Gender dysphoria - Treating gender dysphoria

Treatment for gender dysphoria aims to help people with the condition live the way they want to, in their preferred gender identity.

What this means will vary from person to person, and is different for children, young people and adults. Your specialist care team will work with you on a treatment plan that is tailored to your needs.

Treatment for children and young people

If your child is under 18 and thought to have gender dysphoria, they will usually be referred to a specialist child and adolescent Gender Identity Clinic (GIC).

Currently, the only specialist clinic for young people with gender identity issues is run by the Tavistock and Portman NHS Foundation Trust in London, although they occasionally provide satellite clinics in other parts of the country.

Staff at these clinics can carry out a detailed assessment of your child, to help them determine what support they need.

Depending on the results of this assessment, the options for children and young people with suspected gender dysphoria can include:

family therapy
individual child psychotherapy
parental support or counselling
group work for young people and their parents
regular reviews to monitor gender identity development
hormone therapy (see below)

Your child’s treatment should be arranged with a multi-disciplinary team (MDT). This is a group of different healthcare professionals working together, which may include specialists such as mental health professionals and paediatric endocrinologists (specialists in hormone conditions in children).

Most treatments offered at this stage are psychological, rather than medical or surgical. This is because the majority of children with suspected gender dysphoria do not have the condition once they have reached puberty. Psychological support, therefore, offers young people and their families a chance to discuss their thoughts and receive support to help them cope with the emotional distress of the condition, without rushing into more drastic treatments.

Hormone therapy

If your child has gender dysphoria and they have reached puberty, they could be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (man-made) hormones that suppress the hormones naturally produced by the body.

Some of the changes that take place during puberty are driven by hormones. For example, the hormone testosterone, which is produced by the testes in boys, helps stimulate penis growth.

As GnRH analogues suppress the hormones that are produced by your child’s body. They also suppress puberty and can help delay potentially distressing physical changes caused by their body becoming even more like that of their biological sex, until they are old enough for the treatment options discussed below.

GnRH analogues will only be considered for your child if assessments have found that they are experiencing clear distress and have a strong desire to live as their gender identity.

The effects of treatment with GnRH analogues are considered to be fully reversible, so treatment can usually be stopped at any time after a discussion between you, your child and your MDT.

Transition to adult services

When your child reaches 18, their care will usually be transferred to a gender clinic specialising in support and treatment for adults with gender dysphoria.

By this age, doctors can be much more confident in making a diagnosis of gender dysphoria and, if desired, steps can be taken towards more permanent hormone or surgical treatments to alter your child’s body further, to fit with their gender identity.

Treatment for adults

Adults with gender dysphoria should be referred to a specialist adult GIC. As with specialist children and young people GICs, these clinics can offer ongoing assessments, treatments, support and advice, including:

mental health support, such as counselling
cross-sex hormone treatment (see below)
speech and language therapy – to help alter your voice, to sound more typical of your gender identity
hair removal treatments, particularly facial hair
peer support groups, to meet other people with gender dysphoria
relatives' support groups, for your family

For some people, support and advice from a clinic are all they need to feel comfortable in their gender identity. Others will need more extensive treatment, such as a full transition to the opposite sex. The amount of treatment you have is completely up to you.

Hormone therapy

Hormone therapy for adults means taking the hormones of your preferred gender:

a trans man (female to male) will take testosterone (masculinising hormones)
a trans woman (male to female) will take oestrogen (feminising hormones)

The aim of hormone therapy is to make you more comfortable with yourself, both in terms of physical appearance and how you feel. These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity. They usually need to be taken indefinitely, even if you have gender reassignment surgery.

Hormone therapy may be all the treatment you need to enable you to live with your gender dysphoria. The hormones may improve how you feel and mean that you do not need to start living in your preferred gender or have surgery.

Changes in trans women

If you are a trans woman, changes that you may notice from hormone therapy include:

your penis and testicles getting smaller
less muscle
more fat on your hips
your breasts becoming lumpy and increasing in size slightly
less facial and body hair

Hormone therapy will not affect the voice of a trans woman. To make the voice higher, trans women will need voice therapy and, rarely, voice modifying surgery.

Changes in Trans men

If you are a trans man, changes you may notice from hormone therapy include:

more body and facial hair
more muscle
your clitoris (a small, sensitive part of the female genitals) getting bigger
your periods stopping
an increased sex drive (libido)

Your voice may also get slightly deeper, but it may not be as deep as other men’s voices.

Risks

There is some uncertainty about the possible risks of long-term masculinising and feminising hormone treatment, and you should be made aware of the potential risks and the importance of regular monitoring before treatment begins.

Some of the potential problems most closely associated with hormone therapy include:

blood clots
gallstones
weight gain
acne
hair loss from the scalp
sleep apnoea – a condition that causes interrupted breathing during sleep

Hormone therapy will also make both trans men and trans women less fertile. Your specialist should discuss the implications for fertility before starting treatment, and they may talk to you about the option of storing eggs or sperm (known as gamete storage) in case you want to have children in the future. However, this may not be available on the NHS.

There is no guarantee that fertility will return to normal if hormones are stopped.

Monitoring

While you are taking these hormones, you will need to have regular check-ups, either at your gender identity clinic or your local GP surgery. You will be assessed, to check for any signs of possible health problems and to find out if the hormone treatment is working.

If you do not think that hormone treatment is working, talk to the healthcare professionals who are treating you. If necessary, you can stop taking the hormones (although some changes are irreversible, such as a deeper voice in trans men and breast growth in trans women)

Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it will take a few months for some changes to develop. Hormones cannot change the shape of your skeleton, such as how wide your shoulders or your hips are. It also cannot change your height.

Hormones for gender dysphoria are also available from other sources, such as the internet, and it may be tempting to get them from here instead of through your clinic. However, hormones from other sources may not be licensed and safe. If you decide to use these hormones, let your doctors know so that they can monitor you.

Social gender role transition

If you want to have gender reassignment surgery, you will usually first need to live in your preferred gender identity full time for at least a year. This is known as "social gender role transition" (previously known as "real life experience" or "RLE") and it will help in confirming whether permanent surgery is the right option.

You can start your social gender role transition as soon as you are ready, after discussing it with your care team, who can offer support throughout the process.

The length of the transition period recommended can vary, but it is usually between one and two years. This will allow enough time for you to have a range of experiences in your preferred gender role, such as holidays and family events.

For some types of surgery, such as a bilateral mastectomy (removal of both breasts) in trans men, you may not need to complete the entire transition period before having the operation.

Surgery

Once you have completed your social gender role transition and you and your care team feels you are ready, you may decide to have surgery to permanently alter your sex.

The most common options are discussed below, but you can talk to members of your team and the surgeon at your consultation about the full range available.

Trans man surgery

For trans men, surgery may involve:

a bilateral mastectomy (removal of both breasts)
a hysterectomy (removal of the womb)
a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
phalloplasty or metoidioplasty (construction of a penis)
scrotoplasty (construction of a scrotum) and testicular implants
a penile implant

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm or lower abdominal wall to create a penis. A metoidioplasty involves creating a penis from the clitoris, which has been enlarged through hormone therapy.

The aim of this type of surgery is to create a functioning penis, which allows you to pass urine standing up and to retain sexual sensation. You will usually need to have more than one operation to achieve this.

Trans woman surgery

For trans women, surgery may involve:

breast implants
facial feminisation surgery (surgery to make your face a more feminine shape)
an orchidectomy (removal of the testes)
a penectomy (removal of the penis)
vaginoplasty (construction of a vagina)
vulvoplasty (construction of the vulva)
clitoroplasty (construction of a clitoris with sensation)

The vagina is usually created and lined with skin from the penis, with tissue from the scrotum (the sack that holds the testes) used to create the labia. The urethra (urine tube) is shortened and repositioned. In some cases, a piece of bowel may be used during a vaginoplasty if hormone therapy has caused the penis and scrotum to shrink a significant amount.

The aim of this type of surgery is to create a functioning vagina with an acceptable appearance and retained sexual sensation.

Some trans women cannot have a full vaginoplasty for medical reasons, or they may not want to have a functioning vagina. In such cases, a cosmetic vulvoplasty and clitoroplasty is an option, as well as removing the testes and penis.

Life after surgery

After surgery, most transsexuals are happy with their new sex and feel comfortable with their gender identity. One review of a number of studies that were carried out over a 20-year period found that 96% of people who had gender reassignment surgery were satisfied.

Despite high levels of personal satisfaction, people who have had gender reassignment surgery may face prejudice or discrimination because of their condition. Treatment can sometimes leave people feeling:

isolated, if they are not with people who understand what they are going through
stressed about or afraid of not being accepted socially
discriminated against at work

There are legal safeguards to protect against discrimination (see guidelines for gender dysphoria), but other types of prejudice may be harder to deal with. If you are feeling anxious or depressed since having your treatment, speak to your GP or a healthcare professional at your clinic.

Sexual orientation

Once transition has been completed, it is possible for a trans man or woman to experience a change of sexual orientation. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person, and the sexual orientation of many transsexuals does not change.

If you are a transsexual going through the process of transition, you may not know what your sexual preference will be until it is complete. However, try not to let this worry you. For many people, the issue of sexual orientation is secondary to the process of transition itself.

Gender
In this article, gender refers to the feeling of being either male or female.

Gender dysphoria
A condition that describes a feeling of mismatch between your biological sex and your gender identity.

Gender identity
Gender identity is your personal sense of knowing which gender you belong to, or the way that you see yourself.

Hormones
Hormones are groups of powerful chemicals that are produced by the body and have a wide range of effects.

Ovaries
The ovaries are two small, round organs in the female reproductive system that release an egg every month.

Sex
In this article, sex refers to male or female, the biological sex that you were born with.

Testicles (testes)
The testicles are part of the male reproductive system. They produce sperm and are located within the scrotum (a loose bag of skin) hanging down behind the penis.

Transsexual
A transsexual is someone with an extreme and long-term case of gender dysphoria, who seeks to alter their biological sex to match their gender identity.

Vagina
The vagina is a tube of muscle that runs from the cervix (the opening of the womb) to the vulva (the external sexual organs).

Womb
The uterus (or womb) is a hollow, pear-shaped organ in a woman where a baby grows during pregnancy.