Gender incongruence is not a psychiatric disorder. However, a psychiatrist may be one of the professionals involved within a medical gender affirming path. Access to care requires a signed informed consent. In particular, the psychiatrist works together with the psychologist in understanding the nature of the distress that a transgender person may report.

Not all people with gender incongruence experience clinically significant distress. However, a history of depression or anxiety disorders, such as panic disorders or generalized anxiety are often reported (70% of cases according to some studies). Several studies show a drastic decrease of depressive symptoms, body discomfort, suicidal ideation following the start of a medical gender affirming path. The origin of psychological distress may be linked to different reasons. Psychological functioning may be impaired due to both internalized transphobia and transphobia. Sometimes, trangender people report severe body discomfort, usually mainly towards those body parts (genitalia, chest, beard, hair, muscles) related to the assigned gender at birth. Body distress can be severe to the point to cause self-harm or extreme food retrinctions that may mimic Anorexia Nervosa (for more information, please refer to the ISSalute.it website under the heading "Anorexia nervosa").

The psychiatrist should identify potential distressing conditions and may suggest drug therapy for concomitant psychiatric disorders (if any). Many studies show a drastic reduction in depressive symptoms, bodily discomfort and suicidal ideas following gender-affirming medical interventions (when suffering is secondary to the inconsistency between gender identity and biological sex). Finally, the psychiatrist has the role of excluding that the forms of suffering and discomfort are actually attributable to other clinical pictures such as:

• personality disorders that interfere with self-definition
• psychotic symptoms that can determine the absolute belief of belonging to a gender
• distorted beliefs about one's own body (body dysmorphism: thinking you have deformed body parts).

Bibliography

Bandini E, Fisher AD, Castellini G, et al. Gender identity disorder and eating disorders: similarities and differences in terms of body uneasiness. J Sex Med. 2013; 10(4):1012-23.

Coleman E,  Radix AE, Bouman W,et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022; Sep 6;23(Suppl 1):S1-S259.

Fisher AD, Castellini G, Ristori J, et al. Cross-Sex Hormone Treatment and Psychobiological Changes in Transsexual Persons: Two-Year Follow-Up Data. J Clin Endocrinol Metab. 2016; 101(11):4260-69.

Heylens G, Elaut E, Kreukels B, et al. Psychiatric characteristics in transsexual individuals: multicentre study in four European countries. Br J Psychiatry. 2014; 204(2):151-6.

Vocks S, Stahn C, Loenser K, Legenbauer T. Eating and body image disturbances in male-to-female and female-to-male transsexuals. Arch Sex Behav. 2009; 38:364–77.