Gender Dysphoria

What Is Gender Dysphoria?

Gender dysphoria involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify. People with gender dysphoria may be very uncomfortable with the gender they were assigned, sometimes described as being uncomfortable with their body (particularly developments during puberty) or being uncomfortable with the expected roles of their assigned gender.

People with gender dysphoria may often experience significant distress and/or problems functioning associated with this conflict between the way they feel and think of themselves (referred to as experienced or expressed gender) and their physical or assigned gender.

The gender conflict affects people in different ways. It can change the way a person wants to express their gender and can influence behavior, dress and self-image. Some people may cross-dress, some may want to socially transition, others may want to medically transition with sex-change surgery and/or hormone treatment. Socially transitioning primarily involves transitioning into the affirmed gender’s pronouns and bathrooms.

People with gender dysphoria may allow themselves to express their true selves and may openly want to be affirmed in their gender identity. They may use clothes and hairstyles and adopt a new first name of their experienced gender. Similarly children with gender dysphoria may express the wish to be of the opposite gender and may assert they are (or will grow up to be) of the opposite gender. They prefer, or demand, clothing, hairstyles and to be called a name of the opposite gender. (Medical transition is only relevant at and after the onset of puberty.)

Gender dysphoria is not the same as gender nonconformity, which refers to behaviors not matching the gender norms or stereotypes of the gender assigned at birth. Examples of gender nonconformity (also referred to as gender expansiveness or gender creativity) include girls behaving and dressing in ways more socially expected of boys or occasional cross-dressing in adult men. Gender nonconformity is not a mental disorder. Gender dysphoria is also not the same being gay/lesbian.

While some children express feelings and behaviors relating to gender dysphoria at 4 years old or younger, many may not express feelings and behaviors until puberty or much later. For some children, when they experience puberty, they suddenly find themselves unable to identify with their own body. Some adolescents become unable to shower or wear a bathing suit and/or undertake self-harm behaviors.

Diagnosis Diagnosis The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults. In adolescents and adults gender dysphoria diagnosis involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following: A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics 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 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 In children , gender dysphoria diagnosis involves at least six of the following and an associated significant distress or impairment in function, lasting at least six months. A strong desire to be of the other gender or an insistence that one is the other gender A strong preference for wearing clothes typical of the opposite gender A strong preference for cross-gender roles in make-believe play or fantasy play A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender A strong preference for playmates of the other gender A strong rejection of toys, games and activities typical of one’s assigned gender A strong dislike of one’s sexual anatomy A strong desire for the physical sex characteristics that match one’s experienced gender For children, cross-gender behaviors may start between ages 2 and 4, the same age at which most typically developing children begin showing gendered behaviors and interests. Gender atypical behavior is common among young children and may be part of normal development. Children who meet the criteria for gender dysphoria may or may not continue to experience it into adolescence and adulthood. Some research shows that children who had more intense symptoms and distress, who were more persistent, insistent and consistent in their cross-gender statements and behaviors, and who used more declarative statements (“I am a boy (or girl)” rather than “I want to be a boy (or girl)”) were more likely to become transgender adults. 3, 4

Treatment Treatment Treatment options for gender dysphoria include counseling, cross-sex hormones, puberty suppression and gender reassignment surgery. Some adults may have a strong desire to be of a different gender and to be treated as a different gender without seeking medical treatment or altering their body. They may only want support to feel comfortable in their gender identity. Others may want more extensive treatment including hormone treatment and gender reassignment surgery leading to a transition to the opposite sex. Some may choose hormone treatment or surgery alone. Individual therapy can help a person understand and explore his/her/their feelings and cope with the distress and conflict. Couples therapy or family therapy may be helpful to improve understanding and to create a supportive environment. Parents of children with gender dysphoria may also benefit from counseling. Peer support groups for adolescents and adults and parent/family support groups can also be helpful. A child’s treatment typically involves a multi-disciplinary team of health care professionals, which may include a pediatrician, a psychiatrist, other mental health professionals, a pediatric endocrinologist (specialists in hormone conditions in children) and an advocate. Treatment may focus primarily on affirming psychological support, understanding feelings and coping with distress, and giving children a safe space to articulate their feelings. For many children the feelings do not continue into adolescence and adulthood. A person may also address social and legal transition to the desired gender.

Challenges/Complications Challenges/Complications Gender dysphoria is associated with high levels of stigmatization, discrimination and victimization, contributing to negative self-image and increased rates of other mental disorders. Transgender individuals are at higher risk of victimization and hate crimes than the general public. Adolescents and adults with gender dysphoria are at increased risk for suicide. In adolescents and adults, preoccupation with cross-gender issues can interfere with daily activities and cause problems in relationships or in functioning at school or work. Children with gender dysphoria may experience teasing and harassment at school or pressure to dress more like their assigned gender. Children with gender dysphoria are at higher risk of emotional and behavioral problems, including anxiety and depression. Transgender individuals may also face challenges in accessing appropriate health care and insurance coverage of related services.

Definitions and Pronouns

Definitions 1, 5, 6 Gender - denotes the public (and usually legally recognized) lived role as boy or girl, man or woman. Biological factors combined with social and psychological factors contribute to gender development.

denotes the public (and usually legally recognized) lived role as boy or girl, man or woman. Biological factors combined with social and psychological factors contribute to gender development. Assigned gender - refers to a person’s initial assignment as male or female at birth. It is based on the child’s genitalia and other visible physical sex characteristics.

refers to a person’s initial assignment as male or female at birth. It is based on the child’s genitalia and other visible physical sex characteristics. Gender-atypical - refers to physical features or behaviors that are not typical of individuals of the same assigned gender in a given society.

refers to physical features or behaviors that are not typical of individuals of the same assigned gender in a given society. Gender-nonconforming - refers to behaviors that are not typical of individuals with the same assigned gender in a given society.

refers to behaviors that are not typical of individuals with the same assigned gender in a given society. Gender reassignment - denotes an official (and usually legal) change of gender.

denotes an official (and usually legal) change of gender. Gender identity - is a category of social identity and refers to an individual’s identification as male, female or, occasionally, some category other than male or female. It is one’s deeply held core sense of being male, female, some of both or neither, and does not always correspond to biological sex.

is a category of social identity and refers to an individual’s identification as male, female or, occasionally, some category other than male or female. It is one’s deeply held core sense of being male, female, some of both or neither, and does not always correspond to biological sex. Gender dysphoria - as a general descriptive term refers to an individual’s discontent with the assigned gender. It is more specifically defined when used as a diagnosis.

as a general descriptive term refers to an individual’s discontent with the assigned gender. It is more specifically defined when used as a diagnosis. Transgender - refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their gender at birth. (Note: the term transgendered is not generally used.)

refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their gender at birth. (Note: the term transgendered is not generally used.) Transsexual - refers to an individual who seeks, or has undergone, a social transition from male to female or female to male. In many, but not all, cases this also involves a physical transition through cross-sex hormone treatment and genital surgery (sex reassignment surgery).

refers to an individual who seeks, or has undergone, a social transition from male to female or female to male. In many, but not all, cases this also involves a physical transition through cross-sex hormone treatment and genital surgery (sex reassignment surgery). Genderqueer - blurring the lines around gender identity and sexual orientation. Genderqueer individuals typically embrace a fluidity of gender identity and sometimes sexual orientation.

blurring the lines around gender identity and sexual orientation. Genderqueer individuals typically embrace a fluidity of gender identity and sometimes sexual orientation. Gender fluidity - having different gender identities at different times.

having different gender identities at different times. Agendered - ‘without gender,’ individuals identifying as having no gender identity.

‘without gender,’ individuals identifying as having no gender identity. Cisgender - describes individuals whose gender identity or expression aligns with the sex assigned to them at birth.

describes individuals whose gender identity or expression aligns with the sex assigned to them at birth. Gender expansiveness - conveys a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system.

conveys a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system. Gender expression - the manner in which a person communicates about gender to others through external means such as clothing, appearance, or mannerisms. This communication may be conscious or subconscious and may or may not reflect their gender identity or sexual orientation.

Preferred Gender Pronouns

Some transgender and gender-nonconforming people may prefer gender-neutral or gender-inclusive pronouns when talking to or about them. “They” and “their” are sometimes used as gender-neutral singular pronouns. Singular gender-neutral pronouns also include “ze” (or “zie”) and “hir.”

Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Fifth edition. American Psychiatric Association. 2013 Excerpted from DSM-5. Note: The term gender dysphoria replaced the term gender identity disorder used in an earlier version of DSM. Sherer, I, et al. 2015. Affirming gender: Caring for gender-atypical children and adolescents. Contemporary Pediatrics. Steensma, TD, et al. 2013. Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. J Am Acad Child Adolesc Psychiatry, 52(6):582-90. PFLAG Glossary Human Rights Campaign, survey

Physician Review By:

Ranna Parekh, M.D., M.P.H.

February 2016