What is Gender Dysphoria?

The term “transgender” refers to a person whose sex assigned at birth (i.e. the sex assigned at birth, usually based on external genitalia) does not align their gender identity (i.e., one’s psychological sense of their gender). Some people who are transgender will experience “gender dysphoria,” which refers to psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.

People who are transgender may pursue multiple domains of gender affirmation, including social affirmation (e.g., changing one’s name and pronouns), legal affirmation (e.g., changing gender markers on one’s government-issued documents), medical affirmation (e.g., pubertal suppression or gender-affirming hormones), and/or surgical affirmation (e.g., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.). Of note, not all people who are transgender will desire all domains of gender affirmation, as these are highly personal and individual decisions.

It is important to note that gender identity is different from gender expression. Whereas gender identity refers to one’s psychological sense of their gender, gender expression refers to the way in which one presents to the world in a gendered way. For example, in much of the U.S., wearing a dress is considered a “feminine” gender expression, and wearing a tuxedo is considered a “masculine” gender expression. Such expectations are culturally defined and vary across time and culture. One’s gender expression does not necessarily align with their gender identity. Diverse gender expressions, much like diverse gender identities, are not indications of a mental disorder.

Gender identity is also different from sexual orientation. Sexual orientation refers to the types of people towards which one is sexually attracted. As with people who are cisgender (people whose sex assigned at birth aligns with their gender identity), people who are transgender have a diverse range of sexual orientations.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)¹ provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children and for adolescents and adults.

The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated 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 different from one’s assigned gender)
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-5-TR defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

• A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
• In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
• 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
• In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
• A strong dislike of one’s sexual anatomy
• A strong desire for the physical sex characteristics that match one’s experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Treatment

Support for people with gender dysphoria may include open-ended exploration of their feelings and experiences of gender identity and expression, without the therapist having any pre-defined gender identity or expression outcome defined as preferable to another.² Psychological attempts to force a transgender person to be cisgender (sometimes referred to as gender identity conversion efforts or so-called “gender identity conversion therapy”) are considered unethical and have been linked to adverse mental health outcomes.^2,3

Support may also include affirmation in various domains. Social affirmation may include an individual adopting pronouns, names, and various aspects of gender expression that match their gender identity.^4,5 Legal affirmation may involve changing name and gender markers on various forms of government identification.⁶ Medical affirmation may include pubertal suppression for adolescents with gender dysphoria and gender-affirming hormones like estrogen and testosterone for older adolescents and adults.^{7, 8,9,10,11,12} Medical affirmation is not recommended for prepubertal children.^{7, 8} Some adults (and less often adolescents) may undergo various aspects of surgical affirmation.^7,8,13

Family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender.¹⁴ Family and couples’ therapy can be important for creating a supportive environment that will allow a person’s mental health to thrive. Parents of children and adolescents who are transgender may benefit from support groups. Peer support groups for transgender people themselves are often helpful for validating and sharing experiences.

Challenges/Complications

Transgender people suffer from high levels of stigmatization, discrimination and victimization, contributing to negative self-image and increased rates of other mental health disorders.¹⁵ Transgender individuals are at higher risk of victimization and hate crimes than the general public. Suicide rates among transgender people are markedly higher than the general population.¹⁶

Transgender children and adolescents are often victims of bullying and discrimination at school, which can contribute to serious adverse mental health outcomes.¹⁷ Interventions are often needed to create safe and affirming school environments.

Transgender individuals may also face challenges in accessing appropriate health care and insurance coverage of related services.

Terminology

Important terms related to Gender Dysphoria:¹⁸

• Cisgender: Describes a person whose gender identity aligns in a traditional sense with the sex assigned to them at birth.
• Gender diverse: An umbrella term describing individuals with gender identities and/or expressions and includes people who identify as multiple genders or with no gender at all.
• Gender dysphoria: A concept designated in the DSM-5-TR as clinically significant distress or impairment related to gender incongruence, which may include desire to change primary and/or secondary sex characteristics. Not all transgender or gender diverse people experience gender dysphoria.
• Gender expression: The outward manifestation of a person’s gender, which may or may not reflect their inner gender identity based on traditional expectations. Gender expression incorporates how a person carries themselves, their dress, accessories, grooming, voice/speech patterns and conversational mannerisms, and physical characteristics.
• Gender identity: A person’s inner sense of being a girl/woman, boy/man, some combination of both, or something else, including having no gender at all. This may or may not correspond to one's sex assigned at birth.
• Nonbinary: A term used by some individuals whose gender identity is neither girl/woman nor boy/man.
• Sex/gender assigned at birth: Traditional designation of a person as “female,” “male,” or “intersex” based on anatomy (e.g., external genitalia and/ or internal reproductive organs) and/or other biological factors (e.g., sex chromosomes). “Sex” and “gender” are often used interchangeably, but they are distinct entities. It is best to distinguish between sex, gender identity, and gender expression and to avoid making assumptions about a person regarding one of these characteristics based on knowledge of the others. This is sometimes abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth).
• Sexual orientation: Describes the types of individuals toward whom a person has emotional, physical, and/or romantic attraction.
• Transgender: An umbrella term describing individuals whose gender identity does not align in a traditional sense with the gender they were assigned at birth. It may also be used to refer to a person whose gender identity is binary and not traditionally associated with that assigned at birth.

References

1. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). American Psychiatric Association. 2022
2. The American Academy of Child & Adolescent Psychiatry. (2018). Conversion Therapy. https://www.aacap.org/AACAP/Policy_Statements/ 2018/Conversion_Therapy.aspx. Accessed November 7, 2020.
3. Turban, J. L., Beckwith, N., Reisner, S. L., & Keuroghlian, A. S. (2020). Association between recalled exposure to gender identity conversion efforts and psychological distress and suicide attempts among transgender adults. JAMA Psychiatry, 77(1), 68-76.
4. Durwood, L., McLaughlin, K. A., & Olson, K. R. (2017). Mental health and self-worth in socially transitioned transgender youth. Journal of the American Academy of Child & Adolescent Psychiatry, 56(2), 116-123.
5. Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3).
6. Scheim, A. I., Perez-Brumer, A. G., & Bauer, G. R. (2020). Gender-concordant identity documents and mental health among transgender adults in the USA: a cross-sectional study. The Lancet Public Health.
7. Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., ... & T’Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903.
8. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Monstrey, S. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism, 13(4), 165-232.
9. Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).
10. van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.
11. Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2022). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health, 70(4), 643-649.
12. Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.
13. Almazan, A. N., & Keuroghlian, A. S. (2021). Association between gender-affirming surgeries and mental health outcomes. JAMA Surgery, 156(7), 611-618.
14. Klein, A., & Golub, S. A. (2016). Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT health, 3(3), 193-199.
15. Reisner, S. L., Poteat, T., Keatley, J., Cabral, M., Mothopeng, T., Dunham, E., ... & Baral, S. D. (2016). Global health burden and needs of transgender populations: a review. The Lancet, 388(10042), 412-436.
16. James, S., Herman, J., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. A. (2016). The Report of The 2015 US Transgender Survey. http://www.ustranssurvey.org/reports. Accessed November 7, 2020.
17. Turban, J. L., King, D., Li, J. J., & Keuroghlian, A. S. (2021). Timing of social transition for transgender and gender diverse youth, K-12 harassment, and adult mental health outcomes. Journal of Adolescent Health, 69(6), 991-998.
18. Perzanowski, E. S., Ferraiolo, T., & Keuroghlian, A. S. (2020). Overview and Terminology. In Forcier, M., VanSchalkwyk, G., & Turban, J.L. (Eds.), Pediatric Gender Identity: Gender-affirming Care for Transgender & Gender Diverse Youth (pp. 1-13). Springer Nature.

Physician Review

Jack Turban, M.D., M.H.S.