Individuals who experience gender dysphoria can develop distress in their formative years, and it can persist into their adolescence and adulthood. The distress includes discomfort with their designated sex, such as feeling uncomfortable with their physical body (which intensifies during puberty) to feeling uncomfortable with the expected social roles associated with their designated sex.1
What Is Gender Dysphoria?
Gender dysphoria refers to the persistent emotional and psychological distress a person experiences due to a mismatch between their gender identity and designated sex at birth.2,3 For example, a person whose designated sex at birth is male may come to realize they emotionally, physically, and psychologically feel and identify as female.
Gender dysphoria is not considered pathological or a mental disorder; rather, it defines an area of vulnerability leading to the development of social and psychological challenges.3
There are several important terms associated with gender dysphoria. Gender identity development is an expected and natural part of the human lifespan. In order to support those who experience gender dysphoria, one must be able to understand and acknowledge the difference between gender as a social construct—or how society has developed beliefs, norms, and expectations based on a gender binary of male and female—and the biological aspects of sex.
Biological sex is also known as sex assigned at birth or desingated sex at birth, which refers to the external characteristics of a newborn, like genatalia and/or secondary sex characteristics, utilized by healtchare providers to declare a newborn as male, female, or intersex.
However, gender refers to a person’s innermost concept of self as male, female, a combination of both, or neither.4
Gender identity involves a complex makeup of biological, environmental, and cultural factors reflecting a person’s internal sense of oneself—in other words, how they perceive themselves and what they call themselves.5 This identity can be the same or different from their gender assigned at birth and is also known as a person’s expressed and/or experienced gender.
Transgender is considered an umbrealla term that comprises all individuals whose gender identity does not conform to expectations based on their gender assigned at birth.6
Cisgender refers to a person whose gender identity aligns with those typically associated with their gender assigned at birth. Gender identity was previously understood as a binary—male or female; however, in recent years gender has come to be understood as a spectrum of identities from male and female, to a combination of both, or neither.
Finally, gender is different from sexual orientation. Sexual orientation refers to a person’s inherent or enduring emotional, romantic, and/or sexual attraction to other people (e.g., lesbian, gay, bisexual, straight, queer, etc.).4 There are many combinations of gender and sexuality identities, making it important for people to not assume based on outward appearances or stereotypes.
Signs of Gender Dysphoria: What It Looks Like
Gender dysphoria can appear in several different ways for children, youth, and adults. Overall, the main attribute of dysphoria occurs when one experiences consistent and persistent distress in the mismatch of their gender identity and their designated sex at birth.
Signs of Gender Dysphoria in Children
Throughout childhood, it is common for children to display periods of nonconforming gender expression in their play, such as taking an interest and playing dress up in the clothes associated with the opposite sex. This play typically does not persist into their grade school or adolescent years and reflects a naturally occurring phenomenon in human development.6 These children are considered to be gender expansive, gender variant, or gender nonconforming.
However, some children, at very young ages, begin to recognize their gender is different from the sex they were assigned at birth.6 This discovery can occur anywhere between the age of 2-4 years and is conveyed through their identity, expression, or both.7 Early-onset gender dysphoria occurs when a child, in their preschool or elementary school years, presents with persistent and consistent distress regarding their sex assigned at birth and the gender they believe themselves to be.8
Examples of this can be seen in correcting parents when incorrect pronouns or gender labels are used as well as in an increase in externalizing (e.g., angry outbursts, meltdowns, aggressive behavior) or internalizing (e.g., social withdrawal, somatic complaints, feelings of nervousness or unloved) behaviors when referred to by the wrong gender.7
Signs of Gender Dysphoria in Adolescents & Youth
The rate of adolescents referred to mental health services for gender identity concerns has rapidly increased over the past two decades.9 Adolescence is an integral time for gender and sexual identity development, particularly for youth who experience gender identity concerns.
Gender identity typically develops earlier than sexual orientation, with identities becoming more resolved during adolescence.7 As previously stated, early-onset gender dysphoria may be more readily recognized by parents who support their child with gender identity concerns. On the other hand, late-onset gender dysphoria may come as a total surprise for the youth and their parents, and both may not necessarily be aware of it.
Teens with gender dysphoria are different from teens who are gender nonconforming, or those who behave and express their gender in ways that don’t align with their gender assigned at birth. Teens with gender dysphoria experience persistent distress in the mismatch of their gender identity with their designated sex at birth. They will have a deep desire to be seen and treated as their gender identity.
Teens who experience gender dysphoria are more inclined to hide their gender identity concerns in fear of rejection, ridicule, or disapproval, not only from their peers but especially their parents.10 This makes it even more important for parents to know the significance of gender dysphoria and what it looks like.
Signs of gender dysphoria in adolescents include but are not limited to:
- Persistent and consistent expressed desire they were born the wrong gender
- Expressed desire that others treat them and refer to them as their gender identity
- Changing their outward appearance to pass as their gender identity (e.g., dressing, grooming, presenting)
- Feelings of disgust with their genitals to avoiding activities that would require them to touch or see their genitals (i.e., showering, having sex)
- Distress and internal conflict causing impairment in one or more significant areas of life: Schooling, occupational, and social functioning
Late-onset gender dysphoria may be preceded by or coupled with other adjustment and/or mental health concerns such as school aversion, low self-esteem, anxiety, depressed mood, body image and eating disorders, non-suicidal self-harm (e.g., hitting, cutting, burning), and suicidal thoughts and behaviors.11
It is always necessary to take suicidal thoughts and behaviors seriously, and they should never be ignored or minimized. Adolescents with gender dysphoria are particularly at risk for suicide2 making it paramount for parents to engage in conversations with their teens about their gender identity and finding ways to support them.
If gender dysphoria is not adequately addressed in childhood, as adolescents transition into their young adulthood, they may experience increased emotional and psychological distress as well as poorer quality of life outcomes.
Sign of Gender Dysphoria in Adults
As of 2016, it was estimated there are 1.4 million transgender adults living in the United States, or 0.6% of the population.12 A recent Cedars-Sinai study revealed that untreated gender dysphoria can result in poor quality of life for transgender people, beginning in childhood and lasting throughout their adolescence and adulthood.
The study revealed that most gender dysphoria is established by the age 7. The average age of transgender individuals’ earliest memories and experience of gender dysphoria occurred early on, with transgender women’s earliest memory and first experience of gender dysphoria at 4.5 and 6.7 years, respectively, and transgender men’s at 4.7 and 6.2 years, respectively.13
Moreover, the study revealed that transgender adults lived several years before receiving support that aided their social and/or medical transition. Gender questioning, gender-variant, and transgender adults pursue mental health or other allied healthcare services for a variety of reasons including stress, anxiety, depression, phase of life concerns, career, and relationship distress.
Transgender adults experience disproportionate stigmatization and discrimination, including increased risk of experiencing violence, stigmatization of identity, discrimination in schools, workplaces, and healthcare, and access to care,14 resulting in greater health disparities than their cisgender counterparts.
These are exacerbated for Black trans individuals and trans people of color.12 The overall goal of counseling adults with gender dysphoria is to address the unique and individual needs of each person in living their experienced truth.
Diagnosis of Gender Dysphoria
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5)15 describes one overarching diagnosis of gender dysphoria with separate specific criteria for children, adolescents, and adults. The diagnosis of gender dysphoria hinges on the marked difference between one’s expressed and/or experienced gender and their sex assigned at birth.
This distress must also create problems or significant stress in other areas of a person’s functioning, including relationships, school/occupation, and social life.
A mental health counselor, helping professional, and other allied healthcare providers will follow the World Professional Association for Transgender Health Standards of Care (WPATH SOC)16 to diagnose and treat persons with gender dysphoria.
In order for an adolescent or adult to be diagnosed with gender dysphoria, they must meet at least two of the following criteria lasting over the past 6 months:
- 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 gender16
In children, gender dysphoria diagnosis requires at least six of the following criteria 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 gender16
Gender Dysphoria Statistics
The overall population of transgender individuals in the United States is not fully understood, largely in part to previous US Census data excluding gender identity. Meerwijk and Sevelius17 estimated the size of transgender population in the United States. Their study found approximately 1 million transgender adults are living in the US, with this estimate indicative of younger adults representing more than 50% of the participants in their study.
In a different study, Flores and colleagues found that approximately 1.4 million adults, or 0.6% of the population is comprised by transgender individuals.12
Under- or nonrepresentation of transgender individuals in population surveys is just one barrier to understanding social determinants and health disparities faced by this population. More research is needed to better understand the causation of gender dysphoria as well as how to better support transgender individuals. The figure below depicts the estimated percentage of transgender adults living in the United States by race and ethnicity:
Source: Flores et al., 2016
Treatment of Gender Dysphoria
There are many facets to treating gender dysphoria as well as the transition experience for trans individuals.18 The most common assumptions for treating gender dysphoria and transitioning are hormonal and surgical treatments. However, these are not always the ultimate routes. There are several pathways a trans person can pursue to increase their quality of life.
People who experience gender dysphoria seek care from their primary care providers, endocrinologists, and/or mental health providers. Gender dysphoria and transitioning are at times at the forefront of treatment, whereas other mental health concerns may take precedent.
More and more, trans individuals are seeking care earlier than in adulthood or late adolescence due to increased awareness of gender dysphoria and representation of trans individuals, social acceptance, and continued access to care. When working with mental health and other allied healthcare providers, it is important to note there is no singular way of treating gender dysphoria and providers will pursue referrals in support of the trans person’s unique needs.19
Counseling Process for Gender Dysphoria & Transitioning
Overall, the purpose of counseling is to increase the quality of life for people who experience gender dysphoria and identify as transgender. Mental health providers will assist trans individuals and their loved ones to understand the emotional and physical impact of gender dysphoria, as well as explore the decision and resources to transition.10
Moreover, mental health providers will assist in identifying and building coping skills to reduce the intensity of gender dysphoria and possible comorbid mental health concerns (i.e.,anxiety, depression, suicidal ideation). Different counseling modalities are used to facilitate this process including individual, couples, family, group counseling, and/or psychiatric medication.
Mental health providers will utilize different counseling approaches to support the individual’s unique needs including Person-Centered, Cognitive Behavioral, Mindfulness Stress-Reduction, Trauma-Informed, Solution-Focused, Dialectical Behavioral, and Family Systems approaches, to name a few.
All mental health providers are expected to utilize gender-affirming care, maintain respect for the individual’s self-determination, and have a multicultural and social justice understanding of gender diversity in addition to the legal and medical aspects of care.18
The main aspects to transitioning and gender dysphoria management in counseling will cover:
Social Aspects
In addition to gender identity, trans people have several other social identities, including but not limited to age, race/ethnicity, sexual orientation, socioeconomic status, emotional, physical, and social ability, spirituality, educational level, and immigration status. The purpose of social transition is to assist the individual in integrating these identities and live authentically.
There are many aspects of social transition, including changing one’s name and/or pronouns, using different restrooms, and living in a gender role or expressing gender that differs from their assigned gender at birth. In counseling, mental health providers will help support clients to increase their awareness of their gender identity through exploration of their gender expression, how they want others to know about their gender identity, and how they want to be addressed.
Furthermore, navigating restrooms and other sex-segregated spaces in a safe manner and their emotional/physical impact on the client may be explored.
Relational Aspects
Mental health providers will support trans clients and their loved ones in understanding gender dysphoria and the associated emotions and reactions to the transition process as well as coming to terms with the individual’s gender identity.22 It is common for parents/caregivers, family members, and peers to experience a wide range of emotions and may go through a grief process when they first learn about their child coming out as transgender or LGBTQ+.
Feelings like sadness, shock, anger, and worry are all natural to experience. Even though it is challenging, loved ones can utilize counseling as a space to explore these emotions and increase awareness of how they can be supportive of the individual with gender dysphoria.
Legal Aspects
A person may decide to legally transition as part of their gender-affirming care. Mental health providers will support the individual in obtaining necessary legal documents to change their name and gender marker (i.e., change the gender on their identification, passport, and/or birth certificate).
The necessary documentation and paperwork may change from state to state and counselors will educate clients and their loved ones on how to navigate the legal process as well as explore its emotional impact.
Educational and Vocational Aspects
Several challenges exist for trans people in their educational and workplace settings. Mental health providers will explore client’s goals, concerns, and feelings regarding their educational and vocational pursuits.
Gender dysphoria may be a significant barrier to academic performance for some trans students.18,9,6 Therefore, counseling may coordinate with professionals across disciplines like school principals, teachers, and other medical providers in support of the student’s educational success.
Medical Aspects
As previously mentioned, medical transition may not be a primary objective for clients who are seeking care for gender dysphoria.19,7 With that being said, mental health providers working with trans individuals and their loved ones may assist those who are seeking guidance on medical transition.
The World Professional Association for Transgender Health Standards of Care (WPATH SOC)16 is typically utilized by mental health providers as a guide for treating gender dysphoria. The SOC are commonly adhered to by healthcare providers and insurance companies for those seeking gender-affirming medical interventions.
Typically, mental health providers play an evaluative role in a trans client’s medical transition process and will inform the client of the different options, benefits, and potential risks/challenges associated with medical transition.18 Below are the two branches of medical transition: Hormone therapy and gender-affirming surgeries.
Hormone Therapy
Transgender individuals may pursue hormone therapy to suppress their endogenous hormones and develop secondary sex characteristics different from those associated with their designated sex at birth. People assigned female at birth may be prescribed testosterone to advance toward a more masculine or non-binary presentation, and people assigned male at birth may be perscribed estrogen and testosterone-blocking hormones to advance toward a more feminine or non-binary presentation.
Research has shown that in addition to the positive physical effects of masculinizing and feminizing hormone therapy for trans people, there is also a significant increase in emotional well-being.18,19
Gender-Affirming Surgery
Mental health providers working with clients pursuing gender-affirming surgeries will support the client in familiarizing themselves with their options, as well as the financial demands and recovery process from surgery. Trans individuals who desire gender-affirming surgical interventions may elect for some surgeries over others. These interventions differ based on the needs and desires of that individual.19,16
Surgical interventions for trans feminine individuals include facial feminization surgeries, vocal cord surgery, chest reconstructive surgery, and genital reconstructive surgeries – such as orchiectomy and vaginoplasty. Surgical interventions for trans masculine individuals include chest reconstructive surgeries, hysterectomy and oophorectomy, and genital reconstructive surgeries such as metoidioplasty and phalloplasty.18
Chest reconstructive surgeries are sometimes referred to as top surgeries, whereas genital reconstructive surgeries are sometimes referred to as bottom surgeries. Other gender-affirming medical procedures include hair removal or implants and vocal training.19
This is just a brief overview of gender-affirming surgical procedures for trans people. It is important to note that gender nonconforming people who may not necessarily identify as transgender but who also experience gender dysphoria may seek these surgeries.
Mental health providers supporting individuals who experience gender dysphoria and are interested in gender-affirming medical care will discuss several pertinent topics associated with these interventions, including expectations, emotional preparation, coping and relaxation skills, financial planning and concerns, medical stability, substance use, and recovery process.
How to Get Help for Your Child with Gender Dysphoria
If you are a parent or caregiver, it may be overwhelming to first learn about gender dysphoria, especially if gender and sexuality were not common topics discussed in your family upbringing. There are some helpful strategies to begin the dialogue process with your child and loved ones.
First, it is important to remember that it is also overwhelming for the person who experiences gender dysphoria; they may already be experiencing several negative emotions like shame, fear, worry, and guilt. The first step to seeking support, especially if you are a parent of a child who may present with gender dysphoria, is to talk with your child.
It is helpful to set aside any judgements or negative feelings you may have about trans people and/or gender dysphoria, as youth who hear and/or observe negative messaging surrounding their gender may result in further internalized shame, guilt, or suicidality.6,20
When initiating the conversation, it is okay to let your child know about the behaviors you have been observing. Reassure your child that you want to support them in the best way possible. You can expect your child may resist or deny when this topic is brought up, so it is important to remember to do your part in keeping the lines of communication open.
Equally important, if your child opens up to you, it is best to remain calm and listen to your child’s emotions and needs. Check in with how you can support them at this time. And remember, there is no rush or timeline for this process as this may still be very new to you and your child.
The next step is to set up an appointment for your child to be evaluated by your pediatrician or psychiatrist who specializes in working with trans individuals and treating gender dysphoria. The remaining step is to pursue mental health counseling. Treatment of gender dysphoria requires a multidisciplinary approach.21
When searching for a mental health provider, you can ask what their knowledge of the World Health Association for Transgender Health Standards of Care is and how they integrate them into their clinical work. Your family doctor may also be able to help you find a mental health provider who understands the unique needs of individuals struggling with gender identity issues.
The aforementioned guidelines are also helpful for transgender adults who would like to broach discussions on their gender identity with loved ones.
How to Support Your Loved One with Gender Dysphoria
Family acceptance and support of trans people, particularly youth, are associated with higher quality of life, lower depressive symptoms, and reduced psychological distress associated with transgender identity and, as a result, decreased suicidality.22,8
The goal in mental health counseling is to support the trans client and their loved ones move toward a place of acceptance and support of their identity. Loved ones can also show their support by educating themselves on gender identity terms and experiences of transgender people.
If you make a mistake with the chosen name and pronouns your transgender loved one goes by, that is okay. Simply correct yourself and move on. Avoid getting lost in your explanations.
On a different note, trying to change the individual’s gender identity—either by denial, punishment, reparative therapy or any other strategy—is ineffective and dangerous. Multiple organizations, including the American Psychological Association, the American Medical Association, the American Psychiatric Association, and the World Professional Association for Transgender Health, plus many others, have deemed reparative and conversion therapies as psychologically harmful.
Individuals who are out and/or have transitioned and living openly as their affirmed identity are often significantly happier than before coming out.4 If that is the case with your family member, it’s worth pointing out to others that they feel happier because of this support.
All things considered, remember your transgender family member is still the same person. Only now, they are living the truth they have felt they needed to hide. The more knowledge and understanding you have of their identity will support you in supporting them. Below are additional resources to understand these different topics.
Living with Gender Dysphoria: Coping & Managing Symptoms
Anyone who experiences gender dysphoria may find these tips helpful to cope and take care of themselves:
Seek Support
Making sense of your identity and experiences is a challenging road to walk alone. Consider the many avenues to seek support including individual therapy, family therapy, and group support. If you experience suicidal thoughts, call the National Suicide Prevention Hotline, available 24/7 for support: 1-800-273-8255
Utilize Coping Skills to Decrease Intensity of Emotions
Stress and anxiety are normal emotions to experience in life. These emotions help motivate us to solve problems and achieve the goals we have set for ourselves. However, when anxiety and stress become excessive, they leave us feeling discouraged, demoralized, and disrupts us from living the life we want to live.
Coping skills like exercise, disconnecting from social media, getting creative, practicing gratitude, deep-breathing, and practicing self-care are all important strategies to maintain wellness while living gender dysphoria
Recognize and Allow Your Emotions Without Judgement
It may be challenging to be non-judgemental towards oneself for many reasons. Practicing mindfulness (recognizing without overly identifying) and compassion (allowing with lovingkindness) toward your feelings will help decrease their intensity and suffering associated with them. “Never underestimate the power of a queer [trans] person who loves themselves” – Uknown
Pivot to Action
Feeling out of control is one experience that may intensify for a person experiencing gender dysphoria. This can lead to further negative emotions. The Trevor Project lists several skills to support LGBTQ+ individuals. For example, one way to decrease feelings of out of control is to engage in action. This can look like activism, helping someone else, volunteering, and/or donating money/time to organizations that are important to you.
For Further Reading
There are several organizations that provide information and access to support for gender dysphoria and trans individuals.
Organizations:
- Human Rights Campaign
- It Gets Better
- The Trevor Project
- GLAAD
- PFLAG
- Gender Spectrum
- National Center for Transgender Equality
- The Brown Boi Project
- The Transgender Law Center
Books & Workbooks:
- Singh, A. A. (2018). The queer and transgender resilience workbook: Skills for navigating sexual orientation and gender expression. New Harbinger Publications.
- Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring gender identity. New Harbinger Publications.
- Lev, A. I., & Gottlieb, A. R. (Eds.). (2019). Families in Transition: Parenting Gender Diverse Children, Adolescents, and Young Adults. Columbia University Press.
Resources for Further Learning:
Gender Dysphoria Infographics
