What are the treatment options for individuals with gender dysphoria?

Treatment Options for Gender Dysphoria

Individuals with gender dysphoria should receive multidisciplinary care centered on gender-affirming interventions, including mental health support, hormone therapy (estradiol with anti-androgens for feminization or testosterone for masculinization), and surgical options when appropriate, with treatment decisions guided by the patient's experienced gender identity rather than assigned sex at birth. 1

Core Treatment Framework

The treatment approach requires a specialized multidisciplinary team consisting of:

• 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

This team-based approach is essential because gender-affirming care improves mental health outcomes, reduces suicide rates, and lowers overall healthcare costs by decreasing mental health-related and substance abuse-related expenses. 2

Hormone Therapy Options

For Feminizing Therapy (Male-to-Female Transition)

Estradiol is the cornerstone medication, available in oral, transdermal, or injectable forms, combined with anti-androgen therapy to suppress testosterone. 1

• Target estradiol levels should be maintained in the cisgender female reference range 1
• Expected physical changes include 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
• Anti-androgens are co-prescribed to lower endogenous testosterone and block androgen receptor binding 2
• Progesterone may be added for its anecdotal effect of increasing breast growth 2

For Masculinizing Therapy (Female-to-Male Transition)

Testosterone therapy is administered via intramuscular or subcutaneous injection of testosterone cypionate or enanthate. 1, 3

• Target testosterone levels: Maintain trough levels between 300-1,000 ng/dL, targeting the mid-normal range 1, 3
• Expected physical changes include voice deepening due to thickened vocal cords, facial and body hair growth, menstrual suppression, clitoral growth, increased muscle mass, decreased fat mass, and increased libido 3
• Hemoglobin increases to the male reference range within 3 months of starting therapy 1, 3
• Alternative for needle-phobic patients: Transdermal testosterone gel (1.62%) starting at 40.5 mg daily, which has lower risk of erythrocytosis compared to injectable formulations 3

Critical monitoring for testosterone therapy:

• Monitor for erythrocytosis/polycythemia (particularly common with injectable formulations); consider switching to transdermal route if it develops 3
• Monitor blood pressure, as testosterone may increase it 3
• Check lipid profiles regularly (testosterone may increase triglycerides and LDL cholesterol while decreasing HDL) 3
• Avoid supraphysiologic dosing, which increases adverse effects without additional benefit 3

Surgical Interventions

Gender-affirming surgery should only be performed after confirmation of persistent gender dysphoria by the multidisciplinary team and demonstration of informed consent capacity. 1

Surgical decisions should consider:

• Diagnosis and genital appearance 1
• Potential fertility implications 1
• Therapeutic requirements 1
• Familial and cultural factors 1

Important distinction: Decisions regarding surgical intervention are not directly linked to gender assignment decisions and must be individualized based on the patient's goals. 1

Mental Health and Psychosocial Support

Gender-affirming hormone therapy is medically necessary for many transgender individuals, with strong evidence showing improvements in quality of life and relief of psychological distress associated with gender dysphoria. 2, 3

• Affirming a person's gender identity (including using correct pronouns and names) is associated with less psychological distress and suicidal ideation 2
• Psychotherapy should focus on supporting the individual's gender identity exploration and addressing comorbid conditions (anxiety, depression), not attempting to change gender identity 4, 5
• Ongoing counseling is required to identify maladaptive coping strategies and facilitate age-appropriate information sharing 2

Critical Pitfalls and Considerations

Gender identity cannot be reliably predicted by clinical data, including degree of genital masculinization or prenatal androgen exposure. 1, 6

• Up to 25% of individuals may develop signs of gender dysphoria over time, even with appropriate gender assignment 1
• The interaction between prenatal androgens and multiple postnatal factors in determining gender identity is highly complex and variable 1
• Not all transgender individuals experience psychological distress or meet criteria for the formal DSM-5 diagnosis of Gender Dysphoria 6
• Gender dysphoria describes psychological distress from gender incongruence—the experience is distinct from the capitalized Gender Dysphoria diagnosis 2, 6

Insurance Coverage and Access

Without insurance coverage, treatment costs may be prohibitively expensive, with extensive sexual reassignment surgeries costing tens of thousands of dollars, not including counseling, hormone therapy, or aftercare. 2

• The cost of including transgender healthcare in employee health benefits plans is minimal and unlikely to raise costs significantly 2
• Many professional medical organizations (American Medical Association, American Psychological Association, American Psychiatric Association, American Congress of Obstetricians and Gynecologists, American Academy of Family Physicians) consider gender transition-related medical services medically necessary 2