What Is Gender Dysphoria? - American Psychiatric Association

Treatment. Support for people with gender dysphoria may include open-ended exploration of their feelings and experiences of gender identity and expression, ... AsdescribedinthePrivacyPolicyoftheAmericanPsychiatricAssociation(APA),thiswebsite&applicationutilizecookies.Byclosingthismessage,continuingthenavigationorotherwisecontinuingtoviewtheAPA'swebsites&applications,youconfirmthatyouunderstandandacceptthetermsoftheAPA'sPrivacyPolicy,includingtheuseofcookies.ReadOurPrivacyPolicy Iagree Patients&FamiliesGenderDysphoria Patients&FamiliesWhatIsPsychiatry?FindaPsychiatristAddictionandSubstanceUseDisordersAnxietyDisordersDepressionDissociativeDisordersEatingDisordersGenderDysphoriaObsessive-CompulsiveDisorder(OCD)PersonalityDisordersPosttraumaticStressDisorder(PTSD)SchizophreniaViewMoreTopics» BacktoGenderDysphoria GenderDysphoria WhatIsGenderDysphoria? Theterm“transgender”referstoapersonwhosesexassignedatbirth(i.e.thesexassignedbyaphysicianatbirth,usuallybasedonexternalgenitalia)doesnotmatchtheirgenderidentity(i.e.,one’spsychologicalsenseoftheirgender).Somepeoplewhoaretransgenderwillexperience“genderdysphoria,”whichreferstopsychologicaldistressthatresultsfromanincongruencebetweenone’ssexassignedatbirthandone’sgenderidentity.Thoughgenderdysphoriaoftenbeginsinchildhood,somepeoplemaynotexperienceituntilafterpubertyormuchlater. Peoplewhoaretransgendermaypursuemultipledomainsofgenderaffirmation,includingsocialaffirmation(e.g.,changingone’snameandpronouns),legalaffirmation(e.g.,changinggendermarkersonone’sgovernment-issueddocuments),medicalaffirmation(e.g.,pubertalsuppressionorgender-affirminghormones),and/orsurgicalaffirmation(e.g.,vaginoplasty,facialfeminizationsurgery,breastaugmentation,masculinechestreconstruction,etc.).Ofnote,notallpeoplewhoaretransgenderwilldesirealldomainsofgenderaffirmation,asthesearehighlypersonalandindividualdecisions. Itisimportanttonotethatgenderidentityisdifferentfromgenderexpression.Whereasgenderidentityreferstoone’spsychologicalsenseoftheirgender,genderexpressionreferstothewayinwhichonepresentstotheworldinagenderedway.Forexample,inmuchoftheU.S.,wearingadressisconsidereda“feminine”genderexpression,andwearingatuxedoisconsidereda“masculine”genderexpression.Suchexpectationsareculturallydefinedandvaryacrosstimeandculture.One’sgenderexpressiondoesnotnecessarilyalignwiththeirgenderidentity.Diversegenderexpressions,muchlikediversegenderidentities,arenotindicationsofamentaldisorder. Genderidentityisalsodifferentfromsexualorientation.Sexualorientationreferstothetypesofpeopletowardswhichoneissexuallyattracted.Peoplewhoaretransgenderhavethesamediversityofsexualorientationsaspeoplewhoarecisgender(peoplewhosesexassignedatbirthmatchestheirgenderidentity). Diagnosis Diagnosis The DiagnosticandStatisticalManualofMentalDisorders(DSM-5)1providesforoneoverarchingdiagnosisofgenderdysphoriawithseparatespecificcriteriaforchildrenandforadolescentsandadults. TheDSM-5definesgenderdysphoriainadolescentsandadultsasamarkedincongruencebetweenone’sexperienced/expressedgenderandtheirassignedgender,lastingatleast6months,asmanifestedbyatleasttwoofthefollowing: Amarkedincongruencebetweenone’sexperienced/expressedgenderandprimaryand/orsecondarysexcharacteristics(orinyoungadolescents,theanticipatedsecondarysexcharacteristics) Astrongdesiretoberidofone’sprimaryand/orsecondarysexcharacteristicsbecauseofamarkedincongruencewithone’sexperienced/expressedgender(orinyoungadolescents,adesiretopreventthedevelopmentoftheanticipatedsecondarysexcharacteristics) Astrongdesirefortheprimaryand/orsecondarysexcharacteristicsoftheothergender Astrongdesiretobeoftheothergender(orsomealternativegenderdifferentfromone’sassignedgender) Astrongdesiretobetreatedastheothergender(orsomealternativegenderdifferentfromone’sassignedgender) Astrongconvictionthatonehasthetypicalfeelingsandreactionsoftheothergender(orsomealternativegenderdifferentfromone’sassignedgender) Inordertomeetcriteriaforthediagnosis,theconditionmustalsobeassociatedwithclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning. TheDSM-5definesgenderdysphoriainchildrenasamarkedincongruencebetweenone’sexperienced/expressedgenderandassignedgender,lastingatleast6months,asmanifestedbyatleastsixofthefollowing(oneofwhichmustbethefirstcriterion): Astrongdesiretobeoftheothergenderoraninsistencethatoneistheothergender(orsomealternativegenderdifferentfromone’sassignedgender) Inboys(assignedgender),astrongpreferenceforcross-dressingorsimulatingfemaleattire;oringirls(assignedgender),astrongpreferenceforwearingonlytypicalmasculineclothingandastrongresistancetothewearingoftypicalfeminineclothing Astrongpreferenceforcross-genderrolesinmake-believeplayorfantasyplay Astrongpreferenceforthetoys,gamesoractivitiesstereotypicallyusedorengagedinbytheothergender Astrongpreferenceforplaymatesoftheothergender Inboys(assignedgender),astrongrejectionoftypicallymasculinetoys,games,andactivitiesandastrongavoidanceofrough-and-tumbleplay;oringirls(assignedgender),astrongrejectionoftypicallyfemininetoys,games,andactivities Astrongdislikeofone’ssexualanatomy Astrongdesireforthephysicalsexcharacteristicsthatmatchone’sexperiencedgender Aswiththediagnosticcriteriaforadolescentsandadults,theconditionmustalsobeassociatedwithclinicallysignificantdistressorimpairmentinsocial,occupational,orotherimportantareasoffunctioning. Treatment Treatment Supportforpeoplewithgenderdysphoriamayincludeopen-endedexplorationoftheirfeelingsandexperiencesofgenderidentityandexpression,withoutthetherapisthavinganypre-definedgenderidentityorexpressionoutcomedefinedaspreferabletoanother.2Psychologicalattemptstoforceatransgenderpersontobecisgender(sometimesreferredtoasgenderidentityconversioneffortsorso-called“genderidentityconversiontherapy”)areconsideredunethical.2,3 Supportmayalsoincludeaffirmationinvariousdomains.Socialaffirmationmayincludeanindividualadoptingpronouns,names,andvariousaspectsofgenderexpressionthatmatchtheirgenderidentity.4,5Legalaffirmationmayinvolvechangingnameandgendermarkersonvariousformsofgovernmentidentification.6Medicalaffirmationmayincludepubertalsuppressionforadolescentswithgenderdysphoriaandgender-affirminghormoneslikeestrogenandtestosteroneforolderadolescentsandadults.7,8Medicalaffirmationisnotrecommendedforprepubertalchildren.7,8Someadults(andlessoftenadolescents)mayundergovariousaspectsofsurgicalaffirmation.7,8 Familyandsocietalrejectionofgenderidentityaresomeofthestrongestpredictorsofmentalhealthdifficultiesamongpeoplewhoaretransgender.9Familyandcouples’therapycanbeimportantforcreatingasupportiveenvironmentthatwillallowaperson’smentalhealthtothrive.Parentsofchildrenandadolescentswhoaretransgendermaybenefitfromsupportgroups.Peersupportgroupsfortransgenderpeoplethemselvesareoftenhelpfulforvalidatingandsharingexperiences. Challenges/Complications Challenges/Complications Transgenderpeoplesufferfromhighlevelsofstigmatization,discriminationandvictimization,contributingtonegativeself-imageandincreasedratesofothermentalhealthdisorders.10Transgenderindividualsareathigherriskofvictimizationandhatecrimesthanthegeneralpublic.Suicideratesamongtransgenderpeoplearemarkedlyhigherthanthegeneralpopulation.11 Transgenderchildrenandadolescentsareoftenvictimsofbullyinganddiscriminationatschool.Interventionsareoftenneededtocreatesafeandaffirmingschoolenvironments. Transgenderindividualsmayalsofacechallengesinaccessingappropriatehealthcareandinsurancecoverageofrelatedservices. Terminology12 Cisgender:Describesapersonwhosegenderidentityalignsinatraditionalsensewiththesexassignedtothematbirth. Genderdiverse:Anumbrellatermdescribingindividualswithgenderidentitiesand/orexpressionsthatvaryfromexpecteddevelopmentalnorms.Thisincludespeoplewhoidentifyasmultiplegendersorwithnogenderatall. Genderdysphoria:AconceptdesignatedintheDSM-5asclinicallysignificantdistressorimpairmentrelatedtoastrongdesiretobeofanothergender,whichmayincludedesiretochangeprimaryand/orsecondarysexcharacteristics.Notalltransgenderorgenderdiversepeopleexperiencedysphoria. Genderexpression:Theoutwardmanifestationofaperson’sgender,whichmayormaynotreflecttheirinnergenderidentitybasedontraditionalexpectations.Genderexpressionincorporateshowapersoncarriesthemselves,theirdress,accessories,grooming,voice/speechpatternsandconversationalmannerisms,andphysicalcharacteristics. Genderidentity:Aperson’sinnersenseofbeingagirl/woman,boy/man,somecombinationofboth,orsomethingelse,includinghavingnogenderatall.Thismayormaynotcorrespondtothegenderassignedatbirth. Nonbinary:Atermusedbysomeindividualswhosegenderidentityisneithergirl/womannorboy/man. Sex/genderassignedatbirth:Traditionaldesignationofapersonas“female,”“male,”or“intersex”basedonanatomy(externalgenitaliaand/orinternalreproductiveorgans)and/orbiology(sexchromosomesand/orhormones).“Sex”and“gender”areoftenusedinterchangeably,buttheyaredistinctentities.Itisbesttodistinguishbetweensex,genderidentity,andgenderexpressionandtoavoidmakingassumptionsaboutapersonregardingoneofthesecharacteristicsbasedonknowledgeoftheothers.ThisissometimesabbreviatedasAFAB(assignedfemaleatbirth)orAMAB(assignedmaleatbirth). Sexualorientation:Describesthetypesofindividualstowardwhomapersonhasemotional,physical,and/orromanticattachments. Transgender:Anumbrellatermdescribingindividualswhosegenderidentitydoesnotaligninatraditionalsensewiththegendertheywereassignedatbirth.Itmayalsobeusedtorefertoapersonwhosegenderidentityisbinaryandnottraditionallyassociatedwiththatassignedatbirth. References DiagnosticandStatisticalManualofMentalDisorders(DSM-5),Fifthedition.AmericanPsychiatricAssociation.2013 TheAmericanAcademyofChild&AdolescentPsychiatry.(2018).ConversionTherapy.https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx.AccessedNovember7,2020. Turban,J.L.,Beckwith,N.,Reisner,S.L.,&Keuroghlian,A.S.(2020).Associationbetweenrecalledexposuretogenderidentityconversioneffortsandpsychologicaldistressandsuicideattemptsamongtransgenderadults. JAMAPsychiatry, 77(1),68-76.  Durwood,L.,McLaughlin,K.A.,&Olson,K.R.(2017).Mentalhealthandself-worthinsociallytransitionedtransgenderyouth. JournaloftheAmericanAcademyofChild&AdolescentPsychiatry, 56(2),116-123. Olson,K.R.,Durwood,L.,DeMeules,M.,&McLaughlin,K.A.(2016).Mentalhealthoftransgenderchildrenwhoaresupportedintheiridentities. Pediatrics, 137(3). Scheim,A.I.,Perez-Brumer,A.G.,&Bauer,G.R.(2020).Gender-concordantidentitydocumentsandmentalhealthamongtransgenderadultsintheUSA:across-sectionalstudy. TheLancetPublicHealth. Hembree,W.C.,Cohen-Kettenis,P.T.,Gooren,L.,Hannema,S.E.,Meyer,W.J.,Murad,M.H.,...&T’Sjoen,G.G.(2017).Endocrinetreatmentofgender-dysphoric/gender-incongruentpersons:anendocrinesocietyclinicalpracticeguideline. TheJournalofClinicalEndocrinology&Metabolism, 102(11),3869-3903. Coleman,E.,Bockting,W.,Botzer,M.,Cohen-Kettenis,P.,DeCuypere,G.,Feldman,J.,...&Monstrey,S.(2012).Standardsofcareforthehealthoftranssexual,transgender,andgender-nonconformingpeople,version7. Internationaljournaloftransgenderism, 13(4),165-232. Klein,A.,&Golub,S.A.(2016).Familyrejectionasapredictorofsuicideattemptsandsubstancemisuseamongtransgenderandgendernonconformingadults. LGBThealth, 3(3),193-199. Reisner,S.L.,Poteat,T.,Keatley,J.,Cabral,M.,Mothopeng,T.,Dunham,E.,...&Baral,S.D.(2016).Globalhealthburdenandneedsoftransgenderpopulations:areview. TheLancet, 388(10042),412-436. James,S.,Herman,J.,Rankin,S.,Keisling,M.,Mottet,L.,&Anafi,M.A.(2016).TheReportofThe2015USTransgenderSurvey.http://www.ustranssurvey.org/reports.AccessedNovember7,2020. Perzanowski,E.S.,Ferraiolo,T.,&Keuroghlian,A.S.(2020).OverviewandTerminology.InForcier,M.,VanSchalkwyk,G.,&Turban,J.L.(Eds.), PediatricGenderIdentity:Gender-affirmingCareforTransgender&GenderDiverseYouth(pp.1-13).SpringerNature. PhysicianReviewBy: JackTurban,M.D.,M.H.S.November2020 ExpertQ&A:GenderDysphoria FindanswerstoyourquestionsaboutGenderDysphoriawrittenbyleadingpsychiatrists. ViewMore PatientStories:GenderDysphoria ReadpatientstoriesaboutGenderDysphoriaandlearnhowtoshareyourstory. ViewMore