Trans and Gender Diverse Care / Gender Dysphoria

Key Concepts

Gender diversity

Gender diversity is not a mental illness
Trans, gender diverse and non-binary people may or may not experience gender dysphoria
Care should be:
- Respectful
- Affirming
- Trauma-informed
- Patient-centred
- Individualised

Gender dysphoria

Distress or discomfort from mismatch between:
- Sex assigned at birth
- Gender identity
DSM-5 focuses on distress/impairment, not identity itself

Important Definitions

Term	Meaning
Sex assigned at birth	Sex recorded at birth, usually male/female
Gender identity	Internal sense of gender
Gender expression	External presentation, eg clothing, hairstyle, voice
Transgender	Gender identity differs from sex assigned at birth
Non-binary	Gender identity not exclusively male or female
Gender dysphoria	Distress related to gender incongruence

GP Approach

First consultation

Establish rapport
Ask respectfully:
- Preferred name
- Pronouns
- Gender identity
- Preferred title
Avoid assumptions about:
- Sexual orientation
- Desire for hormones
- Desire for surgery
- Family support
Ask what name/pronouns are safe to use in:
- Letters
- Referrals
- SMS
- Phone calls
- Family discussions

Inclusive Practice

Practice environment

Display inclusive signage/resources
Provide gender-neutral bathrooms if possible
Train reception/admin staff
Forms should include:
- Legal name
- Preferred name
- Sex assigned at birth
- Gender identity
- Pronouns

Two-step gender question

“What sex were you assigned at birth?”
“How do you describe your gender?”
“What are your pronouns?”

History

Gender history

Age of onset
Duration of gender incongruence
Pubertal distress
Social transition history
Current goals
Expectations of treatment
Concerns about treatment
Family/social acceptance

Psychosocial history

Use HEADSS-style assessment:

Home/family support
Education/employment
Activities/relationships
Drugs/alcohol
Sexual history
Suicide/self-harm
Depression/anxiety
Safety/bullying/discrimination

DSM-5 Gender Dysphoria – Adults/Adolescents

Requires:

≥2 criteria
≥6 months
Significant distress or functional impairment

Features include:

Incongruence between experienced gender and sex characteristics
Desire to remove sex characteristics
Desire for sex characteristics of another gender
Desire to be treated as another gender
Strong belief of having feelings/reactions of another gender

Mental Health

Higher risk of

Depression
Anxiety
Self-harm
Suicide attempts
Social isolation
Bullying
Abuse
Discrimination

GP role

Screen for depression/anxiety
Suicide risk assessment
Safety plan if needed
Mental health care plan if appropriate
Link to psychology/peer support
Validate patient experience

Examination

Principles

Trauma-informed
Consent-based
Explain each step
Avoid unnecessary genital/breast examination

Genital examination

Not routine for gender dysphoria assessment
Only if clinically indicated, eg:
- Genital symptoms
- Suspected intersex variation
- Trauma/self-harm concern
- STI concern requiring examination

Differential Diagnoses

Differential	Key distinction
Transvestic disorder	Cross-dressing linked to sexual arousal; no persistent gender identity incongruence
Body dysmorphic disorder	Distress about perceived body defect, not gender identity
Psychosis	Gender belief may be delusional
Borderline personality disorder	Broader unstable self-identity
Autism spectrum disorder	May have intense preoccupations; still can have true gender dysphoria
Dissociative identity disorder	Gender experience may be linked to alternate identity states

Investigations

Diagnosis

Clinical diagnosis
No blood test required

Before hormone therapy

Baseline:

BP
BMI
FBE
UEC/eGFR
LFT
FSH/LH
Oestradiol
Testosterone

Consider:

HbA1c
Lipids
STI screen
Pregnancy test if relevant
Cervical screening if cervix present
Breast/chest screening as anatomy-appropriate

Management Overview

Individualised options

Social affirmation
Voice therapy
Counselling/psychology
Peer support
Hormone therapy
Surgery
Legal document changes

Social affirmation

May include:

Name/pronoun change
Clothing/hair changes
Binding/tucking advice
School/workplace support
Family counselling

Gender-Affirming Hormone Therapy

General principles

Goal:
- Align physical appearance with gender identity
- Reduce distress
- Improve wellbeing
Start low, titrate gradually
Individualise therapy
Usually long-term, but not always lifelong
Can be prescribed in GP setting using informed consent model

Informed Consent Model

Core elements

Patient self-determination
Shared decision-making
Explain:
- Expected changes
- Timeline
- Reversible vs irreversible effects
- Risks/side effects
- Fertility implications
Document capacity and consent

Psychiatry review recommended if

Unable to provide informed consent
Active psychosis
Severe unstable mental illness

Not contraindications

Depression
Anxiety
These require support but do not automatically prevent hormone therapy.

Feminising Hormones

Main treatment

Oestradiol:
- Oral
- Patch
- Gel
- Implant

Avoid

Ethinylestradiol due to higher thrombotic risk

Transdermal oestradiol preferred if

Age >40
Smoking
VTE risk
Cardiovascular risk factors

Expected effects

Early:

Softer skin
Reduced libido
Erectile dysfunction
Calmer mood

6–12 months:

Fat redistribution
Reduced muscle mass
Reduced testicular volume
Breast development

Important:

Oestrogen does not feminise voice
Refer to speech pathology if voice dysphoria

Anti-Androgens

Medication	Key points
Spironolactone	Monitor K+, BP; can cause postural hypotension/diuresis
Cyproterone acetate	More potent; monitor mood/LFTs; high-dose risk of hepatotoxicity/meningioma

Effects

Reduced libido
Erectile dysfunction
Reduced acne
Slower body hair growth
Facial hair often persists → laser/electrolysis may be needed

Feminising Therapy Monitoring

Frequency

3-monthly in first year
Then 6–12 monthly

Monitor

Oestradiol
Testosterone
FBE
UEC/eGFR
LFT
BP/BMI
Mental health

Suggested targets

Oestradiol roughly cisfemale range: 300–800 pmol/L
Avoid >1000 pmol/L
Testosterone target often <2 nmol/L if aiming for cisfemale range

Masculinising Hormones

Main treatment

Testosterone:
- Testosterone undecanoate IM
- Testosterone esters/enanthate IM
- Testosterone gel
- Testosterone cream

Expected effects

Early:

Acne
Oily skin
Increased libido
Clitoral enlargement

6–12 months:

Amenorrhoea
Increased muscle mass
Fat redistribution
Facial/body hair
Voice deepening

Important:

Voice deepening is usually irreversible
Testosterone is not contraception

Testosterone Side Effects

Acne
Weight gain
Androgenic alopecia
Sleep apnoea
Polycythaemia
Mood irritability
Vaginal atrophy/irritation

Vaginal atrophy management

Consider low-dose vaginal oestradiol pessary if acceptable to patient

Masculinising Therapy Monitoring

Frequency

Usually 6-monthly

Monitor

FBE
LFT
Testosterone level
BP/BMI
Lipids if cardiovascular risk
Mental health

Testosterone target

Trough total testosterone approx 10–15 nmol/L if aiming for cismale range

Polycythaemia

Concern if:

Haematocrit >0.50

Management:

Reduce testosterone dose
Extend injection interval
Change formulation
Consider haematology referral if persistent

Fertility Counselling

Before feminising therapy

Discuss sperm cryopreservation

Before masculinising therapy

Discuss fertility goals
Oocyte preservation can be considered
Ovulation may resume after stopping testosterone

Contraception

Testosterone does not reliably suppress ovulation
Pregnancy can occur
Discuss contraception if pregnancy possible
Oestrogen-containing contraception may be unacceptable or dysphoria-provoking for some transmasculine patients

Children and Adolescents

Usually managed in tertiary gender services
GP role:
- Safe environment
- Mental health support
- Family support
- Referral
- Interim menstrual suppression if appropriate

Menstrual suppression

Norethisterone may reduce distress while awaiting specialist care

Preventive Care

Use anatomy-based screening.

Examples

Cervical screening if cervix present
Breast screening based on breast tissue/risk
Prostate considerations if prostate present
STI screening based on sexual practices
Cardiovascular risk assessment
Smoking cessation
Vaccination
Bone health if prolonged hypogonadal state

Legal Document Changes – Australia

Surgery or hormone therapy is not necessarily required for gender marker change in Australian Government records
GP/psychologist letter may assist with:
- Medicare
- Centrelink
- Passport
- Driver licence
- ATO records

Australian Supports

National / professional

AusPATH
WPATH
TransHub
Headspace
PFLAG
Gender Centre

	Services	Support
National	Headspace	Ausgender Gender Agenda Gender Centre Transhealth Australia
Victoria	Southern Health Gender ClinicThe Royal Childrens’ Hospital – Gender Clinic	Transgender Victoria Seahorse Victoria Butch FemmeTrans Melbourne Rainbow Network Victoria
NSW	The Gender CentreTaylor Square Private Clinic	Twenty10
QLD	Cairns Sexual Health ServiceBrisbane Gender ClinicGoldcoast Sexual Health	The Australian Transgender Support Association Queensland PFLAG Transbridge – Townsville
TAS	Sexual Health Service Tasmania	Working It Out Rainbow Tasmania
ACT	Canberra Sexual Health Service	Gender Agenda
NT	Royal Darwin Hospital – Endocrine unit	Nil specifically identified for transgender
WA	Not available	WA Gender Project Living Proud Freedom Centre
SA	South Australia Gender Dysphoria Clinic	Bfriend

GP Monitoring and Long-Term Care

Overall GP Role

Longitudinal care
Hormone monitoring
Preventive healthcare
Mental health support
Sexual health care
Chronic disease management
Coordination of multidisciplinary care
Advocacy and social support
Trauma-informed and affirming care

Follow-Up Frequency

Before Hormone Therapy

Usually several consultations for:

Assessment
Education
Informed consent
Baseline investigations
Fertility counselling
Mental health review

First Year After Starting Hormones

Usually every 3 months:

Review physical changes
Monitor side effects
Mental health review
BP and BMI
Blood tests
Adherence
Goals and expectations

Stable Long-Term Patients

Usually every 6–12 months depending on:

Stability
Comorbidities
Hormone formulation
Mental health
Patient preference

At Every GP Review

Gender-Affirming Care Review

Assess:

Satisfaction with transition
Desired physical changes
Dysphoria/distress
Side effects
Medication adherence
Injection/patch/gel technique
Voice concerns
Surgical goals/plans

Mental Health Monitoring

Screen for:

Depression
Anxiety
Self-harm
Suicide risk
Trauma
Eating disorders
Substance use

Assess:

Family support
Social isolation
Workplace/school stress
Bullying/discrimination
Relationship safety
Housing instability

Important:

Suicide risk remains elevated
Protective factors include:
- Family acceptance
- Community connection
- Affirming healthcare

Physical Monitoring

Routine Monitoring

At follow-up:

Blood pressure
Weight/BMI
Smoking status
Alcohol/drug use
Exercise
Sleep
Cardiovascular risk

Blood Test Monitoring

Feminising Hormone Therapy

Frequency

Every 3 months initially
Then every 6–12 months

Monitor

Oestradiol
Testosterone
FBE
UEC/eGFR
LFTs

Consider:

Lipids
HbA1c
Prolactin if symptomatic

Suggested Targets

Oestradiol:
- Approximately 300–800 pmol/L
Avoid:
- Oestradiol >1000 pmol/L
Testosterone:
- Often <2 nmol/L if aiming for cisfemale range

Masculinising Hormone Therapy

Frequency

Usually every 6 months

Monitor

Testosterone
FBE
LFTs

Consider:

Lipids
HbA1c
Cardiovascular risk assessment

Suggested Target

Trough testosterone:
- Approximately 10–15 nmol/L

Long-Term Risks

Feminising Therapy Risks

Venous Thromboembolism (VTE)

Higher risk with:

Smoking
Obesity
Older age
Oral oestrogen
Immobility

Risk reduction:

Smoking cessation
Weight management
Exercise
Consider transdermal oestrogen

Cardiovascular Disease

Monitor:

BP
Lipids
Diabetes risk
Smoking

Liver Dysfunction

Monitor LFTs

Hyperkalaemia

Especially with spironolactone:

Monitor electrolytes and renal function

Mood Changes

Especially with cyproterone acetate

Masculinising Therapy Risks

Polycythaemia

Concern if:

Haematocrit >50%

Management:

Reduce testosterone dose
Extend interval
Change formulation
Haematology referral if persistent

Sleep Apnoea

Assess:

Snoring
Daytime somnolence
Obesity

Acne

Management may include:

Topicals
Oral antibiotics
Isotretinoin referral

Androgenic Alopecia

Discuss:

Minoxidil
Finasteride considerations

Bone Health

Osteoporosis Risk Factors

Hypogonadism
Stopping hormones long-term
Orchidectomy/oophorectomy without replacement
Eating disorders
Low BMI
Smoking

Consider:

Vitamin D
Calcium
DEXA if risk factors

Fertility and Reproductive Care

Ongoing Discussions

Review:

Fertility goals
Pregnancy intentions
Contraception

Important Points

Testosterone is NOT contraception

Ovulation may still occur

Oestrogen Therapy

Usually reduces fertility significantly

Sexual Health Care

STI Screening

Based on:

Sexual practices
Partners
Condom use
HIV risk
PrEP suitability

Vaccination

Consider:

HPV
Hepatitis A/B

Preventive Screening – Anatomy Based

Important Principle

Screen according to organs present.

Organ Present	Screening
Cervix	Cervical screening
Breast tissue	Breast cancer screening
Prostate	Prostate assessment when appropriate
Uterus/ovaries	Gynaecological review if symptomatic

Surgical Follow-Up

Monitor:

Wound healing
Pain
Infection
Urinary symptoms
Sexual function
Psychological adjustment

Voice and Speech

Speech Pathology Referral

Consider if:

Voice dysphoria
Vocal fatigue
Occupational voice demands
Desire for voice feminisation support

Social and Community Care

Support Areas

Family conflict
Workplace/school advocacy
Housing
Legal documents
Social isolation

Helpful Supports

Peer groups
TGDNB organisations
Online communities
Counselling

Lifestyle and Preventive Care

Important Measures

Smoking cessation
Exercise
Weight optimisation
Healthy diet
Sleep hygiene
Alcohol reduction
Harm minimisation

Red Flags / Urgent Review

Feminising Therapy

Urgent review for:

Chest pain
Dyspnoea
Calf swelling/pain
Severe headache
Neurological symptoms

Consider:

VTE
Stroke

Masculinising Therapy

Urgent review for:

Symptomatic polycythaemia
Severe mood changes
Severe acne/infection
Sleep apnoea symptoms

Mental Health Red Flags

Suicidal ideation
Self-harm
Psychosis
Severe functional decline

Multidisciplinary Team

May involve:

GP
Endocrinologist
Sexual health physician
Psychologist
Psychiatrist
Speech pathologist
Surgeon
Social worker
Peer support worker

Pearls

Start by asking name/pronouns respectfully
Do not pathologise being transgender
Gender dysphoria diagnosis requires distress/impairment
Assess suicide risk early
Genital examination is not routine
Depression/anxiety are not automatic contraindications to hormones
Hormone therapy can be GP-led under informed consent model
Always discuss fertility before hormones
Monitor hormones, FBE, LFTs, UEC and cardiovascular risk
Provide anatomy-based preventive screening
GP’s therapeutic relationship is central

References

Atkinson SR, Russell D. Gender dysphoria. Australian Family Physician. 2015;44(11). RACGP.
Cundill P. Hormone therapy for trans and gender diverse patients in the general practice setting. Australian Journal of General Practice. 2020;49(7). RACGP.
Strauss P, Winter S, Cook A, Lin A. Supporting the health of trans patients in the context of Australian general practice. Australian Journal of General Practice. 2020;49(7). RACGP.