Gender Dysphoria: Diagnosis and Treatment

Gender dysphoria (GD) is characterized by an incongruence of a person’s assigned sex, meaning the sex determined by a doctor at the time of that person’s birth, and their internal sense of their own gender. People with GD may experience extreme distress or discomfort in their bodies due to a mismatch between their natal sex and gender identity. Although cases of Gender Dysphoria are reported to be quite rare, there appear to be growing rates due to increased transgender visibility made possible by social change, legal protections and anti-discriminatory laws, medical and technological advances, and access to mass communication, social media and gender affirming care.    

Gender Dysphoria Symptoms

Gender dysphoria is defined by consistent and persistent mental anguish experienced when a person’s sex determined at birth does not line up with their internal sense of gender or their lived/experienced gender. Here are some symptoms of gender dysphoria:

  • Desire to be rid of any main sex characteristics associated with the sex determined birth.
  • Need to be treated as the opposite or other gender.
  • Desire to have the secondary or primary sex characteristics of the affirmed gender or other gender.
  • Insistence on the incongruence of assigned gender and natal sex. 
  • Preference for opposite gender roles.
  • Strong and persistent rejection of games, toys, and any other things associated with the gender determined at birth.
  • Wearing clothing that is associated with the opposite or other gender

Distinction Between Gender Identity and Gender Dysphoria

Gender Dysphoria is a psychiatric diagnosis, whereas gender identity is a person’s internal sense of their gender and how they move through the world.

Transgender and nonbinary persons have gender identities that, typically, do not align with the social construction of gender stereotypes and expectations. While natal sex is based on the biological and chromosomal make-up of a human, a person’s gender identity is based on a person’s personal sense of self with respect to their gender. Although many transgender and nonbinary individuals experience dysphoria, they may not experience all the symptoms related to gender dysphoria.

Being trans is a gender identity, while gender dysphoria is a psychiatric diagnosis that may require mental health services and treatment. Gender Dysphoria can certainly take a heavy toll on a person’s mental health and wellbeing, which is why it is necessary to address it properly.

Types of Treatment Approaches

Nonbinary, Transgender and Gender Non-Conforming (TGNC) people can have psychiatric symptoms of eating disorders, anxiety, and mood disorders just like any other part of the population. When a person seeks counseling for gender dysphoria, a careful assessment is made to either rule out other diagnoses or determine if there are any co-existing ones.

A trained therapist and their client will piece together treatment goals and objectives to help mitigate symptoms, thus raising the client’s quality of life and sense of livelihood. Providers are trained to do exactly that at the end of the day. The moment a client walks through the therapist’s office, the therapist has begun to work on building mutual trust. Once honesty and trust are established, affirming therapy begins!

Wait and See Approach

Watchful waiting is a method that is often used for children and young adults experiencing gender dysphoria. This often involves delaying transition despite the negative impact this can have on trans individuals. Trans kids and young adults may have to stay on waiting lists for long periods of time, thus placing them at risk of increased gender dysphoria, anxiety, depression, and suicidality. It can make it harder to assert their gender and be taken seriously about transitioning socially at home, school and the community. “Wait and See” can be used constructively if the client and family prefer this and the child is considered to be safe and well-supported.  According to the WPATH, “Gender identity is common to all human beings, is developed in early childhood, and is thought to be firmly established in most people—transgender or not—by age 4, 1 though for some transgender individuals, gender identity may remain somewhat fluid for many years, 2 while for others, conditions specific to individual lives may constrain a person from acknowledging or even recognizing any gender dysphoria they may experience until they reach adulthood”

Gender Affirming Therapy

The therapist does not hold any prior beliefs or biases about gender identity outcomes. Best practice involves a process of initial and ongoing assessment, focusing on treating symptoms, and creating a treatment plan that involves addressing presenting problems and underlying issues. Affirming therapy is the belief that a client has the right to explore their identity as they would any other identity or life-phase transition, such as parenthood, sexual identity, professional identity, etc. The role of the therapist is to create a judgment-free zone and safe space where this can happen, and to guide and support clients through a process of self-determination.

Like any other person seeking mental health services, the therapist and client can decide together whether the client might benefit from a referral to services in the community, which may or may not involve medical and psychiatric consultation for additional interventions.

Not all clients, trans or non-trans, require these types of referrals. The therapist’s job is not to assume the goal outcome of the client, including a direct pathway to medical transition. This process takes careful consideration and assessment of any preexisting factors that may take precedence before other options can be explored together with the client. After all, the client is entrusting their care to a professional who is required to follow certain guidelines/rules, code of ethics and best practices. 

Social Transition

Social transition involves coming out to friends and family, exploring changes in a person’s appearance (i.e., clothing articles, accessories, hair, shaving, etc), voice training, using a different name and pronouns, or using gender-neutral language when referring to self in social interactions, pursuing legal name and/or gender marker change, and any other physical changes that do not involve medical intervention.

Medical Transition

Some medical treatments can help people feel true in their bodies according to the gender they relate to:

  • Puberty Blockers put a pause on puberty in children so they can further explore their gender identity. The effects of puberty blockers are reversible.
  • Hormone Replacement Therapy (HRT) can help manage secondary sex characteristics like facial hair and breasts, while hormone therapy can maximize masculinization or feminization.
  • Gender Confirmation Surgery can include masculinizing or feminizing surgical procedures to change secondary sex characteristics such as a person’s chest, facial features, body contour, external sex organs, and internal sex organs. Adults seeking gender confirmation surgery must have been treated for at least one year with hormone replacement therapy.

 **Children are not considered candidates for surgery.

The World Professional Association for Transgender Health offers these criteria for surgical and hormonal treatments for gender dysphoria:

  • Well-documented, persistent gender dysphoria to justify medical necessity
  • Fully informed consent and the decision on the treatment
  • Legal age according to local requirements
  • Mental or medical concerns can be reasonably controlled

Evaluation for this treatment can include:

  • Family and personal medical history
  • Physical exam
  • Assessment for sex- and age-appropriate screenings
  • Lab tests
  • Management and identification of drug, tobacco, and alcohol misuse
  • Tests for sexually transmitted infections like HIV combined with treatment if needed
  • Assessments for fertility referral or preservation if needed for egg, sperm, ovarian tissue, or embryo

Additional Therapies

There are many other types of evidenced-based therapeutic models that can be used as an add-on to gender affirming therapy. These types of therapies can help enhance a person’s relationship with them self, others, and the world. Some to name a few are ACT, Accountability Compassion Therapy, CBT, Cognitive Behavioral Therapy, DBT, Dialectical Behavior Therapy, and Mindfulness Therapy. These therapies help raise a person’s capacity to regulate their emotions, edit their thoughts, improve communication and interpersonal skills that can help clients navigate and come to terms with their gender identity.

In Conclusion

Gender dysphoria is a very real problem that many people face across the globe. It can take a heavy psychological toll on a person, which is why it is necessary to seek professional help.

Angelina Valentin, LCSW-R

Angelina offers counselling services and has worked with clients from all sorts of backgrounds, welcoming clients of all genders, race, sexuality, and more. Angelina runs the Q Therapy podcast which you can also find on YouTube.