Care of transgender adults

'Transgender' is an umbrella term that is used to describe people whose gender identity is different from their birth-assigned sex (known as gender incongruence/gender dysphoria). Differences and debates about appropriate terminology exist, and there is no single term which effectively and uncontroversially describes all people experiencing gender incongruence/dysphoria.

Many transgender adults will not seek specialist medical intervention, and prevalence is likely underestimated; UK census data from 2021 suggest prevalence to be about 0.5%.

For those seeking gender-affirming medical or surgical treatment, the diagnosis should be confirmed by a medical professional with appropriate experience. Treatment is complex and should only be undertaken as part of a package of care provided by a multidisciplinary team with extensive experience in this area.

Options for gender-affirming care include hormone therapies and surgeries. Adjunctive options include hair removal, speech and language therapy and supportive counselling. Management is highly individualised, and that there is no ‘one size fits all’ approach to treatment. Transgender people may choose to undergo all, some, or none of the above interventions to support their gender affirmation.

Although gender incongruence is not in itself a mental disorder, transgender people are at increased risk of certain mental health conditions, for example, depression and anxiety, compared with the general population; rates of autism spectrum disorder are also elevated.

Transgender people (often called trans people) experience gender incongruence to at least some degree.

Gender incongruence, as defined in ICD-11, is characterised by a marked and persistent discordance between an individual´s experienced gender and their birth-assigned sex, which often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, for example, through hormonal treatment, surgery or other healthcare services.[1]World Health Organization. International statistical classification of diseases and health related problems (ICD). 11th revision. Jan 2022 [Internet publication]. https://icd.who.int/en ​ The ICD diagnosis does not require distress or dysfunction to be present.[1]World Health Organization. International statistical classification of diseases and health related problems (ICD). 11th revision. Jan 2022 [Internet publication]. https://icd.who.int/en

In contrast, gender dysphoria (as defined in DSM-5-TR) is characterised by a marked gender incongruence that is accompanied by distress or dysfunction.[2]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2022.

The precise nature of gender transition may vary widely between individuals. Although gender transition can involve a change in physical characteristics, it may additionally (or alternatively) involve social aspects such as changing styles of clothing and hair, changing name, arranging new identity documents, or simply the use of a more suitable gendered pronoun.[3]Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet. 2016 Jul 23;388(10042):390-400. http://www.ncbi.nlm.nih.gov/pubmed/27323925?tool=bestpractice.com

It is important to note that only some gender non-conforming people experience gender dysphoria at some point in their lives.[4]Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(suppl 1):S1-S259. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644 http://www.ncbi.nlm.nih.gov/pubmed/36238954?tool=bestpractice.com

Differences and debates about appropriate terminology are common, and, given the diversity of presentation, there is no single term which effectively and uncontroversially describes all people experiencing gender dysphoria and incongruence.[4]Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(suppl 1):S1-S259. https://www.tandfonline.com/doi/full/10.1080/26895269.2022.2100644 http://www.ncbi.nlm.nih.gov/pubmed/36238954?tool=bestpractice.com This topic uses the terminology ‘transgender person’ to refer to people experiencing gender incongruence/dysphoria, whether or not there is distress or dysfunction present.

The term ‘transgender man’ is used to mean a person who was assigned female at birth, but who identifies as a man or trans man.

The term ‘transgender woman’ is used to mean a person who was assigned male at birth, but who identifies as a woman or trans woman.

Note that gender identity and sexual orientation are separate; transgender people may identify as heterosexual, homosexual, bisexual, or none of the above.[5]Centers for Disease Control and Prevention. Transgender persons. Apr 2023 [internet publication].​ https://www.cdc.gov/lgbthealth/transgender.htm

The historical terms ‘transvestite’ and ‘transsexual’ are considered outdated and stigmatising, and their use should generally be avoided, unless a person specifically claims or identifies with these terms. ‘Gender identity disorder’ (as defined in DSM-IV) is also now considered an obsolete term.

Note: This topic covers the care of transgender adults only. In children and adolescents, presentation is particularly complicated, may be associated with higher levels of comorbidity, and may change form as patients mature, making specialist multidisciplinary assessment especially important.