Gender incongruence is characterized by incongruity between one's own gender identity and the gender assigned at birth or perceived by others. Transgenderism (formerly transsexualism) refers to the strongest manifestation of gender incongruity. In most cases, the gender identity of a transgender person is that of a man or a woman, but it may also be non-binary, for example (see also Non-Binary Gender Identity).
Transgenderism is associated with distress because the individual, due to his or her physical characteristics, is not treated as a representative of the gender he or she identifies with and cannot therefore live in a gender role with which he or she identifies. The sexual anatomy of the body also feels alien and inappropriate.
Transgenderism that causes distress is treated with sex reassignment therapy. The aim is to bring body characteristics and anatomy closer to those of the gender with which the person identifies, as well as to facilitate integration into the social role of the opposite sex.
Investigations and surgery are often only available in specialist centres.
Transgenderism is becoming obsolete as a diagnostic concept. In ICD-11, the name of the diagnosis has been changed to gender incongruence and the diagnostic criteria take into account more extensively than before individuals suffering from various kinds of gender-related experiences of incongruence.
No genuine population studies to determine the prevalence of transgenderism are available.
Studies of the prevalence of all variations of experienced gender identity carry some uncertainty. Based on many results, approx. 0.6-4% of people have a gender identity that is not completely consistent with the gender entered in the population register. Not all individuals seek examination or sex reassignment.
Many theories prevail about the aetiology of transgenderism ranging from psychosocial to biological (for example, the differentiation of brain structures controlling sexual behaviour proceeding along a developmental pathway inconsistent with the rest of the body).
Diagnosis
Addresses mainly the differential diagnosis of gender identity disorders.
Individuals with mental health disorders, rather than transgenderism, should be identified and referred to appropriate care.
Multiprofessional team approach
In Finland, patients below 18 years of age are examined by an adolescent psychiatric team and those of 18 years or over by an adult psychiatric team.
Outpatient investigations usually go on for several months, often more than a year.
In the end, an individually tailored care pathway is drawn up together with the patient (aims, interventions). Some individuals do not wish to undergo all the treatment available.
For referral, it is advisable to utilize the instructions locally available by relevant specialist units and services.
In Finland, the patient can be referred by any physician licensed in Finland but most appropriately by the physician who best knows the patient's overall mental status.
Social and legal aspects of gender transition
When transgender individuals feel the time is right, they start to openly live in their preferred gender role and, at the same time, usually acquire gender-appropriate first names. Social gender transition overlaps with physical sex reassignment therapy.
International guidelines usually stipulate that the individual must function in his or her preferred gender role continuously for about 12 months (real-life test, RLT) before the gender is officially confirmed. However, the length of the RLT period should be agreed on individually. After this period, an assessment should be made as to whether the individual has benefited from the gender transition so far, and whether he or she wishes to have a gender-appropriate personal identity number).
In Finland, there are two separate units doing gender identity examinations. Official confirmation of the legal gender requires positive opinions based on personal examination performed by psychiatrists from both of these units, and an infertility certificate provided by a gynaecologist.
An application for a new personal identity number must be submitted to the local registry office.
Physical sex reassignment therapy
Most treatments that result in permanent changes (particularly surgical treatments) are available for adult patients only.
Based on individual judgement, hormone therapies may be started in minors as well.
Hormone therapy
After a comprehensive psychiatric evaluation, a psychiatrist usually refers the individual to a (gynaecologist) endocrinologist for initiation of hormone therapy.
If a gynaecological, or andrological, examination and laboratory tests reveal no contraindications to hormone therapy, a female-to-male (FtoM) transgender patient is started on testosterone treatment and a male-to-female (MtoF) transgender patient usually on oestrogen and an anti-androgen product.
Hormone therapy that permanently alters the sexual characteristics can be started from the age of 16 years onwards. In younger persons, suppression of puberty may be considered.
The duration of hormone therapy is long, and after the initial phase the monitoring may be carried out in a healthcare facility other than the hospital where the treatment was started, i.e. usually within primary care.
Chest reconstruction surgery
The majority of FtoM transgender people benefit from breast reduction surgery, which is often the only surgical procedure they wish for.
If, despite sufficiently long hormone therapy (lasting for at least 2-3 years), the breasts of an MtoF transgender person are not large enough to pass as female sexual characteristics, augmentation surgery is warranted.
Surgery is usually performed in specialized centres.
Voice, body hair and facial surgery
Hormone therapy does not alter the voice of MtoF transgender people, and the majority will need to be assessed for voice therapy by a phoniatrician and will often need speech therapy. If voice feminisation is not achieved with conservative methods, vocal cord surgery may be considered. A referral for surgery is usually made by the treating phoniatrician.
MtoF transgender individuals require the removal of masculine body hair since hormone therapy has little effect on hair growth. The availability of treatments such as laser epilation, intense pulsed light or electrical epilation (the last carried out by a beautician/aesthetician) and their reimbursement policies may vary between health care systems.
A small portion of MtoF transgender people would benefit from facial surgery to feminise a masculine nose, jaw or forehead. Depending on national practice, the public healthcare system may or may not cover this.
Genital surgery
Genital reconstruction surgery is usually carried out towards the end of the gender transition process.
In Finland, referral for such surgery requires positive opinions from psychiatrists in both specialized units examining gender identity.
In Finland, surgery is organized in the following manner:
Reconstruction of the external genitals is centralized to one spezialized centre.
In FtoM surgery, the first phase includes removal of the vagina at either of the two specialized centres (department of gynaecology and obstetrics); the uterus and ovaries are usually removed at the same time.
Removal of only the uterus and ovaries may also be performed in the individual's own hospital district if the individual is not planning to later seek surgery to reshape the external genital organs. Removal of the vagina alone after removal of the uterus and ovaries is a very arduous procedure.
A considerable share of FtoM transgender people choose not to proceed with external genital reconstruction surgery. Several surgical techniques have been developed, and the method chosen usually represents a compromise depending on the patient's wishes and body structure, among other factors.
MtoF transgender people seek genital reconstruction surgery more frequently than FtoM transgender people.
Aids and appliances
Depending on the national reimbursement policies, when requirements for providing aids and appliances are met, a transwoman can be provided with a wig, and a transman with a penile or erection prosthesis. Breast prostheses or binders may be medically justifiable alternatives to chest surgery.
In Finland, Ministry of Social Affairs and Health Council for Choices in Health Care (COHERE), the outlined that when the criteria for the provision of medical rehabilitation aids are met, the aforementioned aids and appliances may be provided within public health care, based on individual assessment http://palveluvalikoima.fi/documents/1237350/22895838/Summary+transgender.pdf.
Psychosocial support
Gender transition is a demanding process, and some transgender people are in need of psychosocial support during the transition period. A supportive therapeutic relationship or other support should be arranged near the person's place of residence, if possible, perhaps at a mental health clinic, child guidance and family counselling centre or psychiatric outpatient clinic.
Various associations offer training, family interventions and psychosocial support, as well as counselling and support for legal problems or discrimination, for instance. Transgender individuals have also formed peer groups, and many find support from internet discussion groups.
Follow-up and prognosis
Follow-up at a gender identity research unit occurs less frequently after the initial assessment phase, and will gradually terminate after the interventions recorded in the individual care pathway have been completed.
The monitoring of long-term hormone therapy can be allocated, with accompanying instructions, to primary or occupational healthcare providers.
No other follow-up is indicated. Specialist centres can be consulted if necessary.
Sex reassignment therapy is a holistic and rehabilitative process which, at its best, greatly eases the suffering caused by a gender conflict and improves the individual's functional capacity.
Complications of the physical interventions, not having received all the necessary treatment, possible experiences of discrimination or lack of support from the surrounding community may all impair the person's quality of life, but even so only very few transgender people regret sex reassignment. Any patient expressing regret over the treatment process should be referred to a unit coordinating such treatment for assessment of possible reverse sex reassignment and planning of treatments supporting this.
References
Kuyper L, Wijsen C. Gender identities and gender dysphoria in the Netherlands. Arch Sex Behav 2014;43(2):377-85. [PubMed]
Kaltiala-Heino R, Lindberg N. Gender identities in adolescent population: Methodological issues and prevalence across age groups. Eur Psychiatry 2019;55():61-66. [PubMed]