Gender dysphoria - Treatment 

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 some people will need more treatment than others.

Once you or your child has been diagnosed with gender dysphoria, different treatments can be considered. Counselling (a talking therapy) about the range of available treatment options and their implications should be offered to you or your child. See counselling for more information.

Treatment for children

If your child is under 18 years of age, they should be referred to a specialist child and adolescent gender identity clinic.

These clinics can offer ongoing assessment for children with gender dysphoria, and specialised treatment and support for children and their families. Your child will be fully assessed before any treatment begins.

Your child’s treatment should be arranged with a multi-disciplinary team (MDT), a team of different healthcare professionals working together. Your child’s MDT may include:

  • a mental health professional, who is trained in dealing with gender dysphoria in children and teenagers
  • a paediatric endocrinologist, a specialist in hormone conditions in children

Children before puberty

If your child is diagnosed with gender dysphoria before they reach puberty (when a child progresses into a sexually developed adult), they will not receive endocrine treatment. Endocrine treatment is treatment with hormones (powerful chemicals). It is the first step to developing the physical signs of your preferred gender.

Guidelines from The Endocrine Society do not recommend endocrine treatment for young children because a diagnosis of transsexualism cannot be made before a child has reached puberty. Transsexualism involves deep and long-lasting feelings of gender dysphoria that causes someone to seek to change their sex.

The Endocrine Society found that 75-80% of children who were diagnosed with gender dysphoria before they reached puberty did not have the condition after puberty. Therefore, endocrine treatment is not recommended until after puberty, when a diagnosis of gender dysphoria can be confirmed.

Children up to 16

If your child has been diagnosed with transexualism and they have reached puberty, they may be treated with gonadotrophin-releasing hormone (GnRH) analogues. These are synthetic (manmade) hormones that suppress the hormones naturally produced by your body.

The recommendation for endocrine treatment must come from a mental health professional, and they must continue to be part of your child’s ongoing care. An endocrinologist (a specialist in hormonal conditions) must also confirm your child’s diagnosis.

Puberty is divided into stages. These are called Tanner stages, named after James Mourilyan Tanner who first identified them. GnRH analogues may be suitable for children who have reached Tanner stage two, which means a number of physical changes have taken place, such as pubic hair starting to grow. In girls, this is around 11 years of age and in boys it is around 12 years of age.

See symptoms of puberty for more information about the different stages of puberty and the changes that take place.

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 the development of the penis. As GnRH analogues suppress the hormones that are produced by your child’s body, they also suppress puberty.  

GnRH analogues can be taken until your child reaches 16 years of age, after which cross-sex hormones can be taken (see below). 

Children over 16

If your child has been taking GnRH analogues for several years and are still diagnosed as transsexual, they may be offered cross-sex hormones. These can alter your child’s body further to fit with their gender identity. The effects of these hormones are only partially reversible, so they are not offered to children who are under 16 years of age.

Once your child reaches adulthood at 18 years of age, they can begin the process of gender confirmation surgery, which will change their gender irreversibly (also known as transition). Not all children who experience gender dysphoria will go on to transition. In fact, the number of children who go on to become transsexuals is very small.

For more information about cross-sex hormone treatment and gender confirmation surgery, see the section below about treatment for adults.

The amount of treatment that your child has will depend on how strong and long-lasting their feelings of gender dysphoria are. However, all children and their families should be offered counselling and support through their gender identity clinic.

The Department of Health has published a number of leaflets about gender identity, including one aimed at parents whose children are experiencing gender dysphoria.

Treatment for adults

Adults who have been diagnosed with gender dysphoria and transsexuals should be referred to a specialist gender identity clinic. These clinics offer ongoing assessments for people with gender dysphoria. They can also provide support and advice about living in your preferred gender role, including:

  • mental health support
  • hormone treatment
  • ways to dress in your preferred gender role
  • ways to behave in your preferred gender role 
  • language and speech therapy
  • hair removal treatments
  • 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. However, others will need more extensive treatment, such as a full transition from one sex to the other. The amount and extent of treatment you have is completely up to you.

Once you have been referred to a gender identity clinic, it is likely that you will have another full assessment, for a period of approximately three months. This will usually be with the input of a psychiatrist (a doctor who treats mental and emotional health conditions). This assessment is necessary to confirm your diagnosis and, if you want to have hormone therapy, means that you can take the necessary health tests first.

Cross-sex hormone therapy

Cross-sex hormone therapy means taking the hormones of your preferred gender:

  • a trans man (female becoming a male) will take testosterone
  • a trans woman (male becoming a female) will take oestrogen

The aim of hormone therapy is to make you more comfortable with yourself, both in your physical appearance and how you feel psychologically (mentally). These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity.

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.

Fertility

Before you start hormone therapy, your specialist should discuss with you what it can mean for your fertility.

Trans women who take oestrogen may become less fertile because oestrogen can lower sperm count and reduce the quality of the sperm. Some trans women choose to put sperm in a sperm bank before they start hormone therapy, so that they can use this sperm if they want to have children later. 

Trans men taking testosterone may also become less fertile.

For trans men and women, there is no guarantee that fertility will return to normal if hormones are stopped.

Trans woman

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

  • your penis and testicles may get smaller
  • you may have less muscle
  • you may have more fat on your hips
  • your breasts may become lumpy and may increase in size slightly
  • you may have 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 vocal therapy and possibly vocal cord or trachea (windpipe) surgery. Hormone therapy may make it harder to get an erection and have an orgasm.

Trans man

If you are a trans man, some of the changes that you may notice from hormone therapy include:

  • you may have more body and facial hair
  • you may have more muscle
  • your clitoris (a small, sensitive part of the female genitals) may get bigger
  • your periods may stop
  • you may have an increased sex drive (libido)

Hormone therapy can also cause baldness and acne in trans men. Your voice may get slightly deeper, but it will not be as deep as other men’s voices.

Monitoring

While you are taking these hormones, you will need to go for regular check-ups at your gender identity clinic. You will be assessed to find out whether the hormone treatment is benefiting you, as some people may find the effects of hormone treatment unpleasant.

If you do not think that hormone treatment is right for you, discuss it with 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
  • breast growth in trans women

Alternatively, you may be frustrated with how long hormone therapy takes to produce results, as it can take a few months for some changes to develop. Hormones cannot change the shape of your skeleton, for example 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, therefore, may not be safe. If you decide to use these hormones, let your clinic know so that they can monitor you.

Real life experience (RLE)

If you want to have gender confirmation surgery, you will first need to live in your preferred gender identity full time for at least a year. This is known as real life experience (RLE) and will help confirm that permanent surgery is the right decision.

Once your hormone treatment is under way, you can start as soon as you are ready with the support of your clinic. The length of RLE varies from person to person, but is usually between one and two years.

You may have various other surgical treatments during your RLE to prepare for full transition surgery, including:

  • mastectomy (removal of the breasts) for trans men
  • mammoplasty (cosmetic breast surgery) for trans women
  • feminising facial surgery for trans women

Trans women should continue with hormone therapy for at least 18 months before having a mammoplasty to ensure that the treatment has had the maximum effect on the development of the breasts.

Gender confirmation surgery

Once you have completed your RLE and you and your multi-disciplinary team (MDT) feel that 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 whole range of options.

Trans man surgery

For trans men, surgery may involve:

  • a hysterectomy (removal of the womb)
  • a salpingo-oophorectomy (removal of the fallopian tubes and ovaries)
  • construction of a penis using a phalloplasty or a metoidioplasty

A phalloplasty uses the existing vaginal tissue and skin taken from the inner forearm 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 may need to have more than one operation to achieve this.

Trans woman surgery

For trans women, surgery may involve:

  • an orchidectomy (removal of the testes)
  • a penectomy (removal of the penis)
  • construction of a vagina from the leftover tissue of the penis (known as a vaginoplasty)

The vagina is created and lined with skin from the penis, and tissue from the scrotum (the sack that holds the testes) is used to create the labia. The urethra (urine tube) is shortened and repositioned. The aim of this type of surgery is to create a functioning vagina with an acceptable appearance and retained sexual sensation.

After surgery

After surgery, the vast majority of 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 the last 20 years found that 96% of people who had gender reassignment surgery were satisfied. However, some of these studies may not have been of high quality.

Following gender confirmation surgery, one possible complication is that people 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 after transition.

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.


Page last reviewed: 21/05/2012

Next review due: 21/05/2014

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Comments

The 6 comments posted are personal views. Any information they give has not been checked and may not be accurate.

Pickle34 said on 21 January 2014

The description on treatment options makes it sound so simple. In reality this is not the case. If seeking NHS treatment in London expect to wait a year to be seen. Then another year to be diagnosed. It's pot luck if you will be prescribed hormones or not. In any case there is only one option they will give you - Zoladex and a very low dose of estrogen. You also have to begin the RLE before hormones are prescribed. It is unlikely you will get funding for voice therapy or hair removal on the face. The WPATH standards are not used and the clinic has its own way of doing things. This is meant to change in April 2014 and new standards are available to view on the GIRES website. There is no indication at present, given the current poor standards of care that this new standard will be adopted. There is little support from the clinic for partners and families of trans people. In fact their methods have probably been instrumental in breaking up many families as they disapprove of people being in loving, intimate relationships while receiving treatment. It is worth noting that you can be seen at any GIC in the country and if you are unhappy with the treatment you are getting you can change clinics. I would urge anyone who has had poor care to make a complaint as standards need to be brought in line with WPATH guidelines and trans people need to be treated with respect and dignity by the clinics treating them. My partner has been on her RLE for 2 years already but has been refused surgery unless she takes Zoladex for a minimum of 6 months. With waiting times this is unlikely to be less than 1 year. This kind of one size fits all treatment is not patient centred care but clinician centred care.

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janus4u2 said on 23 October 2013

The text above on cross hormone therapy does not say transsexuals have to do the RLE for the hormones to be prescribed. In reality you need reccomendations from two psychiatrists and live for 6 months RLE to get them. And they wonder why we resort to the internet to get hormones, the doctor who saw me today was lovely but made it clear it was my willingness to out myself to all and sundry,change my name and start with RLE before she would or could help.

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gina at choices said on 12 July 2013

I have another entry it occurred after. I was in hospital
I was allowed girls clothes nhs makeup etc and no
complaint was made of me(that was at springfield)
I was told im not psychiatric im physically real.
I now have my own clothes back, my makeup as normal
I can leave my nails permanently, as with everything else. I also had changed my name, the cmht accepted
I do have a physical condition, they have changed my name for me with my deed poll, the n.i. have picked the change up and asked for a copy. also any hrt effects were discussed and I saw the staff who did some of the others. the community around me now know.
I am now miss gina h******* ***** at the dwp too.
as far as im aware. that's fine by me. there is a sex chromosome fault too. I had to get the mental health team to get people off me, and im rated as a makeup
trainer etc,. so the nhs have done it, rom that end
the condition was accepted. now its also true
that those people did that beautifully didn't they ?
it also has to be said amidst all this stuff that
that was good wasn't it ? you might even live.......
thanx everybody that pain was horrific xx


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Steph_h said on 08 January 2013

The narrative above is fine for Scotland, where WPATH v7 has been adopted. England, however, is still mired in the Harry Benjamin S.O.C., 22 years out of date.
This means a two year (not one) RLE and not receiving essential HRT for 6 months to a year after starting (!) the RLE, amongst other things.
Is it any wonder we have such a high proportion of suicides amongt transsexuals.
Steph Holmes xxxx

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Berleigh said on 11 September 2012

I have been on HRT for 12 years and have not found any shrinkage of genitalia, lack of libido or hip development or fat re-distribution. Also facial hair is rarely decreased by HRT and laser will usually need to be implemented. Medical journals seem to hype up the effects and myths of HRT which are very limited in many cases.

Other aspects of this document also need reviewing and updating highlighting the pitfalls and problems with NHS PCT funding depending on what part of the country you live in. Not everyone will get NHS funding towards their transition and many don't and have to go private or overseas in order to facilitate their surgery.

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debunker1 said on 14 June 2012

Actually, the method described here for MTF surgery isn't the only one. There are more than one method of creating a vagina. Not all methods create a vagina using skin from the penis. Some methods completely remove the penis, and the vagina is made from other material... Trust me, I know...

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