The Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People is a publication of the World Professional Association for Transgender Health (WPATH). The overall goal of the SOC is to provide clinical guidance for health professionals to assist transsexual, transgender, and gender nonconforming people with safe and effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being, and self-fulfillment. This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments. The SOC are based on the best available science and expert professional consensus. Because most of the research and experience in this field comes from a North American and Western European perspective, adaptations of the SOC to other parts ...

Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7

ContextIn 2002, an estimated 877 000 lives were lost worldwide through
suicide. Some developed nations have implemented national suicide prevention
plans. Although these plans generally propose multiple interventions, their
effectiveness is rarely evaluated.ObjectivesTo examine evidence for the effectiveness of specific suicide-preventive
interventions and to make recommendations for future prevention programs and
research.Data Sources and Study SelectionRelevant publications were identified via electronic searches of MEDLINE,
the Cochrane Library, and PsychINFO databases using multiple search terms
related to suicide prevention. Studies, published between 1966 and June 2005,
included those that evaluated preventative interventions in major domains;
education and awareness for the general public and for professionals; screening
tools for at-risk individuals; treatment of psychiatric disorders; restricting
access to lethal means; and responsible media reporting of suicide.Data ExtractionData were extracted on primary outcomes of interest: suicidal behavior
(completion, attempt, ideation), intermediary or secondary outcomes (treatment
seeking, identification of at-risk individuals, antidepressant prescription/use
rates, referrals), or both. Experts from 15 countries reviewed all studies.
Included articles were those that reported on completed and attempted suicide
and suicidal ideation; or, where applicable, intermediate outcomes, including
help-seeking behavior, identification of at-risk individuals, entry into treatment,
and antidepressant prescription rates. We included 3 major types of studies
for which the research question was clearly defined: systematic reviews and
meta-analyses (n = 10); quantitative studies, either randomized
controlled trials (n = 18) or cohort studies (n = 24);
and ecological, or population- based studies (n = 41). Heterogeneity
of study populations and methodology did not permit formal meta-analysis;
thus, a narrative synthesis is presented.Data SynthesisEducation of physicians and restricting access to lethal means were
found to prevent suicide. Other methods including public education, screening
programs, and media education need more testing.ConclusionsPhysician education in depression recognition and treatment and restricting
access to lethal methods reduce suicide rates. Other interventions need more
evidence of efficacy. Ascertaining which components of suicide prevention
programs are effective in reducing rates of suicide and suicide attempt is
essential in order to optimize use of limited resources.

Suicide prevention strategies: a systematic review.

At a time when lesbian, gay, bisexual, and transgender individuals—often referred to under the umbrella acronym LGBT—are becoming more visible in society and more socially acknowledged, clinicians and researchers are faced with incomplete information about their health status. While LGBT populations often are combined as a single entity for research and advocacy purposes, each is a distinct population group with its own specific health needs. Furthermore, the experiences of LGBT individuals are not uniform and are shaped by factors of race, ethnicity, socioeconomic status, geographical location, and age, any of which can have an effect on health-related concerns and needs. While some research about the health of LGBT populations has been conducted, researchers still have a great deal to learn. To help assess the state of the science, the National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to assess current knowledge of the health status of lesbian, gay, bisexual, and transgender populations; to identify research gaps and opportunities; and to outline a research agenda to help NIH focus its research in this area. A committee of experts was convened by the IOM to consider this task, and its findings are presented in its report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding.

The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding

Suicidal behavior is a leading cause of injury and death worldwide. Information about the epidemiology of such behavior is important for policy-making and prevention. The authors reviewed government data on suicide and suicidal behavior and conducted a systematic review of studies on the epidemiology of suicide published from 1997 to 2007. The authors' aims were to examine the prevalence of, trends in, and risk and protective factors for suicidal behavior in the United States and cross-nationally. The data revealed significant cross-national variability in the prevalence of suicidal behavior but consistency in age of onset, transition probabilities, and key risk factors. Suicide is more prevalent among men, whereas nonfatal suicidal behaviors are more prevalent among women and persons who are young, are unmarried, or have a psychiatric disorder. Despite an increase in the treatment of suicidal persons over the past decade, incidence rates of suicidal behavior have remained largely unchanged. Most epidemiologic research on suicidal behavior has focused on patterns and correlates of prevalence. The next generation of studies must examine synergistic effects among modifiable risk and protective factors. New studies must incorporate recent advances in survey methods and clinical assessment. Results should be used in ongoing efforts to decrease the significant loss of life caused by suicidal behavior.

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Suicide and Suicidal Behavior

Depression is less prevalent among older adults than among younger adults, but it can have serious consequences. More than half of cases represent a first onset in later life. Although suicide rates in the elderly are declining, they are still higher than in younger adults and are more closely associated with depression. Depressed older adults are less likely to endorse affective symptoms and more likely to display cognitive changes, somatic symptoms, and loss of interest than are depressed younger adults. Risk factors leading to the development of late-life depression likely comprise complex interactions among genetic vulnerabilities, cognitive diathesis, age-associated neurobiological changes, and stressful events. Insomnia is an often overlooked risk factor for late-life depression. We suggest that a common pathway to depression in older adults, regardless of which predisposing risks are most prominent, may be curtailment of daily activities. Accompanying self-critical thinking may exacerbate and maintain a depressed state. Offsetting the increasing prevalence of certain risk factors in late life are age-related increases in psychological resilience. Other protective factors include higher education and socioeconomic status, engagement in valued activities, and religious or spiritual involvement. Treatments including behavioral therapy, cognitive-behavioral therapy, cognitive bibliotherapy, problem-solving therapy, brief psychodynamic therapy, and life review/reminiscence therapy are effective but are too infrequently used with older adults. Preventive interventions including education for individuals with chronic illness, behavioral activation, cognitive restructuring, problem-solving skills training, group support, and life review have also received support.

Depression in Older Adults

In 1983-1984 the Swedish Committee for the Prevention and Treatment of Depression offered an educational program on diagnosis and treatment of depressive disorders to all general practitioners on the island of Gotland. The program has been carefully evaluated; 1982 was used as the baseline and the main evaluation was carried out in 1985. After the educational programs, the frequency of sick leave for depressive disorders decreased, the frequency of inpatient care for depressive disorders decreased to 30% of that at the baseline; the prescription of antidepressants increased, but prescription of major tranquilizers, sedatives and hypnotics decreased. The frequency of suicide on the island decreased significantly. This study describes the long-term effects. In 1988, 3 years after the project ended, the inpatient care for depressive disorders increased, the suicidal rate returned almost to baseline values and the prescription of antidepressants stabilized. Thus, the effects were strictly related in time to the educational programs, indicating that the effects were real and not only a coincidence with local trends on Gotland. Furthermore, the results indicate that educational programs that can have pronounced effects on the health care system have to be repeated approximately every 2 years if long-term effects are to be expected.

Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression.

In 1983-1984 the Swedish Committee for Prevention and Treatment of Depression (PTD Committee) introduced an educational program for all general practitioners (GPs) on the Swedish island of Gotland The primary goal was to increase knowledge about diagnosis and treatment of patients with affective disorders The effects of the educational programs were evaluated in detail; GPs identified more patients with depressive disorders and treated them more accurately The suicide rate on Gotland was followed, primarily to ensure that the new treatment strategies did not include a risk for the individual patients However, it was also hoped that increased awareness of patients with affective disorders and better treatment routines could reduce the suicide rate The suicide rate dropped the year after the educational programs were introduced This was a statistically significant deviation both from the long-term trend on Gotland and from the trends in Sweden as a whole Programs aiming at giving GPs increased capacity and responsibility to treat patients with affective disorders do not increase the frequency of suicide Better primary treatment of patients with depressive disorders may reduce the suicide rate in a given area

Frequency of suicide on Gotland after systematic postgraduate education of general practitioners.

Landen M, Walinder J, Lundstrom B. Prevalence, incidence and sex ratio of transsexualism.



Scand 1996: 93: 221–223. © Munksgaard 1996.



Frequency figures for transsexualism, concerning incidence, prevalence and sex ratio calculated in the 1960s and 1970s, were compared with recent reports. The incidence figures remained constant over time, whereas the prevalence figures tended to increase during the review period. The incidence was found to be of the same magnitude in men and women, while the corresponding ratio for prevalence figures was 3:1. It is suggested that men seeking sex reassignment represent a more heterogeneous group than women, and that the reported male predominance to date is due to a lack of categorical studies of primary/ genuine transsexualism. It would appear that genuine transsexualism is, on the whole, insensitive to societal changes. The fundamental disturbance underlying this psychosexual identity disorder is suggested to be neurobiological in origin.

Prevalence, Incidence and Sex Ratio of Transsexualism

The objective of this study was to evaluate the features and calculate the frequency of sex-reassigned subjects who had applied for reversal to their biological sex, and to compare these with non-regretful subjects. An inception cohort was retrospectively identified consisting of all subjects with gender identity disorder who were approved for sex reassignment in Sweden during the period 1972-1992. The period of time that elapsed between the application and this evaluation ranged from 4 to 24 years. The total cohort consisted of 218 subjects. The results showed that 3.8% of the patients who were sex reassigned during 1972-1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non-core group of transsexuals. In conclusion, the results show that the outcome of sex reassignment has improved over the years. However, the identified risk factors indicate the need for substantial efforts to support the families and close friends of candidates for sex reassignment.

Factors predictive of regret in sex reassignment

Objective: This study was initiated in order to describe and evaluate the effects of a therapeutic drug monitoring (TDM) routine of selective serotonin reuptake inhibitors (SSRIs) on treatment strategies and drug costs in depressed elderly patients.



Method: Blood samples were drawn from elderly depressed patients and analysed for steady-state trough serum concentrations of citalopram (n=48), paroxetine (n=48) or sertraline (n=39). A global efficacy evaluation was made at baseline and after 6–9 months. Antidepressant drug costs before and after TDM were estimated.



Results: Eight samples were excluded due to technical problems or non-compliance. In 65 of the 127 (51.2%) remaining cases, the treatment strategy was changed according to the TDM outcome, in most a reduction of the prescribed dose. Bioanalytical TDM costs included the antidepressant drug costs after TDM were reduced by 10.2%.



Conclusion: The results support the utility of TDM in the search for the individual minimum effective SSRI dose in the elderly.

Therapeutic drug monitoring of selective serotonin reuptake inhibitors influences clinical dosing strategies and reduces drug costs in depressed elderly patients.

Jan Wålinder

Papers

Long-term effects of an educational program for general practitioners given by the Swedish Committee for the Prevention and Treatment of Depression.

Frequency of suicide on Gotland after systematic postgraduate education of general practitioners.

Prevalence, Incidence and Sex Ratio of Transsexualism

Factors predictive of regret in sex reassignment

Therapeutic drug monitoring of selective serotonin reuptake inhibitors influences clinical dosing strategies and reduces drug costs in depressed elderly patients.