Gender incongruence of adolescence or adulthood: characterised by a marked and persistent incongruence between an individual's experienced gender and the assigned sex, which often leads to a desire to be accepted as a person of the experienced gender

Gender incongruence of childhood: characterised by a marked and persistent incongruence between an individual's experienced gender and the assigned sex in pre-pubertal children, has to be present for more than 2 years

Aetiology

• Likely to be a balance of a number of genetic, hormonal and environmental factors, but the cause is essentially unknown

Pathophysiology

Predictive factors affecting progress

• Mental illness and psychological vulnerability
• Absence/poor partner or family support
• Poor social function (including employment)
• Preconceived ideas associated with unrealistic expectations
• Age > 30 years
• Earlier period of life adaptation to biological sex including marriage and parenthood
• Morphological characteristics (e.g. large hands) which are incompatible with 'passing with good credibility' in the new gender, and ambivalence with regard to surgical processes

Co-existing metal health problems

• Anxiety and depression
• Suicidal ideation or attempt
• Often associated with stigma
• Protective factors - pride in identity and support
• Alcohol, drug and other substance misuse has been reported as high

Clinical features