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• Legal Penalties for Physicians Providing Gender-Affirming Care JAMA Viewpoint June 6, 2023 This Viewpoint explains the “legal limbo” physicians may find themselves in, straddling state laws banning gender-affirming care and federal nondiscrimination law, both of which remain unclear due to ongoing legal challenges in the courts. Christy Mallory, JD; Madeline G. Chin, BA; Justine C. Lee, MD, PhD

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Poteat T , Davis AM , Gonzalez A. Standards of Care for Transgender and Gender Diverse People. JAMA. 2023;329(21):1872–1874. doi:10.1001/jama.2023.8121

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Standards of Care for Transgender and Gender Diverse People

• 1 Department of Social Medicine, University of North Carolina, Chapel Hill
• 2 Section of General Internal Medicine, University of Chicago, Chicago, Illinois
• 3 Atrius Health, Boston, Massachusetts
• Viewpoint Legal Penalties for Physicians Providing Gender-Affirming Care Christy Mallory, JD; Madeline G. Chin, BA; Justine C. Lee, MD, PhD JAMA

Guideline title Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (SOC-8)

Release date September 15, 2022

Developer and funding source World Professional Association for Transgender Health (WPATH)

Prior version August 27, 2012

Target population Transgender and gender diverse people

Select major recommendations

Primary care

Transgender and gender diverse patients should receive nonjudgmental care from appropriately trained health care professionals. Gender-affirming primary care includes preventive care, mental health and substance use disorder screening, hormone therapy, and education about nonmedical/nonsurgical gender-affirming interventions.

Assessment of transgender and gender diverse persons

When the adult patient desires gender-affirming medical and/or surgical treatment (GAMST) that aligns physical characteristics with gender identity, this care should be offered when there is a marked and sustained difference between sex assigned at birth and current gender; there is capacity for informed consent; physical and/or mental health conditions that may be affected by GAMST have been assessed; and reproductive implications and options have been discussed.

Children and adolescents require a multidisciplinary approach, which considers developmental stage, neurocognitive function, language skills; offers mental health support; discusses risks and benefits of social transition; and includes parental/guardian involvement in GAMST in almost all situations.

Mental health

Any qualified health professional with the ability to identify gender incongruence may assess patients for GAMST. No more than 1 letter of recommendation is required for GAMST in adults.

Psychotherapy is not required before GAMST, although therapy may be helpful for some.

Therapy to change gender identity or expression is associated with increased suicide risk and should not be offered to transgender and gender diverse patients.

To improve psychosocial functioning and quality of life, clinicians should assess, and if appropriate, initiate and continue hormone therapy for eligible transgender and gender diverse people when it is required.

Eligible adolescent transgender and gender diverse patients may be offered hormone suppression after pubertal onset (Tanner stage 2) and menstrual suppression for eligible adolescents assigned female at birth, when testosterone is not yet indicated.

Clinicians should counsel transgender and gender diverse patients seeking surgical options about associated risks and benefits unless surgery is contraindicated.

Qualified surgeons should have training and continuing education in gender-affirming procedures and should track their surgical outcomes.

The health care workforce should receive transgender and gender diverse cultural awareness continuing education.

Health care training programs should include competencies in transgender and gender diverse health.

Transgender and gender diverse are broad terms used to describe individuals whose gender identities and expressions differ from the gender attributed to the sex assigned at birth, typically either female or male. Estimates of the proportion of transgender and gender diverse individuals worldwide range from 0.6% to 3% and have increased in recent years, particularly among adolescents and young adults. 1

Transgender and gender diverse patients face multiple barriers to medical care, with a 2019 systematic review finding that 27% (range, 19%-40%) had been denied care by a health professional. 2 A 2018 study of primary care clinicians found that 85% were willing to provide care for transgender and gender diverse persons, but 52% were unfamiliar with health care guidelines for transgender and gender diverse people. 3

In a population-based study, transgender and gender diverse participants self-reported mean poor mental health of 14.8 (95% CI, 13-16.7) days per month compared with 6.0 (95% CI, 5.2-6.8) for cisgender participants. 4 Gender-affirming medical and surgical treatment (GAMST) can mitigate psychologic distress and reduce suicide risk by aligning physical characteristics with gender identity when there is marked, persistent incongruence with the sex assigned at birth (gender dysphoria). 1 The guidelines address various gender identities and recommend comprehensive health care beyond hormonal or surgical treatments, including primary care, reproductive and sexual health care, mental health care, voice therapy, hair removal, and prosthetics. GAMST typically involves either feminizing therapy for transgender and gender diverse individuals assigned male at birth or masculinizing therapy for those assigned female at birth. The SOC-8 includes detailed recommendations on use of gender-affirming hormones and their doses, as well as recommendations for preventive care and screening. This synopsis provides an overview of guideline recommendations most relevant for primary care clinicians.

A multidisciplinary SOC-8 guidelines committee included health care professionals, researchers, and stakeholders with diverse perspectives and geographic representation ( Table ). An independent university-based evidence review team conducted a series of systematic reviews that identified 389 studies. The final SOC-8 referenced more than 1400 studies. Recommendation statements were crafted by chapter leads, reviewed through a Delphi process that included all members of the committee, and required approval by at least 75% of members. The strength of the recommendations was determined using an adapted GRADE framework and they were designated as either “recommended” or “suggested” based on potential benefits and harms, confidence in the balance and quality of evidence, values and preferences of health care professionals and patients, and resource use and feasibility.

The expanding evidence base and scientific understanding of gender diversity and GAMST includes increased data on the prevalence of mental health disparities by gender identity and additional evidence of positive outcomes associated with GAMST. A rigorous 2021 systematic review found evidence that gender-affirming hormone therapy may be associated with increased quality of life, decreased depression, and decreased anxiety. 1 A prospective longitudinal cohort study of 18-month gender-affirming hormone therapy found reductions in anxiety and depression symptoms using the Hospital Anxiety and Depression Scale from 7.24 (SD, 4.03) to 5.19 (SD, 3.73) ( P  < .001). 5 A more recent study on pubertal blockers and gender-affirming hormone therapy in adolescents (mean age, 15.8 years) found 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youth who had initiated this therapy, compared with those who had not. Similarly, a systematic review of gender-affirming surgical outcomes found that individuals with gender dysphoria who underwent a variety of surgical interventions experienced significant improvements in quality of life and psychological well-being. 6

The stability of the decision to transition during adolescence has been evaluated. In a Dutch study of 720 individuals receiving gonadotropin-releasing hormone agonist (GnRHa) treatment to delay puberty progression, adolescents assigned male at birth started GnRHa at median age 14.1 years and adolescents assigned female at birth started GnRHa at median age 16.0 years; 98% of people who started this treatment in adolescence were using gender-affirming hormones at age 20 years. 7 Conversely, efforts to change a transgender or gender diverse person’s gender identity (sometimes termed “reparative” or “conversion therapy”) have been associated with major adverse outcomes. 1 Participants exposed to these types of gender identity change efforts had twice the odds of attempted suicide (aOR, 2.27; 95% CI, 1.60-3.24; P  < .001) compared with those who had not been exposed. Among transgender and gender diverse adults exposed to these efforts before the age of 10 years, the odds of suicide attempt were increased 4-fold (aOR, 4.15; 95% CI, 2.44-7.69; P  < .001). 1 A recent study of 317 transgender-identified youth found that 94% of those who socially transitioned at early prepubertal ages (mean, 8.1 years) maintained the same gender identity at an average follow-up of 5 years.

Clinicians must weigh the potential risks of GAMST alongside the known reductions in mental health and substance use morbidity seen with social support and institution of GAMST in transgender and gender diverse people. 1 Expected benefits and potential adverse effects should be reviewed with the patient and for adolescents their parent(s)/guardian(s) in almost all situations. 1 Voice lowering is generally irreversible, and gender-affirming hormone therapy may impair fertility. Gender-affirming hormone therapy for those assigned female at birth (testosterone) or assigned male at birth (estrogens, progestins, and androgen blockers) may be associated with increased risk of cardiovascular events such as stroke, venous thromboembolism, and myocardial infarction. A Dutch study compared mortality risk in transgender individuals receiving hormone treatment with that of the general population over 5 decades. The investigators found that transgender women died more frequently from cardiovascular disease (standardized mortality ratio [SMR], 1.4; 95% CI, 1.0-1.8), lung cancer (SMR, 2.0;, 95% CI, 1.4-2.8), infection (SMR, 5.4; 95% CI, 2.9-8.7), or nonnatural causes of death (SMR, 2.7; 95% CI, 1.8-3.7). In transgender men, the overall mortality risk was comparable with men in the general population (SMR, 1.2; 95% CI, 0.9-1.6). 8 Whether hormone treatment increases the risk of hormone-sensitive cancer has not yet been fully established. 1 , 8

The SOC-8 guidelines recommend following local breast cancer screening guidelines developed for cisgender women in transgender and gender diverse individuals who have received estrogens (considering dose, duration, and timing), and in those with breasts from natal puberty who have not had gender-affirming chest surgery. Individuals with a cervix should follow screening guidelines developed for cisgender women. 1

Gender-affirming surgical treatment for transgender and gender diverse people may include facial, chest, and genital surgeries. Risks differ by procedure, but studies estimate that overall satisfaction with postoperative results among transgender and gender diverse people is greater than 94%. 9 Surgical risks may include rectoneovaginal fistulas, urethral complications, tissue necrosis, and scarring. As with hormone therapy, genital surgeries impact reproductive potential; therefore, the informed consent process should address these risks and discuss options for fertility preservation. 1

The expanded depth and scope of SOC-8 reflect the increase in transgender and gender diverse health research over the past decade. The SOC-8 has moved beyond a singular focus on hormones and surgery to include recommendations for primary care, sexual and reproductive health, mental health, voice, and communication therapy, as well as cultural awareness and human rights. If written documentation or a letter is required to recommend GAMST in an adult, only one letter of assessment from a health care professional who has competencies in the assessment of transgender and gender diverse people is needed, due to the limited clinical value of a second letter. 1 In adolescents, a letter of assessment from a member of a multidisciplinary team is needed and should reflect the assessment and opinion of a team that involves both medical and mental health professionals. 1

At least 6 months of exogenous hormone therapy before gender-affirming surgery is optimal, but not mandatory. 1 Measures to address stigma, discrimination, and human rights violations may be equally important in improving the health for transgender and gender diverse people worldwide, and also improve access to the essential care outlined in the SOC-8 guideline.

Including gender identity measures in all population-based federal surveys would allow for a broader understanding of a variety of health care needs and experiences of transgender and gender diverse people. Longitudinal studies that follow cohorts over decades would expand understanding of the long-term effects of GAMST, including the use of progesterone in transgender and gender diverse women. Such studies would help inform ongoing policy debates that affect issues ranging from insurance coverage for GAMST to the legality of gender-affirming care, especially for transgender and gender diverse youth. 10

Other Resources

National LGBTQIA Health Education Center. Affirmative Services for Transgender and Gender-Diverse People: Best Practices for Frontline Health Care Staff

Corresponding Author: Andrew M. Davis, MD, MPH, University of Chicago Medicine, 5841 S Maryland Ave, Chicago, IL 60637 ( [email protected] ).

Published Online: May 18, 2023. doi:10.1001/jama.2023.8121

Conflict of Interest Disclosures: None reported.

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Treatment - Gender dysphoria

Treatment for gender dysphoria aims to help people live the way they want to, in their preferred gender identity or as non-binary.

What this means will vary from person to person, and is different for children, young people and adults. Waiting times for referral and treatment are currently long.

Treatment for children and young people

If your child may have gender dysphoria, they'll usually be referred to one of the NHS Children and Young People's Gender Services .

Your child or teenager will be seen by a multidisciplinary team including a:

• clinical psychologist
• child psychotherapist
• child and adolescent psychiatrist
• family therapist
• social worker

The team will carry out a detailed assessment, usually over 3 to 6 appointments over a period of several months.

Depending on the results of the assessment, options for children and teenagers include:

• family therapy
• individual child psychotherapy
• parental support or counselling
• group work for young people and their parents
• regular reviews to monitor gender identity development
• referral to a local Children and Young People's Mental Health Service (CYPMHS) for more serious emotional issues

Most treatments offered at this stage are psychological rather than medical. This is because in many cases gender variant behaviour or feelings disappear as children reach puberty.

Hormone therapy in children and young people

Some young people with lasting signs of gender dysphoria who meet strict criteria may be referred to a hormone specialist (consultant endocrinologist). This is in addition to psychological support.

Puberty blockers and gender-affirming hormones

Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.

From around the age of 16, young people with a diagnosis of gender incongruence or gender dysphoria who meet various clinical criteria may be given gender-affirming hormones alongside psychosocial and psychological support.

These hormones cause some irreversible changes, such as:

• breast development (caused by taking oestrogen)
• breaking or deepening of the voice (caused by taking testosterone)

Long-term gender-affirming hormone treatment may cause temporary or even permanent infertility.

However, as gender-affirming hormones affect people differently, they should not be considered a reliable form of contraception.

There is some uncertainty about the risks of long-term gender-affirming hormone treatment.

Children, young people and their families are strongly discouraged from getting puberty blockers or gender-affirming hormones from unregulated sources or online providers that are not regulated by UK regulatory bodies.

Transition to adult gender identity services

Young people aged 17 or older may be seen in an adult gender identity clinic or be referred to one from a children and young people's gender service.

By this age, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary.

Treatment for adults

Adults who think they may have gender dysphoria should be referred to a gender dysphoria clinic (GDC).

Find an NHS gender dysphoria clinic in England .

GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing assessments, treatments, support and advice, including:

• psychological support, such as counselling
• cross-sex hormone therapy
• speech and language therapy (voice therapy) to help you sound more typical of your gender identity

For some people, support and advice from the clinic are all they need to feel comfortable with their gender identity. Others will need more extensive treatment.

Hormone therapy for adults

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. The hormones usually need to be taken for the rest of your life, even if you have gender surgery.

It's important to remember that hormone therapy is only one of the treatments for gender dysphoria. Others include voice therapy and psychological support. The decision to have hormone therapy will be taken after a discussion between you and your clinic team.

In general, people wanting masculinisation usually take testosterone and people after feminisation usually take oestrogen.

Both usually have the additional effect of suppressing the release of "unwanted" hormones from the testes or ovaries.

Whatever hormone therapy is used, it can take several months for hormone therapy to be effective, which can be frustrating.

It's also important to remember what it cannot change, such as your height or how wide or narrow your shoulders are.

The effectiveness of hormone therapy is also limited by factors unique to the individual (such as genetic factors) that cannot be overcome simply by adjusting the dose.

Find out how to save money on prescriptions for hormone therapy medicines with a prescription prepayment certificate .

Risks of hormone therapy

There is some uncertainty about the risks of long-term cross-sex hormone treatment. The clinic will discuss these with you and the importance of regular monitoring blood tests with your GP.

The most common risks or side effects include:

• blood clots
• weight gain
• dyslipidaemia (abnormal levels of fat in the blood)
• elevated liver enzymes
• polycythaemia (high concentration of red blood cells)
• hair loss or balding (androgenic alopecia)

There are other risks if you're taking hormones bought over the internet or from unregulated sources. It's strongly recommended you avoid these.

Long-term cross-sex hormone treatment may also lead, eventually, to infertility, even if treatment is stopped.

The GP can help you with advice about gamete storage. This is the harvesting and storing of eggs or sperm for your future use.

Gamete storage is sometimes available on the NHS. It cannot be provided by the gender dysphoria clinic.

Read more about fertility preservation on the HFEA website.

Surgery for adults

Some people may decide to have surgery to permanently alter body parts associated with their biological sex.

Based on the recommendations of doctors at the gender dysphoria clinic, you will be referred to a surgeon outside the clinic who is an expert in this type of surgery.

In addition to you having socially transitioned to your preferred gender identity for at least a year before a referral is made for gender surgery, it is also advisable to:

• lose weight if you are overweight (BMI of 25 or over)
• have taken cross-sex hormones for some surgical procedures

It's also important that any long-term conditions, such as diabetes or high blood pressure, are well controlled.

Surgery for trans men

Common chest procedures for trans men (trans-masculine people) include:

• removal of both breasts (bilateral mastectomy) and associated chest reconstruction
• nipple repositioning
• dermal implant and tattoo

Gender surgery for trans men includes:

• construction of a penis (phalloplasty or metoidioplasty)
• construction of a scrotum (scrotoplasty) and testicular implants
• a penile implant

Removal of the womb (hysterectomy) and the ovaries and fallopian tubes (salpingo-oophorectomy) may also be considered.

Surgery for trans women

Gender surgery for trans women includes:

• removal of the testes (orchidectomy)
• removal of the penis (penectomy)
• construction of a vagina (vaginoplasty)
• construction of a vulva (vulvoplasty)
• construction of a clitoris (clitoroplasty)

Breast implants for trans women (trans-feminine people) are not routinely available on the NHS.

Facial feminisation surgery and hair transplants are not routinely available on the NHS.

As with all surgical procedures there can be complications. Your surgeon should discuss the risks and limitations of surgery with you before you consent to the procedure.

Life after transition

Whether you've had hormone therapy alone or combined with surgery, the aim is that you no longer have gender dysphoria and feel at ease with your identity.

Your health needs are the same as anyone else's with a few exceptions:

• you'll need lifelong monitoring of your hormone levels by your GP
• you'll still need contraception if you are sexually active and have not yet had any gender surgery
• you'll need to let your optician and dentist know if you're on hormone therapy as this may affect your treatment
• you may not be called for screening tests as you've changed your name on medical records – ask your GP to notify you for cervical and breast screening if you're a trans man with a cervix or breast tissue
• trans-feminine people with breast tissue (and registered with a GP as female) are routinely invited for breast screening from the ages of 50 up to 71

Find out more about screening for trans and non-binary people on GOV.UK.

NHS guidelines for gender dysphoria

NHS England has published what are known as service specifications that describe how clinical and medical care is offered to people with gender dysphoria:

• Non-surgical interventions for adults
• Surgical interventions for adults
• Interim service specification for specialist gender incongruence services for children and young people

Review of gender identity services

NHS England has commissioned an independent review of gender identity services for children and young people. The review will advise on any changes needed to the service specifications for children and young people.

Page last reviewed: 28 May 2020 Next review due: 28 May 2023

• Patient Care & Health Information
• Diseases & Conditions
• Gender dysphoria

Your health care provider might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the presence of gender dysphoria and document how prejudice and discrimination due to your gender identity (minority stress factors) impact your mental health. Your provider will also ask about the degree of support you have from family, chosen family and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. It involves feelings of distress due to a strong, pervasive desire to be another gender.

Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Others might instead show symptoms of a mood disorder, anxiety or depression. Or they might experience social or academic problems.

• Care at Mayo Clinic

Our caring team of Mayo Clinic experts can help you with your gender dysphoria-related health concerns Start Here

Treatment can help people who have gender dysphoria explore their gender identity and find the gender role that feels comfortable for them, easing distress. However, treatment should be individualized. What might help one person might not help another.

Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of gender-diverse people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the chest, external genitalia, internal genitalia, facial features and body contour

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair.

Treatments are based on your goals and an evaluation of the risks and benefits of medication use. Treatments may also be based on the presence of any other conditions and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Legal age in a person's country or, if younger, following the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pre-treatment medical evaluation is done by a doctor with experience and expertise in transgender care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments This evaluation may include:

• A personal and family medical history
• A physical exam
• Assessment of the need for age- and sex-appropriate screenings
• Identification and management of tobacco use and drug and alcohol misuse
• Testing for HIV and other sexually transmitted infections, along with treatment, if necessary
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo or ovarian tissue cryopreservation
• Documentation of history of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria.

The goal of behavioral health treatment is to help you feel comfortable with how you express your gender identity, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couples, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of the stress that results from experiencing prejudice and discrimination because of your gender identity (minority stress)
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A behavioral health evaluation may not be required before receiving hormonal and surgical treatment of gender dysphoria, but it can play an important role when making decisions about treatment options. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance misuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

More Information

Gender dysphoria care at Mayo Clinic

• Pubertal blockers
• Feminizing hormone therapy
• Feminizing surgery
• Gender-affirming (transgender) voice therapy and surgery
• Masculinizing hormone therapy
• Masculinizing surgery

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal thoughts, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Mental health care. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about any anxiety or depression you're experiencing.
• Support groups. Talking to other transgender or gender-diverse people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritizing self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditation or prayer. You might find comfort and support in your spirituality or faith communities.
• Getting involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for your appointment

You may start by seeing your primary care provider. Or you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms , including any that seem unrelated to the reason for your appointment
• Key personal information , including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your health care provider
• Ferrando CA. Comprehensive Care of the Transgender Patient. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
• Hana T, et al. Transgender health in medical education. Bulletin of the World Health Organization. 2021; doi:10.2471/BLT.19.249086.
• Kliegman RM, et al. Gender and sexual identity. In: Nelson Textbook of Pediatrics. 21st ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 8, 2021.
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