Gender-Dysphoria / Gender-Incongruence

Last updated April 8, 2022

Key Points

Key Points

Gender-dysphoric/gender-incongruent persons should receive a safe and effective hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty, and maintain levels of sex steroids within the normal range for the person’s affirmed gender.

Hormone treatment is not recommended for pre-pubertal gender-dysphoric/gender-incongruent persons. 

For the care of youths during puberty and older adolescents, an expert multi-disciplinary team comprised of medical professionals and mental health professionals should manage treatment. 

For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. 

All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy in both adolescents and adults. 

Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones, and/or to reduce steroid levels in advanced age. 

During sex steroid treatment, clinicians should monitor, in both transgender males (female to male) and/or transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment.

Table 1. Definitions of Terms Used in This Guideline

Term Definition
Biological sex, biological male or female These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other (e.g., a person with XY chromosomes may have female-appearing genitalia), the terms biological sex and biological male or female are imprecise and should be avoided.
Cisgender This means not transgender. An alternative way to describe individuals who are not transgender is “non-transgender people.”
Gender-affirming (hormone) treatment See “Gender reassignment."
Gender dysphoria (GD) This is the distress and unease experienced if gender identity and designated gender are not completely congruent (see Table 2). In 2013, the American Psychiatric Association released the fifth edition of the DSM-5, which replaced “gender identity disorder” with “gender dysphoria” and changed the criteria for diagnosis.
Gender expression This refers to external manifestations of gender, expressed through one’s name, pronouns, clothing, haircut, behavior, voice, or body characteristics. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender.
Gender identity/ experienced gender This refers to one’s internal, deeply held sense of gender. For transgender people, their gender identity does not match their sex designated at birth. Most people have a gender identity of man or woman (or boy or girl). For some people, their gender identity does not fit neatly into one of those two choices. Unlike gender expression (see above), gender identity is not visible to others.
Gender identity disorder This is the term used for GD/GI in previous versions of DSM (see “Gender dysphoria”). The ICD-10 still uses the term for diagnosing children, but the upcoming ICD-11 has proposed using “gender incongruence of childhood.”
Gender incongruence (GI) This is an umbrella term used when the gender identity and/or gender expression differs from what is typically associated with the designated gender. Gender incongruence is also the proposed name of the gender identity-related diagnoses in ICD-11. Not all individuals with gender incongruence have gender dysphoria or seek treatment.
Gender variance See “Gender incongruence.”
Gender reassignment This refers to the treatment procedure for those who want to adapt their bodies to the experienced gender by means of hormones and/or surgery. This is also called gender-confirming or gender-affirming treatment.
Gender-reassignment surgery (gender-confirming/gender-affirming surgery) These terms refer only to the surgical part of gender-confirming/gender-affirming treatment.

Diagnosis

...Diagnosis...

...Evaluation of...

...Society (ES) advises that only trained m...

...S advises that only MHPs who meet the fol...

...advises that decisions regarding t...

...S recommends against puberty-blocking and gender-a...

...hat clinicians inform and counsel all individuals...

...-5 Criteria for Gender Dysphoria in Adolesce...

...Criteria for Transsexualism...


Treatment

...Treatment of Adolesc...

...ggests that adolescents who meet diagnostic cri...

...clinicians begin pubertal hormone...

...hat, where indicated, GnRH analogues are used t...

...ents who request sex hormone treatmen...

...hat there may be compelling reasons to initia...

...monitoring clinical pubertal development every 3...


...Hormonal Therapy for Trans...

...s that clinicians confirm the diagnostic criteria...

...that clinicians evaluate and address me...

...S suggests that clinicians measure...

...uggests that endocrinologists provide e...


...e 4. Criteria for Gender-Affirming Hormone...


...ia for Gender-Affirming Hormone Thera...


...ble 6. Tanner Stages of Breast Development and Ma...


...e and Follow-Up Protocol During Suppression o...


...otocol Induction of Puberty...


...able 9. Baseline and Follow-up Protoc...


...10. Medical Risks Associated With Sex Horm...


...rmone Regimens in Transgender Persons ...


...able 12. Masculinizing Effects in Transge...


...inizing Effects in Transgender Females...


...Adverse Out...

...ggests regular clinical evaluation for physical...

...uggests periodically monitoring prolactin...

...ests that clinicians evaluate transgend...

...ecommends that clinicians obtain bone mineral...

...gests that transgender females with no kn...

...t transgender females treated with estrogen...

...at clinicians determine the medical nece...


...toring of Transgender Persons on Gender...


...ring of Transgender Persons on Gen...


...Surger...

...at a patient pursue genital gender-af...

...es that clinicians approve genital...

...the clinician responsible for endocrine t...

...S recommends that clinicians refer h...

...that clinicians delay gender-affirming genit...

...uggests that clinicians determine the timing of...


...Criteria for Gender-Affirming Surgery that...