Transsexual people are becoming increasingly visible in public life and more and more people are ‘coming out’. Some of them realise their trans-sexuality early in life, while many take their time. This scenario is not completely due to society’s concept of gender but has to do also with limited understanding of dysphoria and its ramifications among the populace. Gender dysphoria, in simple terms, refers to the perception of mismatch between a person’s sense of self and internal and external parts of the body (in relation to gender identity and expression). In this article, I try to formulate a simple guide for discovering gender incongruence or dysphoria with exclusive focus on trans women – because it is difficult to write unified guides across even a couple of trans categories.

First of all a few words about the terminology. The concept of “gender incongruence” is sometimes advanced to replace “gender dysphoria” for removing the stigma associated with the latter term (“Dysphoria” is the preferred term in DSM-5). It has also been proposed that the former term should be considered outside of DSM in the first place. The older term, ‘Gender identity disorder’ pathologizes gender variance itself (and is still part of ICD-10 CM), while ‘gender dysphoria’ pathologizes the discontent. Importantly the term “dysphoria” is preferred by WPATH. So I will stick to this terminology in the article. Feel free to replace the term with “incongruence” if you like it.

Before I proceed, it is necessary to clarify basics of sex and gender as these concepts are not understood in a uniform way.

Scientifically, sex of a person is best seen as a tuple of parameters corresponding to hormonal sex, brain sex, clinical sex, chromosomal sex, physical sex and more. Population data relating to this cannot be properly classified. Gender is a vague social concept characterized by arbitrary norms and prescriptions. Modern people recognize that genders exist on a spectrum and do not abide by religious ideas of binary gender with its rigid prescriptions of heteronormativity. Gender identity of a person is the person’s own sense of gender without regard to expression of the same in society. Recent research does prove that a part of the gender identity of a person is in the brain and that it develops in the fetal development state itself – this is almost the same thing as “brain sex” as the latter includes structural and functional differences between brains.

A plural concept is a concept with multiple facets or dimensions. Well known trans feminist and biologist Julia Serano uses the term ‘gender’ in a plural sense in her latest book – “Excluded: Making Feminist and Queer Movements More Inclusive”. She recognizes that biology, culture and environment all interact in an unfathomably complex manner to generate gender diversity and argues that people tend to end up limited ideas of gender, sexuality and sexism because of limited life experiences and social situation. The complexity of interactions therefore forces us to view the components separately. In “what it means to be a women”, she says “I used to think it was a contradiction that some dykes abhorred me for my masculinity while others hated me for my femininity, until I realized that being a woman means that everyone has a stake in seeing what they want to see in me”.

Since gender is such a plural term and transsexuals evolve in so many different ways, it is only natural that self-discovery of gender dysphoria can take on so many forms. You can infer that you have gender dysphoria by simply reflecting on your gender identity and comparing it with other people’s experience of dysphoria or with prototypical models of dysphoria. It is possible that your experiences may not tally with those of others and still you may be having dysphoria.

It is fairly well known that for a given gender identity on the gender continuum a wide range of gender expression may be associable. Thus for example, a person identifying as a woman may have so-called butch features. Some of these women may identify as gender queer women and some may identify as cis women or simply as women. Even people with gender dysphoria have diverse gender expression and some part of this expression can be related to dysphoria – but the centrality of gender identity stands tall in self-discovery of dysphoria.

Gender dysphoria can be detected even in six year olds, but due to the under-developed nature of society and social conditioning many people wait till the problems have become unbearable and have already caused enough damage. Early intervention is important and it would be best if people with gender dysphoria take their own decisions as a therapist’s understanding is liable to be affected by the subjective nature of responses.

In what follows, I have used the limited accounts of dysphoria by prominent trans women, discussions with various trans women on multiple forums, formal literature and my own experience as a lesbian trans woman to arrive at possible characterization of dysphoria as is actually experienced.

Amy Dentata is a writer, game designer, and performer who touches on topics including trauma recovery, mental illness, sexuality, futurism, and trans issues. She started performing music at open mics in her home-town of Cleveland, Ohio, before moving to the Bay to pursue a career as a game artist. She explains the fact that a part of gender identity is an intrinsic part of the person. The interaction of gender identity in the brain with the body towards formation of dysphoria is explained through a brilliant analogy. She does not identify on the binary and her perception of her time-line highlights other aspects of her dysphoria.

Since 2008, Zinnia Jones has been a writer and video-blogger. She’s written extensively on the subjects of secularism, feminism, and being a trans woman. She describes aspects of her dysporic experience in considerable detail in her blog post and notes that many trans women (including herself) fail to recognize symptoms of dysporia as being connected to gender for considerable periods of time. Further she mentions “The real extent of my dysphoria only became clear after I began to transition (motivated largely by the desire to induce physical feminization and prevent further masculinization, rather than the need to treat a clear dysphoria), and these feelings dissipated for the first time ever. Once I had this basis for comparison, I could see that I was indeed experiencing gender dysphoria all along – it was just so indirect that I had failed to recognize it as specifically gender-related”. Some of her proposed symptoms are mixed up with her own general attitude to life and so I had to abstract the essentials from those.

Rebecca Williams identifies on the binary and describes herself as a “femme, mildly androphobic queer trans feminist”. Her description of dysphoria can be garnered from across many articles in her blog. She says that she cannot possibly describe the wonderful feeling of her hormonal system getting wired up correctly (after HRT) and that even tiny corrections to physical form by HRT are always for the better and that it helped a lot with her social acceptance. The relation between dysporia and normality is expressed thus “I think the thing about specific parts of dysphoria is that once they’re treated, it’s gone forever. There’s no particular feeling other than feeling normal … … I think really, this is what it’s all about. Just wanting to feel normal.”

Below I list a number of severe dysphoria related characteristics (not necessarily without overlap) that a trans woman may have. Various combinations of weak versions of these are sufficient for a diagnosis of dysphoria.

Body Related:

S1. Extreme discomfort with most male secondary characteristics.

S2. Extreme discomfort with most male secondary characteristics to the point of misandry.

S3. Strong Aversion to use Pre-HRT genitalia in any sexual activity.

S4. The distinct feeling of testosterone poisoning.

S5. Experiences of apparently phantom sensations of female genital stimulation and orgasms as part of regular sexual interaction and fantasies.

S6. Depression due to inability to eliminate male secondary characteristics.

S7. Depression due to inability to eliminate genitals/testes.

S8. Inability to perform sexually due to genital dysphoria by way of suppression of libido.

S9. Strong suicidal tendencies.

Depression Inclusive:

A. Depression due to inability to fit in desired female role.

B. Depression due to missing feminization of existing features.

C. Depression in general due to latent dysphoria (about which subject is not explicitly aware of).

Social Interaction Related:

I1. A strong feeling of interacting in a dehumanized society due to forced male presentation that increases by recursion with the living.

I2. Strong tendency to escape from gendered social interaction.

I3. No male role models

I4. Some female role models

I5. No interest in acquiring perceived male characteristics.

I6. Strong desire to acquire perceived female characteristics like smooth, beautiful, evenly-toned, hairless skin.

I7. Strong desire to behave as per desired as opposed to assigned gender role.

I8. Adopted features selected from male role models do not have any gender related import.

I9. Adopted features selected from female role models have strong gender related import.

Other

O1. Awareness of glaring differences in spousal expectations (relative their libido) and desired personal presentation.

O2. Workaholism originating from desire to escape from oppressive social life and effects of testosterone.

O3. Substance abuse originating from desire to escape from the oppressive social life and effects of testosterone.

O4. Gender expression in drag-like modes results in depression and feelings of inadequacy.

O5. Severe numbing of emotions due to perceived long-term latent dysphoria.

O6. Awareness of severe differences in body chemistry in relation to people of assigned gender.

O7. Androphobia

O8. Awareness of being different from others.

O9. A notable escalation in the severity of all of these symptoms during puberty.

It is well known in statistical terms (as well) that the class of transsexual people suffer additional psychiatric problems at the same rate as normal people. So we have additional reasons to exclude any other psychiatric conditions (including mild ones) from the considerations.

In the above S1 or S2 and S4 and any of the S* conditions is a sufficient indication of gender dysphoria. Many weakenings of the above may be sufficient conditions. Zinnia Jones for example, experienced only a vague and weak version of S1 in her pre-transition period and came to realize the full extent of what she was missing out only after some HRT. Some trans women have reported S1 and O7. Others have confirmed combinations like S1, a little S2, mild S3, S6, S7, S9 (mainly in the past), A, B, C (prior to 2000), I1, I2, I3, I4, I5, I6, O1, possibly O2, O7.

A weak form S1 and I1 or I2 in people who are past twenty five is often suggestive of dysphoria that requires more attention – mainly because it is not such a nice thing to wait till the condition worsens.

I3 to I9 are useful for understanding one’s own internal evolution of gender expression and realize dysphoria in presence of suitable indications from the S* or I* conditions.

If any person has O5, then they need to be more careful in their analysis because everything probably would be lacking in intensity in their perspective. Depression is pretty common in society and may be organic without reason. So it is necessary to trace the exact reasons for it. If can be due to dysphoria and often (if not always) accompanies it in mild to chronic form.

Some heterosexual/bisexual trans women who apparently take the “gay/drag route” (relative to a conservative society) to realize themselves. O4 is typically experienced by such women. Other O* conditions are not related to sexual orientation. Obviously trans women with S2 are likely to be lesbians. It is known that a majority (as much as 2/3rd in the largest survey) of trans women are lesbians or bisexual. Though trans-sexuality in general is independent of orientation in the sense that a transsexual may have any kind of orientation, connections between dysphoria conditions and orientation are natural – and natural even when we transcend stereotypical expressions of orientation (because people take time to learn).

All of S2, S4, S6, S9, B, I1, I2, I3, I5, I7, I8, I9, O2, O6, O8, and O9 apply to my experience of dysphoria. A dense account of this can be found in my blog post. Since my high school days, I have always identified as a lesbian and being a lesbian is not just about my orientation, but is part of my identity. It did affect socialization, but I am not mixing that up with dysphoria related reasons. I never had any real role models, though I have always admired a lot of women (mostly older) and usually abstracted positive traits from them and adapted them in my own way. I* conditions are not about dysphoria per se, but I do feel that they are important for investigating latent dysphoria in people in their social context.

Most of the symptoms associated with dysphoria resolve substantially upon initiating HRT. But that is no way of checking whether one has dysphoria or not.

Hope all this helps you in your gender explorations!