What is gender affirming care for transgender or non-binary individuals?

What is Gender Affirming Care

Gender-affirming care is a comprehensive, multidisciplinary approach that includes psychosocial support, hormone therapy (estrogen or testosterone), and surgical interventions (such as chest masculinization, breast augmentation, vaginoplasty, or phalloplasty) aimed at aligning an individual's physical characteristics with their gender identity rather than their sex assigned at birth. 1

Core Components of Gender-Affirming Care

Medical Interventions

Hormone Therapy:

• Feminizing therapy uses estradiol (oral, transdermal, or injectable) combined with anti-androgen medications to suppress testosterone, targeting estradiol levels within the cisgender female reference range 2
• Physical changes include breast development, decreased lean body mass (5% decrease in thigh muscle volume), skin softening, decreased body/facial hair, and significant decreases in hemoglobin levels 2
• Masculinizing therapy involves intramuscular or subcutaneous testosterone cypionate or enanthate, maintaining trough testosterone levels between 300-1,000 ng/dL in the mid-normal range 2
• Hemoglobin increases to the male reference range within 3 months of starting testosterone therapy 2, 3

Surgical Interventions:

• Gender-affirming surgeries include chest masculinization or breast augmentation, vaginoplasty, vulvoplasty, phalloplasty, metoidioplasty, and gonadectomy 1
• Surgery should only be performed after confirmation of persistent gender dysphoria by the multidisciplinary team and demonstration of informed consent capacity 2

Multidisciplinary Team Requirements

The treatment approach must involve specialized professionals including: 2

• An endocrinologist for hormone management
• A mental health professional (psychologist/psychiatrist) for assessment and ongoing support
• A surgeon experienced in gender-affirming procedures when surgical intervention is considered
• Social work and nursing support when available

Terminology and Language

Preferred terminology is "gender affirmation" or "gender-affirming care" rather than outdated terms like "gender reassignment" 1, 4

Key definitions: 1

• Gender is a spectrum of identities incorporating behavioral, psychological, social, and cultural traits critical to an individual's identity as a man, woman, or nonbinary person
• Sex refers to biologic and anatomic features that define assignment to male, female, or intersex at birth
• Transgender women (trans women) are individuals assigned male at birth who identify and live as women 1, 4
• Transgender men (trans men) are individuals assigned female at birth who identify and live as men 1, 4
• Gender diverse/nonbinary describes people with gender identities different from social and cultural expectations attributed to their sex assigned at birth 1

Using correct pronouns (she/her for trans women, he/him for trans men, they/them for nonbinary individuals) is a powerful tool for healthcare professionals to demonstrate inclusivity and provide better healthcare 2, 4

Clinical Context and Outcomes

Gender dysphoria describes psychological distress from the incongruence between biological sex and gender identity—not all transgender individuals experience dysphoria 1, 2

Evidence for mental health benefits: 5, 6

• Gender-affirming medical care during adolescence is negatively associated with severe psychological distress in adulthood
• Studies demonstrate clearly beneficial—even lifesaving—mental health impact of gender-affirming medical care in transgender and gender diverse youth

Population scope: Over 2 million individuals in the United States openly identify with a gender that differs from their sex assigned at birth, and this number is increasing 1

Critical Clinical Considerations

Documentation requirements: 3

• Confirm sex assigned at birth and current gender identity using a two-step question approach in a private setting
• Document all gender-affirming surgeries performed, including chest procedures, genital surgeries, and facial/neck procedures
• Record current hormone therapy regimen, dosage, duration, and route of administration
• Ask about fertility preservation and presence/absence of reproductive organs

Common barriers to care include finances and insurance issues, lack of service availability, fears or worries, systemic bias within medical and mental health fields, and lack of medical provider awareness and education 7