Gender dysphoria


Gender dysphoria is the distress a person experiences due to inconsistency between their gender identitytheir personal sense of their own genderand their sex assigned at birth. The term replaced the previous diagnostic label of gender identity disorder in 2013 with the release of the diagnostic manual DSM-5. The condition was renamed to remove the stigma associated with the term disorder. The ICD-11, which does not consider it a mental disorder, uses the term gender incongruence instead of gender dysphoria, defined as a marked and persistent mismatch between gender identity and assigned sex, regardless of distress or impairment.
Not all transgender people have gender dysphoria. Gender nonconformity is not the same thing as gender dysphoria and does not always lead to dysphoria or distress. In pre-pubertal youth, the diagnoses are gender dysphoria in childhood and gender incongruence of childhood. The causes of gender incongruence are unknown but a gender identity likely reflects genetic, biological, environmental, and cultural factors.
Diagnosis can be given at any age, although gender dysphoria in children and adolescents may manifest differently than in adults. Complications may include anxiety, depression, and eating disorders. Treatment for gender dysphoria includes social transitioning and often includes hormone replacement therapy or gender-affirming surgery, and psychotherapy.
Some researchers and transgender people argue for the declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender. However, this declassification could carry implications for healthcare accessibility, as HRT and gender-affirming surgery could be deemed cosmetic by insurance providers, as opposed to medically necessary treatment, thereby affecting coverage.

Signs and symptoms

In the DSM-5, a marked incongruence between a person's felt gender and assigned sex or gender is the core component of the diagnosis, which requires distress about the incongruence. In pre-pubertal youth it may manifest as an insistence that they are, or will grow up to be, another gender than the one assigned at birth, an aversion to their assigned gender, or an insistence they have or desire to have different genitalia. They may express aversions to stereotypically gendered activities and desire opposite sex-typical toys, games, activities, or playmates though this may be less prominent in surroundings with fewer stereotypes.
The DSM-5 states that gender dysphoria tends to be early-onset or late-onset in non-intersex individuals. Those with early-onset GD which continues into adolescence mostly identify as heterosexual, being attracted to their assigned gender at birth. In some cases, the GD desists or is denied, during which the youth may identify as lesbian or gay, though some may experience a later resurgence in GD. Some of those with late-onset GD report desire to transition during childhood that was not verbalized and others have no recollections of childhood gender dysphoria. According to the American Psychiatric Association, those who experience gender dysphoria later in life "often report having secretly hidden their gender dysphoric feelings from others when they were younger". No particular sexual orientation indicates gender dysphoria. A 2021 review in Dialogues in Clinical Neuroscience found no relation to sexual orientation, but acknowledged that historically the two were often erroneously conflated. The British National Health Service also stated "gender dysphoria is not related to sexual orientation".

Causes

In a 2020 position statement, the Endocrine Society stated that in the late 20th century, transgender and gender incongruent people were thought to suffer a mental health disorder and gender identity was considered malleable and subject to external influences. However, this was no longer considered valid as "considerable scientific evidence has emerged demonstrating a durable biological element underlying gender identity. Individuals may make choices due to other factors in their lives, but there do not seem to be external forces that genuinely cause individuals to change gender identity".
The cited evidence includes that attempts to change the gender identity of intersex patients to match their genitalia or chromosomes are generally unsuccessful, that there is evidence that higher levels of exposure to androgens in utero causes higher rates of male gender identity among those with female chromosomes, that those with complete androgen insensitivity syndrome among those with male chromosomes typically have a female gender identity, that identical twins are more likely to both be transgender than non-identical twins, and that brain scans have shown associations with gender identity rather than genitalia or chromosomes.
Their 2017 clinical practice guidelines stated "Results of studies from a variety of biomedical disciplines—genetic, endocrine, and neuroanatomic—support the concept that gender identity and/or gender expression likely reflect a complex interplay of biological, environmental, and cultural factors" and noted research pointing to unique brain phenotype associated with gender dysphoria and gender incongruence, heritability of the conditions, the role of pre- and post-natal androgens in gender development, and gender identities among intersex people.

Diagnosis

DSM-5

The American Psychiatric Association permits a diagnosis of gender dysphoria in adolescents or adults if two or more of the following criteria are experienced for at least six months' duration:
  • A significant incongruence between one's experienced or expressed gender and one's sexual characteristics
  • A strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed gender
  • A strong desire for the sexual characteristics of a gender other than one's assigned gender
  • A strong desire to be of a gender other than one's assigned gender
  • A strong desire to be treated as a gender other than one's assigned gender
  • A strong conviction that one has the typical reactions and feelings of a gender other than one's assigned gender
In addition, the condition must be associated with clinically significant distress or impairment.
The diagnosis also contains two specifiers:
  • "With a disorder/difference of sex development" should be used for those with intersex conditions, in which case the condition should be coded.
  • "Posttransition" may be used if the patient "has transitioned to full-time living in the experienced gender " and has or will undergo "at least one gender-affirming medical procedure or treatment regimen—namely, regular gender-affirming hormone treatment or gender reassignment surgery".
The DSM-5 stated that "Gender dysphoria as a general descriptive term refers to the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. However, it is more specifically defined when used as a diagnostic category. It does not refer to distress related to stigma, a distinct although possibly co-occurring source of distress."
Neither the DSM-I nor the DSM-II contained a diagnosis analogous to gender dysphoria. Gender identity disorder first appeared as a diagnosis in the DSM-III, where it appeared under "psychosexual disorders" but was used only for the childhood diagnosis. Adolescents and adults received a diagnosis of transsexualism. The DSM-III-R added "Gender Identity Disorder of Adolescence and Adulthood, Non-Transsexual Type". The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own. The diagnosis was renamed from gender identity disorder to gender dysphoria, after criticisms that the former term was stigmatizing. Subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults, as "gender dysphoria in children". The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it if they have insight. Other specified gender dysphoria or unspecified gender dysphoria can be diagnosed if a person does not meet the criteria for gender dysphoria but still has clinically significant distress or impairment. Intersex people are no longer excluded from the diagnosis of GD.

ICD-11

The International Classification of Diseases lists three conditions related to gender identity:
ICD-11 defines gender incongruence as "a marked and persistent incongruence between an individual's experienced gender and the assigned sex", with no requirement for significant distress or impairment, and a note that "gender variant behaviour and preferences alone are not a basis for assigning the diagnosis.
The ICD-10 contained the diagnoses "transsexualism" and "gender identity disorder of children" under the "Mental and behavioral disorders" chapter. The ICD-11 renamed the conditions "gender incongruence of adolescence" or adulthood and "gender incongruence of childhood" and moved them into the chapter "Conditions related to sexual health" to reflect "current knowledge that trans-related and gender diverse identities are not conditions of mental ill-health, and that classifying them as such can cause enormous stigma". The World Health Organization said its inclusion in the ICD-11 "should ensure transgender people's access to gender-affirming health care" and health insurance.

Co-occurring conditions

Several psychiatric and neurodevelopmental conditions have been observed to disproportionately co-occur with gender dysphoria. Comorbidity with psychiatric diagnoses has been found in 62.7% of individuals with GD. Major depressive disorder, mood disorders, anxiety, and substance abuse are all seen in disproportionate levels in people with GD compared to adults without it.
Gender dysphoria's frequent co-occurrence with psychiatric and psychological disorders is seen within youth populations in addition to adult populations. Among youth, around 20% to 30% of individuals attending gender clinics meet the DSM criteria for an anxiety disorder. Gender dysphoria is also associated with an increased risk of eating disorders in transgender youth. In addition, children and adolescents with gender dysphoria are also more likely to have ADHD, depression, and histories of suicidality, self-harm, and adverse childhood experiences.
A widely held view among clinicians is that there is an over-representation of neurodevelopmental conditions amongst individuals with GD, although this view has been questioned due to the low quality of evidence. Studies on children and adolescents with gender dysphoria have found a high prevalence of autistic traits or a confirmed diagnosis of autism. Adults with gender dysphoria attending specialist gender clinics have also been shown to have high rates of autistic traits or an autism diagnosis as well. It has been estimated that autistic children were over four times as likely to be diagnosed with GD, with autism being reported from 6% to over 20% of teens referring to gender identity services.
Autistic people are more likely to be gender diverse and in those with gender dysphoria there is an overrepresentation of autistic traits. In prepubertal youth, increasing age is associated with more behavioral and emotional problems due to increasing nonacceptance of gender nonconforming behaviors than others, while children and adolescents in affirming environments show less or no psychological problems. Younger children are also less likely to express extreme and persistent dysphoria about their anatomy.