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Self-report as the basis of gender identity

For "gender identity", self-report is the main source of information: there is no validated objective test. Critics find that too little as a basis for far-reaching medical steps. In practice, self-report is one of the sources in a diagnostic process.

What self-report is — and is not

Self-report means that the patient reports on an internal state themselves, without external verification. In empirical social science this is a common method, but with known limitations: socially desirable answers, recall bias, impression management and the absence of an objective reference point. In diagnostics, self-report is usually one source among others: observation, medical history, laboratory tests, imaging, course over time.

For gender identity: no objective marker

With pain, self-report can be supplemented with imaging, behavioural observation and physiological measurements, and with depression by validated scales and clinical observation. For gender identity such an independent reference point is missing. The Cass Review writes that there is no clear evidence for a straightforward biological cause of gender incongruence, although a biological predisposition may play a part in some people (para. 8.21) (source). See also no measurable marker, no brain marker and no genetic marker. ICD-11 moved gender incongruence from the chapter on mental disorders to the chapter "Conditions Related to Sexual Health" (source).

The Cass Review on assessment

According to the final report of the Cass Review (2024), few guidelines recommend formal measurement tools for gender dysphoria, and the tools that exist are poorly validated (source). The report calls the diagnosis of gender dysphoria not reliably predictive of whether someone will later continue to experience gender incongruence, or of whether medical treatment is the best option (source). Cass also writes that some clinicians dropped the usual broad assessment of the patient (source) and recommends a broad, holistic assessment for every child (source). SBU (2022) and NICE (2020) rated the evidence for the effects of treatment as insufficient and as very low certainty respectively (source, source). That concerns the evidence for treatment, not self-report itself.

The circular reasoning that remains

Without an independent criterion, self-report risks ending up in circular reasoning: "I am trans because I feel trans, and I feel trans because I am trans." Critics therefore call the claim unfalsifiable. In the Netherlands, according to the Health Council, somatic care only follows after extensive diagnostics and an indication by a multidisciplinary team (source); self-report is therefore one source within a pathway.

Comparison with other domains

Critics compare it with other conditions: with anorexia, self-report of body image is taken seriously as a symptom, not as reality, and with body integrity dysphoria no healthy limb is amputated. Supporters see gender identity precisely as an experience that only the person can report. It fits into a broader debate about being versus feeling.