Gary, a 40-year-old married accountant with two children, presented with a painful ankle. When he removed his shoe and sock, he revealed bright pink nail varnish on his toes. His GP examined the ankle, then commented that his toenails were a nice colour and asked Gary if there was anything else he wanted to talk about. Gary admitted that he had been wanting to talk to his GP for a long time. He said that he felt like a woman trapped inside a man's body.
Although uncommon, GPs might, from time to time, see patients who express concerns about gender-related issues. It is essential that those presenting for the first time are treated with empathy and referred to appropriate specialists.
Relatives and partners of those with gender issues might present in search of support. The children of people undergoing treatment might need support. They might be at risk of being bullied and excluded by their peers.
It is increasingly felt that treatment should focus on quality of life and that it is not helpful to focus on the aetiology of the condition.
Transsexualism is defined as a gender identity disorder in which there is a strong and on-going cross-gender identification and a desire to live and be accepted as a member of the opposite sex. There is a persistent discomfort with the anatomical sex and a sense of inappropriateness in the gender role of that sex. The diagnosis requires that dysphoria persists for two years or more.
Transsexualism is a distinct clinical entity in terms of ICD10 and DSM IV classifications. It should not be confused with transient cross-dressing behaviour, intersex conditions (congenital adrenal hyperplasia and androgen insensitivity syndrome) or persistent preoccupation with penectomy or castration (without the desire to adopt the opposite gender role).
Since the syndrome was described in the 1950s it has been increasingly accepted that a combination of factors - genetic, prenatal hormonal, social and hormonal - are involved. Studies have found that an area of the hypothalamus in male-to-female transsexuals is smaller than in men and more similar in size to that found in women (Nature 1995; 2: 15-6).
It is particularly important that GPs listen to teenagers who may have gender identity disorder and ensure that they are referred to an appropriate psychiatrist. Adolescents often find it difficult to discuss sensitive issues with GPs, so it is imperative that when they do present they are given time and asked open questions to enable them to voice their feelings and concerns.
Treatment is by a multi-professional approach involving psychiatrists, psychologists and counsellors, speech therapists and surgeons.
Those who are seeking surgery are required to first live as the opposite gender for at least two years. They are expected to assume their new gender both in the workplace or place of study and while socialising, and to adopt a new name. They are also expected to change their name on their documents. This period is referred to as 'transition' or 'real-life experience'.
Hormone treatment is offered after an individual has assumed their new identity for two or three months.
The opinions of two psychiatrists are sought before surgery is considered. Individuals have to demonstrate that they function better, psychologically, in their 'new' gender role than previously.
Specialists commence male-to-female transsexuals on oestrogen treatment. These prep-arations are not licensed for this use. Doses are higher than those in HRT and the Pill. Oestradiol valerate is often used in preference to ethinyl oestradiol.
It is essential that the GP monitors lipids, LFTs, and BP. The risks of thromboembolic events and hepatic dysfunction are greater because doses are higher. The long-term effects, and incidence of breast cancer, are unknown.
After starting hormone therapy men notice a loss of libido and gradually a loss of erections. There is no evidence that progesterone helps in terms of feminisation compared with oestrogen alone. Breast sensitivity and mood swings are common. If there are menopausal symptoms, changing to a different preparation may help. Breast development is irreversible after six months of hormones.
Hormones are stopped pre-operatively, and restarted at lower doses after the post-op recovery period. If high doses are restarted post-op, vasomotor symptoms are common. Discontinuing hormones completely post-op would cause menopausal symptoms and osteoporosis.
Antiandrogens can be recommended pre-op. LFTs, fasting glucose and BP should be monitored. Cyproterone is not recommended because it can cause hepatotoxicity. Depression, fatigue and nausea can occur. Tablets should be taken after food, and advice about driving given.
Those on flutamide should have their FBC monitored in addition to BP and LFTs because haemolytic anaemia and hepatic necrosis can occur. Finasteride is sometimes recommended to reduce male-pattern baldness. Spironolactone is no longer recommended for fluid retention because side-effects are a problem and electrolytes have to be monitored.
GnRH agonists may be used in depot form.These are not without side-effects, including transient BP changes, and paraesthesia.
Male-to-female surgery may include vaginoplasty (from scrotal and penile tissue), penectomy, orchidectomy, clitoroplasty (constructing a clitoris from penile tissue), breast augmentation, and rhinoplasty.
Thyroid chondroplasty and crico-thyroid approximation and anterior commisure advancement reduce the size of the Adams apple and make the voice higher in pitch.
Some patients undergo jaw remodelling and hair transplantation.
Female-to-male transsexuals are given androgens. They often experience irritability and acne in addition to the desired effects of coarsening of features, fat redistribution, muscle development, voice changes and clitoral elongation. Menses cease within months and libido is increased.
Voice changes, facial hair and male-pattern baldness are irreversible after four months of androgen treatment. Testosterone can increase the risk of heart disease and therefore BP, LFTs and lipids should be monitored.
Female-to-male surgery might include hysterectomy and oophorectomy, mastectomy and phalloplasty. Skin from the forearm or lower torso can be transplanted. Testicular implants may be used and some surgeons use inflatable penile implants such as those used for the treatment of impotence.
GPs should be aware of post-op complications. Superficial infections and wound dehiscence may occur after reconstructive surgery. Other genitourinary surgery complications may include UTIs, bleeding or DVT. Urinary retention can develop or patients may present later with hesitancy, suggesting urethral stenosis.
Treatment for transsexualism has been available on the NHS in certain circumstances. Recent changes following the Gender Recognition Act of 2004 means that, since April 2005, individuals can apply for a gender recognition certificate.
After patients apply to the panel for recognition, a medical pro forma will be sent out to the GP to be completed. Alternatively, the GP can give the patient copies of notes and/or letters about their case to support their application.
Information relating to gender recognition applications and gender history is protected by the Act and breaches are punishable by fines. Doctors are advised that if anyone else has access to patient files, the patient's consent should be obtained before recording any information that could later be seen by a third party.
- Dr Miller is a GP in west London. With thanks to Professor Richard Green, consultant psychiatrist, Gender Identity Clinic, Charing Cross Hospital, west London, for comments
- www.beaumontsociety.org.uk - advice and support to transgender, transvestite, transsexual and cross-dressing communities, wives and partners.
- www.depend.org.uk - information and support for family and friends.
- www.mermaids.freeuk.com - support for children and teenagers with gender issues and their families.
- www.gendertrust.org.uk - The Gender Trust.
- www.gires.org.uk - Gender Identity Research and Education Society.