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. 

What is informed consent? 

The informed consent model (also known as ‘Affirmation Enablement’) offers a framework that supports GPs to commence and manage gender affirming hormonal therapy, and is not fundamentally different to the consent procedures that GPs conduct around any other form of care. Learn more about the informed consent model here. 

Does it require a diagnosis? 

No. Informed consent allows patients to make choices around their bodies and enables patient led care. A diagnosis centric model frames trans people seeking affirmation as being ill or unhealthy and requiring intervention, rather than active participants in the gender-affirming process. For further discussions of why and how the requirement of diagnosis is no longer considered best practice, see the Diagnoses section below. 

How do I ensure my client is capable of giving informed consent? 

Instead of assessing whether a patient ‘needs’ gender affirmation via diagnosis, informed consent involves a doctor providing information that enables a person to make an informed decision regarding potential affirming medical treatment. As part of informed consent, an individual must understand the risks and benefits of the intervention, and how this may affect any existing medical or mental health care needs. 

Medical affirmation can be difficult to begin and it is important to ensure that your client is in a safe position, particularly in regards to protective factors like mental health support, stable housing and social support. These needs can be assessed in discussion with the patient or via self-reporting scales that emphasis wholistic healthcare, such as the ones below. 

While ensuring a patient is supported and safe is a vital aspect of care, clinicians should be cautious of gatekeeping and not introduce any unnecessary steps prior to providing affirming care.  

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 72 refers to gender dysphoria as the 

 discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). 

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

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. Read more about gender dysphoria as experienced by some trans people here, and read more about the evolution of gender diagnoses here.   

It is important to note that the experience of gender non-conformity or gender dysphoria is not in and of itself a disorder, as discussed in the WPATH SoC 7: 

transsexual, transgender, and gender nonconforming individuals are not inherently disordered. Rather, the distress of gender dysphoria, when present, is the concern that might be diagnosable and for which various treatment options are available. The existence of a diagnosis for such dysphoria often facilitates access to health care and can guide further research into effective treatments. 

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 codes, but this distress is not a universal aspect of the trans experience.  

You can read the whole entries for the codes here. 

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.

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, visit our hormones page here. We highly recommend the use of a management plan such as our Masculinising hormones GP management plan or Feminising hormones GP management plan. 

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

While diagnosis is not strictly required for gender affirming surgery, a surgical readiness referral is still 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. You can read more about surgical readiness referrals here. 

The WPATH Standards of Care V7 include the need for “documentation of persistent gender dysphoria by a qualified mental health professional.” They also read “For some surgeries, additional criteria include preparation and treatment consisting of feminizing/ masculinizing hormone therapy and one year of continuous living in a gender role that is congruent with one’s gender identity.” 

It’s important to understand that the Standards of Care outline a set of best practice guidelines for gender affirming care as of 2012. 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. 

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, and can be found here.  

Other scales include: 

• The 38 question GCLS scale (Gender Congruence and Life Satisfaction Scale), which helps to evaluate feelings about distress due to gender incongruence, and can be found here. 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 here. Limitations of this scale include an emphasis on dysphoria and distress, which are not be relevant, see Dysphoria section above. 

All of these scales can also be found on the Clinicians Downloads page here.