by Zinnia Jones — September 10, 2013

Update, June 2017: Please see my latest post on depersonalization symptoms in gender dysphoria for further details on the dissociative phenomena described in this article.

I am not a doctor, and none of this should be taken as medical advice or as diagnostic of any medical condition. These are anecdotes sourced from my experiences and those of others.

Gender dysphoria is widely described and experienced as distress due to discomfort with one’s assigned sex, and the desire to live as another sex. The condition of gender dysphoria is common among transgender people, although being transgender is not itself a condition or disorder, nor is the presence of gender dysphoria required in order for someone to be transgender. Not all trans people have significant gender dysphoria or experience their dysphoria in the same way: different trans people may be uncomfortable with different aspects of their assigned sex, their body, their presentation, the gender role expected of them, and so on.

Nevertheless, the common thread of gender dysphoria is that it is linked with our gender and the various components of this. The distress of dysphoria, and hopefully its resolution, are contingent on how closely the overall situation of our gender aligns with what we need it to be. For this reason, people typically understand the experience of gender dysphoria as being very clearly and self-evidently centered on gender. The most widespread notion is that we become aware of our dysphoria in very direct, gender-related ways, such as knowing from a young age that we’re actually women or men despite the sex we were assigned, feeling “trapped” in our bodies due to their inappropriate sex characteristics, needing to make our “outside” match our “inside”, and strongly wishing to present and live as another gender.

Diverse experiences of dysphoria

This understanding of gender dysphoria is an incomplete one. A largely unrecognized facet of dysphoria is that not all trans people initially recognize or experience this as being unmistakably connected to our genders. Some of us suffer the distress that stems from dysphoria, but without many clues that this is about gender, and its relation to our genders may be obvious only in retrospect. Much attention is focused on the “gender” part of this, the well-defined cross-gender identities and needs and feelings. Less is given to the experience of more general dysphoria.

What is dysphoria? Outside of gender dysphoria, it’s hard to find much useful information on what dysphoria itself is supposed to mean. It’s certainly not limited to gender dysphoria – it can be a symptom of various other conditions as wide-ranging as anxiety disorders, personality disorders, major depression, bipolar disorder, schizophrenia, insomnia, PMS, and stress, and it can also be a side effect of antipsychotic drugs.

But what does dysphoria actually feel like – how does it present itself? You won’t find much more detail than a simple list of other symptoms. Wikipedia describes it as “a state of feeling unwell or unhappy; a feeling of emotional and mental discomfort”. Another page lists anxiety as a symptom of dysphoria, and dysphoria as a symptom of anxiety. As a 2007 paper in Australasian Psychiatry concluded:

The current semantic status of dysphoria is most unsatisfactory. Its definitions are usually too broad or too simplistic and, therefore, not clinically useful. There is no agreement on what the term means.

People in distress want to understand exactly what it is they’re experiencing and why they’re experiencing it, and vague references to “feeling unwell” are not helpful. We already know we’re not feeling well. Why? And what can we do about it?

That’s the question faced by trans people whose gender dysphoria doesn’t present in ways that are directly and plainly connected to gender. My gender dysphoria primarily took the form of this indirect dysphoria, and I’ve spoken with many other trans people whose dysphoria also did not initially have a clear and unavoidable association with gender. Due to the lack of strong indicators that these “unwell feelings” are actually a matter of gender, it can take us quite a long time just to realize that we’re trans or that what we’re feeling is dysphoria. This can be so non-obvious that even as some of us do begin to explore the possibility of transitioning, we still might not make the connection that our unwell feelings are a symptom of dysphoria, or that transitioning is something that could help with this.

The importance of recognizing dysphoria

When you don’t know what this is, or that it’s even an actual condition, it’s easy to mistake it for who you naturally are. You might think it’s part of your innate personality and disposition, and something you just have to learn to cope with. This can delay recognizing that you’re trans or that transitioning is an appropriate choice for you. Because I viewed my lifelong unease in this way, I initially believed that I didn’t even experience dysphoria, and that I was already okay. I didn’t know there was anything wrong with me.

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.

Trans and questioning people sometimes doubt that they’re trans simply because they don’t have distinct feelings of gender-related unease. They might otherwise face a great deal of confusion about what it is they’re feeling, but they can be aided in their self-understanding by the insight that gender dysphoria doesn’t always manifest as a neon sign flashing “FIX YOUR GENDER”. For them, it can help to realize that their less specific feelings of discomfort might also be due to gender dysphoria. It can give them a possible answer to explore. It can give them hope.

But they won’t get that from uselessly opaque lists of symptoms like “discomfort” and “unhappiness”. Words like “anhedonia” and “malaise” don’t capture the detailed, visceral, day-to-day reality of this indirect dysphoria. Here, I aim to define it ostensively, with real-life examples of this dysphoria that seem broadly common to the experiences of myself and others.

Again, not all trans people will necessarily have all or any of these signs, as everyone’s gender dysphoria is different. Some people have more obviously gender-related symptoms than others. Similarly, not everyone with these signs is necessarily trans. They aren’t inherently limited to sufferers of gender dysphoria and can potentially be due to any of the other conditions previously listed, like garden-variety depression or anxiety disorders – but for some trans people, these are indeed symptoms which resolve once the dysphoria is addressed.

This is an initial attempt to feel out a phenomenon that isn’t yet widely known, named, or defined. Some trans people may recognize their experiences in this list, and others may not. But if I had known these things, it would have made my transition a lot easier. And perhaps cis people, too, can start to understand just how damaging dysphoria can be – and how important it is to treat it.

Signs of indirect gender dysphoria

1. Continual difficulty with simply getting through the day. For most of my life, everything was inexplicably stressful, and it was hard to work up the effort to do even the smallest everyday things. Going to the store, cleaning up the house, getting in the shower, any little thing people asked of me… it all just felt like too much. Even when there was no situational cause for this stress, nothing came easily to me. It was more than a mere habit of laziness – it was like I was so mentally fatigued that everything was a constant burden and a struggle.

I could force myself to get things done, but it would take a lot out of me. I would be irritable, snappish, annoyed by everything, and in anywhere from a mildly bad mood to a very bad mood almost every day. What happiness I did experience was typically short-lived and compromised by the ongoing undertone of dissatisfaction and, well, grumpiness. I didn’t like this at all. It was a constant tension, and I wished more than anything that I could find some way to relax and unwind. I didn’t want to be this way.

2. A sense of misalignment, disconnect, or estrangement from your own emotions. I was always on an unsteady footing with my feelings. As a child, I would cry almost every day at the drop of a hat. Anything could trigger it – being even mildly reprimanded, getting a wrong answer on schoolwork, the sort of insignificant things that no one else around me ever cried so frequently about. It really was abnormal, and eventually most of the people around me got pretty tired of it. It was so embarrassing and I tried to stop it because I didn’t want to cry so much, either. But I couldn’t control it.

In my teen years, this shifted: I could almost never cry at all, even when I wanted to. I would feel like crying, I would know on some level that I should be crying, but I just couldn’t make it happen. When I rarely did manage to cry, that was even worse. It was too much, and I would be overcome by it to the point of uncontrollable wailing sobs. There was no in-between, no moderate amount of tears. I cried as much at the death of a month-old pet rat as I did at my grandmother’s funeral.

And I dreaded crying, because afterward and for the next day or so, I would be smothered in this horrible feeling of emotional deadness. It felt like my head was full of concrete, like my consciousness was trying to wade through molasses, and it was a feeling that seemed to be genuinely physical in nature. It seemed as though my brain simply ran out of whatever fueled my ability to feel anything at all – like I had no emotions left. There was no way to “get over it” or force myself to perk up, I just had to wait it out. I resented anyone or anything that made me cry. I feared the awful choking numbness that was bound to happen next time.

3. A feeling of just going through the motions in everyday life, as if you’re always reading from a script. Everything always seemed like it was somehow less real than it ought to be. I didn’t feel like I was my own person – I had no sense of myself as someone who could make my own choices and decisions as I wished. I often lacked that internal initiative that wants things and seeks things for no reason other than the fact that you simply want them and that’s that. I didn’t even think of that kind of wanting as a feeling I was capable of – there was just no drive for it.

In the absence of a well-defined identity and a strong sense of self-direction, other people’s obligations filled the void. Since I didn’t want to do anything, I just did whatever was expected of me and said whatever was expected of me. That was all I ever did. I felt like an actor, being handed my lines by someone else, and I didn’t know how to be anything other than that. I didn’t know I should be anything other than that. I often thought of wanting to tear my face off to see if there was anything real underneath.

4. A seeming pointlessness to your life, and no sense of any real meaning or ultimate purpose. Even when I did find things to do that I vaguely enjoyed, it still felt like I was just killing time. Each day was like checking off a box, knowing that eventually the days would run out, but not really knowing how else to spend the time. When I worked on things, there wasn’t any higher sense of eventually working toward anything.

You live for a while, and then you die, and that’s that. I didn’t think there was anything else to life. So why bother with any real long-term goals? When I did set goals for myself, it was just for the sake of it – not because I was motivated by any purpose that I genuinely cared about. Nothing made me feel truly fulfilled, like I was accomplishing anything meaningful. So why bother?

5. Knowing you’re somehow different from everyone else, and wishing you could be normal like them. I often wondered how other kids could just go about their lives, talking and laughing and being so calm and happy, like nothing was wrong. I don’t know what I really expected of them – I didn’t have the vaguest idea of what was “wrong”, either. I didn’t know why I felt so anxious all the time, I just did. I had no idea why the rest of the world didn’t feel the same way, and I wanted to know what that was like.

It felt like my mind was constantly talking to itself without any interruption, and it was overanalyzing everything around me. Some second, parallel existence seemed to be running alongside my direct experience of consciousness: an inner monologue of sorts, but a very toxic one. I couldn’t stop thinking about everything – it was as though this loud voice in my head kept me from simply existing in the moment.

There was no way to shut off that voice and just be, like everyone else. I wanted those two sides to line up and merge so I could feel natural and at ease too. But it wouldn’t go away, no matter how hard I tried. There always seemed to be some invisible skin separating me from the rest of reality – I could move around in the real world, interact with it, but never actually touch it or feel it.

6. A notable escalation in the severity of these symptoms during puberty. Around 12 or 13, things really started going downhill for me. While it was already difficult to cope with school, friends, and a troubled home life, I was able to handle it before the onset of puberty. Not anymore. For a few years, my emotions weren’t just blunted or dysfunctional – they went missing almost entirely. I felt nothing, day in and day out. And each day was the same, a robotic routine of just waiting for the time to pass. I couldn’t even force myself to care about anything. This, too, felt like a truly physical thing that I couldn’t fight.

I knew I was failing every class, and it just didn’t matter to me. I handed in blank tests without a care in the world. I was fully aware of what the long-term consequences would be, but none of it seemed real. I’d already hit bottom – nothing could make it any worse. I couldn’t bring myself to get anything done no matter how much anyone lectured or threatened or punished me.

They told me I was throwing away my future – I didn’t even see any problem with that. What future? Why did anyone care about me? I sure didn’t. My parents withdrew me after sophomore year because there was no point to keeping someone in school who just didn’t do anything. So I stayed indoors like a hermit for most of my teen years, and didn’t do anything there, either.

7. Attempting to fix this on your own through various coping mechanisms. I often wondered whether some substance, like cannabis, was what I needed to loosen up and finally relax. I tried that. I tried drinking, I tried Vicodin, I even tried nootropics like piracetam, all of it in the hopes that it could improve my mood and make life feel easier. I wanted to find something, anything, that would be the key to repairing what I increasingly saw as the broken parts of myself. Some of it helped for a short while, thought not significantly. By no means did it “fix” me in any meaningful sense – it took my mind off things for a bit, but the problem was still there.

When none of that worked, I tried to train my mind to shy away instinctively from negative thoughts so that I wouldn’t spiral off into depressive ruminations as I had for most of my teen years. This was mostly successful, and it wasn’t a bad idea by any means, though the fundamental unhappiness and anxiety remained. I figured all I could do was ignore it as much as possible and focus on whatever positives I could find – I gave up hope of ever truly fixing this.

8. Substantial resolution of these symptoms in a very obvious way upon transitioning, particularly upon initiating HRT. While this is somewhat of a diagnosis-by-treatment, this is what makes it clear that these difficulties are indeed specifically gender-related, and not due to other conditions. If we’re fortunate, then one way or another, we eventually start to pick up on our own personal hints that lead us in the direction of reconsidering our gender. And at a certain point in the process, we begin to realize that this might be what we’ve been searching for all our lives.

For me, as I transitioned a little, it helped a little. When I presented in a feminine way and took on a feminine identity, I started to come into my own and take shape as a real person. I began to steer my life in a direction that I wanted. It was easier to have goals and things I derived satisfaction from, and this encouraged me to start caring about myself more. I was able to fall in love and have a real relationship for the first time – something I never saw the point of before, and had resigned myself to doing without.

Still, my general sense of discomfort and irritability remained, and it kept making my life difficult. I was tired of feeling bad every single day. But as it turned out, when I transitioned a lot, it helped a lot. Once I started HRT, the effect was immediate: these symptoms totally dissipated. It was such a stark difference, it became clear that what I’d been suffering before likely was indeed physical and chemical in nature. I could tell it had been gender dysphoria, because it just wasn’t there anymore once I received the treatment for gender dysphoria.

Now, I could actually relax – it was so amazing to be truly calm for the first time in my life. And it lasted, and there was no more pain to hide. I could cry and feel good afterward, as if it replenished me rather than draining me of emotion. It was possible to feel things in all their detail and depth and texture, rather than being limited to either numbness or emotional overload. The skin of separation was gone, and life was a breeze: I was just happy, all day, without constantly intrusive thoughts distracting me and separating me from the world. I can truly care about everything I choose to work towards, because it matters now. I’m the normal person I always wanted to be, and I can get on with simply living.

Finally, I was a whole human being. Nothing was wrong and nothing was missing anymore. I found what I was looking for, and it gave me back the life that dysphoria had taken from me.

Again, these signs aren’t shared by all trans people – every person’s dysphoria is a little different, and transitioning can have differing effects on us. But it seems that a significant portion of trans people, whether their dysphoria is clearly gender-related or more subtle, report having feelings similar to these. If you’ve been reevaluating your gender, and these experiences seem relatable to you, it may be worth considering that this could be gender dysphoria – and that it’s potentially treatable.

Note, March 2014: Please also see my followup post on my later experience of being diagnosed with depression after transitioning.