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Gender dysphoria

Gender-incongruent; Transgender; Gender identity disorder

Gender dysphoria is the term for a deep sense of unease and distress that may occur when your biological sex does not match your gender identity. In the past, this was called gender identity disorder. For example, you may be assigned at birth as a female gender, but you feel a deep inner sense of being male. In some people, this mismatch can cause severe discomfort, anxiety, depression, and other mental health conditions.

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Causes

Gender identity is how you feel and identify, and can be as a female, male, or both. Gender is typically assigned at birth, based on a baby having the outward appearance (genital organs) of either a male or a female as per a social construct of a binary system of two genders (male or female).

If your gender identity matches the gender assigned to you at birth, this is called cisgender. For example, if you were born biologically as a male, and you identify as a man, you are a cisgender man.

Transgender refers to identifying as a gender that is different from the biological gender assigned when you were born. For example, if were born biologically female and were assigned a female gender, but you feel a deep inner sense of being a man, you are a transgender man.

Some people express their gender in ways that do not fit into traditional binary social norms of male or female gender. This is called non-binary, gender non-conforming, genderqueer, or gender-expansive. In general, most transgender people do not identify as non-binary.

It is important to mention that the anxiety transgender people may feel due to having the body of the wrong gender is deeply distressing. As a result, the transgender community has a higher rate of mental health problems and risk of attempted suicide.

No one knows exactly what causes gender dysphoria. Some experts believe that hormones in the womb, genes, and cultural and environmental factors may be involved.

Symptoms

Children and adults can experience gender dysphoria. Symptoms vary, depending upon a person's age, but most people want to live in a way that matches their gender identity. As an adult, you may have had these feelings from a young age.

Children may:

• Insist that they are the other gender
• Strongly want to be the other gender
• Want to dress in the clothes typically used by another gender and resist wearing clothes associated with their biological gender
• Prefer to act the conventional roles of the other gender in play or fantasy
• Prefer toys and activities conventionally thought of as of the other gender
• Strongly prefer to play with children of the other gender
• Feel a strong dislike of their genitals
• Want to have the physical characteristics of the other gender

Adults may:

• Strongly want to be the other gender (or a gender different from the one they were assigned at birth)
• Want to have the physical and sexual characteristics of the other gender
• Want to be rid of their own genitals
• Want to be treated like the other gender
• Want to be addressed as the other gender (pronouns)
• Strongly feel and react in ways associated with of the other gender

The emotional pain and distress of gender dysphoria can interfere with school, work, social life, religious practice, or other areas of life. People with gender dysphoria may become anxious, depressed, and in many cases, even suicidal.

Exams and Tests

It is very important for people with gender dysphoria to receive psychological and social support and understanding from medical professionals. When choosing a health care provider, look for individuals who are trained to identify and work with people with gender dysphoria.

To make a diagnosis, your provider will take your medical history and, in some cases, do a full psychiatric evaluation. Gender dysphoria is diagnosed if you have had two symptoms or more for at least 6 months.

Treatment

The main goal of treatment is to help you overcome the distress you may feel. You can choose the level of treatment that helps you feel most comfortable. This may include helping you transition to the gender you identify with.

Treatment for gender dysphoria is individualized, and may include:

• Counseling to help you understand your feelings and to provide you with support and coping skills
• Couples or family counseling to help reduce conflicts, create understanding, and provide a supportive environment
• Gender-affirming hormone therapy (in the past called hormone replacement therapy)
• Gender-affirming surgery (in the past called sex-reassignment surgery)

Not all transgender people need all forms of treatment. They can select one or more of the treatments listed above.

Before making a decision about surgery, it's likely you will first have had gender-affirming hormone therapy and have lived as your chosen gender for a minimum of one year. There are two main types of surgery: one affects fertility, the other does not. Not everyone chooses to have surgery, or they may choose only one type of surgery.

Societal and family pressures and lack of acceptance can cause anxiety and depression and other mental health issues. This is why it's important that you receive counseling and support throughout and even after your transition. It is also important to have emotional support from other people, such as from a support group or from close friends and family.

Outlook (Prognosis)

Recognizing and treating gender dysphoria early can reduce the chance of depression, emotional distress, and suicide. Being in a supportive environment, being free to express your gender identity in a way that makes you comfortable, and understanding your options for treatment can help relieve anxiety and depression.

Different treatments can relieve symptoms of gender dysphoria. However, reactions from others to the person's transition including social and legal difficulties during the transitioning process can continue to create problems with work, family, religious, and social life. Having a strong personal support network and choosing providers with expertise in transgender health greatly improve the outlook for people with gender dysphoria.

When to Contact a Medical Professional

Make an appointment with a provider with expertise in transgender medicine if you or your child has symptoms of gender dysphoria.

If you or someone you know is thinking about suicide, call or text 988 or chat 988lifeline.org. You can also call 1-800-273-8255 (1-800-273-TALK). The 988 Suicide and Crisis Lifeline provides free and confidential support 24/7, anytime day or night.

You can also call 911 or the local emergency number or go to the hospital emergency room. DO NOT delay.

If someone you know has attempted suicide, call 911 or the local emergency number right away. DO NOT leave the person alone, even after you have called for help.

References

American Psychiatric Association. Gender dysphoria. In: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing. 2013:451-460.

Bockting WO. Gender and Sexual Identity. In: Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM, eds. Nelson Textbook of Pediatrics. 21st ed. Philadelphia, PA: Elsevier; 2020:chap 133.

Garg G, Elshimy G, Marwaha R. Gender dysphoria. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2020. PMID: 30335346 pubmed.ncbi.nlm.nih.gov/30335346/.

Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. PMID: 28945902 www.ncbi.nlm.nih.gov/pubmed/28945902/.

Safer JD, Tangpricha V. Care of Transgender Persons. N Engl J Med. 2019;381(25):2451-2460. PMID: 31851801 pubmed.ncbi.nlm.nih.gov/31851801/.

Shafer LC. Sexual disorders and sexual dysfunction. In: Stern TA, Fava M, Wilens TE, Rosenbaum JF, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 2nd ed. Philadelphia, PA: Elsevier; 2016:chap 36.

White PC. Sexual development and identity. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 220.

Review Date: 7/28/2022  

Reviewed By: Fred K. Berger, MD, addiction and forensic psychiatrist, Scripps Memorial Hospital, La Jolla, CA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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