I don’t think they thought I was ready for surgery… They wouldn’t hear me out… I felt like they didn’t believe me. Until I was like “I’m in therapy, and I’m in this” and… I felt like at that point they can’t deny me because I’m doing everything they asked and telling them everything they want to hear. And at that point I’d been presenting as female for almost 4 years [3 years beyond the WPATH requirement for lower surgery].

Trans patient, quoted in MacKinnon et al., (2020), International Journal of Mental Health

Hormones

WPATH Criteria for hormones & top surgeries

Re-interpretation

The Path to Patient-Centred Care

  • WPATH Criteria for hormones & top surgeries

    Persistent, well-documented gender dysphoria

  • Re-interpretation

    Discuss patient’s gender identity and transition goals; Avoid using DSM criteria to diagnose “gender dysphoria”

  • The Path to Patient-Centred Care

    Patients are best positioned to define their gender identities; Research has demonstrated that when a diagnosis is required to access medical treatments, trans people strategically recite gender dysphoria diagnostic criteria

  • WPATH Criteria for hormones & top surgeries

    Capacity to make a fully informed decision and to give consent for treatment

  • Re-interpretation

    Emphasize patient autonomy and collaboration in medical decision-making;

    Some clinicians have patients sign an “informed consent form” to orient conversations with patients, and to keep in the patient’s chart

  • The Path to Patient-Centred Care

    When patients have information on known risks, benefits and alternative options to treatments they are well- positioned to make an autonomous decision.

  • WPATH Criteria for hormones & top surgeries

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

  • Re-interpretation

    Contextualize within the patient’s history; Involve patients in determining whether their mental health is “well-controlled"; Understand that gender dysphoria may be a primary diagnosis contributing to other mental health concerns (e.g., depression; anxiety); Research associates access to hormones with improvements in mental health and wellness outcomes2 3

  • The Path to Patient-Centred Care

    Involve patients in determining readiness for hormones; When patients have information on known risks, benefits and alternative options they are in a position to make an autonomous decision.

Surgeries

WPATH Criteria for Hysterectomy, Salpingo-Oophorectomy, and Orchiectomy

Re-interpretation

The Path to Patient-Centred Care

  • WPATH Criteria for Hysterectomy, Salpingo-Oophorectomy, and Orchiectomy

    Persistent, well documented gender dysphoria

  • Re-interpretation

    Discuss patient’s gender identity and transition goals; Avoid using DSM criteria to diagnose “gender dysphoria”

  • The Path to Patient-Centred Care

    Patients are best positioned to understand and define their gender identities; Research has demonstrated that when it is required to access medical treatments, trans people strategically recite diagnostic criteria to obtain a diagnosis.;

    Patient-Provider trust and collaboration is improved

  • WPATH Criteria for Hysterectomy, Salpingo-Oophorectomy, and Orchiectomy

    Capacity to make a fully informed decision and to give consent for treatment

  • Re-interpretation

    Emphasize patient autonomy and collaboration in medical decision-making; Use decision-making aids to assist patient in selecting surgical procedures/techniques;

    Some clinicians may feel more confident having patients sign an “informed consent form” to orient conversations with patients, and to keep in the patient’s chart

  • The Path to Patient-Centred Care

    When patients have information on known risks, benefits and alternative options to treatments they are well-positioned to make an autonomous decision

  • WPATH Criteria for Hysterectomy, Salpingo-Oophorectomy, and Orchiectomy

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

  • Re-interpretation

    Contextualize within the patient’s history; Involve patients in determining whether their mental health is “well-controlled”; Understand that gender dysphoria may be a primary diagnosis contributing to other mental health concerns (e.g., depression; anxiety); Research associates access to surgeries with improvements in mental health and wellness outcomes2 3

  • The Path to Patient-Centred Care

    Involve patients in determining readiness for surgeries; When patients have information on known risks, benefits and alternative options they are in a position to make an autonomous decision.

  • WPATH Criteria for Hysterectomy, Salpingo-Oophorectomy, and Orchiectomy

    12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual)

  • Re-interpretation

    Explain medical rationale for this criterion; Follow informed consent procedures, emphasizing patient autonomy; For orchiectomy with transfeminine spectrum people/trans women, explore desire for future vaginoplasty techniques that require scrotal tissue.

  • The Path to Patient-Centred Care

    Patient-Provider trust and collaboration is improved when clinicians explain the medical rationale for WPATH criteria

WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

Re-interpretation

The Path to Patient-Centred Care

  • WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

    Persistent, well documented gender dysphoria

  • Re-interpretation

    Discuss patient’s gender identity and transition goals; Avoid using DSM criteria to diagnose “gender dysphoria”

  • The Path to Patient-Centred Care

    Patients are best positioned to understand and define their gender identities; Research has demonstrated that when it is required to access medical treatments, trans people will strategically recite diagnostic criteria to obtain a diagnosis.

  • WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

    Capacity to make a fully informed decision and to give consent for treatment

  • Re-interpretation

    Emphasize patient autonomy and collaboration in medical decision-making; Use decision-making aids to assist patient in selecting surgical procedures/techniques

  • The Path to Patient-Centred Care

    When patients have information on known risks, benefits and alternative options to treatments they are well-positioned to make an autonomous decision;

    Patient-Provider trust and collaboration is improved

  • WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

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

  • Re-interpretation

    Contextualize within the patient’s history; Involve patients in self-determining whether their mental health is “well-controlled”; Understand that gender dysphoria may be a primary diagnosis contributing to other mental health concerns (e.g., depression; anxiety); Research associates access to surgeries with improvements in mental health and wellness outcomes2 3;

    Some clinicians may feel more confident having patients sign an “informed consent form” to orient conversations with patients, and keep in the patient’s chart

  • The Path to Patient-Centred Care

    Involve patients in determining readiness for surgeries; When patients have information on known risks, benefits and alternative options they are in a position to make an autonomous decision;

    Patient-Provider trust and collaboration is improved

  • WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

    12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual)

  • Re-interpretation

    Explain medical rationale for this criterion; Follow informed consent procedures emphasizing patient autonomy and collaboration in medical decision-making ;

    For orchiectomy with transfeminine/trans women, explore desire for future vaginoplasty techniques that require scrotal tissue.

  • The Path to Patient-Centred Care

    Patient-Provider trust and collaboration is improved when clinicians explain the medical rationale for WPATH criteria

  • WPATH Criteria for Metoidioplasty or Phalloplasty, and Vaginoplasty

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

  • Re-interpretation

    Discuss patient’s gender identity and transition goals; Give patients autonomy in self-determining if they have lived in a gender congruent role; Contextualize this criterion with respect to a patient’s unique circumstance and understand the risks associated with being a "visibly" trans person in public; Avoid asking employers/friends/family for guarantor letters or other “proof” of a patient’s gender role.

  • The Path to Patient-Centred Care

    This criterion could be flexibly applied given that some trans people who desire TRS may have non-binary gender identities, or may be unable to safely navigate the world "visibly" trans 100% of the time;

    Patient-Provider trust is improved when collaborating together.

Footnotes
  1. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, G., DeCuypere, J… & Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism 13(4), 165-232.
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  2. Bauer, G. R., Scheim, A. I., Pyne, J., Travers, R., & Hammond, R. (2015). Intervenable factors associated with suicide risk in transgender persons: A respondent driven sampling study in ontario, Canada. BMC Public Health 15(525),1-15. ↩︎ ↩︎ ↩︎
  3. Tomita, T., Testa, R.J. & Balsam, K.F. (2018). Gender-affirming medical interventions and mental health in transgender adults. Psychology of Sexual Orientation and Gender Diversity. DOI: http://dx.doi.org/10.1037/sgd0000316. ↩︎ ↩︎ ↩︎