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 biology. It can include gonads, sex chromosomes, sex hormones, internal reproductive organs, and external genitalia.³ Gender refers to a society’s feelings and attitudes towards a certain sex.³ It includes the behaviors and expectations associated with that sex. Gender identity is a term that has been gaining popularity in recent years. It refers to a person’s sense of themselves as male, female, both, or neither.³ It does not necessarily relate to a person’s biological sex. Knowing the difference between these three terms is vital to understanding gender dysphoria.

Gender dysphoria occurs when a person’s biological sex and gender identity do not match up. It is defined as the distress or discomfort that arises from this discrepancy, and can oftentimes be very severe.⁷ People living with gender dysphoria often feel that they were born in the wrong body, which can be devastating. 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 are exhibiting symptoms of gender dysphoria, it is important to go to your healthcare provider for help. The earlier it is treated, the better the prognosis.² Gender dysphoria, although extremely traumatizing, can be treated through the joint efforts of a patient, their loved ones, and their healthcare provider(s).⁷ Many people report relief from their symptoms after speaking to a professional, even if they choose not to undergo any physical treatments.⁷ Psychotherapy is an important part of overcoming this devastating condition.

Classification

Originally known as gender identity disorder, gender dysphoria was once considered a mental illness.¹ The name was changed to try to erase the stigma associated with experiencing it. 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.¹

Statistics

In the United States, 1 in 30,000 males and at least 1 in 100,000 females have sought a sex reassignment.⁸ 1% 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.

Nearly 100% of boys with severe gender dysphoria live in a home without a father figure⁸, and 52% of gender dysphoric kids between the ages of four and eleven live with additional health conditions or illnesses.⁸

Causes

The causes of gender dysphoria are not yet fully understood. Although it was originally thought to be a mental illness, more recent studies have indicated that there is a biological component that affects the development of gender identity before birth.¹ Much of the development of one’s gender identity happens in the womb.⁵

A person’s biological sex is determined by two chromosomes – 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.⁵ Typically, there is no mismatch between sex and identity, meaning that people born male tend to identify as male and vice versa.⁵

However, there are some factors that could alter gender identity, most of which are caused by hormones. 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

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

Symptoms

The official criteria for a diagnosis, as laid out by the DSM-V, is that the symptoms of 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 Symptoms of gender dysphoria differ slightly between children and adults. Some common symptoms in children include 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

However, it is important to keep in mind that some of these symptoms are just part of being a child, and are 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. Normally this is just a phase, and a normal part of growing up. As a matter of fact, 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.⁶ Additionally, more extreme nonconformity in childhood increases the likelihood that their gender dysphoria will continue into adulthood.⁷

If these symptoms persist 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 1.⁷ Formal 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

Treatment

Treating gender dysphoria requires a multidisciplinary approach and must be tailored to each person’s specific needs. At the very least, treatment involves speaking with a psychotherapist or other mental health professional. The intention of psychotherapy is not to change how a person feels about their identity, 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.⁷ A qualified professional must have knowledge of gender nonconforming identities and expressions and the ability to assess for and diagnose gender dysphoria and help with treatment. They should also be involved in continuously educating themselves in the treatment and 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 Technology can help improve access to healthcare and psychological professionals.⁷ It would be ideal for everyone to be able to speak with trained professionals near them, and hopefully in the future, qualified professionals will be more widespread.

Mental health care consists of much more than just a diagnosis. A psychotherapist provides assessment and diagnosis 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 forms of physical treatment, which can be different for children, teens, and adults.

In recent years, more dysphoric children have been starting to 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: reversible interventions, partially reversible interventions, and 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 dysphoric adolescents desire 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 high chance of causing to 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 1% of those who have undergone masculinization surgery and 1 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 could 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 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 usually must follow up with their doctor to continue to receive hormone therapy and to ensure that no complications arise.⁷

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 theyundergo hormone therapy and/or surgery to physically transition to their internal gender.⁴ The transition generally happens in steps and takes years to be fully completed.⁴

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 incredible.⁷

Although certain aspects of treatment for gender dysphoria require lifelong maintenance, 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 and help from health professionals, 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. Recovery is possible, and society is becoming more and more accepting of alternative sexual and gender identities as time goes on.

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.