Approach

The clinician should confirm that the gender dysphoria has been present for more than 2 years, and that it is not a direct symptom of any mental illness.[4] It should also be determined whether there is a preceding history of gender dysphoria of childhood, using informants if possible.

Clinical presentation

The history should elicit whether the gender dysphoria has been preceded by fetishistic transvestism, dual role transvestism (cross-dressing), or feminine/masculine homosexuality. Unprescribed hormone and other drug consumption should be investigated, as should any earlier attempts at treatment, including surgery.

Sexual orientation is an attribute wholly distinct from gender identity, but in purely statistical terms, most born-female patients are sexually interested in women, while born-male patients might be interested in either sex and are more likely to experience a broadening or changing sexual orientation after a change of social gender role. Libido tends to be low in born-male patients and normal in born females.

Physical examination is usually normal. Clothing and hairstyle may be gender neutral or resemble those of the other sex. Vocal style and mannerisms often resemble those of the other sex, particularly in born-female patients.

It should be assessed whether there is a serious intention to change social gender role, or whether the stated desire for hormone treatment or surgery is aimed at removing the characteristics of one sex without seeking the characteristics of the other, or acquiring the characteristics of both, and vitally, with no change of social gender role at all. This last aspect is more in keeping with body dysmorphic disorder or autogynephilia.

Laboratory investigations

Serum androgens should be checked. The presence of elevated serum testosterone and dihydrotestosterone and unsuppressed follicle-stimulating hormone and luteinising hormone suggests a partial androgen insensitivity syndrome, which requires genetic counselling for the family. Low testosterone and elevated gonadotrophins in males suggests Klinefelter's syndrome. Elevated androgens in females may suggest polycystic ovary syndrome.

Patients being considered for hormone treatment should first be screened for contraindications.[5] Recommended blood tests include liver function tests, lipids, haematocrit and haemoglobin (to evaluate for polycythaemia), and prolactin. Those receiving endocrine treatment who have relative contraindications to hormones (e.g., smoking, diabetes, liver disease, etc.) should have an in-depth discussion with their physician concerning the risks and benefits of therapy.[30] Clinicians should stress the importance of smoking cessation, as smoking increases the thromboembolic risk from hormone treatment.

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