Although the exact aetiology of GID is unknown, several environmental, genetic and anatomical theories have been described
The clinical features, diagnostic approach and management of male‐to‐female GID are reviewed, including the behavioural, psychological and surgical aspects.
The majority of GID patients will eventually go on to have gender realignment surgery, which includes feminising genitoplasty.
GID specifically excludes people with conditions such as intersex states or hermaphroditism
Diagnostic and statistical manual of mental disorders, 4th ed (DSM‐IV) criteria for diagnosis of gender identity disorder4
A strong and persistent cross gender identification (not merely a desire for any perceived cultural advantages of being the other sex)
A persistent discomfort with his or her sex or a sense of inappropriateness in the gender role of that sex
The disturbance is not concurrent with a physical intersex condition
The disturbance causes significant distress or impairment in social or occupational or other important areas of functioning
MDT comprises a psychiatrist and psychologist, reconstructive surgeons, an endocrinologist, speech therapist, a specialist nurse practitioner and counsellors. Mental health professionals play a key role in the process, initially by making the diagnosis and then treating the GID appropriately, after firstly excluding comorbid psychiatric conditions. As up to one in 10 GID sufferers have problems with mental illness, genital mutilation or suicide attempts, mental health professionals need to maintain close contact with people with GID throughout the process
Treatment modalities
Speech therapy-Patients are usually referred to the speech therapist to help them raise their pitch and modulate their resonance so that they can sound more like females.
Hair removal-Almost all patients will need advice on the facial and pubic hair removal process, whether this consists of ablation, shaving, laser or electrolysis
Endocrinologist opinion-This consists of advice about a sensible diet, acceptable weight, reduction of alcohol, stopping smoking and the value of regular exercise.conscent of patient /partner. The patient must have their blood pressure and baseline blood tests (full blood count, urea and electrolytes, liver function test, cholesterol, triglycerides, thyroid function tests) undertaken. Feminising effects of endocrine therapy for male‐to‐female patients
Redistribution of body fat
Reduced muscle mass
Softening of skin
Reduced libido and difficulty reaching orgasm
Reduction in spontaneous erections
Up to 50% reduction in testicular volume → testicular atrophy
Breast growth
Reduction in growth of facial/body hair → hair becomes finer
Commonly prescribed drugs used in hormone therapy for male‐to‐female transsexuals and their method of action
• Cyproterone acetate → androgen receptor blocker
• Spironolactone → interferes with testosterone production
• Finasteride → prevents conversion of testosterone into active metabolite, DHT
• LHRH analogues → continuously stimulate pituitary gland, causing surge of LH followed by surge of testosterone, which ultimately leads to continuous testosterone inhibition by negative feedback
• Oestrogen → induces female characteristics
Gender realignment surgery
the removal of the male external genitalia
the creation of a functional vagina
the creation of a cosmetic vulva
shortening of the urethra
elimination of erectile corporal tissue
creation of a functional clitoris
Different surgical techniques are available for vaginoplasty and these can be classified into five categories:
Postoperatively, patients need to remain in bed for 4 days with a vaginal gauze pack firmly in place, to keep the neovagina open.
On pack removal, the patient is allowed to mobilise.
The urethral catheter is removed and the patient is taught how to adequately clean and dilate the neovagina.
Vaginal dilatation consists of inserting a special dilator for 15 min three times daily, gradually increasing the size of the dilator used.
When the patient is comfortable with this she is discharged, usually on the seventh or eighth postoperative day.
Vaginal dilatation is continued at home, with reducing frequency over a 6 month period
Postoperative follow up
The vast majority of patients report important benefits from feminising genitoplasty at a low risk of complications.Current retrospective follow up studies suggest that about 80% of patients undergoing the procedure are pleased with the functioning and cosmetic appearance of their genitalia.
One of the most comprehensive meta‐reviews analysed 74 follow‐up studies and eight reviews of outcome studies published between 1961 and 1991 (MTF and FTM GID sufferers).
The authors concluded that in this 30 year period, only 1–1.5% of MTFs experienced persistent regret following gender realignment surgery.
Young age, supportive family and adequate social support are positively correlated with long term satisfaction.
Another study found that personal and social instability before surgery, coupled with poor body image and age >30 years, produced patient dissatisfaction postoperatively
