This post is part of a series of guest posts on GPS by the graduate students in my Psychopathology course during Spring 2014. As part of their work for the course, each student had to demonstrate mastery of the skill of “Educating the Public about Mental Health.” To that end, each student has to prepare two 1,000ish word posts on a particular class of mental disorders, with one of those focusing on evidence-based treatments for those disorders and the other focused on a particular myth or misunderstanding about mental illness.
Treatment of Gender Dysphoria by Zak Tedder
Gender Dysphoria (GND) is a diagnosis in the DSM-5 that addresses the distress that can accompany the identification one individual makes with the gender opposing their birth sex. A transgender individual is one who feels as though their biological sex does not match the gender with which they identify. Transgender males report feeling as though they are a female and behave in ways typically associated with females. Transgender females report feeling that they are a male and behave in more masculine ways. The previous diagnosis of such a condition was Gender Identity Disorder (GID) in the DSM-IV-TR. However, alterations in the diagnostic system have turned their focus to the presence of distress in transgender individuals, and GND is the current diagnosis used to treat individuals who are troubled by their transgender situation. Treatments for individuals with GND include psychotherapy, hormone therapy, and gender reassignment surgery.
There are several comorbid disorders that accompany GND, including anxiety, depression, behavioral issues, substance abuse, and suicidality. These comorbid disorders are thought to arise out of the discomfort present in individuals suffering from GND. Psychotherapy is not used to treat GND directly, but rather, it focuses its attention on providing comfort with the transgender situation and the comorbid disorders that tend to accompany GND. Clinical management directed toward the transgender situation is focused on adjusting to life in one’s biologically assigned sex. The most prevalent among the comorbid disorders are anxiety and depression that manifest through feeling unable to be treated as the gender one feels they are. Since such pervasive feelings of being trapped in an inappropriate body have not been shown to be changeable through psychotherapy, hormone therapy and gender reassignment surgery are the most prevalent forms of treatment for GND.
Hormone replacement therapy is the introduction of medication shown to alter naturally occurring hormones and their effects. Since the presentation of GND is different in children, adolescents, and adults, it fits that the hormone therapies for each are also different. Since children have not started to produce hormones that drastically change their bodies, hormone-suppressing treatments are employed to individuals who have parental consent for such treatment. These treatments delay pubertal development of sex characteristics. Godadotropin-releasing hormone analogs (GnRHa) can be prescribed for adolescents to suppress puberty onset. The GnRHa therapy is completely reversible and cessation of the treatment will resume puberty development of the biologically assigned gender. The GnRHa treatment is beneficial for those who suffer from GND in childhood but whose issues resolve themselves in adolescence.
The next stage of treatment is real-life experience (RLE). This is when the individual lives their life as if they were their desired gender. It is recommended that RLE proceed for two years before gender confirmation surgery (GCS), but only one year is required. An important distinction to make is one between transgender and transsexual individuals. Transgender refers to the belief that one is of another gender than their biological sex, but transsexual refers to those people who are seeking or have undergone GCS. The second stage of a physical change intervention is the administration of cross-sex hormones. Estrogen is given to male-to-female (MTF) and testosterone is given to female-to-male (FTM) transgender individuals. Unlike hormone suppression therapy alone, cross-sex hormone therapy combined with hormone suppression therapy can cause irreversible changes to internal reproductive organs. Sperm and egg storage is often recommended for individuals who undergo these treatments who want to preserve their ability to have biological children in the future.
MTF cross-sex hormone treatment involves the prescription of estrogen with the combined use of GnRHa. The combination is important so that the hormones that would be produced naturally are suppressed, while allowing the hormones being introduced to make changes. Breast development begins almost immediately and will usually end after two years of treatment. The option of breast augmentation is available for those who are not satisfied with breast size or shape. FTM cross-sex hormone treatment involves the prescription of testosterone with the combined use of GnRHa. This procedure begins body and facial hair growth, muscle growth, clitoral enlargement, increased libido, and thickening of vocal cords. The deepening of voice that may be experienced during this treatment is irreversible. Both of these hormone therapies for MTF and FTM individuals must be continued through the lifetime to prevent sex hormone deprivation symptoms and osteoporosis.
The GCS administered to MTF transsexuals can involve several operations. Breast surgery is available to those who are not satisfied with the breast size or shape that have resulted from hormone therapy. The following procedures often occur together but can be preformed separately: A penectomy is the removal of the penis, while a creation of a urethral opening allows for urination. An orchiectomy (gonadectomy or orchiectomy) is the removal of the testes. A vaginoplasty is the creation of a neovagina through the conversion of the pre-existing male genitalia into female genitalia. A labiaplasty and clitoroplasty can also be performed to create labia and clitoris, respectively. Additional procedures are available to increase apparent feminine features, including blepharoplasty (for eyelids) and rhinoplasty (for reshaping the nose).
The GCS administered to FTM transsexuals can be a bit more involved than the MTF operations. A mastectomy (aka “top surgery”) is the removal of breast tissue and the excess skin. The top surgery may be the only surgery undergone by a FTM transsexual, as it can often give them the ability to pass for male and greatly improve psychological and social functioning. The “bottom surgery” is much more involved. A hysterectomy is the removal of the uterus and cervix, and a salpingo-oophorectomy is the removal of the fallopian tubes and ovaries; these two operations are often performed together. A vaginectomy involves removal of vaginal mucosa. A metoidioplasty is the creation of a neophallus, which functions as a penis, with clitoral tissue that has been enlarged from hormone treatment. A phalloplasty is also the creation of a neophallus, but it is a complex procedure using skin grafts. This procedure creates a more aesthetically acceptable penis with sufficient dimensions to have sexual intercourse.
The most effective treatments are medical in nature, and psychological intervention does not seem to have significant effects other than treating comorbid issues. The treatments presented in this blog are helping individuals who suffer from Gender Dysphoria to create lives that are more comfortable and help them feel comfortable in their own skin, something everyone should be able to experience.
(many thanks to Vandy Beth Glenn for proof- and content-reading this piece!)