Gender Dysphoria, what is it?
Those diagnosed with gender dysphoria experience an emotional conflict between the gender they’re assigned at birth and the gender by which they identify. Examples include those assigned male at birth, but identify as a female. Frequently having feelings of ‘being in the wrong body’ or feeling uncomfortable with their bodies is commonly experienced by individuals with gender dysphoria. ‘Transgender’ is the term used to describe individuals who feel a misalignment between their gender assignment at birth and the gender to which they most closely identify.
In 1980, the incongruence between the assignment of one’s gender at birth and the gender by which they identify was introduced as ‘Gender Identity Disorder’ as a psychiatric disorder and officially listed in the third edition of the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-III).
The use of the term ‘disorder’ enhanced the stereotype that gender dysphoria is a problem of the mind, a mental illness which offered a double-edged sword to the transgender community. On one hand, classifying an individual as having a disorder exacerbated an already prominent stigma due to it being listed in the DSM, resulted in more opportunity for medical insurance coverage for medications, surgeries, and counseling. On the other hand, however, it perpetuated a misconception of transgender individuals as persons with mental disorders, a misconception that science is working diligently to erase due to recent reports and scientific discoveries which prove being transgender is not a mental illness, but a very real biological part of humans.
Where sex reassignment surgery, a term which has been replaced by Gender Affirmation Surgery (GAS) and Gender Confirmation Surgery (GCS), was previously considered cosmetic only, such psychiatric diagnostic criteria helped to make such procedures medically necessary to alleviate the negative symptoms of gender dysphoria.
The move from “Gender Identity Disorder” to “Gender Dysphoria” occurred in 2012 with the publication of the DSM-V. This occasion was seen as an essential step toward helping to reduce the stigmatization of transgender people by eliminating the word ‘disorder.’ Now, rather than disordered, those experiencing symptoms of gender dysphoria are diagnosed as such when they display emotional distress between one’s assigned and one’s identified gender.
The Causes of Gender Dysphoria
Where early explanations of transgender people pointed to problems of the mind (or mental illness), more current research makes evident that more plausible explanations are rooted deep within a person’s biology.
Here are a few of the many biological scenarios that might further explain gender dysphoria:
- Androgen Insensitivity Syndrome (AIS)
AIS is a genetic defect passed from a mother to genetically male children. Although the mother remains unaffected, the child (with AIS) is unresponsive to testosterone, the hormone responsible for catalyzing the development of male sex organs.
Individuals with AIS are classified as having either CAIS (or Complete Androgen Insensitivity Syndrome) or PAIS (Partial Androgen Insensitivity Syndrome).
Genetically male babies with CAIS are born with female genitalia as testosterone, the hormone needed to catalyze male sex organs has no influence on their sexual development. Genetically male babies with PAIS, are impacted only partially by testosterone, as the name implies. This results in somewhat androgynous genitalia resembling something between the primary sex characteristics of a male and female.
As those born with AIS have a biological difference between their genetic sex and their biological sex, it’s clear that symptoms of gender dysphoria are rooted in biology rather than only in the mind.
- Congenital Adrenal Hyperplasia (CAH)
Those with Congenital Adrenal Hyperplasia (or CAH) have improperly functioning adrenal glands. Adrenal glands are small walnut-sized organs that sit above the kidneys, and are responsible for the production of steroid hormones and androgens. In many cases, those with CAH have a lack of the steroid hormone cortisol and an overproduction of androgen, the group of hormones responsible for the growth and development of the male reproductive system.
Two forms of CAH exist: Classic and Nonclassic.
- Classic CAH is detectable in infants and considered more serious. While both genetically female and male infants may have CAH, only the genitalia of genetically female babies are impacted. While the internal reproductive system develops normally, the external genitalia often appears more male than female. For this reason, some infants are assigned the wrong gender at birth. While the external genitalia of male babies are unimpacted, CAH has serious health risks for infants assigned male and female at birth.
- Nonclassic CAH is considered milder and often presents no symptoms at birth. Although genetalia appear normal at birth, symptoms often appear during late childhood or early adulthood. Females with nonclassic CAH may have unusual menstrual periods, and masculine characteristics like body hair, facial hair, and a deepening voice. Common to females and males is the appearance of early pubic hair and rapid growth during childhood with a shorter than average final height.
Although studies show a small percentage of individuals with CAH demonstrating signs of gender dysphoria, the percentage is higher than gender dysphoria seen in the general population. One study suggests that an incorrect assignment of gender is a contributor, while other studies fail to speculate a potential cause.
- Chromosomal Abnormalities
In its most simplistic sense, the development of an embryo includes the pairing of either XX chromosomes (resulting in a female) or XY chromosomes (resulting in a male). At 4-6 weeks of development, the SRY gene, carried by the male’s Y chromosome, will signal the development of the testes. The testes are responsible for secreting testosterone which acts as a catalyst for the development of primary and secondary male sex characteristics.
In some cases, though, the SRY gene is missing or malfunctions. The absence of the SRY gene, causes a genetically male embryo to develop as a female. In other words, the child has the genetic code of a male but the reproductive organs of a female. One study suggests that this mismatch between the genetics and one’s reproductive organs provides a “…chromosomal basis for sex differences in both brain structures and behaviour.” The study further suggests this sex chromosomal gene expression has more to do with sex differentiation in the brain than previously thought. In other words, aside from differences only in one’s reproductive organs, the malfunctioning gene may also contribute to sex differences held within our mind.
While the biological explanations of gender dysphoria vary, the symptoms experienced across individuals are more similar.
The DSM-5 provides the following criteria for children and adolescents/adults:
In adolescents and adults, a diagnosis of gender dysphoria involves a difference between one’s experienced/expressed gender and assigned gender, and significant distress or problems functioning. It lasts at least six months and is shown by at least two of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics
- A strong desire to be rid of one’s primary and/or secondary sex characteristics
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender
- A strong desire to be treated as the other gender
- A strong conviction that one has the typical feelings and reactions of the other gender
In children, gender dysphoria diagnosis comprises of at least six of the following and an associated significant distress or impairment in function, lasting at least six months.
- A strong desire to be of the other gender or an insistence that one is the other gender
- A strong preference for wearing clothes typical of the opposite gender
- A strong preference for cross-gender roles in make-believe play or fantasy play
- A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
- A strong preference for playmates of the other gender
- A strong rejection of toys, games and activities typical of one’s assigned gender
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender”
Perhaps due to limited societal awareness and acceptance combined with exceptional emotional distress, transgender individuals face stigmatization. The stress of the stigmatization manifests itself in mental health conditions and poor access to health care.
Stigmatization & Discrimination
Recent studies prove that the stigmatization of transgender individuals only heightens the distress associated with gender dysphoria. Transgender people face prejudice, disrespect, harassment, in addition to potential hate crimes and violence. Stigma also contributes to weak support systems resulting in emotional isolation.
Aside from an emotional struggle, discrimination in certain regions of the world result in challenges finding and maintaining employment. One study found trans Americans were twice as likely to face unemployment as their gender-conforming peers, with 16% of those surveyed turning to sex work or the selling of illegal drugs to support themselves.
High-Risk Coping Strategies
As previously mentioned, gender dysphoria is no longer considered a mental illness. However, the related distress can undoubtedly contribute to mental illness and high-risk coping strategies. Anxiety, depression, suicide ideation, and suicide are all too common among transgender individuals. Abuse of alcohol and drugs has also been found to be disproportionately higher in the transgender community when compared to the general population.
Access to Health Care
In addition to stigmatization, discrimination and high-risk coping strategies, many physicians are improperly prepared to help transgender individuals. In many cases, the specialists commonly contacted for sex hormone therapy, gynecologists and endocrinologists, have not received specific training. A Canadian study reported that physicians themselves were fearful to treat transgender individuals due to their lack of knowledge on proper treatment.
Not only are the medical specialists and general practitioners ill-prepared to service the health needs of transgender people, fear of stigma and discrimination itself may prevent a trans person from seeking help in the first place. Limited contact with health care providers then is more likely to result in sub-par health.
Remedies / Treatment
The persistence and emotional impact of gender dysphoria is widely varied, as such the treatment for individuals will vary too. Here are some methods of treatment found to diminish the symptoms of gender dysphoria
Counseling is useful in exploring feelings and further affirming one’s gender identity. Family counseling is also thought to be helpful. Families working towards an increased understanding help in developing a more emotionally supportive environment.
In addition to individual counseling and familial counseling, support groups are beneficial too. Often working to create a safe place to share with those facing similar struggles, peer support groups also allow a person to learn from others who’ve taken a similar journey.
- Cross-Sex Hormones
Cross-sex hormones are administered to align one’s secondary sex characteristics with their preferred gender identity, helping to reduce the distress associated with gender dysphoria. Feminizing hormones include estrogens and antiandrogens, where masculinizing hormones consist of androgens. Cross-sex hormones may be administered to adults, or, may be administered to adolescents following puberty blockers.
- Puberty Suppression
Because the existence of secondary sex characteristics (those arising through puberty) are challenging to reverse, one method of treatment includes puberty suppression. While not permanent, puberty suppression (through puberty blockers) allows an individual more time to affirm their preferred gender identity. Essentially, hitting pause on puberty until one wishes to proceed in their assigned gender, or begin taking cross-sex hormones to transition into their preferred gender identity. [SEE Puberty Blockers: What are they]
- Gender Reassignment Surgery
Often the last step in the transition process, gender reassignment surgery is meant to alter the existence of secondary sex characteristics into one’s preferred gender. For example, a penis and testicles can be removed using some of the tissue to construct a vagina and clitoris. Those looking to feminize may also have facial feminization surgery to alter the look of their eyes, nose, lips and Adam’s apple.
Conversely, transitioning to male after an assignment of a female at birth would include breast removal, closing of the vagina, and the creation of a penis and scrotum.
The Good News
Increasing research into gender dysphoria is helping to dispel harmful myths, thereby working to reduce stigma and discrimination. While the symptoms of gender dysphoria lead to exceptional distress and harmful coping strategies, strong emotional support, accessible medical care, and for some, transitioning from one’s assigned gender into the gender by which they identify will greatly lessen or eliminate the negative symptoms of gender dysphoria.