psychiatric disorders
Gender Incongruence and Gender Dysphoria
Treatment of Gender Dysphoria
For many adults or adolescents, gender-affirming hormone therapy and sometimes gender-affirming surgeries (breast, genital, or facial surgery) Sometimes other treatments (eg, voice therapy, electrolysis) Psychotherapy with adolescents and adults is often helpful to address coexisting mental health concerns, transition-related issues, and other problems, but is not mandatory to access medical and/or surgical treatments for gender dysphoria. The goal of treatment for transgender persons, according to WPATH, is to achieve "lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfilment" ( Treatment references ). Gender-nonconforming or gender-incongruent behavior, such as cross-dressing, is not considered a disorder and does not require treatment if it occurs without concurrent gender dysphoria (clinically significant psychologic distress or functional impairment). When treatment is required, it is aimed at relieving patients' distress and helping them adapt to rather than trying to dissuade them from their identity. Using psychotherapy to try to "convert" a person's established transgender identity (so-called reparative therapy or conversion therapy) is not only ineffective but can be harmful to patients, is considered unethical, and is illegal in some jurisdictions. For most persons with gender dysphoria, the primary objective in seeking medical help is not to obtain mental health treatment, but to obtain gender-affirming treatments in the form of hormone therapy and/or gender-affirming surgery (previously known as sex reassignment or genital surgery) to make their physical appearance consistent with their gender identity. When gender dysphoria is appropriately diagnosed and treated, the psychologic distress may resolve with a combination of psychotherapy, gender-affirming hormone therapy, and gender-affirming surgeries ( Treatment references ). Surgery may help certain patients achieve greater adaptation and life satisfaction. Most experts recommend surgery only for patients who have been assessed by an appropriately trained and experienced clinician and who have been treated according to the current WPATH Standards of Care. Clinicians often advise patients to live in their preferred gender role for a year before having irreversible genital surgery. Fertility-preservation techniques, such as embryo, oocyte, or sperm cryopreservation or delaying initiation of gender-affirming hormonal treatments, should be discussed prior to treatment ( Treatment references ). Studies have found that genital surgery has helped many people with gender dysphoria live happier and more productive lives. Based on these findings, this surgery is considered medically necessary in patients with gender dysphoria who are highly motivated and have been evaluated by appropriate experts and who have met the criteria outlined in the WPATH Standards of Care, version 8 ( Treatment references ). It should be noted that gender-affirming surgeries are not limited to genital interventions but may also include facial changes, vocal cord surgery, breast augmentation, laryngeal shave, or other nongenital surgeries. Although patients with gender dysphoria are no longer required to have psychotherapy before consideration for gender-affirming hormone therapy and surgical procedures, mental health professionals can do the following to help patients make informed decisions: Assess and treat comorbid disorders (eg, Depressive Disorders , Help patients deal with the negative effects of stigma (eg, disapproval, discrimination) Help patients find a gender expression that is comfortable If applicable, facilitate gender role changes, coming out (informing other people about one's transgender identity), and transitioning The decision of an individual to share information about their gender identity with family and the public, independent of desired treatments, is often fraught with potential social problems for patients ( Treatment references ). Such issues include the potential loss of family, spouse/partner, friends and the loss of employment or housing due to continued discrimination against gender-diverse persons. In some parts of the world, being publicly gender diverse is also illegal and subjects transgender persons to potential serious legal consequences, including imprisonment or execution. Participation in gender support groups, available in most large cities or through the internet, is often helpful, especially during the transition process. For transwomen, gender-affirming medical therapies consist offeminizing hormonesin moderate doses (eg,estradioltransdermal patch 0.1 to 0.2 mg/day or oralestradiol2 to 8 mg/day) with an anti-androgen (eg,spironolactone100 to 400 mg/day). This is typically combined with electrolysis, voice therapy, and other feminizing treatments. Feminizing hormones have significant beneficial effects on the symptoms of gender dysphoria, often before there are any visible changes in secondary sexual characteristics (eg, breast growth, decreased facial and body hair growth, redistribution of fat to the hips). Feminizing hormones, even without psychologic support or surgery, are enough to make some patients feel sufficiently comfortable as women. Gender-affirming surgeryis requested by an increasing number of transwomen. Although there are several approaches, the most common surgery involves removal of the penis and testes and creation of a neovagina. A part of the glans penis is retained as a clitoris, which is usually sexually sensitive and retains the capacity for arousal and orgasm in a majority of cases. Some patients also have nongenital, gender-affirming surgical procedures such as breast augmentation, facial feminization surgeries (eg, rhinoplasty, brow lift, hairline changes, jaw reconfiguration, tracheal cartilage shave [reduction of the laryngeal cartilage]), or vocal cord surgeries to change the quality of the voice. Since the 2010s, there have been increasing rates of gender-affirming surgeries in transmen ( Treatment references ). These individuals often request Hysterectomy and oophorectomymay be done after a course ofmasculinizing hormone therapy, including androgenic hormones (eg,testosteroneester preparations 50 to 100 mg intramuscularly or subcutaneously every week or equivalent doses oftestosteronetransdermal patches or gels) if tolerated.Testosteronepreparations permanently deepen the voice, induce a more masculine muscle and fat distribution, induce permanent clitoromegaly, and promote growth of facial and body hair. Some of these physical changes are permanent, even with discontinuation of treatment. treatments in transmen have been reported. Although fertility is potentially negatively impacted, patients assigned female at birth should be counseled that hormone therapy often does not induce sterility and that appropriate contraception should be used ( Treatment references ). Patients may opt for one of the following additional gender-confirming surgeries: An artificial phallus (neophallus) to be created from skin transplanted from the inner forearm, leg, or abdomen (phalloplasty) A micropenis to be created from fat tissue removed from the mons pubis and placed around thetestosterone-hypertrophied clitoris (metoidioplasty) With either procedure, scrotoplasty is usually also done; the labia majora are dissected to form hollow cavities to approximate a scrotum, and testes implants are inserted to fill the neoscrotum. Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for transwomen. This is the possible reason for fewer requests for genital gender-confirmation surgery from transmen; however, as techniques for phalloplasty continue to improve, requests for phalloplasty have increased. Surgical complications are common, especially in procedures that involve extending the urethra into the neophallus. These complications may include Introduction to Urinary Tract Infections (UTIs) , fistulae, In health care settings, nonbinary people are less likely to volunteer information about their gender identity than transgender patients; many have had negative experiences with health care professionals who attempt to treat them as though they are on a linear spectrum of gender identity (binary model), which is usually at odds with the patients' self-perception ( Treatment references ). Some nonbinary people seek gender-affirming medical and/or surgical treatments to alleviate gender dysphoria or incongruence symptoms associated with distress or functional impairment. Treatment goals must be thoroughly understood and the limitations of treatments must be clearly stated. For example, a nonbinary patient assigned male at birth may wish to achieve greater body satisfaction (eg, desired changes in skin, hair growth, fat distribution) through the use of estrogen therapy, but does not wish to develop breasts. These goals may be incompatible with the mechanisms of action of gender-affirming hormonal treatments. Long-term outcome data are lacking regarding medical and surgical treatments in nonbinary populations. and without the presence of their penis and/or testicles ( Treatment references ). Many individuals who identify as eunuchs do not describe themselves as transgender and view themselves as having a distinct gender identity as eunuchs. Eunuchs may seek out both medical and surgical interventions to eliminate the masculinizing effects of The psychosocial treatment of prepubertal children diagnosed with gender dysphoria remains controversial. Current information and guidelines regarding psychosocial treatments, including social transition, are reviewed in the WPATH Standards of Care, version 8 ( Treatment references ). No guidelines or standards endorse or recommend the use of hormonal interventions (puberty blockers or gender-affirming hormones) or gender-affirming surgeries in prepubescent children with a diagnosis of gender incongruence or gender dysphoria ( The majority of children who engage in gender-incongruent behaviors do not have a diagnosis of gender dysphoria or incongruence and do not continue into adolescence or adulthood with a transgender identity. Among young children with a diagnosis of gender dysphoria, at this point, it is not possible to reliably predict if these symptoms will continue into adulthood ( Treatment references ). While there is no clinical consensus on the treatment of prepubertal gender-dysphoric children, it is recognized that attempts to force the child to accept the birth-assigned gender role is usually traumatic and unsuccessful. Therefore, the predominant treatment modality is psychologic support and psychoeducation for children and their parents, using a gender-affirmative model as opposed to a gender-pathologizing model ( Treatment references ). This affirmative approach supports the child in their expressed gender, sometimes including one or more aspects of social transition prior to puberty. There has been a substantial increase in the number of adolescents assigned female at birth reporting for evaluation and clinical care over the past decade, and they now outnumber those assigned male at birth seeking care at most clinics ( Treatment references ). , thereby "blocking" the progression of puberty. These medications may be given at Sexual Maturation , enabling additional time for evaluation of the gender-dysphoric youth prior to permanent pubertal changes ( If a gender-dysphoric youth wishes to continue with full transition to a different gender and is assessed as appropriate for additional transition care, puberty-blocking agents may be discontinued and gender-affirming hormone therapy may be given, enabling the onset of a gender-congruent puberty. These treatments are offered only after evaluation by clinicians with specialized expertise in the diagnosis and management of gender dysphoria in adolescents; this is usually done with consent from parent(s)/guardians and assent from the adolescents (if they are under the age of legal adulthood in a given jurisdiction). 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