Gender dysphoria

« I want to be able to go out as female and be seen as such, and not worry about being embarrassed or ashamed of my gender. » — Anonymous (transfemale)

Gender dysphoria refers to negative feelings arising from some aspect of gender experience, possibly including but not limited to:

• An assigned gender different from one's gender identity
• Body dysphoria, where one’s sexual characteristics seem wrong
• Other’s perceptions of one’s gender
• Social treatment related to perceived or assigned gender

The term gender dysphoria can be used diagnostically, referring to persistent and clinically significant discomfort with an assigned gender, or to refer to individual instances of gender dysphoria, as in, “Calling someone by the wrong pronouns can evoke gender dysphoria.”

Healthcare professionals typically reference either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) in order to confirm a diagnosis of gender dysphoria.

Terminology

Alternate or similar terms include “gender identity disorder” (which was opposed by activists for characterizing the experience as a mental disorder) and “gender incongruence”.

Binary vs. Inclusive Definitions

The term gender dysphoria is typically used in relation to a diagnosis of affected individuals specifically having a male or female identity. For example, the 'Gender Dysphoria Fact Sheet'uses the phrase “the other gender” as if there is only one other gender. However, the symptoms of gender dysphoria are typically applicable to nonbinary as well as binary-identified individuals.

Research

Research on gender dysphoria was historically rare-to-nonexistent, but an increasing number of researchers are taking interest.

The exact cause of gender dysphoria is unknown. It is currently classed as a psychiatric condition (relating to the mind), but many recent studies have suggested that it is more to do with biological development (relating to the body). Research into what causes gender dysphoria is ongoing.

Prevalence

Studies on the frequency of gender dysphoria are typically skewed toward people who seek particular medical treatments, leaving out the wide variety of those who do not seek medical attention. Actual rates of occurrence in the general population are likely much higher, by a still-unknown amount.

A 2017 study in the USA shows:

In childhood, the sex ratio continues to favour birth-assigned males, but in adolescents, there has been a recent inversion in the sex ratio from one favouring birth-assigned males to one favouring birth-assigned females. In both adolescents and adults, patterns of sexual orientation vary as a function of birth-assigned sex. Recent studies suggest that the prevalence of a self-reported transgender identity in children, adolescents and adults ranges from 0.5 to 1.3%, markedly higher than prevalence rates based on clinic-referred samples of adults. The stability of a self-reported transgender identity or a gender identity that departs from the traditional male-female binary among non-clinic-based populations remains unknown and requires further study.

A retrospective study of patients seen from 1972 to 2015 at a Netherlands clinic shows:

During that time, 6,793 people sought help at the center. About 65% were transwomen, and 35% were transmen. The researchers noted a 20-fold increase over time, with 34 gender dysphoria assessments in 1980 and 686 in 2015.

As of the end of 2015, 3,838 people age 16 and over and received treatment for gender dysphoria at the center. Using the over-16 population of the Netherlands as a guide, the researchers estimated that 1 in 3,600 people in that country were transgender, with 1 in 2,800 identified as transwomen and 1 in 5,200 identified as transmen.

Medical Diagnosis

History

The diagnosis of 'Transsexualism' was introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) compiled by the American Psychiatric Association (APA) in 1980 for individuals who had experienced a minimum of two years discontent with the sex they were assigned at birth and the social role associated with that sex. The criteria of the diagnosis focused on individuals whose identities resembled a male-to-female (MTF) or female-to-male (FTM) paradigm. Others experiencing gender dysphoria but whose identities did not fit the MTF/FTM paradigms could be diagnosed with 'Adulthood Nontranssexual Type', or 'Gender Identity Disorder: Not Otherwise Specified' (GIDNOS).

In 1994 the DSM-IV committee replaced the 'Transsexualism' diagnosis; for individuals with MTF/FTM type identities a diagnosis of 'Gender Identity Disorder' (GID) would be applied instead. The diagnostic criteria of GIDNOS was left undefined, bar that the diagnosis be given to those whose 'gender identity disorder' could not be defined within a MTF or FTM paradigm. The 'Transsexualism' diagnosis also appeared in the International Classification of Diseases (ICD-10; F64.0) produced by the World Health Organization (WHO) echoing the DSM-III definition, with a separate diagnosis mirroring the DSM's GIDNOS diagnosis: F64.9 Gender Identity Disorder, Unspecified. Though a gender dysphoric nonbinary individual might use the term 'transsexual' to describe themselves, they would not be considered 'transsexual' within a clinical context.

DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013. Prior to its release, the APA published a 'Gender Dysphoria Fact Sheet' on their website which states,

In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria. This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder and is intended to better characterize the experiences of affected children, adolescents, and adults...

DSM not only determines how mental disorders are defined and diagnosed, it also impacts how people see themselves and how we see each other. While diagnostic terms facilitate clinical care and access to insurance coverage that supports mental health, these terms can also have a stigmatizing effect...

DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition...

Part of removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is “disordered”.

Criticism of the DSM-5

In the GID Reform Weblog, Kelley Winters, Ph.D., describes her critiques of the revised standards in the DSM-5:

The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated...

In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria...

However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis.

More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments. This contradiction may be used to support gender conversion/reparative psychotherapies – practices described as no longer ethical in the current WPATH Standards of Care.

ICD-11

Announced in June 2018, the new International Classification for Diseases (ICD-11) will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come into effect on 1 January 2022. The WHO explains the reasoning behind their changes for trans health:

Gender incongruence, meanwhile, has also been moved out of mental disorders in the ICD, into sexual health conditions. The rationale being that while evidence is now clear that it is not a mental disorder, and indeed classifying it in this can cause enormous stigma for people who are transgender, there remain significant health care needs that can best be met if the condition is coded under the ICD.

Treatment

Main article: Transition

Before the 1960s, few countries offered safe, legal medical options for people experiencing gender dysphoria and many criminalized gender-nonconforming behaviours or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association now known as the World Professional Association for Transgender Healthcare (WPATH) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfilment". The WPATH 'Standards of Care' are today the most widespread clinical guidelines used by professionals working with transsexual, transgender, or gender variant people, and have undergone several revisions since its initial publication.

In Childhood and Adolescence

At present, WPATH asserts that "knowledge of the factors contributing to gender identity development in adolescence is still evolving and not yet fully understood by scientists, clinicians, community members, and other stakeholders in equal measure." The ways in which gender dysphoria affects teenagers and adults differs to the way that it affects children; this is primarily due to the pubertal development of the body and the influence of sexual desire on social relationships. These feelings can often be very difficult to deal with and, as a result, a high percentage of gender dysphoric individuals experience depression, and may feel isolated from their peers; there are high rates of self-abusive behaviours and suicide within the gender dysphoric demographic. Finding a way to interpret and communicate these feelings as a nonbinary individual, at any age, can be profoundly distressing due to the lack of nonbinary reference points within the dominant culture, even more-so when ones nonbinary identity is dismissed by others on that same basis.

"Rapid Onset Gender Dysphoria"

To clarify the actual science regarding "rapid onset gender dysphoria", WPATH issued the following statement:

The World Professional Association for Transgender Health Board of Directors reaffirms the deliberative processes by which diagnostic entities and clinical phenomena are classified and established. These academic processes reside within the respective professional medical organizations and are led by workgroups formed by expert scientists, clinicians, and stakeholders, often over long periods of time, with high levels of scientific scrutiny of the evidence-based literature. The term “Rapid Onset Gender Dysphoria (ROGD)” is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation. ...

WPATH encourages continued scientific exploration within a culture of academic freedom, not censorship. We acknowledge that adolescent gender identity development and the factors influencing the timing of anyone’s gender declaration are multifactorial and that all persons—especially adolescents—are deserving of gender-affirmative evidence-based care that adheres to the latest standards of care and clinical guidelines.