ArticlePDF Available

Gender incongruence in children, adolescents, and adults

Authors:
More individuals are requesting medical
assistance for gender uncertainty or dysphoria
and provision of adult NHS gender identity
services (GIS) is changing.1 Despite minimal
medical input to polarised debates, several
issues are potentially concerning: reports of
poor care; rapid rises in referrals of children
and young people to GIS;2 public conflation
of biological sex with socially influenced
gender roles; and extensive uncertainty in the
evidence base to guide practice.3
Medical practice should happen within
robust human rights frameworks where
individual patients always have their concerns
heard. Generalists, with expertise in whole-
person care, handling uncertainty and
complexity, have a key role when consulted
by identity-questioning and transgender
individuals for routine care, gender identity
concerns, treatments recommended by
private or NHS services, or for referral.
Presentations with prior emotional trauma,
co-existing mental or neurodevelopmental
issues, or ‘bridging hormonesrequests may
make primary care professionals uneasy.
Without a considered approach to practice,
high-quality evidence and guidance, a policy
of active ‘affirmation’ and ‘treat or refer’
may lead to more people receiving medical
interventions with uncertain outcomes.
CHANGING THE LANDSCAPE
The characteristics of those seeking help are
changing. In the past these were predominantly
for male to female medical transition.
Contemporarily, many younger people identify
with a range of gender types (such as, trans,
fluid, non-binary, gender-queer) and there
is greater difficulty distinguishing overlaps
with imaginative processes. The majority
presenting before puberty desist. Some, but
not all, seek interventions with uncertain long-
term outcomes. There is growing demand for
GPs to prescribe cross-sex hormones before
specialist assessments but GMC and BMA
positions differ.4,5 More definitive knowledge is
needed about: the causes of rapid increased
referrals, especially girls and young females;2
the outcomes of interventions or ‘wait and see’
policies in this new demographic; and how
to practice and organise services, especially
anticipating long-term health implications.
The planned recommissioning of adult GIS
in England provides an opportunity to develop
best practice through integrated programmes
of training, research, and service redesign.
Multidisciplinary approaches used within
child and adolescent services might ensure
that adults now being referred also receive
whole-person comprehensive support.
UNDERSTANDING RISE IN REFERRALS
No robust analysis explains why referrals
have risen so fast. While some individuals feel
able to disclose earlier in a less stigmatised
context, it is possible that gender identity
uncertainty and dysphoria may be generated
or exacerbated by societal and psychological
factors, particularly during puberty. A study of
concerned US parents reported their trans-
identifying children had previously identified as
gay, had mental health or neurodevelopmental
problems, recent onset dysphoria, or were in
friendship groups with other trans-identifying
individuals.6 The paper drew intense criticism
despite acknowledging limitations including
distinguishing cause and effect. Likely, the
rise is multifactorial: 35% of those seen in the
Tavistock service have autism traits;1 some
females may favour traditional male roles;
current female stereotypes and appearances
may be rejected; some young females who
are attracted to other females may initially
believe they are transmen, but later identify as
lesbians. While sexual orientation and gender
identity are distinct, such confusion is now not
uncommon.
INTERVENTION OUTCOMES
While a low-quality observational study of
mainly older male-to-female full transitions
has shown high levels of satisfaction,7 there
are no robust contemporary cohort studies
of younger female-to-male outcomes,1 nor
of supportive, non-invasive interventions.
Adolescents, who previously may have come to
terms naturally with the emotional difficulties
of pubescent bodies or with emergent
homosexuality, may consider themselves to
be ‘trans’ and be offered puberty-blocking
drugs prior to psychoactive steroid hormones
and irreversible surgery. We lack information
whether these improve outcome, including
reproductive consequences. Improved mental
wellbeing is the main rationale for intervention
though one study shows high rates of suicide
after surgery.8 This could be due to ineffective
treatment, ongoing prejudice, or co-existent
mental illness. Rates of persistence, benefits
and complications, regret, and detransition,
are unclear. Practitioners have been sued
for not providing sufficient assessment or
information.9
PATHWAYS TO MEDICAL INTERVENTIONS
Gender-questioning individuals need
protection from discrimination, high quality
services, and clear information. Professionals
should be able to refer to bodies of evidence
and guidelines, but there is no UK guidance
designed for generalists. Some international
guidelines advocate ‘affirming’ an individual’s
expressed gender. The 2017 UK Memorandum
Gender incongruence in children,
adolescents, and adults
Editorials
170 British Journal of General Practice, April 2019
Box 1. Medical uncertainties and our response to gender dysphoria
Medical uncertainties Response
What are the causes of The causes of feeling uncomfortable with one’s biological sex are unclear
gender dysphoria? but likely to be multifactorial and include society’s expectations of gender
roles.
Is there a biological basis for Humans are sexually dimorphic, with rare intersex conditions being
the concept of ‘being born in anomalous developments of dimorphic sexual classes. It is not possible to
the wrong body’? change biological sex. There is no agreed scientific basis for someone
having the mind of someone from the opposite sex or being born in the
wrong body.
How should a child or young Questioning is a normal part of growing up, as is discomfort during
person questioning their puberty. Young people should be encouraged to talk about their worries as
they may not have other people they can trust outside of peer groups.
What do shared decision Generalists should feel confident and supported to explore the potential
making look like in the links between gender questioning, emotions and cognitions, and the
absence of evidence? cultural context. Differences in views are likely to occur and provide the
basis for each party to shift position.
How should we advise patients Medical practitioners should be open and clear that, while satisfaction has
about the outcomes of been high for previous cohorts, we know little about the impact on physical
medical treatments given the (for example, fertility), emotional, and social (future intimate relationships)
paucity of evidence? outcomes for the current younger and mainly female group presenting.
of Understanding on Conversion Therapy,10
signed by the RCGP (but not the Royal College
of Psychiatrists), rejects formal ‘conversion
therapy’, but also states that actions which
contribute to a change to gender identity could
be seen as ‘covert’ conversion. So practitioners
might infer they should not explore wider
issues or discuss harms of interventions.
This would be counter to consultation models
which encourage evidence sharing and leave
room for differing views.
Paradoxically, calls for medical intervention
refer to mental distress and suicide risk, while
psychiatric assessment is often rejected. This
is worrying as there are no objective tests
for gender dysphoria, which has no agreed
physical basis and is assessed by interview.
It may be effected by social and cultural
context and has the potential to change over
time. In contrast to previous debates about
depathologisation of sexual orientation, which
led to demedicalisation, the opposite may
occur here; while helping some, interventions
can result in ongoing side effects and medical
dependency. Medical intervention may, in
effect, become another form of ‘conversion,’
whereby some children who would otherwise
have grown up gay or lesbian receive ‘gender
affirming’ cross-sex treatments instead.
Much patient information does not
fully express the known uncertainties of
interventions. Many healthcare organisations
and schools have been educated by charities
and non-NHS groups using inaccurate
information, including exaggerated risks of
suicide.11 NHS material contains concepts
that biological sex is assigned at birth (rather
than observed) and that surgery can change
sex. The wide range of treatment experiences
and outcomes including desistance need to
be included.
For children and young people, an
individualised age-and-developmental-stage
approach is required. The facts in each case
will influence consultation style, for example,
where does the child live, and with whom?
Who are the key carers? Is the child in
education or employment? What are prior
family values and current concerns? Are there
conflicts or safety issues? Practitioners can
draw on a variety of familiar consultation
skills, such as seeing the child alone and
together with family or trusted friends,
gradually gaining insight, allowing the ‘test
of time’. In general, GPs will want to include
parents and/or guardians in consultations,
aiming for all parties to find common ground
in their legal obligations under the Children’s
Act 1989 using the best interests test.
A number of consultation approaches may
be considered: use clear, respectful language
and the patient’s preferred form of address;
take a non-judgemental person-centred
approach; reflect on personal biases; allow
a few appointments to explore issues and
the time frame of gender-related distress,
whether the individual is questioning or has
firm beliefs, and how feelings of gender relate
to sexuality; assess associated mental health
issues such as self harm, anxiety, or body
dysmorphia, as well as autism traits; enquire
about relationships with family, friends,
intimate partners, and online groups, and how
these relate to the patient’s views and wishes;
remember sex is biological and fixed while
gender relates to social roles; allow respectful
space for differing views; share understanding
of the uncertainties of long-term treatment;
and share literature from a variety of sources
to discuss at future meetings (Box 1).
IMMEDIATE ACTION AND RESEARCH
Immediate action could include: examination
of NHS literature on evidence and uncertainty;
creation of coherent guidance for practitioners
not specialising in gender identity; a national
survey of doctors to understand views and
concerns, and development of training to
ensure practitioners are competent and
understand the evidence.
Well-funded, independent, long-term
research is required to ensure doctors meet
their ethical duties to ‘first do no harm’
and fulfil good medical practice. Research
could include: exploration of the interplays
between gender dysphoria, mental health
problems, autism spectrum disorders, sexual
orientation, autogynephilia, and unpalatable
societal gender roles; and exploration of the
different assessment and diagnosis models;
trials of different strategies, including wait-
and-see versus intervention for young people,
puberty-blocking, hormonal, and surgical
treatments.
National reconfiguration of services
is a chance to integrate research, service
redesign, and training, with the creation of
ongoing cohorts to monitor immediate and
longer-term outcomes for all those referred
and receiving different interventions.
Susan Bewley,
Professor Emeritus of Obstetrics and Women’s
Health, Department of Women and Children’s Health,
St Thomas’ Hospital, London.
Damian Clifford,
Consultant Psychiatrist, Cornwall Partnership NHS
Foundation Trust, Bodmin, Cornwall.
Margaret McCartney,
GP, Fulton Street Medical Practice, Glasgow.
Richard Byng,
GP and Academic, Community and Primary Care
Research Group, Faculty of Medicine and Dentistry,
University of Plymouth, Plymouth.
Provenance
Freely submitted; externally peer reviewed.
Competing interests
The authors have declared no competing interests.
DOI: https://doi.org/10.3399/bjgp19X701909
ADDRESS FOR CORRESPONDENCE
Susan Bewley
Department of Women and Children’s Health, Kings
College London, 10th Floor North Wing, St Thomas’
Hospital, Westminster Bridge Road, London SE1 7EH,
UK.
Email: susan.bewley@kcl.ac.uk
British Journal of General Practice, April 2019 171
REFERENCES
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P. Assessment and support of children and
adolescents with gender dysphoria.
Arch Dis
Child
2018; 103(7): 631–636.
2. The Tavistock and Portman NHS Foundation
Trust.
GIDS referrals increase in 2017/18
. 2018.
https://tavistockandportman.nhs.uk/about-us/
news/stories/gids-referrals-increase-201718/
(accessed 8 Mar 2018).
3. Byng R, Bewley S, Clifford D, McCartney M.
Redesigning gender identity services: an
opportunity to generate evidence.
BMJ
2018;
363: k4490.
4. General Medical Council. Trans healthcare.
https://www.gmc-uk.org/ethical-guidance/
ethical-hub/trans-healthcare---advice-based-
on-gmc-guidance#prescribing (accessed Mar
March 2018).
5. British Medical Association. Gender
incongruence in primary care. 2018. https://
www.bma.org.uk/advice/employment/
gp-practices/service-provision/prescribing/
gender- incongruence-in-primary-care
(accessed 8 Mar 2019).
6. Littman L. Rapid-onset gender dysphoria
in adolescents and young adults: a study
of parental reports.
PLoS One
2018; 13(8):
e0202330.
7. Mural MH, Elamin MB, Garcia MZ,
et al
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Hormonal therapy and sex reassignment:
a systematic review and meta-analysis of
quality of life and psychosocial outcomes.
Clin
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8. Dhejne C, Lichtenstein P, Boman M,
et al
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undergoing sex reassignment surgery: cohort
study in Sweden.
PLoS One
2011; 6(2): e16885.
9. Pollock N.
‘I wanted to take my body off’:
detransitioned
. 2018. Jun: https://www.
theatlantic.com/video/index/562988/
detransitioned-film/ (accessed 8 Mar 2018).
10. UK Council for Psychotherapy.Memorandum
of Understanding on Conversion Therapy
in the UK. https://www.bpc.org.uk/sites/
psychoanalytic-council.org/files/MoU2_FINAL_0.
pdf (accessed 8 Mar 2019).
11. Hutchinson K.
Kate Hutchinson: Wrexham
to Euston – my journey to meet the General
Medical Council
. 2017. https://www.
allabouttrans.org.uk/kate-hutchinson-wrexham-
euston-journey-meet-general-medical-council/
(accessed 8 Mar 2018).
... However, Butler et al note there has been one study. 2 This had a natal male to natal female ratio of 1:1.7, and included 201 adolescents referred to the Gender Identity Development Service in London between 2010 and 2014. 3 Another is that charities and non-NHS groups are 'using inaccurate information, including exaggerated risks of suicide', which cites a blog post from the organisation All About Trans. 4 There is no inaccurate information in the blog post. ...
... We are delighted to clarify the evidence in our editorial for Dr White 1 (a full point-bypoint response is available online). 2 White states there is 'no inaccurate information' from All About Trans 3 when countering our claim that charities and non-NHS groups use 'inaccurate information, including exaggerated risks of suicide'. The blog post claims that 'hormones can be "life saving" for young people'. ...
... La práctica médica debe desarrollarse dentro de un marco sólido de derechos humanos en el que los pacientes siempre deben ser escuchados. Los médicos con experiencia en la atención integral de la persona, en el manejo de la incertidumbre y la complejidad, deben orientar a las personas y así mismo ofrecerle toda la información necesaria para tratar de aliviar tal preocupación (Bewley, Clifford, McCartney & Byng, 2019). ...
Thesis
Full-text available
La incongruencia de género en el CIE-11 (Clasificación Internacional de Enfermedades- 11) se caracteriza por “una incongruencia persistente entre la experiencia individual de género y el sexo asignado al nacer”. Su origen es complejo y multifactorial. La primera parte de la investigación se centró en el análisis retrospectivo CpG (citosina-fosfato-guanina) del fragmento III (RIII) de la región promotora del receptor de estrógenos α, en una población de hombres y mujeres con incongruencia de género, antes vs. después de seis meses de tratamiento hormonal de afirmación de género (GAHT). La segunda parte de la investigación se centró en el análisis de la metilación global CpG utilizando el BeadChip de metilación de 850k de Illumina© Infinium. El análisis del perfil de metilación del RIII se realizó mediante secuenciación por bisulfito en 20 personas cisgénero y 20 personas transgénero antes vs. después del GAHT. Los ADNs se trataron con bisulfito, se amplificaron, clonaron y secuenciaron. El análisis estadístico se realizó con el programa QUMA (QUantification tool for Methylation Analysis). El análisis global de metilación se realizó en 16 personas cisgénero y 16 personas transgénero con el BeadChip de metilación de 850K de Illumina© Infinium, después de la conversión con bisulfito. Los perfiles de metilación se analizaron con el programa Partek® Genomics Suite® mediante un ANOVA de 3 vías comparando las poblaciones según grupo, sexo y tratamiento. Finalmente se realizó un análisis de enriquecimiento con el programa Partek® Pathway y la WebGestalt. La primera parte del estudio mostró (i) que en ambas poblaciones, cis y trans, los hombres y las mujeres presentan patrones de metilación diferentes del RIII; (ii) que antes del tratamiento GAHT, ambos grupos trans (hombres y mujeres) presentaban grados de metilación intermedios, no coincidentes con las poblaciones cis; (iii) que el GAHT modificó el patrón de metilación del RIII hacia perfiles más similares al género sentido. En cuanto al estudio de metilación global CpG, el principal resultado es que las poblaciones cis y trans difieren en el grado de metilación antes del tratamiento GAHT. En la población masculina (según el sexo natal asignado), se encontraron 22 islas CpGs que pasaron los criterios estadísticos (FDR p <0.05; fold change o incremento del cambio ≥ ± 2). Los CpGs más significativos se relacionaron con los genes WDR45, SLC6A20, NHLH1, PLEKHA5, UBALD1, SLC37A1, ARL6IP1, GRASP y NCOA6. En cuanto a la población femenina (según el sexo natal asignado), se encontraron 2 CpGs que pasaron los criterios estadísticos, pero ninguno de ellos se ubicaba en islas. Uno de estos CpGs, el relacionado con el gen MPPED2, es compartido por hombres y mujeres trans. El análisis de enriquecimiento mostró que estos genes están involucrados en funciones importantes como la regulación negativa de la expresión génica (GO: 0010629), el desarrollo del sistema nervioso central (GO: 0007417), el desarrollo del cerebro (GO: 0007420), la unión de ribonucleótidos (GO: 0032553) y la unión de ARN (GO: 0003723). Además, seis meses de tratamiento GAHT produjo una disminución significativa en el grado de metilación en ambas poblaciones trans, respecto a la población cis. Los hombres trans mostraron variaciones en 95 islas CpG, de las cuales el 72,63% disminuyó el grado de metilación después del tratamiento. En cuanto a las mujeres trans, seis meses de GAHT modificaron la metilación en 78 islas CpG, de las cuales el 85,9% estaban hipometiladas tras el tratamiento. Por tanto, en ambas poblaciones trans, el tratamiento GAHT indujo una reducción significativa de la metilación.
... La práctica médica debe desarrollarse dentro de un marco sólido de derechos humanos en el que los pacientes siempre deben ser escuchados. Los médicos con experiencia en la atención integral de la persona, en el manejo de la incertidumbre y la complejidad, deben orientar a las personas y así mismo ofrecerle toda la información necesaria para tratar de aliviar tal preocupación (Bewley, Clifford, McCartney & Byng, 2019). ...
Thesis
Full-text available
La incongruencia de género en el CIE-11 (Clasificación Internacional de Enfermedades- 11) se caracteriza por “una incongruencia persistente entre la experiencia individual de género y el sexo asignado al nacer”. Su origen es complejo y multifactorial. La primera parte de la investigación se centró en el análisis retrospectivo CpG (citosina-fosfato-guanina) del fragmento III (RIII) de la región promotora del receptor de estrógenos α, en una población de hombres y mujeres con incongruencia de género, antes vs. después de seis meses de tratamiento hormonal de afirmación de género (GAHT). La segunda parte de la investigación se centró en el análisis de la metilación global CpG utilizando el BeadChip de metilación de 850k de Illumina© Infinium. El análisis del perfil de metilación del RIII se realizó mediante secuenciación por bisulfito en 20 personas cisgénero y 20 personas transgénero antes vs. después del GAHT. Los ADNs se trataron con bisulfito, se amplificaron, clonaron y secuenciaron. El análisis estadístico se realizó con el programa QUMA (QUantification tool for Methylation Analysis). El análisis global de metilación se realizó en 16 personas cisgénero y 16 personas transgénero con el BeadChip de metilación de 850K de Illumina© Infinium, después de la conversión con bisulfito. Los perfiles de metilación se analizaron con el programa Partek® Genomics Suite® mediante un ANOVA de 3 vías comparando las poblaciones según grupo, sexo y tratamiento. Finalmente se realizó un análisis de enriquecimiento con el programa Partek® Pathway y la WebGestalt. La primera parte del estudio mostró (i) que en ambas poblaciones, cis y trans, los hombres y las mujeres presentan patrones de metilación diferentes del RIII; (ii) que antes del tratamiento GAHT, ambos grupos trans (hombres y mujeres) presentaban grados de metilación intermedios, no coincidentes con las poblaciones cis; (iii) que el GAHT modificó el patrón de metilación del RIII hacia perfiles más similares al género sentido. En cuanto al estudio de metilación global CpG, el principal resultado es que las poblaciones cis y trans difieren en el grado de metilación antes del tratamiento GAHT. En la población masculina (según el sexo natal asignado), se encontraron 22 islas CpGs que pasaron los criterios estadísticos (FDR p <0.05; fold change o incremento del cambio ≥ ± 2). Los CpGs más significativos se relacionaron con los genes WDR45, SLC6A20, NHLH1, PLEKHA5, UBALD1, SLC37A1, ARL6IP1, GRASP y NCOA6. En cuanto a la población femenina (según el sexo natal asignado), se encontraron 2 CpGs que pasaron los criterios estadísticos, pero ninguno de ellos se ubicaba en islas. Uno de estos CpGs, el relacionado con el gen MPPED2, es compartido por hombres y mujeres trans. El análisis de enriquecimiento mostró que estos genes están involucrados en funciones importantes como la regulación negativa de la expresión génica (GO: 0010629), el desarrollo del sistema nervioso central (GO: 0007417), el desarrollo del cerebro (GO: 0007420), la unión de ribonucleótidos (GO: 0032553) y la unión de ARN (GO: 0003723). Además, seis meses de tratamiento GAHT produjo una disminución significativa en el grado de metilación en ambas poblaciones trans, respecto a la población cis. Los hombres trans mostraron variaciones en 95 islas CpG, de las cuales el 72,63% disminuyó el grado de metilación después del tratamiento. En cuanto a las mujeres trans, seis meses de GAHT modificaron la metilación en 78 islas CpG, de las cuales el 85,9% estaban hipometiladas tras el tratamiento. Por tanto, en ambas poblaciones trans, el tratamiento GAHT indujo una reducción significativa de la metilación.
... First, because there are different pathways to GD (see Zucker, 2019), which demands from clinicians an individualized approach that allows discerning its possible causes, developmental trajectories, and potential outcomes. Second, because individuals with GD may present with a range of additional concerns relating to sexuality, gender, family, and friendships (Bewley, Clifford, McCartney, & Byng, 2019) that may play an important role in the experience of GD and during the whole gender transition process. Third, because GD may come in associated with other complex psychological issues, such as mood, anxiety, and eating disorders, ASD, substance abuse, deliberate self-harm, suicidal ideation, and suicide attempts (e.g., Bechard, VanderLaan, Wood, Wasserman, & Zucker, 2017;de Graaf et al., 2020;de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011;Donaldson et al., 2018;Holt, Skagerberg, & Dunsford, 2016; Kaltiala-Heino, Sumia, Ty€ ol€ aj€ arvi, & Lindberg, 2015; Khatchadourian, Amed, & Metzger, 2014;Olson, Schrager, Belzer, Simons, & Clark, 2015;Peterson, Matthews, Copps-Smith, & Conard, 2017;Reisner et al., 2015;Sevlever & Meyer-Bahlburg, 2019;Spack et al., 2012). ...
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... The novel cohort of young GD patients increasingly presenting for help is poorly understood. It is overrepresented by adolescent females with recent-onset GD and with comorbid mental health and neurocognitive issues (Bewley, Clifford, McCartney, & Byng, 2019;de Graaf, Giovanardi, Zitz, & Carmichael, 2018;Kaltiala-Heino, Bergman, Työläjärvi, & Frisen, 2018;Littman, 2018;Zucker, 2019). The trajectory of GD among these young patients, including the rates of desistance and detransition, remains unknown. ...
... There is no empirical evidence that can be used to diagnose GD. No genetic marker, biochemical test, brain imaging, or objective measurement exists in medical practice for gender identity, which is itself of an unknown aetiology (NHS 2016, Bizic et al. 2018, Gerritse et al. 2018, Bewley et al. 2019. The central claim rests on a consistent declarative statement of the trans patient's subjective experience of self-hood. ...
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The treatment for transsexualism is sex reassignment, including hormonal treatment and surgery aimed at making the person's body as congruent with the opposite sex as possible. There is a dearth of long term, follow-up studies after sex reassignment. To estimate mortality, morbidity, and criminal rate after surgical sex reassignment of transsexual persons. A population-based matched cohort study. Sweden, 1973-2003. All 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) in Sweden, 1973-2003. Random population controls (10:1) were matched by birth year and birth sex or reassigned (final) sex, respectively. Hazard ratios (HR) with 95% confidence intervals (CI) for mortality and psychiatric morbidity were obtained with Cox regression models, which were adjusted for immigrant status and psychiatric morbidity prior to sex reassignment (adjusted HR [aHR]). The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8-4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8-62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9-8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0-3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls. Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population. Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.
Article
To assess the prognosis of individuals with gender identity disorder (GID) receiving hormonal therapy as a part of sex reassignment in terms of quality of life and other self-reported psychosocial outcomes. We searched electronic databases, bibliography of included studies and expert files. All study designs were included with no language restrictions. Reviewers working independently and in pairs selected studies using predetermined inclusion and exclusion criteria, extracted outcome and quality data. We used a random-effects meta-analysis to pool proportions and estimate the 95% confidence intervals (CIs). We estimated the proportion of between-study heterogeneity not attributable to chance using the I(2) statistic. We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male-to-female, 801 female-to-male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68-89%; 8 studies; I(2) = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56-94%; 7 studies; I(2) = 86%); 80% reported significant improvement in quality of life (95% CI = 72-88%; 16 studies; I(2) = 78%); and 72% reported significant improvement in sexual function (95% CI = 60-81%; 15 studies; I(2) = 78%). Very low quality evidence suggests that sex reassignment that includes hormonal interventions in individuals with GID likely improves gender dysphoria, psychological functioning and comorbidities, sexual function and overall quality of life.
Wrexham to Euston - my journey to meet the General Medical Council
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