The word “gender” was derived from the Old French word “gendre” (now “genre”), which signified “kind, sort, genus.” Based on their chromosomes and morphology, infants are often assigned a gender at birth. For the majority of children, this gender assignment aligns with their gender identity, which is an inborn sense of being either male or female. However, some children may grow up to be transgender adults due to incongruence.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) defines gender dysphoria (GD) as a “marked incongruence between the experienced or expressed gender and the one they were assigned at birth.” This condition was previously known as “gender identity disorder.”
Cultural stigmatization can arise when children or teenagers experience this internal conflict, being unable to match their gender expression to the established societal binary male or female roles. This often results in relationship problems with friends, family, and peers in many areas of their everyday lives. It can also lead to social rejection, interpersonal conflicts, symptoms of anxiety and depression, substance use disorders, a poor sense of well-being, low self-esteem, and a higher risk of self-harm and suicidality.
In order to view gender expression as a continuum from male to female rather than rigid binary standards, greater awareness needs to be raised. This may lessen the mental health issues caused by stigma and help society better understand individuals dealing with gender dysphoria.
Sexual Orientation vs. Gender Identity
Sexual orientation and gender are distinct concepts. Even if a transgender man (biological female) identifies as heterosexual, he may still find women attractive, and vice versa.
The Cause of Gender Dysphoria
Although the exact cause of gender dysphoria (GD) remains unclear, it is believed to arise from a complex biopsychosocial connection.
People with congenital adrenal hyperplasia or androgen insensitivity syndrome, despite frequently cross-dressing and experiencing an innate sense of belonging to the other sex, are typically raised and socialized as girls. These tendencies become more noticeable during puberty, and this is one known biological connection.
There is evidence suggesting that individuals with conditions like schizophrenia and autism spectrum disorder are more likely to develop GD. However, this connection may be neuroanatomical, and further research is needed to clarify the link. Some studies aim to refute this theory.
Additionally, there is increasing evidence linking GD to maltreatment, neglect, and physical or sexual abuse during childhood. These factors contribute to poorer mental health outcomes, increased body dissatisfaction, substance abuse, depression, and suicidal thoughts.
Pathophysiology of Gender Dysphoria
Biological Factors
Gender dysphoria (GD) may become more accepted across social and medical fields if the biological and hereditary components of GD are better understood. Although several theoretical postulates have been proposed, the subject remains poorly understood. In the 1970s, the idea that GD was a purely learned environmental condition gained traction, with strategies such as conversion therapy used to correct “feminine” traits in young boys. However, these approaches did not address the complexity of gender identity.
It is now widely accepted that gender exists on a continuum that includes both “cis-gender” and “transgender” categories, rather than being confined to a binary system. Several heritability studies involving twins and families have shown that GD is polygenetic. However, no specific genes linked to GD have yet been identified through molecular genetic research.
Psychosocial Factors
The way children’s temperaments interact with their parents’ traits and their dynamic relationship may influence how gender is developed during childhood. According to cultural standards, young females are expected to be nurturing, warm, and sensitive, while young boys are not expected to exhibit effeminate behaviors. While there may be differences, children typically begin identifying with a gender between the ages of three and five. Children with GD are often observed engaging in cross-gender activities, and over the past few decades, this incongruence has become more noticeable. Sigmund Freud, a renowned psychotherapist, argued that gender dysphoria in infants is caused by conflicts within the oedipal triangle.
Symptoms of Gender Dysphoria
Gender Dysphoria in Children
A marked incongruence between one’s experienced/expressed gender and the assigned gender, lasting for at least six months, is 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 due to incongruence with their 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).
The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify:
- Whether a disorder of sexual development exists (e.g., a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome).
- Post-transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen, such as regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in natal males; mastectomy or phalloplasty in natal females).
Treatment for Gender Dysphoria
Treatment for gender dysphoria is highly individualized and depends on the unique needs of each patient. It often focuses on assisting the person in exploring and expressing their gender identity in a way that aligns with their internal sense of gender. This may involve adopting alternative names and pronouns, wearing clothing that aligns with their gender identification, or undergoing surgical procedures to physically alter their body.
Age is an important factor in determining treatment. As Sadock et al. recommend:
- Children should be allowed to explore and receive guidance on gender preference through individual, family, and group therapy.
- Teenagers, especially with the added concerns of puberty, may benefit from a combination of hormonal therapy and psychotherapy.
- Adults may explore psychotherapy, hormonal therapy, and surgery as treatment options.
