Gender dysphoria

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Gender dysphoria
Other namesGender identity disorder
Transitioning, psychotherapy[2][3]
MedicationHormones (e.g., androgens, antiandrogens, estrogens)
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t
  • e

    • Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their

    stigma associated with the term disorder.[7]

    People with gender

    Gender nonconformity is not the same thing as gender dysphoria[9] and does not always lead to dysphoria or distress.[10]

    The causes of gender incongruence are unknown but a gender identity likely reflects genetic, biological, environmental, and cultural factors.[11][12][13] Diagnosis can be given at any age, although gender dysphoria in children and adolescents may manifest differently than in adults.[14] Complications may include anxiety, depression, and eating disorders.[8] Treatment for gender dysphoria includes social transitioning and often includes hormone replacement therapy (HRT) and/or gender-affirming surgeries, and psychotherapy.[2][3]

    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.[15] 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.[16]

    Signs and symptoms

    Distress arising from an incongruence between a person's felt gender and assigned sex/gender (usually at birth) is the cardinal symptom of gender dysphoria.[17][18]

    No particular sexual orientation indicates gender dysphoria.[19][20] A 2021 review in Dialogues in Clinical Neuroscience found no relation to sexual orientation, but acknowledged that historically the two were often erroneously conflated.[21] The British National Health Service also stated "gender dysphoria is not related to sexual orientation".[22]

    Gender dysphoria in those

    assigned female at birth (AFAB), with those experiencing early-onset GD being most likely to be attracted to women and those with late-onset being most likely to be attracted to men and identify as gay.[23][24]

    Symptoms of GD in children include preferences for opposite sex-typical toys, games, activities, or playmates as well as a great dislike of their own genitalia.

    poor self-esteem, and suicide.[4] Transgender people are also at heightened risk for eating disorders[26] and substance abuse.[27] According to the American Psychiatric Association,[28] those who experience gender dysphoria later in life "often report having secretly hidden their gender dysphoric feelings from others when they were younger".[29]

    Causes

    See also: Causes of gender incongruence

    The specific causes of gender dysphoria remain unknown, and treatments targeting the

    studies of twins suggests that genetic factors play a role in the development of gender dysphoria.[11][12] Gender identity is thought to likely reflect a complex interplay of biological, environmental, and cultural factors.[13] Neurobiological basis of GD has been proven by the "distinct gray matter volume and brain activation and connectivity differences" in people with GD when compared to controls; and this "leads to the concept of brain gender".[31]

    Diagnosis

    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:[25]

    • 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 significant incongruence between one's experienced or expressed gender and one's sexual characteristics
    • A strong desire for the sexual characteristics of a gender other than one's assigned gender
    • A strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed 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.[25]

    The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own.[25] The diagnosis was renamed from gender identity disorder to gender dysphoria, after criticisms that the former term was stigmatizing.[32] 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.[33] 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.[25] Intersex people are no longer excluded from the diagnosis of GD.[34]

    The International Classification of Diseases (ICD-11) lists 3 conditions related to gender identity:[35]

    • Gender incongruence of adolescence or adulthood (HA60)
    • Gender incongruence of childhood (HA61)
    • Gender incongruence, unspecified (HA6Z)

    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.[35]

    Treatment

    Treatment for a person diagnosed with GD may include psychological counseling, supporting the individual's gender expression, or may involve physical transition resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries.[36] The goal of treatment may simply be to reduce problems resulting from the person's transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing.[37]

    Guidelines have been established to aid clinicians. The

    Standards of Care are used by some clinicians as treatment guidelines. Others use guidelines outlined in Gianna Israel and Donald Tarver's Transgender Care.[38] Guidelines for treatment generally follow a "harm reduction" model.[39][40][41]

    Children

    Main article: Gender dysphoria in children

    Medical, scientific, and governmental organizations have opposed conversion therapy, defined as treatment viewing gender nonconformity as pathological and something to be changed, instead supporting approaches that affirm children's diverse gender identities.[42][43][44] People are more likely to keep having gender dysphoria the more intense their gender dysphoria, cross-gendered behavior, and verbal identification with the desired/experienced gender are (i.e. stating that they are a different gender rather than wish to be a different gender).[45]

    Professionals who treat gender dysphoria in children sometimes prescribe puberty blockers to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal or surgical gender reassignment is in their best interest.[46][47] Short-term side effects of puberty blockers include headaches, fatigue, insomnia, muscle aches and changes in breast tissue, mood, and weight.[48] Research on the long-term effects on brain development, cognitive function, fertility, and sexual function is limited.[49][50][51]

    A review published in Child and Adolescent Mental Health found that puberty blockers are reversible, and that they are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.[52]

    According to the American Psychiatric Association, "Due to the dynamic nature of puberty development, lack of gender-affirming interventions (i.e. social, psychological, and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Trans-affirming treatment, such as the use of puberty suppression, is associated with the relief of emotional distress, and notable gains in psychosocial and emotional development, in trans and gender diverse youth".[14]

    In its position statement published December 2020, the Endocrine Society stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.[53] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty (Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". They recommend a multidisciplinary team of medical and mental health professionals manage the treatment for those under 18 and recommend "monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment".[54]

    The World Professional Association for Transgender Health's Standards of Care 8, published in 2022, declare puberty blocking medication as "medically necessary", and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal data shows improved outcomes for transgender patients who receive them.[55] Some medical professionals disagree that adolescents are cognitively mature enough to make a decision with regard to hormone therapy or surgery, and advise that irreversible genital procedures should not be performed on individuals under the age of legal consent in their respective country.[56]

    A review commissioned by the UK Department of Health found that there was very low certainty of quality of evidence about puberty blocker outcomes in terms of mental health, quality of life and impact on gender dysphoria.[57] The Finnish government commissioned a review of the research evidence for treatment of minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria.[58] Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that "pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood."[59]

    In the

    National Board of Health and Welfare in Sweden issued new guidelines recommending that puberty blockers only be given in "exceptional cases" and said that their use was grounded in "uncertain science." Instead, they recommended child psychiatric treatment, psychosocial interventions, and suicide prevention measures to be offered by clinicians.[67][68]

    Psychological treatments

    Main article: Psychotherapy

    Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to their assigned sex. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Psychotherapy may be used in addition to biological interventions, although some clinicians use only psychotherapy to treat gender dysphoria.[30] Psychotherapeutic treatment of GD involves helping the patient to adapt to their gender incongruence or to explorative investigation of confounding co-occurring[69][70][71][72] mental health issues. Attempts to alleviate GD by changing the patient's gender identity to reflect assigned sex have been ineffective and are regarded as conversion therapy by most health organizations.[42][73]: 1741 

    Biological treatments

    Main article:
    Gender-affirming care

    Biological treatments physically alter

    WPATH Standards of Care state that psychotherapy should not be an absolute requirement for biological treatments.[75]

    Hormonal treatments have been shown to reduce a number of symptoms of psychiatric distress associated with gender dysphoria.[31] A WPATH commissioned systematic review of the outcomes of hormone therapy "found evidence that gender-affirming hormone therapy may be associated with improvements in [quality of life] scores and decreases in depression and anxiety symptoms among transgender people." The strength of the evidence was low due to methodological limitations of the studies undertaken.[76] Some literature suggests that gender-affirming surgery is associated with improvements in quality of life and decreased incidence of depression.[77] Those who choose to undergo sex reassignment surgery report high satisfaction rates with the outcome, though these studies have limitations including risk of bias (lack of randomization, lack of controlled studies, self-reported outcomes) and high loss to follow up.[78][79][80]

    For adolescents, much is unknown, including persistence. Disagreement among practitioners regarding treatment of adolescents is in part due to the lack of long-term data.[20] Young people qualifying for biomedical treatment according to the Dutch model[81][82] (including having GD from early childhood on which intensifies at puberty and absence of psychiatric comorbidities that could challenge diagnosis or treatment) found reduction in gender dysphoria, although limitations to these outcome studies have been noted, such as lack of controls or considering alternatives like psychotherapy.[83]

    In its position statement published December 2020, the Endocrine Society stated that there is durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. They noted a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.[53] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty (Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". They recommend a multidisciplinary team of medical and mental health professionals manage the treatment for those under 18. They also recommend "monitoring clinical pubertal development every 3 to 6 months and laboratory parameters every 6 to 12 months during sex hormone treatment".[54]

    A review published in Child and Adolescent Mental Health found that puberty blockers are fully reversible, and that they are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.[52]

    More rigorous studies are needed to assess the effectiveness, safety, and long-term benefits and risks of hormonal and surgical treatments.[78] For instance, a 2020 Cochrane review found insufficient evidence to determine whether feminizing hormones were safe or effective, due to the lack of "completed studies that met [their] inclusion criteria."[84] Several studies have found significant long-term psychological and psychiatric pathology after surgical treatments.[78]

    In 2021, a review published in Plastic and Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision. It concluded that "There is an extremely low prevalence of regret in transgender patients after GAS. We believe this study corroborates the improvements made in regard to selection criteria for GAS. However, there is high subjectivity in the assessment of regret and lack of standardized questionnaires, which highlight the importance of developing validated questionnaires in this population."[85]

    Comorbidities

    Among youth, around 20% to 30% of individuals attending gender clinics meet the DSM criteria for an

    eating disorders in transgender youth.[87]

    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.[88] Studies on children and adolescents with gender dysphoria have found a high prevalence of autism spectrum disorder (ASD) traits or a confirmed diagnosis of ASD. Adults with gender dysphoria attending specialist gender clinics have also been shown to have high rates of ASD traits or an autism diagnosis as well.[89] It has been estimated that children with ASD were over four times as likely to be diagnosed with GD,[88] with ASD being reported from 6% to over 20% of teens referring to gender identity services.[20]

    Epidemiology

    See also: Transgender § Population figures and prevalence, and Transsexual § Prevalence

    Different studies have arrived at different conclusions about the prevalence of gender dysphoria. The DSM-5 gives a gender dysphoria prevalence of 0.005% to 0.014% of people assigned male at birth (5-14 per 100k) and 0.002% to 0.003% of people assigned female at birth (2-3 per 100k).[90] The DSM-5 states that these numbers are likely underestimates, being based on the number of referrals to specialty clinics.[90] Not all adults seeking medical transition are referred to specialty clinics.[90]

    According to

    sex reassignment surgery.[92] Studies of hormonal treatment or legal name change find higher prevalence than sex reassignment, with, for example a 2010 Swedish study finding that 1 in 7,750 (13 per 100k) adult natal males and 1 in 13,120 (8 per 100k) adult natal females requested a legal name change to a name of the opposite gender.[92]

    Studies that measure transgender status by self-identification find even greater prevalence of gender identity different from sex assigned at birth (although some of those who identify as transgender or gender nonconforming may not experience clinically significant distress and so do not have gender dysphoria). A study in New Zealand found that 1 in 3,630 natal males (13 per 100k) and 1 in 22,714 (4 per 100k) natal females have changed their legal gender markers.[92] A survey of Massachusetts adults found that 0.5% (500 per 100k) identify as transgender.[92][93] A national survey in New Zealand of 8,500 randomly selected secondary school students from 91 randomly selected high schools found 1.2% (1,200 per 100k) of students responded "yes" to the question "Do you think you are transgender?".[94] Outside of a clinical setting, the stability of transgender or non-binary identities is unknown.[92]

    Research indicates that among people who transition in adulthood, individuals are up to three times more likely to be male assigned at birth. However, among people transitioning in childhood, the sex ratio is closer to 1:1.[95] The prevalence of gender dysphoria in children remains uncertain due to the lack of formal prevalence studies.[45] A 2022 literature review reported that approximately 36% of adolescents assessed in specialized gender clinics were natal males, and 63% were natal females. One study highlighted in the review found no significant change in these proportions from 2014-2016.[96] However, when comparing more recent data with earlier studies, there has been a shift favoring natal females (ratio of 1:3) as opposed to nearly equal proportions in earlier studies (ratios of 0.8–0.9:1).[97]

    History

    Neither the

    DSM-III (1980), where it appeared under "psychosexual disorders" but was used only for the childhood diagnosis. Adolescents and adults received a diagnosis of transsexualism (homosexual, heterosexual, or asexual type). The DSM-III-R (1987) added "Gender Identity Disorder of Adolescence and Adulthood, Non-Transsexual Type" (GIDAANT).[98][99][100] DSM-V (2013) replaced gender identity disorder (GID) with gender dysphoria (GD) to avoid the stigma of the term disorder.[1]

    Society and culture

    A sign at a trans rights rally: "Gender is like that old jumper from my cousin: It was given to me and it doesn't fit."

    Researchers disagree about the nature of distress and impairment in people with GD. Some authors have suggested that people with GD suffer because they are stigmatized and victimized;[15][101] and that, if society had less strict gender divisions, transgender people would suffer less.[102]

    Some controversy surrounds the creation of the GD diagnosis, with Davy et al. stating that although the creators of the diagnosis state that it has rigorous scientific support, "it is impossible to scrutinize such claims, since the discussions, methodological processes, and promised field trials of the diagnosis have not been published."[34]

    Some cultures have

    feminine males, are mostly socially accepted. The fa'afafine appear similar to transgender women in terms of their lifelong identities and gendered behavior, but experience far less distress than do transgender women in Western cultures. This suggests that the distress of gender dysphoria is mostly not caused by the cross-gender identity itself, but by difficulties encountered from social disapproval by one's culture.[103] Overall, it is unclear whether or not gender dysphoria persists in cultures with third gender categories.[104]

    Classification as a disorder

    The

    gender nonconformity is not the same thing as gender dysphoria,[9] and that "gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition."[1]

    Individuals with gender dysphoria may or may not regard their own cross-gender feelings and behaviors as a disorder. Advantages and disadvantages exist to classifying gender dysphoria as a disorder.

    pathologizes gender variance and reinforces the binary model of gender.[15]

    An analysis of the Samoan third gender fa'afafine suggests that the DSM-IV-TR diagnostic component of distress is not inherent in the cross-gender identity; rather, it is related to social rejection and discrimination suffered by the individual.[103] Psychology professor Darryl Hill insists that gender dysphoria is not a mental disorder, but rather that the diagnostic criteria reflect psychological distress in children that occurs when parents and others have trouble relating to their child's gender variance.[108] Transgender people have often been harassed, socially excluded, and subjected to discrimination, abuse and violence, including murder.[4][102]

    In December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states, "What transsexualism is not ... It is not a mental illness."[111] In May 2009, the government of France declared that a transsexual gender identity will no longer be classified as a psychiatric condition,[112] but according to French trans rights organizations, beyond the impact of the announcement itself, nothing changed.[113] Denmark made a similar statement in 2016.[114]

    In the ICD-11, GID is reclassified as "gender incongruence", a condition related to sexual health.[35] The working group responsible for this recategorization recommended keeping such a diagnosis in ICD-11 to preserve access to health services.[115]

    Gender euphoria

    In 1990, Virginia Prince ended an article wishing her readers "gender euphoria."

    Gender euphoria (GE) is a term for the satisfaction, enjoyment, or relief felt by trans and non-binary people when they feel their gender expression matches their personal gender identity.[92][116][117] Psych Central's definition is "deep joy when your internal gender identity matches your gender expression."[118] It is proposed that feelings of gender euphoria require societal acceptance of gender expression.[116] In academics and the medical field, a consensus has not yet been reached on a precise definition of the term, as it has been mainly used within a social context.[119][120] The first attempt to rigorously define gender euphoria through an online survey took place in 2021, conducted by Will Beischel, Stéphanie Gauvin, and Sari van Anders.[120][121] Transgender congruence is also used to ascribe transgender individuals feeling genuine, authentic, and comfortable with their gender identity and external appearance.[122][123]

    The term gender euphoria has been used by the transgender community since at least the mid-1970s.[121] Originally, it referred to the feeling of joy arising from fulfilling a mix of gender roles, which was different from the concept of gender dysphoria, which is used to describe individuals who wished to medically transition to a different sex.[121] In the 1980s, the term was published in trans contexts, coming up in interviews with trans people.[124][125][126] For example, in a 1988 interview with a trans man, the subject states, "I think that day [Dr. Charles Ilhenfeld] administered my first shot of the 'wonder-drug' must have been one of the 'peak-experiences' of my life -- talk about 'gender euphoria'!"[127] The interview indicates he is referring to testosterone.[127]

    Other figures, including Mariette Pathy Allen and Virginia Prince, have used the term in their work. In 1990, Virginia Prince used the phrase in the trans magazine Femme Mirror, ending an article with, "...from here on you can enjoy GENDER EUPHORIA - HAVE A GOOD LIFE!"[128] Starting in 1991, a monthly newsletter named Gender Euphoria was released,[129] featuring articles about transgender topics; Leslie Feinberg read the newsletter to better understand the transgender community.[130] However, there are instances in which gender euphoria has been used with a different meaning, such as in 1979, when the Black feminist Michele Wallace used it to describe the male privilege present in Black men.[131][132]

    The term has been embraced as part of a movement to stop pathologizing being transgender.[133] In 1989, Mariette Pathy Allen published an unnamed transgender person's quote in her photography book Transformations: "The shrinks may call it 'gender dysphoria,' but for some of us, it's gender 'euphoria,' and we're not going to apologize anymore!"[134] The movement to focus on the positive side of gender expression was also advocated for in 1994, when the Scottish "TV/TS" periodical The Tartan Skirt wrote, "Let's accentuate the positive, discard the negative, and promote the new condition of 'Gender Euphoria.'"[135] In 1997, Patrick Califia described transgender activists picketing using signs that read "Gender Euphoria NOT Gender Dysphoria" and handing out "thousands of leaflets" at protests.[133] The following year, in 1998, Second Skins: The Body Narratives of Transsexuality reported:

    The transactivist group Transexual Menace is campaigning to have the diagnosis "Gender Identity Disorder" removed entirely from the Diagnostic and Statistical Manual of Mental Disorders. "Gender Euphoria NOT Gender Dysphoria"; its slogans invert the pathologizing of transgender, offering pride in queer difference as an alternative to the psychiatric story.[136]

    Similarly,

    gender-affirming care, they must be diagnosed with gender dysphoria, which is not always accessible and entails people must be experiencing significant distress before they can fully express their own gender identity.[139] Ashley's stance that gender euphoria does not need to be preceded by a clinical diagnosis of gender dysphoria, and that gender euphoria is complex, is echoed by Elliot Tebbe and Stephanie Budge in their 2022 Nature Reviews Psychology[140] article, in which they write, "Gender euphoria is not merely the absence of gender dysphoria, but rather a conglomeration of positive emotions and subjective well-being in response to being affirmed in one’s gender."[141]

    Gender euphoria has also been expressed through art. In 2019, the Midsumma festival in Australia hosted "Gender Euphoria," a cabaret focusing on "bliss" in transgender experiences, including musical, ballet, and burlesque performances.[142][143][144][145] A reviewer described it as "triumphant – honest, unpretentious, touching, and a vital celebration."[143] Moreover, photography in the East Village in Manhattan has served as means to express gender euphoria, contrasting fashion photography, which is said to reinforce the gender binary.[146]

    See also

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    Further reading

    External links

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