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
...iagnosi...
Evaluation of Youth and Adults
...ne Society (ES) advises that only trained mental h...
...dvises that only MHPs who meet the fo...
...t decisions regarding the social transition...
...recommends against puberty-blocking and ge...
...mmends that clinicians inform and counsel...
...riteria for Gender Dysphoria in Adoles...
Table 3. ICD-10 Criteria for TranssexualismH...
Treatment
Treatment
...tment of Adolesce...
...that adolescents who meet diagnostic crite...
...clinicians begin pubertal hormone suppress...
...that, where indicated, GnRH analogues are us...
...lescents who request sex hormone treatment (gi...
...e that there may be compelling reasons t...
...suggests monitoring clinical pubertal developmen...
...Therapy for Transgender Adults
...recommends that clinicians confirm the diagno...
...mmends that clinicians evaluate and addr...
...ggests that clinicians measure hormone...
...t endocrinologists provide education to...
...e 4. Criteria for Gender-Affirming Hormo...
...iteria for Gender-Affirming Hormone Th...
...6. Tanner Stages of Breast Develo...
...7. Baseline and Follow-Up Protocol Durin...
...Protocol Induction of Puberty Inducti...
...e 9. Baseline and Follow-up Protocol...
...ical Risks Associated With Sex Hormone Therapy...
...rmone Regimens in Transgender Persons ...
...ulinizing Effects in Transgender MalesHaving tr...
...Feminizing Effects in Transgender FemalesHavin...
...dverse Outcome Prevention and Long-T...
...gests regular clinical evaluation for physical c...
...riodically monitoring prolactin levels i...
...that clinicians evaluate transgender p...
...nds that clinicians obtain bone mineral densi...
...at transgender females with no known incre...
...ggests that transgender females treate...
...that clinicians determine the medical necessity...
...14. Monitoring of Transgender Persons...
...Monitoring of Transgender Persons on Gende...
...r Sex Reassignment and Gender Confirmation...
...mmends that a patient pursue genital gender-aff...
...hat clinicians approve genital gender-affirming...
...dvises that the clinician responsible for endoc...
...hat clinicians refer hormone-treated transgend...
...t clinicians delay gender-affirming ge...
...ests that clinicians determine the tim...
...ia for Gender-Affirming Surgery that Affects Fer...