Gender affirmation pathways in Italy

By Giorgia Esposito, Doctor of Pharmacy, specializing in Gender Medicine

Terms like dysphoria, incongruence and gender variance describe different aspects of trans identity and experience, and it is a medical and social duty to understand their meaning and use them appropriately. The terminological confusion that often surrounds these concepts contributes to misunderstandings, stigmatization, and sometimes, inadequate clinical practices. Understanding the distinctions between psychological distress, gender identity, and the plurality of gender expressions is the first step to overcoming a pathologizing view and adopting a truly inclusive and respectful approach towards transgender and gender diverse (TGD) individuals. In this context, medicine, scientific research, and law are called upon to question not so much the origin of gender identity, but rather how to ensure health, self-determination, and equitable access to care, recognizing the bio-psycho-social complexity of gender experiences.

‍Definitions

Gender Dysphoria

Gender dysphoria refers to severe psychological distress caused by the discrepancy between one's assigned gender at birth and one's experienced gender (example: a person assigned female at birth who identifies as male and experiences distress about their body or how they are socially treated). 

Gender Incongruence

Gender incongruence, according to WHO classification, refers to a mismatch between assigned gender and identity without necessarily implying distress (example: a person assigned male at birth who identifies as female, without psychological distress, but who wishes to modify their body). 

Gender Variance

Finally, gender variance is a non-clinical concept that recognizes and values diversity in gender expressions compared to cultural norms (example: a child who loves to dress in feminine clothes or play with dolls, without this causing discomfort or requiring intervention).

Does it really make sense to explain why a person is transgender?

Some scientific research, available on PubMed, has attempted to understand the "etiology" of gender identity, but the results show a complex and non-definitive picture. There is no evidence that gender identity is influenced by external factors such as upbringing, nor have specific genes or brain regions that determine gender identity been identified. Some studies suggest that prenatal exposure to androgens may have an influence, while others, such as that conducted by Zhou and colleagues, have observed in post-mortem studies that the bed nucleus of the stria terminalis (BST), a brain region normally larger in males, has similar dimensions in transgender women and cisgender women. However, these data are not sufficient to exhaustively explain the origin of gender identity.

This research raises an important question: does it really make sense to seek a single cause for such a profoundly subjective and social reality? Perhaps, rather than finding "the explanation," it is necessary to understand how science can contribute to protecting the health and well-being of TGD individuals, without reducing every variation to an anomaly.

Legal and healthcare process for gender affirmation

In Italy, the gender affirmation pathway (commonly referred to as transition) represents a complex and multidimensional process through which an individual can decide to modify their body and/or legal status to align them with their gender identity. Since October 1, 2020, with the approval of AIFA, the Italian Medicines Agency, access to hormonal treatments through the National Health Service is subject to a clinical diagnosis of gender dysphoria, according to the criteria outlined in the DSM-5.

This model is based on an integrated and interdisciplinary pathway involving various professionals (psychiatrists, psychotherapists, endocrinologists, surgeons) called upon to collaborate to ensure qualified care that is attentive to the bio-psycho-social complexity of the individual. Psychiatric evaluation, while providing a medical framework for the process, continues to raise ethical questions regarding the risk of pathologizing trans identity. In stark contrast to this framework is the so-called informed consent model, prevalent in some areas of the United States, which allows access to hormonal or surgical therapies without the requirement of a prior psychiatric evaluation.

From a legal perspective, Law 164 of 1982 long served as the regulatory reference for the rectification of sex assigned in civil registry documents. The procedure involves an appeal to the competent court, which may order specialist consultations to assess the psycho-sexual conditions of the individual concerned and authorize any necessary medical-surgical interventions. Following the intervention, the judge orders the civil registry rectification, which also entails the automatic dissolution of marriage.

In recent years, however, important rulings by the Constitutional Court have helped redefine this process with a greater respect for individual rights. Specifically, judgments no. 221/2015 and no. 180/2017 established that imposing surgical intervention as a prerequisite for legal gender recognition constitutes a violation of the right to personal identity. Medical treatment should therefore not be mandatory, but can represent one of the ways in which a trans* person pursues their psycho-physical well-being. With judgment no. 143 of 2024, the Court further simplified access to surgical interventions: those who have already obtained civil registry rectification can now access gender affirmation surgery without needing to obtain new judicial authorization, significantly reducing waiting times and bureaucratic obstacles.

It is important to emphasize how the experience of gender dysphoria, especially in contexts where social and medical recognition is still hindered by cultural and institutional barriers, can be associated with increased psychological vulnerability. Clinical studies and epidemiological observations report a higher incidence of depressive disorders, anxiety, and dysfunctional eating behaviors among transgender individuals, often as a response to contexts of marginalization, stigma, and limited access to adequate care. It is therefore crucial that gender affirmation pathways are accompanied by competent and non-pathologizing psychological support, integrated within a broader vision of health and self-determination.

Pharmacology in gender affirmation pathways

Not all transgender individuals choose to undergo medical or surgical treatments or the same hormonal pharmacology, and when they do, the pathway is always personalized based on individual needs. International guidelines, such as those proposed by WPATH (World Professional Association for Transgender Health), along with the directives from Italian health institutions, provide a framework to ensure safe, informed, and respectful care. In Italy, the Infotrans.it portal, a result of collaboration between the National Institute of Health and the National Office Against Racial Discrimination, offers a useful tool for navigating public and affiliated healthcare facilities that provide these services.

Masculinizing hormone therapy

Masculinizing hormone therapy involves the use of testosterone, administered intramuscularly or transdermally, with the aim of reducing feminine sexual characteristics and developing masculine ones. The first changes are observed after a few months and include the cessation of the menstrual cycle, deepening of the voice, body hair growth, changes in muscle mass distribution, and sometimes the onset of acne and androgenetic alopecia. 

Demasculinizing hormone therapy

Conversely, demasculinizing therapy, aimed at reducing masculine sexual characteristics, is based on antiandrogen drugs such as cyproterone acetate, spironolactone, or GnRH analogues, which act by blocking the action of testosterone. This treatment can reduce hair growth, sebum production, and sexual function, but it has no effect on voice pitch, which remains unchanged if therapy is started in adulthood. Finally, feminizing therapy is based on the intake of estrogens, available in various formulations, which promote breast development, redistribution of body fat, and increased skin softness. However, individual response to therapy varies, and many transgender women subsequently resort to plastic surgery to complete their body affirmation.

The beauty of one's identity

These therapeutic paths must be approached with the understanding that medicine cannot and should not reduce a person's identity to hormones or bodily modifications. Dominant narratives, which still today pit binary categories like "true man" and "true woman" against each other, risk obscuring the beauty of individual experiences and the spectrum of personalities that can only enrich a social context with new and diverse ideas, thoughts, forms, and bodies. The intersectional approach offers a more ethical and realistic interpretation: inequalities are not solely the result of personal characteristics, but rather the intertwining of systemic oppressions, from sexism to racism, classism to transphobia. 

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