Gender dysphoria involves a strong, persistent feeling that a person's anatomic sex does not match their inner sense of self as masculine, feminine, mixed, neutral, or something else (gender identity). This feeling of mismatch causes significant distress or greatly impairs the person's ability to function. The most extreme form of gender dysphoria, once known as transsexualism, often includes the desire for treatments and procedures to change their physical appearance to match their gender identity.
- Children focus on activities typically associated with the other sex and have negative feelings about their genitals.
- Doctors base the diagnosis on symptoms indicating a strong preference to be the other sex.
- Most people who feel a strong need to live as the other sex seek treatment—hormone therapy and sometimes irreversible genital surgery—that will make their physical appearance like that of the gender they feel they are.
- Some people who feel that their anatomic sex does not match their gender identity are satisfied by working, living, and dressing in society as a member of the opposite gender, but many of these people do not have symptoms that meet the criteria for gender dysphoria.
People with gender dysphoria believe that they are victims of a biologic accident and that they are cruelly imprisoned in a body incompatible with their inner sense of self as masculine, feminine, or something else (gender identity). For example, some people who are labeled male at birth feel like women trapped in a man's body, and vice versa. This feeling of mismatch (called gender incongruity or gender nonconformity) is not considered a disorder unless it causes significant distress or interferes with the person's ability to function. The distress is typically a combination of anxiety, depression, and irritability. Some brain imaging studies have shown that gender-dysphoric people have functional and anatomic findings that are consistent with their felt gender (gender identity) rather than their birth sex.
Some people feel that they are neither masculine nor feminine, that they are somewhere in-between, that they are a combination of the two, or that their identity changes. Genderqueer is a catchall term that refers to some of these variations of gender identity. Other terms that may be used include nonbinary and agender.
How many people have gender dysphoria is not known, but it is estimated to occur in 5 to 14 of 1,000 babies whose birth sex is male and 2 to 3 of 1,000 babies whose birth sex is female. Many more people identify themselves as transgender than meet the criteria for gender dysphoria.
In transvestism (cross-dressing), people (almost always men) become sexually aroused by wearing clothing of the opposite sex, but they do not have an inner sense of actually belonging to that sex.
For some people with gender dysphoria, the incompatibility felt between anatomic sex and gender identity is complete, severe, disturbing, and long-standing, and they are likely to seek drug treatment and procedures to resolve the incompatibility. The term transsexualism has been used to describe this condition but has fallen out of favor among professionals; however, many people with a gender identity different from that usually associated with their biologic sex refer to themselves as "trans."
Most of these people are biologic males who identify themselves as females, sometimes early in childhood, and regard their genitals and masculine features with repugnance. However, most children with gender identity problems do not become trans adults.
People who were born with genitals that are not clearly male or female (ambiguous genitals) or who have a genetic abnormality, such as Turner syndrome or Klinefelter syndrome, may suffer from varying degrees of gender dysphoria. However, when children are clearly and consistently considered and reared as either boys or girls, even when genitals are ambiguous, most of them have a clear sense of their gender identity.
Gender dysphoria in children usually develops by age 2 to 3 years old.
Gender dysphoria symptoms in children
Children who have gender dysphoria may do the following:
- Prefer cross-dressing
- Insist that they are of the other sex
- Wish that they would wake up as the other sex
- Prefer participating in games and activities associated with the other sex
- Have negative feelings toward their genitals
For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may sit to urinate and wish to be rid of his penis and testes. For boys with gender dysphoria, distress at the physical changes of puberty is often followed by a request for treatment that will make their body more like a woman’s.
However, most children who prefer activities considered to be more appropriate for the other sex (called gender-nonconforming behavior) do not have gender dysphoria. And very few of the children actually diagnosed with gender dysphoria remain gender dysphoric as adults. As a result, there is controversy around whether or when to support a child's social and/or medical transition to the other gender.
Gender dysphoria symptoms in adults
Although most people with gender dysphoria began having symptoms or began feeling different in early childhood, some do not acknowledge these feelings until adulthood.
People, usually men, may be cross-dressers first and not acknowledge their identification with the other sex until later in life. Some of these men marry women or take stereotypically masculine jobs as a way to escape or deny their feelings of wanting to be the other sex. Once they accept these feelings, many publicly adopt a satisfying and convincing feminine gender role, with or without hormone therapy or sex-reassignment surgery. Others experience problems, such as anxiety, depression, and suicidal behavior. The stress of not being accepted by society and/or by family may cause or contribute to these problems.
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- A doctor's evaluation, based on specific criteria
Most children with gender dysphoria are not evaluated until they are 6 to 9 years old.
Doctors diagnose gender dysphoria when people (children or adults) do the following:
- Feel that their anatomic sex does not match their gender identity and have felt that way for 6 months or longer
- Feel greatly distressed or cannot function normally because of this feeling
- Have certain other symptoms, which vary by age group
The other symptoms required for a doctor to diagnose gender dysphoria are slightly different in children than in adolescents and adults.
Children must also have at least six of the following symptoms:
- A strong, persistent desire to be or insistence that they are the other gender (or some other gender)
- A strong preference for dressing in clothing of the opposite gender and, in girls, resistance to wearing typically feminine clothing
- A strong preference for pretending to be the opposite gender when playing
- A strong preference for toys, games, and activities typical of the other gender
- A strong preference for playmates of the other gender
- A strong rejection of toys, games, and activities typical of the gender that matches their anatomic sex (for example, boys refuse to play with trucks or footballs)
- A strong dislike of their anatomy
- A strong desire for the sex characteristics that match their gender identity
Adolescents and adults must also have one or more of the following symptoms:
- A strong desire to be rid of their sex characteristics and, for young adolescents, to prevent the development of secondary sex characteristics (those that occur during puberty)
- A strong desire for the sex characteristics that match their gender identity
- A strong desire to be the other gender (or some other gender)
- A strong desire to live or be treated as another gender
- A strong belief that they feel and react like another gender
- Sometimes hormone therapy
- Sometimes sex-reassignment surgery and other gender-related surgeries
Adults who feel that their anatomic sex does not match their gender identity may not require treatment if they do not have psychologic distress or trouble functioning in society. Some people are satisfied with changing their gender role by working, living, and dressing in society as a member of the opposite gender. This approach may include obtaining identification (such as a driver's license) that helps them work and live in society as the opposite gender. They may never seek to alter their anatomy in any way. Many of these people do not have symptoms that meet the criteria for a mental health disorder. In most Western cultures, most individuals with severe gender dysphoria who request treatment are people whose anatomic sex is male, who identify as female, and who regard their genitals and masculine features with disgust.
When most of these people seek treatment, they do not want psychologic treatment. They want hormone therapy and/or surgery that will make their physical appearance resemble their felt gender identity.
Many appear to be helped most by a combination of the following:
- Hormone therapy
- If desired, genital (sex-reassignment, or gender-confirming) surgery, which is irreversible
Psychotherapy is no longer required before people can be given hormone therapy and/or have sex-reassignment surgery. However, mental health care practitioners can help by doing the following:
- Determining whether any mental health disorders (such as depression or a substance use disorder) are present
- Helping people deal with problems (such as disapproval or discrimination) that their condition may have provoked
- Helping people find a way to express their felt gender in a way that is comfortable
- If applicable, helping them change gender roles, come out, and transition to another gender
Some people with gender dysphoria, in addition to adopting the behavior, dress, and mannerisms of the opposite sex, receive hormone treatments to change their secondary sex characteristics:
- In biologic males, use of the female hormone estrogen causes breast growth and other body changes, such as decreased facial and body hair, wasting of the genitals (genital atrophy), and the inability to maintain an erection.
- In biologic females, use of the male hormone testosterone causes such changes as growth of facial hair, deepening of the voice, and changes in body odor and distribution of body fat and muscle.
In addition to physical effects, hormone therapy has significant beneficial psychologic effects, including feeling more at ease, less anxious, and more able to interact as the preferred gender.
Other people request sex-reassignment (or gender-confirmation) surgery. This surgery is irreversible.
For both sexes, surgery is preceded by
- Use of the appropriate sex hormone ( estrogen in male-to-female transformation and testosterone in female-to-male transformation)
- Living full-time in the opposite gender role for at least 1 year
For biologic males, surgery involves removal of part of the penis and the testes and creation of an artificial vagina. The part of the penis that is left acts as a clitoris. The remaining part is usually sexually sensitive and makes orgasm possible. Male-to-female transformation may also include nongenital cosmetic surgeries to create or enhance feminine attributes (for example, breast augmentation, rhinoplasty, brow lift, tracheal shave [paring down the Adam's apple], and/or jaw reconfiguration). Some people undergo vocal cord surgeries to change the quality of the voice.
For biologic females, surgery involves removal of the breasts (mastectomy) and sometimes the internal reproductive organs (uterus and ovaries), closure of the vagina, and creation of an artificial penis and usually a scrotum. Results of female-to-male surgery are less satisfactory than male-to-female surgery in terms of appearance and function, possibly explaining why fewer females request sex-reassignment surgery. Also, complications, mainly urinary problems, are common. But techniques for female-to-male surgery continue to improve, and more biologic females are requesting surgery.
Although people with severe gender dysphoria who have sex reassignment surgery cannot procreate, many are able to have satisfactory sexual relations. The ability to achieve orgasm is often retained after surgery, and some people report feeling comfortable sexually for the first time. However, few people endure the sex-reassignment process for the sole purpose of being able to function sexually as the opposite sex. Confirmation of their inner sense of gender identity is the usual motivation.