Gender Dysphoria

Gender dysphoria, also referred to as gender identity issues, occurs when a person believes the gender they were assigned at birth is not the same as the gender they perceive themselves to be.12 It is important to note that signs or feelings of gender dysphoria are not a reason for panic. While these feelings may seem abnormal and frightening, there are steps than can be taken to ease one’s mind and help resolve the feelings of dysphoria. No matter what one feels their gender is, it is important to know that whatever a person is feeling is okay and should not be a reason for them to feel ashamed. Gender dysphoria is only one term to describe a complex set of behaviors and feelings involving gender. Terms that describe experiences related to those of gender dysphoria are transgender or intersex. Hopefully, this article can bring assurance to you or a loved one that feelings of gender dysphoria are okay and possible to deal with in a healthy manner.

Although traditionally, the words ‘sex’ and ‘gender’ have been used interchangeably, it is important to note that there is a significant difference between the meanings of the two. The term sex is used to describe a person’s biologyand can include any sex defining characteristic suchas sex chromosomes, sex hormones, internal reproductive organs, and, most commonly, external genitalia.3 Moments after birth, individuals are immediately assigned either a male or female sex based off the external genitalia present on their body. This assignment leads to what is defined as one’s birth sex or natal sex. However, an exception to this male or female assignment is known as intersex. Intersex is a term often used to describe a person born with external genitalia that does not align with either the male or female sex.16 This leads parents, the child, and others to then determine and assume the child’s gender­-a society’s feelings and attitudes towards a certain sex3-based off this assignment.14 Gender oftenincludes the behaviors and expectations associated with that sex. Gender identity is a term that has been gaining popularity in recent years, especially in relation to transgenderism and the LGBTIA+ community. Gender identity refers to a person’s sense of self as male, female, both, neither, or anything in-between.3 In other words, gender identity is a person’s innermost sense of their gender14. Many people identify as cisgender, meaning their gender identity and sex align with each other; however, sometimes, people do not identify with the societal expectations of the gender and/or sex they have been assigned. These feelings can lead to gender dysphoria as one’s gender identity may be different than the biological sex they were assigned at birth.14 Gender dysphoria is often talked about in the same conversations as transgenderism, which deals with the same feelings of gender incongruence.

Gender dysphoria is defined as the distress, discomfort, and confusionthat ariseswhen a person believes their assigned sex and gender do not align with their gender identity.7 People living with gender dysphoria often feel that they were born in the wrong body, which can be devastating to one’s physical and mental health.Due to the severe consequences this can have on a person’s well-being, timely recognition and treatment of gender dysphoria are vital. If you believe that you or your child may be experiencinggender dysphoria, there is no need to panic. Gender dysphoria, although extremely confusing and distressing, can be treated through the joint efforts of a patient, their loved ones, their healthcare providers, and mental health professionals.7 Psychotherapy is an important part of overcoming gender dysphoria and many people report relief after speaking to a professional, even if they choose not to undergo any physical treatments.7 

 

Classification

Originally known as gender identity disorder, gender dysphoria was once considered a mental illness.1 However, the idea that a person with gender dysphoria is “disordered” is incorrect and harmful.1 The Diagnostic and Statistic Manual of Mental Disorders, Volume five (DSM-V), created by the American Psychiatric Association and regarded as the universal authority on psychiatric treatment, gives gender dysphoria its own section and makes sure to clearly separate it from sexual dysfunctions and paraphilias.Alterations are being called for in the ICD-11 (The International Classification of Disease)—created by the World Health Organization (WHO)—to change gender dysphoria and gender identity issues from a medical condition to a behavioral condition.11Additionally, WHO has also been asked to remove gender identity disorders from the same chapter that discusses mental and behavioral disorders in ICD-11, as this frames gender identity issues as an illness11.

Statistics

In the United States, one in 30,000 males and at least 1 in 100,000 females have sought a sex reassignment.One percent of the population identifies as “gender variant,” meaning that they behave and express their gender in ways that are not congruent with accepted masculine and feminine gender roles.8 However, these numbers are a huge underestimation because so many gender dysphoric individuals live in secret.

Common Signs

The official criteria for a diagnosis, as laid out by the DSM-V, is that the common signsof dysphoria and the conflicts between identity and biological sex must be present for at least six months.1 However, some clinicians will wait up to two years before giving a diagnosis, especially when they are diagnosing children.2 With that being said, do not solely rely on the word of a medical professional to determine whether you or your child are experiencing gender dysphoria. Additionally, it is important to remember that gender dysphoria is hot a medical condition. A gender dysphoric individual is not sick or unhealthy, however psychotherapy can be utilized to make the experience less frustrating and confusing. 

Common signsof gender dysphoria differ slightly between children and adults. Some common signs inchildren include, but are not limited to, the following:5

·       Insisting that they are the other sex

·       Wearing clothes designed for the other sex, and expressing dislike for clothes designed for their sex

·       Preferring to play with kids of the other sex

·       Rejecting urination habits typical of their sex—boys may want to urinate sitting down; girls may want to urinate standing up

·       Being disgusted by their genitals2

·       Expressing hope/belief that they will grow up to be the other sex2

·       Being extremely distressed with the physical changes in puberty

It is important to keep in mind that some of these symptoms are just part of being a childandare not necessarily indicative of gender dysphoria.5 For example, girls may behave “tomboyish,” or boys may play dress up in their mother’s or sister’s clothes. Usually, this is just a phase, and a normal part of growing up. Less than 23% of children diagnosed with gender dysphoria still have it as an adult; it often disappears just before or in early adolescence.7 However, for some, gender dysphoria appears or increases in severity during puberty. This is likely in part due to the development of secondary sex characteristics, which include breasts in females and facial hair in males.6Additionally, more extreme nonconformity in childhood increases the likelihood that gender dysphoria will continue into adulthood.7

 If these signspersist into adolescence and adulthood, it is usually indicative of gender dysphoria rather than a common phase. Teens and adults with gender dysphoria may do the following:

·       Want to live as the other sex5

·       Want to get rid of or change their genitals5

·       Dress or act like the other sex2

·       Desire to hide signs of their biological sex (for example, taping breasts or removing body hair)5

·       Only feel comfortable when exhibiting their preferred gender identity5

In children under age 12, there is a discrepancy between the number of boys and girls who have gender dysphoria. For every girl, there are three to six boys diagnosed with gender dysphoria. By adolescence, the ratio is closer to 1 to 1.7Formal studies on the prevalence and persistence of gender dysphoria are lacking, but one follow up study of 70 adolescents being treated with puberty suppressing hormones showed that all continued with their transition as adults.7

 

Seeking Help

Seeking help forgender dysphoria requires a multidisciplinary approach and must be tailored to each person’s specific needs. At the very least, finding help can start byspeaking with a psychotherapist or other mental health professional. The intention of psychotherapy is not to change how a person feels about their identity, instead, it is to help them process and accept their feelings of discontent with their biological sex.1 It is vital to find a mental health professional that is trained in and has experience working with gender dysphoria and gender nonconforming individuals.7A qualified professional must have knowledge of gender nonconforming identities, expressions, and the ability to understand varying levelsof gender dysphoria in different people.They should also be able tohelp with future actions. Additionally, they should also be involved in continuously educating themselves in the assessment of gender dysphoria, by doing things such as taking workshops, attending seminars, or conducting research.7 Unfortunately, qualified mental health professionals are not available everywhere, and access to healthcare can also be limited due to lack of health insurance and/or high costs.7  It would be ideal for everyone to be able to speak with trained professionals near them, and hopefully in the future, qualified and highly educated professionals will be more widespread.

Mental health care consists of much more than just a diagnosis. A psychotherapist provides assessment of gender dysphoria and must be able to treat coexisting mental health issues such as depression and anxiety.7 They can help the individual explore their gender identity, role, and expression, and accept that their gender identity conflicts with their physical sex.7 They can also give referrals to doctors for physical treatment and suggest peer support resources such as group therapy. Therapy for family members and significant others is also recommended.7   In addition to psychological support, there are many common forms of physical treatment, which can be different for children, teens, and adults.

In recent years, children who experience varying degrees of gender dysphoriahavebegunto live as their preferred gender when they are young. Allowing children to express their preferred gender identity has shown to improve mental health in early years, but no long-term studies have been done and thus there is no reliable evidence that it benefits their mental health long term.7

For teenagers, physical treatment is divided into three categories: 

  1. reversible interventions
  2. partially reversible interventions
  3. irreversible interventions.7

 Puberty-suppressing hormones are considered reversible.7 Hormone therapy with the intention of masculinizing or feminizing a person is considered to be partially reversible – some results of these treatments, such as breast growth, can be reversed through surgery.7 Other results of hormonal treatment, such as deepening of the voice from testosterone, cannot be reversed. Finally, irreversible interventions, such as surgeries to change one’s anatomy, are considered to be permanent. Many adolescents with gender dysphoriadesire surgery and hormones, and an increasing number of them have begun living as their desired identity by the time they reach high school age.7

Before beginning hormonal treatment, it is important to discuss the benefits and drawbacks with one’s healthcare professional. Certain hormones can have unintended, unpleasant, or harmful side effects. For example, people receiving feminizing hormones have a high incidence of gallstones, elevated liver enzymes, and weight gain.7 Masculinizing hormones have a significant chance of causing weight gain, acne, and sleep apnea.7 Hormonal treatment may also result in infertility, so doctors should inform the patient of this risk before any treatment has begun. Some patients choose to preserve their eggs or sperm prior to receiving treatment if they are considering having biological children in the future.7

For adults, sex reassignment surgery in addition to hormonal treatment can be highly effective at treating gender dysphoria. 97% of patients were highly satisfied with their masculinization surgeries and 87% were satisfied with feminization surgeries.7 There is a very low incidence of regrets – less than one percent of those who have undergone masculinization surgery and one to 1.5% for those who have undergone feminization.7 Surgery to change other sex characteristics can also prove to be very helpful. A person may have cosmetic surgery to alter their facial features, or undergo body contouring, which may involve the redistribution of body fat to give a more feminine or masculine figure.7

For people who want to live as the other gender but do not want to undergo surgery or hormonal treatment, there are other options. Biological females who identify as male may bind their breasts.7 Biological males who identify as females may undergo hair removal treatments and may use padding or prostheses to give the appearance of having breasts.7

Speech therapy and communication therapy are also options that can help all gender dysphoric people who wish to live as their identified gender.7 This can help them adapt their voice and the way they communicate in a way that conforms to their gender identity.

It is recommended that people with gender dysphoria continue to meet with their mental health professional even after their treatment has been “completed,” since the struggle with gender dysphoria does not necessarily end after transitioning.6 A person can still be left dealing with residual distress and trauma, and living as a “new” person can bring about additional mental health problems. People who have transitioned must usually follow up with their doctor to continue to receive hormone therapy and to ensure that no complications arise.7

 

Causes

The causes of gender dysphoria are not yet fully understood and controversial. Recent studies have indicated that there is a biological component that affects the development of gender identity before birth.1 

A person’s biological sex is determined by two chromosomes, far before a baby is even born – one from the mother, and one from the father.5 Early in pregnancy, all fetuses are female because the X chromosome (which is inherited from the mother) is the only active chromosome. During week 8, the chromosome inherited from the father becomes active. If the Y chromosome is inherited, testosterone and other male hormones are produced, and if an X chromosome is inherited, female hormones are produced. Thus, a male baby is born with XY chromosomes and a female baby is born with XX chromosomes.5Typically, there is no mismatch between sex and identity, meaning that people born male tend to identify as male and vice versa.5

Additionally, a great deal of physical and brain development occurs before birth.14This development is directly related to hormones that have an impact on the baby in the womb13.The sexual differentiation of a child begins as testosterone levels increase during weeks six to twelve of pregnancy.10 The presence of testosterone during this time is critical to the formation of a boy’s sexual organs (penis, scrotum, prostate).15In contrast, the lack of these hormones leads to the formation of female sex organs.15

Later during the second half of pregnancy, hormones such as testosterone, estrogen, and progesterone permanently impact the development of a child’s brain.13The sexual differentiation in the brain that happens during this time frame occurs independently from the differentiation of the genitals.15This idea brings up the possibility that a child’s brain could develop for one sex and their genitals for the other. With that being said, the research surrounding this topic is very new, uncertain, and inconclusive. 

There are additional hormonal factors that could alter gender identity. If a mother has a hormonal imbalance, perhaps from a medical condition or a medication, this will affect the child.5 Fetal insensitivity to certain hormones, called androgen insensitivity syndrome (AIS), is another variable that could affect gender identity. If the hormones that act on the brain, genitals, and reproductive system are different or imbalanced, they can cause a mismatch between biological sex and gender identity.5

Congenital Adrenal Hyperplasia (CAH) is a condition that occurs when the adrenal glands in a female fetus produce high levels of male hormones.5 This hormonal imbalance results in more male-looking genitals, such as an enlarged clitoris and shallow vagina.5 Sometimes the clitoris may look so much like a penis that the baby may even appear to be male even though the internal reproductive system is female. Individuals born with CAH may identify as male or female.5

Additionally, thereare some exceptions to these developmental trends and the science is not certain. Overall, factors—due to hormonal changes in the body—seem to show that gender develops on a mosaic or spectrum. Factors lead to a gender “mosaic” in which there are always variations even in something that feels as binary as male and female.14

Intersex conditions can cause babies to be born with ambiguous genitalia or with the genitalia of both sexes, resulting in their sex being neither male nor female.5 Traditionally, doctors encouraged parents to choose a gender for their child and then raise them as such. However, choosing a gender for the child is now extremely controversial, and health professionals recommend waiting until the child is old enough to choose their gender identity before proceeding with surgery and/or hormonal treatment.5

 

Living with Gender Dysphoria

Those who struggle with conflicting sex and gender identity express their preferred gender identities in many different ways. Some people choose to cross dress, some seek hormones and surgery, and others privately identify.4

The effects of gender dysphoria on a person’s well-being can be drastic. Most people try to suppress their feelings of conflicting sex and identity, at least at first, but few are able to continue this strategy for long.5 Suppressing these feelings can have devastating consequences on one’s mental health, and can lead to depression, anxiety, self-harm, drug abuse and addiction, or even suicide.5 Many people feel alone and experience social isolation, either by choice or because of ostracization from their peers.6 This isolation can lead to low self-esteem, and in children and teens, increases their risk of dropping out of school. Children in particular often struggle with separation anxiety disorder (exhibiting extreme distress upon being separated from their parents), generalized anxiety disorder, and depression.6 Adolescents are at an extremely high risk of depression, suicidal ideation, and suicide.6 The distress caused by gender dysphoria can be so severe that a person’s life will revolve entirely around reducing their distress regarding gender.

Every person has a different way of expressing their gender identity. Some will choose to live as their assigned gender (biological sex), whereas others choose to present themselves as their internal gender identity, but without undergoing any hormonal or surgical treatments.4 Many people who do display their internal gender do so only situationally, like with groups of friends, but do not come out to other people such as co-workers or family members.8 Some people also choose to transition, meaning that they undergo hormone therapy and/or surgery to physically transition to their internal gender.4The transition generally happens in steps and takes years to be fully completed.At this point, these people often refer to themselves as transgender.

Changing of one’s name and sex on legal identity documents, usually done after surgery has been completed, can be extremely empowering for a person who has struggled with gender dysphoria for their entire life.7 It can be seen as the final step of their transition, and the relief felt from having their outward gender match up with their internal sense of gender can be life changing.7

Although certain aspects of treatment for gender dysphoria can bring about lifelong complications, it is very possible to live a fulfilling, happy life. There are many options available for people struggling with gender dysphoria, and with the support of loved ones, help from health professionals, and support groups, one can live normally. Coming out or transitioning are both very difficult things to do, but the benefits of being open and receiving treatment usually greatly outweigh the distress, depression, and anxiety that accompany living in secret. As society becomes more accepting of alternative sexual and gender identities, those living with feelings of gender dysphoria will only gain a more supporting world to live in.

If you feel that you or someone you know may be experiencing gender dysphoria, approach the situation knowing that no matter what the next steps taken will be, it is possible to live a completely normal, happy, and fulfilling life with gender dysphoria or as a transgender individual.

 

References:

  1. American Psychiatric Association. “Gender Dysphoria.” DSM-5. American Psychiatric Publishing, 2013. Web. 10 February 2016.
  2. Berger, Fred K. “Gender Dysphoria.” MedlinePlus. US National Library of Medicine, 24 April 2014. Web. 10 February 2016.
  3. “Definition of Terms: Sex, Gender, Gender Identity, Sexual Orientation.” American Psychological Association. American Psychological Association, February 2011. Web. 8 March 2016.
  4. “Fact Sheet: Gender Dysphoria in Adolescents and Adults.” Canadian Psychological Association. Canadian Psychological Association, 2014. Web. 20 February 2016.
  5. “Gender Dysphoria.” NHS Choices. NHS, 29 April 2014. Web. 10 February 2016.
  6. “Gender Dysphoria.” Psychology Today. Psychology Today, 27 December 2015. Web. 16 February 2016.
  7. Weber-Main, Anne Marie. “Standards of Care.” WPATH. World Professional Association for Transgender Health, n.d. Web. 20 February 2016.
  8. “14 Unique Gender Identity Disorder Statistics.” Health Research Funding. Health Research Funding, 28 July 2014. Web. 16 February 2016.
  9. The Gender Spectrum Collection
  10. Bao, Ai-Min, and Dick F. Swaab. "Sex Differences in the Brain, Behavior, and Neuropsychiatric Disorders." The Neuroscientist, digital ed., vol. 16, 2010, pp. 550-65.
  11. Beek, Titia F., et al. "Gender Incongruence of Adolescence and Adulthood: Acceptability and Clinical Utility of the World Health Organization's Proposed ICD-11 Criteria." PLOSPLOS.
  12. Fraser, Lin. Gender Dysphoria: Definition and Evolution Through the Years. Management of Gender Dysphoria, edited by Carlo Trombetta et al., PDF ed., Springer, Milano, 2015, pp. 19-31.
  13. Garcia-Falgueras, Alicia, and Dick F. Swaab. "Sexual Hormones and the Brain: An Essential Alliance for Sexual Identity and Sexual Orientation." Pediatric Neuroendocrinology, digital ed., vol. 17, 2010, pp. 22-35.
  14. Nguyen, Hillary B., et al. "What Has Sex Got to Do with It? The Role of Hormones in the Transgender Brain." Neuropsychopharmacology, PDF ed., vol. 44, 2019, pp. 22-37.
  15. Smith, Elke, et al. "Gender Incongruence and the Brain-Behavioral and Neural Correlates of Voice Gender Perception in Transgender People." Hormones and Behavior, digital ed., vol. 105, 2018, pp. 11-21.
  16. "What Is Intersex." Planned Parenthood, www.plannedparenthood.org/learn/sexual-orientation-gender/gender-gender-.... Accessed 1 May 2019.

Last Updated: 2 May 2019.