Gender Dysphoria

Gender dysphoria occurs when there is a persistent sense of mismatch between one’s experienced gender and assigned gender.

Definition

Gender dysphoria (formerly gender identity disorder) is defined by strong, persistent feelings of identification with the opposite gender and discomfort with one's own assigned sex that results in significant distress or impairment. People with gender dysphoria desire to live as members of the opposite sex and often dress and use mannerisms associated with the other gender. For instance, a person identified as a boy may feel and act like a girl. This incongruence causes significant distress, and this distress is not limited to a desire to simply be of the other gender, but may include a desire to be of an alternative gender. 

Identity issues may manifest in a variety of different ways. For example, some people with normal genitals and secondary sex characteristics of one gender privately identify more with the other gender. Some may dress in clothes associated with the gender with which they identify, and some may seek hormone treatment or surgery as part of a transition to living full-time in the experienced gender.

Gender dysphoria can be present in children or adolescents and adults, and can manifest differently in different age groups. Young girls may express the wish to be a boy, state that they are a boy, or assert that they will grow up to be a man. They may also prefer boys' clothing and hairstyles, and have intense negative reactions when their parents attempt to have them wear dresses or other feminine attire. Similarly, young boys may express the wish to be a girl or state that they will grow up to be a woman. They may role-play feminine figures, prefer stereotypically female toys (such as dolls) and avoid stereotypically masculine toys (such as cars, trucks). Additionally, some young boys will pretend to not have a penis or express a wish to have a vagina. 

Adults with gender dysphoria may adopt the behavior, clothing, and mannerisms of the gender they experience. They feel uncomfortable being regarded by others as their assigned gender, and have a strong desire to be rid of the primary and sex characteristics of their assigned gender. It is important to note that these behaviors in adults and children are only considered a disorder if the person also experiences significant distress or impairment in major areas of life as a result of the incongruence. 

Associated Features and Disorders of Gender Dysphoria

Many individuals with gender dysphoria become socially isolated, whether by choice or through ostracism, which can contribute to low self-esteem and may lead to school aversion or even dropping out. Peer ostracism and teasing are especially common consequences for boys.

Boys with gender dysphoria often show marked feminine mannerisms and speech patterns.

The disturbance can be so pervasive that the mental lives of some individuals revolve only around activities that lessen gender distress. They are often preoccupied with appearance, especially early in the transition to living in the opposite sex role. Relationships with parents also may be seriously impaired. Some males with gender dysphoria resort to self-treatment with hormones and may (very rarely) perform their own castration or penectomy. Especially in urban centers, some males may engage in prostitution, placing them at a high risk for human immunodeficiency virus (HIV) infection. Suicide attempts and substance-related disorders are common.

Children with gender dysphoria may manifest coexisting separation anxiety disorder, generalized anxiety disorder and symptoms of depression.

Adolescents and adults with gender dysphoria before gender reassignment are at increased risk for suicidal ideation, suicide attempts, and completed suicides. After gender reassignment, suicide risk may persist depending on the adjustment of the individual.

Adults may display anxiety and depressive symptoms. Some adult males have a history of transvestic fetishism as well as other paraphilias. Associated personality disorders are more common among males than among females being evaluated at adult gender clinics.

Gender dysphoria has been reported across many countries and cultures. Among individuals who are assigned male gender at birth, approximately 0.005 percent to 0.014 percent are diagnosed with gender dysphoria. Among individuals who are assigned female gender at birth, approximately 0.002 percent to 0.003 percent are diagnosed with gender dysphoria. Because these estimates are based on the number of people who seek treatment, including hormone treatment and surgical reassignment, these rates are likely an underestimate of the real prevalence rates. 

The level of distress experienced by someone with gender dysphoria is significant, and people do much better if they are in supportive environments and are given knowledge that biomedical treatments exist to reduce the sense of incongruence they feel between who other people tell them they are, and who they feel they are. 

Symptoms

Gender dysphoria looks different in different age groups. Below is the criteria that health professionals look at to diagnose gender dysphoria in children, adolescents and adults.

Children

  • An incongruence between the child's experienced/expressed gender and the gender they were assigned at birth. This incongruence is present for at least six months.
  • A strong desire to be of the other gender or an insistence that one is the other gender
  • In boys (assigned gender), a strong preference for cross-dressing
  • In girls (assigned gender, a strong preference for wearing only typical masculine clothing
  • A strong preference for cross-gender roles in make-believe or fantasy play
  • A strong preference for the toys, games, or activities stereotypically used by the other gender
  • A strong dislike of one's sexual anatomy
  • Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life

Adolescents and Adults

  • An incongruence between the individual's experienced/expressed gender and primary sex characteristics (sexual organs) and/or secondary sex characteristics (breasts, underarm hair). This incongruence is present for at least six months.
  • A strong desire to be rid of one's primary primary and/or secondary sex characteristics
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender)
  • A strong desire to be treated as the other gender
  • A strong conviction that one has the typical feelings and reactions of the other gender
  • Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life 

Cross-gender behaviors begin as early as 2 years, which is the start of the developmental period in which children begin expressing gendered behaviors and interests. Early-onset gender dysphoria typically starts in childhood and continues into adolescents and adulthood, which late-onset gender dysphoria occurs around puberty or much later in life. 

Causes

The cause of gender dysphoria is unknown, but hormonal influences in the womb are suspected to be involved. The condition is rare and may occur in children or adults.

Onset of cross-gender interests and activities is usually between ages 2 and 4 years, and some parents report that their child has always had cross-gender interests. Only a very small number of children with gender dysphoria will continue to have symptoms in later adolescence or adulthood. Typically, children are referred around the time of school entry because of parental concern that what they regarded as a phase does not appear to be passing.

Adult onset is typically in early to mid-adulthood, usually after or concurrent with transvestic fetishism. There are two different courses for the development of gender dysphoria:

  • The first, typically found in late adolescence or adulthood, is a continuation of gender dysphoria that had an onset in childhood or early adolescence.
  • In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood usually following, but sometimes concurrent with, transvestic fetishism.

The later-onset group:

  • May be more fluctuating in the degree of cross-gender identification
  • More ambivalent about sex-reassignment surgery
  • More likely to be sexually attracted to women
  • Less likely to be satisfied after sex-reassignment surgery.
  • Males with gender dysphoria who are sexually attracted to males tend to present in adolescence or early childhood with a lifelong history of gender dysphoria. In contrast, those who are sexually attracted to females, to both males and females or to neither sex tend to present later and typically have a history of transvestic fetishism. If gender dysphoria is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported.

Treatments

Individual and family counseling is recommended for children, and individual or couples therapy is recommended for adults. Sex reassignment through surgery and hormonal therapy is an option, but identity problems may continue after this treatment and should be discussed in psychotherapy.

Many adults with gender dysphoria find comfortable, effective ways of living that do not involve all the components of three-phase treatment—psychological, surgical and hormonal. While some individuals manage to do this on their own, psychotherapy can be very helpful in bringing about personal discovery and maturation that facilitate self-comfort. The best outcomes are associated with early diagnosis, a supportive environment, and comprehensive treatment that respects the wishes and desires of the individual.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Institutes of Health - National Library of Medicine

Last reviewed 04/19/2017