By Dr Ananya Mandal, MD
Gender dysphoria is a mental condition but is not a mental disorder. However, it may be accompanied with severe impairment of social, occupational and other functioning.
There may also be accompanying psychiatric conditions like anxiety, depression and suicidal thoughts. In these cases treatment and therapy may be needed.
Treatment is a multidisciplinary approach. The team includes a mental health professional trained in gender dysphoria, a neuropsychiatrist, a psychologists, counsellors, behavioral and occupational therapists and an endocrinologist who specializes in hormones.
A urological surgeon who specializes in surgery of the genitals and urinary tract may also be included.
Types of treatment
There are several types of treatment for gender dysphoria, these include psychological intervention, hormone therapy and so forth. (1-5)
Psychological intervention may be beneficial in some persons.
Persons with the condition are made to understand and deal with the gender issues.
There may be a need for marital, family and group therapies to allow for a helpful and supportive environment to the person with this condition.
This is needed in some patients. Hormone therapy is usually most beneficial in adolescents before their secondary sexual characteristics have developed.
For male-to-female conversions
For male-to-female conversions, original sex characteristics are suppressed using luteinizing hormone–releasing hormone (LHRH) agonists, progesterones (medroxyprogesterone acetate), spironolactone, flutamide, and cyproteronacetate.
The LHRH supresses the release of male hormones.
Ethinyl estradiol (0.1-0.5 mg/d) and conjugated estrogen (7.5-10 mg/d) are the essential female hormones that help promote breasts, increased body fat, widening of the hips, less musculature, less facial and body hair, reduction in size of penis and testes and a feminine body shape.
For female-to-male conversions
For female-to-male conversions testosterone cypionate (200 mg IM every 2 wk), the male hormone, is given.
It leads to increased facial and body hair, enlarged clitoris, reduction in breast size, stoppage of menstruation, increase sexual drive and muscle development.
There may be a slight deepening of the voice and male-pattern of baldnesss.
Hormone therapy and children
According to the Guidelines from the Endocrine Society, children, before they reach puberty should not receive hormone therapy because a diagnosis of transsexualism cannot be made before a child has reached puberty.
The Endocrine Society found that 75-80% of children diagnosed with gender dysphoria before they reached puberty did not have the condition after achievement of puberty.
Pharmacotherapy, or therapy with drugs, is needed in patients with concurrent psychiatric disorders.
Studies have shown that 50-70% of individuals with gender dysphoria may have symptoms of depression, anxiety, or psychosis and may be of histrionic (hysteric), borderline, antisocial or schizoid (schizophrenia like) personalities.
These patients may need therapy for depression (antidepressants), anxiety (anxiolytics) or frank psychosis (antipsychotics).
Education and family counselling
Patient education and family counselling may be needed.
While education and counselling focus on understanding and dealing with gender issues; the family, partners and friends should be explained the potential for harm to themselves.
They are made aware of the steps they can take to cope with unpleasant situations while continuing to provide support.
Prior to surgery
Before surgery is attempted, the persons need to live as their preferred sex for a while. This is called Real life experience or RLE.
Surgery may include mastectomy (removal of the breasts) for women who identify themselves as men.
Cosmetic breast surgery or breast augmentation and feminising facial surgery may be opted for in men who identify themselves as women.
The whole surgery and its preparation may take two to three years in United Kingdom.
Gender confirmation surgery
In females to males
Gender confirmation surgery in females to males includes removal of the womb, fallopian tubes and ovaries and construction of a penis using a phalloplasty or a metoidioplasty.
A phalloplasty is done using vaginal tissue and skin from the forearm to create a penis.
A metoidioplasty involves creating a penis from the clitoris that has been enlarged through hormone therapy.
In males to females
Gender confirmation surgery in males to females includes removal of the testes, removal of the penis, and reconstruction of a vagina from the tissues of the penis (vaginoplasty).
The scrotal skin is used to create the labia and vulva to simulate the female genitalia.
The urethra that runs within the penis in males is shortened and made to lie within the newly created vagina.
Problems after surgery
Some of the problems after surgery include isolation from peers, social discrimination and fear and stress of not being accepted in society.
These individuals are protected legally against discrimination.
Other treatments include:
- Speech therapy to modulate and speak like the identified sex may be useful
- Behavioral therapy that includes suggestions on ways to dress in preferred gender roles, peer support group therapy etc.
Outcome & prognosis
Psychotherapy alone fails to produce complete and long-term correction of gender dysphoria.
Sometimes gender re-assignment may be needed.
Complications include depression or anxiety, emotional distress, isolation and poor self esteem and rarely suicidal thoughts. (1, 3, 5)
Edited by April Cashin-Garbutt, BA Hons (Cantab)
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