Gender Dysphoria

Gender dysphoria occurs when there is a persistent sense of mismatch between an individual’s gender identity and the sex and/or gender they were assigned at birth, and when this mismatch causes the individual intense distress.

Definition

Gender dysphoria (formerly known as gender identity disorder in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM) is defined by strong, persistent feelings of identification with another gender and discomfort with one's own assigned gender and sex; in order to qualify for a diagnosis of gender dysphoria, these feelings must cause significant distress or impairment. People with gender dysphoria often desire to live in accordance with their gender identity and may dress and use mannerisms associated with the gender with which they identify in order to achieve this goal.

Both gender identity issues and feelings of dysphoria may manifest in a variety of different ways. A person with female sex characteristics, for example, may privately identify as a man, but continue to publicly present themselves as a woman. Another may choose to dress in clothes associated with the gender with which they identify, while yet another may seek hormone treatment or surgery as part of a transition to living full-time as the gender with which they identify. Each of these individuals may—or may not—experience significant feelings of distress or impairment as a result of their gender identity concerns. Adults with gender dysphoria typically feel uncomfortable being regarded by others as their assigned gender and often desire to be rid of the physical sex characteristics associated with it

Gender identity incongruence and the feelings of distress that indicate gender dysphoria can be present in children, adolescents, or adults, and can manifest differently across age groups. A child who is assigned one gender may express the wish to be a different gender, state that they are, or assert that they will grow up to be. They may also prefer the clothing, hairstyles, or toys typically associated with the other gender and may demonstrate intense negative reactions when adults in their life attempt to have them wear clothing associated with their assigned gender. Additionally, some children will show discomfort with their physical sex characteristics.

Gender dysphoria in adults and children is considered a disorder if the person also experiences significant distress or impairment in major areas of life as a result of the incongruence. Identifying with a gender different from the one that was assigned is no longer considered a mental disorder in itself.

Associated Features and Disorders of Gender Dysphoria

Due to feelings of distress and stigma, 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.

In some cases of gender dysphoria, the disturbance can be so pervasive that an individual’s mental life revolves around activities that lessen gender-related distress. These individuals may be preoccupied with their appearance, especially prior to or early in a formal gender transition. Relationships with family members may also be seriously impaired, particularly in cases where family members hold negative or stigmatizing views about transgender or gender non-conforming individuals.

Suicidal ideation, suicide attempts, and substance-related disorders are relatively common among those experiencing gender dysphoria. After gender transition occurs, suicide risk may dissipate or persist, depending on the adjustment of the individual. Children with gender dysphoria may manifest coexisting separation anxiety disorder, generalized anxiety disorder, or symptoms of depression. Adults may display anxiety and depressive symptoms as well.

Gender dysphoria has been reported across many countries and cultures, and incongruences between sex and gender have existed in human society for thousands of years. According to the DSM-5, among individuals who are assigned male at birth, approximately 0.005 percent to 0.014 percent are later diagnosed with gender dysphoria. Among individuals who are assigned female at birth, approximately 0.002 percent to 0.003 percent are later diagnosed with gender dysphoria. Because these estimates are based on the number of people who seek formal treatment—including hormone therapy and/or surgical reassignment—these rates are likely an underestimate of actual prevalence. 

The level of distress experienced by someone with gender dysphoria is significant, and individuals do much better if they are in supportive environments, allowed to express their gender in the way that’s most comfortable to them, and are given knowledge that, if necessary, treatments exist to reduce the sense of incongruence they feel. 

Symptoms

Gender dysphoria looks different in different age groups. According to the DSM-5, health professionals deciding whether to diagnose gender dysphoria in children, adolescents, and adults should look for the presence of the following symptoms:

Children

  • An incongruence, present for six months or longer, between the child's experienced/expressed gender and the gender they were assigned at birth
  • A strong desire to be of the other gender (or another gender identity, such as non-binary) or an insistence that one is another gender
  • In boys (assigned gender), a strong preference for wearing or simulating female attire, and/or a resistance to wearing traditional masculine clothing
  • In girls (assigned gender), a strong preference for wearing typical masculine clothing, and/or a resistance to wearing traditional feminine 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

If at least six of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

  • 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), lasting for at least six months
  • A strong desire to be rid of one's 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 an alternative gender
  • A strong desire to be treated as the other gender or an alternative gender
  • A strong conviction that one has the typical feelings and reactions of the other gender or an alternative gender

If at least two of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes:

  • Clinically significant distress or impairment in major areas of functioning, such as social relationships, school, or home life 

Cross-gender behaviors can begin as early as 2 years old, 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 adolescence and adulthood; late-onset gender dysphoria, on the other hand, occurs around puberty or much later in life. 

Causes

The causes of gender dysphoria are currently unknown, but genes, hormonal influences in the womb, and environmental factors are all suspected to be involved. 

The onset of cross-gender interests and activities is usually between ages 2 and 4 years, and many parents later report that their child has always had cross-gender interests. Only a small number of children with gender dysphoria will continue to have symptoms in later adolescence or adulthood. Typically, children with gender dysphoria are referred around the time of school entry, particularly if peer relationships become challenging or parents suspect that their child’s gender identity issues are not a phase.

Adult onset is typically in early to mid-adulthood. There are two common courses for the development of gender dysphoria:

  • The first, typically observed 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.

Treatments

Individual and family counseling is recommended for children with gender dysphoria, while individual and/or couples therapy is recommended for adults. Surgery and hormone therapy are options, but they are not desired by every individual, and feelings of distress may continue after this treatment. These possibilities should be discussed in psychotherapy.

While some individuals manage to overcome symptoms of distress on their own, psychotherapy is often very helpful in bringing about the personal discovery that facilitates self-comfort and in dealing with strong emotions that may have resulted from peer-related challenges or social stigma. The best outcomes for those with gender dysphoria 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 02/22/2019