Cisgender: People whose gender identity and gender expression align with their biological sex. This is a newer term used within the transgender community to refer to those who are not transgender.

Gender identity: An individual's internal sense of gender, or sense of being a man, woman, both, or neither. Gender identity may not be binary, and some now consider it to be a spectrum. A person's gender identity may or may not match their biological sex.

Gender identity disorder (GID): A DSM-IV-TR diagnosis given when strong and persistent cross-gender identification, combined with a persistent discomfort with one's sex or sense of inappropriateness in the gender role of that sex, causes clinically significant distress. This term has been replaced in the DSM-5-TR with "gender dysphoria."

Transgender man (transman): A transgender individual who, assigned female at birth, currently identifies as a man. In this course, the terms transgender man, female-to-male transgender person, and FTM are used interchangeably. It is important to note that these patients are men and do not require additional description unless medically necessary.

Transvestite: One who dresses in the clothing of the opposite sex. This is the older clinical name for crossdresser and is considered pejorative and outdated; the preferred term is crossdresser. This term was first included in the DSM-II [2].

In the United States during the 1960s and 1970s, gender identity centers were established at academic medical centers, notably Johns Hopkins, Stanford University, and the University of Minnesota. Although many in the public considered this controversial, the involvement of these prestigious medical institutions helped to "legitimize" the care and diagnosis of transgender individuals. This care was largely covered by health insurance policies and incorporated psychological counseling, endocrine care, and GCS. Despite good outcomes, in 1975 Paul McHugh, chairman of the Department of Psychiatry at Johns Hopkins, advocated against providing care to transgender patients. He asked Johns Hopkins psychiatrist Jon Meyer for follow-up data on patients who received GCS in order to determine how much the surgery had helped them. Meyer found that most of the patients were content with what they had done and only a few regretted it. Despite this, McHugh stated, "But in every other respect, they were little changed in their psychological condition. They had much the same problems with relationships, work, and emotions as before. With these facts in hand I concluded that Hopkins was fundamentally cooperating with a mental illness. We psychiatrists, I thought, would do better to concentrate on trying to fix their minds and not their genitalia" [6]. Shortly thereafter, Johns Hopkins closed their clinic. Other clinic closings followed, with the exception of the University of Minnesota [5]. In the 1970s, the psychological literature on transgender issues was limited and generally pathologized transsexual persons [7].

The DSM-IV abandoned the term "transsexualism" and instead used the term "gender identity disorder" [10]. The DSM-5 now uses the term "gender dysphoria." This is defined as "the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender" [11]. The critical element of this diagnosis is the presence of clinically significant distress associated with the condition, as the American Psychiatric Association (APA) points out that gender nonconformity is not a mental disorder. The intent of this change was to better characterize the experiences of affected children, adolescents, and adults and to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender [11].

At present, scientific investigation has neither established the true incidence nor clarified the etiology of non-conforming gender identity formation [17]. Genetic, physiologic, and psychological causes have been investigated, and available evidence seems to support physiologic causes. Gender dysphoria is not explained by variations in chromosomal patterns or identifiable hormonal abnormalities, nor is there convincing evidence that psychological factors (e.g., being exposed to certain family dynamics or being raised as a member of the opposite sex) cause this condition [18].

Because of variability in terminology and definitions, differing modes of presentation, and reluctance to disclose for fear of social stigmatization, it is difficult to obtain accurate data about the prevalence of transgender individuals in the general public [30]. However, as society becomes more accepting and familiar with transgender individuals, more transgender individuals are willing to "come out." The result is that this condition is more prevalent than previously thought.

All of these published studies indicate a greater incidence of MTF than FTM transsexualism, with a ratio of anywhere between 2.5:1 and 6:1 [32]. A ratio of 3:1 is common throughout the Western world, but not necessarily elsewhere (e.g., Japan, Serbia). Before puberty, there is a preponderance of MTF individuals, but gender dysphoria in children often resolves, and in adolescents the ratio is closer to 1:1 [29]. The subsequent increase in the MTF to FTM ratio is explained by the higher frequency of men with late-onset gender dysphoria [18].

Transgender individuals are at risk for HIV as a result of engaging in unprotected sex and from sharing needles used for hormone injections [40,41]. A significant percentage of transgender individuals engage in sex work; 11% of transgender respondents in a large national survey reported engaging in sex work for income, compared with 1% of women in the United States [39]. This survey has been the largest to date of the transgender population, involving 6,450 transgender and gender non-conforming individuals across all 50 states, as well as the District of Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands. The study was conducted on behalf of the National Gay and Lesbian Task Force and the National Center for Transgender Equality.

A staggering 41% of respondents to the survey reported attempting suicide, compared with 1.6% of the general population [39]. The highest rates of suicide attempts in transgender individuals are among those 18 to 44 years of age. Rates are lower among older individuals, with 16% of those older than 65 years of age reporting a suicide attempt, which is inverse to the rates in the general population.

Transgender individuals may experience or fear reprisal at work related to their gender identity. Employment was noted as one of the top three immediate perceived needs in the Transgender Needs Assessment Survey [49]. Finding employment is challenging for transgender individuals, especially those who are preoperative and do not have proof of identity in the chosen gender. Transgender people have double the national unemployment rate, and 26% report having lost a job because of their transgender status [50]. A large majority (97%) reports having experienced mistreatment, harassment, or discrimination on the job. In an incidental finding of a study of 376 FTM individuals in the United States, although 48% had a Bachelor's degree or higher, the majority earned less than the U.S. national average [50].

Before 2014, the Centers for Medicare and Medicaid Services (CMS) did not cover the cost of GCS based on a 1981 evaluation that described the surgery as experimental and cited "the lack of well-controlled, long-term studies of the safety and effectiveness" and "a high rate of serious complications" [58]. However, long-term studies done in Europe have found that GCS is effective, with low complication rates [1]. This policy banning GCS was overturned in May 2014, but because policy guidelines are issued from Medicare contractors by region, widespread implementation has been slow [53]. While the Veterans Administration (VA) has policies in place to provide comprehensive care to transgender veterans, including ongoing hormone therapy, mental health care, and long-term care following GCS, the VA specifically does not cover GCS, on the basis of a VA regulation excluding gender alterations from the medical benefits package [59,60].

Sufficient time has not yet elapsed for the ACA requirement of coverage for transition-related care to apply to grandfathered policies. The ACA bans coverage denial based on being transgender as a pre-existing condition [61]. Although the ACA prohibits discrimination on the basis of sex, including gender identity, in any hospital or health program that receives federal funds and The Joint Commission requires that discrimination on the basis of gender identity is prohibited to maintain accreditation, this information is not widely known and many transgender patients still experience discrimination. The American Medical Association, the APA, the American Congress of Obstetricians and Gynecologists (ACOG), the American Academy of Family Physicians, and the National Association of Social Workers have called for public and private health insurance coverage for this condition [61,62].

Lack of health insurance, when combined with provider ignorance about the healthcare needs of transgender people, deters some transgender individuals from seeking and receiving high-quality health care and makes them more likely to obtain hormones illicitly and participate in risky behaviors such as needle sharing and smoking [39,56]. Many transgender individuals have been victims of hostility or discrimination at the hands of healthcare providers [63]. In a large survey of transgender individuals, 19% reported being refused medical care due to their transgender or gender non-conforming status, with even higher numbers among people of color [39]. Even more alarming is the fact that 28% of respondents in this same study reported verbal harassment in medical settings and 2% were physically attacked in medical offices [39]. In 1995, Tyra Hunter, a young, African American, preoperative transgender woman, was injured as a passenger in a car accident. Emergency medical technicians at the scene of the accident uttered derogatory epithets and withdrew medical care after discovering she had male genitalia. After transfer to the emergency department, Hunter received dilatory and inadequate care, resulting in her death. A jury subsequently awarded Hunter's mother $1.75 million in a wrongful death suit [64].

While an increasing number of providers and clinics use the informed consent model for hormone therapy, American surgeons provide GCS based on the WPATH guideline. Insurance providers also generally require adherence to the WPATH Standards of Care in order to consider GCS to be medically necessary.

While obtaining a referral for hormone therapy is the main reason that transgender individuals seek psychological therapy, other reasons include understanding the meaning of their feelings; whether to externally express those feelings; coming out to self, work, and family; seeking to network following a negative experience; or following up on information obtained on the Internet. In some cases, an individual may have been "caught" expressing his or her gender variance by a spouse or significant other or when there has been a program on transgender issues in the popular media [72]. Coming out trans is a time of heightened vulnerability [73]. Not everyone transitions. Some learn to live comfortably in their role consistent with their assigned birth sex, and others may transition partially or totally [7].

Common diagnostic presentations in transgender individuals include anxiety, depression, conduct disorder, oppositional defiant disorder, autism spectrum disorder, substance use disorder, and dissociative disorder [72]. The incidence of autism spectrum disorder has been found to be 10 times higher in the population of gender dysphoric individuals than in the general population [74]. In a major study of MTF individuals, more than 50% had suffered from major depression at some point in their life, as opposed to 19.6% in the general population [42]. In a review of the literature on depression in transgender individuals, Rotondi concludes that this is a multifaceted condition, with the common causative factors being: discrimination, disclosure, identity support, hormones and GCS, sociodemographics, socioeconomic factors, substance use, and access to health and social services [75]. Transgender individuals commonly report victimization and post-traumatic stress disorder, systemic stressors, and depression [76]. Interestingly, when a gender identity is truly and authentically affirmed, some of these conditions resolve [72].

Common diagnostic presentations in transgender individuals include anxiety, depression, conduct disorder, oppositional defiant disorder, autism spectrum disorder, substance use disorder, and dissociative disorder [72]. The incidence of autism spectrum disorder has been found to be 10 times higher in the population of gender dysphoric individuals than in the general population [74]. In a major study of MTF individuals, more than 50% had suffered from major depression at some point in their life, as opposed to 19.6% in the general population [42]. In a review of the literature on depression in transgender individuals, Rotondi concludes that this is a multifaceted condition, with the common causative factors being: discrimination, disclosure, identity support, hormones and GCS, sociodemographics, socioeconomic factors, substance use, and access to health and social services [75]. Transgender individuals commonly report victimization and post-traumatic stress disorder, systemic stressors, and depression [76]. Interestingly, when a gender identity is truly and authentically affirmed, some of these conditions resolve [72].

Research on the incidence of suicide in transgender people is scarce, but transgender people are believed to have similar suicide risks as other people who experience major life changes, relationship difficulties, chronic medical conditions, or discrimination on the basis of minority status. The incidence of suicide ideation is as high as 64% and suicide attempts as high as 38% in the adult transgender population [76]. These rates are significantly higher than in the general population [76]. Predictors of suicide among transgender individuals are similar to those of the general population, most notably previous suicide attempts or near attempts, past psychiatric hospitalizations, and past psychiatric treatment. Parental rejection is one of the highest risk factors for suicide among transgender youth [73].

The goal of hormone therapy is to reduce the unwanted secondary sex characteristics of the original gender and to induce the development of secondary sex characteristics of the desired gender. Hormone therapy has also been found to enhance the person's sense of self and well-being [81]. Criteria for hormone therapy include persistent, well-documented gender dysphoria, a capacity to give informed consent, age of majority, and control of any significant medical or mental health issues [71]. In accordance with the WPATH guideline, it is recommended, though not required, that the decision to initiate hormone therapy be made in consultation with a qualified mental health professional [71].

When transgender individuals seek hormones, some providers will require an initial visit to conduct a thorough history, physical, and laboratory tests; provide referrals for mental health if needed; obtain informed consent; and provide appropriate vaccinations and a skin test for tuberculosis. Hormones are then prescribed at the second visit. Follow-up visits should take place every two to three months for the first year, after which patients can be seen every 6 to 12 months [71].

The Tom Waddell Health Center in San Francisco uses the following protocols for the initial visit for a patient seeking hormone therapy [82]:

The main risk of GCS is rectal wall tear resulting in rectovaginal fistula, which is estimated to occur in 1 of 400 vaginoplasties [117]. This complication may develop in the immediate postoperative period or following discharge from the hospital. Symptoms include intestinal distress and intrusion of intestinal fluids, gases, and feces into the vagina. For a small fistula, the only clue may be a brown discharge. If rectovaginal fistula is suspected, a tampon may be inserted into the vagina and an enema of clear water with food coloring administered to determine if the tampon is stained [130]. Some fistulas spontaneously resolve as the neovagina heals. A liquid or low-residue diet will help during the healing process, and dilation and sexual intercourse should be discontinued. If the fistula does not heal spontaneously, surgical repair with skin grafts may be indicated.

There are several choices of hormone therapy for the MTF transition and maintenance (Table 1). The goals of hormone therapy prescribed for MTF individuals are to induce breast formation and a more female distribution of fat and to reduce male-pattern hair growth while neutralizing the biologic effects of endogenous androgens [18]. Additional effects include decreased muscle mass and strength, softening of skin, decreased libido, decreased sperm production and testicular volume, and less frequent and less firm erections [71]. Commonly, hormonal treatment of MTF individuals will include an anti-androgen along with an estrogen.

Anti-androgens reduce endogenous testosterone levels, allowing the full effect of estrogen therapy. The anti-androgen of choice in the United States is usually spironolactone (Aldactone), a potassium-sparing diuretic that directly inhibits testosterone secretion and inhibits androgen binding to the androgen receptor. It is usually given orally at a dose of 50 mg twice daily [82]. Side effects of spironolactone include gastrointestinal upset, hyperkalemia, increased urinary output, and hypotension. It is contraindicated in patients with renal insufficiency or with serum potassium levels greater than 5.5 mEq/L. Spironolactone should not be given with digoxin, angiotensin-converting enzyme inhibitors, other potassium-sparing diuretics, and angiotensin receptor blockers [82]. Patients taking spironolactone should have baseline levels of electrolytes, blood urea nitrogen (BUN), and creatinine, and repeat levels in two months or at every dose change, and then every six months when the dose is established [82].

In the MTF individual, estrogen will soften the skin, stimulate breast development, and cause a more feminine redistribution of fat while reducing testosterone levels via negative feedback on the hypothalamus. Estrogen also down-regulates gonadotropins to lower serum testosterone levels. This reduces the frequency of erections and ultimately causes prostate and testicular atrophy and infertility. It is unclear whether estrogen has a permanent effect on spermatogenesis, though it is likely to be related to the duration of therapy. However, there are no data on restoration of spermatogenesis after prolonged estrogen treatment [17].

Estrogen can be given orally, transdermally, or parenterally, and each type of delivery has advantages and disadvantages. Estrogen given sublingually, transdermally, and parenterally avoids first-pass metabolism (with less effect on liver enzymes) and is associated with fewer vascular complications in patients older than 40 years of age [17]. Oral forms of estrogen have the additional advantage of being easy to titrate or stop. One study of long-term cross-sex hormone usage revealed that the use of ethinyl estradiol in MTF individuals was associated with an increased risk of death from thrombotic events [88]. This is one reason that the Endocrine Society, the Waddell protocols, and the WPATH Standards of Care no longer recommend ethinyl estradiol as a safe medication for feminizing hormone therapy [17,71,82].

Common side effects of estrogens include breast tenderness, nausea and vomiting, depression, dry skin, brittle nails, headaches, and in some cases, increased appetite and weight gain [17,82,87]. More rarely, patients may experience migraines, gallbladder disease, abnormal liver function tests, mood disorder/depression, melasma, acne, lipid abnormalities, hypertriglyceridemia, increased risk of myocardial infarction, hepatitis, stroke, and increased risk of breast and other cancers [82,89]. In addition, estrogens may interact with other medications and foods (Table 2).

When boys reach puberty, the increase of androgens causes the larynx to grow and the vocal cords to lengthen and thicken, resulting in a deeper pitch. Additionally, the growth of facial bones, sinus cavities, the nose, and the throat creates more vocal resonance in men. Being perceived as a woman in vocal interactions is of importance to MTF individuals. Because the physiologic changes affecting the voice are not reversed with the use of female hormones, many MTF individuals will seek out voice therapy (with a speech therapist or speech-language pathologist) to change the quality of the voice to a more feminine range.

Voice therapy involves the conscious manipulation of the vocal mechanism to produce a more feminine-sounding voice [100]. The goal of therapy is not merely raising the pitch of the voice, but also "feminizing" the resonance, intonation (rhythm of speech), rate of speech, volume, intensity, choice of language, articulation, and social rules of communication [101]. The process includes an assessment of the individual's current voice, resonance, articulation, spoken language, and non-verbal communication. The patient is also assessed for vocal health and current practices that may be damaging to the voice.

Feminine voices have a higher pitch and breathier vocal quality, and they resonate at higher frequencies and have different speech rates, inflections, and intonations. The fundamental frequency (pitch) of the adult male voice is about 100 Hz, with a range of 77–482 Hz; the adult female voice has an average frequency of 195 Hz, with a range of 137–634 Hz. There is considerable overlap between the two ranges, but in order to be perceived as female, the fundamental frequency should be around 172 Hz (165–180 Hz). According to a study by King et al., a mean speaking pitch above 180 Hz and maintaining a speaking pitch range of approximately 140–300 Hz appear to be the most powerful acoustic features or markers in the perception of a female voice in MTF individuals [102]. Raising the fundamental frequency near this range is one of the goals of voice therapy.

The goal of hormone therapy for FTM individuals is masculinization of the body through the use of testosterone (Table 3). Testosterone therapy in FTM individuals results in cessation of menses within three to five months due to suppression of the hypothalamic-pituitary axis. However, ovulation may continue, and pregnancies have been reported in FTM persons even after prolonged testosterone treatment [17,106]. As such, it is important to discuss contraception with FTM individuals who have sex with men. Other effects of testosterone therapy include increased libido, increased facial and body hair, increased skin oiliness, increased muscle, mild breast atrophy, and redistribution of fat mass, usually within three months of the initiation of testosterone therapy.

Within one year, the voice usually deepens, clitoromegaly occurs, and male pattern hair loss may be apparent [17]. After 13 years of testosterone use, androgenic alopecia occurs in 50% of FTM individuals [99]. On average, the clitoris enlarges to 3–5 cm, and in some cases, testosterone may be applied topically to the clitoris to stimulate growth [106]. These changes in voice range, hair follicles, and clitoral size are permanent. Other effects, such as increased muscle mass, acne, increased libido and energy level, and amenorrhea are reversible if testosterone is discontinued [82]. FTM individuals report a better quality of life after receiving male hormones regardless of the duration of treatment [50].

Contraindications to testosterone include estrogen receptor-sensitive breast cancer; uterine, endometrial, and/or ovarian cancer; pregnancy; and hypersensitivity to sesame or cottonseed oil, if injectable testosterone is used. Testosterone should be used with caution in individuals with uncontrolled coronary heart disease or any unstable heart disease, hyperlipidemia, diabetes, liver disease, cigarette smoking, extreme obesity, hypertension, kidney failure, prolactinoma, or active thyroid disease [106].

There is little standardization in hormone regimens for FTM individuals, and the choice of product may be limited by a patient's economic situation or geographic location. The Endocrine Society guidelines provide specific guidance regarding the types of hormones and suggested dosages that have proven effective [17]. In the United States, oral testosterone is not available, so it will not be discussed in this course.

Spontaneous vaginal bleeding may be caused by missed testosterone doses, excessive testosterone, weight increase, or thyroid disorders. Atrophic vaginitis may occur, resulting in bacterial vaginitis or candidiasis. If bacterial vaginitis is suspected, the vagina should be cultured for atypical bacteria [108]. Pelvic cramping has been noted in some people on testosterone for longer than three to six months, in some cases associated with orgasm. The pain typically lasts 10 to 15 minutes and can be alleviated by pre-medicating with nonsteroidal anti-inflammatory drugs [108].

Some FTM individuals have had successful pregnancies during transition. A survey of 41 FTM individuals who gave birth after transitioning with or without the use of testosterone showed that FTM individuals may desire to have children and be willing and able to conceive, carry a pregnancy, and give birth [111]. Ovarian function may not be completely suppressed by testosterone, and it is possible that ovulation continues regardless of the presence of amenorrhea. One-third of pregnancies in FTM individuals are unplanned, as many transmen believe that testosterone acts as a contraceptive [111].

FTM individuals may be averse to taking estrogen in any form, so may prefer to avoid a combined oral contraceptive. Moreover, there is a theoretical risk of venous thromboembolism when combining estrogen and testosterone. Progestin-only contraceptives (e.g., levonorgestrel intrauterine device [LNG IUD], depot medroxyprogesterone acetate [DMPA or Depo Provera], etonogestrel implants, progestin-only pills) are reasonable contraceptive options. The DMPA injection and the LNG IUD may be desirable because they contribute to amenorrhea, a desirable situation in transmen [185].

Pregnancy outcomes were not significantly different from the general population, except for an increased incidence of postpartum depression. Most FTM individuals who had used testosterone gave birth via cesarean section. Although most transgender men in the study received prenatal care from physicians and delivered in hospitals, participants used non-physician providers and nonhospital birth locations more frequently than the general public. The researchers speculate that the choice of healthcare provider and delivery location may have been responses to actual or anticipated negative experiences [111].

The WPATH guideline suggests criteria for surgery for transgender individuals. The criteria for adults include [71]:

Hormone therapy is not a prerequisite, but at least six months of hormone treatment, or a longer period if required, unless hormone therapy is either not desired or is medically contraindicated, is recommended in the case of MTF individuals seeking augmentation mammoplasty, as this will result in better surgical (aesthetic) results.

Occasionally, patients may have unrealistic expectations about what it means to be a member of the opposite sex; it is important that these are brought to light before surgery is done. The real-life experience has been shown to reduce gender dysphoria and improve social and sexual functioning [18].

The most common complications of breast augmentation surgery include the general surgical complications of bleeding, infection, or hematoma. Complications specific to augmentation mammoplasty are capsular contraction, asymmetry, malpositioned implants, and altered nipple sensation. Infection is rare [87,117].

Facial feminization surgery includes forehead modifications, cheek/zygomatic bone modifications, rhinoplasty, mandibular angle changes, and genioplasty. Modifications to the brow include burring of the brow or removal of the anterior table along with osteotomies and miniplates and repositioning of the periosteum. Very often, this is combined with a brow lift and scalp advancement, as women generally have less distance between the brows and the hairline.

A chondrolaryngoplasty (tracheal shave) may be requested to remove or reduce the laryngeal prominence (Adam's apple). This procedure is not designed to feminize the voice—only to alter the appearance. A small incision is made on the upper crease of the neck or in a wrinkle in the skin. Using a laryngoscope, the vocal cords are visualized and this location is marked externally. The surgeon then exposes the thyroid cartilage and removes all of the prominent cartilage and its borders above the vocal cord marking. The incision is then closed and cleaned and a bandage is placed over the incision. During the first 24 to 48 hours after the surgery, it is common to experience some bruising and swelling as well as a sore throat. Discomfort is typically minor; however, pain medication is often given in order to keep the patient as comfortable as possible [119]. Complications may include a scar, changes in vocal quality, pain, and difficulty swallowing [117].

As a prerequisite to GCS surgery, patients often undergo genital electrolysis to remove hair from the scrotum and base of the penis in order to prevent intravaginal hair growth in the neovagina [116]. If the individual smokes, smoking cessation is recommended for at least one month prior to surgery and six months following surgery. Some surgeons also require that the patient's body mass index be less than 28 [128]. Two to four weeks before the surgery, estrogens are discontinued to prevent potential thromboembolic events. Any other medications that may inhibit blood clotting are also discontinued. The day/evening before surgery, a bowel preparation is necessary to evacuate the bowels. Some institutions also recommend a skin scrub using chlorhexidine prior to surgery, and prophylactic antibiotics may be administered either the night prior to surgery or just before incision. The patient is kept NPO (nothing by mouth) after midnight prior to surgery, which is common to most surgical procedures [116].

Potential complications of GCS include bladder damage, nerve injury, rectovaginal fistula, urethro-vaginal fistula, urethral stenosis, vaginal stenosis, granulation tissue, and vaginal prolapse [117]. In a retrospective review of 117 patients who underwent penile inversion vaginoplasty, the most common complications were granulation tissue (26%), intravaginal scarring (20%), and prolonged pain (20%) [131]. The majority of patients (90%) were satisfied with the outcomes despite complications.

Since the WPATH Standards of Care have been in place, there has been a steady increase in patient satisfaction with the outcome of GCS. The vast majority of follow-up studies have shown an undeniable beneficial effect of GCS on postoperative outcomes such as subjective well-being, cosmesis, and sexual function [71]. A meta-analysis of 32 studies found that positive results were achieved, both aesthetically and functionally, in most cases [125]. One study reported 90% of patients were satisfied with both aesthetic outcomes and orgasmic capability, although only 58% acknowledged sexual intercourse at that time. Orgasmic capability following vaginoplasty ranges from 63% to 92% [124].

Researchers from one facility reported maintenance of sexual sensation in 98.6% and achievement of orgasm (at least occasionally) in 94% of 71 MTF individuals after an average of 4.2 years following vaginoplasty [124]. A separate study reported decreased orgasmic ability but 75% more sex, resulting in high overall sexual satisfaction [124]. Due to the massive reconstruction necessary in vaginoplasty, postoperative orgasms may be more difficult to achieve. In some cases, transdermal testosterone or a phosphodiesterase-5 enzyme inhibitor (e.g., sildenafil, tadalafil, vardenafil) may improve a patient's ability to achieve orgasm [130].

Procedures that maintain attachment of the dorsal portion of the glans penis to the dorsal neurovascular bundle result in lasting neoclitorides and higher levels of sexual satisfaction [125]. Higher risk of sexual dissatisfaction is associated with techniques in which reattachment of the glans onto the dorsal neurovascular bundle was attempted.

An estimated 1% to 2% of individuals who have had GCS regret it; MTF patients with late (adult)-onset gender dysphoria are at the greatest risk for regret [18]. This may be a reflection of difficulties in making the transition to a different gender because of personal appearance or limited social skills. It is imperative for patients with late-onset gender dysphoria who have lived in their natal sex for a long time to understand the importance and impact of actually living as the other sex before undergoing GCS [18].

In some cases, the clitoris becomes sufficiently hypertrophied after testosterone exposure to serve as a microphallus. Otherwise, a phalloplasty or metoidioplasty may be performed (Table 6). The choice of technique may be restricted by anatomical or surgical considerations or the patient's financial considerations. If a patient wishes to have a phallus of good appearance, the ability to urinate while standing, sexual sensation, and/or coital ability, there are several separate stages of surgery and frequent technical difficulties that may require additional operations. Even metoidioplasty, which in theory is a one-stage procedure for construction of a microphallus, often requires more than one surgical procedure, and the goal of standing micturition with this technique cannot always be ensured [71].

Metoidioplasty involves elongation and reconstruction of the hormonally enlarged clitoris as a small neophallus with erectile function, analogous to penile tissue. During this procedure, the clitoris is released from its surrounding tissue and a flap of skin from the labia minora is wrapped around the clitoris to create a small phallus. The resulting neophallus is sensate. With ring metoidioplasty, a variation of the simple metoidioplasty, the urethra is lengthened using a flap of tissue from the anterior vaginal wall and labia minora to create the urethral extension. This carries urine to the distal end, similar to a natural penis. This procedure is less complex than a phalloplasty, has fewer complications, and has the benefit of providing greater erogenous sensation. However, the resulting neophallus is often not large enough to use for sexual penetration. Using this technique results in an average phallus length of 5.7 cm, with a range of 4–10 cm [136]. Testicular implants may be placed in the labia majora as part of the procedure.

Annual breast exam, including mammogram, is indicated in MTF women who are older than 50 years of age who have been taking estrogen for five or more years [57]. While this is recommended as a screening protocol, the actual risk is likely no different than in natal males. In a series of 2,200 MTF individuals studied between 1975 and 2005, there were no cases of breast cancer reported [99].

For patients using androgen therapy who have not had a complete hysterectomy, there may be an increased risk of endometrial and ovarian cancer [57]. Therefore, a regular Pap test is indicated. It is important to be sensitive when performing a pelvic exam on a transsexual man. As noted, FTM individuals often experience emotional and psychological distress with pap testing due to gender dissonance. This may be given as a reason for avoiding gynecologic examinations altogether [146]. It may be difficult to get a good sample, as the cervix will be atrophic; intravaginal estrogen cream can be used a few days prior to the Pap test to improve results.

When transgender children begin school, they begin to suppress cross-gender activities, as pressure from peers, parents, and schools quickly represses these unwanted behaviors. Children then become secretive. The behavior can be changed, but the internal sense of gender remains. However, for 75% to 80% of children who exhibit gender dysphoria, the disorder does not persist into adolescence, and complete gender role change and hormone treatment is not recommended in prepubertal children [17].

In general, psychological therapy and support can assist transgender children/adolescents to complete developmental tasks on schedule, achieve self-acceptance and understanding, and manage and cope with social problems (e.g., peer and/or family conflict) and the stress of the change process [159]. Three models of therapy for children who display gender dysphoria have been described. The first of these is affirming approaches, based on the concept that being transgender is not a mental illness [28]. This approach encourages the child's exploration of gender identity and assists the child and his or her family to explore interventions such as social transitioning and hormone therapy. Dreger defines this approach as the "accommodation" mode [161]. The second treatment approach involves supportive therapies—a "wait and see" approach to determine how the child's gender identity unfolds. With this approach, there are no gender-related interventions. The third approach is a "corrective" approach that seeks to align the child's gender identity with his or her biological sex. This approach is also described by Dreger as the "therapeutic" model that views the child's gender dysphoria in terms of familial dysfunction and seeks to guide the child into a less stressful, more sustainable family environment and gender identity [161]. This last approach has been generally dismissed or condemned by organizations like the APA [162].

In MTF individuals as well, gender dysphoria generally intensifies when adolescents develop unwanted secondary sex characteristics. Many gender dysphoric adolescents actually begin living in their true gender upon entering high school and desire hormones and surgery at that point. High levels of emotional distress, major depression, suicidality, and gender-related psychological and physical abuse during early adolescence were reported in a large study of MTF individuals [42]. The depression is thought to be a product of the strain and confusion associated with forming a sexual identity that is at odds with societal norms. This research strongly suggests that psychological and physical abuse play a major role in the incidence of depression.

Because of estrangement from their families, lack of affordable housing, mental health and addiction problems, and emotional and physical abuse, as many as one in five transgender youth become homeless, and transgender youth are disproportionately represented in the homeless population of the United States [48]. Most homeless shelters are segregated by birth sex, regardless of the individual's gender identity, and homeless transgender youth may even be ostracized by agencies that serve their LGB peers. Moreover, transgender youth have fewer legal protections from job and housing discrimination than other sexual minorities and often face additional complications in obtaining appropriate care. Lack of stable housing can compound problems in gaining or maintaining employment, further lessening life stability. Evidence suggests that because of this lack of housing or employment, many homeless transgender people turn to survival sex, which obviously increases their risk for exposure to sexually transmitted infections and becoming victims of violence. Street youth may also go to great lengths to access body-altering substances (e.g., illegal silicone injections, hormones) because they wish to halt the development of secondary sex characteristics [48].

Beginning treatment for gender dysphoria at puberty appears to be associated with better psychological outcomes than beginning treatment in adulthood, by which time irreversible secondary sex characteristics may pose lifelong barriers to successful sex reassignment. Additionally, limited observational data from transgender youth have indicated that gender dysphoria is reduced and relationships and academic skills are improved when therapy is started early [18]. The first longitudinal study of 55 transgender youth (22 MTF and 33 FTM) who received puberty suppression, cross-sex hormones, and in some cases GCS, was performed in the Netherlands in 2014 [160]. The researchers reported that gender dysphoria and body-image difficulties persisted through puberty suppression but remitted after the administration of cross-sex hormones and GCS. None of the individuals reported regret during puberty suppression, cross-sex hormone administration, or after GCS. Psychological functioning improved steadily over time, and overall well-being was comparable to non-transgender peers. In fact, a higher percentage of the transgender study group was pursuing higher education than the general public. The researchers speculated that this success was not only due to the medical treatment but also due to access to care (covered by health insurance) and the involvement of a multidisciplinary team of mental health professionals, physicians, surgeons, and supportive parents [160]. Another follow-up study done in the Netherlands revealed that young transgender adults who completed puberty suppression, hormone therapy, and GCS as youth reported becoming more sexually active following these treatments, although as a group they were still less sexually active than their cisgender peers. The researchers concluded that many transgender youth begin their sex lives only after having received gender-affirming medical care [190].

Transgender care is generally lacking in medical school curricula. Among 132 U.S. and Canadian medical schools surveyed in 2011, the median reported combined hours dedicated to LGBTQIA content was five hours [166]. One-third of medical schools reported no hours of LGBT content during clinical years, and less than 40% of medical schools taught transgender-related content, such as GCS, body image, or transitioning, despite research that shows that medical students who have clinical exposure to LGBTQIA patients during their training perform more comprehensive histories, have a more positive attitude toward these patients, and possess greater knowledge of LGBTQIA healthcare concerns than students with little or no clinical exposure [56]. In addition, the results of one survey indicate that, contrary to official American Public Health Association policy, public health schools seldom offer planned curricula that address comprehensive LGBT health [167]. Barriers to increased transgender health exposure include limited curricular time, lack of topic-specific competency among faculty, and underwhelming institutional support [168].

Coverage of transgender care is also lacking from most nursing education. A review of the top 10 nursing journals from 2005 to 2009 found only eight articles (out of nearly 5,000) that focused on LGBT issues and only one that mentioned transgender issues [169]. None of the eight articles came from U.S. researchers. As stated, in 2010, the National Student Nurses Association adopted a resolution to include LGBT content in nursing school curricula to improve cultural competence, with additional resolutions adopted in 2015, 2016, 2019, and 2021 [68].