Last updated March 18, 2022

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons

Diagnosis

Evaluation of Youth and Adults

Endocrine Society (ES) advises that only trained mental health professionals (MHPs) who meet the following criteria should diagnose GD/GI in adults: ( UGPS )
  1. Competence in using the Diagnostic and Statistical Manual of Mental Disorders (DSM) and/or the International Statistical Classification of Diseases and Related Health Problems (ICD) for diagnostic purposes
  2. The ability to diagnose GD/GI and make a distinction between GD/GI and conditions that have similar features (e.g., body dysmorphic disorder)
  3. Training in diagnosing psychiatric conditions
  4. The ability to undertake or refer for appropriate treatment
  5. The ability to psychosocially assess the person’s understanding, mental health, and social conditions that can impact gender-affirming hormone therapy, and
  6. A practice of regularly attending relevant professional meetings
699
ES advises that only MHPs who meet the following criteria should diagnose GD/GI in children and adolescents: (UGPS)
  1. Training in child and adolescent developmental psychology and psychopathology
  2. Competence in using the DSM and/or the ICD for diagnostic purposes
  3. The ability to make a distinction between GD/GI and conditions that have similar features (e.g., body dysmorphic disorder)
  4. Training in diagnosing psychiatric conditions
  5. The ability to undertake or refer for appropriate treatment
  6. The ability to psychosocially assess the person’s understanding and social conditions that can impact gender-affirming hormone therapy
  7. A practice of regularly attending relevant professional meetings, and
  8. Knowledge of the criteria for puberty-blocking and gender-affirming hormone treatment in adolescents.
699
ES advises that decisions regarding the social transition of prepubertal youths with GD/GI are made with the assistance of an MHP or another experienced professional. ( UGPS )
699
ES recommends against puberty-blocking and gender-affirming hormone treatment in prepubertal children with GD/GI. ( 1-L )
699
ES recommends that clinicians inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults. ( 1-M )
699

Treatment

Treatment of Adolescents

ES suggests that adolescents who meet diagnostic criteria for GD/GI, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development. (2-L)
699
ES suggests that clinicians begin pubertal hormone suppression after girls and boys first exhibit physical changes of puberty (Tanner stages G2/B2). (2-L)
699
ES recommends that, where indicated, GnRH analogues are used to suppress pubertal hormones. (1-L)
699
In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), ES recommends initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/GI and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years. ( 1-L )
699
We recognize that there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/GI, even though there are minimal published studies of gender-affirming hormone treatments administered before age 13.5–14 years. As with the care of adolescents ≥16 years of age, ES recommends that an expert multidisciplinary team of medical practitioners and MHPs manage this treatment ( 1-VL )
699
ES suggests monitoring clinical pubertal development every 3–6 months and laboratory parameters every 6–12 months during sex hormone treatment. ( 2-L )
699

Hormonal Therapy for Transgender Adults

ES recommends that clinicians confirm the diagnostic criteria of GD/GI and the criteria for the endocrine phase of gender transition before beginning treatment. (1-M)
699
ES recommends that clinicians evaluate and address medical conditions that can be exacerbated by hormone depletion and treatment with sex hormones of the affirmed gender before beginning treatment. ( 1-M )
699
ES suggests that clinicians measure hormone levels during treatment to ensure that endogenous sex steroids are suppressed and administered sex steroids are maintained in the normal physiologic range for the affirmed gender. ( 2-L )
699
ES suggests that endocrinologists provide education to transgender individuals undergoing treatment about the onset and time course of physical changes induced by sex hormone treatment. ( 2-VL )
699

Adverse Outcome Prevention and Long-Term Care

ES suggests regular clinical evaluation for physical changes and potential adverse changes in response to sex steroid hormones and laboratory monitoring of sex steroid hormone levels every 3 months during the first year of hormone therapy for transgender males and females and then once or twice yearly. ( 2-L )
699
ES suggests periodically monitoring prolactin levels in transgender females treated with estrogens. ( 2-L )
699
ES suggests that clinicians evaluate transgender persons treated with hormones for cardiovascular risk factors using fasting lipid profiles, diabetes screening, and/or other diagnostic tools. ( 2-L )
699
ES recommends that clinicians obtain bone mineral density (BMD) measurements when risk factors for osteoporosis exist, specifically in those who stop sex hormone therapy after gonadectomy. ( 1-L )
699
ES suggests that transgender females with no known increased risk of breast cancer follow breast-screening guidelines recommended for non-transgender females. ( 2-L )
699
ES suggests that transgender females treated with estrogens follow individualized screening according to personal risk for prostatic disease and prostate cancer. (2-VL)
699
ES advises that clinicians determine the medical necessity of including a total hysterectomy and oophorectomy as part of gender-affirming surgery. ( UGPS )
699

Surgery for Sex Reassignment and Gender Confirmation

ES recommends that a patient pursue genital gender-affirming surgery only after the MHP and the clinician responsible for endocrine transition therapy both agree that surgery is medically necessary and would benefit the patient’s overall health and/or well-being. ( 1-L )
699
ES advises that clinicians approve genital gender-affirming surgery only after completion of ≥1 year of consistent and compliant hormone treatment, unless hormone therapy is not desired or medically contraindicated. ( UGPS )
699
ES advises that the clinician responsible for endocrine treatment and the primary care provider ensure appropriate medical clearance of transgender individuals for genital gender-affirming surgery and collaborate with the surgeon regarding hormone use during and after surgery. ( UGPS )
699
ES recommends that clinicians refer hormone-treated transgender individuals for genital surgery when:
  1. The individual has had a satisfactory social role change
  2. The individual is satisfied about the hormonal effects, and
  3. The individual desires definitive surgical changes.
( 1-VL )
699
ES suggests that clinicians delay gender-affirming genital surgery involving gonadectomy and/or hysterectomy until the patient is ≥18 years old or legal age of majority in his or her country. ( 2-L )
699
ES suggests that clinicians determine the timing of breast surgery for transgender males based upon the physical and mental health status of the individual. There is insufficient evidence to recommend a specific age requirement. (2-VL)
699

Recommendation Grading

Overview

Title

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons

Authoring Organization

Publication Month/Year

September 13, 2017

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult

Health Care Settings

Ambulatory

Scope

Diagnosis, Management

Diseases/Conditions (MeSH)

D000068116 - Gender Dysphoria, D005783 - Gender Identity, D019968 - Sexual and Gender Disorders

Keywords

gender-dysphoric, gender-incongruent, transsexual, gender identity disorder, transgender

Source Citation

Wylie C Hembree, Peggy T Cohen-Kettenis, Louis Gooren, Sabine E Hannema, Walter J Meyer, M Hassan Murad, Stephen M Rosenthal, Joshua D Safer, Vin Tangpricha, Guy G T’Sjoen, Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658