Gender dysphoria: definition
If you want to understand the term gender dysphoria, you first need to know what gender incongruence is:
In short: some people who were born with a penis still feel like a girl/woman and not a boy/man. Conversely, some people with breasts and a vagina feel male instead of female. Or those affected do not identify clearly with either the male or female sex (non-binary).
Others, however, suffer from gender incongruence – experts refer to this as gender dysphoria.
Persistent suffering
In concrete terms, this means that gender dysphoria is present if someone suffers from it persistently:
- not feeling that they (only) belong to the gender that corresponds to their own physical sex characteristics, and/or
- being perceived by others as a man/woman, even though this does not correspond to their own gender identity.
It is therefore important that people with gender dysphoria receive the right help and support. This can take the form of psychotherapy, for example, and possibly also medical measures to adapt the body to one’s own gender identity (see Treatment).
Keyword Trans
You can read more about transsexuality on our partner portal Mylife.de.
Keyword Inter*
The term inter* (intersex, intersexuality) refers to people with variations in physical gender development: Their body has both male and female characteristics (sex chromosomes, sex hormones, sex organs).
Find out more about intersexuality on our partner portal Mylife.de.
Trans is no longer considered a mental disorder
Whether a condition is classified as sick or normal also depends on the zeitgeist. This is reflected in the International Classification of Diseases and Related Health Problems (ICD), which is published by the World Health Organization (WHO).
Its predecessor, the ICD-10, still uses the term transsexualism. It assigns it as a “gender identity disorder” to the chapter on mental disorders – more precisely, to personality and behavioral disorders. This form of identity is therefore classified as pathological.
This has changed with the ICD-11:
- On the one hand, the term “gender incongruence” is used instead of “transsexualism”.
The WHO member states currently have a flexible transition period of at least five years to prepare for the introduction of the revised classification system.
It is not yet clear when the ICD-11 will finally replace the ICD-10 in the individual countries. This depends, among other things, on how quickly an official translation into the respective national language is available. In Germany, Austria and Switzerland, too, the ICD-10 is currently still used for billing.
How those affected perceive the discrepancy between their biological sex and their gender identity in individual cases varies. For example, the following “signs” are possible:
- a deep sense of being a man or a woman on the outside, but not feeling like one at all
- Rejection of one’s own body and a strong desire to get rid of sexual characteristics (such as penis, Adam’s apple, breasts, vulva, vagina) that are perceived as inappropriate
- the strong desire to be viewed and treated by the environment in a way that corresponds to one’s own gender identity (e.g. as a man, as a woman or as a non-binary person)
For doctors to be able to diagnose gender dysphoria, these feelings must persist for a long time (see diagnosis) and be associated with considerable distress.
Accompanying mental disorders
Some people with gender incongruence/gender dysphoria also suffer from psychological problems or disorders. Studies show that these occur more frequently in them than in the general population. These mental disorders include
- depression
- Suicidal thoughts and actions
- anxiety disorders
- Personality disorders
- Dissociative disorders
- Eating disorders
- Substance abuse (e.g. drug or medication abuse)
Sometimes a mental illness is also an initially successful (unconscious) way of coping with gender dysphoria. For example, anorexia in adolescents can be an attempt to stop the body from developing in the direction of the unwanted sex (beard growth, onset of menstruation, etc.).
Gender dysphoria: causes
It is not yet known why some people develop gender dysphoria – either as early as childhood or later. Experts assume that various factors are involved.
It now seems most likely that gender identity is formed before birth. Genetic factors and/or hormonal influences during development are conceivable.
None of these factors alone can cause gender dysphoria. Experts believe that the discrepancy between perceived and assigned gender only develops in some people as a result of the interaction between them.
When symptoms of gender dysphoria suddenly develop during puberty, experts speak of “rapid-onset gender dysphoria”. The causes of this rapid-onset gender dysphoria are also unknown.
Gender dysphoria: diagnosis
Those affected can therefore only find out for themselves whether they feel they belong to a different gender or neither gender, regardless of their own biology – and how much this affects them and what personal consequences this has.
Experienced doctors and therapists can support those affected in this process with openness and respect.
A holistic view of those affected
- Important developmental steps before, during and possibly after puberty
- Previous body and relationship experiences
- Coming out experiences, reactions in the social environment (e.g. family, circle of friends)
- Possible experiences of discrimination based on gender identity
- Living situation, i.e. housing situation, school or professional situation, partnership, etc.
- Biographical data (especially stressful life events, family relationships)
- any previous illnesses
- Possible indications of variants in physical sexual development
- Mental state (using standardized methods)
Doctors or therapists also try to determine whether the gender incongruence/gender dysphoria has been constant for several months, is temporary or intermittent. This is also possible.
Orientation towards DSM-5
Doctors / therapists can use the DSM-5 as a guide when diagnosing gender dysphoria. This is the fifth (and currently valid) edition of the Diagnostic and Statistical Manual of Mental Disorders (according to ICD-10, which is currently still widely used, transsexualism is still classified as a mental disorder, but no longer in the new ICD-11 version).
According to this, the diagnosis of gender dysphoria in adolescents and adults is based on two points:
- Pronounced discrepancy between the perceived gender and the primary sexual characteristics such as ovaries, penis and/or secondary sexual characteristics such as breasts, beard (in adolescents: the expected secondary sexual characteristics)
- pronounced desire to get rid of one’s own primary and/or secondary sexual characteristics (in adolescents: to prevent the development of secondary sexual characteristics)
- pronounced desire to belong to the opposite sex (male/female) or an alternative sex
- Pronounced conviction to exhibit the typical feelings and reactions of the opposite sex (male/female) or an alternative sex
2. clinically relevant suffering or impairments in social, educational or other important areas of functioning
What happens next?
Important points are for example:
- Should the unwanted pubertal development of an adolescent be stopped with medication (puberty blockers)?
- Is gender reassignment desired? If so, with which measures and in which order (e.g. mastectomy, testicular removal)?
- Is psychotherapy useful (e.g. to clarify such issues) or even necessary (e.g. for mental disorders)?
Gender dysphoria: treatment
The right support can be crucial in helping people with gender dysphoria to find their own way of dealing with the discrepancy between their biological and perceived gender. The best form of support depends on the individual case.
The first step is often to seek advice from a competent contact person, for example at a relevant counseling center. Psychotherapy can also be useful for gender dysphoria.
Counseling
You can find competent contacts on the subject of gender incongruence and gender dysphoria at trans* organizations and community-based advice centres.
As part of an informative consultation, you can, for example, find out about legal issues (such as changing your name) or generally about various treatment options for gender dysphoria (including their risks).
Counseling can also focus on psychological issues (intervention counseling) – for example, if someone is struggling with their assigned gender and is searching for their own gender identity. Empathetic counselors can also offer a sympathetic ear and support in difficult life situations (such as at school or in the family).
Psychotherapy
- cannot come to terms with the fact that their own body is the “wrong” gender (possibly associated with feelings of inferiority, guilt or shame)
- need support in developing their own identity
- need support in decision-making processes (e.g. with regard to gender reassignment)
- need support after gender reassignment (e.g. through hormone treatment)
- have problems in the family, partnership or with their own parental role
Psychotherapy is particularly indicated for accompanying psychological problems such as anxiety or depression.
Gender dysphoria is complex. The psychotherapist should therefore have as much experience as possible with the topic!
Puberty blockade in children and adolescents
Children and adolescents with gender dysphoria may be given so-called puberty blockers (such as leuprorelin).
These drugs postpone puberty. This gives adolescents time to become definitively clear about their gender identity and, if necessary, to make a final decision for or against gender reassignment (and in what form).
You can read more about this topic in our article on puberty blockers.
Body modification treatments aim to harmonize the body with the perceived gender (gender identity). This can be achieved through hormone treatments and/or surgery, for example. Other treatment measures (such as voice and speech training and various aids) can also support those affected in gender reassignment.
Hormone treatments
It is important that any hormone therapy is supervised by a doctor. Hormones influence many processes in the body and also entail risks. It is therefore not advisable to take hormones on your own (e.g. preparations from the internet)!
Speech therapy
Voice and speech training can make the voice of people with gender dysphoria appear more masculine or more feminine to those around them.
Decisive factors include voice frequency, speech patterns, timbre and speech melody. With special exercises carried out regularly, you can change your own voice so that it sounds more masculine or more feminine.
Masculinizing interventions and aids
Various interventions can make a body appear more masculine from a biological point of view. Those affected often feel more in harmony with their body afterwards, which can be a great psychological relief.
Alternatively or as an accompaniment, various aids can support gender reassignment. Below you will find a selection of masculinizing procedures and aids:
Compression vests or shirts: These so-called binders are a possible alternative to mastectomy. They can be used to visually flatten the breasts.
Such binders can also be worn to bridge the time before the mastectomy in order to at least visually reduce the unwanted breast size.
When wearing binders, care must be taken to ensure that the compression does not block the blood supply to the tissue or cause postural damage.
Surgeons can also use such access routes to remove the ovaries and fallopian tubes (adnectomy). Because these produce important sex hormones, you have to take hormones such as testosterone for the rest of your life. Otherwise there is a risk of health problems such as osteoporosis.
Penoid reconstruction is a very complex procedure. The most common complications include urethral strictures and fistulas. Get comprehensive information from experienced surgeons!
Penis-testicle epithesis: This is a penis imitation made of silicone that can be attached to the genital region with a medical adhesive. It looks and feels very similar to a real penis.
Wearing a penile-testicular epithesis is a possible alternative to surgical construction of a penis. It can also help those affected to decide for or against surgical penoid reconstruction.
The epithesis can also be helpful after such an operation: Anyone who has not (yet) had a corpora cavernosa prosthesis inserted can use it to give themselves a stiff penis for sexual intercourse.
Feminizing procedures and aids
Depilation (epilation): The male hair type (hard, chest hair, etc.) can be a major problem for trans women. Epilation can be used to get rid of unwanted hair. It may be necessary to repeat the treatment if the hair grows back (e.g. on the face).
Seek advice from a specialist (e.g. dermatologist) if you are unsure about the choice of epilation procedure.
Operation on the vocal apparatus: This can help if someone suffers greatly from the fact that their voice does not sound more feminine despite speech therapy. The procedure on the vocal folds makes the voice sound higher. Speech therapy can also be used to make the speech pattern more “feminine” afterwards.
Breast prostheses: They can also help you achieve the breasts you want, at least visually. The silicone breast implants are inserted into the bra or attached to the skin with a special adhesive.
Correction of the Adam’s apple: A prominent Adam’s apple appears masculine and can be very disturbing for people with gender dysphoria who experience themselves more as women. Whether the procedure makes sense or not does not depend on the size of the Adam’s apple, but on how distressing people with gender dysphoria find it.
For example, you can have your penis and testicles removed. Similar to oophorectomy, hormones must be taken for life after testicular removal (orchiectomy). This can compensate for the loss of hormone production.
A further possible surgical step in the process of adapting to the female sex is the creation of a vagina (neovagina). The clitoris and labia can also be surgically reshaped.
Gender reassignment – carefully considered
For many people with gender dysphoria, gender reassignment is the way out of years of suffering. This is shown by studies with data from a total of more than 2,000 trans people who had undergone hormone treatment and/or surgical procedures:
Nevertheless, interested parties should obtain comprehensive information on the topic in advance – from several competent sources if necessary:
- Which methods of gender reassignment are possible in my case?
- What results can I expect?
- How exactly does the hormone therapy / operation work?
- What side effects and risks can I expect?
- What costs are associated with the procedures? Does health insurance cover part of the costs?
