In the early 1970s, professional tennis player Renée Richards brought gender identity disorder (GID), then called transsexualism, to the American public’s awareness. Since then, guidelines for treatment of GID—also called gender dysphoria—have been developed in the United States.
Because family physicians may encounter transgendered persons in their practices, it is important to understand basic treatment plans, adverse effects of treatment, and referral options. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., GID is the severe and persistent belief that a person’s gender identity is not congruent with his or her biologic gender.1 The desire for gender change must be present for at least two years, be independent of sexual orientation, and be alleviated by transgender identification.1 A recent study in the Netherlands estimated the incidence of GID to be about one in 11,900 males and one in 30,400 females.2–4 Like sexual orientation, GID is thought to be related to genetic and environmental factors. Behavioralists have not come to a consensus on any set cause.5
The degree of dissatisfaction or dysphoria with biologic gender will inf luence the degree to which the person changes gender identity. To be eligible for treatment, patients must work with mental health professionals skilled in the diagnosis and treatment of GID. After months or years of counseling, the patient begins real-life gender role experience combined with or followed by hormonal therapy and possibly surgery.2,6
Estrogen is the cornerstone of feminizing hormonal treatment.4,6 Antiandrogens such as spironolactone may be added to potentiate the feminizing effects of estrogen.6 The hormonal treatment for masculinization is androgen treatment with testosterone.2,4,6 With either hormonal regimen, body changes that ensue are gradual and not reversible. Genital surgery is the definitive step in therapy, but it is costly and complex. For many persons with GID, there is no need for genital-altering surgery because hormonal therapy and cosmetic procedures are sufficient.2,4,6 A study of factors associated with regret or satisfaction after male-to-female surgery found that participants who achieved good cosmetic and functional results were highly satisfied with their surgery and reported improved quality of life.7
As with biologic women who take estrogen and progestin, transgendered patients treated with these agents may be at risk of thromboembolic events and breast cancer.6,8 The most common adverse effects of androgen therapy are increased cardiovascular risk factors of the metabolic syndrome and increased hematocrit levels.2,4,6 Although hormonal therapy and surgery carry risks of life-threatening complications, failure to treat patients with GID carries risks of depression and high rates of substance abuse and suicide, especially in young adults.9
Transgendered persons face many difficulties because of societal and familial lack of acceptance and understanding of GID. One of the most important issues a transgendered person must face is the recognition of their new gender in legal documents. In the United States, transgendered persons are permitted to have their gender changed on legal documents after providing proof of gender identity modification, usually defined as a surgical procedure. In cases of divorce and child custody, the key issue is whether to legally recognize the postoperative gender identity. Most courts in the United States recognize the postoperative gender identity and will grant marriage nullifications.10
Discrimination and violence often are encountered by transgendered persons in the workplace. Patients who disclose their new gender identity and request workplace accommodations may face negative consequences such as harassment, intimidation, property destruction, and termination. More than 50 percent of transgendered patients report undergoing some form of harassment, and at least 25 percent report that they have been involved in a violent incident. Violence is more often directed at male-to-female transgendered persons.11
Patients considering transgender treatment should be aware of the consequences that can affect most areas of life: health, family, work, and relationships. Information and support is available from physicians and organizations that work closely with lesbian and gay health issues (Table 1).