Review

Journal of the Royal Society of Medicine; 2017, Vol. 110(4) 144–152

DOI: 10.1177/0141076817696054

Gender identity and the management of the transgender

patient: a guide for non-specialists

Albert Joseph1, Charlotte Cliffe1, Miriam Hillyard2 and Azeem Majeed1

1
Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK
2
North West Thames Foundation School, Imperial College Healthcare NHS Trust, London W2 1NY, UK
Corresponding author: Albert Joseph. Email: [email protected]

Summary transgender patients on primary care physicians and

their teams.1 With waiting lists for most gender iden-
In this review, we introduce the topic of transgender
medicine, aimed at the non-specialist clinician working in tity clinics extending beyond 12 months and increas-
the UK. Appropriate terminology is provided alongside ing numbers of patients coming forward for
practical advice on how to appropriately care for trans- treatment, hospital doctors are also likely to encoun-
gender people. We offer a brief theoretical discussion on ter transgender patients in their clinical practice.
transgenderism and consider how it relates to broader Research in the area of transgender health is
understandings of both gender and disease. In respect to limited, but the emerging consensus is that many
epidemiology, while it is difficult to assess the exact size of people identify as transgender, and that some of
the transgender population in the UK, population surveys these individuals will suffer from an often distressing
suggest a prevalence of between 0.2 and 0.6% in adults, associated condition, gender dysphoria.2 Appropriate
with rates of referrals to gender identity clinics in the UK treatment can lead to profound improvements in
increasing yearly. We outline the legal framework that pro-
well-being.2 Treatment is also largely safe and well
tects the rights of transgender people, showing that is not
legal for physicians to deny transgender people access to
tolerated but has some risks.2 Transgender individ-
services based on their personal beliefs. Being transgender is uals may have unique health needs and expectations
often, although not always, associated with gender dys- that health professionals need to be aware of to
phoria, a potentially disabling condition in which the discord- provide optimal care. In this essay, we introduce
ance between a person’s natal sex (that assigned to them at and outline this emerging field for physicians, not
birth) and gender identity results in distress, with high asso- specialised in this area, aiming largely at a British
ciated rates of self-harm, suicidality and functional impair- audience but with relevance to non-specialists outside
ment. We show that gender reassignment can be a safe the UK.
and effective treatment for gender dysphoria with counsel-
ling, exogenous hormones and surgery being the mainstay of
treatment. The role of the general practitioner in the man- Methods
agement of transgender patients is discussed and we con-
sider whether hormone therapy should be initiated in
This was a non-systematic review, utilising Google
primary care in the absence of specialist advice, as is sug- Scholar and PubMed searches to locate publications
gested by recent General Medical Council guidance. deemed to be relevant to the aims of this review,
namely to provide a practical introduction to the
Keywords field of transgender health for the non-specialist
Transgender, gender identity, gender dysphoria, gender clinician. Both our literature search and decisions
reassignment, transition, primary care, general practitioner regarding what was included in the final manuscript
were guided by discussions with general practi-
tioners with experience managing transgender
patients, gender identity specialists, public health
professionals, academics working in the field of
Introduction transgender studies and transgender patients with
Transgender people, whose gender identities, expres- experience being treated in the NHS.
sions or behaviours differ from those predicted by
their sex assigned at birth, are receiving increased
Terminology
attention both in the media and in the scientific
press. Recent guidelines in the UK have proposed It is important to know the accepted terminology
placing much of the responsibility of care for when discussing gender identity and also to be

! The Royal Society of Medicine 2017

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Joseph et al. 145

aware that terms have changed throughout time and Box 1. Terms used in the field of transgender health.
will continue to do so. A recent study of 166 medical
students in the UK demonstrated a significant posi- Preferred terms
tive correlation between familiarity with relevant ter-
Gender identity: An individual’s internal (i.e. not visible to
minology and positive attitudes towards Lesbian, others) sense of being male, female or something else.
Gay, Bisexual, Trans, and Queer patients.3 Further
studies demonstrate improvement in attitudes Gender non-conforming/Variant: Individual with gender
towards transgender individuals amongst healthcare expression differing from societal expectations related to
professionals after education, suggesting that famil- gender.
iarity with terminology might help overcome negative Transgender: Gender identity, expression or behaviour is
preconceptions.4 We provide a list of terms derived different to gender assigned at birth.
from the National Centre for Transgender Equality,
split based on whether they are preferred at time of Cisgender: Gender identity, expression and behaviour
writing (Box 1).5 conform to that assigned at birth.
There is an important distinction between trans- Gender non-binary: Not conforming to either binary
gender and the Disorders of Sex Developmenta (alter- gender forms of ‘male’ or ‘female’.
natively known as ‘intersex’), which is a term from
the Diagnostic and Statistical Manual of Mental Trans (gender) man: Individual most likely assigned as
Disorders (DSM) 5.a Intersex encompasses a range female at birth but now identifies as a man (‘Female to
of conditions where individuals are born with Male’).
sexual anatomy and/or chromosomal or hormonal Trans (gender) woman: Individual most likely assigned male at
patterns not fitting stereotypical definitions of birth but now identifies as a woman (‘Male to Female’).
‘male’ or ‘female’. In general, transgender individuals
should be referred to by the pronoun of their current Gender dysphoria/Gender identity disorder: Terms used in
identified gender rather than their assigned gender DSM-5 and ICD-10, respectively, describing conditions
whereby gender non-conformity leads to distress.
at birth. If there is any confusion, it is sensible to clarify
with a simple question such as ‘which pronouns do Genderqueer: Individual identifies as neither male nor
you use?’2 The answer may include gender-neutral female. The term ‘queer’ might be viewed as derogatory to
pronouns such as ‘they’ or ‘ze’ rather than ‘she’ or ‘he’. some but can also be used to describe a political stance which
aligns transgender with lesbian, gay and bisexual activism.

What is transgender? Transition: Time over which a person begins to live as

gender with which they identify rather than their gender
Although frequently conflated, the terms sex and assigned at birth.
gender have different meanings. Sex is defined as
the anatomical, genetic or gonadal dimorphism that Crossdresser: Individual who dresses in clothing stereo-
typically allows individuals to be placed in one of two typically worn by the opposite gender but generally without
categories, ‘male’ or ‘female’. Gender, in contrast, intent to live full time as the other gender.
relates to a person’s internal experience of ‘being Drag queen: A man who dresses in female clothing, often
masculine, feminine or androgynous. Rather than a for the purpose of entertainment or performance.
binary concept, gender identity includes gradations of
masculinity to femininity ... as well as identification as Drag king: A woman who dresses in male clothing, often
neither essentially male nor female’.6 Although for the purpose of entertainment or performance.
related, a person’s sex and gender are distinct from Non-preferred terms
their sexual orientation – whether they are sexually
attracted to men, women, both, neither and so on. In Transsexual: Non-preferred term for transgender.
the majority of cases, a newborn is assigned as ‘male’
Transvestite: Non-preferred term for cross dresser.
or ‘female’ at birth and a congruent gender identity
and gender role of ‘boy’ or ‘girl’ usually forms, Drag queen: When used to refer to transgender women,
respectively. Gender roles are a set of often-stereo- this can be derogatory and should be avoided.
typed social and behavioural norms considered
appropriate for persons of a specific sex, though
these vary widely between and within cultures. physiological differences leading to dimorphic sets
Debate continues on the extent to which these of behaviours and personalities, or does differing
gender roles are socially constructed – do typical socialisation usually lead to children internalising
men and women actually have inbuilt genetic or and ‘performing’ the correct gender roles?
146 Journal of the Royal Society of Medicine 110(4)

Individuals whose gender identity and expression bearing in mind that it is an area where numerous
differs from their circumscribed categories of ‘male’ perspectives are likely to be encountered. As always
and ‘female’ have clearly existed throughout tem- sensitivity, empathy and respect when dealing with
poral and sociocultural contexts, and within the transgender patients is paramount.
field of Western medicine, the term ‘transsexual’ or
‘transvestite’ was historically used to describe such
individuals. ‘Transgender’ as a noun and later an
Epidemiology
adjective first gained prominence in the early 1990s, There are only limited data on the prevalence of
with the rise of transgender studies, which attempted transgender people. There are also challenges in
to critically analyse and give a voice to the experi- defining the transgender community. Legally, the
ences of a coherent movement of individuals strug- transition from one gender to another is formally
gling to overcome marginalisation and political enshrined through completion of a gender recogni-
injustice.7 In recent years, various theories of gender tion certificate and as of 2014 only 3877 of these
identity development have been advanced, ranging certificates had been issued in the UK.13 It is likely
from ideas about an innate ‘brain sex’ (e.g. the however that gender recognition certificate figures
brain of a trans woman might show more homology grossly underestimate the size of the transgender
with that of a natally assigned woman than a natally community in the UK. By the year 2009 it was esti-
assigned man)8 to proposals that for at least some mated that between 5000 and 6200 people had under-
transgender people, the desire to become the ‘other’ gone gender reassignment surgery in the UK.14 In the
gender results from a sense of erotic gratification.9 past decade, numbers of gender recognition certifi-
Notions of binary, ‘biological’ sex may also be seen cate applications have fallen (likely due to cost and
as social constructions.6 What is clear is that gender a complex administrative process), yet referrals to
identity arises from a complex interaction of bio- gender identity clinics have soared15 (Figure 1). In
logical, social and cultural factors and its aetiology population surveys, estimates of prevalence of trans-
is highly contentious area. gender in Western populations are higher than might
be expected. A survey by Reed et al.14 estimated that
0.2% of the British population in the over-16 age
Transgender as a ‘disorder’
group identify as transgender, although these data
Complexities in understanding transgender are did not undergo peer review before publication. In
reflected in the difficulties labelling and classifying a recent large telephone survey carried out in the
it. At present Diagnostic and Statistical Manual-5 Unites States of America, 151,456 respondents were
and International Classification of Diseases (ICD)- asked ‘do you consider yourself to be transgender?’ A
10 include ‘gender dysphoria’ and ‘gender identity total of 0.53% reported identifying as transgender
disorder’, respectively, under mental health condi- and, through statistical extrapolation, the authors
tions. However, it is likely International estimated a population prevalence of 0.6% in the
Classification of Diseases-11 will reclassify gender United States (16).
identity disorder as a sexual disorder.10 This repre- There is pronounced variation in the prevalence of
sents a profound shift in perspective: the transgender transgender people based on locality. For instance,
person no longer suffers because of pathological rates of attendance to gender identity clinics in
mental processes leading to a desire for an altered Sussex per head of the population are double that
physical or social identity. The suffering occurs compared with the rest of the country.2 Whether
because non-pathological mental processes occur in this is due to differences in attitudes towards trans-
the context of the ‘wrong’ physical body and a patho- gender individuals, or the effect of patterns of migra-
logical social response to that body. tion remains unclear. Furthermore, while estimates
Gender dysphoria is, by definition, distressing, suggest that the median age at which individuals
causing social and occupational dysfunction, is asso- undergo transition is 42 years,14 there has been a
ciated with a significant risk of suicide and self- large increase in the number of referrals to child
harm11 and can often be treated either medically or and adolescent gender identity clinics in recent
surgically. It is for these reasons that it is labelled as a years.16 A retrospective study of transgender adults
disorder. But for those calling for the ‘depsycho- suggests that 76% (92/121) knew that their gender
pathologisation’ of transgender, gender variance is identity differed from their assigned gender by the
viewed as a normal dimension of human experience time they had left primary school.16 In the US tele-
with much of the suffering experienced by trans- phone survey noted above, a greater proportion of
gender people originating from social perspectives.12 people aged 18–24 were estimated to identify as trans-
For the non-specialist clinician it is worthwhile gender (0.66%) than those in the 25–64 (0.58%) and
Joseph et al. 147

Figure 1. Epidemiological trends: (a) Bar chart demonstrating increased referral to gender identity clinics across the UK, 2010–
2016. The data were compiled as a part of a Guardian special report; data obtained from all gender identity clinics in UK except for
Aberdeen under the Freedom of Information Act (15) and (b) government statistics demonstrate an increasing proportion of
female to male vs female to male requests for gender recognition certificates between years 2005 and 2014.13

the over 65 (0.5%) age brackets.17 It is possible that would be to have information on gender identity
with increased media discussion of transgender issues, incorporated into national statistics, so that gender
people now feel comfortable to openly identify as identity sits alongside race, social class and age as a
transgender at a younger age. It must be noted how- key measure of population variation.
ever that despite positive (Western) media attention,
transgender people remain disproportionately at
much higher risk of abuse, hate crime, suicide and
Legislation
have a lower average income than non-transgender In 2004, the Gender Recognition Act19 was passed in
people.17,18 the UK, allowing individuals to be issued with a
To address gaps in knowledge, well-conducted epi- gender recognition certificate, legalising an individ-
demiological research into the transgender population ual’s change in gender from the gender they were
is needed. This research would improve the capacity assigned at birth. In the 2010 Equality Act, ‘gender
of the NHS to plan services effectively according to reassignment’ was designated as a ‘protected charac-
need and also aid the transgender community’s cam- teristic’ and individuals are legally protected against
paign for further rights and support. One possibility any discrimination and harassment.20 The NHS
148 Journal of the Royal Society of Medicine 110(4)

constitution also supports the right of individuals to preparations, often bought online. Uncertainties
seek gender reassignment without discrimination.2 around contaminants, dosage, quality of medications
Physicians therefore do not have a legal right to and lack of monitoring make these potentially harm-
deny transgender people access to services based on ful. It is important to ascertain how the patient is
their own personal beliefs. administering these preparations and enquire about
the use of sterile needles and needle sharing if applic-
able.1 The General Medical Council recommends that
Gender reassignment – treatment options self-medication is a reason for general practitioners to
Gender reassignment involves healthcare profes- initiate hormone therapy without input from a special-
sionals from multiple disciplines including primary ist1 (see below).
care, psychology, psychiatry, social services, endo- As a complement to medication, speech and lan-
crinology and surgery, according to the wishes of guage therapists might be involved and trans women/
an individual patient. Gender reassignment is safe non-binary patients may also want to undergo facial
and effective for most patients but outcome studies and body hair removal. Electrolysis is the preferred
are limited by poor follow-up and inadequate study method due to its permanence. Surgical reassignment
design.1,2 However, not all transgender individuals procedures are manifold and are summarised in
will desire all, or indeed, any of the available medical Figure 2(d).25 Many of these surgical procedures
and surgical interventions. form part of the core list of therapies recommended
The mainstay of pharmacological management is by NHS England for public funding summarised in
hormone replacement therapy. Until recently, an Figure 2(e).26 Additional surgical interventions, such
adult person was required to undergo a period of as breast augmentation or thyroid chondroplasty, are
‘real life experience’ where they would spend a signifi- considered on a case-by-case basis by local clinical
cant time period (typically three months or more) commissioning groups.26 General practitioners
living as their preferred gender with relevant changes might play a role in supporting applications for sur-
to social, legal and health documents before receiving gery (normally two supporting opinions are
hormonal therapies.2 During this time, they would required). As a number of procedures involve
ideally receive counselling and psychological support. removal of gonadal tissues, collection and freeze stor-
In the most recent guidelines from the World age of gametes prior to any surgery is recommended
Professional Association for Transgender Health, in some cases.2 In the case of children and adolescents
which sets global standards of care, a period of real under 16, hormonal and surgical gender reassignment
life experience is no longer essential,21 though it cannot be initiated, but hormone blocking therapy
remains desirable. All that is required is a letter of (e.g. gonadotropin releasing hormone analogues)
support from a gender identity specialist, hence the might be used from ages 12 to 16 to stall pubertal
importance for rapid referral to a gender identity changes while a decision is made regarding preferred
clinic by general practitioner. gender.2 This is likely to be an area of future ethical
Hormonal therapy in gender reassignment is often debate, given the controversy regarding age at which
referred to as ‘cross-sex hormone therapy’,22 where gender identity is determined.27
estrogens are prescribed for trans women and testos-
terones for trans men. The forms in which these drugs Gender reassignment – the role of the
can be prescribed, their effects, risk profiles and
necessary monitoring investigations are outlined in
general practitioner
Figure 2. In some cases, it might also be necessary General Medical Council guidance published in 2016
to block endogenous sex hormone production with a recommended that general practitioners play a key
gonadotropin releasing hormone analogue. The use role in the care of transgender patients.1 This includes
of a five alpha-reductase inhibitor might also be indi- counselling or appropriate referral (which can be
cated in trans women to prevent androgenic pattern done directly by general practitioners, without an
balding. Current evidence suggests hormone treat- interim referral to general psychiatry) but also, in
ments in transgender patients are safe, if correct some cases, the initiation and maintenance prescrip-
monitoring is performed and treatment is not asso- tion of hormone therapy. If a patient is self-medicat-
ciated with either an increased mortality or increased ing from non-verified sources or is suicidal due to
risk of cancer.22–24 Long-term follow-up studies with gender dysphoria, the General Medical Council and
large cohorts are however lacking24 and should be the Royal College of General Practitioners argue that
focus of future research. a primary care physician should start cross-sex hor-
It is not uncommon for transgender patients to self- monal therapy as a bridge treatment until the patient
medicate with unregulated and unlicensed hormonal is seen in the specialist gender identity clinic,1 with or
Joseph et al. 149

Figure 2. Boxes demonstrating (a) the effects of cross-sex hormonal medications for trans men and women (whether these are
desirable or unwanted will depend on individual patient preference), (b) risks of hormone medications, (c) recommended
monitoring if cross-sex hormone medications are prescribed,1,21,25 (d) surgical options for gender reassignment25 and (e) non-
surgical and surgical treatment options recommended for funding by the NHS.26

(a) (b)
Trans Women Trans Men
Trans Women Trans Men
Breast development (takes ~ 2 years) Beard and body hair growth
Hair loss slowed down Male paern baldness Thrombosis Polycythaemia
Muscle bulk reduced Enlarged Clitoris
Elevated liver enzymes Elevated liver enzymes
Erecon/orgasm harder to achieve Heighted libido
Weight gain for both Acne Gallstones Hypertension
Reproducve implicaons for both Sleep apnoea
Hypertriglyceridaemia Hyperlipidaemia
Hyperprolacnaemia Cardiovascular disease
Type 2 diabetes Type 2 diabetes
(c)
Trans women Trans men
Baseline BMI, BP, FBC, urea and electrolytes, LFTs, HbA1c, lipid profile,
monitoring testosterone, estradiol, prolacn, T4 and TSH

Ongoing BMI, BP, FBC, urea and electrolytes, LFTs, HbA1c, lipid profile,
monitoring testosterone, estradiol, prolacn

Time frame 6 monthly for first 3 years, then annually

Example drugs Goserelin intramuscular injecon, 3.6 mg monthly or 10.8 mg
(Gn-RH analogues) every three months
Example drugs Estradiol patches 50-150 mcg Transdermal testosterone:
every three days Tesm® or Testogel® 5mg daily
(cross-sex
hormones) Oestrogel 2-3 measures per day Intramuscular testosterone:
Nebido® 1 g every three months
Oral estradiol 1-6 mg daily Sustenon® 250 mg every 2-3 weeks

Important informaon:
• Dose is trated to blood
estradiol level
• Patches and gels have lower
thrombosis risk
• Stop 3-4 weeks prior to
surgery in light of thrombosis
risk

(d) (e)
Trans men Trans women Trans men Trans women
Chest reconstrucon Facial feminising, thyroid chondroplasty Psychotherapy Psychotherapy
and breast augmentaon Hormone therapy Hormone therapy
Speech therapy Speech therapy
Hysterectomy, salpingo-oophorectomy, Penectomy, orchidectomy
vaginectomy Breast reconstrucon surgery Laser hair removal
Phalloplasty, metatoidioplasty, Vaginoplasty cliteroplasty and labioplasty Vaginectomy Penectomy
urethroplasty, scrotoplasty, tescular Hysterectomy Bilateral Orchidectomy
prosthesis and erecle prostheses Salpingoophorectomy Vaginoplasty
Hair transplantaon Phono-surgery Metoidoplasty/Phalloplasty Clitoroplasty and labiaplasty
Urethroplasty
Scrotoplasty
Penile Prosthesis

without additional referral to general psychiatry. The General Medical Council guidelines may force some
guidance recommends general practitioners should general practitioners to prescribe beyond their level of
initiate therapy if advised to do so by a specialist, competence,28 while others have argued that the guide-
provide maintenance prescriptions and ensure any lines are appropriate given the low-risk profile of the
screening and monitoring blood tests are carried out.1 hormone therapies.23 In our view, it is unreasonable to
The British Medical Association’s General require general practitioners to prescribe medications
Practitioner Committee has raised concerns that the that they feel are outside their area of competence. At
150 Journal of the Royal Society of Medicine 110(4)

the same time, it is clear that gender identity clinics are receive regular cervical smears to reduce his risk of
currently too overstretched to adequately address the advanced cervical cancer, or a 65-year-old trans
needs of transgender people in a timely fashion. Hence, woman would have screening for an abdominal
NHS commissioners at both local and national level aortic aneurysm, given that she will to retain the
must invest in an expansion of capacity in specialist risk of her natal sex for developing this condition.
clinics so that access is improved, waiting times to see Steps must be taken to ensure that patients are not
specialists reduced and specialist services have much removed from relevant recall systems after legal
greater ability to provide support to both non-specialist gender and name changes.
clinicians and patients. Although screening programmes promote health
Expanding the capacity of the NHS to manage on a population level, being invited or included in
this group of patients will also require the provision screening can provoke intense dysphoria for trans-
of adequate training to non-specialist physicians, gender people, which may make them reluctant or
including general practitioners (see e-learning unable to participate. In general, be sensitive but
module25). Innovative approaches to provision of explicit when asking questions about gendered anat-
specialist advice to general practitioners in the com- omy, genitalia or secondary sexual characteristics; if
munity might also be beneficial, e.g. telephone, video such questioning is medically necessary, explain the
or email consultation with a specialist. Further roles reasons for inquiring. The individual should be asked
for general practitioners include optimising fitness which healthcare professional they would prefer to
before gender reassignment surgery (e.g. smoking ces- perform the procedure and how it could best be
sation, weight loss, improving diabetic con- adapted to their comfort. As an example, a trans
trol) and ensuring successful post-operative man may have specific preferences about the size of
rehabilitation while monitoring for any complica- speculum used for the cervical smear.
tions. Development of primary care-based services It is recommended that trans women are included
could be through the implementation of an optional in national breast cancer screening, in addition to
‘Enhanced Service’, responding locally to increased managing the risk of prostate cancer as for natally
demands for service provision beyond what is assigned men.30 For patients who have undergone
required under the core general practitioner contract. gonadectomy or stop cross-sex hormonal therapy
The specification for such an enhanced service would after a gonadectomy, bone mineral density measure-
need to define the role of the general practitioner, ments should be considered; they are also recom-
including guidance on prescribing and monitoring, mended for those with any additional risk factors
as well as payment for providing the service. for osteoporosis.30 Specialist involvement might be
At the same time, specialist clinics also need required in certain situations, for example when hor-
to play a greater role in supporting patients in the mone treatments might impact on risk profiling for
community. For example, one reason commonly conditions such as cardiovascular disease or osteo-
given by specialists as to why general practitioners porosis. Therefore, advice from an endocrinologist
should prescribe for this group of patients is that may need to be sought in some cases.
they can then have their prescription dispensed at a
local pharmacy. Specialists who make this argument
seem unaware that hospital specialists can also issue
Conclusions
FP10s (the prescription form used to obtain medica- Gender identity is a complex subject where research
tion from a community pharmacy).29 Furthermore, is lacking and preconceptions abound. Physicians
the NHS Electronic Prescription Service now makes from all fields should address transgender patients
it straightforward to send prescriptions electronically with acceptance, compassion and a non-judgemental
to almost any community pharmacy in England,29 approach. Formal education and training on gender
and this should make it possible for specialists to identity and reassignment is needed for general prac-
take on a greater role in long-term prescribing. titioners, primary care trainees and clinicians from
other specialties who will see an increasing number
of such patients. Education can change attitudes for
Screening in transgender patients the better, overcome difficulty and confusion for
Transgender patients, at whatever stage of their tran- patients and doctors alike. In the interim, innovative
sition, should continue to be included in appropriate approaches are needed to bridge the gap in know-
national screening programmes. The best principle ledge between specialist centres and primary care;
is to screen the target organ, not the gender.2 This specialist advice via telephone or email might be a
might mean a trans man (assuming he has not under- simple but effective solution. Not only would under-
gone surgery to remove the cervix) would continue to standing the unmet needs and concerns of
Joseph et al. 151

transgender patients alleviate suffering for many, but identity and sexual orientation. Prog Brain Res 2010;
it would also offer unique insights on questions relat- 186: 41–62.
ing to human identity and personality. 9. Blanchard R. Varieties of autogynaephilia and their
relationship to gender dysphoria. Arch Sex Behav
1993; 22: 241–251.
Declarations
10. Drescher J, Cohen-Kettenis P and Winter S. Minding
Competing Interests: None declared. the body: situating gender identity diagnoses in the
Funding: None declared. ICD-11. Int Rev Psychiatry 2012; 24: 567–577.
11. Maguen S and Shipherd J. Suicide risk among trans-
Ethical approval: Not applicable since neither patients nor gender individuals. Psychol Sex 2010; 1: 34–43.
laboratory testing was involved. 12. Robles R, Fresán A, Vega-Ramı́rez H, Cruz-Islas J,
Rodrı́guez-Pérez V and Domı́nguez-Martı́nez T.
Guarantor: AM. Removing transgender identity from the classification
of mental disorders: a Mexican field study for ICD-11.
Contributorship: AJ, CC and AM conceived of the manuscript.
Lancet 2016; 3: 850–859.
AJ wrote the manuscript with help from CC and MH. AM
reviewed the manuscript and provided some additional content. 13. Ministry of Justice. Gender Recognition Certificate
Statistics. See https://www.gov.uk/government/collec-
Acknowledgements: Imperial College London is grateful for tions/gender-recognition-certificate-statistics (2004–14,
support from the NW London NIHR Collaboration for last checked 23 August 2016).
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