Gender Dysphoria Treatment & Management

Updated: Apr 24, 2019
  • Author: Mohammed A Memon, MD; Chief Editor: Glen L Xiong, MD  more...
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Treatment

Approach Considerations

Modalities that may be considered in the treatment of gender dysphoria include pharmacologic therapy, psychological and other nonpharmacologic therapies, and sexual reassignment surgery (SRS). Negative attitudes toward SRS appear to be changing among professionals, and scientific interest is increasing. Nevertheless, it must be kept in mind that SRS does not promote a trouble-free life. Post-SRS psychotherapy may substantially improve overall outcome.

Pharmacological treatments in children and adolescents are even more complex. This highly vulnerable population with gender dysphoria suffers through intense psychopathological burden. Puberty suppression by gonadotropin-releasing hormone analog (GnRHa) is prescribed to relieve the distress associated with pubertal development in adolescents with gender dysphoria. According to data published on long-term outcome of puberty suppression with GnRHas and subsequent hormonal and surgical treatment reflects possibility of improved psychological outcomes. Brain imaging study results did not show negative effects of the treatment on brain development. [15] Psychological support and puberty suppression both are found to be associated with an improved global psychological functioning in gender dysphoric adolescents. [16]

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Psychological and Speech Therapy

Psychological intervention may be beneficial. Individual treatment focuses on understanding and dealing with gender issues. Group, marital, and family therapy can provide a helpful and supportive environment.

Speech therapy may help male-to-female individuals use their voice in a more feminine manner.

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Pharmacologic Therapy

Hormone therapy may also be necessary. Consequently, the endocrinologist should be involved in multiple phases of the treatment process. [6]

In male-to-female individuals, original sex characteristics can be suppressed with luteinizing hormone–releasing hormone (LHRH) agonists, progestational compounds (eg, medroxyprogesterone), spironolactone, flutamide, and cyproterone acetate. Breasts, increased body fat, and a more feminine body shape can be promoted with ethinyl estradiol (0.1-0.5 mg/day) and conjugated estrogen (7.5-10 mg/day). In female-to-male individuals, facial and body hair growth may be promoted with testosterone cypionate (200 mg IM every 2 weeks).

Pharmacotherapy may also be required for comorbid psychiatric diagnoses. Patients commonly experience symptoms of depression, anxiety, or psychosis. Medications may include antidepressants, anxiolytics, and antipsychotics. Clinically referred children and adolescents with gender dysphoria appear to have a higher incidence of autism spectrum disorder than is found in the general population [1] ; this may be true of adults as well. [17]

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Sexual Reassignment Surgery

Controversy exists regarding whether adolescents should be allowed to pursue SRS. Many countries deny SRS to adolescents; however, early treatment may be beneficial in adolescents whose secondary sex characteristics (eg, facial hair, lowered voice, and breast development) have not yet developed fully. In such cases, parental involvement and approval are essential.

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Complications

Complications may occur after SRS. In persons who undergo male-to-female SRS, the vagina can scar and become shorter and narrower, necessitating additional surgical intervention. Bouts of recurring cystitis are common. In persons who undergo female-to-male SRS, considerable scarring may occur as a consequence of breast tissue removal. Additionally, surgical complications from phalloplasty (construction of a scrotum with plastic testicles and a penislike appendage) are not uncommon.

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