Gender dysphoria is the clinically significant, persistent distress that comes from the distance between the gender a person experiences as their own and the one they were assigned at birth. It is not the same as being transgender: it is the distress that can come with it, and the DSM-5-TR requires it to last at least six months before a diagnosis can be made.
This page explains what gender dysphoria is and, above all, what it means in Italy: how the diagnosis works here, who can issue it and what an Italian court asks for before changing the gender marker on your documents under Law no. 164 of 14 April 1982. If you are looking for the procedure step by step, it is set out in changing gender in Italy.
Table of contents
What is gender dysphoria?
Gender dysphoria is marked by strong emotional and cognitive distress in relation to the gender assigned at birth. The DSM-5-TR requires it to have been present for at least six months and to cause significant impairment in social, school or work functioning.
Three words are often confused:
- Transgender: someone who identifies, temporarily or persistently, with a gender different from the one assigned at birth.
- Transsexual: someone who wishes to undertake, or has undertaken, a transition from male to female or the other way round.
- Gender dysphoria: the clinically relevant distress. You can be transgender without dysphoria; it is the distress, not the identity, that receives a diagnosis.
I am Gianluca Piemonte, an Italian lawyer. Together with Alessandra Scaffidi I have worked for years on legal gender recognition proceedings before Italian courts. The clinical answers on this page come from Alessandra Merola, a psychologist and psychotherapist; the legal part is mine.
Is gender dysphoria a mental illness?
No, and the source is the World Health Organization. In ICD-11, the international classification of diseases, gender incongruence was moved out of the chapter on mental disorders and placed in the chapter on conditions related to sexual health, under code HA60 for adolescence and adulthood. The WHO explained the move by the stigma that classifying it as a mental disorder produces, while keeping the entry in the classification so that access to psychological, hormonal and surgical care remains guaranteed.
The DSM-5-TR still includes gender dysphoria, but what it diagnoses is the distress, not the identity. The distinction matters in court: an application for legal gender recognition does not ask the judge to find a pathology.
What are the symptoms?
Anxiety, depression, irritability and substance abuse often come with gender dysphoria.
Adolescents and adults with gender dysphoria who have not yet started a gender affirmation process are at higher risk of suicidal ideation and suicide attempts. It is one of the reasons why psychological support does not stop once the diagnosis is made.
Difficulties in relationships and in sexual life are also frequent, as is impaired performance at school or at work: stigma, discrimination and experiences of victimisation all feed a negative self-image.
At what age does it appear?
Gender-atypical behaviour usually appears between the ages of 2 and 4. That is when children begin to show behaviours and interests linked to gender, and it is also why the mere presence of those behaviours in childhood is not enough for a diagnosis.
Children, adolescents and adults: different criteria
According to the DSM-5-TR, gender dysphoria in children, adolescents and adults is characterised by a marked incongruence between the experienced or expressed gender and the assigned gender, lasting at least six months. The criteria required in each age group are different, which is why a child is not assessed with the same instrument used for an adult.
In children it shows through clothing, games, chosen playmates and the name they ask to be called by. In adolescents there is often concern about the secondary sex characteristics that are about to develop. In adults there is usually a wish to be rid of the sex characteristics of the gender assigned at birth. For minors the path and its legal consequences follow their own rules: see gender change for minors.
Can gender dysphoria be temporary?
This is the question parents ask most often. The honest answer is that the six-month criterion and the extended assessment exist precisely to tell a phase apart from a persistent condition: no serious clinician makes a diagnosis after a single session, and in childhood the assessment is more cautious still.
On persistence rates in developmental age the scientific literature is not in agreement, and the figures circulating online often come from studies with very different selection criteria. For the legal side the point is a different one: an Italian court does not decide on a prediction, it decides on a path already taken and documented.
How is gender dysphoria diagnosed?
The diagnosis is based on the DSM-5-TR criteria. What matters is the incongruence between the gender assigned at birth and the gender the person experiences, together with the distress it causes.
Who can make it. A psychologist-psychotherapist, a psychiatrist, or a child neuropsychiatrist for minors. A public facility is not required: a report from a private practitioner carries the same weight before an Italian court.
How long it takes. The assessment is not a single appointment. Italian centres work with a period of observation of several months before the report is issued.
What the report must contain, for the court. The report filed with the application must set out the diagnosis, the path taken, the persistence of the condition and the person’s awareness of the step they are taking. It is the document the judge decides on.
Where can you get a diagnosis in Italy?
In Italy the path can be followed within the national health service or privately. For public facilities there is an institutional map, run by the Istituto Superiore di Sanità with UNAR on the Infotrans.it portal, which can be filtered by region and by type of service and is the only list that is kept up to date.
To give an idea of how these services are organised: at Niguarda hospital in Milan the path runs through the Gender Incongruence Clinic within the endocrinology department, accessed with a referral for an endocrinological consultation. At Careggi University Hospital in Florence it is handled by the Andrology and Gender Endocrinology unit, which also coordinates the regional centre for gender identity in Tuscany and works with endocrinologists, psychologists, psychotherapists, child neuropsychiatrists and psychiatrists.
The difference between public and private affects waiting times and costs, not legal weight: what the court looks at is that the report exists and is reasoned, not which institution issued it.
What is the treatment?
A course of psychotherapy is needed to reach a diagnosis. Since transition is a delicate period, it is advisable to continue it after the diagnosis has been made.
After the diagnosis. Hormone therapy is started with an endocrinologist and does not require authorisation from a judge. Surgery is optional: see sex reassignment surgery for costs and procedure.
From diagnosis to legal gender recognition in Italy
In Italy legal gender recognition is obtained by a judgment of the court, under Law no. 164 of 14 April 1982. The proceedings follow the ordinary rules set out in Article 31 of Legislative Decree no. 150 of 1 September 2011, and are started by a writ of summons before the court of the place of residence, with the public prosecutor taking part.
What you file: the specialist’s report with the diagnosis and the path taken, documentation of any hormone therapy, and civil status certificates. The judgment granting the application orders the registrar to amend the birth record, and the other documents are updated from there. The full procedure, with timings and costs, is in changing gender in Italy.
Do you need surgery to change your documents in Italy?
No. The Italian Constitutional Court, in judgment no. 221 of 2015 and then no. 180 of 2017, ruled out that surgery removing or altering the primary sex characteristics is a necessary condition for legal gender recognition: what the judge ascertains is the transition path, not an anatomical requirement.
Judgment no. 143 of 2024, filed on 23 July, went the same way: it struck down Article 31(4) of Legislative Decree 150/2011 in so far as it required the court’s authorisation for medical and surgical treatment even where the changes already made were considered by that same court sufficient to grant the application. In the same ruling the Court declared inadmissible the questions on the recognition of a non-binary gender, leaving that choice to the legislature.
CONCLUSIONS
Do you already have a diagnosis and want to change your documents in Italy? The next step is the application to the court. You can write to me at supporto@studiopiemonte.com or through the CONTACT US page. You may also find the 45 frequently asked questions on gender change useful.
