Gender Dysphoria

Distress arising from an incongruence between a person’s experienced/expressed gender and their sex assigned at birth. Being transgender or gender-diverse is not itself a mental illness — the DSM-5 diagnosis specifically requires clinically significant distress or impairment associated with the incongruence, not merely the incongruence itself (a deliberate shift from the older, more pathologising “gender identity disorder” terminology).

Presentation

Can present at any age. In children, presentation is often via a parent’s concern about persistent, consistent, and insistent cross-gender identification/behaviour — most childhood gender-diverse expression does not persist into adolescence/ adulthood, so a cautious, exploratory (not presumptive) approach is appropriate at this age. In adolescents and adults, presentation is more predictive of a persistent transgender identity.

GP role: provide a safe, non-judgemental, affirming space; screen for and manage the significantly elevated rates of depression, anxiety, self-harm, and suicidality seen in transgender and gender-diverse people (largely attributable to minority stress, discrimination, and lack of access to affirming care, not to being transgender itself); and coordinate/refer for gender-affirming care where wanted.

Assessment and referral

• Take a thorough history of gender identity development, current distress, and goals — not every gender-diverse person wants or needs medical intervention.
• Screen for coexisting mental health conditions and treat these on their own merits — don’t assume all distress is attributable to gender dysphoria, and conversely, don’t delay gender-affirming care pending resolution of comorbid conditions unless they specifically impair informed decision-making.
• GAHT for adults is frequently initiated by specialist gender clinics or upskilled general practitioners (GPs), endocrinologists and sexual health physicians. Refer if you are not set up to do it; either way, GPs provide the long-term care.
• For children and adolescents specifically, refer to a specialised paediatric gender service — decisions here (e.g. puberty blockers, hormone therapy) involve complex, evolving clinical and ethical considerations and should not be managed in isolation in general practice.

Gender-affirming hormone therapy

• Trans feminine (assigned male at birth) — oestrogen ± an anti-androgen (e.g. spironolactone, cyproterone).
• Trans masculine (assigned female at birth) — testosterone.
• Puberty blockers (GnRH agonists) can be used in early puberty to pause physical development, giving time for further exploration before an adolescent reaches an age/stage for a more definitive decision — a specialist paediatric gender-service decision.

Standard Australian regimens:

Agent	Usual dose
Estradiol valerate or hemihydrate, oral	2–8 mg daily
Estradiol patch	50–200 mcg/24 hours, changed twice weekly
Spironolactone	50–200 mg daily
Cyproterone acetate	12.5 mg weekly to 25 mg daily
Testosterone undecanoate IM	1000 mg every 10–14 weeks (loading dose at 6 weeks)
Testosterone enanthate IM	250 mg every 2–4 weeks
Testosterone 1% gel	50 mg daily

Monitoring targets

• Monitoring requirements (hormone levels, metabolic/cardiovascular risk factors, bone density where relevant) are agent-specific — see eTG/AMH and the prescriber’s monitoring plan.
• Estradiol-based GAHT: In Australia, typical target ranges for serum estradiol and total testosterone concentrations are 250 to 600–1000 pmol/L and <2 nmol/L, respectively. Time the blood test against the last dose.
• Spironolactone may not lower serum testosterone, because it blocks the androgen receptor rather than suppressing production.
• Testosterone-based GAHT: For individuals treated with intramuscular testosterone undecanoate, the general aim is trough testosterone concentration 10–15 nmol/L, whereas for people treated with transdermal testosterone, serum testosterone concentrations should fall within the cisgender male reference range (approximately 10–30 nmol/L).
• Polycythaemia is a well-documented risk on testosterone, higher with IM than transdermal. Define it on the male reference range, or haematocrit >0.50.
• Some people want lower doses for slower or partial changes. Titrate to their goals.

Reading blood results

The reference range of the affirmed gender should be used for tests with sex-specific reference ranges after 3 months GAHT. That applies to:

• haemoglobin, haematocrit and red cell count
• creatinine and eGFR — female CKD-EPI on estradiol, male CKD-EPI on testosterone
• liver enzymes (the shift is usually not clinically significant).

Exceptions and cautions:

• Troponin and BNP shift toward the affirmed gender, but there isn’t enough data for a set range. Follow the trend.
• PSA on estradiol-based GAHT runs much lower than in cisgender men. There is no validated cutoff, so act on a rising trend even below the lab cut-off.
• People on low-dose GAHT, or recently started, may sit between the two ranges. People not on GAHT use the range for their sex recorded at birth.

The clinician should specify the desired sex-specific reference range on the laboratory request, particularly in those with a discordant gender marker.

Ongoing GP care

• Most TGD people, especially those on GAHT, will be eligible for a GP chronic condition management plan (GPCCMP). Health assessments (701, 715) and the heart health check (699) also apply.
• Use the patient’s correct name and pronouns consistently, including in clinical records and referrals where the system allows it.

Cardiovascular risk

Feminising GAHT roughly doubles VTE risk compared with cisgender men. The Australian CVD risk calculator recommends using sex presumed at birth. In trans women on GAHT that may still underestimate risk. Treat BP, lipids and smoking as usual.

Lipids shift with GAHT. Masculinising GAHT tends to elevate non-HDL cholesterol, lower HDL cholesterol and increase triglycerides. Feminising GAHT does the reverse.

Contraception and fertility

• Testosterone is teratogenic and should not be relied on as contraception. About a third of amenorrhoeic trans men on testosterone still ovulate.
• Feminising GAHT tends to suppress spermatogenesis, but it is not considered adequate contraception alone.
• Be aware of relevant fertility-preservation counselling before starting hormone therapy, since it can affect fertility. Revisit fertility plans over time.

Sexual health

STI and BBV screening should be offered to all sexually active TGD people. Choose the sample by the organs present. People with a neovagina should be offered first-pass urine collection for this indication. Offer hepatitis A, hepatitis B, mpox and HPV vaccination and HIV PrEP where at risk.

Bone health

Bone density on GAHT will generally be stable or improve. Baseline bone mineral densitometry may be considered if there has been prolonged hypogonadism (>1 year). That includes time on GAHT with inadequate hormone levels. For feminising GAHT, serum oestradiol ≥180 pmol/L is considered bone-protective.

Cancer screening

Screen by the organs and tissues the person has, using the usual national program rules.

• Cervix: offer cervical screening at 25–74 as usual. Only 38.9% of eligible TGD peoples in Australia have been screened for cervical cancer. Offer self-collection, the smallest speculum or self-insertion.
• Breast: trans men and non-binary people assigned female at birth without chest surgery screen as usual. For trans women, most states recommend 2-yearly mammography at 50–74 after at least 5 years on GAHT. WA does not.
• Prostate: trans women keep their prostate even after genital surgery. Offer PSA testing as for cisgender men, but expect a low baseline on GAHT.
• Bowel and lung: no change from the national programs.

Transgender women taking cyproterone have a four times higher incidence of meningioma when compared with cisgender women. There’s no screening, but watch for visual field changes, headache and galactorrhoea (prolactinoma is also more common).