Gender dysphoria: definition, signs, and treatments

Gender dysphoria is a term describing a feeling of inner turmoil, including worry and anxiousness between a person’s assigned gender at birth and their expressed gender. The discontent could be so powerful that it can trigger anxiety and depression. Gender dysphoria was previously called gender identity disorder.

Gender dysphoria is a difficulty expressing one’s gender with traditional societal binary female or male roles due to a mismatch between biological sex and a person’s gender identity. People with gender dysphoria often face discrimination, oppression, and stigmatization, which puts a heavy load on their mental health, explains the National Library of Medicine.

The signs of gender dysphoria are lack of confidence, social withdrawal or isolation, anxiety or depression, assuming unnecessary dangers, and putting oneself last.

Treatments of gender dysphoria are medical and behavioral. Treatments, such as hormone therapy, can help those who seek maximum masculinization or feminization. Surgery is also available such as procedures that offer changes in body contours, as well as internal and external genitalia.

What is gender dysphoria?

Gender dysphoria is psychological distress that occurs when there is a conflict between the sex assigned at birth and the gender with which a person identifies. It stems from someone’s sex-related physical features or gender assigned at birth. Gender-diverse individuals and transgenders can have gender dysphoria at some point in their lives.

Gender dysphoria is included in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) by the American Psychiatric Association. Before DSM-5, the condition was called gender identity disorder.

Dysphoric means being very unhappy, dissatisfied, or uneasy. Different types of dysphoria exist.

Gender dysphoria as a concept was first coined by psychiatrist Norman M. Fisk in the early 1970s. Dr. Fisk wrote that the term transsexual was coined by Dr. Harry Benjamin in the 1960s. At that point, transsexualism was a necessary diagnosis for a person in order to be elected for sex reassignment surgery. Diagnostic criteria were strict and not flexible. Fisk suggested his colleagues set these criteria because they wanted to stick to their oath which implied they should do no harm.

In 1968, Fisk and his colleagues started working on research, which involved in-depth interviews with patients that applied for treatment. They learned that many patients didn’t fit into the classical transsexual type. Fisk found that for many people the “problem” wasn’t the body itself, but the strict norms regarding how men and women should behave. He suggested conceptualization of gender dysphoria as a spectrum of gender-related distress.

What are the signs of gender dysphoria?

Signs of gender dysphoria are listed below.

• Lack of confidence
• Withdrawing or isolating oneself from society
• Anxiety or depression
• Assuming unnecessary dangers
• Putting oneself last

1. Lack of confidence

Lack of confidence is when you don’t trust yourself or have faith in what you can do. The more confidence you lose, the harder it is to believe in your ability to perform. For example, people with a lack of confidence have a lot of doubt, or “just have a feeling” that something will always go wrong.

Lack of confidence with gender dysphoria might be associated with the feeling of unease or discomfort with the way people look. An assigned man at birth with gender dysphoria might hate the bony structures in their face since they make them look masculine. Technically, a person doesn’t want to change them because of their gender. Instead, they want to fix that unease.

Lack of confidence itself can’t cause gender dysphoria, but it can be a symptom of gender dysphoria. According to 2019 reports from Clinical Child Psychology and Psychiatry, transgender adolescents and children show high rates of co-occurring psychopathology. This could be connected to low self-confidence.

Individuals with a severe lack of confidence often joke about themselves in an overly negative manner. They insult or criticize themselves and believe they don’t deserve to have fun. They tend to ignore their achievements and the goals they reached in life.

Instead, they focus on all the negatives and failures. Those with poor self-esteem and confidence find it difficult to adapt to social interactions and might feel inadequate, unloved, and incompetent. These are all characteristics of lack of confidence often recorded in people with gender dysphoria.

2. Withdrawing or isolating oneself from society

Withdrawal is when people don’t go to places, activities, or events they often enjoy. They don’t attend the parties they used to, go to places they liked to visit before, or like to leave their house. Social withdrawal may lead to social isolation i.e. a person avoids socializing and spending time with friends, family, or coworkers.

People with gender dysphoria can go through a powerful sense of isolation. There are many reasons they might withdraw or self-isolate due to gender dysphoria. These include potential rejection, vulnerability, stress, fear of other people’s reactions, lack of understanding, shame, and anxiety. When someone with gender dysphoria is withdrawing or isolating, they might want to be left alone. That’s because they can feel upset or tired when they spend time around other people. They may need time to process their emotions or feel discouraged since they feel other people can’t understand them.

People with gender dysphoria may show signs of isolation or withdrawal during the transitioning phases, for example, right after finishing high school and going to college. When in high school, they might have made a small community of friends they could trust. But, now in college, it could be difficult to connect to a completely new network of friends. In cases such as these, many individuals with gender dysphoria can feel lonely.

To understand the impact of loneliness on mental health, it’s crucial to point out that trans people make up a fraction (roughly 0.6%) of the general population. They are of minority status. Research shows that the impact of psychological distress arises from loneliness and social isolation. These are well-documented reports from first-hand experiences around the world, explains the London School of Hygiene and Tropical Medicine.

Transphobia affects the ability of gender-diverse people to access spaces where they can fit in, especially when people spot the signs of a feminine man. Considering derogatory remarks, and verbal, and non-verbal abuse, it’s easy to see why someone with gender dysmorphia would prefer to withdraw or isolate from others.

3. Anxiety or depression

Anxiety is recurring or constant feelings of worry and unease. Depression is a mood disorder that leads to the loss of interest or persistent feelings of sadness. Anxiety or depression can be present in those who feel they have the body of the wrong gender. Gender anxiety can be so deeply distressing that it can contribute to severe adverse mental health outcomes.

Other stressors can make things worse , such as internalized cissexism. People with internalized cissexism can feel ashamed of judgment from others, their gender expression, and their identity.

The 2018 research paper from the Journal of Affective Disorders suggests that non-treated trans individuals have an almost 4-fold higher risk of depression. This is a serious disorder that can have a drastic impact on someone’s quality of life and well-being.

Transgender mental health needs further acknowledgment since trans youth are more likely to feel depressed.

4. Assuming unnecessary dangers

Many people are fond of taking unnecessary risks, like rock climbing, cliff jumping, or skydiving. It gives them an adrenaline boost. But, the extent to which they take these unnecessary risks can vary from person to person. These risks can become unnecessary dangers.

According to a study from the Journal of Adolescent Health, transgender and gender non-conforming (TGNC) youth are more likely to engage in high-risk behaviors. Two-thirds or 61.3% out of 2168 TGNC participants reported suicidal ideation.

When dealing with gender dysphoria and mental illness, people might not ever openly admit to their discomfort. So, they try different forms of risk-taking to prove to people that they are wrong. One example of assuming unnecessary dangers is risky sexual behavior. A paper from Adolescent Health, Medicine and Therapeutics suggests that risky sexual behavior stems from identity experiments or because underlying mental health problems increase a person’s search for comfort in intimacy.

5. Putting oneself last

Putting yourself last means that even if you are feeling down, you constantly try to take care of others around you and fail to prioritize yourself. People with gender dysphoria might adopt the mentality of being a martyr on behalf of those they care about.

Regardless of whether someone is a biological male or female when they put themselves last, it can mean they lack self-love. With dysphoria, that’s a lot more evident. The inner conflict between the perceived gender and the biological one can affect the way a person evaluates oneself.

Many people lack self-acceptance. They blame themselves for being different, put themselves last, and let others “off the hook” all the time. They are ready to forgive and sacrifice themselves over and over again, no matter how many times they’ve been hurt.

Although this sweet and soft heart can be a blessing, this kind of behavior is often underappreciated and abused. People who lack self-love tend to put themselves in the situations where they can be considered the victims or, as mentioned above, the martyrs.

How is gender dysphoria diagnosed?

Gender dysphoria is diagnosed after a behavioral health evaluation. The healthcare provider starts by assessing the patient’s reactions to discrimination and prejudice against their gender identity. They also strive to determine how prejudice against one’s gender identity affects their mental health.

To get as much information as possible, a healthcare professional will also consult friends or family of a patient.

Based on the information gathered, the healthcare provider may suspect a patient has gender dysphoria. To be sure, they will use DSM-5 to see whether a patient meets diagnostic criteria. The release of DSM-5-TR (Text Revision) separated diagnostic criteria for children and adults and adolescents.

In adolescents and adults, gender dysphoria is a marked incongruence between a person’s experienced and expressed gender and assigned gender lasting at least six months.

In order to diagnose an adolescent or adult with gender dysphoria, the incongruence should be manifested by at least two out of six criteria. These include significant incongruence between experienced/expressed gender and primary and/or secondary sex characteristics (or anticipated secondary sex characteristics in young adults), a strong desire to be rid of primary or secondary sex characteristics due to incongruence with experienced/expressed gender, and a strong desire for primary and/or secondary characteristics of the other gender. Other criteria include a strong desire to be of the other gender, to be treated as the other gender, and a strong conviction that one has the typical feelings and reactions of the other gender.

Diagnostic criteria for gender dysphoria imply the condition must be linked to significant distress or impairment in social, occupational, and other areas of functioning.

As per DSM-5-TR, children also need to experience marked incongruence between experienced/expressed gender and assigned gender lasting at least six months manifested by at least six out of eight criteria. The first criteria, which must be present for this diagnosis, is a strong desire to be of the other gender or insistence that one is the other gender. Other criteria include a strong preference for cross-dressing or simulating female attire (for boys) and strong preference for masculine clothing and resistance to wear typical feminine clothing (for girls), preference for cross-gender roles in make-believe play, and a strong preference for toys, games, and activities stereotypically used by the other gender. Other diagnostic criteria for gender dysphoria include strong preference for playmates of the other gender, strong rejection of typically masculine toys and avoidance or rough-and-tumble play (for boys) and a strong rejection of typically feminine toys (for girls), a strong dislike of one’s sexual anatomy, and a desire for the physical sex characteristics that match a child’s experienced gender.

What are the causes of gender dysphoria?

The causes of gender dysphoria are multifactorial and include cultural, biological, genetic, and environmental factors.

Cultural factors encompass ideologies or set of values within a certain community. For example, only being able to identify oneself as feminine or masculine in the community you live in can feel oppressive for someone who would like to express themselves in another manner. The more oppressed you feel, the more likely you are to try and resist.

Abnormal biological processes, like genetic mutations, could cause abnormal gonadal development.

Certain environments are hostile towards gender-diverse individuals. So, it can be the people around them that contribute to the development of this condition. There is growing evidence that childhood neglect, abuse, and maltreatment could be associated with gender dysphoria. According to the National Library of Medicine, people with higher body dissatisfaction and gender dysphoria often have poor mental health.

What are some gender dysphoria’s potential effects?

The potential effects of gender dysphoria are listed below:

• Anxiety
• Depression
• Self-harm
• Eating disorders
• Substance misuse

1. Anxiety

People with gender dysphoria may experience intense worry and unease, which is associated with anxiety.

When the feeling of the gender not matching a person’s biological sex becomes substantial, adolescence can be particularly traumatic. In the early stages, it is important to wait before changing from man to woman. Making that decision too soon can have a drastic impact on the patient’s mental health.

Proper support and care can make the difference between feeling constantly anxious and enjoying the transition to youth. A health expert can provide some practical insight into what dysphoria is and recommend useful strategies to help patients manage anxiety.

Signs and symptoms of anxiety include restlessness, irritability, difficulty concentrating, sleep problems, headaches, stomach aches, and other physical changes.

2. Depression

One of the biggest complications or effects of gender dysphoria is depression. Those facing a gender identity crisis showcase their depression in different ways.

A person assigned male at birth may use makeup, wear high heels and attempt to achieve a feminine look through clothes and colors. However, they may develop depression after puberty. The emotional and psychological impacts of the struggle between assigned and experienced/expressed gender become overbearing. During puberty, a person assigned male at birth notices their voice becomes deeper, face develops more masculine features, and they start growing hair. As a result, they can start feeling unworthy of others and themselves.

According to a review from the International Review of Psychiatry, people with gender dysphoria are vulnerable to psychiatric conditions such as depression and anxiety.

Signs and symptoms of depression include persistent sadness, feelings of worthlessness and hopelessness, loss of interest in activities once enjoyed, lack of energy, changes in sleep pattern, and social withdrawal.

3. Self-harm

Self-harm is often a manifestation of a psychiatric or psychological disorder. For someone with gender dysphoria, it could be a psychological stressor. Self-harm can stem from severe stress, past trauma and pent-up feelings. When someone is forced to look like a woman or man, it can give them a deep sense of distress, especially if they spend time around hostile people who try to hurt, manipulate, or deceive them. All of these pressures or overwhelming situations can make someone contemplate suicide.

A study from The Lancet Child and Adolescent Health found that young people with gender dysphoria diagnosis are five times more likely to have been admitted for a suicide attempt or self-harm than their counterparts without gender dysphoria.

Signs and symptoms of self-harm include cuts, bruises, and scars on wrists and other parts of the body such as thighs. A person may use clothes to cover up scars and cuts. For example, they may wear long sleeves even when it’s hot outside.

4. Eating disorders

In an effort to look skinnier or a certain way, people with gender dysphoria can develop eating disorders such as bulimia and anorexia. That’s why there are high rates of pathological eating behaviors and disordered diets in people with gender dysphoria.

Both gender dysphoria and eating disorders have something in common; unhappiness with one’s body and a strong desire to change it. Eating disorders stem from efforts to lose weight and look a certain way. A person with gender dysphoria may develop unhealthy eating habits leading to eating disorders due to their attempt to achieve a look that makes them more comfortable in their skin.

Signs and symptoms of eating disorders depend on the specific disorder. For example, symptoms of bulimia are episodes of binge eating, self-induced vomiting, and misuse of laxatives and diuretics. Signs and symptoms of anorexia are food restriction, dizziness, and fainting. Symptoms of binge-eating disorder are consumption of large amounts of food and not being able to stop eating.

5. Substance misuse

Substance misuse is when a person uses over-the-counter medicine, illegal substances, or alcohol in a way that is dangerous or harmful to their health. Gender dysphoria by itself might not lead to substance abuse. But, severe stress could be a trigger. The “minority stress” can also make people prone to a range of addictive behaviors. Many with gender dysphoria might search for compassion, equality, understanding, and acceptance.

Those who don’t know how to cope with gender dysphoria can turn to substance abuse. Any substances they use could worsen their anxiety and symptoms of gender dysphoria. These individuals could be more at risk of using methamphetamines and cocaine compared to their peers. They can also be vulnerable to prescription pain medication misuse.

According to a review from Addictive Behaviors, transgender adults are prone to substance abuse. The mental health information website The Mental Elf mentions, people with gender dysphoria might be misusing substances as an escape from their anxiety or depression.

When does gender dysphoria first show up?

Gender dysphoria may first show up in early childhood or adolescence, but it can also appear in adulthood. The onset of gender dysphoria can be as early as 4 to 6 years old. Many experience it at the age of 7 whereas others around the age of 13, according to a paper from Sexual Medicine. For many patients, feelings of gender dysphoria are among their earliest childhood memories. But, this can vary from person to person.

Does gender dysphoria affect people of all ages?

Yes, gender dysphoria affects people of all ages. Even though most patients have experienced signs of gender dysphoria in childhood, people can develop it later in life as well. It is important to talk to a specialist, regardless of how old you are, if you are facing gender identity problems.

What gender dysphoria treatments are available?

The available treatments for gender dysphoria are listed below.

• Medical treatment
• Behavioral health treatment

1. Medical treatment

Different medical treatments can help patients with gender dysphoria. Hormone therapy can fix masculinization or feminization. Hormone therapy can help align the person’s body with their preferred gender identity. The main goal of hormonal therapy is to suppress the internally produced hormones and to administer and maintain cross-sex hormones.

Hormonal therapy is administered to patients who meet criteria such as persistent and well-documented gender dysmorphia, capacity to consent for the treatment, and mental or medical underlying issues are in control.

For transgender women, the main objective is to eliminate facial hair, induce breast formation, and create female contour. Doctors may prescribe a combination of anti-androgens, progestins, medroxyprogesterone acetate, finasteride and estrogen, and GnRH agonists. These hormones suppress expression of testosterone. Patients are advised not to smoke, especially those receiving estrogen. Every three months during the first year of hormone therapy, clinical and laboratory evaluation is performed. After that point, patients need evaluation once or twice a year. Transgender females also need speech/voice therapy that may include vocal training and speech therapy.

Transgender men need hormone therapy to look more masculine by suppressing feminine features. They usually receive testosterone injectables once a week. During the first few months of the therapy, patients may notice cessation of menstruation, increased muscle mass, higher libido, and formation of acne. Following three to six months of hormone therapy, more permanent changes may occur such as enlarged clitoris and deepening of the voice. Patients may need regular monitoring of testosterone levels, hemoglobin, hematocrit, liver function, cholesterol and diabetes screening.

Surgery can help with body reconstruction and accommodate the different needs of genital satisfaction. Multiple surgical interventions are available for people with gender dysphoria. These can include facial feminization, voice surgery, masculinizing scrotoplasty and clitoral enlargement. Each surgical intervention is tailored toward the patient’s individual needs.

Patients with gender dysphoria may need medications to treat underlying mental health problems such as depression. Doctors may prescribe antidepressants such as selective serotonin reuptake inhibitors (SSRIs), which increase serotonin levels, which helps positively influence sleep, emotion, and mood.

The main goal of medical treatment is to help a patient become more comfortable in the body or gender they identify with.

2. Behavioral health treatment

Behavioral therapy is a term that describes different types of therapies. This form of therapy helps change or identify unhealthy behaviors, self-destructive tendencies, or other harmful behaviors. Behavioral treatment aims to improve the psychological health and well-being of a patient. It also aims to improve quality of life and self-fulfillment. The goal of behavioral therapy isn’t to alter the gender identity, but to help a patient explore gender concerns to lessen the severity of their gender dysphoria.

Cognitive behavioral therapy is one of them. Through this form of therapy, people can understand what dysphoria is and the things they are going through. It is a great way of developing self-esteem and rational thinking.

During cognitive behavioral therapy, a therapist can help people with poor gender mental health develop a plan to address the social issues connected to their transition. Therapy empowers people to come out to their family and friends. Thanks to therapy, people with gender dysphoria can make healthier decisions that improve their quality of life.

Acceptance and commitment therapy (ACT) is another form of behavioral health treatment. This is a form of psychotherapy that includes behavioral analysis done by a mental health expert. Patients learn acceptance strategies and mindfulness skills. These techniques help them become more psychologically flexible and change their negative behavior.

Is gender dysphoria a mental disorder?

No, gender dysphoria is not a mental disorder. In the past, the medical community defined gender dysphoria as a mental disorder called gender identity disorder, according to a post from the National Library of Medicine. But, compassion and research led the World Health Organization to classify it as psychological distress that stems from incongruence. In 2019, WHO revised their International Classification of Diseases (ICD) and its 11th edition (ICD-11). They replaced transsexualism and gender identity disorder of children with gender incongruence of adolescence and adulthood and gender incongruence of childhood respectively. Changing this outdated diagnosis had a liberating effect on people around the globe, BBC reported.