for orchiectomy in MtF patients:

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 well controlled.

12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones). The aim of hormone therapy prior to gonadectomy is primarily to introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.

These criteria do not apply to patients who are having these procedures for medical indications other than gender dysphoria.

Criteria for metoidioplasty or phalloplasty in FtM patients and for vaginoplasty in MtF patients:

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 well controlled;

12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless the patient has a medical contraindication or is otherwise unable or unwilling to take hormones).

12 continuous months of living in a gender role that is congruent with their gender identity;

The recommended content of the referral letters for surgery is as follows:

The client’s general identifying characteristics

Results of the client’s psychosocial assessment, including any diagnoses;

The duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date;

An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery;

A statement about the fact that informed consent has been obtained from the patient;

A statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.

For providers working within a multidisciplinary specialty team, a letter may not be necessary, rather, the assessment and recommendation can be documented in the patient’s chart.

Transitioning While Mentally Ill

It’s possible to transition while struggling with mental illness. It can be harder , especially if you’re severely mentally ill or if you have stigmatized disorders like a schizo-spectrum diagnosis, but it isn’t impossible to do.

The WPATH guidelines say:

“Any co-existing psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment"

The presence of co-existing mental health concerns does not necessarily preclude possible changes in gender role or access to feminizing/masculinizing hormones or surgery; rather, these concerns need to be optimally managed prior to or concurrent with treatment of gender dysphoria. In addition, clients should be assessed for their ability to provide educated and informed consent for medical treatments.

When patients with gender dysphoria are also diagnosed with severe psychiatric disorders and impaired reality testing (e.g., psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated.

Reevaluation by a mental health professional qualified to assess and manage psychotic conditions should be conducted prior to surgery, describing the patient’s mental status and readiness for surgery. It is preferable that this mental health professional be familiar with the patient. No surgery should be performed while a patient is actively psychotic.”