Gender-Dysphoria / Gender-Incongruence
Key Points
Key Points
Hormone treatment is not recommended for pre-pubertal gender-dysphoric/gender-incongruent persons.
For the care of youths during puberty and older adolescents, an expert multi-disciplinary team comprised of medical professionals and mental health professionals should manage treatment.
For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient.
All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy in both adolescents and adults.
Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones, and/or to reduce steroid levels in advanced age.
During sex steroid treatment, clinicians should monitor, in both transgender males (female to male) and/or transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment.
Table 1. Definitions of Terms Used in This Guideline
| Term | Definition |
|---|---|
| Biological sex, biological male or female | These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other (e.g., a person with XY chromosomes may have female-appearing genitalia), the terms biological sex and biological male or female are imprecise and should be avoided. |
| Cisgender | This means not transgender. An alternative way to describe individuals who are not transgender is “non-transgender people.” |
| Gender-affirming (hormone) treatment | See “Gender reassignment." |
| Gender dysphoria (GD) | This is the distress and unease experienced if gender identity and designated gender are not completely congruent (see Table 2). In 2013, the American Psychiatric Association released the fifth edition of the DSM-5, which replaced “gender identity disorder” with “gender dysphoria” and changed the criteria for diagnosis. |
| Gender expression | This refers to external manifestations of gender, expressed through one’s name, pronouns, clothing, haircut, behavior, voice, or body characteristics. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender. |
| Gender identity/ experienced gender | This refers to one’s internal, deeply held sense of gender. For transgender people, their gender identity does not match their sex designated at birth. Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two choices. Unlike gender expression (see above), gender identity is not visible to others. |
| Gender identity disorder | This is the term used for GD/GI in previous versions of DSM (see “Gender dysphoria”). The ICD-10 still uses the term for diagnosing children, but the upcoming ICD-11 has proposed using “gender incongruence of childhood.” |
| Gender incongruence (GI) | This is an umbrella term used when the gender identity and/or gender expression differs from what is typically associated with the designated gender. Gender incongruence is also the proposed name of the gender identity-related diagnoses in ICD-11. Not all individuals with gender incongruence have gender dysphoria or seek treatment. |
| Gender variance | See “Gender incongruence.” |
| Gender reassignment | This refers to the treatment procedure for those who want to adapt their bodies to the experienced gender by means of hormones and/or surgery. This is also called gender-confirming or gender-affirming treatment. |
| Gender-reassignment surgery (gender-confirming/gender-affirming surgery) | These terms refer only to the surgical part of gender-confirming/gender-affirming treatment. |
Diagnosis
...Di...
...Ev...
...ine Society (ES) advises that only train...
...advises that only MHPs who meet the following cri...
...es that decisions regarding the socia...
...gainst puberty-blocking and gender-affirming ho...
...commends that clinicians inform and counsel...
...e 2. DSM-5 Criteria for Gender Dysph...
...ble 3. ICD-10 Criteria for Transsexualism...
Treatment
...Treatment...
...Tr...
...suggests that adolescents who meet diagnostic...
...suggests that clinicians begin pubertal ho...
...that, where indicated, GnRH analogues are u...
...scents who request sex hormone treatment...
...at there may be compelling reasons to i...
...itoring clinical pubertal development every...
...Hormonal Thera...
...ecommends that clinicians confirm the diagnost...
...recommends that clinicians evaluate...
...suggests that clinicians measure hormone l...
...ts that endocrinologists provide educat...
...able 4. Criteria for Gender-Affirming...
.... Criteria for Gender-Affirming Hormone Therapy f...
...le 6. Tanner Stages of Breast Development and M...
...ble 7. Baseline and Follow-Up Proto...
...l Induction of Puberty Induc...
...able 9. Baseline and Follow-up Protocol During...
.... Medical Risks Associated With Sex Hormone Th...
...mone Regimens in Transgender Perso...
...e 12. Masculinizing Effects in Transgender Mal...
...inizing Effects in Transgender Females...
...Adverse Outcome...
ES suggests regular clinical evaluati...
...gests periodically monitoring prolactin level...
...that clinicians evaluate transgender...
...ommends that clinicians obtain bone...
...t transgender females with no known...
...at transgender females treated with estrogen...
...that clinicians determine the medical necessity o...
...Monitoring of Transgender Persons on Gender-Af...
...toring of Transgender Persons on Gender-...
...Surgery for Sex...
...S recommends that a patient pursue...
...ises that clinicians approve genital ge...
...the clinician responsible for endocrine treatment...
...ecommends that clinicians refer hormone-tr...
...t clinicians delay gender-affirming genital sur...
...ts that clinicians determine the timing...
...ble 16. Criteria for Gender-Affirming Surger...