For Healthcare Providers
An overview on clinical approaches to gender-affirming care
Healthcare providers may draw from several different practice models when providing medical and non-medical gender-related healthcare. The World Professional Association for Transgender Health (WPATH) publishes the main standards of care (SOC) and is the most up to date practice guideline. The newest version, the SOC8, was derived from evidence review and expert consensus. They have published clinical guidelines on their website, which you can find here. In recent studies (MacKinnon, et al., under review; Pullen Sansfacon et al., 2023), some people who later detransitioned reflected not feeling fully supported to make an informed decision about gender-related medical interventions. In the Re/DeTrans Canada study, study participants expressed the most support for individualized care outlined by the WPATH-SOC8, but they added that care should be offered from a neutral clinical position that embraces nonbinary identities, gender nonconformity, and non-medical interventions to address gender dysphoria. In the Detrans Discourses study some transitional-age young adults (e.g., 18) reported they accessed hormones at a gender clinic and were asked to sign an informed consent form which did not serve their needs given they felt they lacked support in making a decision. At the time, it felt like appropriate care, but in hindsight it was insufficient.
How do I choose which model of care is best for my patient?
It can be difficult given all of these options to know which model of care is best for your patient. The WPATH SOC8 has recommendations based on age and developmental needs of trans and gender-diverse people. Different models of care delivery and approaches to assessment may diverge based on age, other personal characteristics, and life histories. Providers should never aim to change a patient’s gender identity or sexual orientation or be invested in any specific identity outcome (e.g. cisgender; transgender; heterosexual). This would be considered a form of “conversion therapy” or sexual orientation/gender identity change efforts (SOGICE). SOGICE has been shown to be associated with negative psychosocial outcomes among 2SLGBTQ+ populations and these clinical practices are criminalized in some jurisdictions.
What clinical considerations should I consider for care-seeking individuals?
Age and developmental stage of the patient must be taken into consideration when assessing decision-making capacity and care needs. Emerging evidence suggests that some individuals who detransition have histories of trauma and/or additional mental health concerns or neurodivergence (ADHD or Autism). However, not everyone who detransitions has these experiences. And at the moment, research does not seem to clearly indicate the presence of neurodivergence or mental health concerns is a predictor of future detransition. You may already routinely screen for these factors that may require additional care and support as part of your intake process, which is outlined by the SOC8. If not, a comprehensive evaluation inclusive of mental health and neurodivergences may be helpful in supporting differential diagnosis. Some participants in the Re/DeTrans Canada study explained that only years after medically transitioning and experiencing declining mental health were they diagnosed and able to access support for various mental health challenges. They felt that knowing this information about themselves prior to starting hormones or accessing surgery might have been helpful. As a note, when providers are assessing mental health concerns or identifying treatment needs, this should be done without pathologizing or aiming to change a person’s gender identity or expression.
What are the cultural considerations I should consider when discussing gender care with care-seeking individuals?
Stories about individuals who detransition have been mentioned in media, sometimes to validate a position for questioning trans identities or restricting gender-related healthcare. Because of these media narratives, it can be difficult to talk to patients about the possibility of detransition and/or regret without patients sometimes inferring that their healthcare provider is invalidating of transgender experiences. These conversations are still important, though, to achieve fully informed consent about the full range of possible outcomes following gender-related healthcare. Below are some ideas of how to have these discussions with patients.
How can I talk about detransition with patients in a way that validates and respects their identity, experience, and needs?
Talking about detransition with patients can elicit very strong feelings, not the least because of the above political and cultural context. Patients may worry that your discussing the possibility of regret or detransition may indicate that you endorse anti-transgender views. Conversely, some patients worry that their own discussion and recognition that identities and goals may shift over time will be used to deny them care.
How do I make sure that informed consent is actually well-informed?
Gender care assessment and informed consent practices sometimes vary depending on geography, institution, or even across different healthcare providers. Some providers feel comfortable supporting their patients to independently review the health risks and benefits associated with gender care by providing them with information packages. Others choose a lengthier conversation to verbally review health risks and benefits and expected outcomes with all patients and continuously prompt patients for any questions or concerns. One way to ensure informed consent is to verbally confirm that your patient is aware of all health risks and benefits, and all possible outcomes, including shifts in identity, regret and/or detransition. This approach offers opportunity to evaluate your patient’s competency to make health care decisions for themselves. This consideration may be especially pertinent for younger patients, if the patient is neurodiverse, or if they have a learning disability. Not all patients digest information in the same way.
Clinical Interview Guide for Working with Transgender and Gender-Diverse Young People
Providers may discuss the possibility of regret when working with individuals who pursue gender-related care. For instance, providers working from an informed consent model may review that some interventions are partially or completely irreversible. However, the possibility of regret and/or detransition may be difficult to discuss with service users because stories of regret and detransition may feel invalidating for people who are actively pursuing care (as many transgender people do) and entering into those discussions may cause some patients to fear medications or surgeries will be withheld if the individual is not “certain” about choices. Below are a few suggestions regarding how to open up the conversation in a way that may be validating for your patients.
- Share how you, as a provider, relate to the context of gender affirming care: “I have been working with transgender people for 10 years and believe that gender-related medical care is an important treatment for many. I also believe that everyone has their own individual story that deserves to be recognized and validated, and that for some people, identities can shift over time.”
- Emphasize your goal to have a discussion to identify individual care needs: “I want to ask some questions about your history of gender identity and expression, and any identity shifts to better understand your history and care needs. It is helpful for me to know more about your thoughts and feelings at this time and whether you understand the possibility for identity shifts occurring in the future and what that might mean in the context of your life.”
- Ask open-ended questions to evaluate your patient’s attitudes about detransition and regret:
- “What do you notice about stories shared publicly by people who themselves have expressed regret and/or detransitioned?”
- “Do you ever worry that you may have regrets?”
- “What do you think you might regret?”
- “How have you dealt with regrets with big life decisions in the past?”
- Provide psychoeducation regarding detransition: “Some people do stop or reverse gender-related medical treatments if they begin to feel like these interventions are not making them feel happier or are actually making them feel less comfortable in their bodies. Stopping or reversing these interventions can sometimes help these people to feel more comfortable in their bodies.
- Emphasize the full range of detransition narratives and possibilities, which can include positive, neutral, or negative: “Some people who detransition may struggle with regret or other negative feelings even after detransitioning. However, others feel happy they detransitioned because they feel more comfortable. Some also feel positively about their initial transition because they feel they have gained new and important perspectives about themselves. Others feel they lacked adequate support and non-medical care options when they were making treatment decisions, and would not access medical transition if they could go back and do it over again.”
- Return to current decision-making: “Having considered your own life and care needs, how are you feeling right now? What are your current needs? Do you feel supported and informed to make a decision? Remember that exploring any doubts, additional questions, or aspects of treatment that you do not fully understand, does not mean that treatments will not be made available to you in the future.”
In addition to the above, it may be helpful to explore more if your patient expresses shifts in identity and desires for treatment, ambivalence, or interest in detransition after an initial transition. For instance, you might use visualization exercises to invite your patient to imagine what it might be like to detransition to further explore their feelings.
However, the above are only included as suggestions about how to start a possibly difficult conversation and should not be taken as clinical advice. Please use your clinical experience to determine appropriateness of these suggestions in working with your patients.