For people who suffer from Gender Dysphoria, there is a powerful conflict between the gender that they were assigned at birth and the gender with which they identify.
It is important to understand that Gender Dysphoria is not the same thing as being gay/lesbian/bisexual and is not the same thing as gender nonconformity — behaving in ways that are socially accepted of the opposite gender.
People with Gender Dysphoria encounter a powerful disconnect between the gender they were assigned at birth, what they may be expected to be, and the gender they identify with; this causes significant distress. They suffer significant emotional distress because of this contrast between social expectations and how they think or feel. Gender Dysphoria can affect people in many different ways, in more mild forms causing gender fluidity, while in more severe cases, may cause an intense desire to transition to the gender with which they identify. Transitioning can take many different forms depending on where the person identifies on the male/female spectrum. For some, adopting habits and behaviors that are typical of the gender they identify with is enough to feel comfortable, and for some, a full medical, hormonal, or social transition is required. Many choose to use a combination of hormone treatment, corrective surgery, changing their name, dressing and presenting themselves to others as their expressed gender, and request that others respect their choice and treat them appropriately.
Signs of Gender Dysphoria can appear at any age, beginning as early as 2 years old. Children with Gender Dysphoria frequently insist that they are of another gender or that they will grow up to be a member of the opposite gender. Starting in adolescence, people with Gender Dysphoria begin to recognize that their genitalia does not match their gender and this becomes a great source of anxiety and emotional distress. As they go through puberty, some individuals may try to hide physical characteristics of their assigned gender, and some may adopt the secondary sex characteristics of another gender via hormone treatment and surgery. Assigned males will often shave their legs and faces to appear feminine, while assigned females will dress to hide their developing breasts. Some people fully transition from male to female or female to male, while others find comfort in another, nonbinary gender expression.
Gender dysphoria and transitioning are cause for consideration of therapy to discover what route will yield the best outcome for the individual. Therapy by a caring mental health professional can help reduce the symptoms of secondary disorders such as anxiety or depression.
Causes and Risk Factors
Prevalence estimates for Gender Dysphoria are rough at best and are most likely usually lower than the true numbers due to social stigma and reluctance of patients to come forward. Gender Dysphoria appears to be at least twice as common in natal men compared to natal women. Rates for natal men are about 0.005-0.014% while rates for natal women are around 0.002-0.003%.
Studies of families have shown that there is a genetic component to Gender Dysphoria. Patients with Gender Dysphoria are more likely to have close family members who also deal with similar gender identity feelings.
Early onset intensity
Only a fraction of patients whose Gender Dysphoria first occurs in childhood continue to experience these feelings into adolescence and adulthood. Although the numbers vary between studies, up to 30% of natal males and 50% of natal females see their Gender Dysphoria continue out of childhood. These patients are most likely those who had the most significant symptoms early in childhood, while those with less intense symptoms are more likely to have their dysphoria subside as they mature.
Congenital hormone issues
There are a host of naturally occurring disorders of hormone production and sensitivity that appear at birth and are sometimes associated with Gender Dysphoria. A common source of this in natal females is Congenital Adrenal Hyperplasia, which subjects these babies to a heavy dose of male hormones during development in the womb. Another disorder, Androgen Insensitivity Syndrome, prevents testosterone from properly guiding the development of genetically male babies. These disorders sometimes produce “ambiguous genitalia”, genitals that are not fully male or female, which contributes to the difficulties these patients face. With these disorders, the baby’s gender may be misidentified at birth, leading parents to raise them as the wrong gender and adding to gender confusion later on in life.
Anxiety and depressive disorders are the most common mental health disorders that accompany Gender Dysphoria. Autism Spectrum Disorder also appears at a higher rate than usual in these patients. Children and adolescents with Gender Dysphoria are more prone to behavioral problems and trouble finding a good group of friends. This is related to lack of acceptance and understanding of the disorder by others in their age group. This environment puts younger patients at risk for disruptive and impulse control disorders.
Diagnosing Gender Dysphoria
Adults and adolescents
Adults with Gender Dysphoria suffer a separation between the gender they were assigned at birth and the gender they feel that they really are. They must experience at least two of several symptoms for at least six months. Many patients feel at odds with the physical sexual characteristics determined by their genes, such as their penis or vagina, breasts, body shape, and body hair patterns. They frequently want to change these sexual characteristics. If they have not gone through puberty yet, they may want to avoid developing the aspects of their assigned gender and desire those of the opposite gender. They want to be another gender and want those around them to recognize this and treat them appropriately. People also feel that their emotions and psychological make-up better fit another gender. These symptoms are so powerful that they disrupt multiple areas of patients’ everyday lives.
Gender Dysphoria can also appear in children, who need to demonstrate at least six symptoms over more than six months. All children with Gender Dysphoria believe they should be the opposite gender. These children often make an effort to dress in the style more typical of the opposite gender. When they play with others, they usually take on roles of another gender. They play with toys and games that are most common with another gender and avoid those usually associated with their birth gender. They often prefer to spend time and play with others of the opposite gender. They don’t like the sexual characteristics they were born with and want to change them. They frequently state that they want to grow up to be someone of the opposite gender. They tend to become upset when their parents try to prevent them from expressing their feelings and acting or dressing like the gender of their choosing.
Gender Dysphoria sometimes accompanies endocrine disorders that affect development of sexual characteristics. These include Congenital Adrenal Hyperplasia, Androgen Insensitivity Syndrome, and cases of ambiguous genitalia. When these kinds of disorders are associated with Gender Dysphoria, the symptoms tend to appear very early in life.
Treating Gender Dysphoria
The treatment of Gender Dysphoria is unique from person to person. Many people are happy just to have psychotherapy to process the feelings of Gender Dysphoria but do not go any further. Some have counseling and hormone therapy but no surgery, while others have all three. A few express themselves not as fully male or female but rather as a unique gender that does not conform to one of these two primary genders.
Psychotherapy for people with Gender Dysphoria is intended to help people explore their feelings and discover the best treatment plan for moving forward. Therapists do not ‘push’ individuals in one direction or another, but instead they provide a comfortable environment for people to process their internal gender conflicts. People with Gender Dysphoria discover how to express their gender and decide whether they will also use hormonal and surgical treatments as well. Therapy also helps people navigate the social difficulties that they frequently encounter when they begin to live openly as the gender of their choosing. Family therapy can also be helpful in educating family members about Gender Dysphoria and enabling them to support the patient during their transition and beyond.
Testosterone therapy is the primary hormonal treatment for female-to-male transgender individuals. In these people, testosterone brings on the physical characteristics associated with maleness. These people grow thicker body hair and begin to grow facial hair as well. Their voices deepen in tone and sound more masculine. They develop more lean muscle and appear more physically male from the hormones changing the distribution of fat on the body. Sexual changes include an increased sex drive, menstrual cycles stopping, and growth of the clitoris.
Male-to-female transgender individuals take estrogen as well as other drugs that suppress the male hormones that their bodies naturally produce. Spironolactone is the most common medication used to inhibit natural male hormones. Other drugs like finasteride and progestins can also be used, but they carry side effects that are more difficult to manage. In total, these medications cultivate a more female body shape by increasing fat around the hips, decreasing muscle mass, and stimulating the development of breasts. Body and facial hair thin, the testicles shrink somewhat, and erections are less frequent and less pronounced.
Sexual Reassignment Surgery
Sexual reassignment surgery is the last stage of the process of transitioning between genders. Women who are transitioning to become men commonly choose to have their breasts removed. Their chests are reshaped and nipples altered to appear more masculine. The uterus and ovaries are also usually removed, and expert surgeons will then use a variety of techniques to create male genitalia from the existing female genitals.
Men who transition to become women often get breast implants to add to the breast growth that comes from hormone therapy. Some of these patients also opt for cosmetic facial surgery to make their appearance more feminine. Genital surgery involves removing the testicles and using the male genitals to create a new vagina.
Although hormone treatment for women transitioning to men makes their voices more masculine, hormone treatment for men transitioning to women does not make their voices more feminine. For these individuals, speech therapy can help them alter their voices to sound more female. Men transitioning to women also frequently seek treatments to remove facial hair.
Managing Gender Dysphoria
Hormone Therapy Side Effects
Although both types of hormone therapy can have several negative side effects, they do not pose a higher risk of death for any of these people. Transgender women taking estrogen have a 2-6% higher risk of blood clots. Long periods of no movement such as long car rides, plane flights, and surgery set the stage for these blood clots, so they have to take extra caution in these situations. These people also have a higher risk of high cholesterol and are more likely to get gallstones. They are at risk for developing type II diabetes, and using oral estrogen does increase the risk of heart disease. Medications that block natural male hormones also decrease bone density, which should be monitored as part of treatment.
Transgender men taking testosterone most commonly develop acne and male pattern baldness. They also are at increased risk for high blood pressure, high cholesterol, and type II diabetes. Although these are all risk factors for heart disease, there does not appear to be an increased risk for heart attack in these patients. Administration of testosterone can also cause issues with existing mental disorders, such as Bipolar Disorder and psychotic disorders. High doses of testosterone can trigger manias and psychotic episodes.
Like most people, individuals with Gender Dysphoria want to have children at some point in their lives. However, the hormone treatments and surgical procedures used to treat Gender Dysphoria will both independently render patients infertile. People who do not address this issue before transitioning are at risk for later regretting having undergone treatment that has made it impossible for them to have children that are genetically theirs. Therapists and physicians should address this early on with these patients. The best options for these individuals are preservation and storage of their sperm or eggs for use at a later point in their lives when they are ready to have children.
The best starting point for someone who has conflicted feelings about their gender is a psychiatrist who has experience treating people with Gender Dysphoria. A psychiatrist who focuses on Gender Dysphoria will have links to the network of other providers who will make up the treatment team. This includes therapists who specialize in this area who will provide individual psychotherapy and family therapy, endocrinologists who prescribe hormone treatments for transitioning, and surgeons with expertise in gender reassignment surgery.
Recruit a support system
Having a team of people who are supportive is crucial when coming out to family and friends and when transitioning publicly. Connecting with not only medical professionals but also the LGBTQ+ community provides people with Gender Dysphoria with a support network of understanding and experienced people. They can provide guidance and advice for strategies on coming out to loved ones, such as writing out and practicing what the persons want to say and then using that during first conversations about it. A supportive circle of family and friends is a critical component to transitioning genders in public as well. They provide a caring network to help the person through the difficult journey ahead.