Overview

Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics.

Transgender and gender-nonconforming people might experience gender dysphoria at some point in their lives. But not everyone is affected. Some transgender and gender-nonconforming people feel at ease with their bodies, either with or without medical intervention.

Gender dysphoria is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual published by the American Psychiatric Association to diagnose mental conditions. This term is intended to be more descriptive than the one that was previously used, gender identity disorder. The term gender dysphoria focuses on one's discomfort as the problem, rather than identity. A diagnosis for gender dysphoria was created to help people get access to necessary health care and effective treatment.

Symptoms

Gender dysphoria might cause adolescents and adults to experience:

• A marked difference between your inner gender identity and assigned gender lasting at least six months, as shown by at least two of the following:
  • A marked difference between your inner gender identity and primary and/or secondary sex characteristics, or anticipated secondary sex characteristics in young adolescents
  • A strong desire to be rid of primary and/or secondary sex characteristics because of a marked difference with your inner gender identity, or a desire to prevent the development of anticipated secondary sex characteristics in young adolescents
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender or an alternate gender different from assigned gender
  • A strong desire to be treated as the other gender or an alternate gender different from assigned gender
  • A strong conviction that you have typical feelings and reactions of the other gender or an alternate gender different from assigned gender
• Significant distress or impairment in social, occupational or other areas of functioning

Gender dysphoria might start in childhood and continue into adolescence and adulthood (early onset). Or, you might have periods in which you no longer experience gender dysphoria followed by a recurrence of gender dysphoria. You might also experience gender dysphoria around the time of puberty or much later in life (late onset).

Complications

Gender dysphoria can impair many aspects of life. Preoccupation with being of another gender than the one assigned often interferes with daily activities. People experiencing gender dysphoria might refuse to go to school, due to pressure to dress in a way that's associated with their sex or out of fear of being harassed or teased. Gender dysphoria can also impair the ability to function at school or at work, resulting in school dropout or unemployment. Relationship difficulties are common. Anxiety, depression, self-harm, eating disorders, substance abuse and other problems can occur.

People who have gender dysphoria also often experience discrimination, resulting in minority stress. Access to health services and mental health services can be difficult, due to fear of stigma and a lack of experienced providers.

Adolescents and adults with gender dysphoria before gender reassignment might be at risk of suicidal ideation, suicide attempts and suicide. After gender reassignment, suicide risk might continue.

Diagnosis

Your health care professional might make a diagnosis of gender dysphoria based on:

• Behavioral health evaluation. Your provider will evaluate you to confirm the incongruence of your gender identity and sex assigned at birth, your history and development of gender dysphoric feelings, the impact of the stigma attached to gender nonconformity on your mental health, and what support you have from family, friends and peers.
• DSM-5. Your mental health professional may use the criteria for gender dysphoria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Gender dysphoria is different from simply not conforming to stereotypical gender role behavior. Gender dysphoria involves feelings of distress due to a strong desire to be of another gender than the one assigned and by the extent and pervasiveness of gender-variant activities and interests.

While some adolescents might express their feelings of gender dysphoria to their parents or a doctor, others might instead show symptoms of a mood disorder, anxiety or depression or display social or academic problems.

Treatment

Treatment can help people who have gender dysphoria to explore their gender identity and find the gender role that feels comfortable for them, easing distress. But treatment needs to be individualized. What might help one person might not help another. The process might or might not involve a change in gender expression or body modifications. Treatment options might include changes in gender expression and role, hormone therapy, surgery, and behavioral therapy.

If you have gender dysphoria, seek help from a doctor who has expertise in the care of transgender people.

When coming up with a treatment plan, your provider will screen you for mental health concerns that might need to be addressed, such as depression or anxiety. Failing to treat these concerns can make it more difficult to explore your gender identity and ease gender dysphoria.

Changes in gender expression and role

This might involve living part time or full time in another gender role that is consistent with your gender identity.

Medical treatment

Medical treatment of gender dysphoria might include:

• Hormone therapy, such as feminizing hormone therapy or masculinizing hormone therapy
• Surgery, such as feminizing surgery or masculinizing surgery to change the breasts or chest, external genitalia, internal genitalia, facial features, and body contouring

Some people use hormone therapy to seek maximum feminization or masculinization. Others might find relief from gender dysphoria by using hormones to minimize secondary sex characteristics, such as breasts and facial hair. Treatments are based on your goals, as well as an evaluation of the risks and benefits of medication use, the presence of any other conditions, and consideration of your social and economic issues. Many people also find that surgery is necessary to relieve their gender dysphoria.

The World Professional Association for Transgender Health provides the following criteria for hormonal and/or surgical treatment of gender dysphoria:

• Persistent, well-documented gender dysphoria.
• Capacity to make a fully informed decision and consent to treatment.
• Age of majority in a given country or, if younger, follow the standard of care for children and adolescents.
• If significant medical or mental concerns are present, they must be reasonably well controlled.

Additional criteria apply to some surgical procedures.

A pretreatment medical evaluation is done by a doctor with experience and expertise in transgender and intersex care before hormonal and surgical treatment of gender dysphoria. This can help rule out or address medical conditions that might affect these treatments or make the treatments inadvisable. This evaluation may include:

• A personal and family medical history
• A physical exam, including an assessment of your reproductive organs
• Lab tests to check your lipids, fasting blood glucose, complete blood count, liver enzymes, electrolytes, prolactin and sex steroid hormones, and a pregnancy test
• Immunizations status, including HPV
• Age- and sex-appropriate screenings
• Identification and management of tobacco use, drug abuse and alcohol abuse
• Identification and management of HIV and other sexually transmitted infections
• Assessment of desire for fertility preservation and referral as needed for sperm, egg, embryo and/or ovarian tissue cryopreservation
• History of potentially harmful treatment approaches, such as unprescribed hormone use, industrial-strength silicone injections or self-surgeries

Behavioral health treatment

This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria. The goal is to help transgender and gender-nonconforming individuals become comfortable with their gender identity expression, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.

Therapy might include individual, couple, family and group counseling to help you:

• Explore and integrate your gender identity
• Accept yourself
• Address the mental and emotional impacts of minority stress
• Build a support network
• Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
• Become comfortable expressing your gender identity
• Explore healthy sexuality in the context of gender transition
• Make decisions about your medical treatment options
• Increase your well-being and quality of life

Therapy might be helpful during many stages of your life.

A pretreatment behavioral health evaluation by a doctor with experience and expertise in transgender and intersex health is needed before hormonal and surgical treatment of gender dysphoria. This evaluation might assess:

• Gender identity and dysphoria
• Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
• Mood or other mental health concerns
• Risk-taking behaviors and self-harm
• Substance abuse
• Sexual health concerns
• Social support from family, friends and peers — a protective factor against developing depression, suicidal ideation, suicide attempts, anxiety or high-risk behaviors
• Goals, risks and expectations of treatment and trajectory of care

Other steps

Other ways to ease gender dysphoria might include use of:

• Peer support groups
• Voice and communication therapy to develop vocal characteristics matching your experienced or expressed gender
• Hair removal or transplantation
• Genital tucking
• Breast binding
• Breast padding
• Packing
• Aesthetic services, such as makeup application or wardrobe consultation
• Legal services, such as advanced directives, living wills or legal documentation
• Social and community services to deal with workplace issues, minority stress or parenting issues

Coping and support

Gender dysphoria can be lessened by supportive environments and knowledge about treatment to reduce the difference between your inner gender identity and sex assigned at birth or sex-related physical characteristics.

Social support from family, friends and peers can be a protective factor against developing depression, suicidal ideation, suicide attempts, anxiety or high-risk behaviors.

Other options for support include:

• Maintaining your mental health. You might see a mental health professional to explore your gender, talk about relationship issues, or talk about anxiety or depression you're facing.
• Seek out support groups. Talking to other transgender or gender-nonconforming people can help you feel less alone. Some community or LGBTQ centers have support groups. Or you might look online.
• Prioritize self-care. Get plenty of sleep. Eat well and exercise. Make time to relax and do the activities you enjoy.
• Meditate or pray. You might find comfort and support in your spirituality or faith communities.
• Get involved. Give back to your community by volunteering, including at LGBTQ organizations.

Preparing for an appointment

You may start by seeing your primary care provider. Or, you may be referred to a behavioral health professional.

Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Your symptoms, including any that seem unrelated to the reason for your appointment
• Key personal information, including major stresses, recent life changes and family medical history
• All medications, vitamins or other supplements you take, including the doses
• Questions to ask your doctor

For gender dysphoria, some basic questions to ask your doctor include:

• What's likely causing my symptoms?
• Other than the most likely cause, what are other possible causes for my symptoms?
• Is my condition likely temporary or chronic?
• What's the best course of action?
• What are the alternatives to the primary approach you're suggesting?
• I have these other health conditions. How can I best manage them together?
• Should I see a specialist?
• Are there brochures or other printed material I can have? What websites do you recommend? 

Don't hesitate to ask other questions.

What to expect from your doctor

Your doctor is likely to ask you several questions, such as:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Have you ever felt like harming yourself or ending your life due to your symptoms?