Gender Incongruence

Abstract

Gender incongruence (GI) (WHO 2018) or gender dysphoria (GD) (APA 2013) is defined as significant distress stemming from an incongruence between the assigned gender (at birth, based on biological sex) and the experienced gender (feeling male, female, or non-binary). Individuals with GI are now also known as “transgender” individuals. International treatment guidelines, as put forwards by the Standards of Care of the World Professional Association for Transgender Health (WPATH), offer a gender-affirming treatment (GAT) to improve quality of life and mental health. Although most individuals with GI attending a gender clinic arrive with a self-diagnosis, an adequate diagnostic assessment, both with regard to gender dysphoric feelings and co-occurring psychopathology, is important to refine both GAT and psychological/psychiatric treatment. Furthermore, (severe) psychiatric comorbidity is a predictor of regret and a worse outcome after GAT. The prevalence of affective disorders is considered to be two to three times higher in trans persons compared to the general population, while the occurrence of other psychiatric problems is similar to the general population. If a diagnosis of a (severe) psychiatric disorder (e.g. psychosis, autism spectrum disorder) is present, GAT can still be considered, if patients are sufficiently stabilized for a longer period. After GAT, the majority of individuals diagnosed with GI reported significant improvement in gender dysphoric feelings, psychological functioning, quality of life, and sexual satisfaction. Although long-term studies are scarce, and often methodologically weak, suicidality appears to be higher compared to general population rates, even after GAT. Therefore, it is recommended to ensure continuity of mental health care beyond transition. Contrary to popular belief, individuals with GI are not “hyposexual”: a desire for satisfying sexual activity is present before, during, and after GAT, also in those individuals not desiring GAT. Both hormonal replacement therapy (HRT) and surgical interventions might impact sexual functioning and satisfaction, but potential sexual changes should not be reduced to its medical aspects. During transition, GAT also impacts self-esteem and confidence, which can of course facilitate the experience of sexual pleasure. Clinicians should assess sexual functioning before, during, and after transition and offer sufficient, evidence-based psycho-education and guidance with these potential sexual changes.