We had a very informative Grand Rounds lecture today by Dr. Dan Karasic, clinical professor of Psychiatry at UCSF. Our OB/GYN dept has provided OB care, hormone therapy, and surgeries for transgender patients, so I was eager to learn the newest Standard of Care (SOC) 7 recs. Here are some interesting bullet points from Dr. Karasic's presentstion:
  1. Transgender surgeries are now covered for San Francisco residents on Medi-Cal or without insurance.
  2. The requirement for 12 weeks of psychotherapy or 12 weeks of living in role of "opposite sex" before starting hormone therapy is being eliminated.
  3. Persistent gender dysphoria and the ability to give informed consent is enough to start hormonal treatment.
  4. Concurrent treatment of gender dysphoria with co-occurring mental illness is often necessary.
  5. Hormonal therapy is safe and effective for gender dysphoria in patients with severe mental illness.
    However, mood symptoms can occur. Bipolar patients should be followed closely after initiation testosterone to watch for hypomania/mania, though it's uncommon. Risks and benefits of treatment must be weighed: mental health improvement with relief of gender dysphoria vs harm from with holding care.
  6. Reduced mental health symptoms overall has been seen in transgender men undergoing testosterone treatment.
  7. Mental health assessments and letters for surgery aid in patient education and preparation for surgery.
  8. SOC 7 requires one mental health assessment for chest surgery and two for genital surgery.
    These assessments should be done by two licensed, knowledgable mental health professionals.
  9. SOC 7 criteria for surgery: 1) Persistent, well documented gender dysphoria, 2) Capacity for informed consent, 3) Well-controlled significant medical or mental health issues
  10. Per SOC 7, Social Transition is not a requirement for hormones, chest/breast surgery, hysterectomy (removing the uterus), salpingo-oophorectomy (removing the Fallopian tubes and ovaries, or orchiectomy (removing the testicles.
    However, for vaginoplasty or phalloplasty, the patient should undergo 12 months of living in a gender role congruent with gender identity.
  11. Hormone therapy is not a prerequisite for chest surgery in transgender men.
  12. Hormone therapy for 12 months is recommended for breast augmentation surgery in trans women for a better outcome.
  13. For genital surgery, 12 continuous months of hormone therapy is recommended.
  14. Some transgender patients will want to have genetically related children. Hormonal or surgical therapy limits this fertility option, which could lead to regret.
  15. Many more people identify as transgender than have had medical and surgical interventions.
  16. Resources: WPATH (World Professional Association for Transgender Health) www.wpath.org www.lgbthealtheducation.org
  17. Extra reading: "We Must Put an End to Gender Conversion Therapy for Kids" by Dr. Dan Karasic and Dr. Diane Ehrensaft
  18. Hope you learned something new, too!