Contact us
  1. You are at: Home
  2. News & policy
  3. Policy and advocacy library
  4. Position statements
  5. Mental health needs of people experiencing Gender Dysphoria / Gender Incongruence

Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence

August 2021

Position statement 103

Summary

This position statement developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) provides an overview of Gender Dysphoria and highlights the importance of respecting an individual’s gender identity.

Purpose

This position statement developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) provides an overview of Gender Dysphoria and highlights the importance of respecting an individual’s gender identity. This statement offers insight into the key issues relevant to the mental health needs of people experiencing Gender Dysphoria and guidance is provided on how psychiatrists and mental health services can support individuals constructively. People experiencing Gender Dysphoria may experience a disproportionate level of mental illness and psychological distress. This position statement makes recommendations for enhancing the mental health sector’s responsiveness to these needs.

Key messages

  • Gender Dysphoria is associated with significant distress.
  • There are polarised views and mixed evidence regarding treatment options for people presenting with gender identity concerns, especially children and young people. It is important to understand the different factors, complexities, theories, and research relating to Gender Dysphoria.
  • It is important that there is adequate, person-centred care, for the mental health needs of people experiencing Gender Dysphoria.
  • Psychiatrists play a crucial role in caring for the mental health needs of people experiencing Gender Dysphoria.
  • Psychiatrists should act in a manner which is supportive, ethical, and non-judgmental.
  • Comprehensive assessment is crucial. Assessment and treatment should be evidence-informed, fully explore the patient’s gender identity, the context in which this has arisen, other features of mental illness and a thorough assessment of personal and family history. This should lead to a formulation. The assessment will be always responsive to and supportive of the person’s needs.
  • Psychiatrists must have regard to the relevant laws and professional standards in relation to assessing capacity and obtaining consent, including the RANZCP Code of Ethics.
  • Gender Dysphoria is an emerging field of research and, at present, there is a paucity of evidence. Better evidence in relation to outcomes, especially for children and adolescents is required.

Definition

Gender Dysphoria, as defined in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), refers to marked incongruence between one’s experienced or expressed gender and one’s assigned gender, associated with clinically significant distress or impairment in functioning.[1] Gender Incongruence is defined in the International Classification of Diseases 11th revision (ICD-11) as is ‘a marked and persistent incongruence between an individual's experienced gender and the assigned sex’.[2]

Terminology

The RANZCP acknowledges the importance of using appropriate terminology when discussing issues of sexual, sex and gender identity.[3] Inclusive language engenders respect and promotes visibility for important issues, and this is integral to improving the health of LGBTIQ+ people.[4] The key terminology section below provides an overview of some key terms used in Australia and New Zealand.

It is important to be mindful of the importance of individual terminology preferences when talking about someone’s sexual orientation or gender identity. Using the individual’s preferred terms, especially pronouns, is very important for trans, gender diverse and non-binary people. Healthcare providers should not refer to someone using terms or pronouns that are against the individual’s wishes. For example, an individual may wish to be referred to by the pronouns ‘they and them’ so as to avoid the gendered pronouns ‘she’ and ‘he’, and this should be respected. It is important to also be aware of the rapidity with which language and terminology can change and develop in this area, and to consider additional research or inquiry with relevant organisations as appropriate (please refer to the list of resources below for more information).

Key Terminology

  • Transphobia encompasses a range of negative attitudes and feelings such as hatred, disgust, contempt, prejudice and fear towards people who are gender variant.
  • Trans, or TGD (trans and gender diverse) are commonly used to describe a broad range of non-conforming gender identities or expressions including transgender, agender (having no gender), bigender (identifying as both a woman and a man), or non-binary (neither woman nor man). Some people may describe themselves as MTF/M2F (male-to-female), FTM/F2M (female-to-male), AFAB (assigned female at birth) or AMAB (assigned male at birth). The term genderqueer is used to refer to gender identity that does not conform to sociocultural norms. Gender fluid is used to refer to gender identity which shifts over time.
  • For TGDNB (trans, gender diverse and non-binary) people, preferred pronouns may include ‘he/him’, ‘she/her’, ‘they/them’ or neopronouns like ‘zi/zim’.
  • Some Aboriginal and Torres Strait Islander peoples use the term sistergirl to refer to sex assigned at birth males who live partly or fully as women and brotherboy to refer to sex assigned at birth females who live partly or fully as men.[3]
  • Takatāpui as a self-descriptor is often used by Māori to describe non-binary gender and/or sexual identity. Specific meaning can vary depending on context.[5] There are several Māori words for transgender people, including whakawahine (trans woman) and whakatāne (trans man).[6]
  • In Pacific Island cultures, there are a number of gender-diverse identities including the Samoan fa’afafine and Tongan fakaleiti.[7]

Background

People experiencing Gender Dysphoria should be supported by mental health services to navigate their experience in a constructive way. Gender Dysphoria can emerge in a variety of ways. Each case should be assessed by a mental health professional, which will frequently be a psychiatrist, with the person at the centre of care. It is important the psychological state and context in which Gender Dysphoria has arisen is explored to assess the most appropriate treatment.

The views about whether psychiatric diagnosis is warranted for people who experience incongruence of gender identity are changing.[8] While ‘Gender Dysphoria’ is classified as a mental disorder in DSM-5, ICD-11 classifies the condition ‘Gender Incongruence’ not as a ‘mental, behavioural and neurodevelopmental disorder’ but as a ‘condition related to sexual health’.[1, 2] ICD-11 has undergone significant revisions to ensure that disorders relating to sexuality and gender identity reflect contemporary evidence while appropriately distinguishing between health conditions and private behaviours.[9]

Gender Dysphoria continues to be widely debated across jurisdictions in Australia and New Zealand. The RANZCP has developed this position statement from the perspective of psychiatry.

Supporting people experiencing Gender Dysphoria/Gender Incongruence

There is evidence that people who experience incongruence between their gender identity and assigned gender have higher levels of mental illness than the general population.[10] In a retrospective study, Reisner et al (2015) found higher rates of depression, anxiety, suicidal ideation and self-harm in youth who identified as transgender.[11]

Data suggest that the number of people seeking help for gender identity issues has increased worldwide, with referrals to gender clinics increasing across age groups, including amongst children and adolescents.[12, 13] Clinics seeing young people have also reported an increasing preponderance of sex assigned at birth females among those seeking intervention and a co-occurrence of autism spectrum disorder and Gender Dysphoria.  [14, 15]

Gender Dysphoria emerges in many different ways and is associated with significant distress for those who experience it. However, Gender Incongruence is not in and of itself pathological. There are polarised views and mixed evidence regarding treatment options for people presenting with gender identity concerns, especially children and young people.

The World Professional Association for Transgender Health (WPATH) uses the terminology “real life experience” defining it as “the act of fully adopting a new or evolving gender role or gender presentation in everyday life”.[16] Real life experience allows transgender individuals who wish to permanently change their gender role, to transition from imagined experience to a lived experience. This experience can differ between individuals, for some the experience is liberating, whereas others can experience disappointment due to transition not living up to the desired expectation.[17]  

A major challenge for clinicians working with children and adolescents who present for treatment of Gender Dysphoria is the impact of polarised socio-political discourse on clinical assessment and decision-making. Polarised views can be unhelpful and can make the task of clinicians assisting young people presenting with complex presentations more difficult.[18] Whilst these debates must be acknowledged, the most important goal currently is to ensure that there is adequate care available to meet the mental health needs of people experiencing Gender Dysphoria.

Role of psychiatrists

There are a number of guidelines and resources available which relate to Gender Dysphoria. [19-27] The RANZCP does not preference any specific guidelines. The RANZCP encourages psychiatrists to be aware there are multiple perspectives and views.

There is some evidence to suggest positive psychosocial outcomes for those who are supported in their gender identity.[28] However, evidence and professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate.[24]

A gender affirmative approach endorses the belief system that children should be able to ‘live in the gender that feels most real or comfortable to that child and to express that gender with freedom from restriction, aspersion, or rejection’ therefore the child’s statements regarding their gender identity should not be questioned, but instead accepted.[29] Affirmative approaches may include consideration of the need for medical treatments including gender affirming hormones, gonadotrophin releasing hormone analogues (GnRH) (in children and adolescents) and surgery. Approaches which don’t include medical treatments may focus on utilising psychotherapy to aid individuals with Gender Dysphoria in exploring their gender identity, and aid alleviation of any co-existing mental health concerns identified in screening and assessment.[24] 

The RANZCP endorses practice which supports and validates the identity, strength, and experience of the individual, recognising that all experiences of gender are equally healthy and valuable. In all cases, clinicians have a crucial role in empathetically supporting the individual and family/whānau assertions and lived experiences. The RANZCP acknowledges the dynamic changes in a child or adolescent’s identity and brain development, appreciating the inherent complexities in the clinical care and assessment of the individual.

Mental health professionals should acknowledge the concerns of children, adolescents, and their families whilst not expressing any negative attitudes towards experiences of Gender Dysphoria. Acceptance, and alleviation of secrecy can provide relief to individuals experiencing Gender Dysphoria as well as their families.[24]

Psychiatric assessment and treatment should be both based on available evidence and allow for full exploration of the person’s gender identity.[20] The RANZCP emphasises the importance of the psychiatrist’s role to undertake thorough assessment and evidence-based treatment ideally as part of a multidisciplinary team, especially highlighting co-existing issues which may need addressing and treating. Psychiatric assessment and treatment must also occur in accordance with professional standards, and in a way which is person-centred, responsive to and supportive of the person’s needs. Psychosocial support should be continuously offered and provided to people and their families before, during and after any treatment to maximise positive mental health outcomes.[20] If appropriate, psychiatrists can additionally facilitate the assessment of eligibility, preparation and referral for treatment.[24]

Mental health professionals including psychiatrists should maintain a collaborative and multidisciplinary approach to the treatment of Gender Dysphoria. Psychiatrists should discuss progress and obtain peer consultation from other professionals competent in the assessment and treatment of Gender Dysphoria, within both mental health and other medical disciplines.[24]

Health professionals should also be aware of ethical and medicolegal dilemmas in relation to medical and surgical treatment for people experiencing Gender Dysphoria. Psychiatrists should practise within the relevant laws and accepted professional standards in relation to assessing capacity and obtaining consent, including the RANZCP Code of Ethics.[30] Consent and authorisation for children and adolescents to commence GnRH and gender affirming hormones are subject to specific legislation in Australia and New Zealand. The legal position is rapidly changing, with the implications for policy and practice differing by jurisdiction. It is important that psychiatrists are aware of the policies and practices within the jurisdiction in which they work.

Given the complexity of these issues, it is essential that sufficient information is provided to people (and their family/whānau, or carer where relevant) to enable informed consent.[31] Further, evidence for clinical decisions about whether a child or adolescent is capable and competent to consent to treatment should be clearly recorded. In all cases, the risks and benefits of different treatments must be carefully assessed and balanced by the multidisciplinary team providing care and support to the person experiencing Gender Dysphoria.

Research on Gender Dysphoria is still emerging. At present, there is a paucity of quality evidence on the outcomes of those presenting with Gender Dysphoria. In particular, there is a need for better evidence in relation to outcomes for children and young people.[20] The RANZCP supports further research being undertaken into the long-term effects of medical and surgical affirming treatment in all age groups, including children and adolescents. Findings from the Australian Trans20 longitudinal cohort study and Gender identity Longitudinal Experience (GENTLE) cohort study are expected to improve our understanding.[32, 33] Such research is crucial in ensuring that individuals can safely access evidence-based therapies for Gender Dysphoria/Gender Incongruence as needed.[34, 35]

Recommendations

The RANZCP recommends the following actions to support the mental health needs of people experiencing Gender Dysphoria/Gender Incongruence:

  • Psychiatrists should engage with people experiencing Gender Dysphoria in a way which is person-centred, non-judgmental and cares for their mental health needs.
  • Assessment and treatment should be based on the best available evidence and fully explore the person’s gender identity and the biopsychosocial context from which this has emerged.
  • Health services should take steps to accommodate the needs and ensure the cultural safety of people experiencing Gender Dysphoria/Gender Incongruence.
  • Further research should be supported and funded in relation to wellbeing and quality of life during and after medical and surgical interventions for Gender Dysphoria/Gender Incongruence.

Further reading

Royal Australian and New Zealand College of Psychiatrists Position Statement 83: Recognising and addressing the mental health needs of the LGBTIQ+ population

Responsible committee: Practice, Policy and Partnerships Committee

1.         American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Fifth ed: American Psychiatric Publishing; 2013.

2.         World Health Organisation. International Classification of Diseases 11th Revision (ICD-11). 2020.

3.         Smith E, Jones T, Ward R, Dixon J, Mitchell A, Hillier L. From Blues to Rainbows: The mental health and wellbeing of gender diverse and transgender young people in Australia. Melbourne: Australian Research Centre in Sex Health and Society; 2014.

4.         Australian Human Rights Commission. Resilient Individuals: Sexual Orientation, Gender Identity and Intersex Rights: National Consultation Report2015. Available from: https://humanrights.gov.au/sites/default/files/document/publication/SOGII%20Rights%20Report%202015_Web_Version.pdf.

5.         Henrickson M. Ko wai ratou? Managing multiple identities in lesbian, gay and bisexual New Zealand Maori. New Zealand Sociology. 2006;21(2):247.

6.         Gender Minorities Aotearoa. Trans 101: Glossary of trans words and how to use them 2020 [Available from: https://genderminorities.com/database/glossary-transgender/.

7.         Schmidt J. 'Gender diversity - Fa'afafine', Te Ara - the Encyclopedia of New Zealand 2015 [Available from: https://teara.govt.nz/en/gender-diversity/page-3.

8.         Eden K, Wylie K, Watson E. Gender dysphoria: Recognition and assessment. Advances in psychiatric treatment. 2012;18(1):2-11.

9.         Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, et al. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016;15(3):205-21.

10.       Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one. 2011;6(2):e16885.

11.       Reisner SL, Vetters R, Leclerc M, Zaslow S, Wolfrum S, Shumer D, et al. Mental health of transgender youth in care at an adolescent urban community health center: a matched retrospective cohort study. Journal of Adolescent Health. 2015;56(3):274-9.

12.       Mahfouda S, Moore JK, Siafarikas A, Hewitt T, Ganti U, Lin A, et al. Gender-affirming hormones and surgery in transgender children and adolescents. The Lancet Diabetes & Endocrinology. 2019;7(6):484-98.

13.       Wiepjes CM, Nota NM, de Blok CJ, Klaver M, de Vries AL, Wensing-Kruger SA, et al. The Amsterdam cohort of gender dysphoria study (1972–2015): trends in prevalence, treatment, and regrets. The journal of sexual medicine. 2018;15(4):582-90.

14.       Strang JF, Meagher H, Kenworthy L, de Vries ALC, Menvielle E, Leibowitz S, et al. Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents. Journal of Clinical Child & Adolescent Psychology. 2018;47(1):105-15.

15.       Kaltiala R, Bergman H, Carmichael P, de Graaf NM, Egebjerg Rischel K, Frisén L, et al. Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK. Nord J Psychiatry. 2020;74(1):40-4.

16.       Levine S, Brown G, Coleman E, Cohen-Kettenis P, Hage JJ, Maasdam J, et al. The HBIGDA standards of care for gender identity disorders. Journal of Psychology & Human Sexuality. 1999;11.

17.       Bockting W, Knudson G, Goldberg J. Counseling and Mental Health Care for Transgender Adults and Loved Ones. International Journal of Transgenderism. 2006;9:35-82.

18.       Kozlowska K, McClure G, Chudleigh C, Maguire AM, Gessler D, Scher S, et al. Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems. 2021;1(1):70-95.

19.       Oliphant J, Veale J, Macdonald J, Carroll R, Johnson R, Harte M, et al. Guidelines for Gender Affirming Healthcare for Gender Diverse and Transgender Children, Young People and Adults in Aotearoa, New Zealand. The New Zealand medical journal. 2018;131:86-96.

20.       Royal College of Psychiatrists. Good practice guidelines for the assessment and treatment of adults with gender dysphoria2013. Available from: https://www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/college-reports/cr181-good-practice-guidelines-for-the-assessment-and-treatment-of-adults-with-gender-dysphoria.pdf.

21.       Royal College of Paediatrics and Child Health. Supporting LGBTQ+ children and young people - principle statement 2020 [Available from: https://www.rcpch.ac.uk/resources/supporting-lgbtq-children-young-people#role-and-responsibilities-of-health-professionals.

22.       Telfer M, Tollit M, Pace C, Pang K. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents Version 1.3. Melbourne: The Royal Children's Hospital; 2020.

23.       Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MH, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2017;102(11):3869-903.

24.       World Professional Association for Transgender Health. Standards of Care for the Health of Transexual, Transgender, and Gender Nonconforming People 2011 [Available from: https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf.

25.       Bhugra D, Eckstrand K, Levounis P, Kar A, Javate KR. WPA Position Statement on Gender Identity and Same-Sex Orientation, Attraction and Behaviours. World psychiatry : official journal of the World Psychiatric Association (WPA). 2016;15(3):299-300.

26.       American Psychiatric Association. Position Statement on Access to Care for Transgender and Gender Diverse Individuals. 2018.

27.       Dahlen S, Connolly D, Arif I, Junejo MH, Bewley S, Meads C. International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment. BMJ Open. 2021;11(4):e048943.

28.       Olson KR, Durwood L, DeMeules M, McLaughlin KA. Mental health of transgender children who are supported in their identities. Pediatrics. 2016;137(3).

29.       Hidalgo M, Ehrensaft D, Tishelman A, et al. The gender affirmative model: what we know and what we aim to learn. Hum Dev 2013; 56(5): 285–290. 

30.       Royal Australian and New Zealand College of Psychiatrists. Code of Ethics 2018 [Available from: https://www.ranzcp.org/files/about_us/code-of-ethics.aspx.

31.       Bell-v-Tavistock Judgment, (2020).

32.       Telethon Kids Institute. GENTLE: The GENder identiTy Longitudinal Experience 2021 [Available from: https://www.telethonkids.org.au/projects/gentle-the-gender-identity-longitudinal-experience/.

33.       Tollit MA, Pace CC, Telfer M, Hoq M, Bryson J, Fulkoski N, et al. What are the health outcomes of trans and gender diverse young people in Australia? Study protocol for the Trans20 longitudinal cohort study. BMJ open. 2019;9(11).

34.       NICE. Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria England: NICE; 2020 [Available from: https://www.evidence.nhs.uk/document?id=2334889&returnUrl=search%3Fq%3Dgender%2Bdysphoria.

35.       Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria: NICE; 2021 [updated 11 March 2021. Available from: https://www.evidence.nhs.uk/document?id=2334888&returnUrl=search%3Fq%3Dtransgender%26s%3DDate.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.