Gender dysphoria and sexual orientation in clinical care

• Gender identity is a person's internal sense of being male, female, both, neither or something else. Sexual orientation is who a person is attracted to. The two are separate; one is not predicted by the other.
• Many transgender and gender diverse (TGD) people never experience distress about their gender and never seek medical care. Gender dysphoria means distress arising from incongruence between a person's experienced gender and the sex assigned at birth.
• Gender incongruence is classified in ICD-11 as a condition of sexual health (code HA60), not as a mental illness. DSM-5-TR describes gender dysphoria and focuses on the distress and impairment that can accompany it. ^[1]
• Care is stepped and individualised: social transition, mental health support, and only when appropriate puberty suppression, gender-affirming hormone therapy and surgery. There is no single pathway that suits everyone.
• Major guidelines agree on respect, consent, capacity and multidisciplinary care, but they differ on how strong the evidence is for hormonal treatment of adolescents. Say this plainly rather than implying certainty.

By the end of this page you should be able to:

1. Define sex, gender identity, gender expression, gender incongruence and gender dysphoria, and distinguish gender identity from sexual orientation.
2. Explain how a health care professional takes an affirming history and creates a safe consultation.
3. Summarise the positions of DSM-5-TR and ICD-11 and the differences between them.
4. Assess a child, adolescent or adult who reports gender incongruence, including risk assessment and differential diagnosis.
5. Outline the evidence for puberty suppression, gender-affirming hormones and surgery, and where the major guidelines disagree.
6. Manage mental health needs, monitoring and follow-up, and know when to refer.

People and institutions use these words differently, so begin by agreeing on the terms you will use with the patient. The definitions below reflect the usage of WPATH Standards of Care, version 8 (2022), and the 2017 Endocrine Society guideline as summarised in Endotext.^[1][2]

Gender identity is not sexual orientation. A trans woman may be attracted to men, women, both or neither, and a person's sexual orientation does not determine whether they are transgender. Asking one question as if it answered the other is a common clinical error.^[1][2]

About 1.8% of United States youth and about 0.6% of United States adults identify as transgender.^[2] Services worldwide are seeing rising referrals, yet provider education has lagged. People report having to teach their own clinicians how to care for them, which is itself a health disparity.^[1][2]

Two paradigms describe the same experience.

• The World Health Organization places gender incongruence in ICD-11 in the chapter on conditions related to sexual health (code HA60), removed from the mental and behavioural disorders chapter.^[1] The aim is to reduce stigma and the harm of labelling a transgender identity as mental illness while still recognising the need for care.
• The American Psychiatric Association retains "gender dysphoria" in DSM-5-TR. It focuses on the clinically significant distress and impairment that can accompany gender incongruence, rather than on the identity itself.^[1]

In practice the overlap is large. In countries where a diagnosis unlocks treatment or reimbursement, clinicians commonly document both.^[1]

Three clinical consequences follow.

1. A transgender identity is not a disorder. Gender diversity is a natural human variation and is not inherently pathological.^[1]
2. Distress is not inevitable. Some TGD people have no significant dysphoria; others have marked, sustained distress. Both groups deserve competent care, including gender-affirming treatment when requested.^[1]
3. Identity and distress can evolve, especially around puberty. Supporting early exploration matters, because persistent non-contentedness is linked to lower self-esteem and worse mental health in follow-up.^[2]

The DSM-5-TR criteria are copyrighted; the summary below is paraphrased. The core requirement is a marked incongruence between experienced or expressed gender and sex assigned at birth lasting at least 6 months, with at least two manifestations from a list, plus clinically significant distress or impairment in important areas of functioning.^[2]

The manifestations include marked incongruence with primary or secondary sex characteristics (or those anticipated at puberty in young adolescents); a strong desire to be rid of them; a strong desire for the characteristics of another gender; a strong desire to be of another gender; a strong desire to be treated as another gender; and a strong conviction of having the typical feelings and reactions of another gender. Specifiers cover coexisting differences of sex development and a "post-transitional" state after medical intervention.

ICD-11 (HA60) centres on marked and persistent incongruence between experienced gender and assigned sex, often leading to gender-affirming treatment. It sits in sexual health rather than mental health and does not treat TGD identity as illness.^[1]

• ICD-11: HA60 (gender incongruence of adolescence and adulthood); HA61 (gender incongruence of childhood).
• DSM-5-TR: F64.0 (gender dysphoria in adolescents and adults); F64.2 (in children). ^[1]
• ICD-10: F64.0 (transsexualism), still used in some countries.

• About 1.8% of United States youth and about 0.6% of United States adults identify as transgender.^[2]
• Centres worldwide report rising referrals, and sex ratios at presentation have shifted since the 2000s, with more people assigned female at birth now referred.^[2]
• In European clinic cohorts, less than a quarter of children referred for gender concerns met criteria for a gender diagnosis after adolescence; early adolescence (roughly 10 to 13 years) is a period when gender identity often consolidates or shifts.^[2]

Clinic data come mainly from specialist services in Western countries and probably understate global diversity.

There is no single cause. Gender identity is shaped by biological, psychological and social factors, none decisive alone. Studies in people with differences of sex development highlight prenatal androgen exposure; twin studies report concordance of gender dysphoria up to about 39% in identical twins. Genetic studies have so far been inconsistent, suggesting at most a small contribution from sex steroid pathways.^[2]

Poor outcomes are driven less by incongruence itself than by context: minority stress, discrimination, family rejection, social marginalisation, violence, and coexisting mental or neurodevelopmental conditions. These are the factors clinicians can often modify.^[1]

There is no structural lesion and no biomarker. The "pathophysiology" is experiential: a mismatch between an internal sense of gender and the body, social role and expectations attached to the sex assigned at birth. Puberty is the key turning point. Unwanted secondary sex characteristics that develop at puberty can intensify previously tolerable incongruence, linking the clinical picture to pubertal neuroendocrine events rather than to disease of an organ.^[2]

There is no single "look" for a gender diverse person.

Themes vary, but common ones include:

• a sense, often from childhood, of being different from the gender expected of them
• discomfort with aspects of the body, especially with approaching or progressing puberty (breast development, menstruation, voice change, facial and body hair, erections, pelvic shape)
• a desire to live, be treated and be recognised as another gender, or as non-binary
• distress, shame, concealment, avoidance (mirrors, swimming, medical examinations)
• social losses from bullying, family rejection, exclusion or violence

Distress is amplified by concealment and social context; it is not a feature of identity itself. A person with stable gender incongruence in a supportive environment may have no significant dysphoria.^[1]

Risk assessment comes first. Then cover:

• mood, anxiety, trauma, self-harm and body-image or eating concerns
• neurodevelopmental features, especially autism spectrum conditions, reported more frequently in gender diverse populations
• substance use and sleep
• family and social support, housing and safety at home, school or work
• goals, expectations and understanding of options
• previous mental health care and what helped

Document name and pronouns as the patient wishes them. Ask directly about self-harm and suicidal thoughts, including plan, intent and means.^[1]

Several conditions can present with body-related distress, social withdrawal or gender-nonconforming expression. They can also coexist with gender dysphoria, in which case both need treatment.

There is no blood test or scan that diagnoses gender dysphoria. Assessment is clinical and relational.

Principles first.

• Use the patient's own words and preferred terms; do not police vocabulary unless you agree together to adjust it.^[1]
• Ask about and use name and pronouns. Many people use names and pronouns not yet on legal documents.^[2]
• Assume nothing about anatomy, relationship status or sexual partners.
• Ask sensitive questions only when clinically relevant, explaining why.
• Allow silence and do not rush.
• Keep questions about gender identity distinct from questions about sexual behaviour.^[1]

Phrasing for younger children such as "Some kids think of themselves as girls, some as boys, some as part girl and part boy, and some as something else entirely" is one way to open the conversation.^[2]

• Use a trauma-informed approach. Explain each step and take consent at each point. Offer a chaperone and choice about who performs the examination.
• Record sex assigned at birth and gender identity as separate fields where the record system allows.
• Examine genitalia or secondary sex characteristics only when clinically indicated, and discuss why. Many find these examinations distressing; defer non-urgent ones where possible.
• If a physical examination is needed, arrange it with notice and with the patient controlling the pace.^[1]

Capacity assessment is central. The WPATH approach expects the clinician to assess whether incongruence is marked and sustained, whether coexisting mental health problems are addressed enough for treatment to proceed, and whether the person has the emotional and cognitive maturity to consent.^[1]

Assessment should not become gatekeeping whose only purpose is to make a person prove that they are "really" transgender. Its purposes are to understand the person, treat coexisting conditions, and support an informed decision.

Gender diverse people experience minority stress, social marginalisation and, in many settings, discrimination and violence, associated with higher rates of depression, self-injury and suicidality than among cisgender populations.^[1] Document these directly. Do not interpret them as evidence that the identity itself is the pathology.

• Safety first. Manage acute suicidal risk as you would for any patient, with means restriction and support.
• Treat mental health crises without delaying gender-affirming care planning; the two run in parallel.
• Avoid telling a pubertal young person that they must simply wait until adulthood. Time-limited options exist and should be discussed openly, including their uncertainties.

Social transition is fully reversible. It may include name, pronouns, clothing, hairstyle, facilities and social role, in any combination.

• For prepubertal children support centres on family, school and social adjustment. Puberty suppression is not indicated before puberty begins.^[1]
• Working with families, schools and workplaces on respect, safety and confidentiality is core care.
• Speech and language therapy, voice training, and updates to gender marker and name on documents can be valuable.
• WPATH notes that social support, including peer support and community organisations, improves wellbeing.^[1]

Puberty suppression is the first medical step for many adolescents, only appropriate once puberty has begun.

• Spontaneous puberty typically starts at about 10 to 11 years in people assigned female at birth (range 8 to 13) and 11 to 12 years in people assigned male at birth (range 9 to 14). Tanner or Sexual Maturity Rating stage 2 is the usual threshold.^[2]
• Agents are GnRH agonists (leuprolide, triptorelin, histrelin) given as injections or implants, and in some settings medroxyprogesterone or other agents. All are used off-label for this indication, although some GnRH preparations are licensed for central precocious puberty.^[2]
• Suppression pauses further pubertal progression and may slightly regress breast tissue or testicular volume. It is reversible: stopping the medication allows endogenous puberty to resume.^[2]

Eligibility criteria recur across guidelines:

1. Endocrine Society 2017 guideline: adolescents who meet diagnostic criteria, fulfil criteria for treatment and are requesting treatment should initially undergo pubertal suppression, beginning after physical puberty starts (Tanner stage 2), once psychological, medical and social problems are addressed, and when the adolescent has sufficient mental capacity to consent.^[2]
2. WPATH SOC 8: incongruence is marked and sustained; diagnostic criteria are met where needed for access; the adolescent has emotional and cognitive maturity for consent; mental health concerns that would interfere with treatment are addressed; reproductive effects and fertility preservation are discussed; and Tanner stage 2 has been reached.^[1][2]

Be honest that this is the most contested part of the topic. In 2025 the position is roughly as follows.

Supportive observations:

• GnRH agonists effectively suppress the hypothalamic-pituitary-gonadal axis in transgender youth in small studies.
• European studies report improved psychological functioning and depressive symptoms during treatment.
• A systematic review reports associations with decreased suicidality in adulthood, improved affect and psychological functioning.
• A 2025 review of 51 studies found improved mental health, with reduced depression, anxiety and suicidality, especially when suppression was followed by gender-affirming hormone therapy.^[2]

Limitations and dissent:

• A meta-analysis of 10 studies judged the overall quality of evidence for gender dysphoria, global function and depression to be low. ^[2]
• A NICE-commissioned systematic review, part of NHS England's policy process, identified a remarkably weak evidence base for puberty blockers and for masculinising and feminising hormones in gender dysphoric young people, to the point that clinical policies could not be developed for their use. In 2024 the Cass Review, commissioned by NHS England in 2020 and chaired by Dr Hilary Cass, concluded that routine use of these treatments in young people is not supported by current evidence and should take place in a structured research framework.^[3]
• Potential risks include impacts on growth, bone health, body composition and fertility. Delaying exposure to sex steroids at the time of peak bone mineralisation may decrease bone mineral density, and the significance of this requires continued study. Puberty suppression is also associated with increased body fat and decreased lean mass.^[2]
• Early suppression affects surgical options, because it limits penile and testicular growth. Testicular biopsy for sperm retrieval has been successful at a testicular volume of at least 10 mL. GnRH agonist treatment impairs spermatogenesis and oocyte maturation temporarily, so fertility counselling is recommended; some individuals choose to delay treatment to preserve fertility.^[2]

Implications for care:

• Puberty suppression should be offered only in specialist, multidisciplinary settings with careful selection, monitoring and, in the United Kingdom, as part of a structured research programme.
• Where services cannot provide it safely, refer if possible and offer psychologically informed care that never implies the identity is the problem.
• WPATH SOC 8 continues to support puberty suppression when criteria are met, so international practice differs. Explain this honestly: guidelines differ, and clinician judgement together with local policy matter.

Hormones induce secondary sex characteristics aligned with gender identity. They are partially reversible in some respects (for example, voice deepening, clitoral growth, breast development are not fully reversible) and require full informed consent.

Adult evaluation and dosing principles outside adolescence are also summarised in Endotext.^[4]

• incongruence is marked and sustained over time
• diagnostic criteria are met where a diagnosis is needed for access
• the person demonstrates the emotional and cognitive maturity required for informed consent or assent
• mental health concerns that could interfere with treatment have been addressed sufficiently
• reproductive effects and fertility preservation have been discussed
• Tanner stage 2 has been reached (for adolescents)^[1][2]

Age: Endocrine Society 2017 recommends sex steroid treatment from a gradually increasing dose schedule after the diagnosis has been confirmed and capacity established; full consent is expected by about 16 years, although there may be compelling reasons to start earlier in some adolescents. WPATH uses Tanner stage 2, not a strict age. Genital surgery is generally from 18 years; chest masculinising surgery may be considered from 16 years in selected cases; 12 months of hormone therapy is usually expected before certain surgeries.^[1][2]

Typical regimens from the Endocrine Society 2017 guideline, as summarised in Endotext:^[2]

• oral or sublingual estradiol: start at 5 microg/kg/day for younger individuals, increasing doses every 6 months, up to an adult dose of 2 to 6 mg/day ^[2]
• post-pubertal adults: typically start at 1 mg/day for 6 months, then 2 mg/day orally
• transdermal: start at 6.25 to 12.5 microg per 24 hours, increasing every 6 months to an adult dose of 50 to 200 microg per 24 hours
• parenteral options: estradiol valerate 5 to 30 mg every 2 weeks, or estradiol cypionate 2 to 10 mg intramuscularly weekly ^[2]

Testosterone blockade can be achieved with spironolactone titrated up to 10 to 300 mg/day orally, cyproterone acetate 25 to 50 mg/day orally where available, bicalutamide 25 to 50 mg daily or every other day, finasteride 2.5 to 5 mg/day, or a GnRH agonist.^[2]

Expected effects of estradiol (with or without antiandrogen) include breast growth, body fat redistribution, decreased muscle mass and strength, softening of skin, thinning and slowing of body and facial hair, decreased libido and erections, and decreased testicular volume, with maximum effects generally after 2 to 3 years. Monitor height, weight, sitting height, blood pressure and Tanner stages every 3 to 6 months, prolactin, estradiol and 25OH vitamin D every 6 to 12 months, and bone density with DXA plus bone age X-ray every 1 to 2 years.^[2]

Potential risks of feminising therapy include thromboembolic disease, breast cancer, stroke, myocardial infarction, gallstones, and hypertriglyceridaemia, especially with smoking and advancing age. Transfeminine people on estradiol have higher risks of stroke and venous thromboembolism than cisgender comparators in observational studies.^[2]

Typical regimens:^[2]

• parenteral testosterone cypionate or enanthate: start at 12.5 mg/week or 25 mg every 2 weeks, with gradual increases to 50 to 100 mg/week or 100 to 200 mg every 2 weeks ^[2]
• transdermal: patch 2.5 to 7.5 mg/day or 1% or 1.6% gel, usually started once an adult dose has been achieved parenterally ^[2]
• expected effects include deepening of the voice, increased muscle mass and strength, facial and body hair growth, clitoral enlargement, cessation of menses usually within months, and increased erythropoiesis

Monitoring for testosterone includes height, weight, sitting height, blood pressure and Tanner stages every 3 to 6 months, and haemoglobin or haematocrit, lipids, testosterone and 25OH vitamin D every 6 to 12 months, plus DXA and bone age where indicated every 1 to 2 years.^[2]

Potential risks include erythrocytosis, acne, alopecia, weight gain, liver enzyme elevation, dyslipidaemia and (less certainly) cardiovascular disease. Testosterone is absolutely contraindicated in pregnancy, and should not be started in a person who could become pregnant without contraception counselling.

Where GnRH or testosterone preparations are unavailable or unaffordable, alternative agents (medroxyprogesterone for suppression, for example) may be used, with appropriate counselling about reduced efficacy and side effects.^[2]

All the regimens above are off-label for this indication and dosing varies between countries, preparations and age groups. Use them as starting points, check your local formulary for available products and their approved doses, and individualise with endocrinology where possible. Do not copy a number from a teaching note into a prescription without confirming the product and the patient.

Surgery is irreversible and should be the endpoint of a considered process, not a first step.

• Gender-affirming surgeries include chest surgery, genital reconstruction, facial surgery and (less commonly considered) other procedures.
• Criteria generally include marked and sustained incongruence, maturity to consent, addressed mental health concerns, and (for many procedures) 12 months of hormone therapy unless not wanted or medically inappropriate.^[1]
• Mental health professional involvement and psychosocial assessment are expected; the aim is ensuring informed consent and readiness, not withholding care.
• Chest masculinising surgery may be considered from 16 years in some centres; genital surgery is generally from 18 years. Age thresholds vary by jurisdiction and by service.^[1][2]
• Perioperative care, thromboprophylaxis, and cancer screening should account for retained anatomy.

• Minority stress is the main driver of health inequality in this population, not identity. Treat depression, anxiety, post-traumatic stress and obsessive-compulsive symptoms with standard evidence-based methods.^[1]
• Strongly oppose conversion practices: attempts to change or suppress gender identity. These are considered unethical and, in an increasing number of jurisdictions, illegal.^[1]
• Peer support, family work, psychoeducation and connection with community organisations improve outcomes.^[1]
• Address internalised stigma and anticipated discrimination; assess safety in home, school, workplace and health care.
• Medication choices (for example antidepressants) are the same as in cisgender patients; monitor for interactions with hormones. Some TGD people on testosterone may need dose review if haematocrit rises; some on estradiol need lipid and blood pressure follow-up.
• Neurodevelopmental conditions, especially autism, are more common. Adapt communication and do not assume incapacity.

• Children (prepubertal): social support and family work; no puberty suppression or hormones before puberty begins.^[1]
• Adolescents: multidisciplinary assessments; offer puberty suppression where indicated; GAHT from Tanner stage 2 with consent; surgery rarely before adulthood. ^[1]
• Older adults: onset or first presentation can occur at any age. Manage comorbidities (vascular risk, osteoporosis) and screen by anatomy. Long-term hormone users should be reviewed for cardiovascular and bone health.
• Pregnancy and fertility: testosterone is contraindicated in pregnancy; stop before conception. Sperm and oocyte cryopreservation should be offered before gonadotoxic therapy. Transgender men on testosterone can ovulate; contraception advice must be explicit. Some TGD people want to parent; affirm and refer.^[1][2]
• Differences of sex development: handle within specialist services.

• After initiating hormones, review every 6 to 12 months, with laboratory monitoring as above.^[2]
• Continue mental health support and screening; many people also need speech therapy, legal advice or peer support.
• Long-term review should include bone density, cardiovascular risk, liver function and (where retained) cancer screening by anatomy.
• Some people reduce or stop hormones later. This is not "detransition" by default; revisit goals without judgement. Good care leaves the door open.

Refer to specialist gender services when:

• a child or young person is asking for puberty suppression or hormones
• there is diagnostic uncertainty or complex coexisting mental health or neurodevelopmental needs
• surgery is being considered
• the patient requests it

Also refer early for acute suicidal risk, eating disorder concerns, psychosis, or any suspicion that treatment would be harmful.

• The most important intervention is respectful, affirming conversation and a safe clinical space. These cost nothing.
• Use the cheapest acceptable monitoring (for example blood pressure, weight, clinical Tanner staging) and tailor hormone choice to local availability.
• Where GnRH agonists are unaffordable, alternatives may be used with careful counselling.
• Mental health support can be delivered by primary care workers trained in basic affirming practice; peer support is often the most accessible.
• Refer to regional endocrinology and psychiatry services for assessment that requires specialist skills, and plan follow-up in primary care.
• Document by anatomy so that screening (cervical, breast, prostate) is not missed in settings where record systems are limited.

Mental health inequality is the main "complication" of the social context, not of the identity. Depression, anxiety, self-harm and suicide are more common than in cisgender populations, driven by minority stress, rejection and violence.^[1] Clinical tasks are to detect, treat and support, and to reduce environmental sources of harm.

Medical complications follow from treatment when used: GnRH therapy and hormones have the risks described above (bone, fertility, cardiovascular, erythrocytosis). Most are manageable with monitoring. Long-term vascular and thrombotic risks of estradiol are dose- and route-dependent; transdermal routes may carry lower thrombotic risk than oral in older adults, which is a prescribing consideration.

With social and, where desired, medical affirmation, most TGD people report improved quality of life and mental health. Low rates of regret after gender-affirming treatment are reported in cohort studies (Dutch cohorts report 1.9% and 3.5% choosing to stop puberty suppression, for example).^[1] However, evidence quality is mixed and outcomes vary, especially when treatment is delayed or unsupported. Prognosis is therefore as much about environment and support as about medical intervention.

See the management notes above. A general point: never let comorbidity (including HIV, learning disability, or incarceration) be a reason to deny assessment. People in institutional or carceral settings often receive poorer care; seek to protect confidentiality and safety.^[1]

There is no prevention of gender incongruence; it is not a disease to prevent. Prevention and screening instead cover:

• suicide prevention and access to crisis care
• screening for depression and anxiety
• HIV and sexual health screening, tailored to sexual behaviour and anatomy
• cancer screening by anatomy and by age, regardless of gender marker
• bone health screening in people with low bone mass, prolonged amenorrhoea, or GnRH exposure

Sexual orientation should be asked about and recorded separately from gender identity. Practical points:

• Use open phrasing ("who are you attracted to?") and avoid assumptions based on gender, age or partner.
• Sexual orientation categories include gay, lesbian, bisexual, pansexual, asexual, queer and heterosexual; but some people prefer no label. Ask rather than assign.^[1]
• Sexual health needs (contraception, sexually transmitted infections, cervical and prostate screening) depend on sexual behaviour and anatomy, not on orientation or gender identity.
• Stigma related to sexual orientation has its own health effects: delayed presentation, minority stress and reduced disclosure. Affirming practice, including asking about orientation respectfully and keeping it confidential, improves care. Conversion practices targeting sexual orientation are also considered unethical and are unlawful in many jurisdictions.^[1]
• Cultural context shapes how easily people discuss sexuality. In some cultures sexuality is taboo; respectful, clear language and attention to confidentiality can reduce shame and misunderstanding.^[1]

• Gender identity and sexual orientation are different dimensions: one is who you are, the other is who you are attracted to.
• Gender dysphoria is distress and/or impairment arising from incongruence between experienced gender and sex assigned at birth.
• Gender incongruence sits in ICD-11 in sexual health, not mental health; DSM-5-TR focuses on the distress. A TGD identity is not a disorder.
• About 1.8% of United States youth and about 0.6% of adults identify as transgender.^[2]
• Care is stepped: social transition (reversible), psychological support, puberty suppression from Tanner stage 2 when puberty has begun (reversible), gender-affirming hormones (partially reversible), and surgery (irreversible), with informed consent at every step.
• WPATH SOC 8 (2022) supports puberty suppression from Tanner stage 2 and hormone therapy from Tanner stage 2 where capacity exists; the Endocrine Society guideline (2017) endorsed pubertal suppression at Tanner stage 2 and adult regimens as summarised in Endotext.
• Evidence for puberty suppression and hormones in young people is limited and contested; a NICE-commissioned review and the 2024 Cass Review concluded that routine use is not supported by current evidence, while WPATH continues to support it when criteria are met. Explain the disagreement honestly.
• Minoritized people, including transgender people, experience minority stress associated with higher rates of depression, self-injury and suicidality. Treat these, reduce harm, and do not interpret them as pathology.
• Inclusive history taking (name, pronouns, identity asked for directly, anatomy-informed screening, goals, fertility, safety) is a clinical skill and improves outcomes.
• Many dosing regimens are off-label; doses are typical adult or adolescent regimens from guidelines, and should be checked against the local formulary.
• Avoid conversion practices; involve multidisciplinary teams; refer when criteria, complexity or patient request warrant it.

Depression and anxiety disorders; autism spectrum disorder; pubertal disorders and precocious puberty; sexual health and contraception; HIV prevention and sexual health; bioethics and consent.

Guideline editions used: WPATH Standards of Care for the Health of Transgender and Gender Diverse People, Version 8 (2022); Endocrine Society Clinical Practice Guideline on Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons (2017), as summarised in Endotext; and the NHS Independent Review of Gender Identity Services for Children and Young People (Cass Review, final report 2024). ^[3]