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
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. |
Gender role | This refers to behaviors, attitudes, and personality traits that a society (in a given culture and historical period) designates as masculine or feminine and/or that society associates with or considers typical of the social role of men or women. |
Sex designated at birth | This refers to sex assigned at birth, usually based on genital anatomy. |
Sex | This refers to attributes that characterize biological maleness or femaleness. The best known attributes include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, internal and external genitalia, and secondary sex characteristics. |
Sexual orientation | This term describes an individual’s enduring physical and emotional attraction to another person. Gender identity and sexual orientation are not the same. Irrespective of their gender identity, transgender people may be attracted to women (gynephilic), attracted to men (androphilic), bisexual, asexual, or queer. |
Transgender | This is an umbrella term for people whose gender identity and/or gender expression differs from what is typically associated with their sex designation at birth. Not all transgender individuals seek treatment. |
Transgender man (also: trans man, female-to-male, transgender male) | This refers to individuals assigned female at birth but who identify and live as men. |
Transgender woman (also: trans woman, male-to-female, transgender female) | This refers to individuals assigned male at birth but who identify and live as women. |
Transition | This refers to the process during which transgender persons change their physical, social, and/or legal characteristics consistent with the affirmed gender identity. Prepubertal children may choose to transition socially. |
Transsexual | This is an older term that originated in the medical and psychological communities to refer to individuals who have permanently transitioned through medical interventions or desired to do so. |
Diagnosis
Evaluation of Youth and Adults
- Endocrine Society (ES) advises that only trained mental health professionals (MHPs) who meet the following criteria should diagnose
GD/GI in adults: (UGPS)- Competence in using the Diagnostic and Statistical Manual of Mental Disorders (DSM) and/or the International Statistical Classification of Diseases and Related Health Problems (ICD) for diagnostic purposes
- The ability to diagnose GD/GI and make a distinction between GD/GI and conditions that have similar features (e.g., body dysmorphic disorder)
- Training in diagnosing psychiatric conditions
- The ability to undertake or refer for appropriate treatment
- The ability to psychosocially assess the person’s understanding, mental health, and social conditions that can impact gender-affirming hormone therapy, and
- A practice of regularly attending relevant professional meetings.
- ES advises that only MHPs who meet the following criteria should diagnose GD/GI in children and adolescents: (UGPS)
- Training in child and adolescent developmental psychology and psychopathology
- Competence in using the DSM and/or the ICD for diagnostic purposes
- The ability to make a distinction between GD/GI and conditions that have similar features (e.g., body dysmorphic disorder)
- Training in diagnosing psychiatric conditions
- The ability to undertake or refer for appropriate treatment
- The ability to psychosocially assess the person’s understanding and social conditions that can impact gender-affirming hormone therapy
- A practice of regularly attending relevant professional meetings, and
- Knowledge of the criteria for puberty-blocking and gender-affirming hormone treatment in adolescents.
- ES advises that decisions regarding the social transition of prepubertal youths with GD/GI are made with the assistance of an MHP or another experienced professional. (UGPS)
- ES recommends against puberty-blocking and gender-affirming hormone treatment in prepubertal children with GD/GI. (1|⊕⊕)
- ES recommends that clinicians inform and counsel all individuals seeking gender-affirming medical treatment regarding options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy of the affirmed gender in both adolescents and adults (1|⊕⊕⊕)
Table 2. DSM-5 Criteria for Gender Dysphoria in Adolescents and Adults
A. A marked incongruence between one’s experienced/expressed gender and natal gender of ≥6 mo in duration, as manifested by at least two of the following: |
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B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. |
Specify if: |
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Reference: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association Publishing. |
Table 3. ICD-10 Criteria for Transsexualism
Transsexualism (F64.0) has three criteria: |
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