UNDERSTANDING GENDER DYSPHORIA

The DSM-5 defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated 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 (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-5 defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

  • A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
  • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
  • 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
  • In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
  • A strong dislike of one’s sexual anatomy
  • A strong desire for the physical sex characteristics that match one’s experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Truths about some common misconceptions of gender dysphoria:

  • Is there a general age that people realize they are transgender or experience gender dysphoria? Can it happen late in life?

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* 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.

  • How does hormone therapy affect a person’s emotional state? (From WPATH SOC)

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.

  • Can a person have gender dysphoria and not seek gender affirming treatments?

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.

Complications

Gender dysphoria can impair many aspects of life. Preoccupation with being of another gender than the one assigned often interferes with daily activities. People experiencing gender dysphoria might refuse to go to school, due to pressure to dress in a way that’s associated with their sex or out of fear of being harassed or teased. Gender dysphoria can also impair the ability to function at school or at work, resulting in school dropout or unemployment. Relationship difficulties are common. Anxiety, depression, self-harm, eating disorders, substance abuse and other problems can occur.

People who have gender dysphoria also often experience discrimination, resulting in minority stress. Access to health services and mental health services can be difficult, due to fear of stigma and a lack of experienced providers.

Adolescents and adults with gender dysphoria before gender reassignment might be at risk of suicidal ideation, suicide attempts and suicide. 

Ways to help people dealing with gender dysphoria:

  • IT’s NORMAL

If someone you know is experiencing it, you need to first understand yourself that not identifying as cis-gender is normal and you need to empathise with what they are going through.

  • Engage Compassionately and Validate Their Experience

The spectrum of emotions experienced with dysphoria can vary from time to time, person to person, or even episode to episode. Some days, the individuals might feel comfortable in their skin; other days, it can be intolerable. Keeping all of this in mind, it’s essential to validate that person’s experience.“Is it really that bad?” is never an okay response. “Why can’t you leave your apartment?” is not an okay response either. And “Get over it, we all have insecurities” is absolutely, 100% an awful response.

All of these responses trivialize this person’s pain and suggest that what they are feeling isn’t worth caring about. “I’m sorry this is happening” or “That sounds really awful” are responses that acknowledge this person’s pain – and moreover, validate that it is real and important.

  • Ask How You Can Help

It’s always best to ask- what they need when they’re experiencing dysphoria. It’s as simple as saying, “How can I help right now?

  • If Needed, Encourage Them to Seek Help

Dysphoria is a beast – and sometimes that beast can take more than just willpower to tame.

If your loved one is engaging in harmful or unhealthy coping behaviors, or is grappling with suicidal ideation, it’s time to seek outside help.

A trans-competent therapist, for example, can be an important safety net for a trans person coping with dysphoria; a local support group at an LGBTQIA+ community center can also be a great resource.

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