Below I describe what the medical establishments requirements are generally speaking. These requirements can and do change depending on the particular situation.

Before undertaking gender affirming surgery, medical and psychological evaluations, medical therapies and behavioral trials are undertaken to help ensure that surgery is an appropriate treatment choice for the individual.

Clients seeking surgery have to meet the following:

A.     The individual is at least 18 years of age; and

B.     The individual has capacity to make fully informed decisions and consent for treatment; and

C.    The individual has been diagnosed with gender dysphoria; and

D.    For individuals without a medical contraindication or intolerance, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and

E.     Documentation** that the individual has completed a minimum of 12 months of successful continuous full time real-life experience in the new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season-specific work or school experiences). This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings); and

F.     Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and

G.    If the individual has significant medical or mental health issues present, they must be reasonably well controlled. If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and

H.    Two referrals from qualified mental health professionals* who have independently assessed the individual. If the first referral is from the individual’s psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required. The letter(s) must have been signed within 12 months of the request submission.

*At least one of the professionals submitting a letter must have a doctoral degree (for example, Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) or a master’s level degree in a clinical behavioral science field (for example, M.S.W., L.C.S.W., Nurse Practitioner [N.P.], Advanced Practice Nurse [A.P.R.N.], Licensed Professional Counselor [L.P.C.], and Marriage and Family Therapist [M.F.T.]) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the specifications set forth above.

**The medical documentation should include the start date of living full time in the new gender. Verification via communication with individuals who have related to the individual in an identity-congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases.

Affirmed gender: When one's gender identity is validated by others as authentic

Agender: Person who identifies as genderless or outside the gender continuum

Cisgender:  persons are those whose gender identity and expression are aligned with the cultural and social expectations of the gender they were assigned at birth. The majority of persons are cisgender. 

Cross dressing: Wearing of clothes typically associated with another gender; the term transvestite can be considered pejorative and should not be used

Cultural humility: Concept of not projecting one's own personal experiences and preconceptions of identity onto the experiences and identities of others

Differences of sex development: Congenital conditions characterized by nuanced chromosomal, gonadal, or anatomic sex development (e.g., congenital adrenal hyperplasia, androgen insensitivity syndrome, Turner syndrome); not a universally accepted term; also called disorders of sex development or intersex

Gender: Societal perception of maleness or femaleness

Gender Affirming Therapy (GAT): the process of counseling a person who experiences persistent incongruence between gender identity and sexual anatomy at birth. Gender affirming psychotherapy is part of a complex process involving multiple medical, psychiatric and psychologic, and surgical specialists working in conjunction with each other and the individual to achieve successful behavioral and medical outcomes. Before undertaking gender affirming surgery, medical and psychological evaluations, medical therapies and behavioral trials are undertaken to help ensure that surgery is an appropriate treatment choice for the individual.

Gender diverse : General term describing gender behaviors, expressions, or identities that are not congruent with those culturally assigned at birth; may include transgender, nonbinary, genderqueer, gender fluid, or non-cisgender identities and may be more dynamic and less stigmatizing than prior terminology (e.g., gender nonconforming).

Gender dysphoria: Distress or impairment resulting from incongruence between one's experienced or expressed gender and sex assigned at birth; DSM-5 criteria for adults include at least six months of distress or problems functioning due to at least two of the following:

Marked incongruence between one's experienced or expressed gender and primary and/or secondary sex characteristics

Strong desire to be rid of one's primary and/or secondary sex characteristics

Strong desire for the primary and/or secondary sex characteristics of the other gender

Strong desire to be of the other gender

Strong desire to be treated as the other gender

Strong conviction that one has the typical feelings and reactions of the other gender

Gender expression: External display of gender identity through appearance (e.g., clothing, hairstyle), behavior, voice, or interests Gender identity refers to the subjective sense of who one is as far as male, female or other. Gender identity is determined more by the brain than by sexual anatomy. It is not something that any of us choose. Most people have a sense of their gender identity by age 4, although this sometimes happens earlier and sometimes later in life.

Gender incongruence: General term describing a difference between gender identity and/or expression and designated sex; an ICD-11 diagnosis that does not require a mental health diagnosis

Gender-nonconforming persons are those whose gender identity or expression are inconsistent with societal expectations typically associated with males and females. Some gender-nonconforming persons do not fit into the gender binary (male or female) as others do and may consider themselves to be gender fluid, gender queer or gender nonbinary. Transgender persons (about 0.6 percent or more of the U.S. population) have a strong inner sense that their bodies and the gender assigned to them at birth are incongruent with their gender identity. They may be assigned-at-birth males who identify as female (male to female or MTF) or assigned-at-birth females who identify as male (female to male or FTM).

Genderqueer : Umbrella term for a broad range of identities along or outside the gender continuum; also called gender nonbinary

Sex: Maleness or femaleness as it relates to sex chromosomes, gonads, genitalia, secondary sex characteristics, and relative levels of sex hormones; these biologic determinants may not necessarily be consistent; sex assigned at birth is typically based on genital anatomy

Sexual orientation: Term describing an enduring physical and emotional attraction to another group; sexual orientation is distinct from gender identity and is defined by the individual

They/them: Neutral pronouns preferred by some transgender persons

Transgender* : General term used to describe persons whose gender identity or expression differs from their sex assigned at birth

Transgender female : A transgender person designated as male at birth

Transgender male : A transgender person designated as female at birth

Transfeminine: Nonbinary term used to describe a feminine spectrum of gender identity

Transmasculine: Nonbinary term used to describe a masculine spectrum of gender identity

Transphobia: Prejudicial attitudes about persons who are not cisgender

Transsexual : Historical term for transgender persons seeking medical or surgial therapy to affirm their gender

Information from:

Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4):e20182162.

Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(9):957–974.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.

American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015;70(9):832–864.

Coleman E, Bockting W, Botzer M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13(4):165–232.

de Vries AL, Klink D, Cohen-Kettenis PT. What the primary care pediatrician needs to know about gender incongruence and gender dysphoria in children and adolescents. Pediatr Clin North Am. 2016;63(6):1121–1135.

Deutsch MB. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. 2nd ed. June 17, 2016. http://transhealth.ucsf.edu/protocols. Accessed July 5, 2018.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline [published correction appears in J Clin Endocrinol Metab. 2018;103(2):699]. J Clin Endocrinol Metab. 2017;102(11):3869–3903.

Lee PA, Nordenström A, Houk CP, et al.; Global DSD Update Consortium. Global disorders of sex development update since 2006: perceptions, approach and care [published correction appears in Horm Res Paediatr. 2016;85(3):180]. Horm Res Paediatr. 2016;85(3):158–180.

Levine DA; Committee on Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):e297–e313.

Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations [published correction appears in World Psychiatry. 2017;16(2):220]. World Psychiatry. 2016;15(3):205–221.

Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet. 2016;388(10042):390–400.Description text goes here

41% transgender persons attempt suicide, compared with less than 2% of the general population.

57% have experienced rejection by their families

53$ have been verbally harassed in public settings

97$ have been harassed or discriminated against in work settings

28% have experienced harassment in medical settings

27% have been refused medical care in the past

78% who completed their transition felt more comfortable at work and improved their job performance, despite mistreatment at work.

Statistics from the 2011 National Transgender Discrimination Study of 6,456 transgender and gender-nonconforming adults:

Achieving Optimal Gender Identity Integration For Transgender Female-to-Male Adult Patients: An Unconventional Psychoanalytic Guide For Treatment (2008), Karisa Barrow.

Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children (2011), Diane Ehrensaft.

Report of the APA Task Force on Gender Identity and Gender Variance.

The Transgender Child: A Handbook for Families and Professionals (2008), Stephanie Brill & Rachel Pepper.

WPATH - the World Professional Association for Transgender Health Standards of Care (currently SOC-7) provides state-of-the-art guidelines for the care of transgender adults and children.

You and your gender identity