APA OFFICIAL ACTIONS
Assessment and Treatment of Gender Dysphoria and
Gender Variant Patients: A Primer for Psychiatrists
William Byne, M.D., Ph.D., Dan H. Karasic, M.D., Eli Coleman, Ph.D., A. Evan Eyler, M.D., M.P.H.,
Jeremy D. Kidd, M.D., M.P.H., Heino F.L. Meyer-Bahlburg, Ph.D., Richard R. Pleak, M.D., Jack Pula, M.D.
The Board of Trustees of the American Psychiatric Associ-
ation (APA) has approved as a Resource Document a report
of the APA Workgroup on Treatment of Gender Dysphoria
titled “Assessment and Treatment of Gender Dysphoria and
Gender Variant Patients: A Primer for Psychiatrists.” The
APA Workgroup was assembled to work toward fulfillment
of the recommendations of the APA Task Force on Treatment
of Gender Identity Disorder. Although diagnosis and treatment
are inextricably linked, they are separate issues. Both the
diagnosis and treatment of gender identity disorder were
controversial, and the respective DSM-5 workgroup set up in
May 2008 drew much professional and public attention. Be-
cause diagnosis, but not treatment, is within the purview of
the DSM, the APA Board of Trustees formed the Task Force
on Gender Identity Disorder to 1) conduct a literature review
to assess the quality of evidence pertaining to the treatment
of gender identity disorder in different age groups and 2) ex-
press an opinion as to whether sufficient credible literature
existed for APA to take the next step and develop treatment
recommendations for gender identity disorder in children,
adolescents, or adults as well as for individuals of any age with
somatic intersex conditions who experience dysphoria related
to their assigned gender. The Task Force reported that, given
the nature of gender identity disorder, evidence of the highest
quality—the randomized double-blind controlled trial—was
not available. The Task Force concluded, nevertheless, that
the empirical database supplemented by clinical consensus
was sufficient for the development of treatment recommen-
dations. In addition to recommending the development of
treatment recommendations, the Gender Identity Disorder Task
Force recommended that APA take a number of additional
actions, including tasking a specific APA component or other
group within the APA to monitor progress with regard to im-
plementing its recommendations, which led to the formation
of the APA Workgroup on Treatment of Gender Dysphoria.
Despite the recommendation of the Task Force, treatment
of gender dysphoria could not be selected for APA Clinical
Guideline development because it did not meet prevalence
and quality of evidence criteria to be prioritized for consid-
eration by the APA Committee on Practice Guidelines. Several
clinical guidelines and standards of care exist to assist mental
health professionals in providing care to individuals with
gender dysphoria but are not targeted specifically toward
1046 ajp.psychiatryonline.org
psychiatrists. These include the World Professional Associa-
tion for Transgender Health Standards of Care, version 7,
published in 2012, and the American Psychological Associ-
ation’s Guidelines for Psychological Practice with Trans-
gender and Gender Nonconforming People published in 2015.
Although the practice of psychiatry overlaps with that of other
mental health fields, psychiatry is unique in several respects.
Psychiatrists often have the primary role in the diagnosis and
treatment of the major mental illnesses in which gender identity
concerns may arise as epiphenomena (e.g., psychotic disorders)
as well as in the pharmacological management of psychiatric
disorders that may coexist with gender dysphoria, including
mood and anxiety disorders, and in monitoring symptoms that
may emerge with endocrine manipulation. While targeted spe-
cifically to psychiatrists, the APA Workgroup’s Resource Doc-
ument should be helpful to providers in other disciplines, since
all are likely to encounter gender diverse patients.
The Resource Document begins with a review of the history
and evolution of conceptualizations of gender and gender var-
iance and its classification and related terminology, including
differences between DSM-IV and DSM-5. It then examines
the prevalence of gender dysphoria and other manifestations
of gender variance before reviewing what is known about
gender development. The largest portion of the document
addresses the mental health assessment and treatment of
gender dysphoria in adults, including those with somatic in-
tersex conditions. This includes mental health evaluations and
referrals for gender-affirming somatic treatments. The document
concludes with an examination of current societal trends, in-
cluding increased social acceptance of gender variance, civil
protections for gender diverse individuals, and increased access
to gender transition services for adults (specific guidance on
these matters for child and adolescent psychiatrists can be found
in the American Academy of Child and Adolescent Psychiatry
Practice Parameter on Gay, Lesbian, or Bisexual Sexual Orienta-
tion, Gender Nonconformity, and Gender Discordance in Chil-
dren and Adolescents). The report includes a glossary of gender
terminology and tables of the currently most widely accepted
criteria for gender-affirming hormonal and surgical treatments.
The full Resource Document accompanies the online ver-
sion of this APA Official Action (ajp.psychiatryonline.org). A ver-
sion of the report revised through peer review is also available
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944396.
Am J Psychiatry 175:10, October 2018