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Between the 1960s and 1990s, some estimates indicate that there has been a three-fold increase in the number of transgender patients presenting to Western medical clinics.[1] This suggests that either more transgender individuals are comfortable seeking treatment or that more individuals are self-associating with the opposite sex.
There has also been a relatively recent media focus on prominent transgender individuals, signaling an opening for a broader conversation on the topic of transgenderism. As a result, transgender individuals and groups are seeking more equality in the wider community, and federal and local governments are responding by protecting these individuals from discrimination and fostering equality, particularly in the setting of health care.
Image of participants at a Washington, DC, transgender pride event courtesy of Flickr/FightHIVinDC.
The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) definition of transsexualism is shown.[2] Thus, transsexualism is a gender identity that is inconsistent with one's assigned sex, combined with a desire to transition permanently to the gender with which one identifies.
The ICD-10-CM further defines transsexualism as the persistent presence of the transsexual identity for at least 2 years and that it is not a symptom of another mental disorder (eg, schizophrenia) or associated with a chromosomal abnormality.[2]
Image courtesy of Medscape (book cover) and the ICD-10-CM (text).[2]
Transsexualism was included as a diagnosis in the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual of Mental Disorders (DSM) until the most recent edition (ie, fifth). The DSM-5 replaced "transsexualism" with "gender dysphoria" to acknowledge that transsexualism is not a mental disorder and thus should not be stigmatized.[3]
The DSM-5 diagnostic criteria for gender dysphoria in adolescents and adults is shown. An additional criterion is that this "condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning."[3]
Image courtesy of Medscape (book cover) and the DSM-5 (text).[3]
The terminology used by the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community for transgender individuals and those who do not identify as transgender is shown.[4,5] Note that "transgender" is an adjective, not a noun.
A transgender man, or a trans man, is a person who was assigned female at birth but who identifies and lives as a man.[5] A transgender woman, or a trans woman, is one who was assigned male at birth but who identifies and lives as a woman.[5]
The term "gender nonconforming" (GNC) refers to individuals whose gender expression does not conform to conventional expectations of masculinity and femininity.[4,5] Some GNC individuals identify as transgender, whereas others do not.
Image courtesy of Dreamstime/Elena Duvernay; text courtesy of Lyndon Cudlitz.
Four components of an individual's identity/experience are shown. They are defined, as follows[4,5]:
Image courtesy of Dreamstime/Elena Duvernay.
Important considerations
During an initial visit with patients who seek gender (sex) reassignment, there are several important considerations that must be taken into account.
Patient goals are vital. Patients' goals are principal factors in gender reassignment. Although many will seek a full transition, including surgery, others will choose to only receive hormone supplementation, opting out of surgical management.
Gender transition should not be done without involvement of a mental health professional (MHP). It is essential for physicians to work closely with an MHP, whose collaboration in the patient's case is critical in the following areas:
Image courtesy of Dreamstime/Gina Sanders.
Treatment discussion
Once a diagnosis of gender dysphoria has been made, individuals who wish to undergo gender reassignment can then begin treatment, including continued therapy with an MHP and a physician.
Management considerations for transgender individuals include discussions of the following:
Image courtesy of Dreamstime/Christian Delbert.
When considering sexual orientation in transgender patients, do not assume heterosexual orientation. During patient interviews, ask open-ended questions (eg, "Are you single or married?" "Tell me about your relationship."), allowing patients to disclose homosexual practice or orientation.[7]
In their 1979 book Homosexuality in Perspective, Masters and Johnson stated that the sexual capacities of the body "function in identical ways, whether we are interacting heterosexually or homosexually."[8] Thus, they supported the concept that "sexual dysfunction be treated with the same therapeutic principles and techniques[,] regardless of the sexual orientation of the distressed individual."[8]
Masters and Johnson believed that sex therapy was not markedly different for heterosexual and homosexual individuals, but that it was critical that the clinician was not homophobic.
Image courtesy of Dreamstime/Karenr.
More recent work by Nichols maintained the basic assertion that sex therapy with people with homosexual orientation is similar to that with heterosexual patients, except that therapy with homosexual patients usually involves specific issues, such as sexual identity, alternative lifestyles, and the nature of some of the sexual practices that become the focus of treatment.[9] Thus, in transgender patients with homosexual orientation, these additional factors should also be considered.
Image courtesy of Dreamstime/Mopic.
Eligibility criteria for hormone therapy
Candidates for transgender hormone therapy must meet criteria, documented in a referral for treatment or the medical chart.
Criteria for feminizing or masculinizing hormone therapy in adults include the following[11]:
Image from a Janet Mock book reading courtesy of Flickr/Ted Eytan. Janet Mock is an author, speaker, television host, transgender rights activist, and a transgender woman.[10]
Goals of hormone therapy
Once a diagnosis of gender dysphoria has been made and the process for gender transition is set, hormone therapy can begin. The goals of hormone therapy are to reduce endogenous hormone levels—and thereby reduce the secondary sex characteristics of the patient's current sex—as well as to replace the endogenous sex hormone levels with those of the reassigned sex.
It is essential that the timing of hormone therapy be determined by the patient in collaboration with the health professionals treating the patient (ie, MHP and physician).
Image of participants at a National Center for Transgender Equality (NCTE) anniversary gala courtesy of Flickr/Ted Eytan.
Male-to-female (MTF) hormone therapy
For MTF transitions, a combination of estrogens and antiandrogens can be used.[12] Estrogen formulations include oral, transdermal, and parenteral preparations. Most published studies report the use of an antiandrogen in conjunction with an estrogen to suppress endogenous testosterone levels and therefore allow estrogen therapy to have its fullest effect. Categories of antiandrogens include progestins with antiandrogen activity and gonadotropin-releasing hormone (GnRH) agonists.
Note that the hormone regimens for MTF transitions are more complex than those for FTM transitions.[12] The Endocrine Society clinical practice guidelines hormone regimens for MTF transitions are summarized below.[12]
MTF estrogen regimens include the following[12]:
MTF antiandrogen regimens include the following[12]:
Image collage of Chris Tina Bruce, a transgender MTF bodybuilder courtesy of Flickr/Chris Tina Bruce.
Female-to-male (FTM) hormone therapy
Hormone therapy in FTM transition is focused on masculinization, and treatment regimens generally parallel those for treating male hypogonadism.[12] Transdermal or parenteral testosterone formulations are used to achieve testosterone levels in the usual male range (generally 300-1000 ng/dL).
FTM testosterone regimens include the following[12]:
Image of Thomas Beatie, a transgender male also known as "Pregnant Man," (left) courtesy of Frankie Fouganthin, and image of a 10-mL vial of testosterone cypionate (Depo-Testosterone) (right) courtesy of the US Drug Enforcement Administration (DEA), both via Wikimedia Commons.
There are numerous expected physical changes that are specific to FTM transgender persons on hormone therapy, including the following[12]:
Moreover, also specific to FTM transgender patients are several notable side effects of testosterone therapy that should be monitored, including the following[13]:
Two other issues that can arise are male-pattern hair growth and/or male pattern-baldness, as well as lipid profile abnormalities, such as hypercholesterolemia.[13] Therefore, it is important to regularly monitor FTM transgender patients who are receiving testosterone therapy.
Image of Chaz Bono, a transgender man, courtesy of Wikimedia Commons/dvsross.
Approximately 60%-70% of transgender patients undergo gender reassignment surgery.[14]
MTF
In the MTF setting, gender reassignment surgery entails orchiectomy, penectomy, vaginoplasty (the making of a new vagina), clitoroplasty, and labiaplasty. The vaginoplasty can be performed using a skin inversion technique with penile or scrotal skin, or with bowel or a skin graft.[15] The penile glans is fashioned into a neoclitoris, and the remaining scrotal skin is used to construct the labia.
Facial feminization (shown) is very important in helping the transgender patient appear closer to their stated sex. This procedure often occurs as a separate surgery either before or after genital reconstruction.
The top images show the facial and lateral views of a MTF transgender patient before gender reassignment facial correction. On the lateral view, note the long face, square chin, flared mandibular angles, and masculine features. The bottom images show the facial and lateral views of the same patient 4 years after facial correction. The patient underwent genioplasty setback and vertical reduction, gonial angles shaving, lateral and inferior cortical shaving of the entire mandible, zygoma advancement osteotomy, removal of buccal fat, revision rhinoplasty, supraorbital rim contouring and subcutaneous fat removal, frontal bossing shaving, eyebrow lifting, hairline lowering, and facial hair removal.
Images courtesy of Shams MG, Motamedi MH. Eplasty. 2009;9:e2. [Open access.] PMID: 19198644, PMCID: PMC2627308.
FTM
In surgical FTM gender transitions, bilateral mastectomy (and often hysterectomy), followed by phalloplasty (sometimes with the placement of a penile prosthesis) are performed. Because phalloplasty is a technically challenging procedure and complications may arise, metaidoioplasty (transformation of a hypertrophic clitoris into a microphallus) may be preferable to a full phalloplasty.[16] Labiaplasty to form the scrotum using scrotal skin, with or without placement of testicular prostheses, may also be performed.
The left images are postmastectomy photographs of a transgender man; the right image is that of another transgender man.
Left images courtesy of Flickr/Charles Hutchins; right image courtesy of Wikipedia/Buck Angel, Buck Angel Entertainment.
Outcomes
Following completion of gender transition, clinicians should consider the outcomes of the process, particularly those related to sexual function. Overall, studies appear to show that transgender persons have adequate sexual function and high rates of sexual satisfaction following hormone therapy and genital surgery.[17]
In a study that compared general and sexual health among selected Dutch and American transgender women who underwent gender reassignment surgery, investigators found that the women scored highly on the physical and mental health domains of the Short-Form-36 (SF-36), a validated health survey.[18] Gender-related body features also showed high values, and appreciation of their appearance as perceived by others, as well as their own satisfaction with their self-image as women, demonstrated good scores.[18]
Table courtesy of Alexander W Pastuszak, MD, PhD. Data source: Weyers S, Elaut E, De Sutter P, et al. J Sex Med. 2009;6(3):752-60. PMID: 19040622.[18]
Sexual function outcomes in transgender women versus women with and without sexual complaints
When specifically evaluating sexual function using the Female Sexual Function Index (FSFI), a validated, self-reported survey metric of female sexual function, the same study showed that transgender women who underwent gender transition scored significantly worse on all FSFI sub-scores (including arousal, lubrication, and pain) compared to women designated as female at birth who did not have sexual complaints.[18]
However, when compared to women designated as female at birth who did have sexual problems in a prior study, transgender women following gender transition had approximately equivalent FSFI scores.[19]
Image courtesy of Flickr/Kevin Dooley.
Transexualism is now termed gender dysphoria. A confirmed diagnosis of gender dysphoria is necessary before hormonal or surgical management is undertaken.
The patient, an MHP, and a physician should all be involved in the care of transgender patients.
Hormone therapy is effective for MTF and FTM transitions, but patients must be both eligible and ready for such treatment.
Sexual function after gender reassignment is adequate, with the most significant complaints in transgender women relating to lubrication, arousal, and pain.
Image courtesy of Dreamstime/Littlepaw.
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