Sex refers to the characteristics and traits of biological sex (such as genitals, chromosomes) used to categorize a person as male or female sex. Gender identity is a person’s internal sense of being male, female, or something else, which may or may not correspond to sex at birth or sex characteristics (such as facial hair, voice, breasts). Gender incongruence is marked and persistent experience of incompatibility between a person's gender identity and sex at birth. Gender dysphoria is discomfort or distress related to 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, this is referred to as transgender. (See Definitions of Terminology Regarding Sex and Gender.)
Some transgender people 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) and impaired functioning.
Treatment options to relieve distress include social transition (living as the identified gender 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 1% of the population 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:
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American Psychological Association: A glossary: Defining transgender terms. Monitor on Psychology 49(8)32, 2018 |
Symptoms of Gender Incongruence and Gender Dysphoria
Gender incongruence or dysphoria in children may develop as early as age 2 to 3 years. Some people do not recognize feelings of gender incongruence until adolescence or adulthood.
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 have or express that they have these symptoms 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 emotional distress, which may include anxiety, depression, and suicidal behavior. The stress of not being accepted by society and/or by family may cause or contribute to these problems.
Gender incongruence and gender dysphoria symptoms in children
Children sometimes prefer activities considered 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 may develop gender dysphoria, and some may continue to have a gender-diverse identity as adults. Research studies have reached different conclusions about how likely it is that children who identify as transgender or have gender dysphoria will 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 children with gender incongruence, distress at the physical changes of puberty is often followed by a request for treatment to make their body consistent with their gender identity.
Diagnosis of Gender Incongruence and Gender Dysphoria
A doctor's evaluation, based on standard psychiatric criteria
During the evaluation for gender incongruence or gender dysphoria (regardless of age), the doctor does the following:
Meets with the person to ask about issues of gender identity and gender expression (present and past). If a child is involved, the doctor also interviews 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 mental health conditions that are often associated with gender dysphoria (such as depression, anxiety, substance use disorders, tobacco use, suicidality).
Most children with gender incongruence or gender dysphoria are not evaluated until they are 6 to 9 years old.
Doctors use standard psychiatric criteria to diagnose gender dysphoria. For people of any age (adults or children), criteria for a diagnosis of gender dysphoria include having all of the following:
Feel that their anatomic sex does not match their gender identity (gender incongruence) and have felt that way for 6 months or longer
Feel greatly distressed or cannot function normally because of this feeling of gender incongruence
For adolescents and adults, criteria for diagnosis of gender dysphoria include also having 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 one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
A strong desire for the primary and/or secondary sex characteristics of the other gender
A strong desire to be the other gender (or some alternative gender different from one’s assigned gender)
A strong desire to be treated as another gender (or some alternative gender different from one’s assigned gender)
A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
For children, criteria for diagnosis of gender dysphoria include also having 6 or more of the following symptoms:
A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
A strong preference for cross-gender roles in make-believe play or fantasy play
A strong preference for toys, games, and activities stereotypical for 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 birth sex
A strong dislike of one's sexual anatomy
A strong desire for the primary and/or secondary sex characteristics that match one's experienced gender
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 incongruence or gender dysphoria. For example, a boy who says he wants to be a girl because he thinks his younger sister receives special treatment.
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 to address any coexisting mental health concerns or transition-related issues
No guidelines or standards endorse or recommend the use of hormonal interventions (puberty blockers or gender-affirming hormones) or gender-affirming surgeries in children who have not gone through puberty who have gender incongruence or a diagnosis of gender dysphoria.
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." Treatment is aimed at relieving persons' distress and helping them adapt to rather than trying to dissuade them from their identity.
When gender dysphoria is appropriately diagnosed and treated in adults or adolescents, a person's psychological distress may resolve with a combination of one or more of the following: psychotherapy, social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries. 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.
Some transgender people's distress is treated by changing their gender expression by working, living, and dressing in society in a way consistent with their gender identity. This is called social transition. People sometimes change their name and obtain identification (such as a driver's license) that helps them work and live in society as the opposite gender.
For most people with gender dysphoria, the primary objective is to obtain gender-affirming treatments in the form of hormone therapy and/or gender-affirming surgery (previously known as sex reassignment or gender affirming surgery) to make their physical appearance consistent with their gender 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.
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
Provide a safe place to explore gender identity and the risks and benefits of potential treatments
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. Hormone therapy is typically combined with electrolysis, voice therapy, and other feminizing treatments. Feminizing hormones do not eliminate facial or body hair; however, therapy may substantially slow male pattern baldness progression.
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.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 irreversible genital 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. After surgery, the ability to achieve orgasm is often retained, 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.
