Diagnoses

Medical gender affirmation does not require a diagnosis, as being trans or gender diverse is not a form of sickness. Historically, gender affirming care was considered treatment for a mental illness that required diagnosis, but modern gender affirming care is moving away from this model. Accessing medical gender affirmation in Australia, unlike the US, does not require a specific diagnosis of gender dysphoria.  

This page outlines the tools available to clinicians who wish to provide medical gender affirmation, moving away from diagnoses such as ‘gender dysphoria’, with an emphasis on the informed consent model.  

The information on this page relates to any people over the age of 18. See our page about people who are under 18 for age specific information.  

Diagnoses

Gender dysphoria 

Gender dysphoria, also known just as ‘dysphoria’ by trans community, is an experience of distress associated with their gender, bodies, or how those around them perceive their gender. As of 2013, Gender Dysphoria has also been a diagnosis in the DSM-5¹.  

The WPATH Standards of Care Version 8² refers to gender dysphoria as a: 

“state of distress or discomfort that may be experienced because a person’s gender… differs from that which is physically and/or socially attributed to their sex assigned at birth” 

These standards differentiate between gender dysphoria and gender incongruence, and stress that not all gender non-conforming people may experience dysphoria. 

“Not all societies, countries, or health care systems require a diagnosis for treatment. However, in some countries these diagnoses may facilitate access to medically necessary health care and can guide further research into effective treatments.”

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included Gender Dysphoria as a mental disorder that appears as a marked incongruence between one’s experience/expressed gender and their presumed gender at birth. While its addition was viewed as a positive step for emphasising an experience of distress rather than a disordered identity, gender dysphoria is not an inherent aspect of being trans and its diagnosis is not a requirement for medical affirmation.

It is important to note that the experience of gender non-conformity or gender dysphoria is not in and of itself a disorder. The WPATH’s Standards of Care 8 states that,  

“While marked and sustained gender incongruence should be present, it is not necessary for TGD people to experience severe levels of distress regarding their gender identity to access gender- affirming treatments. In fact, access to gender-affirming treatment can act as a prophylactic measure to prevent distress.” 

This is in line with the ICD-11 replacing ‘Gender Identity Disorder’ with ‘Gender incongruence’³,⁴, and moving it out of the ‘mental and behavioural disorders’ chapter and into the new ‘conditions related to sexual health’ category, stating that this “reflects evidence that trans-related and gender diverse identities are not conditions of mental ill health, and classifying them as such can cause enormous stigma.” 

Gender incongruence

In 2019, the World Health Assembly of the World Health Organization (WHO) endorsed two new diagnostic codes: Gender Incongruence in Adults and Adolescents3, and Gender Incongruence in Childhood⁴, for the 11th edition of its International Classification of Diseases (ICD-11). Gender Incongruence provides a medical description of the trans experience that does not emphasis distress (as in the case of Gender Dysphoria).

Treatment provided for the distress is described within the diagnostic codes, but this distress is not a universal aspect of the trans experience.    

A diagnosis of gender incongruence is not essential for medical gender affirmation, and the informed consent model can provide a pathway for affirming care that does not require diagnosis.  

If a patient requests gender affirming care from a GP, the informed consent model can provide a means of doing so without the GP needing to assess the gender incongruence of the patient. If a clinician is interested in assessing gender incongruence in order to validate outcomes of care, we recommend scales such as the T-PIM to do so. 

“A diagnosis of gender incongruence may be necessary in some regions to access transition-related care. When a diagnosis is necessary to access GAMSTs, the assessment for GAMSTs will involve determining and assigning a diagnosis. In these instances, HCPs should have competence using the latest International Classification of Diseases and Related Health Problems (ICD) (WHO, 2019a)”. –

“A diagnosis of gender incongruence may be necessary in some regions to access transition-related care. When a diagnosis is necessary to access GAMSTs, the assessment for GAMSTs will involve determining and assigning a diagnosis. In these instances, HCPs should have competence using the latest International Classification of Diseases and Related Health Problems (ICD) (WHO, 2019a)”. – WPATH Standards 8 (2022)

Affirmation/Treatment

Hormones

Diagnosis is not required for the prescription and provision of gender affirming hormones.  

For more information about supporting your trans client to access gender affirming hormones, explore our hormones resource. We highly recommend the use of our GP Management plans for both Masculinising hormones  and Feminising hormones.  

You can find a flowchart outlining the Informed Consent process here, or in the downloads section below. 

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Surgery

While diagnosis is not strictly required for gender affirming surgery, a surgical readiness referral is often required. This must be signed off by one or two mental health professionals with a minimum of experience, according to the requirements of the gender affirming surgeon. The WPATH Standards of Care provide details on readiness referrals and international guidelines for assessing an adults ability to consent to gender affirming surgery.

The Standards of Care also provides guidance for situations where a diagnosis is necessary to access health care. But the authors themselves do not advocate for imposing this requirement. When and why a surgeon would request a diagnosis prior to surgery depends on a number of factors; including their internal policies and whether or not they feel their client is able to provide consent.  

The Standards of Care provide more details on readiness referrals and international guidelines for assessing an adults ability to consent to gender affirming surgery.  

Our interpretation of the gender dysphoria component is as an understanding of patient’s experience of gender incongruence that can be alleviated through gender affirming surgery, and not a requirement of diagnosis of the condition ‘gender dysphoria’. This goes back to the above understanding of gender dysphoria as an experience that some trans people have, and gender incongruence as a medical understanding of trans experiences, including but not exclusive to gender dysphoria.  

Self reporting scales

Scales, when they are wholistic, can be helpful in assessing what a patient may need before they begin medical affirmation and if they are in a position to give informed consent. When using self-reporting scales, it’s important to consider them as part of a balanced understanding of the patient’s experiences, desires and needs, rather than the mechanism by which one’s gender experience can be accepted or rejected.  

Self-reporting scales have a number of strengths, including:  

  • They can be used to quickly and quantifiably assess levels of distress and gender affirming care needs, 
  • Can be a starting point for conversations around patient needs, 
  • They are useful for evaluating care outcomes.  

However, self-reporting scales can also have weaknesses, including:  

  • Being trans is not a condition that requires diagnosis, 
  • Scales that overemphasise incongruence and distress risk pathologizing the trans experience, which is not an inherently medical or medicalised one, 
  • Respondent burden – scales can be time consuming and/or distressing for the patient to complete  

We recommend the 23 question Transgender Positive Identity Measure (T-PIM) scale, which helps to evaluates feelings about identity, and how identity is related to wellbeing and connection to community.   

Other scales include:  

  • The 38 questions in the GCLS scale (Gender Congruence and Life Satisfaction Scale), which helps to evaluate feelings about distress due to gender incongruence. Limitations of this scale include a strong focus on genitals and other sex characteristics, as well as questions relating to self-harm that could cause discomfort for the respondent; 
  • The 18 question Utrecht Gender Dysphoria Scale – Gender Spectrum (UGDS-GS), which aims to assess levels of gender dysphoria can be found within our resources. Limitations of this scale include an emphasis on dysphoria and distress, which are not be relevant, see Dysphoria section above.  

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