April 2012 | Dan Karasic
Let’s start with some definitions. “Transgender” is a general term, referring to individuals or behaviors that vary from the gender conventions of one’s culture. Older clinical terms include “transexualism,” introduced in DSM-III, and “gender identity disorder” (GID), which is found in DSM-III-R and DSM-IV.
GID has been an unpopular label among patients and professionals alike, because it labels as a “disorder” something that people perceive as being intrinsic to their identity. A person’s subjective gender identity, regardless of the sex they were assigned at birth, can lie anywhere on a gender spectrum. Sometimes, people experience distress or discomfort due to a discrepancy between their gender identity and birth gender. We refer to this as “gender dysphoria,” the term that will replace GID in DSM-5.
Gender dysphoria may be related to discomfort with one’s physical body, one’s social role (and societal expectations), or both. So it’s a very broad term. We should be careful not to confuse it with “gender nonconformity,” which simply means that a person expresses one’s gender in a manner different from what’s conventional. We use this term, for instance, to refer to boys who prefer girls’ play or girls’ dress, or vice versa.
Gender nonconformity is, in itself, not pathological, and does not presuppose that a person experiences distress. If a child exhibits distress, it’s usually due to bullying or rejection by a family member or acquaintance. A national organization called Gender Spectrum works with parents and families of gender-nonconforming children to try to improve their experience. In adults, distress often arises from the effects of stigma, marginalization, or discrimination.
Individuals with gender dysphoria may present to your office with a range of mental health concerns. These concerns—such as anxiety, depression, self-harm, personality disorders, substance abuse, and eating disorders—often are addressed concurrently with steps to relieve gender dysphoria. Psychotherapy, while not a requirement for hormonal or surgical treatments, can be helpful to explore gender identity, to assist the patients in making informed decisions about further treatment, to improve self-esteem, or to build a support network. According to the World Professional Association for Transgender Health (WPATH) standards of care, it is no longer considered ethical to try to change a person’s gender identity or expression in order to be more congruent with one’s birth sex.
Patients with persistent gender dysphoria may choose to undergo “gender transition,” the process of making social role and the body more congruent with gender identity. (The old term for this process was “sex change.”) This process may include social transition, hormonal therapy, and for some, surgery.
This means living in the gender role that the person wants to live in. For someone born male but wanting to transition to female, this would mean living as female, dressing as female, changing one’s name, presenting at work as female, and coming out to friends as transgender.
Some individuals are comfortable with a social transition, and if so, treatment ceases here. Others may proceed to hormonal therapy. In children at Tanner Stage 2 (very early puberty), we may offer gonadotropin-releasing hormone (GnRH) analogs like Lupron to delay the onset of puberty. This is a reversible procedure, but the delay allows more time for the child and therapist to confirm the persistence of gender dysphoria and prepare the patient for possible further hormonal or surgical treatment.
In adults, the goals of hormonal therapy are to reduce endogenous hormones and provide hormones of the reassigned sex. Regimens for those who are male-to-female (MTF) transgender include estradiol and antiandrogens like spironolactone. Female-to-male (FTM) patients typically receive testosterone, either injection, patch or gel (Hembree WC et al, J Clin Endocrinol Metab 2009;94(9):3132– 3154).
Hormonal therapy is generally safe, but risks are not trivial and require monitoring. MTF patients should be screened for thromboembolic disease and elevated triglycerides, as well as hypertension and coronary artery disease, since hormonal treatments can cause or exacerbate these conditions. Testosterone replacement in FTM patients can cause polycythemia, which may lead to myocardial infarction or stroke. Psychotic or manic symptoms induced by testosterone are rare but can be seen with supraphysiologic blood levels of androgens. Be aware that some patients obtain hormones via the Internet or from abroad, so taking a careful history is necessary.
Many MTF patients opt for breast construction surgery and facial feminization surgery, while FTM patients often undergo mastectomy. Most transgender people in the United States—whether male or female—do not have genital surgery. Genital surgery is expensive and difficult to access, and some FTM patients, in particular, find options for phalloplasty unsatisfactory. Moreover, most health insurance plans specifically exclude all transgender surgeries, although allowances are sometimes made for procedures deemed “medically necessary” by therapists. In the past, the US government required that people have surgery to change their gender on legal documents (eg, for passports), but this requirement has been dropped.
An excellent, and easily accessible, resource for anyone interested in the comprehensive care of transgender persons is the WPATH Standards Of Care.
Specific Treatment Concerns
While many transgender adults are mentally healthy, studies show that they suffer high rates of depression and other health concerns. The available data show rates of depression approaching 50% (Bockting WO et al, Int J Transgender 2005;8(2):123–131), and rates of lifetime suicidal ideation ranging from 37% to 52% (The Health of Lesbian, Gay, Bisexual, and Transgender People; Institute of Medicine 2011; bit.ly/yKzbEd). Rates of HIV infection are as high as 28% among MTF transgender women, and many MTFs report engagement in risky sex behaviors (Herbst JH et al, AIDS Behav 2008;12(1):1–17).
One’s gender identity is also independent of one’s sexual orientation, so a transgender identity should not be equated with either homosexuality or heterosexuality. There are many MTF transgender people who are attracted to women, and FTM transgender people attracted to men. We do sometimes see the objects of one’s sexual attraction change after transition; for example, a female-to-male patient who defined herself as a lesbian before transition may become attracted to men and identify as a gay man afterward.
As people become more comfortable discussing gender identity, transgender patients and others with gender dysphoria may seek your care. Their specific needs may include exploring gender identity and expression, facilitating a coming out process, or an assessment for a medical intervention. It’s important that you not try to impose any particular conception or belief, but instead help them to achieve lasting comfort in their gender identity expression, and to identify the resources with which to do so.