Red Flags in Gender Assessment: 3 Cases That Required Deeper Investigation

After 20 years and over 7,200 comprehensive gender assessments, most people who come to me are trans—they know it, I confirm it, they move forward. But I've encountered cases where something didn't add up, not because someone was lying, but because gender dysphoria wasn't the primary issue. Sometimes people want to transition to escape trauma rather than because their gender is incongruent. Sometimes gender dysphoria appears during active psychosis or mania with no prior history. Sometimes transition is sought as a solution to depression, loneliness, or existential emptiness that has nothing to do with gender.

This is sensitive territory—the trans community is rightfully wary of gatekeeping. But ignoring red flags doesn't help anyone. If someone transitions expecting it to fix trauma or depression and those issues remain, that's harm, not affirming care.

In this video, I walk through three red flags I've learned to watch for: wanting transition as escape from trauma or oppression (with examples of sexual assault survivors, people rejecting toxic masculinity, and those fleeing cultural oppression), active psychosis or severe mania (with examples of delusional systems incorporating gender), and seeking transition to fix unrelated problems like depression, isolation, or midlife crisis. For each red flag, I provide multiple detailed real-world examples from my practice and offer three reflection questions to help you think clearly about what you're experiencing.

Watch this video to understand responsible comprehensive assessment—with specific questions to help clarify whether gender dysphoria is the primary issue or whether something else needs addressing first.