Procedures

The WPATH standards of care for trans individuals, in their latest version, propose criteria to be considered for performing surgeries that transgender patients undergo. It is important to emphasize that these “standards” are flexible and aim to promote excellent healthcare for our patients, allowing private practice professionals to adjust them as necessary, always documented through informed consent to ensure quality care.

However, in Spain, Law 4/2023, of February 28, prioritizes gender self-determination, eliminating requirements such as medical or psychological diagnoses or mandatory periods of real-life experience or hormonal therapy to access transition-related treatments.

IM GENDER

What are the procedures?

In the case of gender-affirming surgery, the following criteria were previously applied based on WPATH recommendations:

Well-documented transsexuality.
Ability to make a decision and provide fully informed consent for treatment.
Age of majority in the country.
If medical or psychological problems are present, they should be under reasonable control.
12 months of continuous hormone therapy appropriate to the patient’s gender goal (unless the patient has medical contraindications or is unable or unwilling to take hormones).
12 continuous months of real-life experience in a gender role that is congruent with their gender identity.

With Law 4/2023, these requirements have been eliminated in Spain, leaving informed consent as the sole requirement for surgery, respecting the individual’s gender self-determination.

The WPATH recommendations, such as those related to hormone therapy, social transition, and psychological counseling, may still be considered useful for those who wish to follow them but are not mandatory under the current legislation.

How does hormone therapy affect the body?

h HORMONE THERAPY IN TRANSGENDER WOMEN

During hormone treatment, the trans woman will experience the following changes:

Breast growth
Smoother skin
Decreased body hair
Fat redistribution (giving a feminine contour)
Delay or interruption of the hair loss process
Decreased strength
Reduced fertility
Reduced testicle size
Less firm and frequent erections

WPATH recommends that individuals receive hormone therapy for 12 consecutive months before undergoing gender-affirming surgery (unless there are medical contraindications, or the individual cannot or does not wish to take hormones).

It is important to note that after gender-affirming surgery, ongoing hormone therapy is often necessary, albeit at lower doses.

The treatment must be supervised by a specialist to ensure safety and prevent adverse effects, such as liver problems or osteoporosis.

HORMONE THERAPY IN TRANSGENDER MEN

Hormone therapy in transgender men typically leads to the following changes:

A deeper voice.
Increased upper body strength.
Weight gain.
Decrease in adipose tissue around the hips (reduced fat in this area).
Increased facial and body hair.
Male-pattern baldness.
Mild breast atrophy.
Permanent clitoral enlargement.
Increased sexual desire.
Greater capacity for arousal.

The maximum effects of hormone therapy may not manifest until one or two years after starting treatment. The response to this treatment depends on the individual’s genetic makeup.

Hormone blockers for minors

To alleviate the distress that many transgender children may experience when their bodies develop contrary to their gender identity, pharmacological treatment may be recommended. This involves hormone blockers or puberty suppressors, such as GnRH analogs, to inhibit the production of estrogen or testosterone.

This treatment is entirely reversible, as the hormonal development resumes once the treatment is stopped. Its purpose is to provide minors with time to decide on their gender identity without irreversible physical changes. According to Law 4/2023, access to these treatments requires the informed consent of legal guardians and a medical evaluation.

PSYCHOLOGICAL ANALYSIS

Transsexuality is by no means a psychological or psychiatric disorder. However, psychological support can be beneficial to accompany transgender individuals through the so-called transition process.

There is no mandatory timeline for this transition process, and each trans person should decide how and when to carry it out, at what pace, and which changes to make.

Usually, the process begins when the trans individual feels ready to take the step. Although there is no “correct” way or “adequate protocol” to undergo this process, most experience some common social changes, which may include adopting a different style of dress, hairstyle, expression, or presentation, modifying their name and sex on identification documents, undergoing hormone therapy, or having surgical procedures.

THE PROCESS

While our society is becoming increasingly aware of trans identities, transitioning can pose challenges, particularly in academic, professional, familial, or social settings. Having familial or social support is crucial for anyone undergoing this process.

Previously, WPATH proposed 12 months of real-life experience as a prerequisite for gender-affirming surgery. However, Law 4/2023 removes this requirement in Spain, allowing transgender individuals to decide the steps in their transition based on their personal needs.

At IM GENDER, we understand that trans individuals often have different needs, and these standards are seen as flexible to adapt to the diverse needs of each person.

“The Charter of Fundamental Rights of the European Union (2000) includes, among others, the right to the integrity of the person, to free and informed consent, and the right of access to health care”.

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