Gender Dysphoria (Gender Incongruence)
Summary
Gender Dysphoria is the clinical distress caused by a discrepancy between a person's Gender Identity (internally sensed gender) and their Sex Assigned at Birth. In ICD-11, the diagnosis has been renamed Gender Incongruence and moved from "Mental and Behavioural Disorders" to "Conditions related to Sexual Health" to reduce stigma. The condition is not the identity itself, but the distress associated with it. [1,2]
Clinical Pearls
Pronouns Save Lives: Using a patient's chosen name and pronouns is the single most effective intervention a non-specialist can make. It reduces suicide risk and builds rapport instantly. Mistaking them (misgendering) breaks trust.
"Binder" Safety: Trans men may use chest binders to flatten breasts. Risks include rib fractures, restricted breathing, and skin infections. Advise: "take breaks", "never sleep in it", and "don't buy one too small".
The "Wait" for GIC: Waiting lists for NHS Gender Identity Clinics are currently years long. GPs must support mental health and physical monitoring (e.g., bloods) in the interim ("Bridging Prescriptions" guidance exists but is complex).
Demographics
- Prevalence: Estimates vary widely (0.5% - 1.0% of population).
- Trends: Increasing referrals, particularly in adolescents and birth-registered females.
- Co-morbidity: Higher rates of Autism Spectrum Disorder (ASD), Anxiety, and Depression compared to cisgender population.
Terminology
- Cisgender: Identity matches birth sex.
- Transgender: Identity differs from birth sex.
- Non-binary: Identity falls outside the male/female binary.
Aetiology
- Biological: Some evidence for hormonal environment in utero affecting brain development.
- Genetic: Twin studies suggest heritability.
- Multifactorial: Complex interplay of biological, psychological, and social factors. It is NOT caused by parenting style or trauma.
| Condition | Distinguishing Factors |
|---|---|
| Gender Dysphoria | Persistent, consistent incongruence causing distress. Focus is on being the other gender. |
| Body Dysmorphic Disorder | Fixation on specific "defect" (e.g., nose size) but identity remains cisgender. |
| Transvestic Disorder | Sexual arousal from cross-dressing (Paraphilia). Rarely seeks transition. |
| Psychosis | Delusional belief of being changed sex (rare). |
Adults
Children/Adolescents
Assessment (Specialist Only)
- Diagnosis is made by extensive psychosocial assessment, usually by two specialists at a Gender Identity Clinic (GIC).
- No blood test or scan diagnoses gender dysphoria.
Baseline Health (GP Role)
- Bloods: LFT, Lipids, HbA1c, FBC, Hormones (Oestradiol, Testosterone, Prolactin, LH/FSH) prior to hormone therapy.
- Sexual Health: Screen for STIs.
Management Algorithm (The Pathway)
REFERRAL TO GIC
(GP to Specialist Centre)
↓
ASSESSMENT
(Psychosocial history)
(Confirm diagnosis)
↓
SOCIAL TRANSITION (Phase 1)
- Name change (Deed poll)
- Pronouns / Clothing
- Living in role
↓
MEDICAL TRANSITION (Phase 2)
┌─────────┴─────────┐
FEMINISING MASCULINISING
(MtF) (FtM)
- Oestrogens - Testosterone
- Anti-androgens (Gel/Injection)
↓
SURGICAL TRANSITION (Phase 3)
(Usually required >1yr hormones)
- Mastectomy ("Top Surgery")
- Genital Recon ("Bottom Surgery")
- Facial Feminisation
1. Hormone Therapy (Cross-Sex Hormones)
- Trans Women (MtF):
- Oestradiol (Gel/Patch/Pill): Breast growth, softer skin, fat redistribution. Risk: VTE (esp. smokers).
- GnRH Analogues / Finasteride: To suppress Testosterone.
- Trans Men (FtM):
- Testosterone (Gel/IM Injections): Voice deepening (irreversible), hair growth, clitoral enlargement, cessation of menses. Risk: Polycythaemia, Acne, Liver strain.
2. Fertility
- Crucial: Hormones and surgery impair fertility.
- Gamete Storage: Sperm/Egg freezing must be discussed before starting hormones.
3. Children (Cass Review Context)
- Puberty Blockers (GnRH Analogues): Paused puberty (reversible).
- Current Status (UK): Following the Cass Review (2024), puberty blockers are not routinely prescribed outside of research trials due to insufficient evidence on long-term outcomes (bone density, cognitive development). Focus is on holistic psychosocial support.
- Mental Health: High rates of self-harm and suicide, often linked to societal discrimination and waiting times.
- Medical: VTE (Oestrogen), Polycythaemia (Testosterone), Osteoporosis (if sex hormones are too low).
- Surgical: Stricture, fistula, unsatisfactory aesthetic result.
- Transition: Recent evidence shows high rates of satisfaction and reduced suicide risk post-transition for carefully assessed adults.
- Regret: Rates of regret/detransition are low (~1%) but require support.
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Standards of Care | WPATH (Vers 8) | International gold standard for trans health. |
| UK Service | NHS Specifications | Adults GIC vs Child & Adolescent services. |
| Adolescents | Cass Review (2024) | Shift from "affirmative medicalisation" to "holistic exploration". Caution on hormonal interventions less than 18. |
Landmark Shifts
1. The Cass Review
- A major independent review of gender identity services for children and young people in England. It concluded that the evidence base for medical intervention (blockers/hormones) was weak and recommended a more cautious, multi-disciplinary approach focusing on mental health and neurodiversity.
What is Gender Dysphoria?
It is the deep, uncomfortable feeling that your gender identity (who you know yourself to be inside) doesn't match your body or the sex you were assigned at birth.
Is it a mental illness?
No. Being trans is a variation of human diversity. The "diagnosis" exists so that healthcare systems can treat the distress it causes and provide access to transition related care.
What is transitioning?
It is the process of living as your true gender.
- Social: Changing name, clothes, pronouns.
- Medical: Taking hormones to change physical features.
- Surgical: Operations to alter the body.
Where can I get help?
Your GP can refer you to a Gender Identity Clinic (GIC). While waiting, support groups and mental health services are vital.
Primary Sources
- World Professional Association for Transgender Health (WPATH). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. 2022.
- Cass H. The Cass Review: Independent review of gender identity services for children and young people. 2024.
- NHS England. Service Specification: Gender Identity Services for Adults. 2019.
Common Exam Questions
- Safety: "Trans man with pelvic pain?"
- Answer: Remember they may still have a uterus/ovaries. Consider pregnancy (if sexually active), atrophy, or cancer.
- Screening: "Cervical screening?"
- Answer: If a patient has a cervix, they need screening, regardless of gender identity. Automatic recall systems often miss trans men registered as male - manual request needed.
- Endocrinology: "Monitoring testosterone?"
- Answer: Check FBC (Polycythaemia) and Lipids.
- Referral: "Can a GP start hormones?"
- Answer: Generally No. Specialist initiation recommended. GP can prescribe under "Shared Care" once stabilised.
Viva Points
- The Cass Review: Discuss the shift in paediatric management (caution, research-only blockers) versus the established adult pathway.
- Bridging Prescriptions: The GMC allows GPs to prescribe hormones before GIC specialists only in specific "harm reduction" cases (e.g., patient buying black market drugs), but it is a complex medicolegal area.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.