The term “transgender” describes individuals whose gender identity (their internal sense of being male, female, both, or neither) differs from the sex they were assigned at birth, typically based on external genitalia. A subset of transgender people experience gender dysphoria, a psychological condition characterized by distress arising from the mismatch between their gender identity and assigned sex. Gender dysphoria can emerge in childhood, adolescence, or adulthood.
Individuals experiencing gender dysphoria may seek various forms of gender affirmation. These can include social affirmation, such as adopting a new name and pronouns; legal affirmation, like changing gender markers on official documents; medical affirmation, which might involve puberty blockers or hormone therapy; and surgical affirmation, encompassing procedures like vaginoplasty or chest reconstruction. It’s crucial to recognize that the pursuit of gender affirmation is a deeply personal journey, and not all transgender individuals desire all available avenues.
Gender identity is distinct from gender expression, which is how someone outwardly presents their gender to the world. For instance, wearing dresses or tuxedos are considered gendered expressions within specific cultural contexts, but these norms are not universal and shift across time and cultures. Gender expression may or may not align with gender identity, and diverse gender expressions, like diverse gender identities, are not indicative of mental illness.
Similarly, gender identity differs from sexual orientation, which refers to attraction to others. Transgender people, like cisgender people (those whose gender identity aligns with their sex assigned at birth), exhibit a wide spectrum of sexual orientations.
Diagnosis: A Psychological Perspective
In the realm of psychology, diagnosis, according to its psychology definition, is the process of identifying a disease, condition, or injury based on its signs and symptoms. For gender dysphoria, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) serves as the authoritative guide, offering specific diagnostic criteria for both children and adolescents/adults.
The DSM-5-TR defines gender dysphoria in adolescents and adults as a pronounced incongruence between an individual’s experienced or expressed gender and their assigned gender, persisting for at least six months, and evidenced by at least two of the following criteria:
- A significant mismatch between one’s experienced/expressed gender and their primary and/or secondary sex characteristics (or, in younger adolescents, anticipated secondary sex characteristics).
- A strong desire to eliminate primary and/or secondary sex characteristics due to this incongruence (or, in younger adolescents, to prevent their development).
- A marked yearning for the primary and/or secondary sex characteristics of the opposite gender.
- An intense desire to be the other gender (or an alternative gender different from their assigned one).
- A strong wish to be treated as the other gender (or an alternative gender).
- A firm belief that one possesses the typical feelings and reactions of the other gender (or an alternative gender).
Crucially, for a diagnosis of gender dysphoria to be made, these conditions must cause clinically significant distress or impairment in social, occupational, or other vital areas of life.
For children, the DSM-5-TR defines gender dysphoria as a marked incongruence between experienced/expressed gender and assigned gender, lasting at least six months, and manifested by at least six of the following (with the first criterion being mandatory):
- A strong desire to be of the other gender or insistence that they are the other gender (or an alternative gender).
- In boys (assigned gender), a preference for cross-dressing or mimicking female attire; in girls (assigned gender), a preference for masculine clothing and resistance to feminine clothing.
- A strong preference for cross-gender roles in make-believe or fantasy play.
- A strong preference for toys, games, or activities stereotypically associated with the other gender.
- A strong preference for playmates of the other gender.
- In boys (assigned gender), rejection of masculine toys, games, and activities and avoidance of rough play; in girls (assigned gender), rejection of feminine toys, games, and activities.
- Dislike of their sexual anatomy.
- A desire for the physical sex characteristics that align with their experienced gender.
Similar to the criteria for adolescents and adults, childhood gender dysphoria must also be associated with clinically significant distress or functional impairment.
Treatment and Psychological Support
Support for individuals with gender dysphoria often begins with exploring their gender identity and expression in a non-directive therapeutic environment. Ethical therapeutic approaches prioritize exploration and affirmation, avoiding pre-conceived outcomes. Attempts to force cisgender identity on transgender individuals, often termed “gender identity conversion therapy,” are considered unethical and harmful to mental health.
Affirmative support can encompass various aspects of an individual’s life. Social affirmation involves adopting gender-affirming names, pronouns, and expressions. Legal affirmation includes changing legal gender markers. Medical affirmation for adolescents and adults may include puberty suppression or hormone therapy. Surgical affirmation is an option for some adults and, less frequently, adolescents. Medical interventions are generally not recommended for prepubertal children.
Family and societal acceptance are vital for the well-being of transgender individuals. Rejection is a significant risk factor for mental health challenges. Family and couples therapy can foster supportive environments. Support groups can be beneficial for both transgender individuals and their families.
Challenges and Mental Health Complications
Transgender people face significant stigma, discrimination, and victimization, contributing to negative self-image and increased rates of mental health disorders. They are disproportionately vulnerable to hate crimes and violence. Suicide rates within the transgender community are alarmingly high.
Transgender children and adolescents are frequently targets of bullying and discrimination in schools, leading to adverse mental health outcomes. Creating safe and affirming school environments is crucial.
Access to appropriate healthcare and insurance coverage for gender-affirming care can also be a significant challenge for transgender individuals.
Terminology: Key Definitions in Understanding Diagnosis Psychology
Understanding the correct terminology is crucial for discussions surrounding diagnosis and psychology related to gender identity:
- Cisgender: Describes individuals whose gender identity aligns with their sex assigned at birth.
- Gender diverse: An umbrella term for individuals with diverse gender identities and expressions, including those identifying with multiple or no genders.
- Gender dysphoria: In the DSM-5-TR, this refers to clinically significant distress or impairment due to gender incongruence, potentially including a desire to alter sex characteristics. Not all transgender people experience gender dysphoria.
- Gender expression: The external presentation of gender, which may or may not reflect inner gender identity and is based on societal expectations. It includes aspects like clothing, mannerisms, and physical characteristics.
- Gender identity: An individual’s internal sense of being a woman, man, both, neither, or another gender. It may or may not align with assigned sex at birth.
- Nonbinary: Describes individuals whose gender identity is neither exclusively woman nor man.
- Sex/gender assigned at birth: The designation of “female,” “male,” or “intersex” based on anatomy or biological factors. “Sex” and “gender” are distinct concepts. It is important to differentiate between sex, gender identity, and gender expression and avoid assumptions. Commonly abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth).
- Sexual orientation: Describes patterns of emotional, physical, and/or romantic attraction to others.
- Transgender: An umbrella term for individuals whose gender identity differs from their assigned sex at birth. It can also refer to individuals whose gender identity is binary but not traditionally associated with their assigned sex.
Physician Review
Jack Turban, M.D., M.H.S.
August 2022
