How Gender Dysphoria Is Diagnosed

Criteria Used to Identify Gender Incongruence

Gender dysphoria is the term used to describe the distress caused when a person's biological sex and gender identity do not match cultural expectations.

For example, a person with a penis may exist as a woman, while a person with a vagina may exist as a man.

Additionally, someone may exist as a gender outside of the binary categories of man and woman altogether, regardless of their sex characteristics.

Hand with transgender symbol written on it
nito100 / Getty Images 

Background

In the past, mental health professionals referred to the condition using terms like "cross-gender identification," suggesting people simply identified with the opposite sex.

In its latest edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-5) the American Psychiatric Association (APA) reclassified it as "gender dysphoria."

Instead of suggesting that a person "wants to be the 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 as a gender dysphoria test.

There's longstanding controversy surrounding "gender dysphoria" diagnoses. Many trans people oppose the presence of "gender dysphoria" as a diagnosis in the DSM, often asserting that it stigmatizes being trans and brands it as an illness.

Classification

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.

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.

Gender dysphoria is in no way associated with sexual orientation, nor does it refer to homosexuality in any way. Rather, gender dysphoria places the focus on distress with one's body due to social enforcement of sex and gender binaries.

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 at birth by medical professionals.

Gender, by contrast, refers to social roles or gender performance expectations that vary across cultures.

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 sex reassignment surgery nor experience gender dysphoria to be transgender; you simply are considered transgender based on 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, or the idea that you are either a man or woman. Rather, it describes people who exist outside of the constraints society places on gender categories and performance.

Sometimes, people who identify with both or neither genders will refer to themselves as "non-binary" or "genderqueer." While some non-binary or genderqueer people are transgender, not all members of this community are trans. It is best to not assume.

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 whose sex assigned at birth aligns with social expectations of gender identification.

A 2017 study in the American Journal of Public Health suggested 390 out of every 100,000 people in the United States—approximately one million—are transgender. Due to definition confusion and the stigmatization of transgender people, researchers believe the numbers are actually 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 two 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 the one assigned at birth
  2. A strong desire to be treated as a gender other than that assigned at birth
  3. An incongruence between one's experienced or expressed gender and one's sex characteristics
  4. A strong desire to have the sex characteristics of an alternative sex
  5. A strong desire to be rid of one's sex characteristics
  6. A strongly held belief that one has the typical reactions and feelings of another gender

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

Diagnosis in Children

Diagnosing gender dysphoria in children is far more difficult. That's because children may have less insight into what they're experiencing or lack the ability to express those insights. 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 six of the following and associated significant distress or impairment in function, lasting at least six months:

  1. A strong desire to be another gender or an insistence that one is another gender
  2. A strong preference for wearing clothes of another 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 another gender
  5. A strong preference for playmates of another gender
  6. A strong rejection of toys, games, and activities typically associated with their sex assigned at birth
  7. A strong dislike of one’s sexual anatomy
  8. A strong desire for the physical sex characteristics associated with another gender

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 are 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% or as high as 80%.

However, children are typically under intense pressure to maintain societal norms and are tacitly discouraged from transitioning.

Many children surrender to pressure and claim to be cisgender even if dysphoria persists. For this reason, psychologists assess their overall emotional state to better characterize the nature of their responses. It's often better to do this away from parents and other influences, however well-intentioned.

A Word From Verywell

While you can "self-test" yourself or your child for gender dysphoria, this should only be considered the first step toward a 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. Often, parents 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's important to work with a clinician experienced in gender dysphoria to help you reach an affirmative diagnosis and find appropriate care. You can start your search with the APA's online psychologist locator.

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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  2. Meerwijk EL, Sevelius JM. Transgender population size in the United States: a meta-regression of population-based probability samples. Am J Public Health. 2017;107(2):e1-e8. doi:10.2105/AJPH.2016.303578

  3. 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

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