Mental health assessment required for youths seeking gender-affirming care

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Photo by cottonbro / Pexels
Photo by cottonbro / Pexels

Under the World Professional Association for Transgender Health's (WPATH) newly released standard of care (SOC), Transgender and gender-nonconforming youth will be required to undergo a mental health assessment prior to receiving any form of gender-affirming care.

WPATH, which "promotes the highest standards of health care for Transsexual, Transgender, and gender-nonconforming people," released its seventh version of the SOC 20 years after the last. (The next one is expected this spring.) The new version is a 120-page document produced for healthcare professionals and based off the best available science, according to WPATH. The information is derived from Western European and North American sources.

"The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender-nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment," stated the document.

According to WPATH, the new SOC is not intended to limit the best available healthcare for all people, but rather for healthcare professionals to utilize to assist patients with understanding the full range of health services available to them.

Care of children and adolescents
The seventh version incorporates a section regarding Transgender and gender-nonconforming children and adolescents.

"In children and adolescents, a rapid and dramatic developmental process (physical, psychological, and sexual) is involved and there is greater fluidity in outcomes, particularly in prepubertal children," states the report.

WPATH acknowledges gender dysphoria in children and adolescents, and brings up how it does not always continue into adulthood. The rates of gender dysphoria are much higher in adolescents in comparison to children, according to the report.

The SOC mentions how children as young as age 2 may exhibit features that indicate gender dysphoria, such as being unhappy about physical and sexual characteristics and functions, and wishing to be the opposite sex, including preferring clothing, toys, and games that are commonly associated with the opposite gender.

"Many, but not all, gender dysphoric adolescents have a strong wish for hormones and surgery. Increasing numbers of adolescents have already started living in their desired gender role upon entering high school," according to the SOC document.

"It is relatively common for gender dysphoric children to have coexisting internalizing disorders such as anxiety and depression," the report added. The SOC also mentions that autism-spectrum disorder rates are greater in clinically referred children with gender dysphoria.

What the report fails to mention is whether these disorders are a result of the condition, or if they existed prior.

Psychological assessment of children and adolescents
In the section of the new SOC dealing with children and adolescents, there is a portion on psychological assessments that differs from the adult care section.

According to the document, while healthcare professionals should not be dismissive of nonconforming gender identities or gender dysphoria, "a psychodiagnostic and psychiatric assessment — covering the areas of emotional functioning, peer and other social relationships, and intellectual functioning/school achievement — should be performed," reads the SOC. "Assessment should include an evaluation of the strengths and weaknesses of family functioning. Emotional and behavioral problems are relatively common, and unresolved issues in a child's or youth's environment may be present."

For adolescents, the assessment should be utilized to inform youth and their families about the various forms of treatment, including the limitations of treatment.

"Correct information may alter a youth's desire for certain treatment, if the desire was based on unrealistic expectations of its possibilities," says the SOC.

Transgender and gender-nonconforming adults, on the other hand, do not require any sort of psychological assessment prior to receiving gender-affirming care. According to the report, healthcare professionals should screen adult patients for coexisting disorders, such as anxiety and depression, and discuss treatment options.

Physical interventions for adolescents
"Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken," says the SOC. "The duration of this exploration may vary considerably depending on the complexity of the situation."

Per the SOC, physical interventions for adolescents fall into three categories: fully reversible interventions, partially reversible interventions, and irreversible interventions. Fully reversible interventions include but are not limited to the use of GnRH analogs to suppress testosterone or estrogen production in order to delay physical changes associated with puberty.

"Adolescents may be eligible for puberty-suppressing hormones as soon as pubertal changes have begun," reads the SOC.

The document lists criteria for those wishing to undergo puberty-suppressing hormones. Adolescents must have demonstrated a "long-lasting and intense pattern" of gender nonconformity or gender dysphoria; the latter must have appeared or worsened with the onset of puberty; any coexisting psychological, medical, or social issues that may interfere with treatment must have been addressed; and the adolescent must give informed consent — if they are too young to be able to medically consent (generally 18 years of age), then parents or guardians must consent to treatment.

Partially reversible interventions include hormone therapy to feminize or masculinize the body, and irreversible interventions consist of surgical procedures.

According to the SOC, genital surgery should not be carried out until the patient reaches the legal age of consent for medical procedures, in addition to the patient living in the gender role that's congruent to their gender identity for one year.

However, the document also states, "Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization... withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents."

Analysis: Additional barriers and stigma for Trans and gender-nonconforming youth
A 2019 research study conducted by the University of Washington, among others, titled "Similarity in Transgender and Cisgender Children's Gender Development," found that "Transgender children showed a clear pattern of gender development associated with their current gender and not their sex assigned at birth." In short, gender-nonconforming and Transgender children are in touch with their gender identities prior to reaching adulthood.

WPATH's new psychological assessment requirement for children and adolescents has the potential to do more harm than good. Over the past few years, receiving assistance for mental health has become more accepted, although some still hold the belief that those with mental health disorders are "violent," "crazy," or "dangerous." In turn, that increases the stigma of criminality for those with mental health disorders.

The new psychological assessment requirement merely feeds into that stigma. Furthermore, it implies that Transgender and gender-nonconforming youth have mental health disorders that may alter their view toward their gender identities. In turn, this can prevent youth from accessing gender-affirming care.

Additionally, it is important to note that coexisting mental health disorders, such as anxiety and depression, are not uncommon among Transgender youth due to stigma, discrimination, and a lack of acceptance. In the psychological assessment portion, the SOC neglected to address mental health disorders being a direct result of hardships that Transgender and gender-nonconforming youth experience during their most formative years.

To check out WPATH's new standard of care document, visit