Gender Dysphoria

What Causes Gender Dysphoria?

Scientists don’t know what causes gender dysphoria in some people and not others. Biological or genetic predispositions may likely put some people at increased risk for the discomfort that defines the condition. However, external factors undoubtedly play a significant role. Gender-diverse people are subjected to discrimination, social stigma, and threats of violence. These factors are likely to create or exacerbate anxieties and fears related to a person’s gender identity.

Is Gender Dysphoria Hereditary?

Some scientists suspect there is a genetic component to gender dysphoria, but no studies have yet found a definite link between the condition and any gene or genes.

How Is Gender Dysphoria Detected?

The Diagnostic and Statistical Manual (DSM), the manual used by mental health professionals as a diagnostic guide, allows the diagnosis of gender dysphoria in children who express a strong desire to be perceived as a different gender than the one they were assigned at birth, along with five of the following symptoms: 

• Preference for the clothes traditionally associated with a different gender
• Desire to play the role of a different gender during imaginative play
• Preference for the toys and activities traditionally associated with a different gender
• Desire to play with children of a different gender
• Discomfort with the sex-related characteristic of their body
• Desire to have the physical sex-related characteristics of a different gender

These symptoms must be expressed for at least six months.

How Is Gender Dysphoria Diagnosed?

Diagnosis of gender dysphoria begins with determining that a person has a cluster of symptoms that meet the diagnostic criteria for the disorder. The results of a health care professional’s psychological assessments are compared to the diagnostic criteria for gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for gender dysphoria in adolescents and adults include:

• The person feels a strong mismatch between their gender identity and the gender they were assigned at birth.
• The person has a strong desire to change their physical sex-related characteristics to match their gender identity.
• The person has a strong desire to have the sex-related characteristics of a different gender.
• The person has a strong desire to express a different gender identity than the one they were assigned at birth.
• The person wants to be treated as a different gender.
• The person believes they have the feelings and reactions typical of a different gender.

At least two of these symptoms must be present for at least six months for a diagnosis to be possible.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Gender Dysphoria Treated?

The recommended treatment for gender dysphoria is taking steps to affirm the gender that matches the person’s gender identity. This may involve changes to allow the person to behave and be perceived as the appropriate gender, as well as medical treatments that help support the affirmation of that gender.

Gender Expression

Steps that can help you explore the social and behavioral aspects of gender expression include:

• Changing your name
• Changing the pronouns people use to refer to you
• Changing the gender designation on official IDs
• Wearing clothing that matches your gender identity
• Making personal appearance changes (e.g., removing facial hair, wearing makeup)

Medical Treatments and Therapies

Medical, surgical, and therapeutic interventions sometimes used to treat gender dysphoria may include:

• Hormone therapy. The administration of masculine hormones (testosterone) or feminine hormones (estrogen and progesterone) can help develop some secondary sex characteristics of the appropriate gender.
• Gender-affirming surgery. These surgical procedures can help create the primary (genitalia) and secondary (breasts) sex characteristics of the appropriate gender.
• Cosmetic surgery. Cosmetic surgical procedures can help produce facial features more consistent with the appropriate gender.
• Voice and speech therapy
• Psychotherapy to address any co-existing mental health-related issues (e.g., depression or anxiety)

How Does Gender Dysphoria Progress?

Gender dysphoria is not directly a mental health issue. However, the resulting discomfort it can cause, along with the stigmatization experienced by anyone who doesn’t conform to traditional gender norms, puts a person with gender dysphoria at risk of significant complications. Serious long-term impacts of untreated gender dysphoria can include:

• Discrimination
• Harassment
• Bullying
• Assault and other violence
• Social isolation 
• Depression
• Anxiety
• Substance abuse
• Eating disorders
• Suicide or suicide attempts

How Is Gender Dysphoria Prevented?

There is no known way to prevent gender dysphoria. However, seeking help from health care professionals may lead a person toward gender-affirming interventions that can prevent or lessen the harmful consequences of the problem.

Gender Dysphoria Caregiver Tips

Many people with gender dysphoria also suffer from other mental health-related issues, a situation called co-morbidity. Here are a few of the disorders commonly associated with gender dysphoria:

• Many people with gender dysphoria also suffer from depression.
• Anxiety disorders are often co-morbid with gender dysphoria.
• Eating disorders such as bulimia or anorexia are common in people with gender dysphoria.
• People with gender dysphoria are at significantly increased risk of suicide.

Gender Dysphoria Brain Science

For decades (or even centuries), scientists have explored the possibility that sex and gender differences exist in the structure and function of the brain. The idea that men’s and women’s brains are somehow different from one another has persisted, but scientific evidence has failed to back up that assumption. Recent studies have shown little difference between brains of different sexes or genders, and slight variations are more accurately attributed to factors other than sex.

Some studies have concluded that certain areas of the brain vary in size depending on a person’s sex, and some scientists suggest that these differences are due to the action of sex hormones during brain development. However, other studies have concluded that structural differences between brains are correlated with overall body size, not sex.

Although some scientists continue to pursue the idea that men’s and women’s brains work differently, scientific evidence showing differences in male and female brain activity, consistent across cultures, has been scarce.

Gender Dysphoria Research

Title: Transgender Therapeutic Support Groups

Stage: Not Yet Recruiting

Principal investigator: Rachel Narr, PhD

Denver Health and Hospital Authority

Denver, CO 

Currently, in the scientific literature, there are no known studies of the effectiveness of therapeutic support groups for supporting mental and physical health in transgender or gender nonconforming (TGNC)-identified individuals undergoing gender-affirming surgical interventions. Gender affirmation surgeries have been shown to decrease anxiety and depression and increase well-being for TGNC individuals compared to the well-being of TGNC individuals who do not access surgery. Despite this, surgery is inherently stressful for people undergoing it, and many medical and psychological complications may be faced by people undergoing these surgeries.

Denver Health has greatly expanded gender-affirming interventions in the past three years due to the creation of the Center of Excellence; however, mental health services are still catching up. While support from other TGNC individuals has proven effective in reducing anxiety and depression, community support groups are starting to be offered regularly to support TGNC individuals. Surgical support groups do not appear to be largely offered. However, a high proportion of TGNC individuals desire post-surgical support around surgery results (84.6% in a sample of 415 people), and over 90% of people favor peer support around medical interventions. In other areas, specifically bariatric surgery, peer therapeutic support groups have been found to help with continued post-operative weight loss and mental health, likely due to the additional opportunities for support and connection with others undergoing similar things, group provision of ideas, and additional therapeutic support. While individual therapy is, and should continue to be, offered for this population, the addition of a group attended by individuals going through similar situations is likely to be helpful, above and beyond individual therapy, due to the provision of peer support, as well as the opportunity for participants to offer support to their peers. Seeing oneself as a help provider, rather than simply a help recipient (helper-therapy principle), has been demonstrated to have a powerful impact on the helper’s well-being across a host of medical and psychological situations.

Currently, therapeutic support groups are being developed to offer TGNC patients at Denver Health who are undergoing gender-affirming surgeries. Investigators will systematically collect data on well-being and mental health, as well as the mediating effect of feelings of cohesion on well-being, as well as the number of emergency department visits for participants in the groups as compared to the average number of emergency department visits across all TGNC patients in the Denver Health system for patients involved in these groups. Based on the deficit of groups of this nature and information on the helpfulness of therapeutic support groups for people undergoing gender-affirming surgeries, the investigators expect this may be the first study on this topic. The study hypothesis is that participants in pre- and post-surgical support groups will experience increased well-being and mental health over a six-month period, and these increases will be mediated by group cohesion. Investigators also expect attendance at these groups will lead to lower utilization of emergency services due to decreased anxiety and distress.

Title: Skeletal Health and Bone Marrow Composition Among Youth

Stage: Recruiting

Principal investigator: Catherine M. Gordon, MD, MSc

Boston Children’s Hospital

Boston, MA 

Children and adolescents experiencing gender dysphoria feel increased distress with the onset of puberty. Gender clinics treat these young adolescents by “blocking” puberty using gonadotropin-releasing hormone (GnRH) agonist medications. This has the possibility of impacting bone development as sex steroids are important to bone mass development. In this multi-site study, the investigators will examine bone marrow composition (by MRI) in 40 transgender youth and bone density and body composition before/after pubertal blockade compared to healthy participants.

The investigators propose to identify the effects of pubertal blockade on bone density and size in pediatric transgender individuals. Information is limited regarding bone health and metabolism for this group, especially for children who are transgender. Further, the team’s expertise in magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS), dual-energy x-ray absorptiometry (DXA), and peripheral quantitative computed tomography (pQCT), examining the natal female skeleton in previous NIH-funded studies, and extensive clinical expertise, provides an ideal foundation to apply this protocol to examine transgender female and transgender male skeleton. Findings from this study will allow us to identify potential preventative strategies to counter the long-term effects of puberty blockade, such as osteoporosis, and raise awareness of this medical consequence among medical care providers of transgender patients. The proposed project seeks to answer the clinically relevant question of how bone marrow composition relates to body composition, and its relation to both bone density and skeletal strength, in transgender patients who are undergoing puberty blockade, the first phase of therapy preceding gender-affirming hormone therapy.

Title: Development of Effective, Opioid Sparing Techniques for Peri-operative Pain Management of Transgender Patients Undergoing Gender Affirming Surgeries

Stage: Recruiting

Principal investigator: Maurice M. Garcia, MD, MAS

Cedars-Sinai Medical Center

Los Angeles, CA 

This study will compare the current standard-of-care pain treatment regimen options available to patients undergoing gender-affirming surgery. This research aims to determine if any of these options are more (versus less) effective than the others in managing post-surgery-related pain.