Understanding Gender Dysphoria

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A person has gender dysphoria when they experience discomfort caused by a difference between their assigned or recorded gender from birth and the gender with which they identify. For example, if someone identifies as female but was assigned a male gender when they were born, they may experience gender dysphoria. Gender dysphoria is the mental health diagnosis that is currently given to transgender and gender non-binary individuals who may be seeking gender affirming care to align their bodies to their gender identities.

Gender dysphoria was previously referred to as gender identity disorder. However, in recent years it has been clearly established that having a gender identity different from the one associated with your assigned sex is not a disorder or problem. Instead, the problem is experiencing psychological or physical discomfort because your gender identity is not aligned with your recorded sex. (People whose gender identity is aligned with their recorded sex are referred to as cisgender.)

Diagnoses in Adults and Adolescents

The diagnostic criteria used for identifying gender dysphoria are defined by the current edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders—the DSM-5. In order for an adolescent or adult to be diagnosed with gender dysphoria, they need to have at least two symptoms.

Furthermore, the symptoms must last for at least six months, and they must cause significant distress or problems functioning. These symptoms that may be present in adolescents and adults with gender dysphoria include:

  • a difference between their experienced or expressed gender identity and the primary or secondary sexual characteristics of their body. (feeling that their body doesn't fit)
  • wanting to be rid of their primary or secondary sex characteristics
  • wanting to have the primary or secondary sex characteristics of the sex that they were not assigned at birth. (for instance, someone assigned male wants female sex characteristics)
  • wanting to be a different gender
  • wanting to be treated as a different gender
  • believing that they have the feelings and reactions that are usually associated with a different gender

Of note, in the DSM-5, these are described in more binary terms. However, there is a growing recognition that gender dysphoria does not only occur across two binary sexes, which are male and female. This is also why there has been a move from terminology such as "cross-sex hormone therapy" to "gender affirming hormone therapy."

Diagnoses in Children

There are different criteria for gender dysphoria in children than there are in adolescents and adults. First off, they need to have six symptoms associated with significant distress—as with adults, those symptoms have to last at least six months. Symptoms looked for in children include:

  • a desire to be a different gender or believing they are a different gender
  • preferring to wear clothes associated with a different gender
  • preferring other-gender roles in imaginary play
  • preferring toys and other activities stereotypically used by a different gender
  • preferring playmates of a different gender (in general, children prefer same-gender playmates through much of childhood)
  • rejecting toys and games usually associated with their assigned gender
  • disliking their sexual anatomy
  • wanting the physical characteristics that match their gender identity

Children are required to have more symptoms than adults for a gender dysphoria diagnosis because any one or two of these symptoms on their own does not necessarily reflect persistent gender identity concerns. Some children just share more interests with children of the other sex. Others find other sex clothes more convenient or comfortable.

These behaviors don't necessarily mean they have a sex-atypical gender identity or gender dysphoria. Gender-atypical behavior is expected as part of normal childhood development.

It is only when these behaviors persist or cause distress that they're likely to be associated with persistent gender dysphoria.

Incidence of Gender Dysphoria

Children generally start developing gendered behaviors sometime between the ages of two and four years old. At this time, children start labeling the genders of others as well as their own. Some children who will later grow up to be transgender start labeling themselves as a gender other than the one associated with their assigned sex as early as this time.

However, this is the exception rather than the rule. Other children may experience gender atypical behavior but not self-label. Still, others may not recognize their gender dysphoria until puberty or even adulthood. It is not uncommon for transgender adolescents and adults to say something like, "I knew something was different but didn't know what it was until I learned about other people who were transgender."

It is also important to note that not all individuals with a gender identity different from that expected from their assigned sex experience gender dysphoria.

Gender dysphoria is defined by the discomfort it causes. It is possible to have an atypical gender identity, including having many of the gender dysphoria symptoms, without experiencing significant distress or trouble functioning. This is more likely to occur in a supporting and accepting environment. If such individuals seek out gender-affirming medical or surgical care, they may still be given a diagnosis of gender dysphoria. This is because the diagnosis is required in order to access care.

History of the Diagnosis

There are records of individuals with gender identities that do not match their assigned sex across cultures and throughout history. Furthermore, scientists had begun to experiment with what used to be known as sex reassignment surgery as early as the 1920s. However, the notion that gender dysphoria could be a diagnosable condition did not occur until much later.

The modern history of the diagnosis of gender dysphoria is a reflection of the modern history of the DSM. The first edition of the DSM was published in 1952, and it was intended to help clinicians identify people with the symptoms of the 128 included diagnoses. The second edition, published in 1968, had 193 diagnoses, and that number kept growing. The third edition, in 1980, had 228 diagnoses; its revision in 1997 had 253.

The DSM-IV, published in 1995, had 393 diagnoses. When the DSM-5 was published in 2013, it contained more than one hundred additional diagnoses—a total of 541.

It was not until the DSM-III that variations gender identity and presentation were identified as associated with any type of mental health diagnosis. At that time, two disorders were defined. The first, which described gender dysphoria in adolescents and adults, was called transsexualism. The second, which described the condition in children, was labeled gender identity disorder of childhood. In the DSM-IV these diagnoses were combined into the category "gender identity disorder," which became the current category of gender dysphoria.

However, it was not only the names of the condition now known as gender dysphoria that would change over time. There were also fundamental differences in how the disorder was understood. That can be seen in the way that gender diagnoses were categorized in the different editions of the DSM:

  • DSM-III: Gender disorders were called "psychosexual disorders"
  • DSM-III-R (revised): This version said that gender disorders were usually first evident in infancy, childhood, or adolescence
  • DSM-IV: Identifies sexual and gender identity disorders
  • DSM-5: Gender dysphoria becomes its own section, separate from sexual dysfunction diagnoses

Initially, a cross-gender identity was initially seen as indicating that the person was delusional or neurotic. Then, it was seen as a form of deviant sexuality, rather than a personality condition. Understanding the experience of gender dysphoria continued to evolve over time.

Today, individuals who have a gender identity different from that associated with their assigned sex at birth are considered to represent normal variation.

They are only considered to have a mental health condition if their gender identity causes them problems with functioning or distress.

This recognition of gender diversity as normal variation is also reflected in the way that medical providers interact with individuals with gender dysphoria. Doctors, nurses, and other physical health providers use the World Health Organization's International Classification of Diseases (ICD) to diagnose their patients, not the DSM. As of spring of 2018, the ICD-11 contains a new diagnosis.

That diagnosis is gender incongruence, and it has been moved from a mental health diagnosis to one affecting sexual health. Although ICD-11 has not yet been voted on and finalized, this represents an important step forward in destigmatizing gender variance and transgender identities.

It recognizes that when transgender and gender non-binary people seek medical treatment, they're not seeking to treat their gender. They're seeking to address the fact that their bodies do not match who they are inside.

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Article Sources

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