Comprehensive Guide to Modern Approaches to Gender Dysphoria Treatment

Gender dysphoria (GD) is the distress an individual experiences because of a mismatch between their gender identity and their sex assigned at birth.^{(1, 2)} Initially termed gender identity disorder and most recently, known as gender incongruence, is most commonly termed gender dysphoria and has been growing significantly, especially in the case of transgender individuals. Several treatment approaches can effectively help people with gender dysphoria win over this distress of gender dysphoria and lead a more content life.

As we read further in this article, we will explore several modern medical and therapeutic approaches to gender dysphoria.

In people with gender dysphoria, their gender identity and biological sex do not match, which results in marked distress. This is usually heightened at the onset of puberty.⁽³⁾ This distress can hinder normal psychological development and daily activities, usually resulting in depression and suicidal ideation. Medical treatments like hormone therapy, surgical approaches, and psychotherapy can improve the prognosis of the condition.⁽⁴⁾

Treatment options for people with gender dysphoria should be designed to foster a good relationship with young people and their families, addressing their specific needs to achieve satisfactory outcomes. Treatment can help people with gender dysphoria explore their gender identity, get appropriate support, and find the gender role that feels comfortable for them, thus easing distress.

Some of the modern medical and therapeutic approaches to gender dysphoria include:

1. Medical Approaches  

   General Criteria for Hormonal and Surgical Treatment of Gender Dysphoria:

   The World Professional Association for Transgender Health (WPATH) has provided the following criteria for hormonal replacement and surgical treatment of gender dysphoria.

   • Persistent, well-documented gender dysphoria.
   • Capacity to make a completely informed decision and consent to these treatment procedures.
   • If any significant mental or medical concerns are found, they must be well controlled.
   • The legal age of the person to undergo the surgery or treatment must be taken into consideration. In the case of children and adolescents, the standard of care must be followed.

   Some additional criteria must be followed in some surgical procedures. These include:

   A pre-treatment medical assessment is to be done by an expert and experienced doctor. This can help rule out or address medical conditions that can affect these treatments. These medical assessments might include:

   • A family and personal medical history
   • A physical examination
   • Laboratory tests
   • Identification and management of drug, alcohol, or tobacco use.
   • Assessment of the need for sex- and- age-appropriate screenings.
   • Testing for HIV and other sexually transmitted infections
   • Assessment of desire for fertility preservation.

   Some of the medical approaches that could be followed to address gender dysphoria are mentioned below.

   1. Hormone Replacement Therapy

      Hormone replacement therapy (HRT) is a non-operative treatment of gender dysphoria that includes feminizing hormone therapy or masculinizing hormone therapy. Hormone replacement therapy requires an in-depth pre-treatment work-up, such as risk screening, thorough medical history, and examinations, and also several laboratory studies to assess the ability of the patient to tolerate hormone replacement safely.⁽⁵⁾ The goal of HRT is to promote the characteristics of the person’s desired gender and minimize the characteristics of the gender assigned at birth (biological gender).⁽⁶⁾

      A.1 Feminizing Therapy for Male-to-Female (MTF) Gender Dysphoria

      Feminizing hormone replacement therapy is for male-to-female (MTF) gender dysphoria. This therapy generates specific effects on the genetically male body; and these effects include, softening of the skin, reducing body hair production, reducing testicular size, reducing muscle mass, and encouraging breast growth. Although the onset of these effects might begin within six months of the treatment, it would take somewhere around one or two years to notice the maximum effects.^{(7, 8)}

      These effects are achieved by combining pro-estrogen and anti-androgen therapy. Pro-estrogen therapy involves oral or transdermal administration of 17 β-estradiol, which activates estrogen receptors and generates effects like softening of the skin, reducing muscle mass, enhancing breast growth, reducing body hair production, and so on. Spironolactone, which is an androgen receptor antagonist that is quite effective at inhibiting the actions of testosterone, is the most recommended anti-androgen therapy. Spironolactone also has some estrogenic activity.⁽⁹⁾

      A.2  Masculinization Therapy for Female-to-Male (FTM) Gender Dysphoria

      The next type of hormone replacement therapy is masculinization therapy for female-to-male (FTM) gender dysphoria. This is a non-operative medical approach to address gender dysphoria in biologically female persons having a male gender identity. Masculinization hormone replacement therapy for FTM gender dysphoria is usually less complex when compared with feminization HRT for MTF gender dysphoria. In the case of masculinization FMT therapy, testosterone is the primary hormone that is supplemented.

      Various medications including testosterone enanthate and testosterone cypionate are available, which are specifically administered via intramuscular injection. However, transdermal gels and patches are some other available options for this. Administering testosterone hormone activates androgen receptors, which produce specific effects on the genetically female body, such as increased facial and body hair production, increased skin oiliness, increased strength, and muscle mass, deepened voice, halted menses, enlarged clitoris, and vaginal atrophy.^{(10, 11)} So, supplementing the body with testosterone provides individuals with their desired body.

      However, anti-estrogen therapy is not required to achieve the physiologic levels of the hormone testosterone in the normal male. That is why this FTM hormone replacement therapy is less complex than MTF therapy.⁽¹²⁾

   2. Gender Confirmation Surgery

      If hormone replacement therapy does not work, people with gender dysphoria would require some sort of surgical treatment to achieve their desired body image and psychological gender identity. Such surgical procedures, including both genital and non-genital, are collectively known as, ‘Gender Confirmation Surgery” (GCS).

      Specifically, genital surgeries are most often the last recommended treatment procedures for people with gender dysphoria. This is due to permanent alteration in fertility and also because of the risks associated with surgery. Gender confirmation surgery should be advised only when hormone replacement therapy and psychotherapy do not work in enhancing gender identities in people with gender dysphoria.^{(13, 14)}

   B.1 Feminizing Genital Gender Confirmation Surgery

   Feminizing genital gender confirmation surgery is the procedure, where the surgeon creates a sensate neo-vagina using part of the original penis of persons with gender dysphoria who are biologically male but have a female gender identity. This surgery is called “Penile inversion vaginoplasty.” Orchiectomy, a surgical procedure is performed where the testicles are removed. The skin from the scrotum is used in making the labia. The neoclitoris is made from the erectile tissue of the penis. The urethra is preserved and functional. This surgical procedure provides the person with functional and aesthetic female genitalia in a 4-5 hour operation.

   B.2 Musculinizing Genital Gender Confirmation Surgery

   Masculinizing genital gender confirmation surgery is for those people with gender dysphoria and willing to go for a female-to-male sex reassignment surgery. This surgery offers a phalloplasty, which is the surgical creation of the penis. This surgical procedure creates an aesthetically appropriate phallus and a urethra for standing urination. As a second stage, a scrotum with testicular implants is constructed.

2. Therapeutic Approaches

   Other therapeutic approaches for gender dysphoria include psychosocial therapy and behavioral health treatment.

   Psychological Therapy

   This is one of the most recommended therapeutic approaches for treating gender dysphoria. Psychosocial therapy and counseling is the first non-operative option for people with gender dysphoria. Its primary goal is to improve the patient’s quality of life through consistent and open communication.⁽¹⁵⁾ The objective of psychosocial therapy and counseling is to support individuals as they begin to implement their gender identity in their society. Mental health professionals offer them support by answering their questions and discussing body image regarding society-based gender norms.

   The benefit of this therapeutic approach is that patients can utilize this support lifelong. The WPATH has recognized that this therapy significantly helps individuals with their gender identity without needing any sort of hormone-based medical therapy or gender-affirmation surgery.^{(15, 16)}

   Behavioral Health Treatment

   Behavioral health treatment for individuals with gender dysphoria aims at improving their psychological well-being, quality of life, and self-fulfillment. This therapeutic approach is not intended to alter an individual’s gender identity, instead, it can help them explore gender concerns and find various ways to reduce symptoms of gender dysphoria. Behavioral health treatment makes you feel comfortable with how one expresses their gender identity and also addresses any other mental health concerns.

3. Some Other Ways to Ease Gender Dysphoria

   Some other ways to ease gender dysphoria include the use of peer support groups, breast binding, breast padding, genital tucking, hair removal or transplantation, voice, and communication therapy, and some sorts of aesthetic services like makeup application, along with legal services, such as advanced directives, or living wills.

Gender dysphoria can be experienced by anyone and it could be difficult to overcome this condition. However, modern medical and therapeutic approaches including hormone replacement therapy, gender confirmation surgery, psychosocial therapy, and behavioral health treatments could help individuals with gender dysphoria lead an improved quality of life.

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