Understanding Gender Dysphoria, page 11
Symptoms of gender dysphoria are not just seen in play, however. In particular, how a child responds to his or her primary and secondary sex characteristics are important considerations. In that same study of children whose gender dysphoria persisted or desisted, those who persisted in their gender dysphoria experienced a marked discomfort “by the fact that their bodies did not conform to their feelings”; regarding anatomy, “persisting girls reported primarily desiring a penis, the persisting boys in contrast wished to get rid of their penis.”8 A biological female whose gender dysphoria persisted shared, “When I was standing in front of the mirror I did not very much mind seeing my genitals, but it made me very sad that I did not have a penis.”9
As I indicated above, other considerations include the desire for cross-gender roles in fantasy play, strong interest in the activities and games often associated with the other gender, and so on.
Gender Dysphoria in Adolescents and Adults
The DSM-5 brings adolescent and adult experiences together for diagnostic purposes. The diagnostic criteria are the same for adolescents and adults but different than the criteria for children. In adolescents and adults, at least two of six symptom presentations would be evident, including:
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 because of a marked incongruence with one’s 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 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).10
Clinicians who work with a person who may meet criteria for Gender Dysphoria are also to note whether a person has an intersex condition. Recall from chapter one that an intersex condition is one in which at birth an infant was unable to be identified as male or female because of ambiguous genitalia. The ambiguous presentation may be due to any number of rare variations that can occur at the level of the chromosomes or gonads. There is also cultural momentum in some nations toward offering those with an intersex condition the option of identifying as either intersex or “X” as an alternative to the male-female binary.11
One of the benefits in meeting with an adolescent or adult is that now the person is older and able to more clearly articulate their experience with gender dysphoria. They may request hormonal treatment, surgery or find other ways to change how they appear to others. The challenges that arise, in my view, have to do with determining when an adolescent’s experiences of gender dysphoria rise to the level of a diagnosis of Gender Dysphoria, when co-occurring issues are present and more salient (e.g., an anxiety disorder), and when family dynamics are such that an adolescent does not receive sufficient empathy and support to even come to an understanding of how to proceed and what options may lay before them.
A Christian couple came to therapy with their sixteen-year-old son. They state that he believed he was a girl, and that they were in conflict about how to relate and where to go from here. They expressed a preference that we refer to their son by his birth name, which was Colton. However, Colton preferred a different name, Caitlyn, but would still respond to his given name. Colton was visibly anxious and, after further assessment, met criteria for an anxiety disorder that kept him homebound from school. He expressed an interest in transitioning to female through hormonal treatment and sex-reassignment surgery. We discussed his options at this point and the current standards of care and what it would mean to wait until he was an adult at which time he could receive a referral to a specialty clinic. Of immediate concern, however, was his anxiety disorder and the effects of his anxiety on social and educational functioning. He was initially unwilling to talk about his anxiety and was convinced that it was due exclusively to his gender dysphoria, which he wanted to resolve through transition as soon as possible.
In adolescence those whose gender dysphoria persisted tended to want to express their gender identity, whether feminine (if a biological male) or masculine (if a biological female). That would be via dress, name/identification or behavior.12 One biological male whose gender dyphoria persisted shared the following:
When I became older, I felt more and more uncomfortable when I had to change clothes in the company of the other boys in gym class. When we went to camp with school I desperately wanted to sleep together with the girls, but I was not allowed to. That was a difficult confrontation. I became more and more aware of how different I was from the other boys.13
One biological female who attempted to live in a female role despite significant gender dysphoria shared:
To prevent being bullied at my new high school, my mom advised me to wear girls’ clothes and stimulated me to let my hair grow. In a way, I hoped and expected that my feeling of being a boy would change and that I would start to feel more like a girl. But from the day I went to my new school, I constantly questioned this whole plan. I was totally not interested in the things the girls were talking about, and felt very uneasy. I felt more and more unhappy with the role I was living in. I wanted to be with the other boys and talk about soccer. I wanted to be one of them.14
In any of these cases—whether a child, adolescent or adult presentation—what I want to be clear about is this: a person could have gender identity questions or concerns or experience gender dysphoria and not meet criteria for the diagnosis of Gender Dysphoria in the official diagnostic manual. Put differently, gender dysphoria can be experienced subthreshold and, as Zucker15 observes, most children or adolescents who are subthreshold may have met criteria for Gender Dysphoria at a younger age with the movement from threshold to subthreshold being the result of efforts to intervene (whether these are formal or informal). Indeed, most children who meet criteria for Gender Dysphoria do not continue to meet criteria as they grow up and enter adolescence. According to the DSM-5, Gender Dysphoria persists from childhood to adolescence in only 2.2 to 30 percent of biological males and 12 to 50 percent of biological females.16 Granted, that is a significant range, and more consistent figures would help us understand the likelihood of persistence (as well as possibly predicting variables), but for our purposes, we can at least acknowledge that in most cases Gender Dysphoria desists over time as children enter into adolescence.
Those who meet the threshold for Gender Dysphoria tend to display “significantly more cross-gender behavior or less same-gender behavior” than those who are subthreshold.17 Those who are subthreshold are still gender nonconforming but essentially less so.
Prevalence
It is hard to get exact figures on how many people’s symptoms rise to the level of a diagnosable Gender Dysphoria (or, formerly, Gender Identity Disorder), let alone experiences of gender dysphoria along a continuum. Most of the research conducted to date was of Gender Identity Disorder, the language and category used in the previous publication on mental health concerns. It is relatively rare for someone to experience gender dysphoria to the extent that we would diagnose that person with Gender Dysphoria, but because it resides on a continuum, any estimates here are likely low when we think of children, adolescents, and adults who experience gender dysphoria somewhere along the continuum but likely do not meet criteria for the formal diagnosis as such and are not going to a specialty clinic.18
The DSM-5 estimates that between 0.005 percent to 0.014 percent of adult males and 0.002 percent to 0.003 percent of adult females have Gender Dysphoria.19 These estimates are based on people seeking out specialty clinics for treatment. This is unlikely an accurate picture of gender dysphoria along a continuum. Findings from other studies put the prevalence estimates in ranges from 1 in 10,000 to 1 in 13,000 males and 1 in 20,000 to 1 in 34,000 females.20
Identifying oneself as transgender is much more common. There is not a lot of research on this, as most studies have not provided the option of transgender in the demographics section until relatively recently. Be that as it may, between 1 in 215 and 1 in 300 people identified themselves as transgender in two probability samples.21 Because transgender is an umbrella term that encompasses many experiences of gender variance, experts22 doubt whether these respondents would meet criteria for Gender Dysphoria, though many may experience some degree of gender dysphoria along a continuum.
Gender Dysphoria as a diagnosis and the broader experience of gender dysphoria along a continuum appears to be more common among males than females, with a ratio of at least 3:1. Zucker has put that ratio as high as 5:1 in terms of referrals to specialty clinics, and he has suggested that it may be due to a more narrow set of cultural expectations for boys to display acceptable masculine behaviors and mannerisms than girls. Think about it this way: even in the English language, we have a neutral word for a girl who demonstrates more masculine interests (i.e., she is tomboyish, which is not a derogatory statement), but we do not have a neutral word for a boy who demonstrates feminine interests. The language used in the 1970s was “sissy” or “sissy-boy syndrome,” which has been discarded for obvious reasons. Language matters, as it reflects our assumptions of what is normal, what is acceptable and what is of concern.
Zucker23 identified several criticisms of the former diagnosis of Gender Identity Disorder that in many ways continue to apply to the current diagnosis of Gender Dysphoria. These include that Gender Dysphoria is a normal variation in experiences of gender identity; that the distress associated with Gender Dysphoria is not inherent to the condition but a reflection of societal rejection; and that the diagnosis is a way to surreptitiously prevent homosexuality. There are debates about what constitutes a mental disorder that are beyond the scope of this chapter,24 but I appreciate Zucker’s observation about where the trajectory of Gender Dysphoria takes a person:
It is difficult to argue that cross-gender feelings and behaviors simply constitute a normative variation or do not constitute an example of impairment if one considers the developmental adolescent or adult “end state,” . . . i.e., the strong desire to align the body via contrasex hormones and sex-reassignment surgery. . . . The required physical interventions are simply too radical to be thought of otherwise.25
What are we to make of the distress? Is the distress a person’s subjective reaction to cross-gender identification? Is it the subjective response to the incongruence? Or is it that but also the cross-gender identification in and of itself? For some experts in this area, the cross-identification is itself a reflection of distress. For example, Zucker goes on to say that the decision to live in a “cross-gendered role” reflects an “in-the-person distress regarding the disjunction between somatic sex and felt psychological gender.”26 It does not do justice to the phenomenon to say that the dysphoria is simply the result of rejection from others. I would concur with Zucker that the desire to be the other sex is itself a reflection of distress, a conflict that resides within between one’s somatic or phenomenal self and one’s psychological or emotional experience of oneself vis-a-vis one’s gender identity.
A challenge that arises is that not all gender nonconformity rises to the level of this cross-gender identification. Remember that this is an extreme and rare form of cross-gender identification that we now refer to as Gender Dysphoria. But gender dysphoria (in a broader sense that is subthreshold) can exist and may not be experienced subjectively by the person in question as distressing, and may very well not rise to the level of true distress in and of itself. This is certainly a complex and complicated area for reflection and consideration.
So there is wisdom in viewing gender dysphoria broadly or along a continuum, to think more broadly than just those who meet criteria for a formal diagnosis of Gender Dysphoria or who are pursuing sex-reassignment surgery.27 Certainly gender dysphoria can exist without the desire for hormonal treatment or surgery.
As we bring this chapter to a close, I also want to revisit the use of the term transgender. Recall that in chapter one we introduced how transgender is an umbrella term for the many ways in which people might experience the gender identity that is different from those in the majority (who experience a sense of congruence between their gender identity and biological sex). Transgender as an umbrella terms extends, too, beyond just the experience of gender identity but also to its presentation or expression (i.e., how it is lived out).
So a person may identify as transgender and be a cross-dresser or someone who dons the clothing of the other gender. We can think of the various aspects involved in cross-dressing across the purpose, extent and locale. The purposes of cross-dressing can vary widely. A person could identify as male in nearly all social settings but cross-dress in a way that expresses another aspect of his gender identity (more for identity validation or expression). Or a person could cross-dress for primarily sexual reasons (sexual arousal). A person could cross-dress as a way of managing gender dysphoria—that is, when the person cross-dresses, the dysphoria he feels lessens to some extent or becomes more manageable. Drag queens and drag kings cross-dress. They perform in a theatrical setting and in a theatrical manner. That can be as a means of expression or as a way to feel arousal. As I have shared previously, they may not experience gender dysphoria or identify as transgender, and some within the transgender community would not see those who perform drag as transgender as such.
Table 4.1. Facets of Cross-Dressing: Purpose, Extent, Locale
Purpose Expression Management Arousal
Extent Underwear Outerwear Outerwear/makeup/hair
Locale At home/private Public/out of the area Public/local area
So a person could cross-dress but not experience gender dysphoria; they might cross-dress because the act of cross-dressing is itself sexually arousing. Kimber28 offers a helpful, educated guess as to what the ratio would be of those who cross-dress in relation to those who eventually seek hormonal treatment and sex-reassignment surgery. Based on these calculations, most cross-dressers either only wear underwear of the other’s sex (about 68% of all who cross-dress) or only wear other sex clothing at home (21%), in contrast to those who range from occasionally cross-dressing when they are out all the way to the person who transitions through hormonal treatment and sex-reassignment surgery. Essentially, Kinder’s estimate is that only one out of three hundred persons who already cross-dresses would make that kind of transition.
The extent of cross-dressing also varies considerably. One person could cross-dress by only wearing undergarments or even a symbolic/meaningful necklace. This can range from something quite unnoticeable to donning an entire outfit that also includes make-up and hairstyle or wig.
In terms of locale, cross-dressing can occur in private or in public. It can be done at home and essentially in private (use of underwear) or at home and in public (cross-dressing in front of one’s family). Or cross-dressing could be done in a public way but out of the person’s local community, as when a person travels and cross-dresses primarily in that other setting. Cross-dressing could also be done in one’s local community in a public way.
Blanchard’s Typology
When we consider gender dysphoria in adulthood, there are again some controversies about how to conceptualize various presentations. One typology suggests three common presentations: (1) Female-to-Male Gender Dysphoria; (2) Male-to-Female Gender Dysphoria (Androphilic Type) and (3) Male-to-Female Gender Dysphoria (Autogynephilic Type).29
Those who are biologically/genetically female at birth but feel that they are male in their gender identity (referred to as Female-to-Male Gender Dysphoric or FtM) typically have long identified as masculine and did not want to be dressed in female attire. They frequently spoke of wanting to be a boy (or that they were a boy), and they had a negative response to the changes their body went through at puberty. Blanchard offers the following description:
Puberty usually brings great emotional turmoil to homosexual female gender dysphorics. They hate their menses, which privately remind them that their bodies are female, and their developing breasts, which proclaim the same fact to the outside world. The awakening of sexual interest in other females brings a new poignancy to their longing for male genitals; the beginnings of dating and going steady among their adolescent peers contrast their frustrated dreams of love with the common reality of others.30
A female-to-male client has not typically been attracted to males; further, they may have tried same-sex because they feel male inside. However, these relationships are not typically satisfying to them. What they are seeking is for a female to be attracted to them as a male.
Clients who are biologically/genetically male at birth but feel that they are female in their gender identity (referred to as Male-to-Female Gender Dysphoric or MtF) have two common presentations: Androphilic Type and Autogynephilic Type. A person who presents as Male-to-Female Androphilic Type is more of the direct parallel to the female-to-male discussed above. The androphilic person was viewed as more effeminate from a young age. As a boy, he often avoided physical rough play and may have shown a preference to dress in female attire, to take on a female persona in play/games, and to prefer being called a female name.31 This boy would often have a strong bond with his mother. The act of cross-dressing is not thought to be sexually arousing (in contrast to the autogynephilic type, which I describe below). If he tries romantic relationships it might be with another male, but same-sex relationships are not typically emotionally satisfying because he is looking for a male who is attracted to him as a female. As Blanchard puts it:
