(In)Equality and Beyond: Achieving Justice in Gender-Affirming Hormone Initiation

December 2021

John Fromson, Harvard Medical School
Christina Macenski, Brigham and Women's Hospital

The gender diverse youth community, which includes individuals who are transgender and non-binary, has long faced discrimination and stigmatization. This has led to barriers in accessing medical care and legislation fraught with prejudice. In 2020, at least sixteen states proposed bills attempting to limit the rights of transgender youth, many which specifically targeted their right to obtain safe and medically sound care. In this context, the World Professional Association for Transgender Health (WPATH) published guidelines in 2011 for the transitional treatment of transgender youth. Despite these person-centered guidelines, their intentional flexibility led to dramatically different interpretations of how to best initiate gender-affirming hormones. Gender clinics throughout the US and internationally now differ significantly in the time it takes from initial assessment and the decision to proceed with hormone initiation. The initial steps also vary significantly in the types of psychological evaluations and degrees of social transitions that are required prior to the prescribing of hormones. While each methodology seeks to promote justice and excellent clinical care, the variable periods of time to pass through stages of the process can create significant psychological distress related to much-needed therapy. Herein lies an opportunity for collaborative discussion amongst experts regarding the merits of each path of transitional care and the opportunity to establish consensus and then articulate, for the first time, specific best practices for initial assessment and the more precise timeline to hormone initiation. These new guidelines could then alleviate psychological distress and be widely disseminated and used in clinical practice.