How to diagnose gender dysphoria. 

how do I know if my patient is transgender?

In my practice I work with many medical students and residents who we train in part to provide gender affirming care. I frequently speak with colleagues who know I have a transgender-inclusive family practice and field many of their questions. One of the most common being, how do I know if my patient is transgender?

ask the patient  

My approach is to ask the patient about their experiences and their journey regarding their gender. I listen and ask questions to help them expand on their answers in order to understand the broader narrative of their experience. I’m listening while considering the DSM-V criteria for gender dysphoria and making note of events, ideas or statements that affirm the diagnosis. 

The American Psychiatric Association permits a diagnosis of gender dysphoria in adolescents or adults if two or more of the following criteria are experienced for at least six months’ duration: A strong desire to be of a gender other than one’s assigned gender A strong desire to be treated as a gender other than one’s assigned gender A significant incongruence between one’s experienced or expressed gender and one’s sexual characteristics A strong desire for the sexual characteristics of a gender other than one’s assigned gender A strong desire to be rid of one’s sexual characteristics due to incongruence with one’s experienced or expressed gender A strong conviction that one has the typical reactions and feelings of a gender other than one’s assigned gender In addition, the condition must be associated with clinically significant distress or impairment.

nervous about gender pronouns

 The pitfalls I see trainees getting into are common. They get nervous about gender pronouns and hung up on acronyms like AMAB/AFAB (assigned male or female at birth). I remind them that there is no predetermined, linear story around gender transition. The medical approach historically did privilege the gender binary and the experience of patients who identified as one sex wanting to be the other and, thus, only provided care to those who were seeking hormones and surgeries to fully treat this condition. 

 

Fortunately our thinking has evolved significantly, and patients’ gender journeys no longer need to fit certain old-school medical parameters. They don’t need to have had experiences of dysphoria their entire lives, perhaps only for the past six months. As with other diagnoses in the DSM-V, we look to the diagnostic criteria for guidance. And we are not the judges of the truth or veracity of our patients’ statements; we are the recorders of information and not the judges of it.

 

In almost all cases, gender dysphoria is the clear diagnosis. Where there is concurrent mental illness, usually psychosis or schizophrenia, I take more time to assess and unpack the gender journey from the mental health presentation, and perhaps involve psychiatry consultation. Even in these cases we still treat gender dysphoria when criteria are met because the evidence is clear that treating gender dysphoria improves mental health, so why wouldn’t we treat it?

 

So, to summarize:

• Listen to you patient’s gender journey and consider in the context of the DSM-V criteria
• Doctors aren’t the judges of truth; take your patients at their word
• It’s more straightforward than you think it is

Anxious about helping a transgender patient? Tweet me @DrMarcusG or send me an email.