by Zinnia Jones — December 31, 2017

American Psychiatric Association

Position Statement on Access to Care for Transgender and Gender Variant Individuals (Drescher, Haller, & APA Caucus of Lesbian, Gay, and Bisexual Psychiatrists, 2012)

Issue: Significant and long-standing medical and psychiatric literature exists that demonstrates clear benefits of medical and surgical interventions to assist gender variant individuals seeking transition. However, private and public insurers often do not offer, or may specifically exclude, coverage for medically necessary treatments for gender transition. Access to medical care (both medical and surgical) positively impacts the mental health of transgender and gender variant individuals. … Therefore, the American Psychiatric Association: 1. Recognizes that appropriately evaluated transgender and gender variant individuals can benefit greatly from medical and surgical gender transition treatments. 2. Advocates for removal of barriers to care and supports both public and private health insurance coverage for gender transition treatment. 3. Opposes categorical exclusions of coverage for such medically necessary treatment when prescribed by a physician.

American Psychological Association

Transgender, Gender Identity, and Transgender, Gender Identity, and Gender Expression Non-Discrimination (American Psychological Association Council of Representatives, 2008)

WHEREAS transgender and other gender variant people benefit from treatment with therapists with specialized knowledge of their issues (Lurie, 2005; Rachlin, 2002), and that the Ethical Principles of Psychologists and Code of Conduct states that when scientific or professional knowledge…is essential for the effective implementation of their services or research, psychologists have or obtain the training…necessary to ensure the competence of their services” (APA, 2002, 2.01b); and … WHEREAS gender variant and transgender people may be denied appropriate gender transition related medical and mental health care despite evidence that appropriately evaluated individuals benefit from gender transition treatments (De Cuypere et al., 2005; Kuiper & Cohen-Kettenis, 1988; Lundstrom et al., 1984; Newfield, et al., 2006; Pfafflin & Junge, 1998; Rehman et al., 1999; Ross & Need, 1989; Smith et al., 2005); … BE IT FURTHER RESOLVED that APA calls upon psychologists in their professional roles to provide appropriate, nondiscriminatory treatment to transgender and gender variant individuals and encourages psychologists to take a leadership role in working against discrimination towards transgender and gender variant individuals; … BE IT FURTHER RESOLVED that APA supports the provision of adequate and necessary mental and medical health care treatment for transgender and gender variant individuals; BE IT FURTHER RESOLVED that APA recognizes the efficacy, benefit, and necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments;

Resolution on Gender and Sexual Orientation Diversity in Children and Adolescents in Schools (American Psychological Association & National Association of School Psychologists, 2015)

WHEREAS a person’s gender identity develops in early childhood and some young children may not identify with the gender assigned to them at birth (Brill & Pepper, 2008; Zucker, 2004); WHEREAS it may be medically and therapeutically indicated for some transgender and other gender diverse children and adolescents to transition from one gender to another using any of the following: change of name, pronoun, hairstyle, clothing, pubertal suppression, cross-sex hormone treatment, and surgical treatment (Coleman et al., 2011; Forcier & Johnson, 2012; Olson, Forbes, & Belzer, 2011);

World Professional Association for Transgender Health

Position Statement on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage in the U.S.A. (World Professional Association for Transgender Health, 2016)

The current Board of Directors of the WPATH herewith expresses its considered opinion based on clinical and peer reviewed evidence that gender affirming/confirming treatments and surgical procedures, properly indicated and performed as provided by the Standards of Care, have proven to be beneficial and effective in the treatment of individuals with transsexualism or gender dysphoria. Gender affirming/confirming surgery, also known as sex reassignment surgery, plays an undisputed role in contributing toward favorable outcomes. Treatment includes legal name and sex or gender change on identity documents, as well as medically necessary hormone treatment, counseling, psychotherapy, and other medical procedures required to effectively treat an individual’s gender dysphoria. … In addition to hormonal balancing, medically necessary gender affirming/confirming surgical procedures are described in section XI of the SOC. These procedures include complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate to each patient, including nipple resizing or placement of breast prostheses, as necessary; genital reconstruction by various techniques which must be appropriate to each patient, including, for example, skin flap hair removal, scrotoplasty, and penile and testicular prostheses, as necessary; facial hair removal, certain facial plastic reconstruction, voice therapy and/or surgery, and gender affirming counseling or psychotherapeutic treatment, as appropriate to the patient. … The medical procedures attendant to gender affirming/confirming surgeries are not “cosmetic” or “elective” or “for the mere convenience of the patient.” These reconstructive procedures are not optional in any meaningful sense, but are understood to be medically necessary for the treatment of the diagnosed condition. In some cases, such surgery is the only effective treatment for the condition, and for some people genital surgery is essential and life-saving. These medical procedures and treatment protocols are not experimental: Decades of both clinical experience and medical research show they are essential to achieving well-being for the transsexual patient.

Royal College of Psychiatrists

Good practice guidelines for the assessment and treatment of adults with gender dysphoria (Royal College of Psychiatrists, 2013)

The following organisations have endorsed the report: British Association of Urological Surgeons

British Psychological Society

Gender Identity Research and Education Society

Gender Trust

Press for Change

Royal College of General Practitioners

Royal College of Nursing

Royal College of Obstetricians and Gynaecologists

Royal College of Paediatrics and Child Health

Royal College of Physicians

Royal College of Speech and Language Therapists

Royal College of Surgeons

UK Council for Psychotherapy … The provision of care for patients experiencing gender dysphoria is an excellent example of an area where multidisciplinary and interdisciplinary care is not only good practice but ensures that a wide choice of treatment pathways are offered, tailored to the needs of the individual patient. This intercollegiate document provides guidelines which we hope will optimise the clinical care pathways for patients who may need to access several medical and allied health professionals. We herald a new approach to care which has evolved from a linear progressive sequence to multiple pathways of care which recognise the great diversity of clinical and presentation needs. Central to the new way of working for healthcare professionals is the recognition of patient-centred care that will result in flexible treatment options, hopefully increasing the likelihood of good outcomes, reduced morbidity and improved quality of life for patients. The joint participation in goal-setting and regular follow-up is crucial to winning the support of both patients and clinicians. Practitioners have a duty of care to enable individuals to make competent, fully informed decisions and choices. … Gender dysphoria is the distress associated with the experience of one’s personal gender identity being inconsistent with the phenotype or the gender role typically associated with that phenotype. This distress, when present, might give rise to an individual seeking clinical consultation. There are gradations of gender experience between the binary ‘man’ or ‘woman’, some of which cause discomfort and may need medical intervention; others may need little or none. … Gender treatment should be established on a multidisciplinary basis and may include input from GPs, psychology, psychiatry, psychotherapy, nursing, speech and language therapy, endocrinology, dermatology, surgery, social work and other related professions. Working in cooperation with other specialist practitioners or colleagues, even if on a different site, and affiliation with peer review and supervision networks, should be the goals of all clinicians.

Endocrine Society

Transgender Health: An Endocrine Society Position Statement (Endocrine Society, 2017)

Transgender individuals are often denied insurance coverage for appropriate medical and psychological treatment. Over the last decade, there has been considerable research on and development of evidence-based standards of care that have proven to be both safe and efficacious for the treatment of gender dysphoria/gender incongruence. There is also a growing understanding of the impact that increased access to such treatments can have on the mental health of these individuals. The Endocrine Society’s Clinical Practice Guideline on gender dysphoria/gender incongruence provides the standard of care for treating transgender individuals. The guideline establishes a framework for the appropriate treatment of these individuals and standardizes terminology to be used by healthcare professionals. These recommendations include evidence that treatment of gender dysphoria/incongruence is medically necessary and should be covered by insurance. … Medical intervention for transgender individuals (including both hormone therapy and medically indicated surgery) is effective, relatively safe (when appropriately monitored), and has been established as the standard of care. Federal and private insurers should cover such interventions as prescribed by a physician as well as the appropriate medical screenings that are recommended for all body tissues that a person may have.

American College of Obstetricians and Gynecologists

Health Care for Transgender Individuals (American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women, 2011)

Within the medical community, transgender individuals face significant barriers to health care. This includes the failure of most health insurance plans to cover the cost of mental health services, cross-sex hormone therapy, or gender affirmation surgery. This barrier exists despite evidence that such treatments are safe and effective and that cross-gender behavior and gender identity issues are not an issue of choice for the individual and cannot be reversed with psychiatric treatment (8). With medical and psychiatric care that affirms transgender identity, the transgender individual can lead an enhanced, functional life (9). … Obstetrician–gynecologists should be prepared to assist or refer transgender individuals. Physicians are urged to eliminate barriers to access to care for this population through their own individual efforts. An important step is to identify the sexual orientation and gender identity status of all patients as a routine part of clinical encounters and recognize that many transgender individuals may not identify themselves. The American College of Obstetricians and Gynecologists urges health care providers to foster nondiscriminatory practices and policies to increase identification and to facilitate quality health care for transgender individuals, both in assisting with the transition if desired as well as providing long-term preventive health care.

Care for Transgender Adolescents (American College of Obstetricians and Gynecologists Committee on Adolescent Health Care, 2017)

Consensus guidelines support initiating medical therapy after an adolescent has an established diagnosis of transgender identity and has reached Tanner stage II development. Medical management involves the suppression of puberty (typically in the form of gonadotropin-releasing hormone agonists) followed by cross-sex hormone therapy to induce puberty at age 16 years. A variety of surgical options are available, including bilateral mastectomy, hysterectomy with bilateral salpingo-oophorectomy or salpingectomy, and possible neophallus creation.

American Academy of Pediatrics

AAP Statement in Support of Transgender Children, Adolescents and Young Adults (Stein & Remley, 2017)

The American Academy of Pediatrics stands in support of transgender children and adults, and condemns attempts to stigmatize or marginalize them. We believe transgender individuals are not a “disruption.” They are members of our families, our communities, and our work force. As pediatricians, we know that transgender children fare much better when they feel supported by their family, school and larger community. Shaming children based on their gender identity or expression is harmful to their social-emotional health and may have lifelong consequences. This includes public discourse that de-legitimizes the contributions that transgender individuals make to society. The AAP supports policies that are gender-affirming for children – an approach that is supported by other key professional organizations. In 2016, the AAP joined with other organizations to produce the document, “Supporting & Caring for Transgender Children,” a guide for community members and allies to ensure that transgender young people are affirmed, respected, and able to thrive.

American Academy of Child & Adolescent Psychiatry

Transgender and Gender Diverse Youth (American Academy of Child & Adolescent Psychiatry, 2017)

Research suggests that accepting a child’s affirmed gender identity and expression can decrease the risk of future psychiatric problems such as depression, anxiety, and suicidal behavior. There are many ways a parent can do this: Talk about gender with your child in an open and understanding way

Use the name and gender pronouns (e.g. “he/she/they”) your child prefers

Allow your child to play with toys and dress in clothes they choose

Stand up for your child if you notice other people acting disrespectfully

Help your child prepare for teasing or bullying, including identifying trusted adults

Learn about school policies and laws that address gender issues. Advocate for changing them if they negatively impact your child

Help your child make decisions about telling others about their gender identity

Connect with other parents raising gender diverse or transgender children

Seek out guidance early on from medical and mental health professionals who have experience with these issues Sometimes children take steps to transition from their assigned gender to their affirmed gender. This is called transitioning. Social transitioning refers to a change of gender roles, expressions, name, and pronouns. Medical transitioning refers to the use of medication to help their body better match their gender identity. Medications can pause some of the physical changes that happen with puberty. Surgical transitioning refers to the use of surgery to match one’s body and gender identity. Surgery is not an option until late adolescence and adulthood. If transitioning is something your child is wondering about, you can explore options with a medical professional who is knowledgeable in this area. These treatments are different from conversion therapy which attempts to force gender identity to match assigned gender. Conversion therapy is not based on evidence and is harmful to the child and their relationship with their parents.

Last updated: December 31, 2017