Gender dysphoria

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.

Gender dysphoria should be treated in line with the NHSScotland gender reassignment protocol which was issued by the Scottish Government in July 2012.

Consent

Children and young people

Adults  

 

Consent


Consent to treatment
You should be a full participant in decisions about your healthcare and wellbeing and be given any information or support that you need in order to do so.

For further information on consent, including when children and teenagers can consent to their own treatment, see our Health A-Z article on consent to treatment.

 

Children and young people

Discussions
Children and young people should contact their local GP or gender identity clinic in the first instance and may then be referred to the NHS Greater Glasgow and Clyde Sandyford Gender Clinic.

For children and young people aged between 12 and 18 in Scotland, the Sandyford Gender Clinic has an assessment service provided through a child and adolescent psychiatrist. Paediatric endocrinology services (specialists in hormonal conditions) from Yorkhill Hospital are also involved.

A full assessment will be carried out and the patient’s family will be invited to participate in discussions, if the young person gives consent. Young people will also have the opportunity to discuss issues without their family being present.

In some circumstances, such as consideration of pubertal suppression (where manmade hormones are used to delay the development of puberty caused by testosterone and oestrogen), young people may be referred for an opinion from a paediatric endocrinologist.

Occasionally, young people may be referred to their local child and adolescent mental health team for further assessment or interventions.

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.  Details of other support services are are included in our Support Services Directory.

The UK Government Department of Health has published a number of leaflets about gender identity, including one aimed at parents whose children are experiencing gender dysphoria. The leaflets are available on the Gender Identity Research and Education Society website.

Endocrine treatment
Endocrine treatment is treatment with hormones (powerful chemicals). It is the first step to developing the physical signs of your preferred gender.

If diagnosed with gender dysphoria before reaching puberty, endocrine treatment will not be received.

Guidelines from the Endocrine Society PDF (341 KB) 

These do not recommend endocrine treatment for young children because a diagnosis of transsexualism cannot be made before a child has reached puberty.

Gonadotrophin-releasing hormone (GnRH)
If your child has been diagnosed with transsexualism, 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.

GnRH analogues may be suitable for children who have reached Tanner stage two in puberty. This 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.

Some of the changes that take place during puberty are driven by hormones. For example testosterone, which is produced by the testes (testicles) 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.

See the Health A-Z topic about Puberty - symptoms for more information about the different stages of puberty and the changes that take place.

Cross-sex hormones
If your child has been taking GnRH analogues for several years and are 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.

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

 

Adults 

 

Discussions
Gender identity clinics offer ongoing assessment for people with gender dysphoria. They can also provide support and advice for you and your family about living in your preferred gender role.

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.

The gender identity clinic will complete an initial assessment with you. 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.

Preoperative 12 month experience
The pre-operative experience must be completed before you can have gender reassignment surgery.

The social aspects of changing your gender role can be challenging. Often more so than the physical aspects. Living in your desired gender role for 12 months allows you to experience, and socially adjust in your desired gender role, before undergoing surgery that cannot be reversed.

Twelve months allows for a range of different life experiences and events that may occur throughout the year. For example, family events, holidays, work or school experiences. You should live consistently in your desired gender role on a day-to-day basis and across all settings of your life. This includes coming out to partners, family, friends, and community members.

You should have access to the following treatments during and beyond the preoperative experience:

  • Transsexual women (MtF) 

Psychotherapy 

Hormone therapy

Facial hair removal

Speech therapy

  • Transsexual men (FM)

Psychotherapy

Hormone therapy

Mastectomy and chest reconstruction

Speech therapy

Once you have completed the preoperative 12 month experience, you will have a second assessment with your gender identity clinic where you will review your progress and further discuss and agree your treatment plan.

Patients who choose not to have surgery can continue on hormone therapy.

The 12 month experience can be extended if you or your gender identity clinic feel that further time is needed. It may also be extended if your attendance at your gender identity clinic is inconsistent.    

Ongoing psychotherapy and counselling 
Your gender identity clinic should offer regular psychotherapy and counselling throughout the process. It is important that your families, partners and carers are also supported during this time.

Your GP or gender identity clinic should be able to help with this and also make you aware of other support networks. Some of these are included in our Support Services Directory.

Hormone therapy
Hormone therapy may be all the treatment you need to live with your gender dysphoria

Before starting hormone treatment you are encouraged to stop smoking, take regular exercise, have a sensible diet and consume no more than 14 units of alcohol per week.

With your consent, blood tests will be taken to determine your health and suitability to begin hormone therapy.

You will need to take hormones for the duration of your life and they should never be taken without your doctor’s involvement. You will be monitored to find out whether the hormone treatment is benefiting you.

You may be frustrated with how long hormone therapy takes to produce results and you will need to be realistic about the extent of changes you can expect. Hormones cannot change the shape of your skeleton, for example how wide your shoulders or your hips are. It also cannot change your height.

Some people may be unable to take hormones due to other health conditions. In this case the gender identity clinic should discuss other options with you.

  • Transsexual women (MtF)

Oestrogen will be prescribed for transsexual women and will be helpful in making your appearance more feminine.

Some changes you may notice include:

  • your penis and testicles may get smaller
  • your body may redistribute body fat into a more female shape
  • you may have less muscle
  • you may have some breast development

There may be side effects, such as mood swings, tiredness and breast tenderness, although some transsexual women report feelings of calm and wellbeing after starting on hormone treatment.

Hormones can also increase the risk of breast cancer and high blood pressure, so it is important to have regular medical check-ups.

  • Transsexual men (FtM)

Testosterone will be prescribed for transsexual men and will be helpful in making your appearance more masculine.

Some changes you may notice include:

  • your voice may get deeper
  • your body may redistribute body fat into a more male shape
  • you may have more muscle tone
  • you may develop male pattern body and facial hair growth
  • you may have an increased sex drive
  • your clitoris (a small, sensitive part of the female genitals) may get bigger
  • your periods may stop

There can be a slightly increased risk of liver complications and there may be side effects such as acne and male pattern baldness, depending on your hereditary factors.

Regular exercise will increase muscle bulk and give maximum impact to the masculinising effects of testosterone.

Hair removal
Facial hair removal

Facial hair removal is a recommended treatment for transsexual women and can begin prior to the preoperative 12 month experience as the beard must grow to visible lengths to be removed.

Electrolysis is the most safe, effective way of removing facial hair and may require between 200 and 400 hours of treatment.

Laser and Intense Pulse Light (IPL) treatment for facial hair removal may require up to 15 sessions. It is most effective if you have dark hair and fair skin but is unsuitable for treating non-pigmented hairs such as grey, white, blonde and red.

Donor site hair removal
Transsexual men will require hair removal prior to radial artery phalloplasty or radial artery urethroplasty; otherwise there will be hair-bearing skin on the inside of the neourethra.  Transsexual women will require hair removal prior to vaginoplasty and labiaplasty.

Electrolysis may require 32 sessions over a period of 6 months (ensuring no re-growth).  An alternative and more cost effective approach is for hair follicles to be removed during surgery, this would have to be discussed and agreed with the surgeon performing the procedure.

Hair removal from the donor site can be performed with a surgeon’s recommendation prior to completion of the preoperative 12 month experience in order to reduce delays in surgery.

Bi-lateral mastectomy (removal of the breasts) and chest reconstruction
If you are a transsexual man this procedure is usually the first surgery performed and for some it is the only surgery undertaken.

The procedure can take place during the preoperative 12 month experience if you have agreed it in your treatment plan with your gender identity clinic and an appropriately qualified professional has recommended it.

A bi-lateral mastectomy cannot be reversed, and timescales for when the surgery should take place should be agreed in discussions between you and your gender identity clinic.

Speech therapy
Hormone therapy will not affect the voice of a transsexual woman. To make the voice higher, you will need speech therapy, which your gender identity clinic can refer you to.

Some transsexual women may require vocal cord or trachea (windpipe) surgery.

Transsexual men’s voices will deepen through hormone therapy but it may not be as deep as other men’s voices.

You may benefit from speech therapy, which your gender identity clinic can refer you to if needed.

Genital surgery
To undergo such major irreversible procedures you must be physically fit and meet the criteria listed in the NHSScotland gender reassignment protocol

Specialist surgery for gender reassignment is not available in Scotland. You may be referred to services in England for this part of your treatment.

Surgery may involve:

  • Transsexual women (MtF) 

Penectomy (removal of the penis)

Orchiectomy (removal of the testes)

Vaginoplasty (creation of the vagina)

Clitoroplasty and labiaplasty (creation of clitoris and labia) 

  • Transsexual men (FtM)

Hysterectomy (removal of uterus)

Vaginectomy (removal of vagina)

Salpingo-oophorectomy (removal of ovaries and fallopian tubes)

Metoidoplasty (creation of micropenis)

Phalloplasty (creation of penis from using skin and muscle tissue from another site, eg forearm or thigh)

Urethoplasty (creation of urethra)

Scrotoplasty (creation of scrotum)

Placement of testicular prostheses 

See the Gender Identity Research and Education Society guides to lower surgery for more information on specialist surgery.

Other treatments
You may need further treatments as part of the process of matching your body to your gender. This should be part of your ongoing discussions with your gender identity clinic.

These treatments are accessed by referral from your gender clinic to plastic surgery. You can find further information on the referral process in the NHSScotland gender reassignment protocol.

Some of the treatments referrals may be made for are:

  • Facial feminisation surgery – such as thyroid chondroplasty/tracheal shave (reducing the size of your Adams Apple), rhinoplasty (nose surgery), facial bone reduction (reducing the jaw line) and blepharoplasty (eyelid surgery)/facelift.
  • Breast augmentation – you should wait between 18 and 24 months to give hormone treatment a chance to fully develop your breasts before seeking additional surgery.

Follow up care
If you have surgery you should have an appointment with your gender identity clinic within six months of surgery to discuss any issues and be provided with a post-operative plan.

You can find further information in our follow up care section.

Last updated: 01 November 2013

Continue to next section: Follow up care