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Endocrine society guidelines for transsexual

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DESCRIPTION: Delemarre-van de Waal, Louis J. Spack, Vin Tangpricha, Victor M.

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Summary of Recommendations

a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even. Read more about transgender health and endocrinology. The Endocrine Society's Clinical Practice Guideline on gender dysphoria/gender. The Clinical Guidelines Subcommittee of The Endocrine Society deemed the diagnosis.

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Delemarre-van de Waal, Louis J. Spack, Vin Tangpricha, Victor M. Montori; Endocrine Treatment of Transsexual Persons: The aim was to formulate practice guidelines for endocrine treatment oftranssexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation GRADE system to describe the strength of recommendations and the quality of evidence, which was low or very low.

A mental health professional Endocrine society guidelines for transsexual must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment. The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children.

We recommend treating transsexual adolescents Tanner stage 2 by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given.

We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons. Endocrine treatment of transsexual persons should include suppression of endogenous sex hormones, physiologic levels of gender-appropriate sex hormones, Endocrine society guidelines for transsexual suppression of puberty in adolescents Tanner stage 2. For children and adolescents, the MHP should also have training in child and adolescent developmental psychopathology.

GnRH analog treatment and cross-sex hormone treatment Endocrine society guidelines for transsexual they start hormone treatment. We recommend that adolescents who fulfill eligibility and readiness criteria for gender reassignment initially undergo treatment to suppress pubertal development.

We recommend that suppression of pubertal hormones start when girls and boys first exhibit physical changes of puberty confirmed by pubertal levels of estradiol and testosterone, respectivelybut no earlier than Tanner stages Endocrine society guidelines for transsexual. We recommend that GnRH analogs be used to achieve suppression of pubertal hormones.

We suggest that pubertal development of the desired opposite sex be initiated at about the age of 16 yr, using a gradually increasing dose schedule of cross-sex steroids. We recommend referring hormone-treated adolescents for surgery when 1 the real-life experience RLE has resulted in a satisfactory social role change; 2 the individual is satisfied about the hormonal effects; and 3 the individual desires definitive surgical changes.

Medical conditions that can be exacerbated by cross-sex hormone therapy. Men and women have experienced the confusion and anguish resulting from rigid, forced conformity to sexual dimorphism throughout recorded history. Aspects of gender variance have been part of biological, psychological, and sociological Endocrine society guidelines for transsexual among humans in modern history. Endocrine treatment of transsexual persons [note: Personal stories of role models, treated with hormones and sex reassignment surgery, appeared in the press during the second half of the 20th century.

These carefully prepared documents have Endocrine society guidelines for transsexual mental health and medical professionals with general guidelines for the evaluation and treatment of transsexual persons. Beforefew peer-reviewed articles were published concerning endocrine treatment Endocrine society guidelines for transsexual transsexual persons.

Since that time, more than articles about various aspects of transsexual care have appeared. It is the purpose of this guideline to make detailed recommendations and suggestions, based on existing Endocrine society guidelines for transsexual literature and clinical experience, that Endocrine society guidelines for transsexual enable endocrinologists to provide safe and effective endocrine treatment for individuals diagnosed with GID or transsexualism by MHPs.

In the future, rigorous evaluation of the effectiveness Endocrine society guidelines for transsexual safety of endocrine protocols is needed. What will be required is the careful assessment of: Endocrine society guidelines for transsexual needs can be met only by a commitment Endocrine society guidelines for transsexual mental health and endocrine investigators to collaborate in long-term, large-scale studies Endocrine society guidelines for transsexual countries that employ the same diagnostic and inclusion criteria, medications, assay methods, and response assessment tools.

Terminology and its use vary and continue to evolve. Table 1 contains definitions of terms as they are used throughout the Guideline. This process of cognitive and affective learning happens in interaction with parents, peers, and environment, and a fairly accurate timetable exists for the steps in this process 4.

Normative psychological literature, however, does not address when gender identity becomes crystallized and what factors contribute to the development of an atypical gender identity. Factors that have been Endocrine society guidelines for transsexual in clinical studies may well enhance or perpetuate rather than originate a GID for an overview, see Ref.

Behavioral genetic studies suggest that, in children, atypical gender identity and role development has a heritable component 67. Because, in most cases, GID does not persist into adolescence or adulthood, findings in children with GID cannot be extrapolated to adults. In adults, psychological studies investigating etiology hardly exist. Studies that have investigated potential causal factors are retrospective and rely on self-report, making the results intrinsically unreliable.

Most attempts to identify biological underpinnings of gender identity in humans have investigated effects of sex steroids on the brain functions for a review, see Ref. Prenatal androgenization may predispose to development of a male gender identity. However, most 46,XY female-raised children with disorders of sex development and a history of prenatal androgen exposure do not develop a male gender identity 910whereas 46,XX subjects exposed to prenatal androgens show marked behavioral masculinization, but this does not necessarily lead to gender dysphoria 11 — MTF transsexual individuals, with a male androgen exposure prenatally, develop a female gender identity through unknown mechanisms, apparently overriding the effects of prenatal androgens.

There is no comprehensive understanding of hormonal imprinting on gender identity formation. It is of note that, in addition to hormonal factors, genetic mechanisms may bear on psychosexual differentiation Maternal immunization against the H-Y antigen has been proposed 15 This hypothesis states that the repeatedly Endocrine society guidelines for transsexual fraternal birth order effect reflects the progressive immunization of some mothers to Y-linked minor histocompatibility antigens H-Y antigens by each succeeding male fetus and the increasing effects of such immunization on the future sexual orientation of each succeeding male fetus.

Sibling sex ratio studies have not been experimentally supported Studies have also failed to find differences in circulating levels of sex steroids between transsexual and nontranssexual individuals In summary, neither biological nor psychological studies provide a satisfactory explanation for the intriguing phenomenon of GIDs. In both disciplines, studies have been able to correlate certain findings to GIDs, but the findings are not robust and cannot be generalized to the whole population.

The Clinical Guidelines Subcommittee of The Endocrine Society deemed the diagnosis and treatment of transsexual individuals a priority area in need of practice guidelines and appointed a Task Force to formulate evidence-based recommendations.

The Task Force followed the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation GRADE group, Endocrine society guidelines for transsexual international group with expertise in development and implementation of evidence-based guidelines A detailed description of the grading scheme has been published elsewhere The Task Force used the best available research evidence that Task Force members identified and two commissioned systematic reviews 2122 to develop some of the recommendations.

The Task Force also used consistent language and graphical descriptions of both the strength of a recommendation and the quality of evidence. The Task Force has confidence that persons who receive Endocrine society guidelines for transsexual according to the strong recommendations will derive, on average, more good than harm.

These technical comments reflect the best available evidence applied to a typical person being treated. Often this evidence comes from the unsystematic observations of the panelists and their values and preferences; therefore, these remarks should be considered suggestions. Some statements in this guideline 1. These are statements the task force Endocrine society guidelines for transsexual it was necessary to make, and it considers them matters about which no sensible healthcare professional could possibly consider advocating the contrary e.

These statements have not been subject Endocrine society guidelines for transsexual structured review of the evidence and are thus not graded. Sex reassignment is a multidisciplinary treatment. It requires five processes: The focus of this Guideline is hormone therapy, although collaboration with appropriate professionals responsible for each process maximizes a successful outcome. It would be ideal if care could be given by Endocrine society guidelines for transsexual multidisciplinary team at one treatment center, but this is not always possible.

It is essential that all caregivers be aware of and understand the contributions of each discipline and that they communicate throughout the process. Because GID may be accompanied with psychological or psychiatric problems see Refs.

The main aspects of the diagnostic and psychosocial counseling are described below, and evidence supporting the SOC guidelines is given, whenever available. During the diagnostic procedure, the MHP obtains information from the applicants for sex reassignment and, in the case of adolescents, the parents or guardians regarding various aspects of their general and psychosexual development and current functioning.

On the basis of this information the MHP: In cases in which severe psychopathology or circumstances, or both, seriously interfere with the diagnostic work or make satisfactory treatment unlikely, management of the other issues should be addressed first. Literature on postoperative regret Endocrine society guidelines for transsexual that severe psychiatric comorbidity and lack of support may interfere with good outcome 30 — For adolescents, the diagnostic procedure usually includes a complete psychodiagnostic assessment 34 and, preferably, a child psychiatric evaluation by a clinician other than the diagnostician.

Di Ceglie et al. During the RLE, the person should fully experience life in the desired gender role before irreversible physical treatment is undertaken. Living 12 months full-time in the desired gender role is recommended Applicants increasingly start the RLE long before they are referred for hormone treatment. The WPATH SOC document requires that both adolescents and adults applying for hormone treatment and surgery satisfy two sets of criteria—eligibility and readiness—before proceeding Endocrine society guidelines for transsexual There are eligibility and readiness criteria for hormone therapy for adults Table 4 and eligibility criteria for adolescents Table 5.

Eligibility and readiness criteria for sex reassignment Endocrine society guidelines for transsexual in adults and adolescents are the same see Section 5. Although the eligibility criteria have not been evaluated in formal studies, a few follow-up studies on adolescents who fulfilled these criteria and had started cross-sex hormone treatment from the age of 16 indicate good Endocrine society guidelines for transsexual results 36 — Readiness criteria for adolescents eligible for cross-sex hormone treatment are the same as those for adults.

However, this study was performed among a group of individuals with a relatively high socioeconomic background For children and adolescents, the MHP must also have training in child and adolescent developmental psychopathology. GID may be accompanied with psychological or psychiatric problems see Refs. It is therefore necessary that the clinician making the GID diagnosis be able to make a distinction between GID and conditions that have similar features, to accurately diagnose psychiatric conditions, and to ensure that any such conditions are treated appropriately.

One condition with similar features is body dysmorphic disorder or Skoptic syndrome, a condition in which a person is preoccupied with or engages in genital self-mutilation, such as castration, penectomy, or clitoridectomy The Task Force placed a very high value on avoiding harm from hormone treatment to individuals who have conditions other than GID and who may not be ready for the physical changes associated with this treatment, and it placed a low value on any potential benefit these persons believe they may derive from hormone treatment.

This justifies the strong recommendation in the face of low-quality evidence. Given the high rate of remission of GID after the onset of puberty, we recommend against a complete social role change and hormone treatment in prepubertal children with GID. The percentages differ between studies, probably Endocrine society guidelines for transsexual upon which version of the DSM was used in childhood, ages of children, and perhaps culture factors.

Clinical experience suggests that GID can be reliably assessed only after the first signs of puberty. This recommendation, however, does not imply that children should be entirely denied to show cross-gender behaviors or should be punished for exhibiting such behaviors.

This recommendation places a high value on avoiding harm with hormone therapy in prepubertal children who may have GID that will remit after the onset of puberty and places a relatively lower value on foregoing the potential benefits of early physical sex change induced by hormone therapy in prepubertal children with GID.

This justifies the strong recommendation in the face of very low quality evidence. We recommend that physicians evaluate and ensure that applicants understand the reversible and irreversible effects of hormone suppression e.

GnRH analog treatment and of cross-sex hormone treatment before they start hormone treatment. In all treatment protocols, compliance and outcome are enhanced by clear expectations concerning the effects of the treatment.

Rekindling an old flame? Objective: To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the. a new guideline from the Endocrine Society suggests that there are compelling reasons to consider treating transgender adolescents even..

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The aim was to formulate practice guidelines for endocrine treatment of transsexual persons. This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation GRADE system to describe the strength of recommendations and the quality of evidence, which was low or very low. A mental health professional MHP must recommend endocrine treatment and participate in ongoing care throughout the endocrine transition and decision for surgical sex reassignment.

The endocrinologist must confirm the diagnostic criteria the MHP used to make these recommendations. Because a diagnosis of transsexualism in a prepubertal child cannot be made with certainty, we do not recommend endocrine treatment of prepubertal children.

We recommend treating transsexual adolescents Tanner stage 2 by suppressing puberty with GnRH analogues until age 16 years old, after which cross-sex hormones may be given. We suggest suppressing endogenous sex hormones, maintaining physiologic levels of gender-appropriate sex hormones and monitoring for known risks in adult transsexual persons.

FIND FRIENDS OVERSEAS Further insight into the characteristics of persons who Endocrine society guidelines for transsexual their decision postoperatively would facilitate better future selection of applicants eligible for sexual reassignment surgery. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. IM, intramuscularly; SC, subcutaneously. Does the prostate really need androgens to grow? This increase may have been associated with the use Endocrine society guidelines for transsexual the synthetic estrogen, ethinyl estradiol Unlike the developmental problems observed with delayed puberty, this protocol requires a MHP skilled in child and adolescent psychology to evaluate the response of the adolescent with GID after pubertal suppression. Endocrine society guidelines for transsexual 870 Endocrine society guidelines for transsexual Mayan sexual relief carvings
  • The participants include an Endocrine Society—appointed task force of nine experts, a methodologist, and a medical writer.
  • The Clinical Guidelines Subcommittee (CGS) of the Endocrine Society deemed the diagnosis and treatment and basic principles of the treatment of transgender persons. The Clinical Guidelines Subcommittee of The Endocrine Society deemed the diagnosis.

To update the "Endocrine Treatment of Transsexual Persons: The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical pen-pusher.

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Increase, and Evaluation approach to describe the strength of recommendations and the importance of evidence. The duty force commissioned two regular reviews and used the best available evidence from other published systematic reviews and individual studies. Assembly meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, divisions and cosponsoring organizations reviewed and commented on prodromic drafts of the guidelines.

Gender affirmation is multidisciplinary treatment in which endocrinologists play an important job. Those clinicians who underwrite gender-affirming endocrine treatments-appropriately trained diagnosing clinicians required Excellent, a mental health provider for adolescents required and mental health professional representing adults recommended -should be knowledgeable about the diagnostic criteria and criteria by reason of gender-affirming treatment, have adequate training and experience in assessing psychopathology, and be willing to participate in the ongoing care everyplace the endocrine transition.

Highest adolescents have this gift by age 16 years old. We recognize that there may be compelling reasons to initiate making love hormone treatment prior to age 16 years, although there is minimal published experience treating prior to For the safe keeping of peripubertal youths and older adolescents, we plug that an expert multidisciplinary team comprised of medical professionals and mental condition professionals manage this treatment.

The treating physician necessity confirm the criteria destined for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents.

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