Sex refers to biological characteristics (such as genitals, chromosomes, and hormones) used to categorize a person as male or female sex. Gender identity is how people see themselves, whether masculine, feminine, or some other gender identity, which may or may not correspond sex at birth. Gender incongruence is a marked and persistent experience of incompatibility between a person's gender identity and the gender expected based on sex at birth. Gender dysphoria is diagnosed when a person with gender incongruence experiences significant psychological distress (such as depression or anxiety) or functional impairment associated with the gender incongruence. The diagnosis is defined by the person's distress rather than by the presence of gender incongruence.
Some people feel that their gender is not compatible with their sex at birth (transgender). (See Definitions of Terminology Regarding Sex and Gender.)
Some transgender people develop gender dysphoria and experience distress or impaired functioning related to the mismatch between their gender identity and their sex at birth.
Doctors base the diagnosis of gender dysphoria on significant symptoms of psychological distress (such as anxiety or depression).
Treatment options to relieve distress include social transition (living as the identified gender, even without medical or surgical treatments), psychotherapy to treat depression or anxiety, gender-affirming hormone therapy, and/or gender-affirming surgery.
Gender identities include traditional masculinity or femininity. However, definitions and categorizations of gender role may differ across cultures and societies. For most people, gender identity is consistent with their anatomic (birth) sex and their gender expression (as when someone born with male anatomy [assigned male at birth] has an inner sense of masculinity and behaves in ways viewed as masculine in his society).
Gender identity is usually well-established by early childhood. However, at any age, some people may begin to feel that their gender identity does not match their birth sex. This is called being transgender or gender diverse. For example, some people who are assigned male at birth feel like a woman trapped in a man's body, and vice versa.
The number of people who identify as transgender is not known. Some studies have found that approximately 0.5 to 1% of adults and 1 to 8% of children and adolescents consider themselves transgender or gender diverse. Among transgender people, a smaller number of individuals meet the criteria for gender dysphoria.
A feeling of a mismatch between birth sex and gender identity is not considered a mental health disorder. Sometimes a transgender person experiences significant emotional distress or difficulties with daily activities, and they should see a health care professional to be evaluated gender dysphoria.
People with gender incongruence or gender dysphoria may want to change their gender expression (gender transition). They may seek help and support from friends, family, support groups, or health care professionals to make decisions about and take steps to make a social transition (living as their identified gender) or medical transition (medications or surgery to change physical characteristics to match their identified gender).
Definitions of Terminology Regarding Sex and Gender
Definitions of terminology regarding sex and gender include the following:
|
American Psychological Association: A glossary: Defining transgender terms. Monitor on Psychology 49(8)32, 2018 |
Symptoms of Gender Incongruence/Dysphoria
Gender incongruence or dysphoria in children may develop as early as age 2 to 3 years old. Some people do not recognize feelings of gender incongruence until adolescence or adulthood.
Gender incongruence and gender dysphoria symptoms in children
Most children who prefer activities considered to be more appropriate for the other sex (called gender-nonconforming behavior) are not transgender and do not have gender dysphoria. Children sometimes prefer activities considered by many in their society to be more appropriate for the other sex (gender-nonconforming behavior). These types of behavior are part of normal development. It does not mean that children have a gender identity that is different from the one typically associated with their sex at birth. However, some children who express gender-nonconforming behavior do identify as transgender, and some may continue to have a gender-diverse identity as adults.
Children who have gender dysphoria may repeatedly do the following:
Prefer cross-dressing
Insist they are of the other sex
Say they wish they would wake up as the other sex
Prefer participating in games and activities associated with the other sex
Have negative feelings toward their genitals
For example, a young girl may insist she will grow a penis and become a boy; she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may also wish to be rid of his penis and testes. For boys with gender incongruence, distress at the physical changes of puberty is often followed by a request for treatment to make their body more feminine.
Research studies have reached different conclusions about whether children who identify as transgender or have gender dysphoria will continue to have a gender-diverse identity as adults.
Gender incongruence and gender dysphoria symptoms in adults
Most people with gender incongruence or gender dysphoria begin having symptoms or feeling different in early childhood, but some do not acknowledge these feelings until adulthood.
Some transgender people make choices at first that are consistent with their birth sex, such as doing a job that is typically associated with that sex or marrying a person with the gender expected by their society, as a way to escape or deny their feelings of wanting to be the other sex. Some men may cross-dress first and not acknowledge their identification with the other sex until later in life. Once people accept these feelings, many transition to their preferred gender, with or without hormone therapy or gender-affirming surgery. Others experience problems, such as anxiety, depression, and suicidal behavior. The stress of not being accepted by society and/or by family may cause or contribute to these problems.
Diagnosis of Gender Incongruence/Dysphoria
A doctor's evaluation, based on standard psychiatric criteria
Most children with gender incongruence or gender dysphoria are not evaluated until they are 6 to 9 years old.
During the evaluation for gender incongruence or gender dysphoria (regardless of age), the doctor does the following:
Conducts an interview to ask about issues of gender identity and gender expression (present and past). If a child is involved, the doctor also interviews the parents and/or caregivers.
Assesses for evidence of gender incongruence or gender dysphoria.
Reviews relevant medical and mental health history. For children, the doctor also reviews developmental history.
Determines whether there are personal and/or family stressors or risks (for example, substance use, exposure to violence, and poverty).
Assesses for other mental health conditions that are often associated with gender dysphoria (for example, depression, anxiety, substance use disorders, tobacco use, suicidality).
Doctors diagnose gender dysphoria when people (children or adults) do all of the following:
Feel that their anatomic sex does not match their gender identity and have felt that way for 6 months or longer
Feel greatly distressed or cannot function normally because of this feeling
To be diagnosed with gender dysphoria based on standard psychiatric criteria, adolescents and adults must also have 2 or more of the following symptoms:
A marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
A strong desire to be rid of their sex characteristics and, for young adolescents, to prevent the development of secondary sex characteristics (those that occur during puberty)
A strong desire for the sex characteristics that match their gender identity
A strong desire to be another gender
A strong desire to live or be treated as another gender
A strong belief that they feel and react like another gender
To be diagnosed with gender dysphoria based on standard psychiatric criteria, children must also have at least 6 of the following symptoms:
A strong, persistent desire to be or insistence that they are the other gender (or some other gender)
A strong preference for dressing in clothing of the opposite gender and, in girls, resistance to wearing typically feminine clothing
A strong preference for pretending to be the opposite gender when playing
A strong preference for toys, games, and activities typical of the other gender
A strong preference for playmates of the other gender
A strong rejection of toys, games, and activities typical of the gender that matches their anatomic sex (for example, boys refuse to play with trucks or footballs)
A strong dislike of their anatomy
A strong desire for the anatomy or other sex characteristics (such as facial hair) that match their gender identity
The child must feel great distress or have trouble functioning in social settings, school, or other important areas.
A child who expresses a desire to be a different gender just to benefit from the perks they think are associated with the other gender is not likely to have gender dysphoria. For example, a boy who says he wants to be a girl because he thinks his younger sister receives special treatment is unlikely to have gender dysphoria.
Treatment of Gender Dysphoria
For many adults or adolescents, gender-affirming hormone therapy and sometimes gender-affirming surgeries (breast, genital, or facial surgery)
Sometimes other treatments (for example, voice therapy or electrolysis)
Psychotherapy with adolescents and adults is often helpful to address any coexisting mental health concerns or transition-related issues, but is not mandatory
The goal of treatment for transgender people with gender dysphoria, according to the World Professional Association for Transgender Health, is to achieve "lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfilment."
Some transgender adults are satisfied with changing their gender expression by working, living, and dressing in society in a way consistent with their gender identity. This is called social transition. They may change their name and obtain identification (such as a driver's license) that helps them work and live in society as the opposite gender.
Most transgender adults who seek medical treatment want hormone therapy and/or surgery that will make their physical appearance resemble that of their identified gender. They do not want psychological treatment. Using psychotherapy to try to "convert" a person's established transgender identity (so-called reparative therapy or conversion therapy) is ineffective and can be harmful.
When medical or surgical treatment is given, it is aimed at relieving a person's distress and helping them adapt to rather than trying to dissuade them from their identity.
Medical or surgical treatments include a combination of the following:
Gender-affirming hormone therapy
Electrolysis
Voice therapy
Gender-affirming surgery
Before starting hormone therapy or having surgery, people should discuss options for fertility preservation with a doctor, if they want to have children in the future. Also, hormone therapy can decrease fertility but is not effective as contraception, and people on hormone therapy should use birth control as needed.
Psychotherapy is no longer required before people can be given hormone therapy and/or have gender-affirming surgery. However, mental health care professionals can help by doing the following:
Determining whether any mental health disorders (such as depression or a substance use disorder) are present
Helping people deal with negative reactions from other people (such as disapproval or discrimination)
Helping people find a way to express their gender identity in a way that is comfortable
If applicable, supporting them when they come out (inform other people about their transgender identity) and transition to another gender
A small number of children are born with genitals that are not clearly male or female (ambiguous genitals; intersex medical conditions), and the management of their medical care and gender identity should involve health care professionals with specialized training and experience in this area. People who were born with ambiguous genitals or who have a genetic abnormality, such as Turner syndrome or Klinefelter syndrome, may suffer from varying degrees of gender dysphoria. However, most children who are clearly and consistently considered and reared as either boys or girls, even when genitals are ambiguous, have a clear sense of their gender identity as adults. Surgeries on the genitals of children with ambiguous genitalia, if any are needed, are often delayed until children are older and can participate in the decision-making.
Gender-affirming hormone therapy
Some people with gender dysphoria, in addition to adopting the behavior, dress, and mannerisms of the opposite sex, receive hormone treatments to change their secondary sex characteristics:
For people assigned male at birth, treatment with the female hormone estrogen causes breast growth and other body changes, such as decreased facial and body hair and redistribution of fat to the hips.
For people assigned female at birth,treatment with the male hormone testosterone causes such changes as growth of facial hair, deepening of the voice, and changes in distribution of body fat and muscle.
In addition to physical effects, hormone therapy has significant beneficial psychological effects, including allowing the person to feel more at ease, less anxious, and better able to interact as their preferred gender.
Gender-affirming surgery
Gender-affirming surgery is irreversible, and doctors recommend it only for people who have received medical care by an appropriately trained and experienced health care professional and who have been treated according to current standards of care.
Before having surgery, doctors typically advise that transgender people
Use gender-affirming hormone therapy
Live full-time in their preferred gender role for at least 1 year
For transgender people assigned male at birth, surgery involves removal of part of the penis and the testes and creation of an artificial vagina. The remaining part of the penis is usually sexually sensitive and makes orgasm possible and is left to function like a clitoris. Male-to-female transformation may also include nongenital cosmetic surgeries to create or enhance feminine attributes (for example, breast augmentation, rhinoplasty, brow lift, tracheal shave [paring down the Adam's apple], and/or jaw reconfiguration). Some people undergo vocal cord surgeries to change the quality of the voice.
For transgender people assigned female at birth, surgery involves removal of the breasts (mastectomy) and sometimes the internal reproductive organs (uterus and ovaries), closure of the vagina, and creation of an artificial penis and usually a scrotum. Results of female-to-male surgery are often less satisfactory than male-to-female surgery in terms of appearance and function, possibly explaining why fewer transgender men request gender-affirming surgery. Also, complications, mainly urinary problems, are common. But techniques for female-to-male surgery continue to improve, and more people are requesting surgery.
Many people who have gender-affirming surgery are able to have satisfactory sexual relations. The ability to achieve orgasm is often retained after surgery, and some people report feeling comfortable sexually for the first time. However, few people endure gender-affirming surgery for the sole purpose of being able to function sexually as the opposite sex. Confirmation of their inner sense of gender identity is usually the motivation.
More Information
The following English-language resources may be useful. Please note that THE MANUAL is not responsible for the content of these resources.
World Professional Association for Transgender Health (WPATH): A nonprofit organization focused on transgender health that supports clinical and academic research to develop evidence-based medicine and promote a high quality of care for transgender and gender-nonconforming individuals internationally.
American College of Obstetricians and Gynecologists: Frequently asked questions about transgender and nonbinary adults.
Trans Lifeline: Transgender peer support hotline.
LGBT National Help Center: National hotlines and online programs that provide peer support, information, and local resources.
