denotes the clinically significant distress that can accompany an incongruence between a person's experienced gender and their sex assigned at birth. The diagnosis is codified in with separate criteria sets for children and for adolescents and adults, and parallels — though does not equate to — the construct of , which sits outside the mental-disorders chapter. Prevalence estimates have risen sharply over the past decade, particularly among adolescents, and the clinical population has shifted in age and sex ratio in ways that remain incompletely explained. Care is multidisciplinary: psychological assessment, , and, where indicated, pubertal suppression, gender-affirming hormones, and surgery. The evidence base supporting gender-affirming medical care is largely observational, with substantial heterogeneity in outcomes and an active international debate about thresholds for intervention in minors. The clinical bottom line is that the diagnosis names distress, not identity, and treatment is aimed at relieving that distress through a combination of psychosocial and, when appropriate, medical interventions tailored to developmental stage and individual goals.
Prevalence figures depend heavily on case definition — self-identification, clinic-referred diagnosis, or documented dysphoria — and have climbed substantially in the past fifteen years, especially in adolescents.
Prevalence
- Adult self-identified transgender prevalence in U.S. population surveys is approximately 0.5-0.6%, with higher rates (about 1.4%) reported among adolescents aged 13-17.[1]
- Clinic-referred and adolescents has increased severalfold across European and North American specialty services since the early 2010s.[2-3]
- Birth-assigned-sex ratios at gender clinics have shifted: historically more birth-assigned-male referrals in childhood, but more recent adolescent cohorts show a predominance of birth-assigned-female referrals.[2-3]
Age of onset
- Two broad developmental trajectories are described — early-onset (childhood, often persisting through puberty) and adolescent- or adult-onset, which may emerge after puberty without a clear childhood history.[4]
- Most prepubertal children with gender-variant behavior do not continue to meet criteria for gender dysphoria into adolescence, though follow-up studies have methodological limitations and may not generalize to recent cohorts.[4-5]
Comorbidity
- Depression, , and suicidal ideation are markedly more prevalent in transgender and gender-diverse populations than in matched cisgender peers.[6-7]
- Autism spectrum diagnoses and traits are over-represented among adolescents presenting to gender clinics, with reported rates ranging from 5% to over 25% depending on screening method.[8]
- Eating disorders, self-harm, and trauma histories are also more common; minority stress is a leading explanatory framework but does not exclude bidirectional contributions.[6-7]
Risk factors
- Family rejection, school-based victimization, and lack of social support strongly predict psychiatric morbidity in transgender youth and adults.[6-7]
- Access to gender-affirming care, when desired, is associated in observational data with reduced depression and suicidality, though randomized data are lacking.[9-10]
The biology of gender identity is incompletely understood. Current models integrate neurodevelopmental, genetic, and prenatal hormonal contributions with psychosocial factors, while acknowledging that no single mechanism explains the phenotype.
Neurobiology
- Postmortem and neuroimaging studies have reported sex-atypical patterns in some brain regions of transgender individuals — including the bed nucleus of the stria terminalis and aspects of cortical structure — but findings are heterogeneous and limited by small samples and confounding by exogenous hormones.[11]
- No reliable neuroimaging biomarker exists for clinical diagnosis.[11]
Genetics
- Twin studies suggest a moderate heritable component to gender identity and gender dysphoria, with monozygotic concordance higher than dizygotic, though estimates vary widely.[12]
- Candidate-gene work has implicated androgen-receptor and estrogen-receptor polymorphisms, but no replicated -level findings have established causal loci.[12]
Prenatal hormonal exposure
- The prenatal androgen hypothesis posits that atypical fetal androgen exposure influences later gender identity; supporting evidence comes from elevated rates of gender dysphoria in 46,XX individuals with and from anatomic and behavioral studies in 5-alpha-reductase deficiency.[13]
- These data inform mechanism but do not translate into clinical prediction at the individual level.[13]
Psychosocial and developmental factors
- Minority stress models attribute much of the psychiatric morbidity in transgender populations to chronic stigma, discrimination, and identity concealment rather than to gender identity itself.[14]
- For adolescent-onset presentations, the relative contributions of biology, social environment, peer influence, and underlying neurodevelopmental conditions remain actively debated and are not resolved by current evidence.[3,15]
Integrative model
- A multifactorial framework — biological predisposition shaped by prenatal hormonal milieu and genetics, interacting with developmental and social context — is the prevailing clinical synthesis.[11-12]
DSM-5-TR places gender dysphoria in its own chapter, separate from sexual dysfunctions and paraphilic disorders, with distinct criteria for children and for adolescents and adults. The diagnosis requires both incongruence and clinically significant distress or impairment; gender variance alone is not pathologized.[16]
Adolescents and adults (Criterion A — at least two of six, for at least 6 months):
- Marked incongruence between experienced gender and primary or secondary sex characteristics.[16]
- Strong desire to be rid of one's primary or secondary sex characteristics because of this incongruence.[16]
- Strong desire for the primary or secondary sex characteristics of the other gender.[16]
- Strong desire to be of the other gender (or some alternative gender).[16]
- Strong desire to be treated as the other gender.[16]
- Strong conviction of having the typical feelings and reactions of the other gender.[16]
Children (Criterion A — at least six of eight, including the first, for at least 6 months):
- Strong desire to be of the other gender or insistence that one is the other gender (required).[16]
- Strong preference for cross-dressing or simulating female or male attire.[16]
- Strong preference for cross-gender roles in make-believe play or fantasy.[16]
- Strong preference for toys, games, or activities stereotypically used by the other gender.[16]
- Strong preference for playmates of the other gender.[16]
- Strong rejection of toys, games, and activities typical of one's assigned gender.[16]
- Strong dislike of one's sexual anatomy.[16]
- Strong desire for the primary or secondary sex characteristics matching one's experienced gender.[16]
Criterion B (both age groups)
- Clinically significant distress or impairment in social, school, occupational, or other important areas of functioning.[16]
Specifiers
- With a disorder of sex development (DSD), when applicable.[16]
- Post-transition, used when the individual has transitioned to living full-time in the desired gender and has undergone — or is preparing for — at least one cross-sex medical procedure.[16]
ICD-11 placement
- ICD-11 replaced the ICD-10 diagnosis of transsexualism with Gender incongruence and moved it from the mental and behavioral disorders chapter to a new chapter on conditions related to sexual health, explicitly to reduce stigma while preserving access to care.[17]
- ICD-11 gender incongruence does not require clinically significant distress, distinguishing it from the DSM-5-TR construct of gender dysphoria.[17]
ICD-11 gender incongruence is no longer classified as a mental disorder. The DSM-5-TR retains gender dysphoria as a diagnosis specifically because distress, not identity, is the clinical target.[16-17]
Presentations vary by developmental stage, cultural context, and individual goals. The unifying feature is sustained incongruence accompanied by distress; the surface manifestations differ widely.
Childhood presentation
- Insistent verbal assertion of being the other gender, persistent cross-gender play and clothing preferences, and distress about one's anatomy, particularly around puberty.[16]
- A substantial proportion of children with gender-variant behavior do not continue to identify as transgender in adolescence, with some emerging as gay or bisexual cisgender individuals; persistence rates in older cohorts range from roughly 10% to 40% but methodology and recent cohort generalizability are contested.[4-5]
Adolescent presentation
- Escalating distress with the onset of secondary sex characteristics is a hallmark; breast development, menses, deepening voice, and facial hair are common precipitants of clinical presentation.[16]
- A subset of adolescents present without a documented childhood history of gender variance, often in the context of significant psychiatric comorbidity; this cohort has been the focus of recent diagnostic and treatment debates.[3,15]
Adult presentation
- May reflect long-standing identity that the individual concealed earlier in life, or may have emerged or crystallized in adolescence or adulthood.[16]
- Distress is often anchored to specific sex characteristics or to social role and documentation rather than to a generalized sense of dysphoria.[16]
Course features
- Social transition — change of name, pronouns, clothing, and presentation — frequently precedes any medical intervention and is reversible.[18]
- Distress may shift across the lifespan; some individuals stabilize with social transition alone, others require medical interventions, and a small minority report changes in identification over time.[15]
Red flags requiring careful evaluation
- Acute-onset distress in the context of recent trauma, severe untreated psychiatric illness, or active psychosis warrants stabilization and broader assessment before gender-specific interventions.[15]
- Coexisting eating disorders that involve denial of secondary sex characteristics require integrated management.[15]
The differential is shaped by the requirement for sustained, identity-based incongruence accompanied by distress. Several conditions can superficially resemble gender dysphoria but lack one or both core features.
Non-conformity without dysphoria
- Gender-nonconforming behavior, dress, or interests in the absence of distress or identity incongruence is not gender dysphoria; this is the most common false-positive in primary care.[16]
Body dysmorphic disorder
- Distress is focused on perceived defects of appearance unrelated to gender identity; the desired change is corrective rather than gender-affirming.[16]
Transvestic disorder
- Sexual arousal associated with cross-dressing distinguishes this paraphilic disorder; gender identity is typically congruent with assigned sex.[16]
Psychotic disorders
- Delusions about one's sex (e.g. as part of a broader delusional system in ) lack the consistency, developmental coherence, and identity quality of gender dysphoria; resolution typically follows treatment of the underlying psychosis.[16]
Autism spectrum disorder
- Cross-gender interests and rigid identity statements in autistic youth require careful longitudinal evaluation, as the two conditions can co-occur and complicate assessment of stability of identity over time.[8]
Disorders of sex development
- Individuals with intersex conditions may experience gender dysphoria; DSM-5-TR includes a specifier for this context.[16]
Medical mimics and contributors
- Endocrinopathies (e.g. virilizing tumors, congenital adrenal hyperplasia), exogenous hormone exposure, and severe depression with somatic preoccupation should be excluded when the clinical picture is atypical.[19]
Assessment is longitudinal, multidisciplinary, and developmentally tailored. The goal is to characterize the nature, duration, and stability of gender incongruence and distress, identify comorbidities, and align next steps with the patient's goals and developmental stage.[20]
Core interview elements
- Onset, developmental course, and stability of gender identity and dysphoria, including childhood history and pubertal experience.[20]
- Specific sources of distress (body, social role, documentation) and the patient's goals for change.[20]
- Sexual orientation and sexual function — distinct from gender identity but clinically relevant.[20]
- Family, school, occupational, and cultural context, including supports and stressors.[20]
- Prior interventions (social transition, hormones, surgeries) and their effects.[20]
Mandatory psychiatric history
- Mood, anxiety, trauma, suicidality, self-harm, eating pathology, substance use, and psychotic symptoms.[20]
- Screen for autism spectrum traits and intellectual functioning when capacity for informed decision-making is in question.[8,20]
Physical examination
- Pubertal staging in adolescents using Tanner criteria when medical intervention is contemplated.[20]
- Baseline cardiometabolic assessment and examination relevant to planned hormonal or surgical interventions.[20]
Validated instruments
- The and its revised version are commonly used measures of dysphoria severity; the is also used in research and specialty settings.[21]
- General measures (, , ) are used to track comorbidity and risk.[20]
Laboratory and imaging
- Baseline labs before hormone therapy typically include CBC, comprehensive metabolic panel, lipid panel, hemoglobin A1c, prolactin, and sex hormone panel; karyotype and imaging are reserved for atypical presentations or suspected DSD.[19,22]
- Bone density assessment (DXA) is considered when prolonged pubertal suppression is anticipated.[22]
What not to order
- Routine neuroimaging, genetic panels, or psychological testing batteries to confirm or refute a gender identity are not indicated; identity is established by clinical history, not by biomarker.[11,20]
GENDER
Goals of the patient; Endorsement of incongruence; Natural history (onset, course); Distress and functional impact; Examination and labs; Risks, comorbidities, and supports — a structured framework for the initial gender-dysphoria assessment.
Treatment is individualized, staged, and reversible-to-irreversible in sequence: psychosocial support and social transition first, then — when clinically appropriate — pubertal suppression in adolescents, gender-affirming hormones, and surgical interventions. Guidelines from the World Professional Association for Transgender Health (WPATH SOC-8) and the Endocrine Society anchor most international practice, while several European health authorities have moved toward more cautious thresholds for adolescent medical intervention since 2020.[18,22-23]
Psychotherapy
- Supportive, exploratory, and developmentally informed psychotherapy is recommended to clarify goals, address comorbidities, and support decision-making; evidence is largely observational.[18]
- Family-based work for children and adolescents addresses parental understanding, conflict, and support.[18]
- Conversion or reparative interventions aimed at changing gender identity are not recommended and are considered harmful by major professional bodies.[18,24]
Pharmacotherapy
- Gonadotropin-releasing hormone analogues (e.g. leuprolide 11.25 mg IM q12 weeks) suppress endogenous puberty and are used in early-pubertal adolescents (Tanner stage 2 or later) to allow time for evaluation before considering irreversible interventions.[22]
- Feminizing hormone therapy typically combines an estrogen — often estradiol 2-6 mg PO QD or transdermal — with an antiandrogen such as spironolactone 100-200 mg PO QD; goals are breast development, fat redistribution, and reduced androgenic features.[22]
- Masculinizing therapy uses testosterone, e.g. testosterone cypionate 50-100 mg IM q1week, titrated to physiologic male range; effects include voice deepening, facial and body hair, fat redistribution, and amenorrhea.[22]
- Treatment of comorbid depression, anxiety, and other psychiatric conditions follows standard practice and should not be deferred pending gender-related care.[20]
Pubertal suppression beyond a brief window has potential adverse effects on bone density and possibly on neurocognitive development; durations, dosing, and monitoring should follow current endocrine guidelines.[22-23]
Neuromodulation
- Neuromodulation has no established role in the treatment of gender dysphoria itself; it remains reserved for comorbid or other indications.[20]
Surgical (adjunctive)
- Gender-affirming surgeries include chest reconstruction (mastectomy or breast augmentation), genital surgeries (vaginoplasty, phalloplasty, metoidioplasty), facial feminization, and voice surgery; eligibility criteria vary by guideline and procedure.[18,22]
- WPATH SOC-8 removed previously required minimum durations of hormone therapy or social transition for many adult surgeries, replacing them with individualized readiness assessment.[18]
Adjunctive
- Voice and communication therapy, hair removal, fertility preservation counseling before gonadotoxic interventions, and legal documentation support are commonly integrated into care.[18]
- Peer support and community engagement are associated with improved psychosocial outcomes in observational studies.[14]
Fertility preservation counseling should occur before initiation of pubertal suppression or gender-affirming hormones, as both can impair future fertility.[22]
| Intervention | Evidence base/Comparator | Benefits | Harms | Certainty | Notes |
|---|---|---|---|---|---|
| Social transition | Observational cohorts; no RCTs | Reduced distress and depressive symptoms in some cohorts | Reversible; minimal direct medical risk | low | Most consistent benefit signal in young children and adolescents |
| Pubertal suppression () | Prospective cohorts, mostly Dutch protocol | Delays distressing puberty; allows time for assessment | Bone density effects; uncertain long-term neurocognitive and fertility effects | low | Recent European reviews call for more cautious use in adolescents |
| Gender-affirming hormones (adults) | Observational cohorts and registry data | Improvement in body satisfaction, depression, and quality of life in most studies | Cardiometabolic, thromboembolic, and fertility effects; specific risks vary by regimen | low to moderate | Long-term safety data accumulating but heterogeneous |
| Gender-affirming hormones (adolescents) | Limited prospective cohorts | Reduced dysphoria in short-term studies | Same as adults plus growth and bone considerations; long-term data sparse | very_low to low | Subject of active international policy debate |
| Gender-affirming surgery | Case series and observational cohorts | High patient-reported satisfaction; low regret in most series | Surgical complications; rare but documented regret | low | Regret rates in recent series under 1-2%, with caveats on follow-up |
| Psychotherapy (supportive/exploratory) | Expert consensus, small studies | Supports decision-making and addresses comorbidity | Minimal when non-coercive | expert_opinion | Conversion approaches contraindicated |
Harms are best understood by intervention. The largest gap is durable, comparative outcome data with adequate follow-up.
Common adverse effects
- Estrogen-based regimens: thromboembolism, hypertriglyceridemia, hyperprolactinemia, breast tenderness, and erectile dysfunction.[22]
- Testosterone: erythrocytosis, acne, androgenic alopecia, lipid changes, and vaginal atrophy with possible dyspareunia.[22]
- Pubertal suppression: hot flashes, mood changes, reduced bone mineral accrual during use.[22]
Serious or rare adverse effects
- Venous thromboembolism risk is elevated with oral ethinyl estradiol relative to transdermal estradiol and is a primary reason ethinyl estradiol is not used in gender-affirming care.[22]
- Potential long-term effects of adolescent pubertal suppression on bone density, fertility, and neurocognition remain incompletely characterized.[22-23]
- Surgical complications include wound healing problems, urethral strictures and fistulae after genital surgery, and reoperation in a meaningful minority of cases.[18]
- Regret leading to detransition is uncommon in long-term cohorts, but recent shifts in the clinical population mean older regret estimates may not generalize.[15,18]
Monitoring and discontinuation
- Hormone monitoring typically includes hormone levels, hematocrit (testosterone), lipids, glucose, prolactin (estrogen), and blood pressure on a structured schedule.[22]
- Abrupt discontinuation can cause vasomotor symptoms and mood instability; tapering and shared decision-making are standard.[22]
Evidence base limitations
- Most outcome data are from observational cohorts, often without comparator groups; randomized trials are scarce and ethically constrained.[15,23]
- Follow-up is typically short relative to the chronicity of the condition, particularly for adolescent cohorts initiated on medical interventions in the past decade.[23]
- Loss to follow-up and selection bias affect both benefit and regret estimates.[15,23]
Care varies considerably by developmental stage, comorbidity profile, and context.
Children
- Management is psychosocial and family-based; medical interventions are not used prepubertally.[18]
- Social transition is a clinical decision made with family involvement; it is reversible but not without psychological weight.[18]
Adolescents
- Pubertal suppression and gender-affirming hormones are used selectively, with multidisciplinary assessment and parental involvement where appropriate.[22]
- Several national reviews (UK Cass Review, Sweden, Finland, Norway) have recommended more restrictive thresholds and prioritization of psychological support for adolescent presentations since 2020.[23]
Older adults
- Gender-affirming care is feasible in older adults; cardiovascular and oncologic risk assessment shapes regimen choice.[22]
Pregnancy and lactation
- Testosterone is teratogenic; contraception or treatment interruption is required for individuals with intact reproductive anatomy who can become pregnant.[22]
- Some transgender men carry pregnancies after stopping testosterone; care is best coordinated with obstetrics.[22]
Comorbid autism spectrum disorder
- Higher prevalence requires careful assessment of stability of identity, capacity for informed consent, and coordinated supports; co-occurrence is not a contraindication to care but warrants longer evaluation.[8]
Comorbid psychotic illness
- Stabilization of psychosis is needed before attributing gender-related content to enduring identity; persistence after remission supports a genuine gender dysphoria diagnosis.[16]
Cultural considerations
Outcomes depend on developmental stage at presentation, comorbidity, social support, and access to desired interventions.
Persistence and desistence
- Childhood gender dysphoria does not reliably persist into adolescence; older studies report desistence in a majority, though methodology and cohort generalizability are debated.[4-5]
- Adolescent and adult-onset dysphoria appears more stable in the medium term, with most individuals continuing to identify as transgender in follow-up cohorts.[15]
Response to intervention
- Most adult observational cohorts report improvement in dysphoria, quality of life, and depressive symptoms after hormonal or surgical intervention; effect sizes are modest to moderate and heterogeneous.[9-10]
- Regret leading to surgical reversal is uncommon in long-term cohorts (typically under 2%), though contemporary detransition rates in younger cohorts are not yet well established.[15,18]
Suicide and mortality
- Suicidal ideation and attempts are markedly elevated in transgender populations relative to cisgender peers; completed suicide rates remain elevated even after gender-affirming care in some registry studies, particularly in those with persistent psychiatric comorbidity.[6-7]
- Cardiovascular and cancer mortality patterns in long-term hormone-treated cohorts are an active area of registry-based research.[22]
Functional outcome
- Employment, housing stability, and educational attainment are strongly influenced by family acceptance, legal recognition, and access to non-discriminatory healthcare.[14]
Acute presentations in transgender patients often involve the intersection of dysphoria, comorbid psychiatric illness, and minority stress; assessment principles mirror general psychiatric emergency care, with several specific considerations.
Suicide risk assessment
- Elevated baseline risk in transgender populations warrants systematic suicide assessment with attention to access to means, recent stressors (family rejection, school or workplace conflict, legal events), and protective factors.[6-7]
- Acute risk markers include recent suicide attempt, severe hopelessness, and active substance use; these guide level of care decisions as in general practice.[20]
Hospitalization criteria
- Standard criteria apply: acute suicidality, danger to others, inability to care for self, severe psychiatric decompensation.[20]
- Inpatient placement decisions should consider safety with respect to gender identity, including room and bathroom arrangements and use of chosen name and pronouns.[18]
Agitation management
- Standard pharmacologic management applies; lorazepam 2 mg IM and haloperidol 5 mg IM are commonly used for severe agitation, with adjustments for comorbidities and current medications.[20]
Discontinuation emergencies
- Abrupt discontinuation of gender-affirming hormones can precipitate vasomotor symptoms, mood instability, and worsening dysphoria; continuity of hormone therapy during hospitalization is best practice when medically feasible.[22]
Misgendering, deadnaming, or forced detransition in clinical settings is associated with worsened distress and increased self-harm risk; affirming environments are a safety intervention, not a courtesy.[14]
Gender dysphoria is among the most actively contested areas of contemporary psychiatry. Several debates have direct clinical implications.
Adolescent medical interventions
- The evidence base for pubertal suppression and gender-affirming hormones in adolescents is largely observational, with short follow-up; systematic reviews commissioned by national authorities have rated certainty as low to very low.[23]
- Sweden, Finland, the UK (following the Cass Review), and Norway have shifted toward more cautious thresholds since 2020, prioritizing psychological support and restricting routine use of pubertal suppression outside research contexts; WPATH SOC-8 and many U.S. specialty bodies maintain a broader gender-affirming approach.[18,23]
Shifts in presenting population
- The rise in adolescent referrals, particularly birth-assigned-female adolescents without childhood gender variance, has prompted debate about contributing factors including social influence, comorbidity, and improved identification; the relative weights of these factors are unresolved.[3,15]
Diagnostic classification
- ICD-11 moved gender incongruence out of the mental disorders chapter; some argue DSM-5-TR should follow, while others argue retaining gender dysphoria as a distress-based diagnosis preserves clinical access and accuracy.[16-17]
Informed consent and capacity
- Capacity to consent to interventions with long-term and partially irreversible effects in adolescents is debated, particularly in the presence of psychiatric comorbidity or .[8,23]
Detransition and regret
- Historical regret rates are low, but contemporary detransition narratives, often involving young adults who started medical transition as adolescents, suggest the current population may differ from historical cohorts; rigorous long-term follow-up is needed.[15]
Research priorities
- Comparative effectiveness studies, prospective cohorts with longer follow-up, and better characterization of subgroups (childhood-onset, adolescent-onset, comorbid autism) are widely identified as needs.[23]
- DSM-5-TR gender dysphoria requires marked incongruence between experienced and assigned gender plus clinically significant distress or impairment, persisting at least 6 months.[16]
- The DSM-5-TR criteria are separated into two sets: children require at least six of eight features including the first (insistence on being the other gender), and adolescents/adults require at least two of six.[16]
- ICD-11 reclassified gender incongruence outside the mental disorders chapter and does not require distress for diagnosis.[17]
- DSM-5-TR specifiers for gender dysphoria are with a disorder of sex development and post-transition.[16]
- Conversion therapy aimed at changing gender identity is contraindicated and is associated with harm.[18,24]
- Pubertal suppression with is initiated in early-pubertal adolescents (Tanner stage 2 or later) and is reversible but has bone and possibly neurocognitive effects with prolonged use.[22]
- Feminizing hormone therapy combines estradiol with an antiandrogen such as spironolactone; oral ethinyl estradiol is avoided because of thromboembolic risk.[22]
- Masculinizing therapy uses testosterone titrated to physiologic male range and is teratogenic, requiring contraception or treatment interruption in those who can become pregnant.[22]
- Autism spectrum disorder is over-represented among adolescents presenting to gender clinics and warrants careful longitudinal assessment.[8]
- WPATH SOC-8 (2022) removed many minimum-duration prerequisites for adult gender-affirming surgeries in favor of individualized readiness assessment.[18]
- The UK Cass Review (2024) and similar European reviews recommended more cautious thresholds for adolescent medical intervention, citing low certainty of evidence.[23]
- Suicidal ideation and attempts are markedly elevated in transgender populations relative to cisgender peers, with minority stress as the leading explanatory framework.[6,14]
- Most childhood gender dysphoria does not persist into adolescence in historical cohorts, though generalizability of these data to recent cohorts is debated.[4-5]
- Fertility preservation counseling is recommended before initiation of pubertal suppression or gender-affirming hormones.[22]
- Affirming clinical environments — correct name and pronoun use — are associated with reduced distress and are considered a safety intervention.[14]
No external funding. No conflicts of interest declared. Peer-review status: pending.
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