The WPATH standards of care for transgender people in their latest version propose criteria to be taken into account so as to be able to carry out the surgeries that transgender patients undergo. It is important to emphasise that these “standards” are flexible and seek to promote excellent health care for our patients, giving professionals in private practice the possibility of adjusting them as necessary, always documenting every step through informed consent to ensure quality care.


What are the formalities?

In the case of gender affirmation surgery, the criteria proposed by WPATH are as follows:

  • Well-documented transsexuality.
  • The ability to make a fully informed decision and consent to 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.

In the following, we will detail the recommendations according to WPATH for hormone therapy, social transition and psychological counselling before undergoing genital surgery. These are criteria proposed in 2011, which are now largely superseded in many respects.

How does hormone replacement affect me?



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

In order to undergo gender affirmation surgery, WPATH recommends that a person should have received hormone therapy for 12 months continuously (unless they have medical contraindications, or are unable or unwilling to take hormones).

It is important to clarify that after gender affirmation surgery, it is usually necessary to maintain treatment for life, albeit at lower doses.

Adverse effects: it should be remembered that excessive doses can cause liver problems, while total withdrawal after surgery can lead to osteoporosis, among other problems. It is therefore important that this treatment be supervised by a specialist doctor.



It has been found that transgender men undergoing hormone treatment experience certain changes. The most common are:

  • A deeper tone of voice
  • Increased upper body strength
  • Weight gain
  • Decreased volume of adipose tissue in the hips (fat accumulation in this area decreases).
  • Increased facial hair
  • Increased body hair
  • Alopecia with distribution similar to male alopecia
  • Mild breast atrophy
  • Permanent clitoral enlargement
  • Increased sexual interest
  • Increased excitation capacity

The maximum effects of hormone therapy may not occur until one or two years after the start of treatment. Each patient’s response to this treatment depends on their genetic inheritance.



In order to avoid the suffering that can be caused for most transgender children by their bodies developing in the opposite direction to their identity, pharmacological treatment consisting of hormone inhibitors or puberty blockers, GnRH analogues to suppress the production of oestrogen or testosterone, may be recommended.

This treatment aims to prevent and/or delay physical changes during puberty and adolescence. This is not an irreversible treatment –once it is stopped, hormonal development continues.


Transsexuality is by no means a psychological or psychiatric disorder. However, psychological monitoring of the transsexual patient is advisable in order to accompany the so-called transition process.

There is no timeframe for this transition process and each transgender person should choose how and when they wish to carry it out, at what pace and what changes they wish to make.

Usually, the process begins when the trans person feels confident to take the step. And while there is no “right” way or “proper protocol” to do this process, most experience some common social changes that may or may not include adopting changes in dress, hairstyle, manner of expression and/or presentation, modification of both name and gender on personal identification documentation, treatment with hormone therapy or surgical procedures.



Although our society is becoming increasingly aware of transsexuality and this transition process is usually carried out at an earlier age, when it is carried out at a later age these changes can cause some problems at first, especially in the academic and/or work, family and social environments. However, it is an inevitable process, whether or not the patient decides to undergo the intervention or whether or not she only continues with hormone treatment. Having family or social support is very important for anyone going through this transition process.

However, what WPATH in this version suggests is 12 months of continuous “real life experience” in a gender role that is congruent with their gender identity before undergoing gender affirmation surgery. Gender affirmation surgery produces irreversible changes, and therefore WPATH proposes as a prerequisite ruling out any transient sexual identity disorder in the person wishing to undergo this type of procedure. Real-life experience is one of the tools to enable any transient sexual identity disorder to be ruled out, according to WPATH.

At IM GENDER, we know that the needs of transgender people are often different, and we understand these rules to be flexible in order to adapt them to each person’s different needs.

“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”.