Editing Gender dysphoria (section)

=== Biological treatments ===
{{Main|Gender-affirming care}}
Biological treatments physically alter [[Primary sex characteristic|primary]] and [[Secondary sex characteristic|secondary]] sex characteristics to reduce the discrepancy between an individual's physical body and gender identity.<ref name="care guidelines">{{cite journal | vauthors = Bockting W, Knudson G, Goldberg J |date=January 2006|title=Counselling and Mental Health Care of Transgender Adults and Loved Ones|journal=International Journal of Transgenderism |volume=9|issue=3–4 |pages=35–82 |doi=10.1300/J485v09n03_03 |s2cid=71503744|quote=As per Figure 1, delusions about sex or gender, dissociative disorders, thought disorders, or obsessive or compulsive features should be evaluated and treated prior to proceeding with hormone therapy or surgery. Thought disorders, dissociative disorders, and obsessive-compulsive disorders can, rarely, cause a transient wish for sex reassignment which disappears or significantly lessens when the underlying mental health condition is treated. It is important to treat these disorders before proceeding with hormones or surgery to ensure that the desire for alteration of primary or secondary sex characteristics is not a temporary desire.}} See also [https://www.wpath.org/publications/soc WPATH Standards of Care, version 7] {{Webarchive|url=https://web.archive.org/web/20150814230505/http://www.wpath.org/uploaded_files/140/files/Standards%20of%20Care%2C%20V7%20Full%20Book.pdf |date=2015-08-14 }}, page 23: "The role of mental health professionals includes making reasonably sure that the gender dysphoria is not secondary to or better accounted for by other diagnoses." And the paradigmatic [http://dx.doi.org/10.1080/00918369.2012.653300 Dutch model] {{Webarchive|url=https://web.archive.org/web/20220609011001/https://www.tandfonline.com/doi/abs/10.1080/00918369.2012.653300 |date=2022-06-09 }} for consideration of comorbid conditions before proceeding with treatment for childhood onset.</ref> Biological treatments for GD are typically undertaken in conjunction with psychotherapy; however, the [[HBIGDA-SOC|WPATH Standards of Care]] state that psychotherapy should not be an absolute requirement for biological treatments.<ref name="SOC28">{{cite web |title=Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People |url=https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf |publisher=World Professional Association for Transgender Health |access-date=15 March 2021 |pages=28–29 |archive-date=18 March 2021 |archive-url=https://web.archive.org/web/20210318100049/https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf |url-status=live }}</ref>

Hormonal treatments have been shown to reduce a number of symptoms of psychiatric distress associated with gender dysphoria.<ref name = Neuroimaging>{{cite journal | vauthors = Altinay M, Anand A | title = Neuroimaging gender dysphoria: a novel psychobiological model | journal = Brain Imaging and Behavior | volume = 14 | issue = 4 | pages = 1281–1297 | date = August 2020 | pmid = 31134582 | doi = 10.1007/s11682-019-00121-8 | url = https://link.springer.com/article/10.1007/s11682-019-00121-8 | url-status = live | quote = A recently published study (Colizzi et al. 2014), where 118 patients were followed before and 12 months after HRT revealed that 14% of the patients had comorbid Axis-I psychiatric diagnosis. Psychiatric distress and impairment were found to be higher in the beginning phase of the study but after HRT, there was a significant improvement in major depressive disorder, anxiety and functional impairment. Similarly, Fisher and colleagues' (Fisher et al. 2013) 2013 paper suggests that the dysfunction and impairment in the transgender population is highly associated with lack of HRT, which may suggest that at least a fraction of the impairment that was documented as comorbid Axis-I psychiatric disorders could in fact be impairment from GD. Finally, a metanalysis done by Dhejne and colleagues (Dhejne et al. 2016) reviewed 38 longitudinal studies that investigated psychiatric comorbidities pre and post gender affirmation treatments in transgender people with GD. The results of this analysis indicate that depression and GAD do have higher prevalence in transgender population but this finding was isolated to baseline (pre-gender affirmation treatments) where after gender affirmation therapies, rate of psychiatric comorbidities decreased to cisgender population levels | s2cid = 167207854 | archive-url = https://web.archive.org/web/20211021113310/https://link.springer.com/article/10.1007/s11682-019-00121-8 | archive-date = 2021-10-21 }}</ref> A WPATH commissioned systematic review of the outcomes of hormone therapy "found evidence that gender-affirming hormone therapy may be associated with improvements in [quality of life] scores and decreases in depression and anxiety symptoms among transgender people." The strength of the evidence was low due to methodological limitations of the studies undertaken.<ref>{{cite journal | vauthors = Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA | title = Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review | journal = Journal of the Endocrine Society | volume = 5 | issue = 4 | pages = bvab011 | date = April 2021 | pmid = 33644622 | pmc = 7894249 | doi = 10.1210/jendso/bvab011 | quote = This systematic review of 20 studies found evidence that gender-affirming hormone therapy may be associated with improvements in QOL scores and decreases in depression and anxiety symptoms among transgender people. Associations were similar across gender identity and age. The strength of evidence for these conclusions is low due to methodological limitations. | doi-access = free }}</ref> Some literature suggests that gender-affirming surgery is associated with improvements in quality of life and decreased incidence of depression.<ref>{{cite journal | vauthors = Wernick JA, Busa S, Matouk K, Nicholson J, Janssen A | title = A Systematic Review of the Psychological Benefits of Gender-Affirming Surgery | journal = The Urologic Clinics of North America | volume = 46 | issue = 4 | pages = 475–486 | date = November 2019 | pmid = 31582022 | doi = 10.1016/j.ucl.2019.07.002 | url = https://www.sciencedirect.com/science/article/pii/S0094014319300497 | access-date = 2021-12-27 | series = Gender Affirming Surgery | s2cid = 201997501 }}</ref> Those who choose to undergo gender-affirming surgery report high satisfaction rates with the outcome, though these studies have limitations including risk of bias (lack of randomization, lack of controlled studies, self-reported outcomes) and high loss to follow up.<ref name=":5" /><ref>{{cite journal | vauthors = Murad MH, Elamin MB, Garcia MZ, Mullan RJ, Murad A, Erwin PJ, Montori VM | title = Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes | journal = Clinical Endocrinology | volume = 72 | issue = 2 | pages = 214–231 | date = February 2010 | pmid = 19473181 | doi = 10.1111/j.1365-2265.2009.03625.x | url = https://pubmed.ncbi.nlm.nih.gov/19473181/ | access-date = 2021-07-17 | url-status = live | quote = The evidence in this review is of very low quality9, 10 due to the serious methodological limitations of included studies. Studies lacked bias protection measures such as randomization and control groups, and generally depended on self-report to ascertain the exposure (i.e. hormonal therapy was self-reported as opposed to being extracted from medical records). Our reliance on reported outcome measures may also indicate a higher risk of reporting bias within the studies. Statistical heterogeneity of the results was also significant. | s2cid = 19590739 | archive-url = https://web.archive.org/web/20210717025223/https://pubmed.ncbi.nlm.nih.gov/19473181/ | archive-date = 2021-07-17 }}</ref><ref>{{cite journal | vauthors = Sutcliffe PA, Dixon S, Akehurst RL, Wilkinson A, Shippam A, White S, Richards R, Caddy CM | display-authors = 6 | title = Evaluation of surgical procedures for sex reassignment: a systematic review | journal = Journal of Plastic, Reconstructive & Aesthetic Surgery | volume = 62 | issue = 3 | pages = 294–306; discussion 306–308 | date = March 2009 | pmid = 18222742 | doi = 10.1016/j.bjps.2007.12.009 | url = https://pubmed.ncbi.nlm.nih.gov/18222742/ | access-date = 2021-07-17 | url-status = live | quote = The evidence concerning gender reassignment surgery in both MTF and FTM transsexism has several limitations in terms of: (a) lack of controlled studies, (b) evidence has not collected data prospectively, (c) high loss to follow up and (d) lack of validated assessment measures. Some satisfactory outcomes were reported, but the magnitude of benefit and harm for individual surgical procedures cannot be estimated accurately using the current available evidence. | archive-url = https://web.archive.org/web/20210717025221/https://pubmed.ncbi.nlm.nih.gov/18222742/ | archive-date = 2021-07-17 }}</ref>

Disagreement among practitioners regarding treatment of adolescents is in part due to the lack of long-term data.<ref name ="Kaltiala-Heino" >{{cite journal |vauthors=Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L |title=Gender dysphoria in adolescence: current perspectives |journal=[[Adolescent Health, Medicine and Therapeutics]] |volume=9 |pages=31–41 |date=March 2, 2018 |pmid=29535563 |pmc=5841333 |doi=10.2147/AHMT.S135432 |quote="for the majority of adolescent-onset cases, GD presented in the context of severe mental disorders and general identity confusion. In such situations, appropriate treatment for psychiatric comorbidities may be warranted before conclusions regarding gender identity can be drawn."; "There is still no clear consensus regarding hormonal treatment for adolescents because long-term data are unavailable"; "In a nationwide long-term follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted as elevated after juridical and medical SR." |doi-access=free}}</ref> Young people qualifying for biomedical treatment according to the Dutch model<ref>{{cite journal |vauthors=Cohen-Kettenis PT, Delemarre-van de Waal HA, Gooren LJ |title=The treatment of adolescent transsexuals: changing insights |journal=The Journal of Sexual Medicine |volume=5 |issue=8 |pages=1892–1897 |date=August 2008 |pmid=18564158 |doi=10.1111/j.1743-6109.2008.00870.x |url=https://pubmed.ncbi.nlm.nih.gov/18564158/ |access-date=April 14, 2021 |url-status=live |archive-url=https://web.archive.org/web/20210413032947/https://pubmed.ncbi.nlm.nih.gov/18564158/ |archive-date=April 13, 2021}}</ref><ref>{{cite journal |vauthors=de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT |title=Young adult psychological outcome after puberty suppression and gender reassignment |journal=Pediatrics |volume=134 |issue=4 |pages=696–704 |date=October 2014 |pmid=25201798 |doi=10.1542/peds.2013-2958 |url=https://pubmed.ncbi.nlm.nih.gov/25201798/ |access-date=April 14, 2021 |url-status=live |s2cid=18155489 |archive-url=https://web.archive.org/web/20210413032943/https://pubmed.ncbi.nlm.nih.gov/25201798/ |archive-date=April 13, 2021}}</ref> (including having GD from early childhood which intensifies at puberty and absence of co-occurring psychiatric conditions that could challenge diagnosis or treatment) found reduction in gender dysphoria, although limitations to these outcome studies have been noted, such as lack of controls or considering alternatives like psychotherapy.<ref>{{cite journal |vauthors=Zucker KJ |title=Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues |journal=[[Archives of Sexual Behavior]] |volume=48 |issue=7 |pages=1983–1992 |date=October 2019 |pmid=31321594 |doi=10.1007/s10508-019-01518-8 |url=https://doi.org/10.1007/s10508-019-01518-8 |access-date=April 14, 2021 |url-status=live |quote=In the Dutch model, several factors were identified in deeming adolescent eligibility for early biomedical treatment. According to Cohen-Kettenis, Delemarre-van de Waal, and Gooren (2008), these included the following: (1) the presence of gender dysphoria from early childhood on; (2) an exacerbation of the gender dysphoria after the first signs of puberty; (3) the absence of psychiatric comorbidity that would interfere with a diagnostic evaluation or treatment; (4) adequate psychological and social support during treatment; and (5) a demonstration of knowledge of the sex/gender reassignment process. Several studies have reported on the benefits of this therapeutic protocol in reducing gender dysphoria (e.g., de Vries et al., 2014, which is the best study to date). Of course, one should bear in mind some of the limitation to these outcome studies, including the fact that not all assessed adolescents were deemed eligible for the treatment protocol (and thus we know relatively little about the longer-term outcomes of these youth) and that study designs have not included alternative treatment options (such as psychosocial therapy) or even being assigned to a wait-list control condition |s2cid=197663705 |archive-url=https://web.archive.org/web/20220609011010/https://link.springer.com/article/10.1007/s10508-019-01518-8 |archive-date=June 9, 2022}}</ref>{{unreliable medical source|reason=Author is, and was at the time of publication, editor-in-chief of this journal. This may count as self-published.|date=September 2024}}

In its position statement published December 2020, the [[Endocrine Society]] stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.<ref name="endocrine-society-2020"/>

A review published in ''Child and Adolescent Mental Health'' found that puberty blockers are fully reversible, and that they are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.<ref name="pubmed.ncbi.nlm.nih.gov"/>

More rigorous studies are needed to assess the effectiveness, safety, and long-term benefits and risks of hormonal and surgical treatments.<ref name=":5">{{cite journal |vauthors=Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, Rosenthal SM, Safer JD, Tangpricha V, T'Sjoen GG |display-authors=6 |title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline |journal=[[Journal of Clinical Endocrinology and Metabolism]] |volume=102 |issue=11 |pages=3869–3903 |date=November 2017 |pmid=28945902 |doi=10.1210/jc.2017-01658 |quote="In the future, we need more rigorous evaluations of the effectiveness and safety of endocrine and surgical protocols.Specifically, endocrine treatment protocols for GD/gender incongruence should include the careful assessment of the following: (1) the effects of prolonged delay of puberty in adolescents on bone health, gonadal function, and the brain (including effects on cognitive, emotional, social, and sexual development); [...] and (4) the risks and benefits of gender-affirming hormone treatment in older transgender people." "Future research is needed to ascertain the potential harm of hormonal therapies (176)." "The satisfaction rate with surgical reassignment of sex is now very high (187)." "Owing to the lack of controlled studies, incomplete follow-up, and lack of valid assessment measures, evaluating various surgical approaches and techniques is difficult." "Several postoperative studies report significant long-term psychological and psychiatric pathology (259–261)." "We need more studies with appropriate controls that examine long-term quality of life, psychosocial outcomes, and psychiatric outcomes to determine the long-term benefits of surgical treatment." | doi-access = free }}</ref> For instance, a 2020 Cochrane review found insufficient evidence to determine whether feminizing hormones were safe or effective, due to the lack of "completed studies that met [their] inclusion criteria."<ref>{{cite journal |vauthors=Haupt C, Henke M, Kutschmar A, Hauser B, Baldinger S, Saenz SR, Schreiber G |title=Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women |journal=[[The Cochrane Database of Systematic Reviews]] |volume=2020 |issue=11 |pages=CD013138 |date=November 2020 |pmid=33251587 |pmc=8078580 |doi=10.1002/14651858.cd013138.pub2 |quote=We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches for transgender women in transition.}}</ref> Several studies have found significant long-term psychological and psychiatric pathology after surgical treatments.<ref name=":5" />

In 2021, a review published in ''Plastic and Reconstructive Surgery'' found that about 1% (95% [[confidence interval|CI]] <1%–2%) of people who undergo gender-affirming surgery regret the decision. It concluded that "There is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population."<ref>{{cite journal |vauthors=Bustos VP, Bustos SS, Mascaro A, Del Corral G, Forte AJ, Ciudad P, Kim EA, Langstein HN, Manrique OJ |display-authors=6 |title=Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence |journal=Plastic and Reconstructive Surgery. Global Open |volume=9 |issue=3 |pages=e3477 |date=March 2021 |pmid=33968550 |pmc=8099405 |doi=10.1097/GOX.0000000000003477 }}</ref>