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Comprehensive Guide to Gender Affirming Care: Health and Well-Being for Transgender and Non-Binary Individuals

What is Gender Affirming Care?

Gender-affirming care describes a variety of multidisciplinary approaches––such as hormone therapy, surgery, vocal therapy, psychotherapy and more. Through accepting, embracing and affirming the patient’s gender-identity, it helps trans, non-binary and gender non-conforming people meet their gender embodiment goals. 

The US Dept of Health and Human Services breaks down gender-affirming care as medical and non-medical interventions for minors and adults such as social affirmation, hormonal therapy and puberty blockers, as well as gender-affirming surgery.

Several peer reviewed studies have demonstrated how addressing gender incongruence in these patient groups can significantly increase their mental health and other quality of life indicators such as self-esteem, a positive body image and lower instances of suicidality in some cases.

The Importance of Gender Affirming Care in Healthcare

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM V) recognizes gender dysphoria as a mental health condition. This condition is characterized by psychological distress that arises from the incongruence between a patient’s gender identity and the sex that they were assigned at birth and/or their body as it develops through their first puberty. Dysphoria is a feeling that can be directed towards someone’s body––like primary or secondary sex characteristics––or triggered by social identifiers––such as the use of incorrect pronouns or names. Please note that not all transgender and nonbinary people experience gender dysphoria.

The World Professional Association of Transgender Health’s (WPATH) Standards of Care 8 (SOC 8) discusses the positive impacts of and recommendations for assessing the candidacy of adults, adolescents and children for undergoing gender-affirming care. In these populations of qualifying trans, non-binary and intersex patients, gender-affirming care shows decreases in symptoms such as deppression, anxiety, negative body image, low self esteem and even suicidal ideation in some cases. 

Gender-affirming medical interventions may include hormonal therapy, vocal therapy, top surgery, genital reconstruction or bottom surgery, body contouring, facial surgery and more. Overall, studies have demonstrated time and time that when these interventions are performed on qualifying populations, regret rates are incredibly low and satisfaction rates are as high as 94%.

Components of Gender Affirming Care

Gender-affirming care encompasses surgical, psychological and other therapeutic interventions. In the sections below, we provide an in-depth overview of the different kinds of services offered.

No matter the kind of gender-affirming medical intervention that a patient undergoes, it is essential that they have a strong support system. For example, while surgery can bring many long-term benefits, patients will need the presence of loved ones to complete daily tasks and provide emotional support if they experience temporary post-operative depression during recovery. 

Medical Interventions

Medical forms of gender-affirming care include surgical and non-surgical treatments. 

Non-surgical Forms of Gender-Affirming Care

• • Hormone replacement therapy (HRT) can involve taking testosterone, estrogen, progesterone and/or any combination of testosterone blockers (also called anti-androgens) at full dosages or microdosing. HRT can have several permanent and reversible effects on a patient, which can include deepening voice, changes in body hair, fat distribution, libido, sexual function and more. Generally speaking, HRT has the possibility of impairing fertility, which is why patients should look into fertility preservation options beforehand. 

• Hair removal and hair transplants can involve undergoing laser hair removal, electrolysis, or hair implant procedures to alter the hairline, remove or reduce hair on the body and/or prepare for bottom surgery.

• Psychotherapy and other forms of accompaniment from a gender-competent professional can help a patient come to terms with their identity, explore their gender, cope with the changes that transition can bring to their life and more. In order to qualify for and/or secure insurance coverage for certain types of gender-affirming surgery, you may need to provide one or more letters of support from a licensed mental health professional.

• Gender-affirming vocal therapy helps patients reach their gender embodiment goals around the use of their voice. Vocal therapy from a qualified, gender-competent provider can help patients make adjustments to the pitch, resonance and other features of their speaking and/or singing voice. 

Surgical Forms of Gender-Affirming Care

• Top surgery refers to surgeries that change the contour of a patient’s chest to align with their gender. This can include chest reconstruction and breast reduction surgeries that flatten or reduce the volume of the chest. Conversely, breast augmentation surgery increases the volume of the breasts through the placement of silicone or saline implants.

• Bottom surgery refers to a series of genital reconstruction surgeries that change the appearance and/or sexual function of a patient’s genitals. These include patients that construct a penis, such as different metoidioplasty and phalloplasty options. Patients can also have their natal genital tissue removed through a hysterectomy, vaginectomy, oophorectomy, ochiectomy or scrootoectomy. Finally, there is another set of bottom surgery procedures that can construct a vulva with or without a functional vaginal canal. Vaginoplasties require lifelong dilation to maintain.

• Facial surgery, such as facial feminization surgery (FFS) and facial masculinization surgery (FMS) encompass a variety of procedures that seek to alter the appearance of the upper, middle and lower thirds of the face. Patients can choose from procedures that permanently adjust the appearance of their hairline, forehead contour, nose, cheeks, lips, chin, jaw and trachea or Adam’s Apple.

• Body contouring covers a variety of skin-excision, liposuction and fat grafting procedures that patients can choose from. These can alter the shape of the body through changes in soft tissue: fat distribution and/or by eliminating unwanted skin overhang.

• Vocal feminization surgery involves making changes to the vocal cords with the goal of elevating a patient’s pitch. 

Psychological Support

Gender-affirming therapy is an approach to psychotherapy that seeks to accompany gender-diverse individuals without pathologizing their gender identities or seeing them as problematic. Rather, these therapeutic approaches deal with themes like trauma, shame, depression, violence, sexuality and others through accepting and affirming their gender identity. 

Licensed mental health professionals are a crucial part of the surgical transition process for many patients. While many patients can access surgery through an informed consent process, others may need to present a support letter from a licensed mental health professional to qualify for and/or secure insurance coverage for their procedure.

Due to costs and other barriers, many trans, non-binary and gender diverse individuals have a hard time accessing psychotherapy with a gender-competent provider. Regardless of whether or not this is the case for you, many of our patients benefit from participating in support groups, programming for gender diverse people at local LGBT+ centers and free hotline support services. For more information on these resources, click here.

Barriers to Accessing Gender Affirming Care

• Financial constraints: For many gender diverse individuals, the costs of therapy, surgery and other forms of medical care are barriers to access. You can find a list of trusted medical creditors and organizations that provide grants to finance the costs of your surgery here. Please note that most surgeons do not offer payment plans for after surgery. That said, some psychotherapists may offer more flexible options such as sliding scale payments that adjust to financial need.
• Location and Accessibility: Gender-affirming medical providers are often concentrated in larger cities where there are higher costs of living. Trans people that live outside of major urban centers and/or outside of states with protections for gender-affirming care may face difficulties accessing care for this reason. We have compiled a free guide on trans friendly resources and savings tips for patients who are traveling into the San Francisco Bay Area for surgery.
• Stigma and Discrimination: Lack of acceptance from family members on top of negative attitudes toward and misunderstandings about gender diversity from providers can make it difficult for trans, non-binary and gender non-conforming folks to access medically necessary care. 

Legal and Policy Considerations

Currently, in the United States, 14 states and Washington D.C. have passed laws protecting access to gender-affirming medical care for trans, non-binary and gender diverse patients. Often called “shield laws,” they offer legal protection for individuals and their families that travel to other states to receive this care so they cannot be criminalized for doing so in their home state. As of late 2024, it is estimated that only 38% of trans youth–children and adolescents–live in states with these “shield laws.”

Despite healthcare to qualified trans minors being established by experts in healthcare as a best practice, 26 states in the U.S. have instated legal restrictions on gender-affirming care for minors. An estimated almost 40% of trans youth in the U.S. live in states with gender-affirming care bans for minors, of which six have made providing this type of care a felony.

Given this political climate, many gender diverse individuals travel to states like California to receive gender-affirming medical care. The California legislature passed the Transgender, Gender Diverse, and Intersex (TGI) Inclusive Care Act, which not only outlaws healthcare discrimination on the basis of gender identity, but also obligates insurance companies operating in the state to cover certain forms of gender-affirming care.

How to Find Gender Affirming Care Providers

Generally speaking, a great place to start to look for the gender-affirming care providers is the list of WPATH members. This directory is a multi-disciplinary list of providers that have education and training that qualifies them to work with trans, non-binary and/or gender non-conforming individuals.

For some patients, it can be difficult to find a gender-competent mental health professional to support them through gender transition, or more specifically, to get a support letter for surgery. Though it may take time, finding someone you are comfortable with is worth the effort. Patients can also consult the directory of the Gender Affirmative Letter Access Project (GALAP) to find a gender-competent, licensed mental health provider. Additionally, there are multiple online therapist directories that can filter for experience working with transgender individuals, the types of insurance they take, and their current availability.

If you have gender-affirming therapists in your area then this will help tremendously. If not, you can pick someone who is committed to learning, or look into support groups and online resources. If you cannot afford therapy, consider reaching out to health centers or local LGBTQ centers for free or low-cost options.