Assess for gender dysphoria using DSM-5 criteria

STEP 1 — Gather Information

Collect patient's self-reported experiences regarding gender identity, duration of incongruence, and specific manifestations: (1) incongruence between experienced/expressed gender and primary/secondary sex characteristics (or anticipated characteristics in young adolescents), (2) strong desire to be rid of primary/secondary sex characteristics, (3) strong desire for primary/secondary sex characteristics of the other gender, (4) strong desire to be of the other gender, (5) strong desire to be treated as the other gender, (6) strong conviction of having typical feelings/reactions of the other gender. Assess for clinically significant distress or impairment in social, occupational, or other important areas of functioning.

STEP 2 — Rule In / Rule Out

Is there a marked incongruence between experienced/expressed gender and natal gender lasting at least 6 months? If no, rule out gender dysphoria. If yes, proceed to evaluate specific criteria and distress/impairment.

STEP 3 — Classify or Stratify

Count how many of the six DSM-5 criteria (items 1–6) are met. If at least two criteria are present AND clinically significant distress/impairment is documented, the patient meets DSM-5 criteria for gender dysphoria. Specify if concurrent with a disorder of sex development or if posttransitional (full-time living in desired gender with at least one sex-related medical procedure).

STEP 4 — Decide

If criteria are met, refer to a qualified mental health provider for formal diagnosis and discuss potential gender-affirming treatment pathways per endocrine guideline. If criteria are not met, explore alternative explanations for distress (e.g., body dysmorphic disorder, depression, anxiety) and consider further psychosocial assessment.

Clinical Guardrails / Mimics / Pitfalls

Do not diagnose gender dysphoria based solely on gender-nonconforming behavior without distress/impairment; avoid conflating with body dysmorphic disorder or other mental health conditions; ensure symptom duration is at least 6 months; consider developmental appropriateness in adolescents (e.g., anticipated secondary sex characteristics); verify that distress is not better explained by another psychiatric disorder or medical condition.

Concrete Clinical Example

A 17-year-old assigned female at birth reports a 10-month history of strong desire to be rid of breasts and menstruation, strong desire to have male-typical chest contour, and persistent distress when misgendered, leading to social withdrawal and declining grades. They meet criteria 2 and 3 with clinically significant impairment, supporting a DSM-5 gender dysphoria diagnosis.

Source: Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2017, DOI:10.1210/jc.2017-01658