Long-awaited global guidelines on transgender care have been scrapped, with no recommendations on age limits for treatment and surgery in adolescents, but acknowledging the complexity of caring for these adolescents amid the lack of research longitudinal study on the impact of gender transition.
The World Professional Association of Transgender Health (WPATH) released its latest Standards of Care (SOC) 8 at the opening of its annual meeting today in Montreal.
It is “the most comprehensive set of guidelines ever produced to help healthcare professionals around the world support transgender and gender-diverse adults, adolescents and children who are taking steps to live their lives of authentic way,” wrote WPATH President Walter Bouman, MD. , PhD, and WPATH President Elect Marci Bowers, MD, in a press release.
The SOC8 is the first updated guidance on the treatment of transgender people in 10 years and appears online in the International Journal of Transgender Health.
For the first time, the association has written a chapter dedicated to transgender and gender-diverse adolescents — separate from the chapter on the child.
The complexity of treating adolescents
WPATH officials said this was due to the exponential growth in adolescent referral rates, more research into adolescent gender diversity care, and the unique developmental and care issues of this age group.
Until recently, there was little information regarding the prevalence of gender diversity among adolescents. Studies of high school samples indicate much higher rates than previously thought, with reports of up to 1.2% of participants identifying as transgender and up to 2.7% or more (for example, 7% to 9%) experiencing some level of self-reporting. gender diversity, says WPATH.
The new chapter “applies to adolescents from the onset of puberty until the legal age of majority (in most cases 18)”, it specifies.
However, WPATH stopped short of recommending lowering the age at which young people can receive cross-sex hormone therapy or gender-affirming surgeries, as previously decreed in draft guidelines. This project suggested that young people could receive hormone therapy at age 14 and surgeries for a double mastectomy at age 15 and for genital reassignment at age 17.
The exception was phalloplasty – surgery to build a penis in female to male individuals – which, according to WPATH, should not be performed before the age of 18 due to its complexity.
Now, the final SOC8 emphasizes that every transgender adolescent is unique and that decisions should be made on an individual basis, with no recommendations on specific ages for any treatment. This could be interpreted in several ways.
SOC8 also acknowledges the “very rare” regret of people who transitioned to the opposite sex and then changed their minds.
“[Healthcare] Providers can consider the possibility that an adolescent may regret gender-affirming decisions made during adolescence, and that a young person may want to stop treatment and return to live in the gender role assigned at birth in the future . Providers can discuss this in a spirit of collaboration and trust with the adolescent and their parents/guardians before beginning gender-affirming medical treatments,” he says.
WPATH, further, emphasized the importance of counseling and supporting regretful patients, many of whom “expressed difficulty finding help during their detransition process and said their detransition was an isolating experience. during which they received neither sufficient nor appropriate support”.
Although it does not give a specific figure on the overall regret rate, in its chapter on surgery, WPATH estimates that 0.3% to 3.8% of transgender people regret gender-affirming surgery.
The SOC8 also acknowledges that “a pattern of unequal ratios by assigned sex has been reported in gender clinics, with patients assigned at birth beginning care 2.5 to 7.1 times more frequently” than patients assigned to a male at birth.
And WPATH states in SOC8 that another phenomenon is the growing number of adolescents seeking care who had not previously experienced or expressed gender diversity during childhood.
He goes on to quote the 2018 paper by Lisa Littman MD, MPH, now president of the Institute for Comprehensive Gender Dysphoria Research (ICGDR). Littman coined the term “rapid onset gender dysphoria (ROGD)” to describe this phenomenon; SOC8 refrains from using this phrase, but acknowledges that “for a selected subgroup of young people, sensitivity to social influence impacting gender may be an important differential to consider”.
The SOC8 recommends that before considering any medical or surgical treatment, healthcare professionals “undertake a comprehensive biopsychosocial assessment of adolescents who present with gender identity issues and seek transition-related medical/surgical care. “.
And he specifically mentions that transgender adolescents “exhibit high rates of autism spectrum disorder (ASD)/characteristics,” and notes that “other neurodevelopmental presentations and/or mental health issues may also be present (e.g., ADHD [attention-deficit/hyperactivity disorder]intellectual disability and psychotic disorders).
Who uses WPATH to guide care? It’s “a big unknown”
WPATH is an umbrella organization with branches in most Western countries, such as USPATH in the United States, EPATH in Europe, and AUSPATH and NZPATH in Australia and New Zealand.
However, it is not the only organization to publish guidance on caring for transgender people; several specialties support this patient population, including, but not limited to: pediatricians, endocrinologists, psychiatrists, psychologists and plastic surgeons.
The extent to which any medical professional or professional body follows WPATH’s advice is extremely varied.
“There is nothing that binds clinicians to the SOC, and the SOC is so broad and vague that anyone can say they follow it, but according to their own biases and interpretations,” Aaron Kimberly, a trans man and mental health clinician from the Gender Dysphoria Alliance said Medcape Medical News
In North America, some clinics practice full “informed consent” without an assessment or order on the first visit, Kimberly said, while others do full assessments.
“I think SOC should be watched. It shouldn’t just be people going rogue,” said Erica Anderson, a clinical psychologist in Berkeley, Calif., former USPATH president and former WPATH member, who is transgender herself. Medscape Medical News. “The reason there are standards of care is because hundreds of scientists have weighed in – is it perfect? No. We have a long way to go. But you can’t just ignore everything we know and leave the people make their own decisions.”
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