Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)
Gender Dysphoria

In this chapter, there is one overarching diagnosis of gender dysphoria, with separate developmentally appropriate criteria sets for children and for adolescents and adults. The area of sex and gender is highly controversial and has led to a proliferation of terms whose meanings vary over time and within and between disciplines. An additional source of confusion is that in English “sex” connotes both male/female and sexuality. This chapter employs constructs and terms as they are widely used by clinicians from various disciplines with specialization in treating gender dysphoria. In this chapter, sex and sexual refer to the biological indicators of male and female (understood in the context of reproductive capacity), such as in sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia. Disorders of sex development or differences of sex development (DSDs) included the historical terms hermaphroditism and pseudohermaphroditism. DSDs include somatic intersex conditions such as congenital development of ambiguous genitalia (e.g., clitoromegaly, micropenis), congenital disjunction of internal and external sex anatomy (e.g., complete androgen insensitivity syndrome), incomplete development of sex anatomy (e.g., gonadal agenesis), sex chromosome anomalies (e.g., Turner syndrome; Klinefelter syndrome), or disorders of gonadal development (e.g., ovotestes).
Gender is used to denote the public, sociocultural (and usually legally recognized) lived role as boy or girl, man or woman, or other gender. Biological factors are seen as contributing, in interaction with social and psychological factors, to gender development. Gender assignment refers to the assignment as male or female. This occurs usually at birth based on phenotypic sex and, thereby, yields the birth-assigned gender, historically referred to as “biological sex” or, more recently, “natal gender.” Birth-assigned sex is often used interchangeably with birth-assigned gender. The terms assigned sex and assigned gender encompass birth-assigned sex/gender but also include gender/sex assignments and reassignments made after birth but during infancy or early childhood, usually in the case of intersex conditions. Gender-atypical refers to somatic features or behaviors that are not typical (in a statistical sense) of individuals with the same assigned gender in a given society and historical era; gender-nonconforming, gender variant, and gender diverse are alternative nondiagnostic terms. Gender reassignment denotes an official (and sometimes legal) change of gender. Gender-affirming treatments are medical procedures (hormones or surgeries or both) that aim to align an individual’s physical characteristics with their experienced gender. Gender identity is a category of social identity and refers to an individual’s identification as male, female, some category in between (i.e., gender fluid), or a category other than male or female (i.e., gender neutral). There has been a proliferation of gender identities in recent years. Gender dysphoria as a general descriptive term refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. However, it is more specifically defined when used as a diagnostic category. It does not refer to distress related to stigma, a distinct although possibly co-occurring source of distress. Transgender refers to the broad spectrum of individuals whose gender identity is different from their birth-assigned gender. Cisgender describes individuals whose gender expression is congruent with their birth-assigned gender (also nontransgender). Transsexual, a historic term, denotes an individual who seeks, is undergoing, or has undergone a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by gender-affirming hormone treatment and genital, breast, or other gender-affirming surgery (historically referred to as sex reassignment surgery).
Although not all individuals will experience distress from incongruence, many are distressed if the desired physical interventions using hormones and/or surgery are not available. The current term is more descriptive than the previous DSM-IV term gender identity disorder and focuses on dysphoria as the clinical problem, not identity per se.



Gender Dysphoria
Diagnostic Criteria

Gender Dysphoria in Children F64.2
• A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1):
– A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).
– In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
– A strong preference for cross-gender roles in make-believe play or fantasy play.
– A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
– A strong preference for playmates of the other gender.
– In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
– A strong dislike of one’s sexual anatomy.
– A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
• The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
Specify if:
• With a disorder/difference of sex development (e.g., a congenital adrenogenital disorder such as E25.0 congenital adrenal hyperplasia or E34.50 androgen insensitivity syndrome).
• Coding note: Code the disorder/difference of sex development as well as gender dysphoria.

Gender Dysphoria in Adolescents and Adults F64.0
• A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following:
– 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 of 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).
• The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
• With a disorder/difference of sex development (e.g., a congenital adrenogenital disorder such as E25.0 congenital adrenal hyperplasia or E34.50 androgen insensitivity syndrome).
• Coding note: Code the disorder/difference of sex development as well as gender dysphoria.
Specify if:
• Posttransition: The individual has transitioned to full-time living in the experienced gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one gender-affirming medical procedure or treatment regimen—namely, regular gender-affirming hormone treatment or gender reassignment surgery confirming the experienced gender (e.g., breast augmentation surgery and/or vulvovaginoplasty in an individual assigned male at birth; transmasculine chest surgery and/or phalloplasty or metoidioplasty in an individual assigned female at birth).

Specifiers
The specifier “with a disorder/difference of sex development” should be used in the context of individuals who have a specific and codable disorder/difference of sex development documented in their medical record.
The “posttransition” specifier may be used in the context of continuing treatment procedures that serve to support the new gender assignment.



Diagnostic Features
Individuals with gender dysphoria have a marked incongruence between the gender to which they have been assigned (usually based on phenotypic sex at birth, referred to as birth-assigned gender) and their experienced/expressed gender. This discrepancy is the core component of the diagnosis. There must also be evidence of distress about this incongruence. Experienced gender may include alternative gender identities beyond binary stereotypes. Consequently, distress may involve not only the experience that the individual is a male or female gender other than the one assigned at birth but also an experience that the individual is an intermediate or alternative gender that differs from the individual’s birth-assigned gender.
Gender dysphoria manifests itself differently in different age groups. The following examples may be less prominent in children raised in surroundings with fewer gender stereotypes.
Prepubertal individuals assigned female at birth with gender dysphoria may express a marked, persistent feeling or conviction that they are a boy, express aversion to the idea of being a girl, or assert they will grow up to be a man. They often prefer boys’ clothing and hairstyles, may be perceived by strangers as boys, and may ask to be called by a boy’s name. Sometimes they display intense negative reactions to parental attempts to have them wear dresses or other feminine attire. Some may refuse to attend school or social events where such clothes are required. These children may demonstrate marked gender nonconformity in role-playing, dreams, gender-typed play and toy preferences, styles, mannerisms, fantasies, and peer preferences. Contact sports, rough-and-tumble play, traditional boyhood games, and boys as playmates are most often preferred. They show little interest in stereotypically feminine toys (e.g., dolls) or activities (e.g., feminine dress-up or role-play). Occasionally, they refuse to urinate in a sitting position. Some may express a desire to have a penis or claim to have a penis or that they will grow one when older. They may also state that they do not want to develop breasts or menstruate.
Prepubertal individuals assigned male at birth with gender dysphoria may express a marked, persistent feeling or conviction that they are a girl or assert that they will grow up to be a woman. They may express aversion to the idea of being a boy. They often prefer dressing in girls’ or women’s clothes or may improvise clothing from available materials (e.g., using towels, aprons, and scarves for long hair or skirts). These children may demonstrate marked gender nonconformity in gender-typed play and toy preferences, styles, mannerisms, and peer preferences. They may role-play female figures (e.g., playing “mother”) and may be intensely interested in female fantasy figures. Traditional feminine activities, stereotypical games, and pastimes (e.g., “playing house”; drawing feminine pictures; watching television or videos of favorite female characters) may be preferred. Stereotypical female-type dolls (e.g., Barbie) may be favorite toys, and girls are their preferred playmates. They avoid rough-and-tumble play and have little interest in stereotypically masculine toys (e.g., cars, trucks). They may state that they find their penis or testes disgusting, that they wish them removed, or that they have, or wish to have, a vagina.
Increasingly, parents are presenting to specialized clinics after their child with gender dysphoria has already socially transitioned.
As the onset of puberty for individuals assigned female at birth is somewhere between ages 9 and 13, and between 11 and 14 for individuals assigned male at birth, their symptoms and concerns may arise in a developmental phase somewhere between childhood and adolescence. As secondary sex characteristics of younger adolescents are not yet fully developed, these individuals may not state dislike of them, but they may be markedly distressed by imminent physical changes.
In adolescents and adults with gender dysphoria, the discrepancy between experienced gender and physical sex characteristics is often, but not always, accompanied by a desire to be rid of primary and/or secondary sex characteristics and/or a strong desire to acquire some primary and/or secondary sex characteristics of another gender. To varying degrees, older adolescents and adults with gender dysphoria may adopt the behavior, clothing, and mannerisms of their experienced gender. They feel uncomfortable being regarded by others, or functioning in society, as members of their assigned gender. Some adults and adolescents may have a strong desire to be of a different gender and treated as such, and they may have an inner certainty to feel and respond as their experienced gender without seeking medical treatment to alter body characteristics. They may find other ways to resolve the incongruence between experienced/expressed and assigned gender by partially living in the desired role or by adopting a gender role neither conventionally male nor conventionally female.



Associated Features
When visible signs of puberty develop, individuals assigned male at birth may shave their facial, body, and leg hair at the first signs of growth. They sometimes bind their genitals to make erections less visible. Individuals assigned female at birth may bind their breasts, walk with a stoop, or use loose sweaters to make breasts less visible. Increasingly, adolescents request, or may obtain without medical prescription and supervision, drugs that suppress production of gonadal steroids (e.g., gonadotropin-releasing hormone [GnRH] agonists) or that block gonadal hormone actions (e.g., spironolactone). Clinically referred adolescents often want hormone treatment and many also wish for gender-affirming surgery. Adolescents living in an accepting environment may openly express the desire to be and be treated as their experienced gender and dress partly or completely as their experienced gender, have a hairstyle typical of their experienced gender, preferentially seek friendships with peers of another gender, and/or adopt a new first name consistent with their experienced gender. Older adolescents, when sexually active, often do not show or allow partners to touch their sexual organs. For adults with an aversion toward their genitals, sexual activity is constrained by the preference that their genitals not be seen or touched by their partners. Not infrequently, adults may seek hormone treatment (sometimes without medical prescription and supervision) and gender-affirming surgery. Others are satisfied with either hormone treatment or surgery alone, or without any gender-affirming medical treatment.
In children, adolescents, and adults with gender dysphoria, an overrepresentation of autism spectrum traits has been observed. Also, individuals with autism spectrum disorder are more likely to exhibit gender diversity.
Adolescents and adults with gender dysphoria before gender-affirming treatment and legal gender change are at increased risk for mental health problems including suicidal ideation, suicide attempts, and suicides. After gender reassignment, adjustment may vary, and suicide risk and mental health problems may persist.
In prepubertal children, increasing age is associated with having more behavioral or emotional problems; this is related to the increasing nonacceptance of gender-nonconforming behavior by others. Children and adolescents who feel supported and accepted in their gender nonconformity may show less or even no psychological problems.



Prevalence
There are no large-scale population studies of gender dysphoria. Based on gender-affirming treatment–seeking populations, the prevalence for gender dysphoria diagnosis across populations has been assessed to be less than 1/1,000 (i.e., <0.1%) for both individuals assigned male at birth and individuals assigned female at birth. Because many adults with gender dysphoria do not seek care at specialty treatment programs, prevalence rates are likely underestimates. Prevalence estimates based on surveys of self-reporting general population samples in the United States and Europe suggest higher numbers, although varied methods of assessment make comparisons difficult across studies. Self-identification as transgender ranges from 0.5% to 0.6%; experiencing oneself as having an incongruent gender identity ranges from 0.6% to 1.1%; feeling that one is a person of a different sex ranges from 2.1% to 2.6%; and the desire to undergo medical treatment ranges from 0.2% to 0.6%.



Development and Course
Because expression of gender dysphoria varies with age, there are separate criteria sets for children versus those for adolescents and adults. Criteria for children are defined in a more concrete, behavioral manner than those for adolescents and adults. Young children are less likely than older children, adolescents, and adults to express extreme and persistent anatomic dysphoria. In adolescents and adults, incongruence between experienced gender and assigned gender is a central feature of the diagnosis. Factors related to distress and impairment also vary with age. A very young child may show signs of distress (e.g., intense crying) only when parents tell the child that he or she is “really” not a member of another gender but only “desires” to be. Distress may not be manifest in social environments supportive of the child’s gender nonconformity and may emerge only if there is parental/social interference with the child’s gender variance. In adolescents and adults, distress may manifest because of strong incongruence between experienced gender and birth-assigned gender. Such distress may, however, be mitigated by supportive environments and knowledge that biomedical treatments exist to reduce incongruence. Impairment (e.g., school refusal, development of depression, anxiety, peer and behavioral problems, and substance abuse) may be a correlate of gender dysphoria.

Gender dysphoria without a disorder of sex development.
For clinic-referred children studied in Canada and the Netherlands, onset of gender-nonconforming behaviors is usually between ages 2 and 4 years. This corresponds to the developmental time period in which most children begin expressing gendered behaviors and interests. For some preschool-age children, both marked, persistent gender-atypical behaviors and the expressed desire to be another gender may be present, or labeling themselves as a member of another gender may occur. In other cases, the gender expression appears later, usually at entry into elementary school. Children may sometimes express discomfort with their sexual anatomy or will state the desire to have a sexual anatomy corresponding to their experienced gender (“anatomic dysphoria”). Expressions of anatomic dysphoria become more common as children with gender dysphoria approach and anticipate puberty.
No general population studies exist of adolescent or adult outcomes of childhood gender variance. Some prepubescent children expressing a desire to be another gender will not seek gender-affirming somatic treatments when they reach puberty. They frequently report nonheterosexual orientations and frequently marked gender-nonconforming behavior, although not necessarily a transgender identity in adolescence/young adulthood. Some children with gender dysphoria in childhood that remits in adolescence may experience a recurrence in adulthood.
In individuals assigned male at birth, studies from North America and the Netherlands found persistence ranged from 2% to 39%. In individuals assigned female at birth, persistence ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated with dimensional measures of severity ascertained at the time of a childhood baseline assessment. Early social transition may also be a factor in persistence of gender dysphoria in adolescence.
Studies have shown a high incidence of sexual attraction to those of the individual’s birth-assigned gender, regardless of the trajectory of the prepubescent child’s gender dysphoria. For individuals whose gender dysphoria continues into adolescence and beyond, most self-identify as heterosexual. In those who no longer have gender dysphoria by the time of adolescence, a majority self-identify as gay, lesbian, or bisexual.
Two broad trajectories have been described for development of gender dysphoria in individuals who identify as either male or female.
As opposed to gender-nonconforming children, individuals with prepubertal-onset gender dysphoria have symptoms that meet diagnostic criteria for gender dysphoria in childhood. The dysphoria can continue into adolescence and adulthood; alternatively, some individuals go through a period in which the gender dysphoria either desists or is denied. At such times, these individuals may self-identify as being gay or lesbian. Some may identify as heterosexual and cisgender. However, it is possible that some of these individuals may experience a recurrence of gender dysphoria later in life.
Regardless of whether the individual’s gender dysphoria persists or desists at a later date, either the onset of puberty or the realization that puberty will begin with development of secondary sex characteristics can prompt distressing feelings of gender incongruence that can exacerbate the individual’s gender dysphoria.
The early/prepubertal-onset group often present for clinical, gender-affirming care during childhood, during adolescence, or in young adulthood. This may reflect a more intense gender dysphoria compared with individuals with late/postpubertal-onset gender dysphoria, whose distress may be more variable and less intense.
Late-onset or pubertal/postpubertal-onset gender dysphoria occurs around puberty or even much later in life. Some of these individuals report having had a desire to be of another gender in childhood that was not expressed verbally to others or had gender-nonconforming behavior that did not meet full criteria for gender dysphoria in childhood. Others have no recollection of any signs of childhood gender dysphoria. Parents of individuals with gender dysphoria of pubertal/postpubertal-onset often report surprise, as they saw no signs of gender dysphoria during childhood.

Gender dysphoria in association with a disorder of sex development.
Individuals with DSDs who require early medical intervention or decisions about gender assignment come to clinical attention at an early age. Depending on the condition, they may have been gonadectomized (often because of risk of future malignancy) before puberty so that administration of exogenous hormones is part of routine care to induce puberty. Infertility is common whether due to the condition itself or to gonadectomy, and genital surgery may have been done in infancy or childhood with the intent of affirming the assigned gender to both the affected individual and caregivers.
Affected individuals may exhibit gender-nonconforming behavior starting in early childhood in a manner that is predictable depending on the specific DSD syndrome and the gender assignment, and thresholds for supporting social and medical gender transition in minors have traditionally been much lower for those with compared to those without DSDs. As individuals with some DSD syndromes become aware of their condition and medical history, many experience uncertainty about their gender, as opposed to developing a firm conviction that they are of another gender. The proportion who develop gender dysphoria and progress to gender transition varies markedly depending on the particular syndrome and gender assignment.



Risk and Prognostic Factors
Temperamental.
Gender-variant behavior among individuals with prepubertal-onset gender dysphoria can develop in early preschool age. Studies suggest that a greater intensity of gender nonconformity and an older age at presentation make persistence of gender dysphoria into adolescence and adulthood more likely. A predisposing factor under consideration, especially in individuals with postpubertal-onset gender dysphoria (adolescence, adulthood), includes history of transvestism that may develop into autogynephilia (i.e., sexual arousal associated with the thought or image of oneself as a woman).

Environmental.
Individuals assigned male at birth with gender dysphoria without a DSD (in both childhood and adolescence) more commonly have older brothers when compared with cisgender males.

Genetic and physiological.
For individuals with gender dysphoria without a DSD, some genetic contribution is suggested by evidence for (weak) familiality of gender dysphoria among nontwin siblings, increased concordance for gender dysphoria in monozygotic compared with dizygotic same-sex twins, and some degree of heritability of gender dysphoria. Research suggests that gender dysphoria has a polygenetic basis involving interactions of several genes and polymorphisms that may affect in utero sexual differentiation of the brain, contributing to gender dysphoria in individuals assigned male at birth.
As to endocrine findings in individuals with gender dysphoria, no endogenous systemic abnormalities in sex-hormone levels have been found in 46,XY individuals, whereas there appear to be increased androgen levels (in the range found in hirsute women but far below normal male levels) in 46,XX individuals. Overall, current evidence is insufficient to label gender dysphoria without a DSD as a form of intersexuality limited to the central nervous system.
In gender dysphoria associated with a DSD, the likelihood of later gender dysphoria is increased if prenatal production and utilization (via receptor sensitivity) of androgens are grossly variant relative to what is usually seen in individuals with the same assigned gender. Examples include 46,XY individuals with a history of normal male prenatal hormone milieu but inborn nonhormonal genital defects (as in cloacal bladder exstrophy or penile agenesis) and who have been assigned to the female gender. The likelihood of gender dysphoria is further enhanced by additional, prolonged, highly gender-variant postnatal androgen exposure with somatic virilization as may occur in female-raised and noncastrated 46,XY individuals with 5-alpha reductase-2 deficiency or 17-beta-hydroxysteroid dehydrogenase-3 deficiency or in female-raised 46,XX individuals with classical congenital adrenal hyperplasia with prolonged periods of nonadherence to glucocorticoid replacement therapy. However, the prenatal androgen milieu is more closely related to gendered behavior than to gender identity. Many individuals with DSDs and markedly gender-variant behavior do not develop gender dysphoria. Thus, gender-nonconforming behavior by itself should not be interpreted as an indicator of current or future gender dysphoria. There appears to be a higher rate of gender dysphoria and patient-initiated gender change from assigned female to male than from assigned male to female in individuals prenatally exposed to a full complement of masculinizing hormonal influences.



Culture-Related Diagnostic Issues
Individuals with gender dysphoria have been reported across many countries and cultural contexts around the world. The equivalent of gender dysphoria has also been reported in individuals living in cultural contexts with institutionalized gender identity categories other than men/boys or women/girls that sanction gender nonconforming development. These include India, Sri Lanka, Myanmar, Oman, Samoa, Thailand, and Indigenous Peoples of North America. It is unclear however, in such cultural contexts, whether the diagnostic criteria for gender dysphoria would be met with these individuals.
The prevalence of coexisting mental health problems differs among cultures; these differences may also be related to differences in attitudes toward gender nonconformity in children, adolescents, and adults. However, also in some non-Western cultures, anxiety has been found to be relatively common in individuals with gender dysphoria, even in cultures with accepting attitudes toward gender-variant behavior.



Sex- and Gender-Related Diagnostic Issues
Sex differences in rate of referrals to specialty clinics vary by age group. In children, sex ratios of individuals assigned male at birth to individuals assigned female at birth range from 1.25:1 to 4.3:1. Studies show increasing numbers of children and adolescents presenting to specialty clinics, presentation at younger ages, more frequent early social transition, and a shift to a greater number of individuals assigned female at birth in adolescents and young adults than individuals assigned male at birth. In adults, estimates generally suggest more individuals assigned male at birth seek gender-affirming treatment, with ratios ranging from 1:1 to 6.1:1 in most studies in the United States and Europe.



Association With Suicidal Thoughts or Behavior
Rates of suicidality and suicide attempts for transgender individuals are reported to range from 30% to 80%, with risk factors including past maltreatment, gender victimization, depression, substance abuse, and younger age. Transgender adolescents referred to gender clinics have substantially higher rates of suicidal thoughts and behaviors when compared with nonreferred adolescents. Prior to receiving gender-affirming treatment and legal gender reassignment, adolescents and adults with gender dysphoria are at increased risk for suicidal thoughts and suicide attempts. After gender-affirming treatment, adjustment varies, and while improvement in coexisting symptoms is often seen, some individuals continue to experience prominent anxiety and affective symptoms and remain at increased risk for suicide.
A study of 572 children referred for gender identity concerns in Canada and several comparison groups (siblings, other referred children, and nonreferred children) largely from other high-income countries found that gender-referred children were 8.6 times more likely to self-harm or attempt suicide than comparison children, even after adjustment for overall behavior and peer relationship problems, and particularly in the second half of childhood. Among adolescents, the highest rate of suicide attempt is among transgender young men, followed by those defining themselves as neither male nor female.



Functional Consequences of Gender Dysphoria
Gender nonconformity may appear at all ages after the first 2–3 years of childhood and may interfere with daily activities. In older children, gender nonconformity may affect peer relationships and may lead to isolation from peer groups and to distress. Many children experience teasing and harassment or pressure to dress in attire associated with their birth-assigned sex, especially when growing up in a nonsupportive and nonaccepting environment. Also in adolescents and adults, the distress resulting from gender incongruence often interferes with daily activities. Relationship difficulties, including sexual relationship problems, are common, and functioning at school or at work may be impaired. Gender dysphoria is associated with high levels of stigmatization, discrimination, and victimization, leading to negative self-concept, increased rates of depression, suicidality, and other mental disorder co-occurrence, school dropout, and economic marginalization, including unemployment, with attendant social and mental health risks, especially in individuals who lack family or social support. In addition, these individuals’ access to health services and mental health services may be impeded by structural barriers, such as institutional discomfort about, inexperience with, or hostility toward working with this patient population.



Differential Diagnosis
Nonconformity to gender roles.
Gender dysphoria should be distinguished from simple nonconformity to stereotypical gender role behavior by the strong desire to be of another gender than the assigned one and by the extent and pervasiveness of gender-variant activities and interests. The diagnosis is not meant to merely describe nonconformity to stereotypical gender role behavior (e.g., “tomboyism” in girls, “girly-boy” behavior in boys, occasional cross-dressing in adult men). Given the increased openness of gender-diverse expressions by individuals across the entire range of the transgender spectrum, it is important that the clinical diagnosis be limited to those individuals whose distress and impairment meet the specified criteria.

Transvestic disorder.
Transvestic disorder is diagnosed in heterosexual (or bisexual) adolescent and adult males (rarely in females) for whom women’s clothing generates sexual excitement and causes distress and/or impairment without drawing their assigned gender into question. It is occasionally accompanied by gender dysphoria. An individual with transvestic disorder who also has clinically significant gender dysphoria can be given both diagnoses. In some cases of postpubertal-onset gender dysphoria in individuals assigned male at birth who are attracted to women, cross-dressing with sexual excitement is a precursor to the diagnosis of gender dysphoria.

Body dysmorphic disorder.
An individual with body dysmorphic disorder focuses on the alteration or removal of a specific body part because it is perceived as abnormally formed, not because it represents a repudiated assigned gender. When an individual’s presentation meets criteria for both gender dysphoria and body dysmorphic disorder, both diagnoses can be given. Individuals wishing to have a healthy limb amputated (termed by some body integrity identity disorder) because it makes them feel more “complete” usually do not wish to change gender, but rather desire to live as an amputee or a disabled person.

Autism spectrum disorder.
In individuals with autism spectrum disorder, diagnosing gender dysphoria can be challenging. It can be difficult to differentiate potential co-occurring gender dysphoria from an autistic preoccupation because of the concrete and rigid thinking around gender roles and/or poor understanding of social relationships characteristic of autism spectrum disorder.

Schizophrenia and other psychotic disorders.
In schizophrenia, there may rarely be delusions of belonging to some other gender. In the absence of psychotic symptoms, insistence by an individual with gender dysphoria that he or she is another gender is not considered a delusion. Schizophrenia (or other psychotic disorders) and gender dysphoria may co-occur. Gender-themed delusions may occur in up to 20% of individuals with schizophrenia. They can usually be differentiated from gender dysphoria by their bizarre content and by waxing and waning with remissions and exacerbations of psychotic episodes.

Other clinical presentations.
Some individuals with an emasculinization desire who develop an alternative, nonmale/nonfemale gender identity do have a presentation that meets criteria for gender dysphoria. However, some males seek genital surgery for either aesthetic reasons or to remove psychological effects of androgens without changing male identity; in these cases, the criteria for gender dysphoria are not met.



Comorbidity
Clinically referred children with gender dysphoria show elevated levels of anxiety, disruptive, impulse-control, and depressive disorders. Autism spectrum disorder is more prevalent in clinically referred adolescents and adults with gender dysphoria than in the general population. Clinically referred adolescents and adults with gender dysphoria often have high rates of associated mental disorders, with anxiety and depressive disorders being the most common. Individuals who have experienced harassment and violence may also develop posttraumatic stress disorder.



Other Specified Gender Dysphoria F64.8
This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The other specified gender dysphoria category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dysphoria” followed by the specific reason (e.g., “brief gender dysphoria,” in which symptoms meet full criteria for gender dysphoria but the duration is less than the required 6 months).



Unspecified Gender Dysphoria F64.9