Mental health certificates needed now for transgenders opting for gender assignment surgery

New Delhi: Transgenders who want to go for pre-hormonal therapy or gender assignment surgery need to be assessed and certified by mental health professionals, according to the Union Health Ministry's standard operating procedures for the purpose.

As for gynaecologists, the 'SoP for Medical Treatment of Transgender Persons' states that they should enquire as to how the patient wishes to be addressed in terms of name and pronoun, and also ensure that the words they use uphold the principles of safety, dignity and respect.

Outlining the responsibilities of mental health professionals, the SoP document said their primary role would include assessment for gender incongruence, as per the current diagnostic system followed by the World Health Organization (WHO), and certification for the same.

Gender incongruence is characterised by a marked and persistent disparity between an individual's experienced gender and the assigned sex. It often leads to a desire for a 'transition' through hormonal treatment, surgery or other healthcare services in order to live and be accepted as a person of the experienced gender.

According to the SOP, "Before endocrinology treatment, a certificate from one psychiatrist is required. Before Gender Affirmation Surgery, two certificates are required -- one by a psychiatrist and one by a clinical psychologist/psychiatrist." Apart from that, a mental health professional would also assess for distress and co-morbid mental and/or substance use disorders and provide management of the same, the document stated.

They would also provide support or therapy, if needed, to cope with issues related to gender incongruence, including participation in integrated cross-disciplinary care and intersectoral collaboration for clients and caregivers.

"The support would be provided pre-hormonal therapy/gender assignment surgery, during the period as well as post-surgery, if need be," it stated.

According to the document, one cannot undergo gender affirmation surgery before the age of 18 years and a certificate of being stable on endocrine treatment for one year and suitability for surgical procedure is required before gender affirmation surgery.

The SOP stressed the need to make STD clinics friendly to gender-diverse patients and such facilities should document gender identity and sex assigned at birth for all patients to improve sexual healthcare for transgenders and gender nonbinary persons.

Primary care providers should take a comprehensive sexual history, including a discussion on Sexually transmitted infection (STI) screening, HIV PrEP and PEP, behavioural health, and social determinants of sexual health.

Clinicians can improve the experience of sexual health screening and counselling for transgender persons by asking for their choice of terminology or modifying language to be used during clinic visits and history taking and examination, the SOP stated.

Options for fertility preservation, pregnancy potential and contraception options should also be discussed, if indicated, the document said.

As for the Fertility Preservation in Transgenders (Female to Male), the SoP states that the established method for fertility preservation includes cryopreservation of embryos and oocytes for females.

Ovarian tissue cryopreservation is also a successful technique for fertility preservation and is no longer experimental, the document stated, adding that it has limited availability and is possible only after attaining puberty.

Transgender patients wishing for total abdominal hysterectomy and salpingoopherectomy should be informed about the option of fertility preservation and an informed decision for surgery may be taken thereafter, it said.

According to the SOP, transgender and gender-diverse people with a uterus who wish to carry a pregnancy should undergo preconception care and prenatal counselling regarding the need to temporarily stop gender-affirming hormones like testosterone, labour delivery breastfeeding and postpartum support.

The document states that gender dysphoria might occur at various developmental stages but commonly escalates with the development of secondary sexual characteristics.

Gender dysphoria is a state in which a person cannot identify with the gender he or she is born in. It is a state of having a gender identity that does not correspond to one's sex assigned at birth.

Gender affirmation surgery has an important role in the treatment of gender incongruence. Various surgical options are available to transgender individuals, which include facial reconstructive surgery, vocal surgery, chest or 'top' surgery, and genital or 'bottom' surgery, the SoP said.