Gender dysphoria: An untold story in Bangladesh

Abstract

Gender identity is an individual’s innate sense of feeling male, female, neither, or some combination of both. Distress or discomfort that may occur when gender identity and birth-assigned sex are not completely congruent is termed as gender dysphoria. Transgender male or trans-man refers to individuals assigned to females at birth but who identify and live as men. Transgender woman or trans-woman refers to an individual assigned male at birth but who identifies and lives as women. Gender dysphoric persons believe that they are “trapped” in the wrong body. Gender affirmation is a multidisciplinary treatment in which endocrinologists play an important role. They require a safe and effective hormone regimen that will suppress endogenous sex hormone secretion determined by the person’s genetic/gonadal sex and maintain sex hormone levels within the normal range for the person’s affirmed gender. Treatment is recommended for gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by the age of 16 years old. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adults, we suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Additionally, clinicians should persistently monitor the adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. In a study done in a tertiary care hospital in Dhaka, it was found that the mean age at presentation was 25.9 years but the mean age for onset of gender dysphoria was 11 years. Legislative approval is an important step in the appropriate care of these cases.

Keywords: Gender dysphoria, Transgender, Gender-affirming surgery