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What are the four stages of gender-affirming care?

It is important to understand that gender-affirming care is individualized with no predetermined approaches or stages. The term “stages” implies that every individual who seeks gender-affirming care chooses to undergo all possible interventions. More often than not, this is not the case. Not all transgender and non-binary individuals choose to undergo medical or surgical intervention. 

Furthermore, when a person, in collaboration with their healthcare team, chooses gender-affirming care, the first step is almost always non-medical.  Each person then chooses which aspects of gender-affirming care best suits their individual needs. 

The order of gender-affirming care is typically as follows:

  1. The first and most fundamental step of gender-affirming care is just that, to affirm and validate the patient’s gender identity. Gender affirming care consists of providing information on what social and medical transition options are available. Non-medical gender-affirming choices related to gender expression and presentation may include changes to hair styling, clothing, make up, accessories, etc. This form of care may also include the person “coming out” as transgender or non-binary, and asking others to use their pronouns and/or gender congruent names.
  2. If a patient chooses to pursue a medical transition, the first step is often hormonal interventions done under the supervision of trained healthcare providers. If a person is pre-pubescent, this step involves the use of puberty blockers to prevent development of secondary sex characteristics that may further increase gender dysphoria. This intervention is most effective when started early in puberty before secondary sexual physical changes develop. Stopping the blockers allows puberty to proceed, meaning the physical effects are reversible. This option affords youth time to explore their gender identity and work with qualified professionals to determine next steps. Further research is needed to better understand the possible risks of using and/or stopping puberty blockers, such as potential impact on mental health and bone health.
  3. The next option involves taking hormones that allow secondary sexual characteristics to develop in a gender-congruent manner. These hormones are typically not made available until the person is at least 16-years-old. People who wish to develop male characteristics will take hormones in the testosterone class; those who wish to develop female characteristics will take estrogen class hormones and possibly testosterone blockers. 
  4. The next option is gender-affirming surgeries, which contrary to some political talking points, are almost never performed on minors. These surgical procedures allow patients to modify their physical appearance to be more gender congruent. Surgical interventions may include such things as changes to facial features, Adam’s apple, chest, and/or genitalia. Each person chooses which, if any, surgical intervention is right for them. 

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