Gender-Dysphoria / Gender-Incongruence

Publication Date: September 13, 2017

Key Points

Key Points

Gender-dysphoric/gender-incongruent persons should receive a safe and effective hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty, and maintain levels of sex steroids within the normal range for the person’s affirmed gender.

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

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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

...gnosis...

...tion of Youth and Adults...

...e Society (ES) advises that only tra...

...dvises that only MHPs who meet the follow...

...t decisions regarding the social t...

...mmends against puberty-blocking and gender-aff...

...recommends that clinicians inform and...

...SM-5 Criteria for Gender Dysphoria in Adole...

...Criteria for TranssexualismHaving trouble...


Treatment

...eatment...

...eatment of Adolescents...

...adolescents who meet diagnostic criter...

...suggests that clinicians begin pubertal hormone...

...nds that, where indicated, GnRH analogues are use...

...ts who request sex hormone treatment (given this i...

...e that there may be compelling reasons to...

...nitoring clinical pubertal development ever...


...nal Therapy for Transgender Adults...

ES recommends that clinicians confir...

...ommends that clinicians evaluate and address...

...that clinicians measure hormone levels during t...

ES suggests that endocrinologists pr...


...e 4. Criteria for Gender-Affirming...


.... Criteria for Gender-Affirming Hormon...


Table 6. Tanner Stages of Breast Development an...


...seline and Follow-Up Protocol During Suppressi...


...ocol Induction of Puberty...


...seline and Follow-up Protocol During In...


...0. Medical Risks Associated With Sex Hormone The...


Table 11. Hormone Regimens in Transgender...


...le 12. Masculinizing Effects in Transgender Male...


...Feminizing Effects in Transgender Fema...


...e Outcome Prevention and Long-Term Care

...uggests regular clinical evaluation for physica...

...eriodically monitoring prolactin levels in transg...

...gests that clinicians evaluate tran...

...s that clinicians obtain bone mineral density...

...ts that transgender females with n...

...that transgender females treated with estr...

...S advises that clinicians determine...


...14. Monitoring of Transgender Persons...


...itoring of Transgender Persons on Gender-Affirmin...


...for Sex Reassignment and Gender Confirmation...

...hat a patient pursue genital gender-a...

...hat clinicians approve genital gen...

...hat the clinician responsible for endocr...

...s that clinicians refer hormone-treated transgend...

...t clinicians delay gender-affirming...

...S suggests that clinicians determine the timing o...


...ia for Gender-Affirming Surgery that Affect...