The finding:
Current guidelines from the World Professional Association for Transgender Health (WPATH) recommend a “Comprehensive biopsychosocial assessment” before initiating pubertal suppression. This article discusses the assessment framework for an adolescent who has reached at least Tanner stage 2 and is considering pubertal suppression.  When assessing transgender individuals, it is important to note that the primary goal is not to ascertain the patient’s authenticity but rather to offer information that aids decision-making for both the patient and their family. This process should encompass identifying and addressing crucial areas of support across medical, legal, social, and educational domains. Adherence to guidelines mandates establishing a diagnosis of gender dysphoria/gender incongruence before commencing pubertal suppression and evaluating for concurrent psychiatric conditions. A comprehensive assessment involves gathering a detailed history and timeline of gender identity development, including the patient’s views on gender roles and physical characteristics. Discussions should include treatment considerations, highlighting the reversible nature of pubertal blockers, future decisions on continuing or discontinuing therapy, and potential effects on fertility, bone health, and delayed puberty relative to peers. Furthermore, assessing the patient’s capacity to provide informed assent and consent based on the Applebaum criteria is essential for an informed and patient-centered approach.

Strength and weaknesses:
This assessment provides an ideal opportunity to emphasize several key points: Patients and families have diverse choices in gender expression, ranging from being cisgender and not conforming to gender roles to being transgender and considering pubertal suppression or choosing not to pursue it. The significance of the gender minority stress framework should also be highlighted, along with the acknowledgment of a small yet existing possibility of one’s gender identity evolving away from a transgender identity. While this offers a general framework for assessment, the actual process can vary significantly based on individual circumstances. For example, the discussion with an adolescent who socially transitioned in early childhood without mental health issues will differ greatly from that with an adolescent experiencing recent gender dysphoria, complex mental health challenges, or facing family or community rejection.

Relevance:
Mental health assessments may come up at multiple stages during gender-affirming medical care. If these assessments are inconsistent in approach, content or lack crucial elements, it creates barriers to care. This article focuses on current guidelines to ensure assessment of transgender youth or adults with awareness of the evidence base as well as patient experience during the process of gender affirming care.