Figure. Nonbinary refers to people who may identify somewhere along the spectrum of the gender binary or somewhere outside of it. This may include people who experience indigenous and non-Western genders (eg, 2-spirit, hijra, Fa’afafine), people with more than 1 gender (eg, bigender, pangender), people who do not identify with any gender (agender), people with a neutral gender identity (neutrois), people with a gender that changes over time (eg, genderfluid, genderflux), and people with a partial connection to a gender (eg, demiboy, demigirl). Some nonbinary individuals also identify as transgender while others do not. Reprinted with permission from Walker, 2020; https://twitter.com/galacticjonah/status/1277648104427335685.

Introduction

The World Professional Association for Transgender Health (WPATH) released their Standards of Care (SOC), version 8 in September 2022 featuring clinical guidance and evidence-based recommendations, a major update since the SOC7 (released in 2012).¹ SOC8 lays the framework for establishing transgender and gender-diverse care in a culturally competent manner; as the transgender and gender-diverse community continues to change, it is imperative to evolve with the community. Herein, we summarize the pertinent updates for the urological community, including guidelines on culturally sensitive and appropriate terminology, gender-affirming fertility care and surgery, and care for the nonbinary patient.

Gender-affirming Fertility Care

Urologists have a role in counseling patients on reproductive and sexual health. Patients should be informed of the potential effects of hormonal and surgical therapies, the limited literature available, and the unknown reversibility of infertility upon hormone cessation. As such, fertility preservation should be discussed and offered. WPATH advises that gender-affirming care should not be denied if the patient elects against fertility preservation. In the appropriately counseled patient, it is reasonable to proceed with gonadectomy without fertility preservation. The impact of all gender-affirming treatments on sexual function, pleasure, and satisfaction should be discussed, with counseling including sexual partners when appropriate. Assessing expectations and level of understanding is critical for successful communication.

Updates on Genital Gender-affirming Surgery and Postoperative Care

SOC8 describes several key changes in the recommendations for genital gender-affirming surgery (gGAS; see Table). These changes are important for urologists performing gGAS, referring patients for gGAS, or providing general urological care for patients after gGAS.

Table. Comparing Major Changes in Terminology, Preoperative Considerations, and Surgical Factors Between World Professional Association for Transgender Health Standards of Care, Versions 7 and 8

Terminology has shifted from sex reassignment (SOC7) to gender-affirming surgery (SOC8). Similarly, “assigned female at birth” and “assigned male at birth” are used instead of female-to-male and male-to-female, respectively. SOC8 highlights the need for advanced training and documented supervision for gGAS. Surgeons should maintain a robust practice in gGAS and track surgical outcomes.

SOC8 advises surgeons to prepare patients for the complexity of gGAS aftercare. Due to the paucity of surgeons familiar with gGAS, many patients need to travel and remain in town for the immediate recovery period. Patients need to be flexible with travel should problems arise. It is imperative that patients have safe, stable housing and resources to perform aftercare; should complications arise, this allows for prompt intervention to prevent long-term morbidity.

Furthermore, gender-affirming hormone therapy (GAHT) is not required for surgery unless necessary to achieve the surgical result, ie testosterone therapy for clitoral growth before metoidioplasty. If GAHT is prescribed, SOC8 recommends patients be on a stable hormone regimen for a minimum of 6 months prior to surgery, instead of the 12 months recommended in SOC7. Additionally, 12 months of social transition is no longer required prior to gGAS, as many patients may not desire or be able to safely pursue social transition. Finally, SOC8 reduced the number of letters of support. If needed, 1 letter from a qualified health care professional (HCP) would suffice. Previously, 2 mental health care providers’ letters were needed. These changes are a shift from rigid SOC7 criteria to more flexible recommendations that are in line with the diversity seen in the transgender and gender-diverse population. However, these guideline changes may not be reflective of requirements adopted by insurance providers.

Nonbinary Patients and Gender-affirming Care

SOC8 is the first version of WPATH guidelines to include a chapter on care for nonbinary individuals (see Figure). As roughly 25% to 50% of the transgender population identify as nonbinary, it is important for HCPs to understand that nonbinary patients may need gender-affirming care. The need for care cannot be predicted by someone’s gender role, expression, or identity.

Nonbinary people have difficulty accessing care due to a lack of support and understanding within the medical community. WPATH recommends that HCPs make it clear that nonbinary people are welcome. For example, have a process for check-in that does not require legal names, have gender-neutral restroom facilities, and ask pronouns (do not assume that all nonbinary patients use “they/them”). Be aware that nonbinary patients are even less likely than binary transgender patients to seek fertility care; therefore, inclusive language is particularly important when discussing fertility options with this patient population.

WPATH recommends that HCPs provide nonbinary people with individualized assessment and treatment. Providers should use open-ended discussion to understand patient goals and should avoid making assumptions about any patient’s desire for care. They recommend that gender-affirming interventions, including hormonal treatment or surgery, be considered for nonbinary people in the absence of “social gender transition.” Nonbinary genders have not been visible in Western culture. It is difficult or impossible for patients to occupy a social role that is not widely accepted or understood. Therefore, it is unethical to insist that patients present a certain social gender role as a prerequisite for care, a paradigm shift from prior guidelines that recommended social transition prior to gender-affirming interventions.

WPATH recommends that surgical interventions be considered in the absence of hormonal treatment unless hormone therapy is required to achieve the surgical result. Some nonbinary patients may not desire hormonal changes but may seek surgical intervention. For patients who elect not to pursue GAHT before surgery, surgeons should review the impact of this on the desired surgery. There is a need for further research and discussion regarding how a lack of GAHT may affect surgical outcomes.

In regard to customized gender-affirming surgical options such as penis-preserving vaginoplasty, WPATH recognizes that evidence on outcomes and complications is limited. They recommend that patients may pursue these surgeries after careful discussion with a multidisciplinary team where the patient understands the limitations of the data on these newer surgical options. The authors anticipate that these newer procedures will continue to be at the forefront of gender-affirming urological care, and that urologists will have a unique role to play in this field as we come to understand and treat the urological sequelae and complications from new surgical procedures.

Conclusion

The authors applaud the efforts of WPATH to bring evidence into the forefront of this update, providing context and better understanding for the recommendations in SOC8. SOC8 acknowledges the potential gatekeeping and breach in patient autonomy in previous requirements for gGAS. Newer recommendations have decreased letter and GAHT duration requirements, which may mitigate problems with access to medical and surgical gender-affirming care. These recommendations may generate questions to providers as insurance requirements do not yet reflect these changes.

As seen in the robust chapters regarding culturally sensitive terminology, SOC8 acknowledges the need for individualized care and recognizes the gender identities spectrum. This moves to dispel the one-size-fits-all concept for gGAS.