Sex and Gender.

I think I may have discovered another area of medicine that I’d like to do more of – primary care of the transgendered individual.

In the past two years I have had 3 individuals disclose to me their desire to change their gender.  It is a fascinating area of medicine, one that I know almost nothing about, but that is all about to change.

Before my maternity leave, one of these transgendered individuals told me about a comprehensive guide developed by the local trans community for primary care physicians.  He gave me the website and I downloaded the guide (about 100 pages) and planned to read it while I was off.  Sadly, it remained on my desk  unread for 6 months, until today!

Gender Identity Disorder is a recognized psychiatric illness in the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), though labeling it as a “psychiatric” illness does little to ease the stigma for these individuals. Thus, a change in terminology is being implemented with the new edition of the manual:

In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria. This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder and is intended to better characterize the experiences of affected children, adolescents, and adults.

The core criteria for diagnosis of Gender Dysphoria are the following:

  • Cross-gender identification
  • Desire to live as a member of the other sex
  • Sense of inappropriateness in the gender role belonging
  • to one’s natal sex
  • Discomfort about one’s assigned sex
  • Desire to have sex characteristics of the other sex
  • Discomfort about one’s anatomic sex 
  • Wish to get rid of one’s natal sex characteristics

All of my patients who have told me they desire to be the opposite sex fit the above criteria.  In my city, there is a multidisciplinary clinic dedicated to Gender Dysphoria and I have referred them all.  Only one has been seen and he recently had chest surgery (ie. elective bilateral mastectomy).  Unfortunately, the wait list is close to 2 years and for the majority of patients seeking to start treatment, this can be an excruciating wait.

Imagine feeling like you were born into the wrong body. Imagine coming to terms with wanting to be the opposite sex. Imagine “coming out” to your family and friends. Imagine the feeling of dressing like the gender you wish to be for the first time.  Imagine telling your family doctor, then imagine having to wait 2 more years to get treatment.  Can you imagine what that must feel like?

I saw such a patient this week.  “He” is a genetic male but has never felt comfortable with his male genitalia.  “He” wants to be a female.  “He” wants all of his male organs removed permanently.  “He” wants to be a “She”. She has picked out her new name and really, really, really wants to start hormone therapy.  She looked at me with desperation in her eyes.  “Can you please help me?”

This patient has been referred to the multidisciplinary clinic and is on a very long waiting list.  The initial referral was made over a year ago and we were told the wait was minimum 16 months.  In the meantime, the patient has gone to trans support groups, has come out to all of her friends and family and is now ready to start making the transition physically.  She eventually wants sex reassignment surgery but realistically, this won’t happen for a few years. In the mean time, she is ready to start looking more female.

She wants to start hormones. My initial thought was, “I can’t do that. I don’t know what to start!” Then I remembered the guidelines handbook my other patient gave me, which I never got around to reading.  While the patient was in the examination room, I went to my office and got it off the pile of other reading on my desk.  I quickly flipped to the section  “Hormone therapy for the male-to-female transgendered individual”.  Together with the patient, I read the guidelines and at the end of the 30+ minute appointment, the patient was given a prescription for an anti-androgen; the first side effects of which would be lessening of coarse facial hair and cessation of spontaneous erections.  The latter side effect made the patient smile with relief.

I sent the patient home with a requisition for baseline blood work, a prescription for the anti-androgen, and a follow-up appointment in a month.

I have to say, it was a such an amazingly satisfying encounter.  I could see the relief on the patient’s face when she realized I would support and assist her in starting hormonal treatment.  I felt like I really made an impact.

As I mentioned at the outset, it’s a growing field of medicine that I feel privileged and honored to be a part of.  These individuals need more physicians to advocate for them.  I hope to become one such physician.