Standards of Care for Hormone Therapy and Surgery

For transgender, non-binary and gender expansive individuals seeking plastic surgery to alter their physical appearance, it is important to determine what procedures are available and when is the most beneficial time to undergo plastic surgery within the framework of making a successful gender transition.

A good place to start is to review the World Professional Association for Transgender Health (WPATH) Standards of Care (SOC), Version VII. This edition is freely available for viewing online as a PDF. The WPATH SOC guidelines are an important reference for both individuals who desire gender transition, as well as for anyone concerned with the diagnosis and treatment of transgender individuals. Following these internationally recognized guidelines for treatment will make gaining approval for medical treatment easier for both public and private insurance companies.

Clinical research and social science studies have advanced the understanding of gender identity and expression, and there have been many positive changes regarding social acceptance and access to treatment. An important change in the 7th Version of the SOC was redefining Gender Identity Disorder (GID) as Gender Dysphoria. Whatever the terminology, the intention of the Standards of Care is to recommend standards of diagnosis, care, and treatment to help individuals achieve quality of life and satisfaction in their preferred gender identity. The SOC allows for variations in treatment to suit the many varieties and degrees of Gender Dysphoria.

Recommendations differ for hormone therapy. For FTM/N top surgery, hormone therapy is not a pre-requisite. Some FTM/N patients will undergo hormone therapy to alter voice, skin and hair patterns before choosing top surgery, while others are satisfied with top surgery alone.

And while not an explicit criterion, it is recommended that MTF/N patients access feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery in order to maximize breast growth to obtain better surgical (aesthetic) results.

Three Stages of Therapy

The care and management of a person transitioning their gender generally consists of therapy in three parts, following a diagnosis of Gender Dysphoria:

  1. psychological examination and counseling
  2. medical intervention with hormones and/or plastic surgery
  3. a period of monitored social integration living in the desired gender

Both the mental and physical health establishment recognize that Gender Dysphoria presents in many ways so there are no fixed criteria for the order in which therapy is undertaken. Everyone, depending on age, social circumstances, emotional status, and–most importantly—degree of dissatisfaction with their current gender, is advised to follow a course of therapy tailored specifically for their situation.

In some cases, an individual may already be living in their true and desired gender identity before seeking counseling and/or hormone therapy, with plastic surgery as a goal in transition. In others, acute dissatisfaction with the gender they were designated at birth triggers emotional or mental problems which result in a diagnosis of Gender Dysphoria and a prescribed course of hormone treatments and social reassignment and review before undergoing physical alterations. Most transgender and gender non-conforming individuals fall somewhere in the middle. One common characteristic is the desire to look, feel, and be accepted by others in the gender they feel is truly their own.

Knowing You’re Ready for Plastic Surgery

Whether seeking a transmasculine, transfeminine or neutrois surgery, the crucial question is, “Are you prepared physically, mentally, emotionally and socially to make this change to your body?” Superficial outward cosmetic and wardrobe changes may bring some degree of comfort; hormone therapy may effect internal and external alternations that add to that comfort level, but hormones can be discontinued and outward appearance reversed if feelings or circumstances change. This sort of plastic surgery is, practically speaking, irreversible, so a cautious 3-stage approach is the logical choice of treatment.

You may be able to answer this question without counseling, hormone treatments, or living in your desired gender. Or, more commonly, you may be ready to make the decision only after exploring your motives with the help of counseling. You may also need to experience living in your desired gender before committing to a permanent bodily change. Alternatively, you may find that counseling and/or hormone therapy plus living in your desired gender gives you a sufficient level of satisfaction without plastic surgery.

Because Gender Dysphoria is often accompanied by emotional distress, it is recommended that counseling be sought before embarking on hormone therapy or plastic surgery. Medical criteria require documentation and recommendations before prescribing hormones or performing plastic surgery as a safeguard for the patient.