Not often does it happen that once one decides to edit a book, the DSM changes the name of the matter of interest. The initial title of this book was Management of Gender Disease that was then changed to Management of Gender Dysphoria according to the new DSM V definition.

In this brief introduction, I will try to explain how I have arrived to this moment.

My initial knowledge of the ‘problem’ started in 1990 when I encountered my first patient, who at that time we called ‘transsexual’. In that period at the Department of Urology of the University of Sassari, we had experience in operating children affected by ‘male pseudohermaphroditism’. Surgery often consisted in creating a neo-vagina in little patients who presented external female aspect but in the complete absence of a vagina. As one can easily understand, it is very difficult to operate in such little space as there is the rectal-prostatic area especially in such small patients.

So I was very happy when 1 day, my teacher and chief, Emanuele Belgrano, told me we had to operate on a … 22-year-old patient. The surgical treatment was very similar, but in this case, he/she was a healthy biological male who wished to become a female. The surgery was easier, the result was satisfactory, but that day my life changed a lot.

I followed her medical history with particular care and interest, and I hope I am correct in stating that both changed each other’s lives and careers for the better.

At the beginning, I thought I was enough to handle all that came along with these patients alone; I tried to follow the psychiatric-psychological part, the hormone therapy, and the follow-up (rehabilitation and physical therapy), but soon I realised that this was not the case.

My initial mistake was due to the fact that at that time, competent medical staff on this specific area of interest was scarce and scattered across Italy.

In 1994 when I arrived in Trieste, I organised myself better because I had the good fortune to meet doctors who accepted to become involved in my project:

In these years, I founded CeDIG (Centro per la diagnosi e la terapia dei Disturbi d’Identità e di Genere) the first Italian centre who wanted to deal with all the medical aspects and problems that are part of the lives of these patients.

The psycho-sexologists are the fulcrum of this venture: Laura Scati has followed more than 1,500 patients and starting from Trieste has created two other centres, in Pordenone and Genoa, in order to help them all. When necessary, the help of Elisabetta Pascolo Fabrici, psychiatrist, is requested.

Bruno Fabris, an internal medicine specialist, developed a great experience in hormone treatment and took part in writing with us our first book in Italian, Il Transessualismo: identificazione di un percorso diagnostico e terapeutico (Kurtis ed., Milan, pgs: 1–374) in 1999.

Michele Pascone was a great plastic surgeon who operated with me on the first female-to-male patient with the cooperation of his young co-workers Giovanni Papa and Vittorio Ramella, who actively continue to cooperate with us, under the direction of Zoran Arnez actual head of the plastic surgery department of the University of Trieste.

Secondo Guaschino, gynaecologist, followed many female-to-male patients who underwent ovariectomy and hysterectomy, which sometimes took place at the same time of mastectomy and/or penile reconstruction.

Maria Assunta Cova, head of the radiology department of the University of Trieste, headed the world’s first radiological evaluation of neo-vaginal width and depth in male-to-female patients by the use of the MR imaging.

Marina Bortul, general surgeon, applied with me for some laparoscopic techniques in those cases in which male-to-female patients needed to undergo re-surgery after partial atrophy of their initial neo-vagina.

CeDIG was officially presented in 2001 at our medical faculty meeting, and subsequently, the cooperation between all of us increased and widened to include other specialties.

On example, we learned the importance of having an infectious disease specialist: since 2010, Roberto Luzzati, and his co-workers, started to work with us, especially in the cases of HIV-positive patients.

Everybody knows that this topic, the management of GID, is particularly difficult and is an issue that can become overwhelming, and I have found in all of these people a great resource for reciprocal help; in particular in the operating room, we experimented this feeling when urologist, plastic surgeons and gynaecologists must work together for a common final result.

The anaesthesiology team has always actively participated in these surgeries; in particular, Simonetta Fasiolo has identified the importance of keeping liquids very low in male-to-female reassignment surgeries in order to prevent excessive swelling of the neo-labia in the immediate post-operative period. This precaution has avoided many post-op complications.

Throughout the years, starting in 2003, our nursing staff as well as the OR staff has organised several courses in order to better comprehend and therefore teach important aspects of how to interact with these patients, from how to greet them to how to teach them the physical rehabilitation.

Starting from the beginning of our experience, my co-worker and I contacted various important persons who have dealt with different aspects of the management of gender dysphoria:

Another important international contact was established when I went to Ghent (Belgium) for a congress organised by the World Professional Association for Transgender Health (WPATH), formerly known as the Harry Benjamin International Gender Dysphoria Association (HBIGDA). WPATH is a well-known professional organisation devoted to transgender health.

Thanks to WPATH and ONIG (Osservatorio Nazionale di Identità e di Genere), the Italian national reference point, I was able to apply the international standards of care in all the procedures of CeDIG.

Every time I organise a ‘little’ congress or meeting on this topic, I find how important it is to speak about these issues. At the end of these meetings, my colleagues often tell me they have learned a great deal of things. Moreover, every time we have involved in this organisation the patient and their associations (such as the LGBT community), the final result has been even greater.

I know that it is difficult to organise new initiatives because the costs are not covered by pharmaceutical industries, who have little interest in this field; for this reason, this particular aspect of medicine needs to be properly inserted in the more important congresses of the scientific society.

Since my effort during the last 15 years, EAU, ESGURS, SIU and SIA have dedicated congressional sessions and work groups to this topic.

Unfortunately, this area of medicine is not given scientific importance due to the fact that nowadays it is still a relatively small reality and thus the research on it has not given much scientific weight. Every time I tell one of my young co-workers to publish a paper on this topic, I perfectly know that if he spent the same amount of time and energy publishing something on prostate or urological cancer, surely his impact factor would be much higher. We are still far from being able to change this way of thinking, but it is a change that needs to happen because the more attention we bring to this field of interest, the better it will be for these patients.

A great part of my life in the last 20 years has been dedicated to:

I graduated from medical school in 1981 with full grades, and some time ago, I was curious to see what I had done in school with regard to gender dysphoria. I went back and looked through my books and unfortunately was not surprised in seeing that little to no information was given on what at that time was called ‘transsexualism’.

Starting from this observation, I decided to change this and nowadays:

To all those in the medical field whom have taken time to learn, to study, and to help and to all the patients, this book is dedicated to you.

To those who are interested in the scientific work on gender dysphoria by Prof. Trombetta and co-workers, a list of readings and congress lectures follows.