Gender Dysphoria

Terminology and Definitions

• Sex: Typically assigned at birth based on external anatomy (e.g. male/female).

• Gender: A social and cultural construct, referring to the roles, behaviours, and identities deemed appropriate for men and women (or beyond a binary understanding).

• Gender Identity: A person’s internal, deeply felt sense of being male, female, both, neither, or another identity. This may or may not align with the sex assigned at birth.

• Gender Dysphoria (DSM-5): Refers to the distress or discomfort that may arise when one’s experienced or expressed gender is incongruent with one’s assigned sex. It replaces the older term “gender identity disorder.”

Aetiology and Contributing Factors

• The aetiology of gender dysphoria is considered multifactorial, involving biological, psychological, and sociocultural components.

• Genetic, hormonal, and neurodevelopmental studies suggest a possible biological underpinning; however, conclusive causal mechanisms remain under investigation.

Clinical Presentation and Diagnosis

• GPs may be the first health professionals approached by patients experiencing gender incongruence.

• Key features:

  • Marked incongruence between one’s experienced/expressed gender and assigned sex.

  • Discomfort with one’s primary and/or secondary sex characteristics.

  • Desire to be of another gender and/or to be treated as another gender.

  • This incongruence often leads to significant distress or impairment in social, occupational, or other important areas of functioning.

Adolescents and Children

• Presentation can start in childhood or adolescence but must be interpreted with caution, recognising that gender exploration can be a normal developmental process for some.

• Persistent, consistent, and insistent expression of cross-gender identification in a child or adolescent warrants further evaluation and possibly referral to specialist services.

Screening and Assessment

• A non-judgemental approach is essential. Begin with open-ended questions about gender identity and explore the patient’s experiences, expectations, and goals.

• Consider using psychosocial assessment tools (e.g. HEADSS for adolescents).

• In cases of suspected gender dysphoria, a comprehensive biopsychosocial evaluation is important:

  • Mental health history (screen for depression, anxiety, self-harm).

  • Physical health (including sexual health, fertility considerations).

  • Family and social context, support systems.

Role of the GP

• GPs play a crucial role in early recognition, support, referral, and ongoing primary care for patients with gender dysphoria.

• Key responsibilities:

  1. Provide a safe, inclusive environment: Use chosen names/pronouns and ensure clinic staff are similarly respectful.

  2. Screen for comorbidities: Higher rates of depression, anxiety, eating disorders, self-harm, and suicidal ideation have been noted among trans and gender diverse people.

  3. Coordinate care: Liaise with mental health professionals, endocrinologists, speech pathologists, and other allied health services involved in transgender care.

  4. Assist with documentation: Offer letters of support for name changes, official identity documents, and workplace accommodations if needed.

Management Approaches

Psychosocial Support

• Counselling or psychotherapy (with a clinician experienced in transgender health) to support exploration of gender identity, address dysphoria, and foster resilience.

• Family therapy or parental support, especially for adolescents, to facilitate a positive family environment.

Hormone Therapy

• Typically managed in collaboration with an endocrinologist experienced in transgender care, or a GP with appropriate additional training/experience.

• Gender-affirming hormones can greatly alleviate dysphoria but require comprehensive assessment and informed consent.

• Oestrogen-based therapy for transfeminine patients; testosterone-based therapy for transmasculine patients.

• Monitoring includes regular blood tests (e.g. hormone levels, lipids, liver function) and ongoing risk-benefit discussions.

Puberty Suppression (Adolescents)

• In early puberty, gonadotrophin-releasing hormone (GnRH) analogues (puberty blockers) may be offered, typically in consultation with specialist paediatric endocrinology and mental health support.

• Puberty suppression aims to pause irreversible secondary sexual characteristic development, giving the young person time to explore their gender identity.

Surgical Interventions

• Gender-affirming surgeries (e.g. chest reconstruction, vaginoplasty, phalloplasty) can be considered in older adolescents or adults with persistent gender dysphoria.

• Surgical decisions require robust assessment, psychological support, and ensuring realistic expectations about outcomes, risks, and benefits.

Ethical, Legal, and Cultural Considerations

Informed Consent and Capacity

• Assess capacity to consent, especially in minors. For individuals under 18, decision-making often involves a multidisciplinary team plus parental/guardian involvement. In some complex cases, legal processes may be required.

Confidentiality

• Strict adherence to privacy and confidentiality laws is critical due to high rates of discrimination and stigma.

Cultural Competence

• Aboriginal and Torres Strait Islander, CALD (Culturally and Linguistically Diverse) communities, and faith-based backgrounds may have unique needs. Ensure culturally sensitive approaches and, where appropriate, engage multicultural or Indigenous liaison workers.

Mental Health Risks and Co-Management

• High rates of suicidal ideation and self-harm in transgender populations highlight the need for vigilant mental health support.

• GPs should screen for depression, anxiety, eating disorders, and substance misuse. Early referral to mental health professionals is recommended if risk factors are present.