By Professor Kevan Wylie on the 1 August 2009.

ABSTRACT

Gender dysphoria is a rare clinical condition that may present to the physician, requiring recognition and appropriate support. Clinical pathways have now been clarified and there are a number of interventions that can be affirmative and supportive for patients who may face considerable social and domestic challenges to their situation.

Atypical gender development can result in the experience of one's self as a man or a woman (gender identity) that is incongruous with the body phenotype (physical sex characteristics). This incongruence may result in gender dysphoria, which in its most persistent and profound state can cause individuals to seek assistance from their GP.

Gender dysphoria is a diagnosis that is essentially made by the patient. As such, the primary care clinician should aim to support patients through subsequent processes that are necessary if they are to secure relief from the dysphoria, including counselling, hormone therapy, surgical confirmation and other related changes.

Increasing awareness and tolerance of diversity in society has led to an increase in the number of patients seeking help with this relatively rare condition. The incidence is unknown, but figures of one trans woman per 12,000 of the population and one trans man per 30,000 are likely to prove underestimates when techniques for calculating prevalence improve.

Initial steps in management

Guidelines for health organisations that commission treatment have been issued by the Parliamentary Forum of Transsexualism and are available from the Gender Identity Research and Education Society. For care providers, the UK draft standards of care are available from the Royal College of Psychiatrists.

These documents provide important information about why care should be commissioned and the standards of care that should be provided by different staff members of gender teams or networks.

Patients who have made transition can apply under the Gender Recognition Act (2004) for a gender recognition certificate, which entitles them to special protection of their privacy. This includes avoidance of unwarranted disclosure of information by healthcare professionals, with such disclosure amounting to a criminal offence.

The GP may act as the co-ordinator of care for a patient undergoing transition, although they will more usually be the catalyst for referral to other specialist teams. The first referral should be to a local sector psychiatrist, for the exclusion of concurrent mental health problems (see box 1). The presence of any of these conditions does not necessarily preclude care for gender-related matters, which may coexist.

BOX 1: MENTAL HEALTH CONDITIONS TO CONSIDER

• Transvestism and fetishist conditions
• Anxiety states
• Social anxiety
• Depressive disorder
• Psychosis
• Alcohol dependence
• Schizophrenia
• Body dysmorphia
• Requests for cosmetic surgery

Concurrently, a patient can be referred to a gender identity team, which may be based in one service or a wider network. A network of individuals (see box 2) may work independently but meet regularly to discuss the progress of patients under their care and to ensure supervision and governance of their work. The role of the psychiatrist and other gender specialists is fourfold. First is the differentiation of concurrent mental health problems. Second, diagnostic assessment confirming the diagnosis, as determined by the criteria of DSM-IV. These are a persisting conviction of belonging to the opposite biological sex, duration at least two years, intensive psychological distress and the disorder not being a symptom of another disorder.

BOX 2: SPECIALISTS INVOLVED IN CARE

• Psychiatrist
• Psychologist
• Psychotherapist
• Specialist nurse practitioner
• Endocrinologist
• GPSI
• Reproductive specialist (gamete storage)
• Electrolysis/laser hair specialist
• Breast surgeon
• Speech and language therapist
• ENT specialist (cricothyroid approximation)
• District nurse

Third is optimising the chance of a successful transformation and fourth is helping patients to gain self-insight, understand their options and develop coping strategies for changes to happen with appropriate medical and psychological support. After a minimum three months of living in the new gender role or undergoing psychotherapy, the patient should be assessed for eligibility and readiness for hormone therapy, in line with international standards of care provided by the World Professional Association for Transgender Health

Eligibility is assessed by the practitioner. Readiness is an interactive exchange where the patient has made a decision based on sufficient knowledge and discussion of the benefits and consequences, as well as limitations of hormone therapy (see box 3). Full written informed consent should be obtained after detailed discussion.

BOX 3: QUESTIONS FOR THE PATIENT

• Do you have a clear mental picture of what you want life to be like after you start taking hormones?
• How do you think you might feel if the results do not match your expectations?
• Are you hoping that taking hormone therapy will fix anything and if so, what?
• What part of your life might change after hormone therapy?
• What do you hope might change and what do you feel might change?
• Do you think your hopes are realistic and how can you tell if they are?
• How much do you know about hormone therapy?
• What more do you need to know for an informed decision?
• Who else in your life will be affected by your decision?
• How do you think they will feel about you taking hormones?
• How will their reactions affect you?
• What do you think is a 'wrong reason' to take hormones?
• What do you think are the 'right reasons'?

Source: Transgender Health Program, Vancouver, Canada.

Prescribing hormone treatment

A full health assessment will have been undertaken and a recommendation for treatment provided by the specialist gender clinician, endorsed by the clinical team involved in assessment to that stage ¹.

Health assessment, including physical examination, is important, particularly in the exclusion of intersex states. Examinations can be stressful for many patients who intensely dislike their genitals. There is a need to prepare the patient and provide necessary support, with either a chaperone or a limited examination, and this should be explained and documented.

Patients who are smokers are encouraged to give up before therapy begins. Hormones may be prescribed by the GP, gender specialist, endocrinologist, or in certain circumstances, nurse prescriber. It is not necessary for an endocrinologist to initiate the prescription unless there is a concurrent hormone disorder.

The hormones usually prescribed are listed in box 4. During hormone therapy, continuing physical assessment is necessary, with regular biochemical and heamatological measurements. Detailed guidance is available within standards of care documents and elsewhere ^{2 3}.

BOX 4: OPTIONS FOR HORMONE TREATMENT

Trans women

• Estrogens, for example, estradiol
• Androgen antagonists, for example, spironolactone, finasteride, cyproterone
• Gonadotropin-releasing hormone (GnRH) agonists
• Topical hair removal creams, for example, eflornithine

Trans men

• Testosterone
• GnRH agonists

Transdermal estrogen is recommended for trans women over 40 years of age ⁴. Minimum laboratory tests must be undertaken within three months of commencing treatment.

As patients prepare for surgical confirmation, it is necessary to withhold certain hormonal therapies because of the increased risk of thrombosis if estrogens are continued more than six weeks before surgery. Other factors, including high BMI and concurrent medical states, should be managed well in advance of the expected time for gender confirmation surgery.

Confirmation surgery

After a minimum of 12 months, during which the patient is supported through the real life experience, it is often the patient's preference to proceed to genital confirmation surgery. To do so, an independent second affirmative recommendation is necessary, which may mean assessment at another clinic.

Once eligibility and readiness for surgery are confirmed, referral to a surgeon with specialist expertise should be undertaken without delay. This is usually done by the local gender team or the lead clinician in a network of patients. At least one of the two recommendations must be from a physician.

The involvement of a district nurse before and after surgery is invaluable, even if this is limited to liaison with the local district nursing team. Provision of postoperative care is necessary for psychological and physical health; sometimes, support continues beyond the time of surgical discharge.

In the past, many patients have abandoned services they found unhelpful during their transition, owing to long periods between initial presentation and final surgery. Now, greater enlightenment among healthcare professionals and care commissioners will allow working relationships to develop between patients and care providers, which will improve the likelihood of engagement post-surgery. Discreet monitoring and follow-up could significantly improve outcome data.

• Professor Kevan Wylie is consultant in sexual medicine at the Porterbrook Clinic, Sheffield