Gender Dysphoria, formerly Gender Identity Disorder (GID), is one of the very few topics broad or complex enough to include apparently unrelated areas of knowledge such as psychology, embryology, and surgery. Once thought to be bearers of misfortune, hermaphrodites were subject to executions in the Greek and Roman empire, as well as profound misunderstanding and hostility during the advent of Christianity.
Nowadays, our current understanding allows us to define gender dysphoria and even assign a series of criteria to aid the diagnosis. This is the current definition according to the World Professional Association for Transgender Health Standards of Care, seventh edition:
Distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)
As this concept emerged, and ethical concerns were met with the actual understanding of its physiologic basis, gender dysphoria became accepted by our modern civilization. It is now an open field of active investigation as new technologies and surgical alternatives emerge to treat these patients.
In this brief guide, you will find everything you need to know about gender dysphoria, starting from diagnosis, signs and symptoms, and progressing into management as well as the most common psychological and surgical concerns associated with its treatment.
Signs and symptoms of gender dysphoria
The first thing we need to make clear is the difference between gender dysphoria and homosexuality. The current guidelines to diagnose gender dysphoria does not include sexual attraction to the same sex because gender dysphoria is a gender discrepancy and does not necessarily involve a given sexual orientation.
The diagnose of gender dysphoria is different according to the age, and it is more conservative in children. They need to meet at least 6 of these criteria, and should always include the first one on the list:
- Strong desire to have a different gender: A strong desire is not an episodic or recurrent thought. It is rather a firm conviction and sometimes a pressing insistence that they are actually of the other gender.
- Preference to wear the other gender’s attire: Boys have an inclination to wear girls’ clothes, or they try to simulate a female’s way of dressing. Girls prefer more masculine clothing. Girls typically show strong resistance when parents and others suggest they should be more feminine.
- Strong preference for another gender in role play: Once again, this is not sometimes. During their role-playing games, they tend to simulate and choose another gender different than the one assigned to them.
- Strong preference for toys and games of the other gender: They are typically engaged with activities and toys stereotypically used by the other gender.
- Strong preference for friends and playmates of the opposite gender: They feel strongly inclined to share their playtime and activities with the opposite gender.
- Rejection of toys and games stereotypically assigned to their gender: They do not only prefer games and toys used by the other gender but also have a strong rejection against activities, toys and games used by other children.
- Dislike of their own genitals: It is not only they feel unsatisfied, but they dislike their sexual anatomy.
- Strong desire for the sexual characteristics of their experienced gender: They want to have, and often try to mimic the physical characteristics of the other sex.
Even if they seem quite similar to each other, the criteria for adolescents and adults are different, and they need to meet at least two of the following:
- An incongruence between their experienced gender and their sexual characteristics: They do not experience the gender they are assigned.
- Strong desire to get rid of their sexual characteristics: Given this incongruence, they want to get rid of their primary and secondary sex characteristics. Adolescents may even want to prevent the development of such changes in their bodies.
- Strong desire for the sexual characteristics of the other gender: They want to have genitals of the other gender, and this is not an episodic or recurrent thought but a strong desire.
- Strong desire to be of the opposite gender: Not necessarily related to their genitalia, they have a strong desire to have another gender.
- Strong desire to be treated as the opposite gender: They are not satisfied with how other people and society treat them and have a strong desire to be treated as the opposite gender.
- Strong conviction of having reactions and feelings of the other gender: They have the common emotions and thoughts stereotypically assigned to the other gender.
To prevent a hasty diagnosis, there’s a lower-bound criterion of 6 months or more with these signs and symptoms. They are associated with significant distress or an impairment in their social functions and may affect various areas of their lives, such as school life, work life, and others.
The exact reason why this happens is not entirely known, but there are various hypotheses and mounting evidence pointing out at a biological foundation to the convictions and preferences in gender dysphoria. What we do know is that deficient parenting, trauma, and other psychopathologic reasons have been progressively discarded and now considered a myth.
Clinical and surgical management of gender dysphoria
Management of gender dysphoria is often complex, even more when it involves children and adolescents. According to the Royal College of Psychiatrists, these patients should follow a four-stage process before starting surgical procedures. A similar approach is followed in adult patients with a few exceptions.
- Stage 1 involves a therapeutic exploration with psychological support and without physical intervention. In most cases, there’s a pressure to go a step further, especially in patients who are about to develop secondary changes in puberty. However, entering a second stage would require very careful informed consent and the request by the patient and their parents.
- Stage 2 includes reversible hormonal intervention by blocking the hypothalamic production of hormones associated with the production of estrogens or testosterone.
- Stage 3 usually requires patients to experience some pubertal changes in order to make an appropriate decision because it includes hormonal treatment that will create a masculine or feminine change that is partially reversible.
- Stage 4 involves surgical procedures and other irreversible changes.
Throughout the treatment, there are various challenges that patients and clinicians need to face. For instance, long-term cross-sex hormonal treatment has multiple side effects, such as osteoporosis and osteopenia, a higher cardiovascular risk, hyperprolactinemia, and breast cancer.
There are various surgery complications to consider, including hematoma, necrosis or bleeding, a prolapse of the neovagina, a displacement of the stitches, poor healing, and post-operatory infection. Lengthy surgeries with an obese patient may also lead to muscular contusion when legs are not correctly positioned.
Nowadays, we are able to perform male to female and female to male surgeries with satisfactory results. After surgery, these patients would also need careful follow-up, not only to make sure they are satisfied with the results and prevent complications but also to guarantee their mental health and prevent various psychiatric problems found in higher rates in these individuals, including suicidal behavior and suicidal thoughts.
- World Professional Association for Transgender Health (2011) SOC7. Int J Transgenderism 13(4):221
- Green, R. (2000). Family cooccurrence of “gender dysphoria”: Ten sibling or parent–child pairs. Archives of sexual behavior, 29(5), 499-507.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
- Di Ceglie, D., Sturge, C., & Sutton, A. (1998). Gender identity disorders in children and adolescents: guidance for management. London: Royal College of Psychiatrists.
- Gijs, L., & Brewaeys, A. (2007). Surgical treatment of gender dysphoria in adults and adolescents: Recent developments, effectiveness, and challenges. Annual Review of Sex Research, 18(1), 178-224.