Sex, gender, and identity
Sex and gender are not the same thing, and they should be considered clinically as distinct characteristics. Terminology regarding sex and gender includes (1, 2)
Sex: Defined by the traits usually used to distinguish between males and females; sex refers especially to the physical and biologic traits that are physically evident at birth and is often captured in the phrases "assigned male at birth" (AMAB) and "assigned female at birth" (AFAB).
Gender identity: An internal sense of being male, female, or something else, which may or may not correspond to an individual's sex assigned at birth or sex characteristics.
Gender expression: Clothing, physical appearance and other external presentations and behaviors that express aspects of gender identity or role.
Gender incongruence: A person’s marked and persistent experience of an incompatibility between that person’s gender identity and the gender expected of them based on their birth-assigned sex.
Gender dysphoria: Discomfort or distress related to an incongruence between an individual's gender identity and the sex assigned at birth.
Cisgender: Used to describe an individual whose gender identity and gender expression align with the sex assigned at birth.
Transgender: An umbrella term encompassing those whose gender identities or gender roles differ from those typically associated with the sex they were assigned at birth.
Gender nonconforming: Describes an individual whose gender identity or gender expression differs from the gender norms associated with the sex they were assigned at birth.
Genderqueer: Describes an individual whose gender identity does not align with a binary understanding of gender, including those who think of themselves as both male and female, neither, moving between genders, a third gender, or outside of gender altogether. Some refer to themselves as nonbinary with respect to their gender identity and/or role.
Gender nonbinary: Includes people whose genders are comprised of more than one gender identity simultaneously or at different times (eg, bigender); who do not have a gender identity or have a neutral gender identity (eg, agender or neutrois); have gender identities that encompass or blend elements of other genders (eg, polygender, demiboy, demigirl); and/or who have a gender that changes over time (eg, genderfluid).
Gender binary: The classification of gender into 2 discrete categories of male and female (a paradigm of the past that did not allow for those who do not identify as male or female).
Transwomen: People who were assigned male at birth (AMAB) and have adopted a gender identity as a woman, regardless of whether they have undergone any medical gender transition.
Transmen: People who were assigned female at birth (AFAB) and have adopted a gender identity as a man, regardless of whether they have undergone any medical gender transition.
Eunuch: An individual assigned male at birth whose testicles have been surgically removed or rendered nonfunctional and who identifies as a eunuch. This differs from the standard medical definition by excluding those who do not identify as eunuch.
Trans-affirmative: Being aware, respectful, and supportive of the needs of transgender and gender-nonconforming individuals.
Sexual orientation: Pattern of emotional, romantic, and/or sexual attractions that people have toward others. It also refers to a person's sense of personal and social identity based on those attractions, related behaviors, and membership in a community of others with similar attractions and behaviors. Sexual identity is different from gender identity.
Transgender and gender diverse are the preferred terms to refer to people with gender identities that differ from the gender that is congruent with the sex they were assigned at birth. Transsexualism is an outdated term that is no longer used by experts in gender dysphoria.
Gender identities include traditional masculinity or femininity, with a growing cultural recognition that some people do not fit—nor necessarily wish to fit—into the traditional male-female dichotomy (gender binary). These people may refer to themselves as genderqueer, nonbinary, nonconforming, or one of many other terms that have become more commonly used. Moreover, definitions and categorizations of gender role may differ across societies. The term cisgender, which applies to the majority of people, is used to refer to people whose gender identity corresponds to their sex assigned at birth.
Many cultures are more tolerant of gender-nonconforming behaviors in young girls (eg, doing activities or wearing clothing that are more typical for boys) than effeminate behaviors in boys. As part of normal development, many boys role-play as girls or mothers, including trying on their sister’s or mother’s clothes or engaging in stereotypical behaviors or expressing interests associated with girls in a given society. Gender incongruence (behavior that significantly differs from cultural norms for a person's birth sex) in children is generally not considered a disorder and usually does not persist into adulthood or lead to gender dysphoria, although persistently gender-incongruent young adolescents may be more likely to identify as homosexual or bisexual as adults (3).
Nonbinary gender identity refers to individuals who experience their gender as different from the typical western views of binary gender identity (masculine or feminine). Nonbinary describes people with different types of gender identity, including people who do not identify with any gender, those who identify with multiple genders, and those who may experience different genders over time or in different contexts (gender fluid) (4). Although some nonbinary people identify as transgender, many do not.
Nonbinary people may use the pronouns they/them/theirs or newly created pronouns such as ze/zir/hir or e/er/ers, among others. Studies have reported that nonbinary people may constitute 25 to 50% of the gender-diverse community, with the higher percentages seen in adolescents and young adults (5). Currently, a majority of nonbinary people were assigned female at birth.
Prior to the 2010s, a majority of patients with gender dysphoria who requested treatment had been assigned male at birth. This has changed, with a substantial increase in the numbers of adolescent patients assigned female at birth coming to clinics worldwide for evaluation and treatment (6, 7).
Gender dysphoria and gender incongruence
For most people, there is congruity between their sex assigned at birth, gender identity, and gender role. However, those with gender dysphoria experience distress associated with some degree of incongruity between their birth sex and their gender identity. Gender dysphoria is a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), and is divided into 2 sets of diagnostic criteria, one for children and one for adolescents and adults (8).
If an individual experiences or displays gender incongruity or gender nonconformity, this itself is not considered a disorder. It is considered a normal variant in human gender identity and expression. However, when the perceived mismatch between birth sex and the internal sense of gender identity causes someone significant distress or functional impairment, a clinical diagnosis of gender dysphoria may be appropriate. The diagnosis is defined by the person's distress rather than by the presence of gender incongruity or identity.
The distress of gender dysphoria is typically described as a combination of anxiety, depression, irritability, and the pervasive sense of not feeling comfortable in one's body. People with severe gender dysphoria may experience severe, disturbing, and long-standing symptoms. They usually have a strong wish to change their body medically and/or surgically to make their body more closely align with their gender identity.
There are insufficient data to determine the precise prevalence of gender incongruence or dysphoria, but studies conducted in large health care systems have reported that 0.02 to 0.1% of patients meet DSM-5-TR criteria for a diagnosis of gender dysphoria. Survey-based studies of individuals in nonclinical settings have reported an even higher proportion of respondents who self-identify as transgender:
In adults, the prevalence was captured in 2 distinct groups:
Those who consider themselves transgender (0.5 to 0.6%)
Those who consider themselves gender-incongruent/diverse (0.6 to1.1%)
In children and adolescents, the same patterns in prevalence were noted:
Those who consider themselves transgender (1.2 to 2.7%)
Those who consider themselves gender-incongruent/-diverse (2.5 to 8.4%)
According to some experts, the diagnosis of gender dysphoria is primarily a general medical condition with attendant psychiatric symptoms, akin to disorders of sex development, and not primarily a mental disorder. As a result, gender incongruence and gender dysphoria are no longer listed as mental health conditions in the International Classification of Diseases, 11th Revision, but rather in a new sexual health chapter (9). The World Health Organization made this change, in part, to reduce stigma for an already stigmatized condition (10, 11). Conversely, others consider even extreme forms of gender incongruity to be neither a medical nor a psychiatric condition, but rather rare normal variants on the spectrum of human gender identity and expression.
Irrespective of the viewpoint about the clinical nature of gender incongruence and dysphoria, there is substantial evidence that transgender persons as a population suffer from an increased burden of medical, mental health, and sexual health diagnoses, often associated with barriers to access to care. Not all the mental health disorders in this population are gender dysphoria (for example, concomitant depression, anxiety disorders, substance use disorders), and gender dysphoria is not experienced by all individuals with gender incongruence. When defined symptoms are present and reach a threshold of clinical significance, a diagnosis of gender dysphoria may be present.
General references
1. American Psychological Association: A glossary: Defining transgender terms. See also Sexual orientation and gender diversity.
2. World Professional Association for Transgender Health: Standards of Care Version 8.
3. Wallien MSC, Cohen-Kettenis PT: Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 47(12)1413-1423, 2008. doi: 10.1097/CHI.0b013e31818956b9
4. Richards C, Bouman WP, Seal, et al: Non-binary or genderqueer genders. Int Rev Psychiatry 28(1):95-102, 2016. https://doi.org/10.3109/09540261.2015.1106446
5. Watson RJ, Wheldon CW, Puhl RM: Evidence of diverse identities in a large national sample of sexual and gender minority adolescents. J Res Adolesc 30(S2):431-442, 2020. https://doi.org/10.1111/jora.12488
6. Okabe N, Toshiki S, Matsumoto Y, et al: Clinical characteristics of patients with gender identity disorder at a Japanese gender identity disorder clinic. Psychiatry Res 157(1-3):315-318, 2008. doi: 10.1016/j.psychres.2007.07.022
7. de Graaf N, Carmichael P, Steensma T, et al: Evidence for a change in the sex ratio of children referred for gender dysphoria: Data from the Gender Identity Development Service in London (2000-2017). J Sex Med 15(10):1381-1383, 2018. doi: 10.1016/j.jsxm.2018.08.002
8. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022.
9. World Health Organization: Eleventh revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11). Accessed April 21, 2023.
10. World Health Organization: Gender incongruence and transgender health in the ICD. Accessed May 19, 2023.
11. Reed GM, Drescher J, Krueger RB, et al: Disorders related to sexuality and gender identity in the ICD-11: Revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry 15(3): 205-221, 2016. doi: 10.1002/wps.20354
Etiology of Gender Incongruence and Gender Dysphoria
The specific etiology of gender incongruence is incompletely understood. Biologic factors (eg, genetics, prenatal hormonal milieu at a critical period in fetal development) are thought to play major roles in determining gender identity. Some studies have found a higher concordance rate for gender dysphoria in monozygotic twins than in dizygotic twins, suggesting a heritable component to gender incongruity (1), whereas others have not found this linkage (2). Some brain imaging studies show functional and anatomic differences in gender-dysphoric people that are consistent with their gender identity rather than their sex assigned at birth (3).
The formation of a secure, unconflicted gender identity and gender role is also influenced by psychosocial factors (eg, the character of the parents’ emotional bond, the relationship that each parent has with the child).
Rarely, gender dysphoria is associated with disorders of sex development (eg, ambiguous genitals) or a genetic abnormality (eg, Turner syndrome, Klinefelter syndrome). When sex labeling and rearing are confusing (eg, in cases of ambiguous genitals or genetic syndromes altering genital appearance [eg, androgen insensitivity syndromes]), children may become uncertain about their gender identity or role, although the additional contribution of environmental factors remains controversial. However, when sex labeling and rearing are unambiguous, the presence of ambiguous genitals may not affect a child’s gender identity development.
Etiology references
1. Coolidge FL, Thede LL, Young SE: The heritability of gender identity disorder in a child and adolescent twin sample. Behav Genet 32(4):251-257, 2002. doi: 10.1023/a:1019724712983
2. Karamanis G, Karalexi M, White R, et al: Gender dysphoria in twins: A register-based population study. Sci Rep 12, 13439, 2022. https://doi.org/10.1038/s41598-022-17749-0
3. Kreukels BPC, Guillamon A: Neuroimaging studies in people with gender incongruence. Int Rev Psych 28(1):120-128, 2016. doi: 10.3109/09540261.2015.1113163
Symptoms and Signs of Gender Incongruence and Gender Dysphoria
Although this section is called symptoms and signs, it also discusses experiences and characteristics of gender-diverse individuals who do not have gender dysphoria.
Symptoms in children
Childhood gender diversity is a frequent occurrence in general human development (1) and is not itself a mental disorder nor necessarily an indication that a child has a transgender identity (2).
Childhood gender dysphoria is a clinical diagnosis that often manifests as early as age 2 to 3 years but may become apparent at any age. Most children with gender dysphoria are not evaluated until they are age 6 to 9. Children with gender dysphoria commonly present with the following for at least a 6-month period (3):
Prefer cross-dressing
Insist that they are of the other sex
Wish that they would wake up as the other sex
Prefer participating in the stereotypical games and activities of the other sex
Prefer playmates of the other gender
Have a strong dislike of their sexual anatomy
For example, a young girl may insist she will grow a penis and become a boy, and she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may also wish to be rid of his penis and testes. For boys, if distress at the physical changes of puberty is present, this is often followed by a request during adolescence for feminizing somatic treatments.
The gender trajectory for gender-incongruent prepubescent children cannot be reliably predicted in advance. Some studies have found that a majority of study participants with childhood gender incongruence remained stable in this gender identity as adolescents (4). In other studies, among study participants diagnosed with gender dysphoria as children, a minority continued to meet diagnostic criteria for gender dysphoria as adults (5, 6), and also a minority of those who expressed nonclinically significant levels of gender incongruence (did not meet diagnostic criteria for gender dysphoria) continued to express gender incongruity as adults.
There is considerable controversy over whether or at which age to support the social and/or medical gender transition of young prepubertal children with gender dysphoria. There is no conclusive research to guide this decision (7, 8); however long-term, prospective studies are underway (4).
The current World Professional Association for Transgender Health (WPATH) Standards of Care, version 8 (9) provide guidance for experts working in this sensitive area. These guidelines recommend that parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity. They also recommend that parents/caregivers and health care professionals support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition (9).
Gender-diverse children and adolescents as a group are more likely to experience trauma, bullying, isolation, and mental health difficulties than their cisgender peers (10, 11). The increase in suicidality and depression in adolescents who identify as transgender or gender diverse has garnered substantial attention and study (12, 13).
Some transgender children or adolescents make a social transition. This may involve one or more of the following changes during childhood: name change, pronoun change, changing sex markers on documents and school records; participation in "other" gender sports, recreational clubs, camps; changing the bathroom and locker room used to be consistent with experienced gender; communication of experienced/affirmed gender to other people publicly; and personal expression changes (eg, hair styles, clothing, jewelery choices) (2).
Symptoms in adults
Many adults diagnosed with gender dysphoria have early gender dysphoria symptoms or experience a sense of being "different" in early childhood, but some do not present until adulthood and had no evidence of childhood gender incongruence. Transwomen may first identify as cross-dressers and only later in life come to embrace their transgender identity.
Some gender-dysphoric persons initially make choices consistent with their sex assigned at birth (eg, marriage, military service), and frequently admit, in retrospect, that they were not comfortable with their emerging transgender/gender-diverse feelings and made life decisions to try to avoid dealing with them. For those assigned male at birth, this has been described as a "flight into hypermasculinity" (14, 15). Once they accept their transgender identity and publicly transition gender, many transgender people blend seamlessly into the fabric of society in their preferred gender identity—with or without gender-affirming hormone therapy or gender-affirming surgery.
Other gender-diverse people experience problems, which may include anxiety, depression, substance use disorders, and suicidal behavior, at levels substantially higher than those of their cisgender peers (16). These problems may be related to societal and family stressors associated with lack of acceptance of gender-nonconforming behaviors and marginalization, often referred to as minority stress. Health disparities in access to mental health and overall health care services are well-documented in gender-dysphoric persons and may be associated with poverty, barriers to access to care, discrimination, and clinician discomfort in providing them with appropriate care.
Symptoms and signs references
1. Endocrine Society, Pediatric Endocrine Society: Position statement: Transgender health. Endocrine Society. Accessed May 19, 2023.
2. Ehrensaft D: Exploring gender expansive expressions. In The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children, edited by Keo-Meier C, Ehrensaft D, American Psychological Association, Washington, DC.
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022.
4. Olson KR, Durwood L, Horton R, et al: Gender identity 5 years after social transition. Pediatrics 150 (2): e2021056082, 2022. https://doi.org/10.1542/peds.2021-056082
5. Singh D, Bradley S, Zucker K: A follow-up study of boys with gender identity disorder. Front Psychiatry Volume 12, 2021. https://doi.org/10.3389/fpsyt.2021.632784
6. Wallien MSC, Cohen-Kettenis PT: Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 47(12)1413-1423, 2008. doi: 10.1097/CHI.0b013e31818956b9
7. Chen D, Edwards-Leeper L, Stancin T, et al: Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions. Clin Pract Pediatr Psychol 6(1):73-83, 2018. doi: 10.1037/cpp0000229 2
8. Travers A:The Trans Generation: How Trans Kids (and Their Parents) Are Creating a Gender Revolution. New York, New York University Press, 2018.
9. World Professional Association for Transgender Health: Standards of Care Version 8.
10. Barrow K, Apostle D: Addressing mental health conditions often experienced by transgender and gender expansive children. In The gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children, edited by Keo-Meier CE, Ehrensaft DE. American Psychological Association. 2018.
11. Ristori J, Steensma TD: Gender dysphoria in childhood. Int Rev Psychiatry 28(1),13-20, 2016. https://doi.org/10.3109/09540261.2015.1115754
12. Turban JL, King D, Carswel JM, et al: Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics e20191725, 2020. https://doi.org/10.1542/peds.2019-1725
13. Turban JL, King D, Kobe J, et al: Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One 17(1): e0261039, 2022. https://doi. org/10.1371/journal.pone.0261039
14. Brown GR: Transsexuals in the military: flight into hypermasculinity. Arch Sex Behav 17(6):527-537, 1988. doi: 10.1007/BF01542340
15. McDuffie E, Grown GR: 70 U.S. veterans with gender identity disturbances: A descriptive study. J Transgenderism 12(1):21-30, 2010. https://doi.org/10.1080/15532731003688962
16. Brown GR, Jones KT: Mental health and medical outcome disparities in 5135 transgender veterans receiving health care in the Veterans Health Administration: A case-control study. LGBT Health 3(2):122-131, 2016. doi: 10.1089/lgbt.2015.0058
Diagnosis of Gender Incongruence and Gender Dysphoria
DSM-5-TR criteria
ICD-11 criteria (not yet used in all countries)
Assessment and diagnosis in all age groups
Assessment of an individual regarding gender incongruence or gender dysphoria often includes
Interview of the individual (and for children, interviewing parents/caregivers) about asserted gender identity and gender expression, currently and historically
Assessment for evidence of dysphoria, gender incongruence, or both
Review of relevant medical and mental health history (and for children, developmental history)
The presence of significant personal or family stressors or risks should be assessed (eg, substance use, exposure to violence, poverty)
Assessment for other mental health conditions that are often associated with gender dysphoria, including depression, anxiety, substance use disorders, tobacco use, suicidality.
In addition, the individual's family and psychosocial contexts are important, including attitudes, support, and challenges regarding gender diversity in the person and among family, friends, and other important contacts (eg, peers, teachers, coworkers, community members). The presence of significant personal or family stressors or risks should be assessed (eg, substance use, exposure to violence, poverty). The WPATH Standards of Care, version 8 provide a detailed section on the evaluation of gender-diverse patients at all stages of the life cycle (1).
Gender incongruence is defined in the ICD-11 as a marked and persistent incongruence between an individual's experienced gender and the assigned sex (2). Because ICD-11 is used in Europe and some other world regions, but not yet in the United States, gender incongruence does not have a diagnostic code in the United States, and in clinical practice, the term is typically used only in reference to children.
Gender dysphoria is expressed differently in different age groups (1). The diagnosis of gender dysphoria in all age groups, per DSM-5-TR criteria, requires the presence of both of the following (3):
Marked incongruity between birth sex and experienced/expressed gender identity that has been present for ≥ 6 months
Clinically significant distress or functional impairment resulting from this incongruity
Diagnosis of gender dysphoria in children
Diagnostic criteria for gender dysphoria in children require ≥ 6 of the following (3):
A strong desire to be or insistence that they are the other gender (or some alternative gender different from their assigned gender)
A strong preference for dressing in clothing typical of the opposite gender and, in girls, resistance to wearing typically feminine clothing
A strong preference for cross-gender roles in make-believe play or fantasy play
A strong preference for toys, games, and activities stereotypical for the other gender
A strong preference for playmates of the other gender
A strong rejection of toys, games, and activities typical of the gender that matches their birth sex
A strong dislike of their sexual anatomy
A strong desire for the primary and/or secondary sex characteristics that match their experienced gender
The condition must be associated with clinically significant distress or impairment in social settings, school, or other important areas of functioning.
Self-identification as a different gender than that assigned at birth must not be merely a desire for perceived cultural advantages of being a different gender. For example, a boy who says he wants to be a girl predominantly because he will receive the same special treatment his younger sister receives is not likely to have a diagnosis of gender dysphoria.
Diagnosis of gender dysphoria in adolescents and adults
Diagnostic criteria for gender dysphoria in adolescents and adults require ≥ 2 of the following (3):
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 (or for young adolescents, prevent the development of) their primary and/or secondary sex characteristics
A strong desire for the primary and/or secondary sex characteristics that match their felt gender
A strong desire to be the other gender (or some alternative gender different from one’s assigned gender)
A strong desire to be treated as another gender
A strong belief that they have the typical feelings and reactions of another gender
The condition must be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Diagnosis references
1. World Professional Association for Transgender Health: Standards of Care Version 8, pp. S31-S68.
2. Jakob R: ICD Update Platform: Gender identity alignment with ICD-11.
3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022.
Treatment of Gender Dysphoria
For many adults or adolescents, gender-affirming hormone therapy and sometimes gender-affirming surgeries (breast, genital, or facial surgery)
Sometimes other treatments (eg, voice therapy, electrolysis)
Psychotherapy with adolescents and adults is often helpful to address coexisting mental health concerns, transition-related issues, and other problems, but is not mandatory to access medical and/or surgical treatments for gender dysphoria.
The goal of treatment for transgender persons, according to WPATH, is to achieve "lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfilment" (1).
Gender-nonconforming or gender-incongruent behavior, such as cross-dressing, is not considered a disorder and does not require treatment if it occurs without concurrent gender dysphoria (clinically significant psychologic distress or functional impairment). When treatment is required, it is aimed at relieving patients' distress and helping them adapt to rather than trying to dissuade them from their identity. Using psychotherapy to try to "convert" a person's established transgender identity (so-called reparative therapy or conversion therapy) is not only ineffective but can be harmful to patients, is considered unethical, and is illegal in some jurisdictions.
For most persons with gender dysphoria, the primary objective in seeking medical help is not to obtain mental health treatment, but to obtain gender-affirming treatments in the form of hormone therapy and/or gender-affirming surgery (previously known as sex reassignment or genital surgery) to make their physical appearance consistent with their gender identity. When gender dysphoria is appropriately diagnosed and treated, the psychologic distress may resolve with a combination of psychotherapy, gender-affirming hormone therapy, and gender-affirming surgeries (1, 2).
Surgery may help certain patients achieve greater adaptation and life satisfaction. Most experts recommend surgery only for patients who have been assessed by an appropriately trained and experienced clinician and who have been treated according to the current WPATH Standards of Care. Clinicians often advise patients to live in their preferred gender role for a year before having irreversible genital surgery.
Fertility-preservation techniques, such as embryo, oocyte, or sperm cryopreservation or delaying initiation of gender-affirming hormonal treatments, should be discussed prior to treatment (1, 3 ).
Studies have found that genital surgery has helped many people with gender dysphoria live happier and more productive lives. Based on these findings, this surgery is considered medically necessary in patients with gender dysphoria who are highly motivated and have been evaluated by appropriate experts and who have met the criteria outlined in the WPATH Standards of Care, version 8 (2). It should be noted that gender-affirming surgeries are not limited to genital interventions but may also include facial changes, vocal cord surgery, breast augmentation, laryngeal shave, or other nongenital surgeries.
Although patients with gender dysphoria are no longer required to have psychotherapy before consideration for gender-affirming hormone therapy and surgical procedures, mental health professionals can do the following to help patients make informed decisions:
Assess and treat comorbid disorders (eg, depression, substance use disorders)
Help patients deal with the negative effects of stigma (eg, disapproval, discrimination)
Help patients find a gender expression that is comfortable
If applicable, facilitate gender role changes, coming out (informing other people about one's transgender identity), and transitioning
The decision of an individual to share information about their gender identity with family and the public, independent of desired treatments, is often fraught with potential social problems for patients (4, 5 ). Such issues include the potential loss of family, spouse/partner, friends and the loss of employment or housing due to continued discrimination against gender-diverse persons. In some parts of the world, being publicly gender diverse is also illegal and subjects transgender persons to potential serious legal consequences, including imprisonment or execution.
Participation in gender support groups, available in most large cities or through the internet, is often helpful, especially during the transition process.
Individuals assigned male at birth (AMAB)
For transwomen, gender-affirming medical therapies consist of feminizing hormones
Feminizing hormones have significant beneficial effects on the symptoms of gender dysphoria, often before there are any visible changes in secondary sexual characteristics (eg, breast growth, decreased facial and body hair growth, redistribution of fat to the hips). Feminizing hormones, even without psychologic support or surgery, are enough to make some patients feel sufficiently comfortable as women.
Gender-affirming surgery is requested by an increasing number of transwomen. Although there are several approaches, the most common surgery involves removal of the penis and testes and creation of a neovagina. A part of the glans penis is retained as a clitoris, which is usually sexually sensitive and retains the capacity for arousal and orgasm in a majority of cases.
Some patients also have nongenital, gender-affirming surgical procedures such as breast augmentation, facial feminization surgeries (eg, rhinoplasty, brow lift, hairline changes, jaw reconfiguration, tracheal cartilage shave [reduction of the laryngeal cartilage]), or vocal cord surgeries to change the quality of the voice.
Individuals assigned female at birth (AFAB)
Since the 2010s, there have been increasing rates of gender-affirming surgeries in transmen (6). These individuals often request mastectomy early in treatment, including in late adolescence, because it is difficult to live in the male gender role with a large amount of breast tissue. Breast binding is often practiced by transmen, but this often makes breathing difficult and large breasts are associated with higher severity of gender dysphoria symptoms.
Hysterectomy and oophorectomy may be done after a course of masculinizing hormone therapy
7).
Patients may opt for one of the following additional gender-confirming surgeries:
An artificial phallus (neophallus) to be created from skin transplanted from the inner forearm, leg, or abdomen (phalloplasty)
With either procedure, scrotoplasty is usually also done; the labia majora are dissected to form hollow cavities to approximate a scrotum, and testes implants are inserted to fill the neoscrotum.
Anatomic results of neophallus surgical procedures are often less satisfactory in terms of function and appearance than neovaginal procedures for transwomen. This is the possible reason for fewer requests for genital gender-confirmation surgery from transmen; however, as techniques for phalloplasty continue to improve, requests for phalloplasty have increased.
Surgical complications are common, especially in procedures that involve extending the urethra into the neophallus. These complications may include urinary tract infection, fistulae, urethral stricture, or a deviated urinary stream.
Nonbinary and other gender-diverse individuals
In health care settings, nonbinary people are less likely to volunteer information about their gender identity than transgender patients; many have had negative experiences with health care professionals who attempt to treat them as though they are on a linear spectrum of gender identity (binary model), which is usually at odds with the patients' self-perception (8).
Some nonbinary people seek gender-affirming medical and/or surgical treatments to alleviate gender dysphoria or incongruence symptoms associated with distress or functional impairment. Treatment goals must be thoroughly understood and the limitations of treatments must be clearly stated. For example, a nonbinary patient assigned male at birth may wish to achieve greater body satisfaction (eg, desired changes in skin, hair growth, fat distribution) through the use of estrogen therapy, but does not wish to develop breasts. These goals may be incompatible with the mechanisms of action of gender-affirming hormonal treatments. Long-term outcome data are lacking regarding medical and surgical treatments in nonbinary populations.
Finally, there are some individuals assigned male at birth who identify as eunuchs and wish to live their lives without the masculine influences of testosterone and without the presence of their penis and/or testicles (9). Many individuals who identify as eunuchs do not describe themselves as transgender and view themselves as having a distinct gender identity as eunuchs. Eunuchs may seek out both medical and surgical interventions to eliminate the masculinizing effects of testosterone, including orchiectomy (1, 10)
Gender dysphoria in children and adolescents
The psychosocial treatment of prepubertal children diagnosed with gender dysphoria remains controversial. Current information and guidelines regarding psychosocial treatments, including social transition, are reviewed in the WPATH Standards of Care, version 8 (1). No guidelines or standards endorse or recommend the use of hormonal interventions (puberty blockers or gender-affirming hormones) or gender-affirming surgeries in prepubescent children with a diagnosis of gender incongruence or gender dysphoria (1, 11). Medical care of transgender children and adolescents is often provided in an academic medical center in specialized clinics by a multidisciplinary team.
The majority of children who engage in gender-incongruent behaviors do not have a diagnosis of gender dysphoria or incongruence and do not continue into adolescence or adulthood with a transgender identity. Among young children with a diagnosis of gender dysphoria, at this point, it is not possible to reliably predict if these symptoms will continue into adulthood (12, 13).
While there is no clinical consensus on the treatment of prepubertal gender-dysphoric children, it is recognized that attempts to force the child to accept the birth-assigned gender role is usually traumatic and unsuccessful. Therefore, the predominant treatment modality is psychologic support and psychoeducation for children and their parents, using a gender-affirmative model as opposed to a gender-pathologizing model (1). This affirmative approach supports the child in their expressed gender, sometimes including one or more aspects of social transition prior to puberty.
There has been a substantial increase in the number of adolescents assigned female at birth reporting for evaluation and clinical care over the past decade, and they now outnumber those assigned male at birth seeking care at most clinics (14).
testosterone and estrogen, thereby "blocking" the progression of puberty. These medications may be given at Tanner Stage II of development, enabling additional time for evaluation of the gender-dysphoric youth prior to permanent pubertal changes (15). (See Endocrine Society Guidelines, 2017.)
If a gender-dysphoric youth wishes to continue with full transition to a different gender and is assessed as appropriate for additional transition care, puberty-blocking agents may be discontinued and gender-affirming hormone therapy may be given, enabling the onset of a gender-congruent puberty. These treatments are offered only after evaluation by clinicians with specialized expertise in the diagnosis and management of gender dysphoria in adolescents; this is usually done with consent from parent(s)/guardians and assent from the adolescents (if they are under the age of legal adulthood in a given jurisdiction). As noted above, fertility-preservation techniques should be discussed prior to the onset of any hormonal or surgical interventions.
Treatment references
1. Coleman E, Radix A E, Bouman WP, et al: Standards of Care for the Health of Transgender and Gender Diverse People, Version 8, Int J Transgend Health, 23:sup1, S1-S259, 2022. doi: 10.1080/26895269.2022.2100644
2. World Professional Association for Transgender Health: Standards of Care Version 8, pp. S31-S68.
3. Nahata L, Chen D, Moravek MB, et al: Understudied and under-reported: Fertility issues in transgender youth—A narrative review. J Paediatrics, 205, 265-271, 2019. https://doi.org/10.1016/j. jpeds.2018.09.009
4. Lev A: Transgender Emergence. Haworth Clinical Practice Press, Binghamton, NY, 2004.
5. Bockting W, Coleman E: Developmental stages of the transgender coming-out process. Toward an integrated identity. In: R Ettner, S Monstrey, E Coleman (Eds). Principles of Transgender Medicine and Surgery, Second Edition. Routledge, NY, 2016; pp 137-148.
6. Chaya B, Berman Z, Boczar D, et al: Gender affirmation surgery on the rise: Analysis of trends and outcomes. LGBT Health 9(8): 582-588, 2022 doi: 10.1089/lgbt.2021.0224
7. Bonnington A, Dianat S, Kerns J, et al: Society of Family Planning clinical recommendations: Contraceptive counseling for transgender and gender diverse people who were female sex assigned at birth. Contraception 102(2):70-82, 2020. doi:10.1016/j.contraception.2020.04.001
8. Vincent B: Non-binary genders: Navigating communities, identities, and healthcare. Policy Press, Bristol, UK. 2020.
9. Johnson RB, Onwuegbuzie AJ, Turner LA: Toward a definition of mixed methods research. 9(2):112-133, 2007. doi 10.1177 1558689806298224
10. Wong STS, Wassersug RJ, Johnson TW, et al: Differences in the psychological, sexual, and childhood experiences among men with extreme interests in voluntary castration. Arch Sex Behav 50(3):1167-1182, 2021. https://doi.org/10.1007/s10508-020-01808-6
11. Chen D, Edwards-Leeper L, Stancin T, et al: Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions. Clin Pract Pediatr Psychol 6(1):73-83, 2018. doi: 10.1037/cpp0000229
12. Bloom TM, Nguyen TP, Lami F, et al: Measurement tools for gender identity, gender expression, and gender dysphoria in transgender and gender-diverse children and adolescents: A systematic review. The Lancet Child & Adolescent Health 5(8):582-588, 2021. https://doi.org/10.1016/s2352-4642(21)00098-5
13. Edwards-Leeper L, Leibowitz, Sangganjanavanich VF: Affirmative practice with transgender and gender nonconforming youth: Expanding the model. Psychology of Sexual Orientation and Gender Diversity 3(2):165-172, 2016. https://doi.org/10.1037/sgd0000167
14. Bauer G, Pacaud D, Couch R, et al; Trans Youth CAN! Research Team. Transgender youth referred to clinics for gender-affirming medical care in Canada. Pediatrics 148(5): e2020047266. https://doi.org/10.1542/ peds.2020-047266
15. Hembree WC, Cohen-Kettenis PT, Gooren L, et al: Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 102(11):3869-3903, 2017. doi: 10.1210/jc.2017-01658
Key Points
Transgender and gender diverse are terms that refer to people with gender identities that differ from the sex they were assigned at birth; some individuals identify as nonbinary, a category of gender identity that is experienced as outside the concept of the masculine-feminine binary.
Only a minority of people who identify as transgender, gender diverse, or nonbinary meet criteria for a diagnosis of gender dysphoria.
Diagnose gender dysphoria only when distress and/or functional impairment associated with gender incongruency are significant and persist ≥ 6 months.
When treatment is required, it is aimed at relieving patients' distress and helping them adapt to rather than trying to dissuade them from their gender identity.
The treatment of prepubertal children diagnosed with gender dysphoria remains controversial but does not include the use of hormonal medications or surgeries.
