Gender dysphoria
Gender dysphoria
Gender dysphoria is the misery caused when someone feels that their sex is mismatched with their gender identity. But the definition has changed over time: in 1978 the International Classification of Diseases included “transsexualism” in a section for sexual deviations and disorders; in 1992 a group of “gender-identity disorders” were defined as adult personality and behaviour disorders; in 2022 “transsexualism” became “gender incongruence”, and was redefined as a condition relating to sexual health.
Definitions of gender dysphoria
The word “dysphoria” comes from Greek, and means the opposite of euphoria: a state of misery that is hard to bear. Gender dysphoria is misery caused by a person’s sex, and their sense that it is mismatched with their gender identity. It is an inner sense of unease, distress, or disgust towards oneself, made up of thoughts, emotions and sensations, and can vary from low-level to incapacitating. The quality and conviction of the accompanying thoughts also vary.
The words used by clinicians for this sort of feeling have changed over time. In 1978 the International Classification of Diseases, an authoritative handbook of conditions and diagnoses, included “transsexualism” in a section entitled “Sexual deviations and disorders”. An update in 1992 included a group of “gender-identity disorders” in a section entitled “Adult personality and behaviour disorders”. The most recent update, published early in 2022, has replaced the term “transsexualism” with “gender incongruence”, which has been moved out of the chapter on mental disorders to a new one entitled “Conditions relating to sexual health”. This chapter also includes sexual dysfunctions, which are also no longer classified as mental disorders.
When it comes to relatable symptoms, such as pain, clinicians are expert at unpicking what their patient is experiencing. They ask about the type, location and intensity of the pain, whether it radiates and what makes it better or worse. They learn during training that 80% of diagnoses are made on the basis of a case history, and as they gain expertise, they learn to understand nuances in what is being described.
Gender dysphoria, by contrast, can be hard to relate to, since a person’s inner sense of themselves cannot be seen or measured, and many people report not having any gender-identity feelings at all. In a clinical setting, such ambiguity is unusual. It will take time for a clinician to understand what a patient with gender dysphoria is feeling, and to start to understand why. Clinicians should take a careful history as they usually would, and use it to explore what a patient means by “gender”, and how they experience dysphoria. While supporting the patient, they must keep an open-minded and dispassionate approach to diagnosis and treatment.
Similarities with body dysmorphia
In seeking to understand how gender dysphoria may arise, whether in childhood or adulthood, it is helpful to consider the related concept of body dysmorphia. In this condition, the miserable feelings are directed at the body, or a part or attribute of it.
Some people experience body dysmorphia as mild, and can quickly soothe or ignore the accompanying distressing thoughts. Someone who dislikes their chin, for example, may have frequent but fleeting thoughts about it, but find it relatively easy to reassure themselves that the shape of their chin doesn’t really matter, and start thinking about something else.
For someone else, such thoughts may become a major preoccupation. They may ruminate for hours and spend a lot of time in front of a mirror, inspecting their chin from different angles. Their feelings about their chin grow more negative and hostile, and affect their mood. They may try to conceal its supposed flaws with makeup, consider cosmetic surgery and browse websites seeking the “perfect” chin. When they go out they may worry that other people are staring at their chin, and thinking negative thoughts about it. Their thoughts become fixed, and friends and doctors saying their chin looks fine cannot persuade them that it is not deformed.
A person whose life is seriously affected by such feelings, for example by being unable to go out or to work, may be diagnosed with body dysmorphic disorder (BDD). This debilitating condition leads many sufferers to seek cosmetic surgery. But research shows that relief may be short-term, and the condition can return, sometimes shifting to another feature. The result can be a series of expensive, risky and ultimately futile surgeries.
What is generally more helpful is a course of cognitive behavioural therapy (CBT). The sufferer learns to re-evaluate their thoughts and modify their behaviours so they become less concerned about perceived imperfections. SSRIs (a type of antidepressant medication), often in combination with CBT, have also been shown to be useful.
The disorder shows how paying attention to and focusing on a bodily feature or idea about ourselves makes us more aware of it. That in turn magnifies our sensations and makes our thoughts more intense and intrusive, and more time-consuming and harder to ignore. Whether the thing that feels wrong is your chin, weight or thinning hair, attention begets attention.
The same can happen with a person’s ongoing examination of their internal sense of gender. Some people say they do not have any such sense, or if they do, they ascribe no importance to it. (This is not the same as being ignorant of gender roles or unaware of sex differences, which are among the first things that children notice about others and themselves.) People with gender dysphoria, by contrast, are preoccupied with what they feel and how others perceive them with regard to their sexed body or gender role.
How gender dysphoria develops
All children notice early that boys and girls have different body parts. But the games, clothes and so on associated with the two sexes vary widely from place to place, and are affected by socialisation and environment. In a class of infant schoolchildren, some girls will be drawn to football and running around, and some boys to dressing up and playing shop. From a clinical perspective, all of this is normal.
A person’s feelings about and experiences of gender will be influenced in part by nature (research suggests that a large part of personality is innate), but also by nurture. Will a two-year-old who refuses to put their shoes on be called naughty or resolute? Will a three-year-old girl playing with a truck be told it is a boy’s toy or encouraged? Will a four-year-old boy who wants to wear a dress be mocked and called a “poofter”, or allowed to wear what he wants? If a child is made to feel ashamed of how they like to play or dress, this can harm the development of their sense of self.
A child with gender dysphoria experiences a profound and intense distress directed towards their gender (the prescribed social role for their sex), and a wish to be or a belief that they are the opposite sex. The gender dysphoria can be associated with early adverse events, or with other psychological problems, such as depression, anxiety or thoughts of suicide.
As they grow up, people use signals received from family, friends, teachers, colleagues and so on to co-construct their personality and inner sense of self. The former can be understood as related to how others view a person, and the latter to how they view themselves. Personality and sense of self interact with each other, and with societal ideas of gender and a person’s own comfort with engaging in “gendered” behaviours.
Any sense of gender an individual experiences will interact with other aspects of their personality and the ideas about gender they are exposed to in their social environment. As with other aspects of their identity, this sense will evolve throughout their lifetime, as they react and adapt to their environment and gain life experience, and as their values and beliefs develop. The idea that a person can have a single, “authentic self” is therefore a strange one. It might be more accurate to say that every person has “true selves”, which will change as they mature from infant to child to adolescent and young adult, and pass through middle and old age.
People commonly feel discontented or uncomfortable with some aspect of themselves, or misunderstood by others, and these feelings can be fleeting or long-held. Adolescence, in particular, can be turbulent, consumed by the psychological task of separating and individuating. As we learn more about ourselves and how others perceive us, we discover how complicated others are, and how easy it is to misread and misunderstand them. Splitting the idea of gender from strands of identity and conceptualising it as a standalone, innate and permanent aspect of a person, especially when young, is unlikely to be helpful, either to a person’s self-understanding or to a clinician’s investigations.
Gender dysphoria can arise when confusing and complicated developmental processes get stuck, and a person’s attention becomes fixated on an inner self that is difficult to define and therefore to describe. The idea that people should have an instinctive understanding of this one aspect of themselves, understood as entirely separate from every other part of their personality or self-concept, is very new. Many professionals think this presents their patients with a pretty much impossible task. This may help explain the proliferation of labels used to define this essence.
What clinicians do know is that people develop in diverse ways. No one should feel put in a box, especially during youth, when opportunities should be opening up rather than becoming more restrictive. Adolescence is a time for exploring and expressing different aspects of selfhood. Pushing back against societal expectations of women and men may be part of that.
How gender dysphoria is diagnosed
The diagnostic criteria for gender dysphoria (previously known as gender-identity disorder) can be found in the Diagnostic and Statistical Manual of Mental Disorders (DSM), an American psychiatric guide widely used in the UK. This book is regularly updated, and diagnostic descriptions reflect societal and cultural change.
The latest edition, DSM-5, defines gender dysphoria in adolescents and adults as a marked incongruence between experienced/expressed gender and assigned gender, lasting at least six months, as manifested by at least two of:
- a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
- a strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- a strong desire for the primary and/or secondary sex characteristics of the other gender
- a strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- a strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Gender dysphoria in children is defined as a marked incongruence between experienced or expressed gender and assigned gender, lasting at least six months, as manifested by the first of these criteria, plus at least five of the others:
- a strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
- in boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
- a strong preference for cross-gender roles in make-believe play or fantasy play
- a strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
- a strong preference for playmates of the other gender
- in boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
- a strong dislike of one’s sexual anatomy
- a strong desire for the physical sex characteristics that match one’s experienced gender.
As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
As clinicians assess a child against these criteria, they must consider what is known about child development, and how the sense of incongruence might have arisen. They should also consider the reactions of the family and others around the child to the gender incongruence, any adverse events in the child’s life, the child’s personality and any neurodevelopmental or psychiatric conditions.
Co-occurring issues for minors with gender dysphoria
Obsessional thinking and rumination
This pattern of thinking may lead to a diagnosis of obsessive compulsive disorder, or may be a feature of people with an obsessional style of personality.
Such people believe there is a perfect way of being or doing things, and will keep going until they feel they have got things right. In small doses this trait can be useful, but once it reaches the level described as “clinical perfectionism” it can harm a person’s life. As their thoughts return over and over to the focus of their obsession, it becomes a debilitating preoccupation.
Interventions that “fix” things and enable them to achieve their desired outcome generally bring only temporary relief, and the obsessional thoughts return, perhaps with a different focus. People with gender dysphoria may display this sort of thinking, and may benefit from specialist therapy to address it.
Autism
Clinical observation suggests that autism, autism spectrum disorder (ASD) and autistic traits are unusually common among people who have gender dysphoria, and among those who identify as transgender. Symptoms include difficulties in social communication, restrictive and repetitive interests and behaviours, and sensory issues.
The reason for the elevated rates of autism and related conditions among people with gender dysphoria is not fully understood, and more research is needed. But there are plausible hypotheses for how certain autistic traits might make gender dysphoria more likely.
Friendship difficulties. Many people with ASD long for peers who are like them and who “get them”. But the stereotype of the autistic person as a loner means their need for social interaction may go unrecognised. They may find the acceptance and companionship they crave in the trans community.
Not fitting in. This can be the result of difficulty understanding and keeping up with social communication, which becomes more complex during puberty. Teenagers are expected to quickly learn new rules about how to behave as they and their peers embark on romantic relationships. Status competition within friendship groups, and communications that have multiple meanings, can be difficult for autistic people to navigate.
Odd or awkward social behaviours. People with ASD may have unusual preoccupations, and can be experienced as blunt, intrusive or bossy. Rather than accepting that this is just how they are, or setting and explaining clear, simple boundaries, their peers may bully or ostracise them.
Sensory differences. These may lead to experiences that a young person interprets as to do with their gender. For example, asexuality is more common in ASD. Sensations related to their pubertal development may be distressing.
Rumination and unusual interests. Young people with ASD may follow chat boards on platforms such as Tumblr or Reddit and become influenced by ideas they read about or videos they watch. Gender can become an obsession, and can lead them to spend a lot of time online as they research every aspect of it. Certain popular assertions in these internet spaces, such as “If you think you may be trans, then you are”, may suggest to young people with ASD that they should adopt a trans identity.
Literal, black-and-white thinking. Rigidity is frequent in people with ASD. They find change and flexibility difficult, including changing their minds. It can be very hard for them to see things from other people’s perspectives. They may struggle to understand metaphors or analogies, which will hinder them in exploring abstract ideas.
Homophobia
In the past, most children referred to clinics for gender dysphoria were boys. Most ceased to experience gender dysphoria by the end of adolescence and grew up to be happy as men, very often bisexual or homosexual. This indicates the importance of differentiating between emergent sexual orientation and gender dysphoria in children and adolescents.
Research suggests that the development of sexual orientation is affected by a combination of biological and social factors. If a young person is struggling to accept their sexuality, or experiencing overt or covert hostility at home or elsewhere, this can be explored in counselling, with action and support provided where necessary. Such support may include investigating concerns about safeguarding, or getting others, such as schools, involved in case of bullying.
Internalised homophobia has been identified as one cause of gender dysphoria. Young lesbian, gay or bisexual people may find it crushing to grow up in a homophobic environment. The experience of stigma, aggression and disgust may lead to depression, anxiety, self-hatred, and self-harming behaviours. This is evident from the accounts of some detransitioners (people who socially or medically transitioned and later return to identifying as members of their sex).
Lesbian and gay people often do not conform with stereotypes for their sex. If others find their non-conformity unacceptable, they may be bullied and teased. A young person who behaves in ways more typical of the opposite sex maybe be told that they “should have been” or “truly are” a member of that sex. A lesbian may feel, consciously or unconsciously, that she is somehow unacceptable because she doesn’t fit the feminine and highly sexualised caricature of how a woman is “supposed to be”.
For an extreme example of an interaction between homophobia and gender dysphoria, consider Iran, where homosexual behaviour is a capital crime. Lesbians and gay people are reportedly coerced into changing their legal sex, and undergoing hormonal and surgical interventions in order to look more like the opposite sex. This allows them to be socially reconceptualised as “heterosexual”.
Despite legal and societal progress, homophobia is still a considerable issue. Mental-health professionals are trained to consider each person’s internal and contextual experiences. It is essential to ask about bullying at school and attitudes at home, and seek to address problems directly or support the individual to do so themselves.
Sexual victimisation
Experience of sexual aggression, sexual assault and rape rise sharply with the onset of puberty. These experiences are pervasive, even between students in educational settings. The great majority of victims are female, and the perpetrators male. A helpline set up to support victims noted that “incidents reported include sexual name-calling, unwanted sexual touching, sexual assault and rape by other pupils, as well as online abuse such as sharing nude images without consent.” Girls may be affected even when the victim is a close friend or relative, rather than themselves.
A girl (indeed, any child or young person) may feel self-conscious, aware of being stared at and afraid of being groped or assaulted. This may come on top of dealing with a history of sexual violence and trauma. This discomfort can then become directed inwards, making her feel, consciously or unconsciously, that she wants her emerging bodily features to disappear. This pattern plays a part in eating disorders. It may also lead girls to experience dysphoria directed towards their growing breasts, and may account for at least part of the desire of many trans-identifying girls to wear breast binders or undergo mastectomies.
Further reading
’What is gender dysphoria?‘ (CAN-SG, 2022)