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Gender Dysphoria

The term “transgender” refers to a person whose sex assigned at birth (i.e. the sex assigned by a physician at birth, usually based on external genitalia) does not match their gender identity (i.e., one’s psychological sense of their gender). Some people who are transgender will experience gender dysphoria,” which refers to psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.

People who are transgender may pursue multiple domains of gender affirmation, including social affirmation (e.g., changing one’s name and pronouns), legal affirmation (e.g., changing gender markers on one’s government-issued documents), medical affirmation (e.g., pubertal suppression or gender-affirming hormones), and/or surgical affirmation (e.g., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.). Of note, not all people who are transgender will desire all domains of gender affirmation, as these are highly personal and individual decisions.

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Expert Q&A: Gender Dysphoria

Transgender is a non-medical term that has been used increasingly since the 1990s as an umbrella term describing individuals whose gender identity (inner sense of gender) or gender expression (outward performance of gender) differs from the sex or gender to which they were assigned at birth. Some people who use this term do not consider themselves as matching a binary gender category of either strictly male or female. In addition, new terms such as gender non-conforming, genderqueer, bigendered, and agendered are increasingly in use.

Transsexual is a historic, medical term that refers to individuals who have undergone some form of medical and/or surgical treatment for gender affirmation or confirmation (historically referred to as sex reassignment). Some transsexual individuals may identify as transgender, although many primarily identify as the male or female gender to which they have transitioned.

People who identify as transgender but who do not seek medical or surgical treatment are not transsexual.

Not all transgender people suffer from gender dysphoria and that distinction is important to keep in mind. Gender dysphoria and/or coming out as transgender can occur at any age.

The DSM-5-TR* distinguishes between Gender Dysphoria in Childhood for those who experience Gender Dysphoria before puberty. The diagnosis of Gender Dysphoria in Adolescents and Adults can occur at any age. For those who experience gender dysphoria later in life, they often report having secretly hidden their gender dysphoric feelings from others when they were younger.

*Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), Fifth edition, Text Revision. American Psychiatric Association. 2013

Many transgender people who take feminizing or masculinizing hormones, estrogen or testosterone respectively, report improvement of emotions as their gender dysphoria lessens or resolves. In general, a person transitioning from male to female (MTF, transwoman) takes feminizing hormones that may reduce libido. A person transitioning from female to male (FTM, transman) takes masculinizing hormones that may increase libido. Less commonly, masculinizing hormones may provoke anxious, hypomanic, manic, or psychotic symptoms in patients who have an underlying psychiatric disorder that include such symptoms. This adverse event appears to be associated with higher doses or greater than average blood levels of testosterone.

As with any medical treatment, the anticipated risks and benefits should be considered by a patient and prescribing doctor on an individual basis

Not all individuals with gender dysphoria choose to undergo medical or surgical treatment. For one, gender affirming surgeries are very expensive and are sometimes not covered by insurance. People with gender dysphoria decide which treatment options are right for them. Some are satisfied with taking hormones alone. Some are satisfied with no medical or surgical treatment but prefer to dress as the felt gender in public. Some people make use of Trans affirming social networks online and in local supportive communities to cope with gender dysphoria and claim a gender identity and forms of expression that do not require medical treatments. Some individuals choose to express their felt gender in private settings only because they are either uncomfortable or fearful of publicly expressing their felt gender. People who are denied or have no access to gender affirming treatments can become anxious, depressed, socially withdrawn and suicidal.

No. Such a desire is called transvestitism and it is not a psychiatric disorder. DSM-5-TR does have a diagnosis of Transvestic Disorder that specifically states it “does not apply to all individuals who dress as the opposite sex, even those who do so habitually.” It is only considered a disorder if “cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement.”

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About the experts

Jack Drescher, M.D.

Clinical Professor of Psychiatry, Columbia University

Adjunct Professor, New York University

Training & Supervising Analyst, W.A. White Institute

Jack Pula, M.D.

Psychiatrist in private practice in New York City

Eric J. Yarbrough, M.D.

Psychiatrist in private practice in New York City

Medical leadership for mind, brain and body.

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