What is gender dysphoria?

Causes and Symptoms

The exact cause of gender dysphoria is not clearly understood or universally agreed upon. Many believe that the condition is not pathological. Others feel that gender dysphoria results from multiple pathways that can work alone or together. These pathways result from an individual’s psychological, sociocultural, biological, and genetic factors and background. Relevant terms in any discussion of gender dysphoria include "sex," which refers to the physical characteristics associated with being either male or female, and "gender," which refers to the culturally defined roles and behaviors associated with a given sex. Concepts related to gender dysphoria include "transsexualism," which refers to people who actively identify with the opposite sex and choose to live as a member of that sex, and "transgender," a catch-all term for people whose gender identity does not match traditional expectations for their sex.

A psychiatrist or psychologist typically makes the diagnosis of gender dysphoria. Diagnostic criteria for both childhood and adult forms have been established by the American Psychological Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM). ("Gender dysphoria" appears in the fifth edition, published in 2013, and represents a renaming of the diagnosis from previous editions, where it appeared as "gender identity disorder.") To carry a diagnosis of childhood gender dysphoria, a child must have an onset of symptoms before puberty. The majority of children resolve their gender dysphoria; others have a continuation of symptoms into adolescence or adulthood. Some people are first diagnosed as adults. Once gender dysphoria is diagnosed in adults, it tends to have a chronic course.

To meet the criteria for diagnosis, an individual must have a cross-gender identification exceeding the desire for perceived cultural advantages of being the other sex. A persistent discomfort with the person's sex or with the gender role of that sex must exist. The disturbance must cause clinically significant distress in important areas of functioning. Gender dysphoria is not necessarily concurrent with disorders of sexual development, a condition in which an individual may be born with ambiguous genitalia (intersexuality). Gender dysphoria is also independent of sexual orientation, occurring in people who identify as both homosexual and heterosexual.

Treatment and Therapy

The World Professional Association for Transgender Health (WPATH, formerly the Harry Benjamin International Gender Dysphoria Association) has a set of guidelines established for the standards of care for gender dysphoria. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People identifies multiple therapeutic approaches to gender dysphoria. These include changes in gender expression and role (cross-dressing and other behavioral changes, either full or part time), hormone replacement therapy (estrogen or testosterone to either feminize of masculinize the body), sex reassignment surgery, and psychotherapy. Therapy should proceed focusing on resolving any comorbid psychological disorders, promoting acceptance, and discussing further treatment options.

Hormone therapy can be given to adolescents to delay puberty. This allows time for an individual to explore gender identity and to make a gender transition more conspicuously. In the United States, estrogen or testosterone can be given to an individual who is eighteen and who demonstrates knowledge about the benefits and risks, has spent a prescribed period living in the desired role or a period of psychotherapy, and demonstrates readiness.

Sex reassignment surgery is the final step that some people with gender dysphoria choose to pursue. Genital reconstruction can occur in both males and females. An individual who is anatomically female may also desire removal of the breasts, uterus, ovaries, and Fallopian tubes, as well as liposuction and other aesthetic procedures. For someone who is anatomically male, surgery may include breast implants, facial feminization surgery, and voice surgery.

Perspective and Prospects

Gender dysphoria exists in every culture. It has been recorded as early as Hippocrates, who is credited with the first classification system for what was called Scythian disease. Magnus Hirschfeld coined the term “transvestism” in 1915, describing individuals who cross-dress. In 1949, David Caudwell coined the term “transsexual.” In 1966, Harry Benjamin developed a Sex Orientation Scale to differentiate the various forms of transvestism and transsexualism. Since then, there has been extensive debate concerning the correct classification and terminology surrounding gender dysphoria and transgenderism.

The diagnosis of gender identity disorder was added to the DSM in 1987. The transgender community campaigned for many years, with eventual success, to have this classification changed, as many transgender people found it offensive and incorrect to label gender dysphoria as a disorder. People argue that concepts of gender roles are socially constructed and therefore wonder how a society can define, scientifically, what a “normal” gender identity is. Many people support the idea that transgendered people are leading the way in redefining and updating traditional concepts of gender.

Bibliography

American Psychological Association. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. Washington, D.C.: Author, 2013.

"Answers to Your Questions about Transgender People, Gender Identity, and Gender Expression." American Psychological Association, 2011.

Brown, Mildred L., and Ann Rounsley. True Selves: Understanding Transsexualism—For Families, Friends, Coworkers, and Helping Professionals. San Francisco: Jossey-Bass, 1996.

Cohen-Kettenis, Peggy T., and Friedemann Pfäfflin. Transgenderism and Intersexuality in Childhood and Adolescence: Making Choices. Thousand Oaks, Calif.: Sage Publications, 2003.

"Gender Identity Disorder." MedlinePlus, February 13, 2012.

"Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People." 7th version. World Professional Association for Transgender Health, 2011.

World Health Organization. International Statistical Classification of Diseases and Related Health Problems: 10th Revision–ICD-10. 2d ed. Geneva, Switzerland: Author, 2000.