Dr Emanuel Vlahakis, Staff Specialist in HIV/Sexual Health, MNC LHD
Gender dysphoria (GD) is the distress or discomfort that may occur when a person’s biological sex and gender identity do not align. The term has replaced ‘gender identity disorder’. This change in terminology removes the ‘pathology’ from being transgender, which is not a mental health condition and shifts the focus of management onto helping treat the dysphoria that is associated with being transgender.
The true prevalence of GD is unknown in Australia because of varying definitions, different cultural norms and paucity of data. New Zealand reported an estimated prevalence of 1-in-6,000, with a natal male-to-female ratio of 6 to 1. However, research suggests the prevalence is much higher than previously thought.
Individuals who identify as transgender are vulnerable, and experience higher rates of discrimination, depression and suicidality, compared with the general population. It is important for GPs to have a basic understanding of gender dysphoria as they will often be the first point of contact for these patients.
When consulting with patients who present with GD it is important to establish what name and pronoun the patients would prefer. For example, Ms Rachael Smith may prefer to be called Mr Ross Smith, and prefer ‘him/his’ to ‘her/hers’. These simple, initial questions will establish understanding and trust in the therapeutic relationship.
Diagnosis
The DSM-5 has diagnostic criteria for gender dysphoria in adults. For GD to be present, a patient must have had at least two DSM-5 criteria for at least six months, and it must be identified by the patient as having caused significant distress. This generally includes any of the following:
- a significant difference between their own experienced gender and their secondary sexual characteristics
- strong desire to be rid of their secondary sexual characteristics or to prevent their development
- wanting secondary sexual characteristics of the opposite gender
- wanting to be treated as the other gender
- the strong belief that they have the feelings/reactions of the opposite gender.
Unless clinicians are experienced in the diagnosis of GD it would be important to enlist the help of a competent mental health professional for assistance. GD often presents with co-existing mental health conditions and so counselling by a clinician with experience or interest in transgender health would be recommended in the vast majority of cases. Psychologists fulfil an important support role to patients and families during transition. They may also aid in the diagnosis of comorbid mental health conditions and can provide reports on the suitability of the individual for surgery. Finding a suitably experienced psychologist may be difficult, especially in rural areas. A psychologist skilled in the management of anxiety and depression may be the best alternative.
Treatment
Some patients may be happy to live in their desired gender role, but many will want to physically transition with the use of hormones, with or without surgery. It would be important to enlist the help of an endocrinologist or sexual health physician for the initiation of treatment, but once established, ongoing care can be provided by GPs.
Hormone therapy has been demonstrated to reduce distress without significant adverse psychological or physical effects. As with any medication, it is important to be aware of the reversible and permanent side effects of hormone therapy to ensure patients are fully informed. This is described well in the Endocrine Society Treatment of Transsexual Persons’ Guidelines.
Surgical options for individuals who identify as transgender often refer to ‘top’ procedures (e.g. chest reconstruction or breast augmentation) and ‘bottom’ procedures (e.g. removal and creation of new genitalia). Surgical reassignment is often performed overseas due to greater expertise and lower cost. Genital surgery is often reserved for patients who have been on hormone therapy for at least one year and living in their desired role, given the permanency of the procedures.
Changing IDs
Successfully changing one’s identity on documents is an affirmation of gender for patients, but it is often an area of confusion for doctors. The Federal Government’s Australian guidelines on the recognition of sex and gender (2013) states specifically that ‘sex reassignment surgery and/or hormone therapy are not prerequisites for the recognition of a change of gender in Australian Government records’. This means legal documents from Centrelink, Medicare, passports, Australian Tax Office, driver’s licence, birth certificate, and any other government agency cards and records can be changed to a preferred gender.
A letter from a registered medical practitioner or registered psychologist is all that is required to change the sex. The guidelines include a section on what should be included in the letter. The forms to change the documents are easily downloaded from government websites.
In conclusion while gender dysphoria is an uncommon presentation, these individuals are often isolated and have higher rates of depression and suicide. It is important to validate and engage with the patient. Gender dysphoria often involves a multidisciplinary team, at the very heart of which is the therapeutic relationship between the GP and the patient. The GP is best placed to provide holistic and ongoing care for a person with gender dysphoria.
Adapted from Atkinson S and Russell D ‘Gender Dysphoria’ volume 44, no 11 2015 p792-792
