{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,23]],"date-time":"2026-09-23T20:51:38Z","timestamp":1790196698770,"version":"4.1.0"},"reference-count":36,"publisher":"Public Library of Science (PLoS)","issue":"8","license":[{"start":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T00:00:00Z","timestamp":1660780800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Blue Cross Blue Shield of Michigan Foundation, Physician Investigator Research Award","award":["#002761.PIRAP"],"award-info":[{"award-number":["#002761.PIRAP"]}]},{"name":"National Institutes for Minority Health and Health Disparities","award":["#K23 MD016950"],"award-info":[{"award-number":["#K23 MD016950"]}]},{"name":"University of Michigan Institute for Research on Women and Gender, Faculty Seed Grant"}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>Gender-affirming hormones (GAH)\u2014the use of sex hormones to induce desired secondary sex characteristics in transgender individuals\u2014is vital healthcare for many transgender people. Among prescribers of GAH, there is debate regarding the value of a universal requirement for an evaluation by a mental health provider prior to GAH initiation. The purpose of this qualitative study was to describe the range of attitudes and approaches to mental health evaluation among GAH providers in the United States. We analyzed the providers\u2019 attitudes and base our recommendations on this analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted semi-structured interviews with 18 healthcare providers who prescribe GAH across the United States. Participants were purposefully recruited using professional networks and snowball sampling to include those who require mental health evaluation and those who do not. We adapted domains from the Theoretical Domains Framework\u2014a framework for understanding influences on health professional behavior\u2014to inform the interviews and analysis. Guided by these domains, we iteratively coded text and identified theoretical relationships among the categories.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>While some felt a universal requirement for mental health \u201cclearance\u201d was necessary for the identification of appropriate candidates for GAH, others described this requirement as a form of \u201cgatekeeping\u201d that limits access to care. Themes we identified included providers\u2019 ability to ascertain gender identity; concern about mental illness; GAH provider and mental health provider expertise; and provider roles. All providers appreciated the potential advantages of mental health support during GAH treatment.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Providers in our study practice on a continuum of care rather than adhering to strict rules about the requirement for mental health evaluation prior to GAH treatment. Where they fall on this continuum is influenced primarily by their perceptions of transgender identity and transition, and their interpretation of risk for significant mental illness and its association with transness. Providers who required universal evaluation by a mental health professional tended to hold essentialist, medicalized, and binary ideas of gender and transness.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0271785","type":"journal-article","created":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T13:42:25Z","timestamp":1660830145000},"page":"e0271785","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":14,"title":["Initiating gender-affirming hormones for transgender and non-binary people: A qualitative study of providers\u2019 perspectives on requiring mental health evaluations"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1205-3217","authenticated-orcid":true,"given":"Daphna","family":"Stroumsa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leah A.","family":"Minadeo","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mariam","family":"Maksutova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Molly B.","family":"Moravek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rob","family":"Stephenson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paul N.","family":"Pfeiffer","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Justine P.","family":"Wu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2022,8,18]]},"reference":[{"key":"pone.0271785.ref001","volume-title":"In: The Williams Institute [Internet]","author":"AR Flores","year":"2016"},{"key":"pone.0271785.ref002","volume-title":"The Report of the 2015 U.S. Transgender Survey","author":"SE James","year":"2016"},{"issue":"6","key":"pone.0271785.ref003","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1097\/AOG.0b013e31823ed1c1","article-title":"Committee Opinion no 512: health care for transgender individuals","volume":"118","author":"Committee on Health Care for Underserved Women","year":"2011","journal-title":"Obstet Gynecol"},{"issue":"4","key":"pone.0271785.ref004","doi-asserted-by":"crossref","first-page":"759","DOI":"10.1007\/s10508-012-9975-x","article-title":"Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder","volume":"41","author":"W Byne","year":"2012","journal-title":"Arch Sex Behav"},{"issue":"4","key":"pone.0271785.ref005","first-page":"e20182162","article-title":"Health Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents","volume":"142","author":"J Rafferty","year":"2018","journal-title":"Pediatrics"},{"issue":"11","key":"pone.0271785.ref006","doi-asserted-by":"crossref","first-page":"3869","DOI":"10.1210\/jc.2017-01658","article-title":"Endocrine Treatment of Gender-Dysphoric\/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline","volume":"102","author":"WC Hembree","year":"2017","journal-title":"J Clin Endocrinol Metab"},{"issue":"1","key":"pone.0271785.ref007","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1089\/trgh.2015.0008","article-title":"A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals","volume":"1","author":"JM White Hughto","year":"2016","journal-title":"Transgend Health"},{"issue":"7","key":"pone.0271785.ref008","doi-asserted-by":"crossref","first-page":"2635","DOI":"10.1007\/s10508-020-01655-5","article-title":"Social and Medical Gender Affirmation Experiences Are Inversely Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults","volume":"49","author":"JMW Hughto","year":"2020","journal-title":"Arch Sex Behav"},{"key":"pone.0271785.ref009","doi-asserted-by":"crossref","first-page":"100470","DOI":"10.1016\/j.jemep.2020.100470","article-title":"The peculiar case of the Standards of Care: Ethical ramifications of deviating from informed consent in transgender-specific healthcare","volume":"13","author":"M. Lipshie-Williams","year":"2020","journal-title":"Ethics Med Public Health"},{"issue":"12","key":"pone.0271785.ref010","doi-asserted-by":"crossref","first-page":"824","DOI":"10.1136\/medethics-2019-105611","article-title":"Hormone replacement therapy: informed consent without assessment?","volume":"45","author":"TC Saad","year":"2019","journal-title":"J Med Ethics"},{"issue":"11","key":"pone.0271785.ref011","doi-asserted-by":"crossref","first-page":"1079","DOI":"10.1001\/journalofethics.2016.18.11.ecas2-1611","article-title":"Should Mental Health Screening and Psychotherapy Be Required Prior to Body Modification for Gender Expression?","volume":"18","author":"TF Murphy","year":"2016","journal-title":"AMA J Ethics"},{"issue":"11","key":"pone.0271785.ref012","doi-asserted-by":"crossref","first-page":"1147","DOI":"10.1001\/journalofethics.2016.18.11.sect1-1611","article-title":"Informed Consent in the Medical Care of Transgender and Gender-Nonconforming Patients","volume":"18","author":"T Cavanaugh","year":"2016","journal-title":"AMA J Ethics"},{"issue":"1","key":"pone.0271785.ref013","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1016\/j.jsxm.2020.10.020","article-title":"The Informed Consent Model of Care for Accessing Gender-Affirming Hormone Therapy Is Associated With High Patient Satisfaction","volume":"18","author":"C Spanos","year":"2021","journal-title":"J Sex Med"},{"key":"pone.0271785.ref014","volume-title":"Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People","author":"World Professional Association for Transgender Health","year":"2011","edition":"7"},{"key":"pone.0271785.ref015","volume-title":"The Diagnostic and Statistical Manual of Mental Disorders","year":"2013","edition":"5"},{"issue":"3","key":"pone.0271785.ref016","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1080\/15532739.2011.675233","article-title":"Use of the Informed Consent Model in the Provision of Cross-Sex Hormone Therapy: A Survey of the Practices of Selected Clinics","volume":"13","author":"MB Deutsch","year":"2012","journal-title":"Int J Transgend"},{"issue":"7","key":"pone.0271785.ref017","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1136\/medethics-2018-105293","article-title":"Gatekeeping hormone replacement therapy for transgender patients is dehumanising","volume":"45","author":"F. Ashley","year":"2019","journal-title":"J Med Ethics"},{"issue":"11","key":"pone.0271785.ref018","doi-asserted-by":"crossref","first-page":"1132","DOI":"10.1001\/journalofethics.2016.18.11.msoc1-1611","article-title":"Understanding Transgender and Medically Assisted Gender Transition: Feminism as a Critical Resource","volume":"18","author":"JL Nelson","year":"2016","journal-title":"AMA J Ethics"},{"key":"pone.0271785.ref019","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1186\/s40985-020-0118-y","article-title":"Trans health care from a depathologization and human rights perspective","volume":"41","author":"A. Suess Schwend","year":"2020","journal-title":"Public Health Rev"},{"issue":"24","key":"pone.0271785.ref020","doi-asserted-by":"crossref","DOI":"10.3390\/ijerph16245088","article-title":"Health Needs of Trans and Gender Diverse Adults in Australia: A Qualitative Analysis of a National Community Survey","volume":"16","author":"S Zwickl","year":"2019","journal-title":"Int J Environ Res Public Health"},{"issue":"1","key":"pone.0271785.ref021","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1177\/0022167817745217","article-title":"The Informed Consent Model of Transgender Care: An Alternative to the Diagnosis of Gender Dysphoria","volume":"58","author":"SL Schulz","year":"2018","journal-title":"J Humanist Psychol"},{"issue":"1","key":"pone.0271785.ref022","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1136\/qshc.2004.011155","article-title":"Making psychological theory useful for implementing evidence based practice: a consensus approach","volume":"14","author":"S Michie","year":"2005","journal-title":"Qual Saf Health Care"},{"issue":"2","key":"pone.0271785.ref023","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1191\/1478088706qp063oa","article-title":"Using thematic analysis in psychology","volume":"3","author":"V Braun","year":"2006","journal-title":"Qual Res Psychol"},{"issue":"4","key":"pone.0271785.ref024","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1542\/peds.2013-2958","article-title":"Young adult psychological outcome after puberty suppression and gender reassignment","volume":"134","author":"AL de Vries","year":"2014","journal-title":"Pediatrics"},{"issue":"4","key":"pone.0271785.ref025","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1097\/MOP.0000000000000240","article-title":"Transgender and gender nonconforming adolescent care: psychosocial and medical considerations","volume":"27","author":"C Guss","year":"2015","journal-title":"Curr Opin Pediatr"},{"issue":"3","key":"pone.0271785.ref026","first-page":"215e21","article-title":"The desire to have children and the preservation of fertility in transsexual women: A survey","volume":"6","author":"P De Sutter","year":"2002","journal-title":"Int J Transgend"},{"key":"pone.0271785.ref027","volume-title":"Transgender History","author":"S. Stryker","year":"2008"},{"issue":"11","key":"pone.0271785.ref028","doi-asserted-by":"crossref","first-page":"996","DOI":"10.1097\/NMD.0000000000000046","article-title":"Hormonal therapy is associated with better self-esteem, mood, and quality of life in transsexuals","volume":"201","author":"A Gorin-Lazard","year":"2013","journal-title":"J Nerv Ment Dis"},{"issue":"8","key":"pone.0271785.ref029","doi-asserted-by":"crossref","first-page":"727","DOI":"10.1176\/appi.ajp.2019.19010080","article-title":"Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study","volume":"177","author":"R Branstrom","year":"2020","journal-title":"Am J Psychiatry"},{"issue":"1","key":"pone.0271785.ref030","first-page":"11","article-title":"Effects of Gender Reassignment on Quality of Life and Mental Health in People with Gender Dysphoria","volume":"29","author":"B Ozata Yildizhan","year":"2018","journal-title":"Turk Psikiyatri Derg"},{"issue":"4","key":"pone.0271785.ref031","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1016\/j.ucl.2019.07.002","article-title":"A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery","volume":"46","author":"JA Wernick","year":"2019","journal-title":"Urol Clin North Am"},{"issue":"4","key":"pone.0271785.ref032","doi-asserted-by":"crossref","first-page":"773","DOI":"10.1016\/j.ecl.2015.08.001","article-title":"Psychological Outcomes and Reproductive Issues Among Gender Dysphoric Individuals","volume":"44","author":"L Schmidt","year":"2015","journal-title":"Endocrinol Metab Clin North Am"},{"issue":"3","key":"pone.0271785.ref033","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1089\/lgbt.2016.0151","article-title":"Mental Health Concerns and Insurance Denials Among Transgender Adolescents","volume":"4","author":"L Nahata","year":"2017","journal-title":"LGBT Health"},{"issue":"4","key":"pone.0271785.ref034","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1016\/j.jadohealth.2015.04.027","article-title":"Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria","volume":"57","author":"J Olson","year":"2015","journal-title":"J Adolesc Health"},{"issue":"2","key":"pone.0271785.ref035","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1891\/0886-6708.VV-D-14-00082","article-title":"Sexual Victimization and Subsequent Police Reporting by Gender Identity Among Lesbian, Gay, Bisexual, Transgender, and Queer Adults","volume":"31","author":"L Langenderfer-Magruder","year":"2016","journal-title":"Violence Vict"},{"issue":"4","key":"pone.0271785.ref036","doi-asserted-by":"crossref","first-page":"398","DOI":"10.1111\/medu.13796","article-title":"Transphobia rather than education predicts provider knowledge of transgender health care","volume":"53","author":"D Stroumsa","year":"2019","journal-title":"Med Educ"}],"container-title":["PLOS ONE"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0271785","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,8,18]],"date-time":"2022-08-18T13:43:04Z","timestamp":1660830184000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pone.0271785"}},"subtitle":[],"editor":[{"given":"Vanessa","family":"Carels","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2022,8,18]]},"references-count":36,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2022,8,18]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pone.0271785","relation":{},"ISSN":["1932-6203"],"issn-type":[{"value":"1932-6203","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,8,18]]}}}