Gender dysphoria: assessment and management for non-specialists

What to say, do, and explain if a patient expresses distress about their gender identity not fitting their body

Anecdotally, the biggest fears for any patient making such a disclosure are of being ridiculed, being judged as mentally unwell, or being roundly dismissed and inappropriately judged afterwards. Clinicians can allay some of those concerns by acknowledging the disclosure, and by explaining that other people in a similar position can find it hard to raise the subject, or have reservations about the implications of the disclosure.

Clinicians might begin to explore how long the patient has experienced these feelings, and what steps, if any, they have taken already to disclose to family and friends, trusted workmates, or employers. Has there been any formal name change or sex marker change on work documents or social profiles online?

Specifically, ask whether patients are self medicating with hormones from online “pharmacies” (table 1⇓). Explore this medication use as you might with any other non-prescribed drug, asking what and how much the patient is taking and how often. Screen for side effects and explain that self medication carries risks, including the loss of natural fertility. To avoid further risk, patients are advised to stop self medication until seen in a specialist clinic for further assessment. The person might not want to stop medication, especially as there can be a long wait to be seen at a gender identity clinic (typically nine to 15 months in the UK, although it is anticipated that referral to treatment times will fall to 18 weeks within the next five years). If patients are unwilling to stop self medication, encourage them to share with you any side effects they experience, and encourage them to inform healthcare staff if they are seen in other settings.

Advice differs in suggested approaches to providing ongoing prescriptions for hormonal treatments before the patient is reviewed by a gender identity clinic, and can be difficult to make a reality. The Royal College of Psychiatrists suggests that non-specialists might consider prescribing hormonal treatments while a patient is awaiting assessment by a specialist.5 The British Association of Gender Identity Specialists position statement does not recommend the practice of “bridging prescriptions” in primary care. Non-specialists might feel uncomfortable issuing such prescriptions and it is difficult for specialists to advise on how best to proceed without having assessed the person, including having screening bloods to make sure that hormone treatment is safe, and having assessed the person's psychological and social circumstances. 

Explain to the patient that you will make a referral to gender services. Explain that their experience isn’t uncommon and that treatment (NHS funded treatment in the UK) is available, although sometimes associated with long waiting lists. These treatments are generally well established and safe, but should be considered on an individual basis according to the patient’s preferences.

Usually it is not necessary to inquire directly about gender dysphoria if a patient does not raise it themselves. If it is suspected, a suggestion of open mindedness about the topic might be useful. For example, you might say that you have noticed an increasing degree of masculinity or femininity in the person over time, and wonder if this reflects an increasingly authentic self expression.

Assessment and treatment that are the same

Patients established in a new gender role develop the same medical problems as everyone else. Standard treatment for those conditions is indicated, and the change of gender role need not be a focus.

Assessment and treatment that can differ

Hormone treatment is initiated in a gender identity clinic, but ongoing prescribing will occur in primary care because it is not challenging and will need to be life long. Gender identity clinics can provide support with this ongoing prescribing if required.

Patients who were assigned female at birth and who are living as men might require a hysterectomy and oophorectomies. This, when required, can be undertaken by local gynaecological services. In making or receiving these referrals consider preserving dignity. For example, ask whether patients would prefer to be seen in general surgical rather than gynaecological outpatient clinics. If seen in a gynaecological clinic, patients might feel less conspicuous if accompanied by a woman. Similarly, consider whether ultrasound scans can be performed in general rather than specifically gynaecology imaging departments, and whether the patient might be admitted to a general rather than a gynaecological ward.

Routine screening tools for cardiovascular, respiratory, and bone health are difficult to apply because normative data risk factors are not available for transgender patients. Share this uncertainty about gender related risk factors with the patient, use common sense, and consider the many non-gender related factors that might elevate or reduce their risk of such conditions.

Gender specific screening—be aware that gender reassignment can alter routine recall systems for common cancer screening. Communicate to those setting up recall and processing testing why the sample might appear to come from a person allocated to the opposite sex from that which they might expect.

Consider birth gender when offering routine screening for cervical and breast cancer and aortic aneurysm. For example, women who were assigned male at birth do not need routine mammography. Their risk of breast cancer is very low because there is no progesterone in their hormone treatment (they don’t need it as they have no uterus to protect from unopposed oestrogen induced malignancy). These patients are eligible for aortic aneurysm screening if they have a history of smoking, but will not be called up automatically.

Anybody with a cervix should be offered routine smear tests but the NHS recall system cannot register men. General practitioners can remind patients and alert the cytology services that they have not made a mistake when sending a sample from a man and do require it to be examined.

Complications of gender related surgery

Where possible, problems with both phalloplasty and vaginoplasty might be referred to a urological surgeon with an interest in gender reassignment. A general gynaecological referral for someone who has undergone a vaginoplasty is not appropriate because the patient’s anatomy, unremarkably female as it might look on initial inspection, did not start out as gynaecological and won’t be familiar to most gynaecologists.

Record keeping and communication in the new gender role

Ask patients who change gender role if they want to be registered in their new role and sex and ensure administrative records are changed.5

Greet, seat, and treat the patient in their new role. Ask which pronoun they would prefer to be used and be careful to use it.

Consider suggesting that transgender patients might use whichever lavatory facilities they feel comfortable with, rather than direct them to accessible toilets that they don’t need unless they are disabled. Patients with the active phases of treatment long behind them often live lives indistinguishable from anyone born into their gender role, and disclosures by clinical and administrative staff can be very distressing.

Psychological and peer support

Many larger cities contain active transgender support groups, usually with an online presence. These offer excellent help to patients with problems that arise outside medical care, or with the stress of waiting for a clinic appointment and, later, with the transition process. Counselling services that are run with trans people in mind can be transformational. Investigate if such a service is available locally. Otherwise counselling and support services run for the general population are quite acceptable for trans people in general, but might struggle with trans specific issues.