Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics. Transgender and gender-nonconforming people might experience gender dysphoria at some point in their lives. 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.
The exact causes of gender dysphoria are not completely understood, but several different factors may play a role. Genetics, hormonal influences during prenatal development, and environmental factors may be involved.
For example, prenatal exposure to certain chemicals has been associated with disruptions in the normal development of sex determination prior to birth. Research also points to a genetic link, since there is a higher shared prevalence between identical twins than between fraternal twins.6
The onset of gender dysphoria is often during early childhood. While the exact mechanisms are unclear, we do know that when children are born, they are assigned a sex-based upon their physical anatomy. The sex that a child is assigned at birth often determines how they are raised and how others interact with them. As they grow older, they may begin to feel that there is a mismatch between their gender identity and their assigned sex. In some cases, this mismatch can lead to feelings of gender dysphoria.
Symptoms of gender dysphoria can include feeling a strong sense of distress or discomfort with one’s assigned gender. Some signs that someone is experiencing gender dysphoria include:
- A desire to no longer have the primary sex characteristics of their birth-assigned gender
- A desire to be treated as the opposite gender
- A desire to have the primary and secondary sex characteristics of their preferred gender identity
- The insistence that they are a gender different from their birth-assigned sex
- Preferences for cross-sex roles
- Strong rejection of toys, games, and other things that are typically associated with their birth-assigned gender
- Wearing clothing typically associated with the opposite gender2
People who experience gender dysphoria may frequently express that they want to be the opposite gender. They often feel uncomfortable with the gender roles and gender expressions of their birth-assigned sex. This might manifest in behaviors such as dressing as their preferred gender, playing with toys that are typically associated with the opposite gender, and rejection of many gender-stereotypical behaviors.
Gender dysphoria is not related to an individual's sexual orientation. People who experience gender dysphoria may be straight, gay, lesbian, or bisexual. People who feel gender dysphoria may also be gender-nonconforming or transgender. However, it is important to recognize that not everyone who is transgender or gender nonconforming experiences gender dysphoria.
Cross-sex hormone therapy
Cross-sex hormone therapy means taking the hormones of your preferred gender:
- a trans man (female becoming a male) will take testosterone
- a trans woman (male becoming a female) will take oestrogen
The aim of hormone therapy is to make you more comfortable with yourself, both in your physical appearance and how you feel psychologically (mentally). These hormones start the process of changing your body into one that is more female or more male, depending on your gender identity.
Hormone therapy may be all the treatment you need to live with your gender dysphoria. The hormones may improve how you feel and mean that you do not need to start living in your preferred gender or have surgery.
Transgender Men (Female to Male): Testosterone hormone therapy (“T”) increases muscle mass, possibly resulting in bone tissue production and an increase in bone mass, at least in the short term. However, long durations of “T” may decrease bone mass and contribute to an increased risk of osteoporosis. Additionally, the effects of “T” may significantly reduce or eliminate the menstrual cycle, which would impact iron needs. It is important to note that once “T” is initiated, it typically is used indefinitely.
Transgender Women (Male to Female): Estrogen may increase risk of thromboembolic disease and progesterone can cause weight gain. In those who have their testicles removed, estrogen replacement can play an important role in preserving bone mass. Compared to cisgender females, whose natural estrogen can decrease over time, consistent estrogen replacement use has been shown to have no negative changes in bone density.
Transgender Adolescents: In 2017, the Endocrine Society published a clinical practice guideline for endocrine treatment of adolescents who are gender-dysphoric/ gender-incongruent. There are multiple considerations for this population. Hormone suppressants may cause complications related to bone health. Recommendations include weight bearing exercises and supplementation with calcium and vitamin D may be warranted.
Behavioral health treatment
This treatment aims to improve your psychological well-being, quality of life and self-fulfillment. Behavioral therapy isn't intended to alter your gender identity. Instead, therapy can help you explore gender concerns and find ways to lessen gender dysphoria. The goal is to help transgender and gender-nonconforming individuals become comfortable with their gender identity expression, enabling success in relationships, education and work. Therapy can also address any other mental health concerns.
Therapy might include individual, couple, family and group counseling to help you:
- Explore and integrate your gender identity
- Accept yourself
- Address the mental and emotional impacts of minority stress
- Build a support network
- Develop a plan to address social and legal issues related to your transition and coming out to loved ones, friends, colleagues and other close contacts
- Become comfortable expressing your gender identity
- Explore healthy sexuality in the context of gender transition
- Make decisions about your medical treatment options
- Increase your well-being and quality of life
Treatment for gender dysphoria focuses on alleviating the patient’s distress surrounding their gender identity. That often means psychotherapy — and dialectical behavior therapyin particular—in which a therapist validates their emotions and helps them develop effective coping skills, to avoid things like self-injuryand suicidality. If their distress has led to depression or anxiety, those may be treated with therapy or medication. Therapists also work with gender dysphoria patients, and their families, to help them determine the best way to shape their gender expression for the healthiest outcome.
Some patients desire hormone therapy or sex reassignment surgery; others do not. Transgender and endocrinology organizations recommend waiting until at least 16 to start hormone treatment, but what is best for the individual needs to be considered. Hormone treatment to suppress puberty for as long as several years is sometimes used to give a patient time to decide whether to do surgery; since it stops the development of secondary sex characteristics — breast development, or the deepening of the voice and growth of facial hair — it also prevents the added distress of a patient’s body acting in a way that does not align with their affirmed gender.