Gender Dysphoria and Its Non-Surgical and Surgical Treatments
Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one’s gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.
1. Flores AR, Herman JL, Gates GJ, Brown TNT. How Many Adults Identify As Transgender in the United States? Williams Inst.2016;(June):13.
2. Collin L, Reisner SL, Tangpricha V, Goodman M. Prevalence of Transgender Depends on the “Case” Definition: A Systematic Review. J Sex Med.2016;13(4):613-626. doi:10.1016/j.jsxm.2016.02.001
3. Goodman M, Adams N, Corneil T, Kreukels B, Motmans J, Coleman E. Size and Distribution of Transgender and Gender Nonconforming Populations: A Narrative Review. Endocrinol Metab Clin North Am.2019;48(2):303-321. doi:10.1016/j.ec 1.2019.01.001
4. Heylens G, De Cuypere G, Zucker KJ, et al. Gender Identity Disorder in Twins: A Review of the Case Report Literature. J Sex Med. 2012;9(3):751-757. doi:10.1111/j.1743-6109.2011.02567.x
5. Altinay M, Anand A. Neuroimaging gender dysphoria: a novel psychobiological model. Brain Imaging Behav.2020;14(4):1281-1297. doi:10.1007/s11682-019-00121-8
6. Luders E, Sánchez FJ, Tosun D, et al. Increased Cortical Thickness in Male-to-Female Transsexualism. J Behav Brain Sci.2012;2(3):357-362. doi:10.4236/jbbs.2012.23040
7. Manzouri A, Savic I. Possible neurobiological underpinnings of homosexuality and gender dysphoria. Cereb Cortex.2019;29(5):2084-2101. doi:10.1093/cercor/bhy090
8. Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry.2016;28(1):13-20. doi:10.3109/09540261.2015.1115754
9. Byne W, Karasic DH, Coleman E, et al. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgender Heal. 2018;3(1):57-70. doi:10.1089/trgh.2017.0053
10. Day DS, Saunders JJ, Matorin A. Gender Dysphoria and Suicidal Ideation: Clinical Observations from a Psychiatric Emergency Service. Cureus.2019;11(11).
11. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet.2016;388(10042):390-400. doi:10.1016/s0140-6736(16)00683-8
12. Silva DC, Salati LR, Fontanari AMV, et al. Prevalence of Gender Dysphoria in Southern Brazil: A Retrospective Study. Arch Sex Behav.2021;50(8):3517-3526. doi:10.1007/s10508-021-02036-2
13. Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam Cohort of Gender Dysphoria Study(1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med.2018;15(4):582-590. doi:10.1016/j.jsxm.2018.01.016
14. Zucker KJ. Epidemiology of gender dysphoria and transgender identity. Sex Health.2017;14(5):404-411. doi:10.1071/sh17067
15. de Graaf NM, Carmichael P, Steensma TD, Zucker KJ. Evidence for a Change in the Sex Ratio of Children Referred for Gender Dysphoria: Data From the Gender Identity Development Service in London(2000-2017). J Sex Med.2018;15(10):1381-1383. doi:10.1016/j.jsxm.2018.08.002
16. Zaliznyak M, Bresee C, Garcia MM. Age at First Experience of Gender Dysphoria Among Transgender Adults Seeking Gender-Affirming Surgery. JAMA Netw Open.2020;3(3):e201236. doi:10.1001/jamanetw orkopen.2020.1236
17. Foreman M, Hare L, York K, et al. Genetic Link between Gender Dysphoria and Sex Hormone Signaling. J Clin Endocrinol Metab.2018;104(2):390-396. doi:10.1210/jc.2018-01105
18. Polderman TJC, Kreukels BPC, Irwig MS, et al. The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table. Behav Genet.2018;48(2):95-108. doi:10.1007/s10519-018-9889-z
19. Uribe C, Junque C, Gómez-Gil E, Abos A, Mueller SC, Guillamon A. Brain network interactions in transgender individuals with gender incongruence. Neuroimage.2020;211:116613. doi:10.1016/j.neuroim age.2020.116613
20. Hines M, Brook C, Conway GS. Androgen and psychosexual development: Core gender identity, sexual orientation, and recalled childhood gender role behavior in women and men with congenital adrenal hyperplasia(CAH). J Sex Res.2004;41(1):75-81. doi:10.1080/00224490409552215
21. Meyer-Bahlburg HFL, Dolezal C, Baker SW, New MI. Sexual orientation in women with classical or non-classical congenital adrenal hyperplasia as a function of degree of prenatal androgen excess. Arch Sex Behav.2008;37(1):85-99. doi:10.1007/s10508-007-9265-1
22. Hines M, Ahmed SF, Hughes IA. Psychological Outcomes and Gender-Related Development in Complete Androgen Insensitivity Syndrome. Arch Sex Behav.2003;32(2):93-101. doi:10.1023/a:1022492106974
23. Green R. Sexual Identity Conflic in Children and Adults. Basic Books; 1974.
24. Stoller RJ. Sex and Gender: The Development of Masculinity and Feminitiy. London: Hogarth press;1968.
25. Wallien MSC. Gender identity dysphoria in childhood: causes and consequences. Published online 2008.
26. Wallien MSC, Van Goozen SHM, Cohen-Kettenis PT. Physiological correlates of anxiety in children with gender identity disorder. Eur Child Adolesc Psychiatry.2007;16(5):309-315. doi:10.1007/s00787-007-0602-7
27. Dora M, Grabski B, Dobroczyski B. Gender dysphoria, gender incongruence and gender nonconformity in adolescence- changes and challenges in diagnosis. Psychiatr Pol.2021;55(1):23-37. doi:10.12740/pp/onlinefirst/113009
28. Davy Z, Toze M. What is gender dysphoria? A critical systematic narrative review. Transgender Heal.2018;3(1):159-169. doi:10.1089/trgh.2018.0014
29. Wang Y, Feng Y, Su D, et al. Validation of the Chinese Version of the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. J Sex Med.2021;18(9):1632-1640. doi:10.1016/j.jsx m.2021.05.007
30. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association; 2013. doi:10.1176/appi.book s.9780890425596
31. Martinerie L, Le Heuzey MF, Delorme R, Carel JC, Bargiacchi A. [Assessment and management of gender dysphoria in children and adolescents]. Arch Pediatr.2016;23(6):668-673. doi:10.1016/j.arcped.2016.03.002
32. Bloom TM, Nguyen TP, Lami F, et al. Measurement tools for gender identity, gender expression, and gender dysphoria in transgender and gender-diverse children and adolescents: a systematic review. Lancet Child Adolesc Heal.2021;5(8):582-588. doi:10.1016/s2352-4642(21)0009$$\begin{array}{l}\\ 8-5\\ \\ \end{array}$$
33. Specht AA, Gesing J, Pfaeffle R, Koerner A, Kiess W. [Symptoms, Comorbidities and Therapy of Children and Adolescents with Gender Dysphoria], Klin Padiatr.2020;232(1):5-12. doi:10.1055/a-1066-4625
34. Day DS, Saunders JJ, Matorin A. Gender Dysphoria and Suicidal Ideation: Clinical Observations from a Psychiatric Emergency Service. Cureus.2019;11(11). doi:10.7759/cureus.6132
35. Byne W, Karasic DH, Coleman E, et al. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgender Heal. 2018;3(1):57-70. doi:10.1089/trgh.2017.0053
36. Giovanardi G, Vitelli R, Vergano CM, et al. Attachment patterns and complex trauma in a sample of adults diagnosed with gender dysphoria. Front Psychol.2018;9(FEB):60. doi:10.3389/FPSYG.2018.00060/BIBTEX
37. Shulman GP, Holt NR, Hope DA, Eyer J, Mocarski R, Woodruff N. A review of contemporary assessment tools for use with transgender and gender nonconforming adults. Psychol Sex Orientat Gend Divers.2017;4(3):304-313. doi:10.1037/sgd0000233
38. Deogracias JJ, Johnson LL, Meyer-Bahlburg HFL, Kessler SJ, Schober JM, Zucker KJ. The gender identity/gender dysphoria questionnaire for adolescents and adults. J Sex Res.2007;44(4):370-379. doi:10.1080/00224490701586730
39. Bauerband LA, Galupo MP. The Gender Identity Reflection and Rumination Scale: Development and Psychometric Evaluation. J Couns Dev.2014;92(2):219-231. doi:10.1002/j.1556-6676.2014.00151.x
40. Barr SM, Budge SL, Adelson JL. Transgender community belongingness as a mediator between strength of transgender identity and well-being. I Couns Psychol.2016;63(1):87-97. doi:10.1037/cou0000 $\underline{127}$
41. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. http://www.wpath.org
42. Hadj-Moussa M, Ohl DA, Kuzon WM Jr. Evaluation and Treatment of Gender Dysphoria to Prepare for Gender Confirmation Surgery. Sex Med Rev.2018;6(4):607-617. doi:10.1016/j.sxmr.2018.03.00 $\underline{6}$
43. Wylie K, Knudson G, Khan SI, Bonierbale M, Watanyusakul S, Baral S. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet. 2016;388(10042):401-411. doi:10.1016/s0140-6736(16)00682-6
44. Meyer G, Boczek U, Bojunga J. Hormonal gender reassignment treatment for gender dysphoria. Dtsch Arztebl Int.2020;117(43):725-732. doi:10.3238/arzteb 1.2020.0725
45. Chew D, Anderson J, Williams K, May T, Pang K. Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review. Pediatrics.2018;141(4). doi:10.1542/peds.2017-3742
46. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline. The Journal of Clinical Endocrinology& Metabolism.2017;102(11):3869-3903. doi:10.1210/jc.2017-01658
47. Shumer DE, Nokoff NJ, Spack NP. Advances in the Care of Transgender Children and Adolescents. Adv Pediatr.2016;63(1):79-102. doi:10.1016/j.yapd.2016.04.018
48. Rosenthal SM. Approach to the Patient: Transgender Youth: Endocrine Considerations. The Journal of Clinical Endocrinology& Metabolism.2014;99(12):4379-4389. doi:10.1210/jc.2014-1919
49. Nguyen HB, Chavez AM, Lipner E, et al. Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition. Curr Psychiatry Rep.2018;20(12). doi:10.1007/s11920-018-0973-0
50. Salas-Humara C, Kimberly L, Folkers K, et al. Ethical Issues in Gender-Affirming Care for Youth. Pediatrics.2018;142(6):20181537. http://publication s.aap.org/pediatrics/article-pdf/142/6/e20181537/1075510/peds 20181537.pdf
51. Bonifacio J, Maser C, Stadelman K, Palmert M. Management of Gender Dysphoria in Adolescents in Primary Care. Canadian Medical Association Journal.2019;191(3):E69-E75. doi:10.1503/cmaj.180672
52. Hadj-Moussa M, Ohl DA, Kuzon WM Jr. Feminizing Genital Gender-Confirmation Surgery. Sex Med Rev.2018;6(3):457-468.e2. doi:10.1016/j.sxmr.2017.11.005
53. Branstrom R, Pachankis JE. Reduction in mental health treatment utilization among transgender individuals after gender-affirming surgeries: A total population study. Am J Psychiatry.2020;177(8):727-734. doi:10.1176/APPI.AJP.2019.19010080/FORMAT/EPUB
54. Littman L. Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners. Arch Sex Behav.2021;50(8):3353-3369. doi:10.1007/s10508-021-02163-w
55. Hamidian Jahromi A, Boyd LC, Schechter L. An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know. World J Surg.2021;45(12):3511-3521. doi:10.1007/s00268-021-06084-6
56. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol.2013;64(1):141-149. doi:10.1016/j.eururo.2012.12.030
57. Bouman MB, van Zeijl MCT, Buncamper ME, Meijerink WJHJ, van Bodegraven AA, Mullender MG. Intestinal vaginaplasty revisited: A review of surgical techniques, complications, and sexual function. J Sex Med.2014;11(7):1835-1847. doi:10.1111/jsm.12538
58. van der Sluis WB, Bouman MB, de Boer NKH, et al. Long-Term Follow-Up of Transgender Women After Secondary Intestinal Vaginoplasty. J Sex Med.2016;13(4):702-710. doi:10.1016/j.jsxm.2016.01.008
59. Hadj-Moussa M, Agarwal S, Ohl DA. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev.2019;7(1):141-155. doi:10.1016/j.sxmr.2018.06.004