What to say? What to prescribe? When to refer? The authors offer advice on how best to communicate with and treat this unique patient population.
Civil rights for the lesbian, gay, bisexual, and transgender population have advanced markedly in the past decade, and the medical community has gradually begun to address more of their health concerns. More recently, media attention to transgender individuals--although focused primarily on the "appropriate" use of restrooms--has encouraged many more to openly seek care. (1,2)
It is estimated that anywhere from 0.3% to 5% of the US population identifies as transgender. (1,3) While awareness of this population has slowly increased, there is a paucity of research on the hormone treatment that is often essential to patients' well-being. Studies of surgical options for transgender patients have been minimal, as well.
Family physicians are uniquely positioned to coordinate medical services and ensure continuity of care for transgender patients as they strive to become their authentic selves. Our goal in writing this article is to equip you with the tools to provide this patient population with sensitive, high-quality care (TABLE 1). (4,7) Our focus is on the diagnosis of gender dysphoria (GD) and its medical and hormonal management--the realm of primary care providers. We briefly discuss surgical management of GD, as well.
Understanding and diagnosing gender dysphoria
Two classification systems are used for diagnoses related to GD: the Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed. (DSM-5) (8) and the International Classification of Diseases, 10th Rev. (ICD-10). (9)
ICD-10 criteria use the term "gender identity disorder;" DSM-5 refers to "gender dysphoria" instead. It is important to emphasize that these classification systems represent an attempt to categorize a group of signs and symptoms that lead to distress for the patient, and are not meant to suggest that being transgender is pathological. In fact, in DSM-5--released in 2013--the American Psychiatric Association revised the terminology to emphasize that such individuals are not "disordered" by the nature of their identity, but rather by the distress that being transgender causes. (8)
For a diagnosis of GD in children, DSM 5 criteria include characteristics perceived to be incongruent between the child's sex at birth and the self-identified gender based on preferred activities or dislike of his or her own sexual anatomy. The child must meet 6 or more of the following for at least 6 months:
* a repeatedly stated desire to be, or insistence that he or she is, of the other gender
* in boys, a preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
* strong and persistent preferences for cross-gender roles in make-believe play or fantasy
* a strong rejection of toys/games typically associated with the child's sex
* intense desire to participate in stereotypical games and pastimes of the other gender
* strong preference for playmates of the other gender
* a strong dislike of one's sexual anatomy
* a strong desire for the primary (eg, penis or vagina) or secondary (eg, menstruation) sex characteristics of the other gender. (8)...
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