Gender Dysphoria

LEARNING OBJECTIVES

  • Describe symptoms and factors associated with gender dysphoria

DSM-5 Diagnostic Criteria

In 2013, the diagnosis for gender dysphoria (GD) was renamed from gender identity disorder (GID) after criticisms that the latter term was stigmatizing. The DSM-5 also moved this diagnosis out of the sexual disorders category and into a category of its own. In order to be diagnosed with gender dysphoria (GD), a person must experience, for at least six months, a noticeable difference between how he or she experiences/expresses his or her own gender and his or her biological sex. Symptoms related to this difference may include the expressed desire for others to treat or perceive him or her as another gender; discomfort with genitals or sex characteristics; wishing these genitals or sex characteristics were different or aligned with another gender; and/or a strong sense of being another gender despite how others perceive him or her. This discrepancy must cause significant impairment in social, occupational, school, or daily life functioning.

Symptoms

The cardinal symptom of gender dysphoria (GD) is distress stemming from an incongruence between a person’s felt gender and assigned sex/gender. Symptoms of GD in children include preferences for opposite-sex typical toys, games, or activities; great dislike of their own genitalia; and a strong preference for playmates of the opposite sex. Some children may also experience social isolation from their peers, anxiety, loneliness, and depression. According to the American Psychological Association, transgender children are more likely to experience harassment and violence in school, foster care, residential treatment centers, homeless centers, and juvenile justice programs than other children.[1] The diagnosis for children has been separated from that for adults. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing or to express it in the event that they have insight. In order for children to be assigned this diagnostic category, they must verbalize their desire to become the other gender.

In adolescents and adults, symptoms include the desire to be and to be treated as the other gender. Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide. Studies indicate that transgender people have an extremely high rate of suicide attempts; one study of 6,450 transgender people in the United States found 41% had attempted suicide, compared to a national average of 1.6%. It was also found that suicide attempts were less common among transgender people who said their family ties had remained strong after they came out, but even transgender people at comparatively low risk were still much more likely to have attempted suicide than the general population.[2] Transgender people are also at heightened risk for eating disorders and substance abuse.

Gender Dysphoria and Transgender Individuals

Many people who are diagnosed with gender dysphoria identify as transgender, genderfluid (a gender that varies over time), or otherwise gender non-conforming (anyone whose appearance and behavior does not reflect the gender roles expected of them) in some way; however, not everyone who identifies as transgender or gender non-conforming experiences gender dysphoria.

Transgender or transsexual is an umbrella term for people whose internal experience of gender does not match their biological sex (normally based on first and secondary sex characteristics). Transgender people may experience discomfort or distress due to their gender not aligning with their sex, and therefore wish to transition to being the gender they identify with.

Some transgender people feel this way from a very young age, while others go through a period of questioning before realizing they are transgender. Transgender people can be men, women, or non-binary (a spectrum of gender identities that are not exclusively masculine or feminine‍). They can have any sexual orientation, express their gender through their appearance in any way, and may or may not fit into society’s views of gender. Every transgender person has different desires for what they want (or do not want) to include in their transition, including surgery and other medical procedures. Transgender people who do not plan to have surgery are sometimes referred to as non-op; transsexual is sometimes used to refer to only those who do. It is important not to make assumptions about what is, was, or will be involved in any individual person’s transition. Transition is any action a transgender person takes in order for the external world to better recognize and reflect their internal gender. This can range from asking people to use different names and pronouns, to a change in dress or appearance, to extensive surgery. The three main forms of transition are social, legal, and medical, although all of these are broad categories that can reflect dozens of different possible actions.

A post-transition specifier was also added for transgender individuals who have transitioned to their chosen gender (i.e., undergone hormonal or surgical procedures to alter their body in a way that matches their experienced gender identity). This specifier helps to ensure post-transition individuals can continue to receive ongoing hormonal or other treatment as needed.

CONTROVERSY SURROUNDING THE DIAGNOSIS OF GENDER DYSPHORIA

The previous diagnosis of gender identity disorder (GID) caused a great deal of controversy. Many transgender people and researchers supported the declassification of gender identity disorder (GID), arguing that the diagnosis pathologizes a natural form of gender variance, reinforces the binary model of gender (i.e., the idea that there are only two genders and that everyone must fit neatly into one of these two genders), and can result in stigmatization of transgender individuals. The official reclassification of gender dysphoria as a disorder in the DSM-5 may help resolve some of these issues, because the term gender dysphoria applies only to the discontent experienced by some persons resulting from gender identity issues, rather than suggesting that their identity is disordered.

Advantages and disadvantages exist to classifying gender dysphoria as a disorder, however. Many people argue that the distress associated with gender dysphoria is not caused by any disorder within the individual, but by difficulties encountered from social disapproval of transgender identities and alternative genders. As such, they argue that any form of diagnosis is still stigmatizing and places the “problem” unnecessarily on the individual, rather than on society. However, because gender dysphoria is classified as a disorder in the DSM-5, many insurance companies are willing to cover some of the expenses related to sex-reassignment therapy. Without the classification of gender dysphoria as a medical disorder, sex reassignment therapy may be viewed as cosmetic treatment—rather than medically necessary treatment for many transgender individuals—and thus may not be covered.

Early and Late-Onset Gender Dysphoria

Gender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset. Early-onset gender dysphoria is behaviorally visible in childhood. Sometimes gender dysphoria will desist in this group and they will identify as gay or homosexual for a period of time, followed by recurrence of gender dysphoria. This group is usually sexually attracted to members of their natal sex in adulthood. Late-onset gender dysphoria does not include visible signs in early childhood, but some report having had wishes to be the opposite sex in childhood that they did not report to others. Trans women who experience late-onset gender dysphoria will usually be sexually attracted to women and may identify as lesbians. It is common for people assigned male at birth who have late-onset gender dysphoria to engage in cross-dressing with sexual excitement. In those individuals who are biologically female, early-onset gender dysphoria is the most common course. This group is usually sexually attracted to women. Trans men who experience late-onset gender dysphoria will usually be sexually attracted to men and may identify as gay.[3]

Epidemiology

Gender dysphoria occurs in one in 30,000 biologically male births and one in 100,000 biologically female births.[4] It is estimated that about 0.005% to 0.014% of biological males and 0.002% to 0.003% of biological females would be diagnosed with gender dysphoria, based on 2013 diagnostic criteria, though this is considered a modest underestimate.[5] Research indicates people who transition in adulthood are up to three times more likely to be biologically male, but that among people transitioning in childhood the sex ratio is close to 1:1.[6]

According to an analysis of national probability samples in 2016, there were 390 per 100,000 adults who were transgender. However, it also suggested that future surveys will probably observe a higher prevalence.[7]

According to a recent national survey, 1.4 million individuals (0.6%) in the United States identify as transgender. It is also believed that these numbers are underrepresented due to the social stigma. Also, a part of this population might not want to engage in studies; hence, the true prevalence remains higher than what is reported. Nevertheless, an increasing shift is observed in this population seeking health care over the last decade.[8]

Substance use disorders are commonly found in men and women with GD, with some studies showing 28% having reported problems with substance use. In a recent study, about 48.3% of a study population had suicidal ideation, and 23.8% had attempted suicide at least once in their lifetime. Although, they were not able to appreciate any clinically significant difference between male-to-female (MTF) or female-to-male (FTM) groups. Anxiety, depression, and personality disorders are also common comorbidities. One study by Madeddu in 2009 found that personality disorder was comorbid in 52% of cases and the most common was Cluster B personality disorders.[9]

Etiology

The etiology of GD remains unclear, but it is thought to originate from a complex biopsychosocial link. Individuals born with congenital adrenal hyperplasia (a condition that involves excessive or deficient production of sex steroids and can alter the development of primary or secondary sex characteristics in some affected infants, children, or adults) or androgen insensitivity syndrome (an intersex condition) are usually brought up and socialized as girls, even though they often cross-dress and have an innate sense of belonging to the opposite sex. These changes are more evident around and during puberty. This is one of the well-established biological links.

Associations have also been found with in-utero exposure to phthalates in plastics and polychlorinated biphenyls. They are known to disrupt the regular endocrinology of sex determination before birth. Phthalates can lead to an increase in total fetal testosterone levels, which in turn increases the risk of autism spectrum disorder as well as GD.

GD has been found to have a higher prevalence in people with psychiatric illnesses such as schizophrenia and autism spectrum disorder. The link seems to be neuroanatomical and needs more research. There was growing evidence those on the autism spectrum have a higher risk of GD; however, certain studies seek to disprove this hypothesis.

There is also growing evidence that childhood abuse, neglect, maltreatment, and physical or sexual abuse may be associated with GD. Individuals reporting higher body dissatisfaction and GD have a worse prognosis in terms of mental health. And as mentioned above in epidemiology, individuals with GD are found to have higher rates of depression, suicidal ideations, and substance use. Neuroanatomical links in those with GD have been found in certain studies, including a faulty neuronal development and differentiation in the hypothalamic links. Functional neuroimaging has shown variations in hemispheric ratios and amygdala connectivity according to gender. A few case reports have reported some association of GD to maternal toxoplasma infection, although additional data is needed for further evidence.

A genetic association is also identified as one of the causes of GD. Heritability and familiarity of GD have been identified: for instance, higher prevalence in monozygotic twins than dizygotic twins. Some alleles (CYP17 and CYP17 T-34C) have also been found to have an association, although it is difficult to say if it is merely association or causation.

WATCH IT

Watch this video to review the definition, diagnosis, treatment, and challenges of gender dysphoria.

You can view the transcript for “Gender dysphoria: definition, diagnosis, treatment and challenges” here (opens in new window).

This video takes a look at the story of transgender advocate and spokesperson, Jazz Jennings.


You can view the transcript for “Transgender at 11: Listening to Jazz Jennings | 20/20 | ABC News” here (opens in new window).

KEY TAKEAWAYS: GENDER DYSPHORIA

TRY IT

GLOSSARY

early-onset gender dysphoria: gender dysphoria behaviorally visible in childhood

genderfluid: a gender identity that varies over time

gender non-conforming:  describes anyone whose appearance and behavior does not reflect the gender roles expected of them

late-onset gender dysphoria: gender dysphoria that does not include visible signs in early childhood

non-binary: a spectrum of gender identities that are not exclusively masculine or feminine‍

transsexual: a term sometimes used to refer to individuals with gender dysphoria who choose to undergo sex reassignment surgery

transition: any action a transgender person takes in order for the external world to better recognize and reflect their internal gender

  1. American Psychological Association (2008). "Resolution on transgender, gender identity, and gender expression non-discrimination" ↵
  2. Grant; Jaime, M.; Mottet, Lisa; Tanis, Justin; Harrison, Jack; Herman, Jody; Keisling, Mara (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (PDF). Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. Archived from the original (PDF) on November 4, 2015. Retrieved May 10, 2015. ↵
  3. Guillamon A, Junque C, Gómez-Gil E (October 2016). "A Review of the Status of Brain Structure Research in Transsexualism". Archives of Sexual Behavior. 45 (7): 1615–48. doi:10.1007/s10508-016-0768-5. PMC 4987404. PMID 27255307. ↵
  4. Gender identity disorders. (2018). In H. Marcovitch (Ed.), Black's Medical Dictionary, 43rd edition (43rd ed.). London, UK: A&C Black. ↵
  5. Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 454. ISBN 978-0-89042-555-8. ↵
  6. Landén M, Wålinder J, Lundström B (April 1996). "Prevalence, incidence and sex ratio of transsexualism". Acta Psychiatrica Scandinavica. 93 (4): 221–3. doi:10.1111/j.1600-0447.1996.tb10638.x. PMID 8712018 ↵
  7. Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 Feb;107(2):e1-e8. ↵
  8. Polderman TJC, Kreukels BPC, Irwig MS, Beach L, Chan YM, Derks EM, Esteva I, Ehrenfeld J, Heijer MD, Posthuma D, Raynor L, Tishelman A, Davis LK., International Gender Diversity Genomics Consortium. The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table. Behav. Genet. 2018 Mar;48(2):95-108. ↵
  9. Garg G, Elshimy G, Marwaha R. Gender Dysphoria (Sexual Identity Disorders) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532313/ ↵

Perspectives and Treatments Related to Gender Dysphoria

LEARNING OBJECTIVES

  • Examine historical and current perspectives on gender dysphoria
  • Describe and evaluate treatments for gender dysphoria

Historical and Modern Perspectives on Gender and Gender Identity

Early Medical Literature

In late-19th-century medical literature, women who chose not to conform to their expected gender roles were called “inverts,” and they were portrayed as having an interest in knowledge and learning and a “dislike and sometimes incapacity for needlework.” During the mid-1900s, doctors pushed for corrective therapy on such women and children, which meant that gender behaviors that were not part of the norm would be punished and changed. The aim of this therapy was to push children back to their “correct” gender roles and thereby limit the number of children who became transgender.

Psychodynamic Perspectives: Freud and Jung’s Views

In 1905, Sigmund Freud presented his theory of psychosexual development in Three Essays on the Theory of Sexuality, giving evidence that in the pregenital phase children do not distinguish between sexes, but assume both parents have the same genitalia and reproductive powers. On this basis, he argued that bisexuality was the original sexual orientation and that heterosexuality was resultant of repression during the phallic stage, at which point gender identity became ascertainable. According to Freud, during this stage, children developed an Oedipus complex where they had sexual fantasies for the parent ascribed the opposite gender and hatred for the parent ascribed the same gender, and this hatred transformed into (unconscious) transference and (conscious) identification with the hated parent who both exemplified a model to appease sexual impulses and threatened to castrate the child’s power to appease sexual impulses. In 1913, Carl Jung proposed the Electra complex as he both believed that bisexuality did not lie at the origin of psychic life and that Freud did not give adequate description to the female child (Freud rejected this suggestion).

1950s and Beyond

During the 1950s and ’60s, psychologists began studying gender development in young children, partially in an effort to understand the origins of homosexuality (which was viewed as a mental disorder at the time). In 1958, the Gender Identity Research Project was established at the UCLA Medical Center for the study of intersex and transsexual individuals. Psychoanalyst Robert Stoller generalized many of the findings of the project in his book Sex and Gender: On the Development of Masculinity and Femininity (1968). He is also credited with introducing the term gender identity to the International Psychoanalytic Congress in Stockholm, Sweden, in 1963. Behavioral psychologist John Money was also instrumental in the development of early theories of gender identity. His work at Johns Hopkins Medical School’s Gender Identity Clinic (established in 1965) popularized an interactionist theory of gender identity, suggesting that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation. His book Man and Woman, Boy and Girl (1972) became widely used as a college textbook, although many of Money’s ideas have since been challenged.

Butler’s views

A portrait of Judith Butler looking to the right of the camera.

Figure 1. Judith Butler is an American philosopher and gender theorist.

In the late 1980s, Judith Butler began lecturing regularly on the topic of gender identity, and in 1990, she published Gender Trouble: Feminism and the Subversion of Identity, introducing the concept of gender performativity, arguing that both sex and gender are constructed.

Present views

Gender dysphoria (GD) exists when a person suffers discontent due to gender identity, causing them emotional distress. Researchers disagree about the nature of distress and impairment in people with gender dysphoria. Some authors have suggested that people with gender dysphoria suffer because they are stigmatized and victimized by society; if the society was more accepting of transgender identities and non-binary expressions of gender, they would suffer less and/or may not experience dysphoria at all. Other research into genetic variation, hormones, and differences in brain functioning and brain structures suggest evidence for the biological etiology of the symptoms associated with gender dysphoria; however, much of this research is preliminary and still controversial.

As you have read, in the past, gender identity development was mostly viewed through cognitive and behaviorist lens—arguing that struggles with gender identity developed from the environment or cognitive schemas. More recent research has been done to understand biological and influences on gender variances and how early social experiences may create lasting epigenetic changes related to sex differences. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior, but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.

For example, early postmortem studies of transsexual neurological differentiation was focused on the hypothalamic and amygdala regions of the brain. Using magnetic resonance imaging (MRI), some transgender women were found to have female-typical putamina that were larger in size than those of cisgender males.[1] Some trans women have also shown a female-typical central part of the bed nucleus of the stria terminalis (BSTc) and interstitial nucleus of the anterior hypothalamus number 3 (INAH-3), looking at the number of neurons found within each.[2]

CHANGING THE STIGMA

Today, most medical professionals who provide transgender transition services to adults now reject conversion therapies (the pseudoscientific practice of trying to change an individual’s sexual orientation from homosexual or bisexual to heterosexual using psychological, physical, or spiritual interventions) as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else.

The APA’s guidelines for psychotherapy with lesbian, gay, and bisexual clients (American Psychological Association, 2000, 2012) serve as a main reference for clinicians and highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision.

Treatment for Gender Dysphoria

The World Professional Association for Transgender Health (WPATH) Standards of Care (Version 7 from 2011) are considered by some as definitive treatment guidelines for providers. The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or surgical transition to the other sex. Clinicians’ decisions regarding patients’ treatment are often influenced by this standard of care (SOC). They are most widespread standard of care (SOC) used by professionals working with transsexual, transgender, or gender variant people.

Other standards of care (SOC) exist, including the guidelines outlines in Gianna Israel and Donald Tarver’s classic 1997 book Transgender Care. Several health clinics in the United States (e.g., Tom Waddell Health Center in San Francisco, Callen-Lorde Community Health Center in New York City, and Mazzoni Center in Philadelphia) have developed protocols for transgender hormone therapy following a harm reduction model that is starting to be embraced by increasing numbers of providers. Willingness to provide hormonal therapy based on assessment of individual patients needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.

Transgender transition services, the various medical treatments and procedures that alter an individual’s primary and/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.

Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual’s own expression of their identity, regardless of their biological gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.

Treatment

A genderqueer person sitting in an exam room and wearing a hospital gown.

Figure  2. Some transgender individuals will undergo top or bottom surgeries, while others may choose not to have any surgery at all.

Today, sex reassignment surgery is performed on people who choose to have this change so that their anatomical sex will match their gender identity. Transgender individuals sometimes wish to undergo this type of surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina, or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants since many adults have regretted that these decisions were made for them at birth.

Gender confirmation surgery (or sexual reassignment surgery) refers to any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity. Surgical procedures are usually preceded by hormone replacement therapy.

Some forms of gender confirmation surgery include

  • bottom surgery, or surgery to alter the genitalia.
  • top surgery, or surgery to alter the chest and breast tissue.
  • facial reconstruction surgery, to alter the appearance of the face.

Those who plan to have surgery but not yet done so are often referred to as pre-op while those who have already had surgery are referred to as post-op. Those who do not wish to include surgery in their transition are referred to as non-op.

Sex reassignment surgery performed on nonconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case following a botched circumcision) when the individual’s sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed. Milton Diamond at the John A. Burns School of Medicine of the University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.

THE HISTORY OF TRANSITION SURGERY

The goal of early transition surgeries was the removal of hormone-producing organs (such as the testicles and the ovaries) in order to reduce their masculinizing or feminizing effects. Later, as surgical technique became more complex, the goal became to produce functional sex organs from sex organs that are already present in the patient.

In the United States in 1917, Dr. Alan L. Hart, an American tuberculosis specialist, became one of the first female-to-male transsexuals to undergo hysterectomy and gonadectomy for the relief of gender dysphoria.

In Berlin in 1931, Dora Richter, became the first known transgender woman to undergo the vaginoplasty surgical approach.

This surgery was followed by Lili Elbe in Dresden during 1930–1931. She started with the removal of her original sex organs, the operation supervised by Dr. Magnus Hirschfeld. Lili went on to have four more subsequent operations that included an orchiectomy, an ovary transplant, a penectomy, and ultimately an unsuccessful uterine transplant, the rejection of which resulted in death. An earlier known recipient of this was Magnus Hirschfeld’s housekeeper, but their identity is unclear at this time.

In 1951, Dr. Harold Gillies, a plastic surgeon active in World War II, worked to develop the first technique for female-to-male sex reassignment surgery, producing a technique that has become a modern standard, called phalloplasty. Phalloplasty is a cosmetic procedure that produces a visual penis out of grafted tissue from the patient.

Following phalloplasty, in 1999, the procedure for metoidioplasty was developed for female-to-male surgical transition by Drs. Lebovic and Laub. Considered a variant of phalloplasty, metoidioplasty works to create a penis out of the patient’s present clitoris. This allows the patient to have a sensation-perceiving penis head. Metoidioplasty may be used in conjunction with phalloplasty to produce a larger, more “cis-appearing” penis in multiple stages.

On 12 June 2003, the European Court of Human Rights ruled in favor of Van Kück, a German trans woman whose insurance company denied her reimbursement for sex reassignment surgery as well as hormone replacement therapy. The legal arguments related to the Article 6 of the European Convention on Human Rights as well as the Article 8. This affair is referred to as Van Kück vs Germany.

In 2011, Christiane Völling won the first successful case brought by an intersex person against a surgeon for non-consensual surgical intervention described by the International Commission of Jurists as “an example of an individual who was subjected to sex reassignment surgery without full knowledge or consent.”

Psychological Treatments

Treatment for a person diagnosed with GD may include psychotherapy or to support the individual’s preferred gender through hormone therapy, gender expression and role, or surgery. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. This may include psychological counseling, resulting in lifestyle changes or physical changes resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries. Psychotherapeutic treatment of GD involves helping the patient to adapt. The goal of treatment may simply be to reduce problems resulting from the person’s transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing or counseling a spouse to help them adjust to the patient’s situation.

Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions. Attempts to alleviate GD by changing the patient’s gender identity to reflect birth characteristics have been ineffective.

Biological Treatments

Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual’s physical body and gender identity. Biological treatments for GD without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GD treatment, they often feel lost and confused when their biological treatments are complete.[3]

Prepubescent Children

The question of whether to counsel young children to be happy with their biological sex or to encourage them to continue to exhibit behaviors that do not match their biological sex—or to explore a transgender transition—is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.[4][5] Other clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.[6]

Professionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender reassignment leading to surgical gender reassignment will be in that person’s best interest.

Psychological and Social Consequences

Overall, psychotherapy, hormone replacement therapy, and sex reassignment surgery together can be effective treating GD when the WPATH standards of care are followed. The overall level of patient satisfaction with both psychological and biological treatments is very high.

After sex reassignment surgery, transsexual individuals (people who underwent cross-sex hormone therapy and sex reassignment surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression, and hostility levels were lower after sex reassignment surgery. They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing sex reassignment surgery.

Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences, it has been suggested that most studies investigating the outcomes of sex reassignment surgery are flawed as they have only included a small percentage of sex reassignment surgery patients in their studies. These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates, and low follow-up rates, which would indicate need for continued study.

Persistent regret can occur after sex reassignment surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide. Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice, and stigmatizing behaviors. The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety, and post-traumatic stress.

Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity, and reduce minority stress. Therefore, it is suggested that psychological support is crucial for patients after sex reassignment surgery, which helps them feel accepted and to have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier sex reassignment surgery process.

WATCH IT

This video tells the first-person account of Jamie’s experience during his hormonal treatment and transition.

You can view the transcript for “My Gender Transition From Female To Male • Dear BuzzFeed” here (opens in new window).

GLOSSARY

bottom surgery: surgery to alter the genitalia

conversion therapies: the pseudoscientific practice of trying to change an individual’s sexual orientation from homosexual or bisexual to heterosexual using psychological, physical, or spiritual interventions

gender confirmation surgery: sexual reassignment surgery or any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity

gender performativity: concept arguing that both sex and gender are constructed

harm reduction model: a set of practical strategies and ideas aimed at providing hormonal therapy based on assessment of individual patient’s needs, history, and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules

identity: the way one understands, describes and expresses oneself and the reflection of those entities to others

interactionist theory of gender identity: a theory that suggests that, up to a certain age, gender identity is relatively fluid and subject to constant negotiation

non-op: those who do not wish to include surgery in their transition

post-op: those who have already had surgery

pre-op: those who plan to have surgery but not yet done so

top surgery: surgery to alter the chest and breast tissue

transgender transition services: the various medical treatments and procedures that alter an individual’s primary and/or secondary sexual characteristics

transsexual: a person who has undergone cross-sex hormone therapy and sex reassignment surgery

World Professional Association for Transgender Health (WPATH) Standards of Care: international clinical protocols outlining the recommended assessment and treatment for gender non-conforming individuals across the lifespan or transgender or transsexual people who wish to undergo social, hormonal, or surgical transition to the other sex

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