Gender Incongruence

Gender incongruence of adolescence or adulthood: characterised by a marked and persistent incongruence between an individual's experienced gender and the assigned sex, which often leads to a desire to be accepted as a person of the experienced gender
Gender incongruence of childhood: characterised by a marked and persistent incongruence between an individual's experienced gender and the assigned sex in pre-pubertal children, has to be present for more than 2 years

Aetiology

  • Likely to be a balance of a number of genetic, hormonal and environmental factors, but the cause is essentially unknown

Pathophysiology

Predictive factors affecting progress

  • Mental illness and psychological vunerability
  • Absence/poor partner or family support
  • Poor social function (including employment)
  • Preconceived ideas associated with unrealistic expectations
  • Age > 30 years
  • Earlier period of life adaptation to biological sex including marriage and parenthood
  • Morphological characteristics (e.g. large hands) which are incompatible with 'passing with good credibility' in the new gender, and ambivalence with regard to surgical processes

Co-existing metal health problems

  • Anxiety and depression
  • Suicidal ideation or attempt
  • Often associated with stigma
  • Protective factors - pride in identity and support
  • Alcohol, drug and other substance misuse has been reported as high

Clinical presentation

  • May present at various stages of transition
  • May present with the symptoms of the stress associated with suppressing feelings, or lack of understanding/support by friends and family

Management

  • Several studies have shown positive benefit with psychotherapy prior to surgery, and subsequent satisfaction
    • Aim is to help the patient set realistic objectives
    • Many patients do not require this but it should be offered as part of the package of care
  • Consider hormones when a trans person has made a full social gender role transition
    • Fully assessed by more than one gender specialist
  • Surgical options include genital surgery and chest reconstructive surgery
  • Postoperative psychotherapy may be linked with favourable outcome