How Gender Dysphoria Is Diagnosed

Criteria Used to Identify Gender Incongruence

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Gender dysphoria is the term used to describe the distress caused when a person's biological sex and gender identity do not match. For example, a person with a penis may identify as female, while a person with a vagina may identify as male.

In the past, mental health professionals referred to the condition using terms such as "cross-gender identification," suggesting that people simply identified with the opposite sex. Today, the American Psychiatric Association (APA) has reclassified it as "gender dysphoria" in their latest edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5).

Instead of suggesting that a person "wants to be other sex," the DSM-5 asserts that there is a tangible conflict or incongruence between one's sexual physiology and one's identity (the qualities, beliefs, personality, looks, and expressions that make you unique).

As the public continues to gain greater awareness about gender dysphoria (and about transgender people in general), efforts have been made to clarify how the condition is diagnosed. To this end, the APA has issued a set of criteria for a diagnosis, which some people refer to a gender dysphoria test.

Background

In the previous DSM-4 issued in 1994, gender dysphoria was classified as gender identity disorder (GID). This placed the condition under a broader classification of sexual disorders, suggesting that treatment was afforded to correct a "psychological abnormality." It was a stigmatizing label that kept many people from seeking treatment and support.

Gender dysphoria is in no way associated with sexual orientation or refers to homosexuality in any way. Rather, it places the focus on distress with one's body rather than conformity with societal gender norms.

It further reframes the condition as distress that can potentially be rectified with gender transition procedures, rather than as a lifelong disorder of the identity.

In providing a framework for diagnosis, the APA has issued a list of criteria a person must meet in order in order to be diagnosed with gender dysphoria. There are two sets of criteria, one for adults and adolescents and the other for children.

Definitions

One of the difficulties faced by individuals, families, and the public alike is the ongoing confusion with terminologies, including the words "sex" and "gender."

Sex refers specifically to biology, namely the reproductive organs to which male and female genders are assigned. Gender, by contrast, refer either to social roles based on a person's sex or one personal identification of being male or female.

People whose assigned sex and gender identity do not match are referred to as transgender and are considered so irrespective of attire, hormonal therapy, or surgery.

As such, you do not need to undergo gender reassignment surgery to be transgender; you simply are considered transgender based on your self-identification.

Gender Nonconformity

Gender dysphoria should not be confused with gender nonconformity (GNC). By definition, GNC does not adhere to a binary model of gender, specifically that you are either male or female. Rather, it describes people who feel that they are neither only male or only female.

In some cases, people who identify with both or neither genders will refer to themselves as "non-binary" or "genderqueer." By contrast, terms like "transsexual" or "cross-dressers" are considered offensive, implying sexual deviation rather than a healthy exploration of one's gender identity.

The term "cisgender" is used to describe people for whom their assigned sex and gender align.

A 2017 study published in the American Journal of Public Health suggested that 390 out of every 100,000 people in the United States—approximately one million—are transgender.

Due to a confusion in definitions, as well as the ongoing stigmatization of transgender people, researchers believe the numbers are, in fact, far greater.

Diagnosis in Adults

Gender dysphoria can be confirmed if certain criteria outlined by the APA are met. The DSM-5 states that at least 2 of the following criteria must be experienced for at least six months in adolescents or adults:

  1. A strong desire to be of the gender other than one that assigned
  2. A strong desire to be treated as a gender other than that assigned
  3. An incongruence between one's experienced or expressed gender and one's sexual characteristics
  4. A strong desire to have the sexual characteristics of a gender other than the one you were assigned
  5. A strong desire to be rid of one's sexual characteristics due to the incongruence with one's experienced or expressed gender
  6. A strongly held belief that one has the typical reactions and feelings of a gender other than the one assigned

In addition, these conditions must cause significant distress during which you are unable to function normally at school, work, or social activities.

Diagnosis in Children

Diagnosing gender dysphoria in children is far more difficult. This is because children often have lesser insight into what they are experiencing or lack the ability to express the insights they are experiencing. To this end, the test is focused as much on behaviors as it is likes, dislikes, and preferences.

According to the DSM-5, children must meet at least 6 of the following for a least six months:

  1. A strong desire to be the other gender or an insistence that one is the other gender
  2. A strong preference for wearing clothes of the opposite gender
  3. A strong preference for cross-gender roles in make-believe play
  4. A strong preference for the toys, games, or activities stereotypically used by the other gender
  5. A strong preference for playmates of the other gender
  6. A strong rejection of toys, games, and activities typical of one’s assigned gender
  7. A strong dislike of one’s sexual anatomy
  8. A strong desire for the physical sex characteristics of a gender other than your own

Because terms like "strong preference" and "strong desire" are highly subjective, clinical judgment from a qualified mental health professional is needed to establish a diagnosis. Even then, it may be hard to assess how long these feelings may or may not persist in children.

With adults, for example, feelings of incongruity may be carried for a lifetime. With children, the intense emotional responses may, in fact, change over time.

The data is often conflicting as to how many children will "desist" and eventually achieve congruence between their sex and gender identity. Depending on which study you refer to, the rate may be as low as 25 percent or as high as 80. However, children are typically under intense pressure to maintain societal norms and are tacitly discouraged from transitioning.

Many children will surrender to the pressures and claim to be cisgender even if the dysphoric feelings persist.

It is for this reason that psychologists will want to assess a child's overall emotional state to better characterize the nature of their responses. In many cases, it is better to do this in the absence of parents and other influences, however well-intentioned they may be.

A Word From Verywell

While people can ostensibly "self-test" themselves or their children for gender dysphoria, this should only be seen as the first step toward an actual diagnosis. Even as adults, people can have difficulty articulating their true feelings or identifying the sources of those feelings.

Moreover, as parents, we may not recognize how our own biases and words unintentionally sway our children's responses. Oftentimes, parents will focus solely on the confirmation of a child's gender identity rather than affirmatively supporting the development of the child's identity, whatever it may be.

It is important to work with a clinician who has experience in gender dysphoria a to help you reach an affirmative diagnosis and direct the appropriate care. You can start your search by using the online psychologist locator managed by the American Psychological Association.

You can then embark on which steps to take if diagnosed with gender dysphoria, including emotional and family support, gender expression counseling, hormone therapy, or surgery.

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Article Sources

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  •  American Psychiatry Association (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (5th ed.). Washington, D.C.: American Psychiatric Publishing; pp. 451-60. DOI: 10.1176/appi.books.9780890425596

  • Meerwijk, E. and Sevelius, J. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 February;107(2):e1-e8. DOI: 10.2105/AJPH.2016.303578

  • Temple Newhook, J.; Pyne, J.; Winters, K. et al. A critical commentary on follow-up studies and “desistance” theories about transgender and gender-nonconforming children. Int J Transgenderism. 2018;19:2;212-24. DOI: 10.1080/15532739.2018.1456390