Gender dysphoria

from – AFP > 2015 > November > Gender dysphoria Volume 44, Issue 11, November 2015

Gender Dysphoria and Transgender Care:

Definition of Gender Dysphoria:
- Distress or discomfort stemming from a disconnect between a person’s biological sex and their gender identity.
- Recognized in the DSM-5, replacing the previous term, “gender identity disorder,” to avoid implying that being transgender is pathological.
Prevalence and Epidemiology:
- True prevalence in Australia is unknown due to diverse definitions, varying cultural norms, and limited data.
- New Zealand reported a prevalence of 1 in 6000 with a natal male-to-female ratio of 6:1, though global estimates suggest prevalence is likely higher.
Vulnerability of Transgender Individuals:
- Higher risks of discrimination, depression, and suicidality compared with the general population, often attributed to social rejection, mental health challenges, and isolation.
- Substance misuse, especially anabolic steroids, occurs frequently, often in pursuit of physical changes to match gender identity

Definitions

Gender

Concept: Gender is a social and cultural construct.
Focus: It encompasses differences in identity, expression, and experience.
Identities:
- Man/Woman: Traditional gender identities.
- Non-Binary: An umbrella term for identities outside the exclusive categories of male and female.

Sex

Assigned at Birth: Based on observed physical characteristics at birth or infancy.
Possibility of Change: A person’s sex may differ from their assigned sex at birth over time.

Sex Characteristics

Definition: Refers to chromosomal, gonadal, and anatomical traits associated with biological sex

Sexual Orientation

Definition: An umbrella term covering a person’s sexual identity, attraction, and behavior.
- Sexual Identity: How a person self-identifies their sexuality (e.g., gay, lesbian, bisexual).
- Attraction: Romantic or sexual interest directed toward another person.
- Behavior: Actual sexual behaviors or interactions.
Fluidity: Sexuality may not be fixed; some people identify as sexually fluid, meaning their orientation may change over time or may not fit one specific label.
Individual Experience: Sexuality can be defined by personal identity, independent of romantic or sexual experiences.

Trans and Cis

Purpose of Terms: Describes the relationship between one’s gender identity and the sex presumed at birth.
- Trans (Transgender): Indicates that a person’s gender identity differs from the sex they were assigned at birth.
- Cis (Cisgender): Indicates that a person’s gender identity aligns with the sex they were assigned at birth.
Usage: These terms are used as prefixes (transgender, cisgender) to describe gender experience rather than as standalone gender labels.

Innate Variations of Sex Characteristics

refers to natural differences in a person’s genetic, hormonal, or physical characteristics that don’t fit typical definitions of male or female bodies.
These variations are present from birth and may affect various aspects of a person’s physical traits associated with sex, including:
- Genital Anatomy: Variations in the appearance or structure of external genitalia.
- Hormonal Profile: Differences in the levels or types of sex hormones (like testosterone and estrogen) present in the body.
- Chromosomal Patterns: Differences in the sex chromosomes, such as having atypical patterns like XXY instead of the usual XX (female) or XY (male).
- Reproductive Organs: Variations in internal reproductive anatomy, which may not align with typical male or female reproductive structures.
Key Terms
- Intersex: Often used as an umbrella term to describe individuals born with these variations.
- Differences/Disorders of Sex Development (DSD): Medical terms sometimes used to describe these variations.
Examples
- Androgen Insensitivity Syndrome (AIS): A condition where an individual has XY chromosomes (typically associated with males) but is resistant to male hormones (androgens), leading to a female appearance.
- Congenital Adrenal Hyperplasia (CAH): A condition affecting hormone production in the adrenal glands, potentially leading to atypical genital development.

Objectives for General Practitioners (GPs):

Role of the GP:
- Create a safe, supportive environment for transgender patients.
- Familiarize with transgender care principles, including individualized management, and potentially complex psychosocial issues.
- Establish therapeutic relationships, address basic needs, and be a resource through the gender transition process.

Initial Consultation and Diagnostic Approach:

Building a Relationship:
- Begin by establishing the patient’s preferred name and pronouns to foster trust.
- Emphasize an open, non-judgmental approach to build understanding and therapeutic rapport.
Initial Assessment:
- Collect a comprehensive history, focusing on age of onset and any significant events that may have influenced gender identity development.
- Assess the duration and intensity of gender dysphoria symptoms.
DSM-5 Diagnostic Criteria:
- Gender Dysphoria in Children DSM-5 Code: 302.6 (F64.2)
  A. Core Diagnostic Criteria
  Duration: ≥6 months
  ≥6 of the following (must include A1):
  A1: Strong desire to be, or insistence that one is, the other gender (or an alternative different from assigned gender)
  – Strong preference for cross-dressing (boys) or only wearing masculine clothing and rejecting feminine clothing (girls)
  – Strong preference for cross-gender roles in fantasy/make-believe play
  – Strong preference for toys/games/activities stereotypically used by the other gender
  – Strong preference for playmates of the other gender
  – Strong rejection of stereotypical gender-specific toys/games/activities
  Boys: avoids masculine play, rough-and-tumble
  Girls: avoids feminine toys/games
  – Strong dislike of one’s sexual anatomy
  – Strong desire for primary/secondary sex characteristics of experienced gender
  B. Functional Impairment
  Associated with clinically significant distress or impairment in social, school, or other important areas of functioning
  Specifier
  With a disorder of sex development (e.g., congenital adrenal hyperplasia)
- Gender Dysphoria in Adolescents and Adults DSM-5 Code: 302.85 (F64.1)
  A. Core Diagnostic Criteria Duration: ≥6 months
  ≥2 of the following:
  – Marked incongruence between experienced gender and primary/secondary sex characteristics (or anticipated in adolescents)
  – Strong desire to be rid of one’s sex characteristics due to incongruence with gender identity
  – Strong desire for sex characteristics of the other gender
  – Strong desire to be of the other gender (or an alternative different from assigned gender)
  – Strong desire to be treated as the other/alternative gender
  – Strong conviction of having feelings and reactions typical of the other/alternative gender
  B. Functional Impairment
  Associated with clinically significant distress or impairment in social, occupational, or other functioning
  Specifiers
  – With a disorder of sex development (e.g., congenital adrenogenital disorder)
  Posttransition: Individual lives full-time in the desired gender and has undergone (or is preparing for) at least one cross-sex medical procedure:
  e.g., cross-sex hormone therapy, gender-affirming surgery

Affirmed Gender and Goals

What gender identity do you identify with?
- Social Affirmation
  - Changing name/pronouns in social or professional settings
  - Dressing and grooming consistent with affirmed gender
  - Seeking support from peers or community
- Medical Affirmation
  - Puberty blockers (for youth)
  - Hormone therapy (e.g. oestrogen, testosterone)
  - Voice therapy
- Surigical Affirmation
  - Gender-affirming surgeries (e.g. chest/top surgery, facial feminisation, hysterectomy, genital surgery)
- Legal Affirmation
  - Changing name and gender marker on documents (e.g. Medicare, driver’s license, passport)
  - Navigating legal protections under anti-discrimination laws
- Psychological Goals
  - Understanding one’s gender identity
  - Coping with gender dysphoria or social stigma
  - Enhancing self-acceptance and resilience
What name and pronouns do you use?
What are your current thoughts or goals regarding social, medical, or legal transition?
What support or barriers have you encountered?
What outcomes are you hoping to achieve?

Developmental and Psychosocial History

Early childhood experiences:
- Can you recall when you first became aware of your gender identity?
- Did you express preferences or discomfort about gendered roles or activities?
Pubertal experiences:
- How did you feel during puberty?
- Were there any physical or emotional changes that felt distressing?
Coming out:
- Have you disclosed your gender identity to family, friends, school/work?
- How was it received?
Current relationship with your body:
- Are there particular aspects of your body that cause distress or dysphoria?
- Are there any affirming aspects?

Social, Emotional and Mental Health Screening

Screen for common comorbidities:
- Depression
- anxiety
- suicidal ideation
- self-harm
- Autism spectrum disorder (ASD)
- Substance use
- Eating disorders
Screen for psychosocial risks:
- History of bullying, trauma, violence, or sexual assault
- Family acceptance or rejection
- School or workplace safety
Parental rejection is a known risk factor for:
- Homelessness
- Self-harm and suicidal ideation
- Disengagement from healthcare

Note: Adolescents and young adults may be especially vulnerable to mental health issues, per [Pediatrics 2018;141(5):e20173845].

Protective Factors and Resilience

Supportive relationships (family, friends, mentors, community)
Involvement in affirming peer groups or activities
Sense of agency or control in decision-making
Access to mental health support or trans-affirming services

Gender Dysphoria Assessment Tools (as clinically appropriate)

Utrecht Gender Dysphoria Scale – Gender Spectrum
- “I wish I had been born as my affirmed gender”
- “Puberty felt like a betrayal”
GIDYQ-AA (Adults/Adolescents):
- “Have you ever felt pressure to be a gender you don’t identify with?”
- “Have you lived or presented yourself in your affirmed gender role?”
GALA™ – Gender Affirmative Lifespan Approach

HEADSSS Psychosocial Framework for Gender-Diverse Adolescents

Domain	Typical Components	Gender-Affirming Additions
H – Home	Who do you live with? What is your relationship like with family members?	– Are family members aware of your gender identity? – Are they supportive, neutral, or rejecting? – Do you feel safe at home as your affirmed gender?
E – Education/Employment	School/work engagement, grades, future plans	– Is your affirmed name/pronouns used at school? – Any bullying, discrimination, or supportive staff? – Access to gender-neutral bathrooms, uniforms?
A – Activities	Peer relationships, hobbies, social support	– Are you connected with other LGBTQIA+ peers or groups? – Do you have safe spaces to express your affirmed gender? – Are there affirming role models or online supports?
D – Drugs and Alcohol	Use of cigarettes, alcohol, or illicit drugs	– Has substance use been used to cope with dysphoria, rejection, or stress? – Any links between substance use and gender-related distress?
S – Sexuality	Relationships, sexual activity, contraception, consent	– What gender(s) are you attracted to? – Are your relationships respectful and affirming of your gender? – Do you feel pressure to conform to certain roles? – Do you feel safe expressing affection or intimacy?
S – Suicide/Depression	Mood, anxiety, self-harm, suicidal ideation	– Do you experience gender dysphoria? – Have you ever felt hopeless or unsafe because of your gender identity? – Any history of suicidal thoughts, self-harm, or trauma related to gender identity? – What helps you cope or feel better?
S – Safety	Physical safety, abuse, exposure to violence	– Have you experienced harassment or violence related to your gender expression? – Do you feel safe in public, at school, or online? – Any risk of conversion practices or emotional abuse?

Physical Examination:

Body Dysphoria in Physical Exams:
- Many transgender patients experience discomfort or distress related to their body, especially secondary sexual characteristics.
- Avoid unnecessary genital or breast exams initially unless medically indicated or requested by the patient.
- Respect the patient’s preference for androgynous appearance if it aligns with their gender expression.

Differential Diagnosis:

Conditions to Differentiate from Gender Dysphoria:
- Transvestic Disorder: Cross-dressing for sexual gratification without identifying as the opposite gender.
- Body Dysmorphic Disorder: Distressing preoccupation with a specific body part without overall gender misalignment.
- Psychotic Disorders: Rarely, psychotic delusions may involve gender identity.
- Borderline Personality Disorder: Can involve identity disturbances, but if suspected, involve mental health professionals.
- Asperger’s Syndrome: Gender dysphoria-like preoccupations can occur; a skilled mental health evaluation can differentiate.
- Dissociative Identity Disorder: Can present with gender identity concerns in distinct personalities; involves complex mental health care.

Investigations:

Baseline for Hormone Therapy:
- No diagnostic tests for gender dysphoria, but baseline labs (e.g., CBC, lipid profile, liver and kidney function) are essential before initiating hormone therapy to monitor health and side effects.

Management Approach:

Psychological Counselling:
- Counselling with experienced mental health professionals is recommended to provide support, manage comorbid conditions, and assist in transitioning.
- Psychologists can also aid in preparing for surgery and diagnosing any concurrent mental health issues.
Hormone Therapy:
- Benefits: Proven to reduce distress related to gender dysphoria.
- Informed Consent: Educate patients on reversible and irreversible effects.
- Specialist Referral: Often started by an endocrinologist or sexual health physician, although GPs may manage ongoing monitoring.
Surgical Transition Options:
- Many transgender individuals opt for surgery to align physical appearance with gender identity.
- Generally, regret rates are low, but thorough pre-surgical counselling is essential for decision-making.
Changing Legal Documents:
- As per Australian Government guidelines, a letter from a registered doctor or psychologist can facilitate changes in gender on official documents (e.g., Medicare, passports) without needing surgery or hormone therapy.

Ongoing GP Role:

Monitoring and Holistic Care:
- Provide preventive care, continuity of support, and a central point for communication among other healthcare providers.
- Monitor hormone therapy, manage any side effects, and screen for ongoing mental health needs.

Practical consent workflow (federal)

Multidisciplinary assessment (Australian Standards of Care v1.3).
Gillick interview – with at least one mental-health clinician experienced in gender dysphoria.
Parent & clinician consensus check.
If consensus: proceed (Stage 1–3 as above).
If dispute on diagnosis, competence or treatment plan: pause and seek Family-Court directions (Re Imogen rule).
Stage-3 surgery: ensure independent surgical second opinion plus endocrine clearance.

Gillick competence

Element	Practical test (drawn from Gillick, Marion’s Case, subsequent Australian authority)
Maturity & understanding	Can the minor explain (in their own words) the purpose, mechanism, benefits, risks, alternatives and long-term consequences of the treatment?
Practical yardsticks for age	≥16 y – generally presumed competent unless evidence to the contrary. Legal Aid Queensland ≈15 y – usually competent for routine care in QLD public guidance. Queensland Health <14 y – competence possible but must be clearly proven and documented.
Reasoning capacity	Demonstrates ability to weigh pros/cons and reach a stable, voluntary choice.
Voluntariness	Free of coercion; decision is the minor’s own.
Consistency with overall welfare	Not formally part of Gillick, but clinicians still consider best-interest factors.

Document your capacity interview verbatim; include decision-making aids used, assessment of cognitive or neuro-developmental factors, and who else was present.

Stage 3 (“surgical”) treatment – after Re Matthew (2018) court authorisation is also not needed when the young person is Gillick-competent and there is full agreement between parents and clinicians.

Disputes & Re Imogen (2020) – whenever any of the following are disputed ― (a) diagnosis, (b) proposed treatment, (c) the child’s Gillick competence ― an application to the Federal Circuit & Family Court remains mandatory.

Current Family-Court position by treatment stage

Stage	Irreversibility¹	Court needed? – If all three agree (child, both parents, treating team & no competence dispute)	Court needed? – If any dispute
Stage 1 (puberty blockers)	Reversible	No since Re Jamie (2013)	Yes – Family Court decides diagnosis/competence/treatment
Stage 2 (gender-affirming hormones)	Partly irreversible	No since Re Kelvin (2017) tcflawyers.com.au	Yes – clarified in Re Imogen (2020) Thorne Harbour
Stage 3 (surgical)	Irreversible	No since Re Matthew (2018) when consensus & competence present Human Rights Law Centre	Yes – if any disagreement or doubts

¹Irreversibility influences how deeply you probe capacity and the threshold for specialist & mental-health review.

Queensland-specific overlay (since 28 Jan 2025)

No new starts for Stage 1 or 2 until the statewide review reports (directive QH-HSD-058).
Current patients may continue.
Private prescribers may initiate treatment but should:
- verify the family is aware of the public-sector pause;
- ensure robust MDT documentation to mitigate later scrutiny;
- consider seeking medico-legal advice if parents are separated or any opposition is foreshadowed.

Gender dysphoria