Gender dysphoria

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

Definition

• Gender dysphoria refers to clinically significant distress or discomfort arising from incongruence between:
  • A person’s sex assigned at birth
  • Their experienced or affirmed gender identity
• DSM-5 replaced the previous term “gender identity disorder” with “gender dysphoria”
• This change emphasises that:
  • Being transgender is not pathological
  • The clinical focus is on distress, impairment, and support needs

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Epidemiology

Prevalence and Epidemiology

• The true prevalence of gender dysphoria in Australia is uncertain.
• Prevalence estimates vary depending on whether studies measure:
  • Diagnosed gender dysphoria
  • Gender incongruence
  • Transgender identity
  • Broader trans and gender diverse identity
• Older studies likely underestimated prevalence because of:
  • Narrow definitions
  • Limited data collection
  • Cultural and social stigma
  • Under-disclosure
• Earlier RACGP AFP guidance cited New Zealand data estimating prevalence at approximately 1 in 6000, although this likely underestimated the broader trans and gender diverse population.
  • New Zealand passport-holder data estimated transsexualism prevalence at least 1:6364, with:
    • Male-to-female: 1:3639
    • Female-to-male: 1:22,714
• More recent Australian estimates suggest:
  • Around 0.9% of Australians aged ≥16 years identify as trans or gender diverse
  • Prevalence is higher in younger people, especially adolescents and young adults.
• Global estimates commonly suggest that approximately 0.5% of the population identify as transgender or gender diverse, but estimates vary by country, age group, methodology and willingness to disclose.
  • World Health Organization estimate that up to 0.5% of the global population identify as transgender or gender diverse.
  • Australia high-school–aged population: 2.7%
  • USA high-school–aged population: 2.3%
  • Adults internationally: approximately 0.5–0.9% TGDNB prevalence.

Vulnerability

• Transgender and gender diverse people have higher rates of:
  • Discrimination
  • Social rejection
  • Depression
  • Anxiety
  • Self-harm
  • Suicidality
• These risks are often related to:
  • Minority stress
  • Family rejection
  • Bullying
  • Social isolation
  • Barriers to healthcare
• Some patients may use non-prescribed hormones or anabolic steroids to achieve desired physical changes, especially when access to care is difficult

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Key Definitions

Gender

• A social, cultural, and personal construct
• Includes:
  • Gender identity
  • Gender expression
  • Lived experience
• Gender identities may include:
  • Man
  • Woman
  • Non-binary
  • Gender diverse identities

Sex Assigned at Birth

• Usually based on observed physical characteristics at birth
• Commonly recorded as male or female
• Does not always align with a person’s later gender identity

Sex Characteristics

• Biological traits associated with sex
• May include:
  • Chromosomes
  • Gonads
  • Hormonal profile
  • External genitalia
  • Internal reproductive organs
  • Secondary sexual characteristics

Sexual Orientation

• Refers to sexual and/or romantic attraction
• Separate from gender identity
• Includes:
  • Sexual identity
  • Attraction
  • Behaviour
• Sexual orientation may be fluid and self-defined

Transgender

• A person whose gender identity differs from their sex assigned at birth

Cisgender

• A person whose gender identity aligns with their sex assigned at birth

Non-Binary

• An umbrella term for people whose gender identity is not exclusively male or female

Intersex / Innate Variations of Sex Characteristics

• Natural variations in sex characteristics that do not fit typical binary definitions of male or female bodies
• May involve:
  • Chromosomal variation
  • Gonadal variation
  • Hormonal variation
  • Genital variation
  • Internal reproductive anatomy variation

Examples:

• Androgen insensitivity syndrome
• Congenital adrenal hyperplasia

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Role of the GP

Core GP Responsibilities

• Create a safe, respectful, and supportive environment
• Use the patient’s affirmed name and pronouns
• Provide non-judgemental care
• Assess psychosocial and mental health risks
• Identify support systems and barriers
• Coordinate multidisciplinary care
• Provide preventive healthcare
• Monitor hormone therapy where appropriate
• Support social, medical, psychological, and legal affirmation

Therapeutic Relationship

• Trust is central to care
• The GP should:
  • Validate the patient’s experience
  • Avoid pathologising gender diversity
  • Avoid assumptions about transition goals
  • Allow the patient to guide the pace of care

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Initial Consultation

Opening the Consultation

Ask respectfully:

• “What name would you like me to use?”
• “What pronouns do you use?”
• “How would you describe your gender?”
• “Is there a different name or title you need used on Medicare, pathology forms, letters, or when contacting family?”

Communication Principles

• Use affirming language
• Avoid intrusive questioning unless clinically relevant
• Explain why sensitive information is being collected
• Ask permission before discussing body parts or sexual history
• Clarify confidentiality, especially with adolescents

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Diagnostic Assessment

Key History Areas

• Age of onset of gender incongruence
• Duration of symptoms
• Pubertal history
• Distress related to secondary sexual characteristics
• Current gender identity
• Social transition history
• Desired goals of care
• Family, school, work, and community support
• Mental health history
• Risk of self-harm or suicide
• Previous use of hormones or blockers
• Current medications and substance use

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DSM-5 Criteria: Gender Dysphoria in Adolescents and Adults

Diagnostic Requirements

• Duration of at least 6 months
• At least 2 relevant features
• Clinically significant distress or impairment

Features

• Marked incongruence between experienced gender and primary or secondary sex characteristics
• Strong desire to be rid of sex characteristics
• Strong desire for sex characteristics of another gender
• Strong desire to be another gender or an alternative gender
• Strong desire to be treated as another gender
• Strong conviction of having feelings or reactions typical of another gender

Functional Impairment

Assess impact on:

• Social functioning
• School or work
• Family relationships
• Mental health
• Daily functioning

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DSM-5 Criteria: Gender Dysphoria in Children

Diagnostic Requirements

• Duration of at least 6 months
• At least 6 features
• Must include a strong desire to be, or insistence that the child is, another gender
• Clinically significant distress or impairment

Possible Features

• Strong preference for clothing typically associated with another gender
• Strong preference for cross-gender roles in play
• Strong preference for toys, games, or activities stereotypically associated with another gender
• Strong preference for playmates of another gender
• Strong rejection of toys, games, or activities associated with assigned gender
• Strong dislike of one’s sexual anatomy
• Strong desire for sex characteristics matching experienced gender

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Affirmation Goals

Social Affirmation

May include:

• Changing name
• Changing pronouns
• Clothing or grooming changes
• School/workplace affirmation
• Peer/community connection

Medical Affirmation

May include:

• Puberty blockers in young people
• Oestrogen therapy
• Testosterone therapy
• Anti-androgens
• Voice therapy
• Fertility preservation discussions

Surgical Affirmation

May include:

• Chest reconstruction
• Breast augmentation
• Facial feminisation surgery
• Hysterectomy
• Genital surgery

Legal Affirmation

May include changing:

• Medicare details
• Driver licence
• Passport
• Centrelink records
• School/work records
• Name and gender marker

Psychological Goals

May include:

• Understanding gender identity
• Coping with dysphoria
• Managing stigma
• Building resilience
• Improving self-acceptance

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Useful History Questions

Gender Identity and Goals

• “How would you describe your gender?”
• “What name and pronouns do you use?”
• “What are your current goals regarding social, medical, or legal affirmation?”
• “Are there any changes you are hoping for?”
• “Are there any changes you do not want?”
• “What are your main concerns about treatment?”
• “What outcomes would feel meaningful for you?”

Developmental History

• “When did you first become aware of your gender identity?”
• “Were there early experiences where your gender felt different from what others expected?”
• “How did puberty affect you?”
• “Were any physical changes particularly distressing?”

Coming Out and Supports

• “Have you told family, friends, school, or work?”
• “How did they respond?”
• “Who is supportive?”
• “Who is not supportive?”
• “Do you feel safe at home, school, work, and online?”

Body Dysphoria

• “Are there parts of your body that cause distress?”
• “Are there aspects of your body or presentation that feel affirming?”
• “Are you using binding, tucking, padding, or other strategies?”
• “Are these strategies safe and comfortable?”

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Psychosocial and Mental Health Assessment

Screen For

• Depression
• Anxiety
• Suicidal ideation
• Self-harm
• Trauma
• Eating disorder symptoms
• Substance use
• Autism spectrum disorder
• Family conflict
• Bullying or harassment
• Sexual assault or violence
• Homelessness or housing instability

Important Risk Factors

• Family rejection
• School/workplace bullying
• Social isolation
• Discrimination
• Conversion practices
• Unsafe housing
• Poor healthcare access

Protective Factors

• Supportive family or friends
• Affirming school/workplace
• Peer support
• Community connection
• Access to trans-affirming healthcare
• Sense of agency in decision-making
• Positive coping strategies

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HEADSSS Framework for Gender-Diverse Adolescents

Domain	Standard Assessment	Gender-Affirming Additions
Home	Living situation, family relationships	Are family aware? Supportive, neutral, or rejecting? Safe at home?
Education/Employment	School/work engagement, performance, goals	Are affirmed name/pronouns used? Any bullying? Access to safe bathrooms/uniforms?
Activities	Hobbies, friendships, social connection	LGBTQIA+ peer support? Safe spaces? Affirming role models?
Drugs/Alcohol	Tobacco, alcohol, substances	Used to cope with dysphoria, rejection, or stress?
Sexuality	Relationships, sexual activity, contraception, consent	Attraction, respectful relationships, safety expressing intimacy
Suicide/Depression	Mood, anxiety, self-harm, suicidality	Hopelessness or distress related to gender identity? Coping strategies?
Safety	Violence, abuse, online/public safety	Harassment, violence, emotional abuse, conversion-practice risk

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Physical Examination

General Principles

• Use a trauma-informed approach
• Explain why examination is needed
• Obtain consent
• Offer chaperone where appropriate
• Allow the patient control over the examination
• Avoid unnecessary genital or chest/breast examination

Genital or Chest Examination

Not routinely required for initial gender dysphoria assessment.

Consider only if:

• Clinically indicated
• Patient requests it
• Symptoms suggest pathology
• There is concern about injury, self-harm, or intersex variation

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Differential Diagnosis

Differential	Distinguishing Features
Transvestic disorder	Cross-dressing associated with sexual arousal; no persistent desire to live as another gender
Body dysmorphic disorder	Distress focused on perceived physical defect rather than gender identity
Psychotic disorder	Gender-related belief may be part of delusional system
Borderline personality disorder	Broader identity disturbance and emotional dysregulation
Autism spectrum disorder	Gender concerns may coexist; avoid dismissing gender dysphoria as “just ASD”
Dissociative identity disorder	Gender identity concerns may occur within alternate identity states

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Investigations

Diagnosis

• No investigation confirms gender dysphoria
• Diagnosis is clinical

Baseline Before Hormone Therapy

Consider:

• FBE
• UEC/eGFR
• LFTs
• Fasting lipids
• HbA1c or fasting glucose
• Testosterone
• Oestradiol
• LH/FSH
• Prolactin if clinically indicated
• Pregnancy test if relevant
• STI screening based on sexual practices

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Management Approach

General Principles

• Individualise care
• Use shared decision-making
• Explore the patient’s goals
• Address mental health and safety
• Discuss reversible and irreversible treatment effects
• Discuss fertility early
• Involve multidisciplinary supports when needed

Psychological Support

• Counselling is useful for:
  • Support during transition
  • Managing anxiety/depression
  • Family support
  • Coping with stigma
  • Assessing comorbid mental health conditions
  • Supporting surgical readiness when relevant
• Refer to a trans-affirming psychologist or mental health clinician where available

Hormone Therapy

• Hormone therapy can reduce gender dysphoria and improve wellbeing
• Prescribing should include:
  • Informed consent
  • Discussion of expected effects
  • Discussion of risks and side effects
  • Baseline assessment
  • Monitoring plan
• Initiation may be GP-led if appropriately trained, or shared with:
  • Endocrinologist
  • Sexual health physician
  • Experienced gender-affirming GP

Surgical Options

• Some patients may pursue surgery; others may not
• Options may include:
  • Chest/top surgery
  • Breast augmentation
  • Facial feminisation surgery
  • Hysterectomy/oophorectomy
  • Genital surgery
• Surgical decisions require careful counselling and specialist assessment

Legal Document Changes

• Australian Government records can generally be changed without requiring hormone therapy or surgery
• A letter from a registered medical practitioner or psychologist may assist with changing sex or gender marker on official documents

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Ongoing GP Role

Monitoring and Long-Term Care

• Provide continuity of care
• Monitor hormone therapy
• Manage side effects
• Screen for mental health issues
• Provide preventive healthcare
• Ensure anatomy-based cancer screening
• Support sexual health
• Coordinate referrals
• Provide letters or advocacy when appropriate

Preventive Health

Screen according to anatomy and risk:

• Cervical screening if cervix present
• Breast/chest screening if breast tissue present
• Prostate considerations if prostate present
• STI screening based on sexual practices
• Cardiovascular risk assessment
• Vaccination
• Smoking cessation
• Bone health assessment when indicated

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Medico-Legal Considerations for Young People

Gillick Competence

Assess whether the young person can:

• Understand the nature and purpose of treatment
• Explain benefits, risks, alternatives, and long-term consequences
• Weigh information and reason through options
• Make a voluntary decision free from coercion
• Communicate a stable and consistent choice

Document:

• Capacity discussion
• Who was present
• Decision aids used
• Cognitive or neurodevelopmental factors
• Risks, benefits, alternatives, and uncertainty discussed

Family Court Considerations

Court involvement may be required if there is dispute about:

• Diagnosis
• Proposed treatment
• Gillick competence
• Parental agreement

Current Australian Family Court Position by Treatment Stage

Stage	Treatment	Reversibility	Court authorisation generally required if consensus?	Court required if dispute?
Stage 1	Puberty blockers	Generally reversible	No since Re Jamie (2013) where the child/young person, parents/persons with parental responsibility, and treating clinicians agree	Yes, if there is a dispute about diagnosis, treatment, or Gillick competence
Stage 2	Gender-affirming hormones	Partly irreversible	No following Re Kelvin where there is no controversy or disagreement	Yes, as clarified in Re Imogen, if diagnosis, treatment, or competence is disputed
Stage 3	Surgical intervention	Irreversible	May not require court authorisation where the young person is Gillick competent and there is full parent/clinician consensus but requires specialist MDT assessment and careful legal consideration	Yes, if there is disagreement or uncertainty about competence, diagnosis, or treatment

Queensland-Specific Caution

• Queensland public-sector policy and access arrangements for youth gender-affirming treatment have changed over time
• Check current Queensland Health guidance before providing advice or initiating treatment
• Seek specialist and medico-legal advice if:
  • Parents are separated
  • There is disagreement
  • Competence is unclear
  • Treatment urgency is disputed
  • The patient is under 18