Management of Transgenderism

Abstract

Gender identity disorder (transgenderism) is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking male-to-female (MTF) change, hormone treatment includes estrogens, finasteride, spironolactone, and gonadotropin-releasing hormone (GnRH) analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a female-to-male (FTM) gender change, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.

Psychological and Medical Care of Gender Nonconforming Youth

“…2 With the creation of an increasing number of multidisciplinary clinics dedicated to the care of the GN youth, there seems to be an increasing number of such youth and their families presenting for care. [4][5][6][7][8] Important tasks are to determine the safest and most efficacious mental and medical approaches for this population. There are many unanswered questions: the impact of pubertal suppression and cross-sex hormone therapy on long-term brain development and on bone health; risks of developing chronic medical conditions, such as diabetes, hypertension, and dyslipidemia; and mental health consequences of recommended interventions.…”

“…GnRH analogs are expensive and often are not covered by insurance, leading to substantial out-of-pocket costs to families. 7 In these situations, other medications can be used. For affirmed females, spironolactone may be used for antiandrogenic effect; for affirmed males, depot medroxyprogesterone may be used to suppress menses.…”

“…3 In recent years, an increasing number of multidisciplinary clinics have emerged in the United States that are dedicated to providing care to this population. [4][5][6][7][8] A challenge to all of these programs is that even with published clinical guidelines and standards of care, management of GN youth remains controversial, with a key factor being that these documents are based primarily on expert opinion rather than scientific data, given the paucity of outcomes data on the effects of mental health and medical interventions. An increasing number of GN youth are presenting for gendersensitive health services.…”

The primary health care of transgender adults

“…Changes to the effectiveness, safety and availability of interventions for gender dysphoria, 4,13,16,35 combined with an evolution of social attitudes, are possible reasons for the observed increase in presentations to gender services for transition. 9,64 The burden of disease attributable to gender dysphoria is difficult to establish, but is likely to be significant. 15 There are likely to be multiple points for interventions that could improve health outcomes.…”

“…Presentations to gender services for medical management of gender dysphoria have increased markedly since 2000. 8,9 Guidelines have been constructed to provide a framework for delivering safe and effective medical care to transgender people. 3,10 Guidelines have concentrated on the diagnosis, endocrine and surgical management of gender dysphoria, aspects that are mainly the focus of specialised gender clinics.…”