---------------------------------------------------------------------------------------------------------------------- Consultants: Dallas Denny MA, Domineco DiCeglie MD, Wolf Eicher MD, Jamison Green, Richard Green MD, Louis Gooren MD, Donald Laub MD, Anne Lawrence MD, Walter Meyer III MD, C. Christine Wheeler PhD
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PART ONE--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, psychologic, 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 problems. Persons with gender identity disorders, their families, and social institutions may use the SOC as a means 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.
The Overarching Treatment Goal. The general goal of the specific psychotherapeutic, endocrine, or surgical therapies for people with gender identity disorders is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment.
The Standards of Care Are Clinical Guidelines. The SOC are intended to provide flexible directions for the treatment of gender identity disorders. When eligibility requirements are stated they are meant to be minimum requirements. Individual professionals and organized programs may raise them. Clinical departures from these guidelines may come about because of a patient's unique anatomic, social, or psychological situation, an experienced professional's evolving method of handling a common situation, or a research protocol. These departures should be recognized as such, explained to the patient, documented both for legal protection and so that the short and long term results can be retrieved to help the field to evolve.
The Clinical Threshold. A clinical threshold is passed when concerns, uncertainties, and questions about gender identity persist in development, become so intense as to seem to be the most important aspect of a person's life, or prevent the establishment of a relatively unconflicted gender identity. The person's struggles are then variously informally referred to as a gender identity problem, gender dysphoria, a gender problem, a gender concern, gender distress, or transsexualism. Such struggles are known to be manifested from the preschool years to old age and have many alternate forms. These forms come about by various degrees of personal dissatisfaction with sexual anatomy, gender demarcating body characteristics, gender roles, gender identity, and perceptions of others. When dissatisfied individuals meet specified criteria in one of two official nomenclatures--the International Classification of Diseases-10 (ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders--Fourth Edition (DSM-IV)--they are formally designated as suffering from a gender identity disorder (GID). Some persons with GID exceed another threshold--they persistently possess a wish for surgical transformation of their bodies.
Two Primary Populations with GID Exist--Biological Males and Biological Females. The sex of a patient always is a significant factor in the management of GID. Clinicians need to separately consider the biological, social, psychological, and economic dilemmas of each sex. For example, when first requesting professional assistance, the typical biological female seems to be further along in consolidating a male gender identity than does the typical biological male in his quest for a comfortable female gender identity. This often enables the sequences of therapy to proceed more rapidly for male-identified persons. All patients, however, must follow the SOC.

PART TWO
A BRIEF REFERENCE GUIDE TO THE STANDARDS OF CARE
CAVEAT-It is recommended that no one use this guide without consulting the full text of the SOC (Part Three) which provides an explication of these concepts.
 1.Professional involvement with patients with gender identity disorders involves any of the following:
  1. Diagnostic assessment
  2. Psychotherapy
  3. Real life experience
  4. Hormonal therapy
  5. Surgical therapy.

 2. The Roles of the Mental Health Professional with the Gender Patient. Mental health professionals (MHP) 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 according to either the DSM-IV or ICD-10 nomenclature
  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 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.

 3. The Training of Mental Health Professionals
  1. The Adult-Specialist
   1. basic clinical competence in diagnosis and treatment of mental or emotional disorders
   2 . the basic clinical training may occur within any formally credentialing discipline--for example, psychology, psychiatry, social work, counseling, or nursing.
   3. recommended minimal credentials for special competence with the gender identity disorders:
    1. master's degree or its equivalent in a clinical behavioral science field granted by an institution accredited by a recognized national or regional accrediting board
    2. specialized training and competence in the assessment of the DSM-IV/ICD-10 Sexual Disorders (not simply gender identity disorders)
    3. documented supervised training and competence in psychotherapy
    4. continuing education in the treatment of gender identity disorders
  2. The Child-Specialist
   1. training in childhood and adolescent developmental psychopathology.
   2. competence in diagnosing and treating the ordinary problems of children and adolescents

 4. The Differences between Eligibility and Readiness Criteria for Hormones or Surgery.
  1. Eligibility--the specified criteria that must be documented before moving to a next step in a triadic therapeutic sequence (real life experience, hormones, and surgery)
  2. Readiness--the specified criteria that rest upon the clinician's judgment prior to taking the next step in a triadic therapeutic sequence

 5. The Mental Health Professional's Documentation Letters for Hormones 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 MHP's rationale for hormones or surgery
  5. The patient's ability to follow 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 or is working without benefit of an organized team approach
  7. The offer of receiving a phone call to verify that the documentation letter is authentic

 6. One-Letter is Required for Instituting Hormone Treatment;
Two-Letters are Required for Surgery
  1. Two separate letters of recommendation from mental health professionals who work alone without colleagues experienced with gender identity disorders are required for surgery and
   1. If the first letter is from a person with a master's degree, the second letter should be from a psychiatrist or a clinical psychologist--those who can be expected to adequately evaluate co-morbid psychiatric conditions.
   2. If the first letter is from the patient's psychotherapist, the second letter should be from a person who has only played an evaluative role for the patient. Each letter writer, however, is expected to cover the same seven elements
  2. One letter with two signatures is acceptable if the mental health professionals conduct their tasks and periodically report on these processes to a team of other mental health professionals and nonpsychiatric physicians.

  7. Children with Gender Identity Disorders
  1. The initial task of the child-specialist mental health professional is to provide careful diagnostic assessments of gender-disturbed children.
   1.the child's gender identity and gender role behaviors, family dynamics, past traumatic experiences, and general psychological health are separately assessed. Gender-disturbed children differ significantly along these parameters.
   2.hormonal and surgical therapies should never be undertaken with this age group.
   3.treatment over time may involve family therapy, marital therapy, parent guidance, individual therapy of the child, or various combinations.
   4.treatment should be extended to all forms of psychopathology, not simply the gender disturbance.

 8. Treatment of Adolescents
  1.In typical cases the treatment is conservative because gender identity development can rapidly and unexpectedly evolve. Teenagers should be followed, provided psychotherapeutic support, educated about gender options, and encouraged to pay attention to other aspects of their social, intellectual, vocational, and interpersonal development.
  2.They may be eligible for beginning triadic therapy as early as age 18, preferably with parental consent.    1.Parental consent presumes a good working relationship between the mental health professional and the parents, so that they, too, fully understand the nature of the GID.
   2.In many European countries sixteen to eighteen-year-olds are legal adults for medical decision making, and do not require parental consent. In the United States, age 18 is legal adulthood.
  3.Hormonal Therapy for Adolescents. Hormonal treatment should be conducted in two phases only after puberty is well established.
   1. in the initial phase biological males should be administered an antiandrogen (which neutralize testosterone effects only) or an LHRH agonist (which stops the production of testosterone only)
   2. biological females should be administered sufficient androgens, progestins, or LHRH agonists (which stops the production of estradiol, estrone, and progesterone) to stop menstruation.
   3. second phase treatments--after these changes have occurred and the adolescent's mental health remains stable
    1. biologic males may be given estrogenic agents
    2. biologic females may be given higher masculinizing doses of androgens
    3. second phase medications produce irreversible changes
  4. Prior to Age 18. In selected cases, the real life experience can begin at age 16, with or without first phase hormones. The administration of hormones to adolescents younger than age 18 should rarely be done.
  1. first phase therapies to delay the somatic changes of puberty are best carried out in specialized treatment centers under supervision of, or in consultation with, an endocrinologist, and preferably, a pediatric endocrinologist, who is part of an interdisciplinary team.
  2. two goals justify this intervention
   1. to gain time to further explore the gender and other developmental issues in psychotherapy
   2. to make passing easier if the adolescent continues to pursue gender change.
  3. in order to provide puberty delaying hormones to a person less than age 18, the following criteria must be met
   1. throughout childhood they have demonstrated an intense pattern of cross-gender identity and aversion to expected gender role behaviors
   2. gender discomfort has significantly increased with the onset of puberty
   3. social, intellectual, psychological, and interpersonal development are limited as a consequence of their GID
   4. serious psychopathology, except as a consequence of the GID, is absent
   5. the family consents and participates in the triadic therapy
 5. Prior to Age 16. Second phase hormones, those which induce opposite sex characteristics should not be given prior to age 16 years.
 6. Mental Health Professional Involvement is an Eligibility Requirement for Triadic Therapy During Adolescence.
  1. To be eligible for the implementation of the real life experience or hormone therapy, the mental health professional should be involved with the patient and family for a minimum of six months.
  2. To be eligible for the recommendation of genital reconstructive surgery or mastectomy, the mental health professional should be integrally involved with the adolescent and the family for at least eighteen months.
  3. School-aged adolescents with gender identity disorders often are so uncomfortable due to negative peer interactions and a felt incapacity to participate in the roles of their biologic sex that they refuse to attend school.
   1. Mental health professionals should be prepared to work collaboratively with school
personnel to find ways to continue the educational and social development of their patients.

 9. Psychotherapy with Adults
  1. Many adults with gender identity disorder find comfortable, effective ways of identifying themselves without the triadic treatment sequence, with or without psychotherapy
  2. Psychotherapy is not an absolute requirement for triadic therapy.
   1. Individual programs vary to the extent that they perceive the need for psychotherapy.
   2. When the mental health professional's initial assessment leads to a recommendation for psychotherapy, the clinician should specify the goals of treatment, estimate its frequency and duration.
   3. The SOC committee is wary of insistence on some minimum number of psychotherapy sessions prior to the real life experience, hormones, or surgery but expects individual programs to set these
   4. If psychotherapy is not done by members of a gender team, the psychotherapist should be informed that a letter describing the patient's therapy may be requested so the patient can move on to the next phase of rehabilitation.
  3. Psychotherapy often provides education about a range of options not previously seriously considered by the patient. Its goals are:
   1. to be realistic about work and relationships
   2. to define and alleviate the patient's conflicts that may have undermined a stable lifestyle and to attempt to create a long term stable life style
   3. to find a comfortable way to live within a gender role and body
  4. Even when the initial goals are attained, mental health professionals should discuss the likelihood that no educational, psychotherapeutic, medical, or surgical therapy can permanently eradicate all psychological vestiges of the person's original sex assignment

 10. The Real-Life Experience
  1. Since changing one's gender role has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what these familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be.
  2. When clinicians assess the quality of a person's real-life experience in the new gender role, 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 new (legal) first or last name
   6.to provide documentation that persons other than the therapist know that the patient functions in the new gender role.

 11. Eligibility and Readiness Criteria for Hormone Therapy for Adults
  1. Three eligibility 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 documented real life experience should be undertaken for at least three months prior to the administration of hormones Or
   4.a period of psychotherapy of a duration specified by the mental health professional after the initial evaluation (usually a minimum of three months) should be undertaken
   under no circumstances should an person be provided hormones who has neither fulfilled criteria #3 or #4.
  2. Three readiness criteria exist:    1. the patient has had further consolidation of gender identity during the real-life experience or psychotherapy
   2. the patient has made some progress in mastering other identified problems leading to improving or continuing stable mental health
   3. hormones are likely to be taken in a responsible manner
  3. Hormones can be given for those who do not initially want surgery or a real life experience. They must be appropriately diagnosed, however, and meet the criteria stated above for hormone administration.

 12. Requirements for Genital Reconstructive and Breast Surgery
  1. Six eligibility criteria for various surgeries exist and equally apply to biological males and biological females
   1.legal age of majority in the patient's nation
   2.12 months of continuous hormonal therapy for those without a medical contraindication    3.12 months of successful continuous full time real-life experience. Periods of returning to the original gender may indicate ambivalence about proceeding and should not be used to fulfill this criterion
   while psychotherapy is not an absolute requirement for surgery for adults, regular sessions may be required by the mental health professional throughout the real life experience at a minimum frequency determined by the mental health professional.
   5.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
  2. Two readiness criteria exist
   1. demonstrable progress in consolidating the new gender identity
   2.demonstrable progress in dealing with work, family, and interpersonal issues resulting in a significantly better or at least a stable state of mental health.

 13. Surgery
  1. Genital, Breast, and Other Surgery for the Male to Female Patient
   1.Surgical procedures may include orchiectomy, penectomy, vaginoplasty, augmentation mammaplasty, and vocal cord surgery.
   2.Vaginoplasty requires both skilled surgery and postoperative treatment. Three techniques are: penile skin inversion, pedicled rectosigmoid transplant, or free skin graft to line the neovagina
   3.Augmentation mammaplasty may be performed prior to vaginoplasty if the physician prescribing hormones and the surgeon have documented that breast enlargement after undergoing hormonal treatment for two years is not sufficient for comfort in the social gender role. Other surgeries that may be performed to assist feminization include: reduction thyroid chondroplasty, liposuction of the waist, rhinoplasty, facial bone reduction, face-lift, and blephoroplasty.
  2.Genital and Breast Surgery for the Female to Male Patient.
   1.Surgical procedures may include mastectomy, hysterectomy, salpingo-oophorectomy, vaginectomy metoidioplasty, scrotoplasty, urethroplasty, and phalloplasty.
   2.Current operative techniques for phalloplasty are varied. The choice of techniques may be restricted by anatomical or surgical considerations. If the objectives of phalloplasty are a neophallus of good appearance, standing micturition, and/or coital ability, the patient should be clearly informed that there are both several separate stages of surgery and frequent technical difficulties which require additional operations.
   3.Reduction mammaplasty may be necessary as an early procedure for some large breasted individuals to make the real life experience feasible.
   4. Liposuction may be necessary for final body contouring
  3. Postsurgical Follow-up by Professionals.
   1.Long term postoperative follow-up is one of the factors associated with a good psychosocial outcome.
   . Follow-up is essential to the patient's subsequent anatomic and medical health and to the surgeon's knowledge about the benefits and limitations of surgery
    1.Postoperative patients may incorrectly exclude themselves from follow-up with the physician prescribing hormones as well as their surgeon and mental health professional.
    2.These clinicians are best able to prevent, diagnose and treat possible long-term medical conditions that are unique to the hormonally and surgically treated.
    3. Surgeons who are operating on patients who are coming from long distances should include personal follow-up in their care plan.
    4. Continuing long-term follow-up has to be affordable and available in the patient's geographic region.
    5. Postoperative patients also have general health concerns and should undergo regular medical screening according to recommended guidelines
   3. The need for follow-up extends beyond the endocrinologist and surgeon, however, 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.

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