Although the true prevalence isn't known, it is estimated that approximately 1 percent of adults in the U.S. have some degree of gender dysphoria. Only a fraction of them seek medically supervised services, and those who do often encounter significant barriers to care. Mayo Clinic provides education and treatment related to gender dysphoria, including medical and psychosocial interventions to assist in optimizing quality of life for transgender, intersex and gender-nonconforming people.
Cesar A. Gonzalez, Ph.D., L.P., a psychologist who provides collaborative care for sexual- and gender-diverse patients at Mayo's campus in Rochester, Minnesota, says initial appointments interweave assessment and education in order to provide validation, realistic expectations and, most important, guidance toward congruence between gender identity and expression.
The evaluation includes an assessment of a patient's mental health, quality of life, levels of minority-related stress, capacity to provide consent and understanding of goals. Treatment is highly individualized and reflects diversity of gender identities and expressions.
"Gender transition is less about how people look and more about helping individuals feel congruent with themselves," Dr. Gonzalez explains. "Some patients don't undergo surgical interventions; for them, taking hormones may be enough. Others want surgery. It's about being open to gender fluidity rather than having a stereotyped idea of the gender binary.
"We don't want to go from one gender box to another. Instead, we want to help patients find their own authentic sense of identity — a practice that may or may not include medical intervention to facilitate changes in gender expression. Ultimately, it's all a process."
For transgender people, the process of confronting cultural expectations of gender expression and how these fit with what is natural for them is intensely complex, challenging and stressful.
Many engage in behaviors designed to protect them from the stigma, harassment and discrimination associated with being a minority group, including a lack of spontaneous expression and social engagement. They also face practical challenges, such as deciding which restroom to use, traveling with a passport and setting expectations with others about preferred names and pronouns.
"Some people will have understood all these issues, but others will not, and that's why we do an assessment," Dr. Gonzalez says. "Anticipating issues and building resilience is extremely important."
Integrated biopsychosocial care model
Mayo providers follow the standards of care established by the World Professional Association for Transgender Health. They also practice a genuinely integrated biopsychosocial model in which various specialists — endocrinologists, psychologists, nurse practitioners, social workers and, eventually, surgeons — play equal roles.
"It's not just that these highly skilled and compassionate providers are involved; we actually talk to each other and we are fully invested," Dr. Gonzalez says.
They are also committed to the Mayo model, which emphasizes research and education in addition to clinical care. "We present at conferences, promote continuing medical education and invite speakers. We also teach Mayo medical students and residents. All of this speaks to the goal of decreasing health disparities among transgender, intersex and gender nonconforming people," Dr. Gonzalez says.