MON-195 Trans-transgender Female: Gender Identity Reversal Following Irreversible Gender Affirming Surgeries

Background: Comprehensive transgender care involves a multidisciplinary team of primary care providers, mental health providers (MHPs), endocrinologists and surgeons. Management of gender dysphoria (GD) includes hormonal and surgical treatment, with the latter being irreversible. Mental health evaluation to confirm GD is an essential step in transgender medical care, especially in children and adolescents. Clinical case: A 29-year-old biological female lived as a transgender male for 10 years after realizing male gender identity during puberty. She began to live as a male at age 16 and was diagnosed with GD by an adolescent MHP. She started transmasculine hormonal therapy at age 17, had a mastectomy at age 18, and hysterectomy-oophorectomy at age 20. At age 25, she was hospitalized for schizophrenia. Around that time, she developed dysphoria about being a transgender male. She later reversed her gender identity and gender expression back to female. She was evaluated by a new MHP, who diagnosed GD with no confounding mental health disorders, and she was started feminizing hormonal therapy with oral 17-beta estradiol. Serum estradiol level has been maintained between 100-200 pg/ml on estradiol 4mg/day. Despite use of feminizing hormones for 3 years, no significant breast development has been observed. She reports regret about her hysterectomy-oophorectomy, but no regrets about her chest surgery as it was essential to her male gender expression at the time of transition. This patient met all of the Endocrine Society criteria for genital gender-affirming surgery. The guideline recommends at least 1 year of consistent hormonal treatment and control of coexisting mental health concerns prior to genital gender-affirming surgery (1). The World Professional Association for Transgender Health (WPATH) Standards of Care recommends two separate referrals by qualified MHPs prior to genital gender-affirming surgery (2). Although this requirement might be challenging in clinical practice, meticulous mental health evaluation should be completed in transgender individuals who consider irreversible gender-affirming surgeries. In this case, the patient had no documented mental health disorder until after transitioning, making this evaluation more challenging, but on repeat mental health evaluation had GD, leading her to ultimately detransition. Conclusion: This case emphasizes the importance of mental health evaluations in transgender care. Although not universally required for initiation of transgender hormone therapy, evaluations by two separate MHPs who are experienced in transgender care are needed prior to irreversible gender-affirming surgeries to ensure GD and decrease the likelihood of detransitioning. References: (1) Hembree et al., J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869–903. (2) Coleman et al., International Journal of Transgenderism. 2012;13:4, 165-232.