What is the treatment for dysphoria?

Treatment of Gender Dysphoria

Gender dysphoria requires a multidisciplinary team-based approach combining mental health support, gender-affirming hormone therapy (GAHT), and surgical interventions when appropriate, with treatment decisions guided by the patient's experienced gender identity rather than assigned sex at birth. 1

Initial Assessment and Team Composition

The treatment team must include:

• Endocrinologist for hormone management 1
• Mental health professional (psychologist/psychiatrist) for assessment and ongoing support 1
• Surgeon experienced in gender-affirming procedures when surgical intervention is considered 1
• Social work and nursing support when available 1

The goal of all treatment modalities is to achieve lasting personal comfort with one's gendered self, maximize overall health and psychological well-being, and reduce distress—which may or may not include physical modification of gender expression. 2

Treatment Outcomes: Why This Matters

When transgender persons receive individualized, medically appropriate care, they demonstrate improved mental health, reduction in suicide rates, and lower overall healthcare costs due to fewer mental health-related and substance abuse-related costs. 2 Gender-affirming treatment is life-saving for many individuals, as it may lessen depression, anxiety, and suicidality. 2

Hormone Therapy Protocols

For Feminizing Therapy (Transfeminine Patients):

• Estradiol is the cornerstone, available in oral, transdermal, or injectable forms 1
• Combine with anti-androgen therapy to suppress testosterone 1
• Target estradiol levels in the cisgender female reference range 1
• Expected physical changes: breast development, decreased lean body mass, skin softening, decreased body/facial hair, 5% decrease in thigh muscle volume, 4% decrease in quadriceps cross-sectional area, and significant decreases in hemoglobin levels 1

For Masculinizing Therapy (Transmasculine Patients):

• Testosterone cypionate or enanthate via intramuscular or subcutaneous injection 1
• Target trough testosterone levels between 300-1,000 ng/dL, aiming for mid-normal range 1
• Hemoglobin will increase to the male reference range within 3 months 1
• Expected physical changes include masculinization of secondary sex characteristics 1

Surgical Interventions

Gender-affirming surgery should only be performed after:

• Confirmation of persistent gender dysphoria by the multidisciplinary team 1
• Demonstration of informed consent capacity 1

Surgical decisions should consider diagnosis, genital appearance, potential fertility, therapeutic requirements, and familial/cultural factors. 1 Many professional medical organizations—including the American Medical Association, American Psychological Association, American Psychiatric Association, American Congress of Obstetricians and Gynecologists, and American Academy of Family Physicians—consider gender transition-related medical services medically necessary. 2

Psychosocial Support and Mental Health

Mental health assessment and psychosocial support are integral components of treatment, not because gender identity itself requires psychiatric treatment, but to address comorbid conditions and support the transition process. 3, 4 Anxiety and depression are the two most common comorbid diagnoses and may be the presenting complaint. 4

Critical Clinical Pitfalls to Avoid

• Do not assume all transgender individuals experience dysphoria—not all transgender and gender-diverse individuals experience psychological distress or meet criteria for the formal DSM-5 diagnosis of Gender Dysphoria. 5, 1
• Use correct pronouns and terminology (she/her for trans women, he/him for trans men, they/them for non-binary individuals) to demonstrate inclusivity and provide better healthcare. 1
• Gender identity cannot be reliably predicted by clinical data, including degree of genital masculinization or prenatal androgen exposure. 1
• Up to 25% of individuals may develop signs of gender dysphoria over time, even with appropriate gender assignment. 1
• Respect patient autonomy regarding GAHT continuation—some transgender individuals may wish to continue exogenous hormones even in the context of hormone-sensitive malignancies, acknowledging and accepting these risks, as approximately 35% would theoretically continue hormone therapy despite a new hormonally dependent cancer diagnosis. 2

Insurance Coverage and Access

The American College of Physicians recommends that public and private health benefit plans include comprehensive transgender health care services and provide all covered services to transgender persons as they would all other beneficiaries. 2 Without insurance coverage, treatment costs may be prohibitively expensive, potentially costing tens of thousands of dollars for extensive surgical procedures, not including counseling, hormone therapy, copays, or aftercare. 2

Treatment Timeline

Treatment typically lasts several years and progresses through stages: psychological/psychiatric evaluations, social transition ("real life" test), hormone therapy to create desired secondary sex characteristics, and finally sex reassignment surgery when appropriate. 6 The frequency and severity of treatment-related morbidity increases progressively as treatments advance from conservative to more invasive interventions. 4