14. Gender Dysphoria
14.1. Gender Dysphoria
In th is C h sp te r , there is one overarching diagnosis of gender dysphoria, with separate
developmentally appropriate criteria sets for children and for adolescents and adults.
The area of sex and gender is highly controversial and has led to a proliferation of terms
whose meanings vary over time and within and between disciplines. An additional source
of confusion is that in English "sex" connotes both male/female and sexuality. This chapter
employs constructs and terms as they are widely used by clinicians from various disciplines
with specialization in this area. In this chapter, sex and sexual refer to the biological
indicators of male and female (understood in the context of reproductive capacity), such
as in sex chromosomes, gonads, sex hormones, and nonambiguous internal and external
genitalia. Disorders of sex development denote conditions of inborn somatic deviations of
the reproductive tract from the norm and/or discrepancies among the biological indicators
of male and female. Cross-sex hormone treatment denotes the use of feminizing hormones
in an individual assigned male at birth based on traditional biological indicators or
the use of masculinizing hormones in an individual assigned female at birth.
The need to introduce the term gender arose with the realization that for individuals
with conflicting or ambiguous biological indicators of sex (i.e., "intersex"), the lived role in
society and/or the identification as male or female could not be uniformly associated with
or predicted from the biological indicators and, later, that some individuals develop an
identity as female or male at variance with their uniform set of classical biological indicators.
Thus, gender is used to denote the public (and usually legally recognized) lived role as
boy or girl, man or woman, but, in contrast to certain social constructionist theories, biological
factors are seen as contributing, in interaction with social and psychological factors, to
gender development. Gender assignment refers to the initial assignment as male or female.
This occurs usually at birth and, thereby, yields the "natal gender." Gender-atypical refers to
somatic features or behaviors that are not typical (in a statistical sense) of individuals with
the same assigned gender in a given society and historical era; for behavior, gender-nonconforming
is an alternative descriptive term. Gender reassignment denotes an official (and usually
legal) change of gender. Gender identity is a category of social identity and refers to an
individual's identification as male, female, or, occasionally, some category other than male
or female. Gender dysphoria as a general descriptive term refers to an individual's affective/
cognitive discontent with the assigned gender but is more specifically defined when used
as a diagnostic category. Transgender refers to the broad spectrum of individuals who transiently
or persistently identify with a gender different from their natal gender. Transsexual
denotes an individual who seeks, or has undergone, a social transition from male to female
or female to male, which in many, but not all, cases also involves a somatic transition by
cross-sex hormone treatment and genital surgery (sex reassignment surgery).
Gender dysphoria refers to the distress that may accompany the incongruence between
one's experienced or expressed gender and one's assigned gender. Although not all individuals
will experience distress as a result of such incongruence, many are distressed if the
desired physical interventions by means of hormones and/or surgery are not available.
The current term is more descriptive than the previous DSM-IV term gender identity disorder
and focuses on dysphoria as the clinical problem, not identity per se.
Individuals with gender dysphoria have a marked incongruence between the gender they
have been assigned to (usually at birth, referred to as natal gender) and their experienced/
expressed gender. This discrepancy is the core component of the diagnosis. There must
also be evidence of distress about this incongruence. Experienced gender may include alternative
gender identities beyond binary stereotypes. Consequently, the distress is not
limited to a desire to simply be of the other gender, but may include a desire to be of an alternative
gender, provided that it differs from the individual's assigned gender.
Gender dysphoria manifests itself differently in different age groups. Prepubertal natal
girls with gender dysphoria may express the wish to be a boy, assert they are a boy, or assert
they will grow up to be a man. They prefer boys' clothing and hairstyles, are often
perceived by strangers as boys, and may ask to be called by a boy's name. Usually, they display
intense negative reactions to parental attempts to have them wear dresses or other
feminine attire. Some may refuse to attend school or social events where such clothes are
required. These girls may demonstrate marked cross-gender identification in role-playing,
dreams, and fantasies. Contact sports, rough-and-tumble play, traditional boyhood games,
and boys as playmates are most often preferred. They show little interest in stereotypically
feminine toys (e.g., dolls) or activities (e.g., feminine dress-up or role-play). Occasionally,
they refuse to urinate in a sitting position. Some natal girls may express a desire to have a
penis or claim to have a penis or that they will grow one when older. They may also state that
they do not want to develop breasts or menstruate.
Prepubertal natal boys with gender dysphoria may express the wish to be a girl or assert
they are a girl or that they will grow up to be a woman. They have a preference for
dressing in girls' or women's clothes or may improvise clothing from available materials
(e.g., using towels, aprons, and scarves for long hair or skirts). These children may roleplay
female figures (e.g., playing "mother") and often are intensely interested in female
fantasy figures. Traditional feminine activities, stereotypical games, and pastimes (e.g.,
"playing house"; drawing feminine pictures; watching television or videos of favorite female
characters) are most often preferred. Stereotypical female-type dolls (e.g.. Barbie) are
often favorite toys, and girls are their preferred playmates. They avoid rough-and-tumble
play and competitive sports and have little interest in stereotypically masculine toys (e.g.,
cars, trucks). Some may pretend not to have a penis and insist on sitting to urinate. More
rarely, they may state that they find their penis or testes disgusting, that they wish them removed,
or that they have, or wish to have, a vagina.
In young adolescents with gender dysphoria, clinical features may resemble those of
children or adults with the condition, depending on developmental level. As secondary
sex characteristics of young adolescents are not yet fully developed, these individuals may
not state dislike of them, but they are concerned about imminent physical changes.
In adults with gender dysphoria, the discrepancy between experienced gender and
physical sex characteristics is often, but not always, accompanied by a desire to be rid of
primary and/or secondary sex characteristics and/or a strong desire to acquire some primary
and/or secondary sex characteristics of the other gender. To varying degrees, adults
with gender dysphoria may adopt the behavior, clothing, and mannerisms of the experienced
gender. They feel uncomfortable being regarded by others, or functioning in society,
as members of their assigned gender. Some adults may have a strong desire to be of a
different gender and treated as such, and they may have an inner certainty to feel and respond
as the experienced gender without seeking medical treatment to alter body characteristics.
They may find other ways to resolve the incongruence between experienced/
expressed and assigned gender by partially living in the desired role or by adopting a gender
role neither conventionally male nor conventionally female.
When visible signs of puberty develop, natal boys may shave their legs at the first signs of hair growth. They sometimes bind their genitals to make erections less visible. Girls may bind their breasts, walk with a stoop, or use loose sweaters to make breasts less visible. Increasingly, adolescents request, or may obtain without medical prescription and supervision, hormonal suppressors ("blockers") of gonadal steroids (e.g., gonadotropin-releasing hormone [GnRH] analog, spironolactone). Clinically referred adolescents often want hormone treatment and many also wish for gender reassignment surgery. Adolescents living in an accepting environment may openly express the desire to be and be treated as the experienced gender and dress partly or completely as the experienced gender, have a hairstyle typical of the experienced gender, preferentially seek friendships with peers of the other gender, and/or adopt a new first name consistent with the experienced gender. Older adolescents, when sexually active, usually do not show or allow partners to touch their sexual organs. For adults with an aversion toward their genitals, sexual activity is constrained by the preference that their genitals not be seen or touched by their partners. Some adults may seek hormone treatment (sometimes without medical prescription and supervision) and gender reassignment surgery. Others are satisfied with either hormone treatment or surgery alone. Adolescents and adults with gender dysphoria before gender reassignment are at increased risk for suicidal ideation, suicide attempts, and suicides. After gender reassignment, adjustment may vary, and suicide risk may persist.
For natal adult males, prevalence ranges from 0.005% to 0.014%, and for natal females, from 0.002% to 0.003%. Since not all adults seeking hormone treatment and surgical reassignment attend specialty clinics, these rates are likely modest underestimates. Sex differences in rate of referrals to specialty clinics vary by age group. In children, sex ratios of natal boys to girls range from 2:1 to 4.5:1. In adolescents, the sex ratio is close to parity; in adults, the sex ratio favors natal males, with ratios ranging from 1:1 to 6.1:1. In two countries, the sex ratio appears to favor natal females (Japan: 2.2:1; Poland: 3.4:1).
Individuals with gender dysphoria have been reported across many countries and cultures. The equivalent of gender dysphoria has also been reported in individuals living in cultures with institutionalized gender categories other than male or female. It is unclear whether with these individuals the diagnostic criteria for gender dysphoria would be met.
Preoccupation with cross-gender wishes may develop at all ages after the first 2-3 years of childhood and often interfere with daily activities. In older children, failure to develop age-typical same-sex peer relationships and skills may lead to isolation from peer groups and to distress. Some children may refuse to attend school because of teasing and harassment or pressure to dress in attire associated with their assigned sex. Also in adolescents and adults, preoccupation with cross-gender wishes often interferes with daily activities. Relationship difficulties, including sexual relationship problems, are common, and functioning at school or at work may be impaired. Gender dysphoria, along with atypical gender expression, is associated with high levels of stigmatization, discrimination, and victimization, leading to negative self-concept, increased rates of mental disorder comorbidity, school dropout, and economic marginalization, including unemployment, with attendant social and mental health risks, especially in individuals from resource-poor family backgrounds. In addition, these individuals' access to health services and mental health services may be impeded by structural barriers, such as institutional discomfort or inexperience in working with this patient population.