Introduction to medical transition

For some transgender individuals, medical transition represents an important aspect of gender affirmation and alleviation of feelings of gender dysphoria. As with other aspects of gender transition, personal preferences and goals related to medical transition can vary widely between individuals. Broadly, interventions can be divided into gender-affirming hormone therapy and surgical interventions. Some transgender individuals choose to undergo medical transition, some choose to undergo surgical interventions, some choose both, and others choose neither.

Barriers to care

Seeking gender-affirming medical care can prove to be challenging for many transgender individuals. An individual's ability to receive gender-affirming care may be limited by location or lack of medical providers with both competence and willingness to provide gender-affirming care. Additionally, health insurance coverage for gender-affirming care is inconsistent, oftentimes requiring prior authorization, and sometimes outright precluding coverage. Depending on location, some individuals may not be able to seek gender-affirming care at all due to legal restrictions. Finally, many individuals are unable to seek gender-affirming medical interventions due to fear of violence, loss of employment, housing, or family and intimate partner acceptance. Due to a multitude of circumstances, medical transition may not be an option for some individuals who would otherwise desire it.

WPATH standards of care guidelines

The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) provides guidelines for both medical and surgical interventions for transgender individuals. The 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” [ ]. The SOC represents a global consensus on the criteria for medical and surgical interventions provided and establishes best practices related to the care of this patient population. The SOC provides clinical guidelines, but individual care providers may modify them based on their own clinical judgment and unique patient needs.

Gender-affirming hormone therapy

Gender-affirming hormone therapy can be initiated and managed by a variety of providers including but not limited to primary care physicians, obstetrician-gynecologists, urologists, pediatricians, endocrinologists, and advanced practice providers such as physician assistants or nurse practitioners. Individuals can be assessed for readiness for hormone therapy either by a mental health provider, or any provider who is comfortable with assessment of gender dysphoria [ ]. Historically, a “referral letter” from a mental health provider has been required in order to initiate gender-affirming hormone therapy, but the SOC recognizes both this method and an informed-consent model, where the prescriber evaluates for decision-making capacity, as valid [ ].

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