Transgender Healthcare Demands Multispecialty Care

Bruce Jenner's Story Sparks Interest in Gender Issues

Wylie Hembree, MD; Christine Wiebe


May 08, 2015

In This Article

Diagnosing Transgender Adults

Medscape: What is the process like for adults who are first seeking care well after puberty?

Dr Hembree: In adults—and I am an internist/endocrinologist, so for the most part I see adults—they may seek out either an endocrinologist or a primary care physician, someone who has specialized in or is at a clinic that specializes in giving hormones to transgender individuals. Those individuals may then have their first long discussion about their experience with gender dysphoria.

In my experience, which began in 1993, most of the adults talk about their feelings when they were a child. They remember being 5 years old and being expected to be a nice little girl, when they only wanted to play with boys' things and dress like a boy and so forth, or the opposite situation depending on their natal sex. And they remember that they went on and did what their parents asked them to do, and they were sort of forced into behaving in a particular way.

They got into puberty and they became more uncomfortable. They didn't really know how to deal with it, so they just suppressed a lot of feelings and went on and did what society, family, and everybody expected them to do; they may even have gotten married and had children.

At some point in their lives, however, they probably were so bothered by gender dysphoria that they may have gone to a mental health professional to discuss it. But it may have been frustrating, because it was not as easy then to find someone who specializes in transgender issues or gender dysphoria.

What they want to do will complicate their lives.

Now, when I work with someone who has had a great deal of psychological difficulties—whose gender dysphoria has interfered with their life and their relationships—I still encourage them to see a mental health professional. I say, "I'd really like to get all of this confirmed by a mental health professional, and I think it would be good for you as you go through the transition. There are going to be parts of it that won't be very easy, that will be difficult to cope with. As the doctor giving you hormones, that's the easy part. I can do that for you and I can take care of you, but there may be other, more complex psychological issues."

Particularly in very young adults in their 20s or so, who still are maturing and growing up, there may be developmental issues that come up that I think would be very good to discuss. Sometimes they haven't really figured out their sexuality, their sexual preferences.

So, should a mental health professional play a role in dealing with adults? In many cases, yes, but there are also some clinicians who have sufficient experience with transgender individuals that they feel comfortable enough to say, "This is a classic case of gender dysphoria, and this individual has thought this out, and I'm ready to start talking about hormone therapy."

Medscape: Of the adult patients you've seen, in how many were you confident that they had gender dysphoria vs situations in which it was harder to tell?

Dr Hembree: I would say that in no more than 5%-10% of the people I saw did I have some real questions.

Medscape: So it is definitely a minority.

Dr Hembree: When I saw my first few transgender patients, I might have been a little insecure about making a diagnosis, but after seeing several individuals, it became much easier to recognize what they are experiencing, and to accept that they knew what they wanted.

Part of the reason for this is that what they want to do will complicate their lives to such an extent that it would be hard to believe anyone would proceed unless there were real, deep-seated reasons.


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