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 sex-associated 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.
Terminology and concepts
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.
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 the diagnostic criteria in ICD-10, the gender identity of a transgender person is described as opposite to the gender assigned at birth (e.g., a person assigned the male gender at birth identifying as female).
If the gender identity is not unambiguously female or male, the term non-binary gender identity is used Non-Binary Gender Identity.
Prevalence and aetiology
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
Assessment of the appropriateness of physical sex reassignment therapy is often concentrated to specialized centres (e.g. gender identity clinics). Check local organization of care, as well as relevant policies and practices.
The assessment at a specialized centre aims to answer key questions concerning the patient, such as: Are the person's gender identity and overall situation sufficiently clear for assuming, based on scientific study and clinical experience, that they will benefit from irrevocable physical sex reassignment therapy, and can such therapy be provided safely?
Any support required to clarify the gender identity, and the diagnosis, treatment and rehabilitation of any coexisting psychiatric disorders are services that may be provided separately, e.g. regionally. Such challenges must be dealt with and the person's functional ability optimized before referring them to the specialized centre.
Investigations mainly address the differential diagnosis of gender identity disorders, i.e. assessment of the autonomy and self-conviction of the gender identity, as well as of any coexisting mental challenges and the correct timing of physical sex reassignment therapy.
Individuals with mental health disorders, rather than transgenderism, are identified and referred to appropriate care.
Multiprofessional team approach
Depending on the patient's age (e.g. below or over 18 years), they may be examined by an adolescent psychiatric team or by an adult psychiatric team. Check locally applied age limits.
Outpatient investigations usually go on for several months, often close to 2 years.
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.
Even if any physician could refer the patient, the patient should most appropriately be referred by a physician who best knows the patient's overall mental status and has the skills required for assessing their mental condition and functional ability.
For referral, it is advisable to utilize the instructions for referral available on the websites of units investigating gender identity as well as other locally relevant guidance.
Legal aspects of gender transition
There is country-specific variation in what procedures are needed for legal gender transition and recognition and how that is related to the medical gender assessment. Also, the required age of the patient and need for a medical certificate may vary. Check local policies.
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 can be 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 chest masculinization, 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 feminization is not achieved with conservative methods, vocal cord surgery may be considered. A referral for surgery is usually made by the treating phoniatrician. If the patient's Adam's apple is notably prominent, the phoniatrician may also refer them for thyroid cartilage reduction.
MtoF transgender individuals require the removal of masculine body hair since hormone therapy has little effect on hair growth. Such help may be available in the public service system only for facial hair, for example. Any treatment of masculine-type body hair must possibly be paid by the patients themselves. Check local policies.
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. It can be done after follow-up of at least one year after diagnosis.
In FtoM surgery, the first phase includes removal of the vagina; the uterus and ovaries are removed at the same time.
Removal of only the uterus and ovaries may also be performed in the individual's own regional health care 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.
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 clinic 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 incongruence 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 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]