- Gender dysphoria refers to the distress caused by the incongruity between gender identity and sex assigned at birth and not the experience of incongruity itself.
- Affected individuals have difficulties in multiple areas of function (e.g., social, academic) due to the incongruity between experienced gender and sex assigned at birth.
Tip
A transgender or gender diverse identity is not a mental disorder but may cause distress potentially leading to psychiatric disorders due to stigma, discrimination, and/or a sense of mismatch between gender assigned at birth and gender identity (e.g., gender dysphoria).
Management
- First-line / Initial Support:
- Psychological Support: Individual and family psychotherapy focused on affirmation, coping strategies, and family education.
- Social Transition: Completely reversible. Includes preferred name, pronouns, gender-affirming clothing/hair, and chest binding/genital tucking (with safe practice education).
- Adolescents (Pubertal Suppression):
- GnRH Agonists (e.g., Leuprolide, histrelin implant).
- Indication: Initiated at Tanner Stage 2 to pause development of irreversible secondary sex characteristics.
- Fully reversible; preserves future surgical options and allows time for cognitive/emotional maturation.
- Gender-Affirming Hormone Therapy (GAHT) (Partially Reversible):
- Fertility Preservation: Must discuss sperm cryopreservation or oocyte banking prior to initiation.
- Feminizing Therapy:
- Estrogen (oral, transdermal, IM 17-β estradiol) + Anti-androgen (e.g., Spironolactone, GnRH analog).
- Monitoring: Serum estradiol, testosterone, electrolytes/Cr (K+ if on spironolactone), prolactin, lipids.
- Masculinizing Therapy:
- Testosterone (IM, subcutaneous, or transdermal).
- Monitoring: Hematocrit (risk of erythrocytosis), LFTs, lipid panel.
- Surgical Intervention (Gender-Affirming Surgery) (Irreversible):
- Typically reserved for age ≥ 18 with persistent dysphoria, capacity to consent, and stable medical/mental health.
- “Top” Surgery: Mastectomy w/ chest contouring (transmasculine) or breast augmentation (transfeminine).
- “Bottom” Surgery: Hysterectomy, oophorectomy, metoidioplasty/phalloplasty (transmasculine); orchiectomy, vaginoplasty (transfeminine).