Clinical Crossroads Section Editor: Edward H. Livingston, MD, Deputy Editor, JAMA.
Author Affiliations: Dr Spack is Associate in the Endocrine Division of Boston Children's Hospital and Cofounder/Codirector of the hospital's Gender Management Service and is Assistant Professor of Pediatrics at Harvard Medical School, Boston, Massachusetts.
Gender identity disorder (transgenderism) is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking male-to-female (MTF) change, hormone treatment includes estrogens, finasteride, spironolactone, and gonadotropin-releasing hormone (GnRH) analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a female-to-male (FTM) gender change, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.
Spack NP. Management of Transgenderism. JAMA. 2013;309(5):478-484. doi:10.1001/jama.2012.165234