research paper about gender dysphoria

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The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis

Kate cooper.

a Centre for Applied Autism Research, Department of Psychology, University of Bath, BA2 7AY, UK

Ailsa Russell

William mandy.

b UCL Research Department of Clinical, Educational, and Health Psychology, Gower Street, London WC1E 6BT, UK

Catherine Butler

c Department of Psychology, University of Bath, BA2 7AY, UK

Gender dysphoria is distress due to a discrepancy between one's assigned gender and gender identity. Adults who wish to access gender clinics are assessed to ensure they meet the diagnostic criteria for gender dysphoria. Therefore, the definition of gender dysphoria has a significant impact on the lives of individuals who wish to undergo physical gender transition. This systematic review aimed to identify and synthesize all existing qualitative research literature about the lived experience of gender dysphoria in adults. A pre-planned systematic search identified 1491 papers, with 20 of those meeting full inclusion criteria, and a quality assessment of each paper was conducted. Data pertaining to the lived experience of gender dysphoria were extracted from each paper and a meta-ethnographic synthesis was conducted. Four overarching concepts were identified; distress due to dissonance of assigned and experienced gender; interface of assigned gender, gender identity and society; social consequences of gender identity; internal processing of rejection, and transphobia. A key finding was the reciprocal relationship between an individual's feelings about their gender and societal responses to transgender people. Other subthemes contributing to distress were misgendering, mismatch between gender identity and societal expectations, and hypervigilance for transphobia.

• • A systematic review of all papers on the lived experience of gender dysphoria
• • Twenty papers with 1606 participants were included in a meta-ethnographic synthesis.
• • Distress was due to gender and sex incongruence, as well as social factors.
• • Results give new insights into the relationships between factors causing distress.

1. Introduction

Transgender is an umbrella term used to describe individuals who have a gender identity which does not align with their assigned gender. Gender dysphoria in adolescents and adults is defined in the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013 ) as marked incongruence between an individual's gender identity and assigned gender with associated distress or impairment; see Table 1 for further details of DSM-5 criteria for gender dysphoria in adolescents and adults. A UK survey found that 1% of adults were gender diverse, or transgender, but it is not known what proportion of these had gender dysphoria ( Reed, Rhodes, Schofield, & Wylie, 2009 ). This is in line with a recent review which suggested that between 0.5 and 1.3% of children, adolescents, and adults self-report a transgender identity ( Zucker, 2017 ). In the Netherlands the prevalence of gender dysphoria was 0.6% in adult natal males, and 0.2% in adult natal females, while 3.2% of adults assigned female at birth and 4.6% assigned male at birth reported an equal identification with each gender or “ambivalent gender identity” ( Kuyper & Wijsen, 2014 ).

Definitions.

The DSM-III (3rd ed.; DSM–III ; American Psychiatric Association, 1980 ) was the first edition of the DSM to include a gender-related diagnosis, called Transsexualism located within the “psychosexual disorders” category. The adult diagnosis of transsexualism referred to “discomfort and inappropriateness” of one's biological sex alongside the wish to be rid of one's genitals and live in one's gender identity. Many changes have been made to the diagnostic criteria since this time ( Beek, Cohen-Kettenis, & Kreukels, 2016 ). In the DSM-IV (4th ed.; DSM–IV ; American Psychiatric Association, 1994 ), the diagnostic terminology was changed and transsexualism became “Gender Identity Disorder”, but the focus on distress in relation to one's assigned gender remained a core component of diagnosis, as it continues to be in the DSM-5. Corneil, Eisfeld, and Botzer (2010) state that it is important to differentiate between transgender individuals who experience distress and those who do not. They argue this helps to normalize transgender identities and highlight that these cause distress in some, but not all cases. Significantly, the DSM-5 gender dysphoria diagnosis now accommodates a spectrum of gender identities, although the wording remains binary, referring to the other gender. This means that non-binary individuals who experience distress in relation to their gender identity can now be diagnosed and more readily receive support for gender dysphoria within the standard healthcare model. See Zucker et al. (2013) for a detailed description of the justification of changes to the diagnostic criteria from DSM IV to DSM-5.

The most recent DSM-5 classification for Gender Dysphoria published in 2013 is contentious ( Davy & Toze, 2018 ). Critics state that including gender dysphoria in the DSM implies that having a transgender identity is a mental health problem, although the DSM is clear that only cases where there is distress or impairment would meet criteria for a diagnosis, while proponents highlight that in current medical practice, diagnosis is a requirement for access to appropriate medical support ( Drescher, 2010 ). Indeed, in most settings a diagnosis of gender dysphoria is a prerequisite for receiving gender-focused support from healthcare services. This is in line with the World Professional Association for Transgender Health (WPATH) Standards of Care ( Coleman et al., 2012 ), although some authors have argued an assessment but not necessarily a diagnosis of gender dysphoria is required according to these guidelines ( Ashley, 2019 ). Therefore, the way in which gender dysphoria is defined affects service provision and availability. Intervention for gender dysphoria ranges from the provision of psychological support to explore gender identity or to make the social transition to live as one's affirmed gender identity, to medical interventions to enable the biological affirmation to one's gender identity through hormone treatment or gender affirming surgery ( Coleman et al., 2012 ).

Gender diversity is not considered a mental health problem. However, transgender people are more likely to experience mental health problems than the general population ( Downing & Przedworski, 2018 ). Individuals with gender dysphoria are also more likely to experience mental health problems, most commonly anxiety and depression ( Dhejne, Van Vlerken, Heylens, & Arcelus, 2016 ). In terms of well-being following transition, a study using the Amsterdam Cohort of Gender Dysphoria from 1972 to 2015 found that of individuals who received a gonadectomy, 0.6% of transwomen and 0.3% of transmen experienced regret ( Wiepjes et al., 2018 ). A meta-analysis investigating mental health quality of life in treatment-seeking transgender adults supported Dhejne et al.'s findings, as mental health quality of life was lower in the transgender population compared to controls ( Nobili, Glazebrook, & Arcelus, 2018 ). The authors then investigated quality of life following cross-sex hormonal treatment; seven studies were included, and mental health quality of life was found to significantly improve following treatment ( Nobili et al., 2018 ).

Some researchers have suggested that higher rates of mental health problems in the transgender population are linked to gender minority stress, or the experiences of stigma and discrimination transgender and gender nonconforming individuals experience which contribute to poor mental health ( Meyer, 2015 ; Testa, Habarth, Peta, Balsam, & Bockting, 2015 ). This has been supported by studies which have found associations in the transgender population between mental health conditions and level of social stigma experienced by participants due to their gender identity ( Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013 ). One example of a social stressor experienced by some transgender individuals is “misgendering” or being treated as or labelled a different gender to their own gender identity. Frequency of experiences of being misgendered, as well as feelings of being stigmatized, have been found to be positively associated with psychological distress in the transgender population ( McLemore, 2018 ).

These high rates of mental health problems need to be better understood through an investigation of the mechanisms contributing to distress in this population. Described above are two distinct conceptualizations of the experience of gender-related distress in individuals with gender dysphoria. There is the diagnostic conceptualization of dysphoria related to a discrepancy between assigned and experienced gender, as defined in diagnostic manuals such as the DSM-5 (5th ed.; DSM-5; American Psychiatric Association, 2013 ), and a more social, stigma focused understanding of distress as described by gender minority stress theory ( Meyer, 2015 ). It is not currently clear how these two forms of distress relate to one another. Zucker, Wood, and VanderLaan (2014) highlight that there is a lack of research investigating distress which is a direct result of gender dysphoria in children and adolescents, and we argue that the same gap is apparent in the adult literature. Given the rapidly increasing societal awareness of transgender identities (e.g. Steinmetz, 2014 ), and substantial increase in referrals to gender clinics (e.g. Aitken et al., 2015 ; Wiepjes et al., 2018 ), it is important to have an up-to-date understanding of the experience of gender dysphoria as described by the individuals themselves. This will help to guide care in clinical settings where an unprecedented number of referrals are being received, and ensure that the current understanding of gender dysphoria according to rigorous research findings is current. Therefore a contemporary systematic review of the phenomenology of gender related distress is critical to improve, update and develop coherence around our understanding of the experience of gender dysphoria, to ensure that it is conceptualized in a consistent way and in line with the current social context.

Scientific research has played an important role in clearly defining gender dysphoria and investigating the efficacy of various treatments for this group. There has been an emphasis on opinion pieces and narrative reviews compared to original empirical studies. A review of primary published literature on gender dysphoria from 1970 to 2011 found that the most common study type published was narrative review at 29% or 479 articles and that commentaries made up a further 7.5% or 124 papers ( Eftekhar et al., 2015 ). Empirical studies based on original data made up a smaller proportion of research at 34% or 555 articles, including qualitative studies, cross-sectional studies, cohort studies, case control studies and clinical trials. The least common method employed was systematic review at 0.4% or 6 articles. Narrative reviews allow authors to select the research they feel has the most value and to summarize this research, which increases the risk of bias in the review (e.g. Littell, 2008 ). There have not been any systematic reviews focused on the phenomenology of gender related-distress, despite distress related to gender identity being a central criterion for individuals hoping to access gender clinics. Given the high level of controversy and emotive nature of this particular research area, it is especially important that more systematic methods are utilized in order to reduce the likelihood of researcher bias and to improve the quality of evidence available.

Systematic reviews employ a replicable search strategy, with a clearly defined screening method to select papers relevant to the review question following predefined inclusion and exclusion criteria ( Moher et al., 2015 ). This significantly reduces the likelihood of bias in terms of studies included in the review. When qualitative evidence requires synthesis, standardized protocols can be followed such as meta-ethnography (Noblit & Hare, 1988), a widely used method of qualitative research synthesis, which ensures a high level of methodological rigor in the synthesis of qualitative results.

This study aims to systematically review and synthesize existing qualitative literature regarding the phenomenology of gender dysphoria in adults. This will result in a deeper and empirically informed understanding of the lived experience of gender related distress, focusing on the cognitive, psychological and physical experiences associated with gender dysphoria. 1

The methods section was developed using the ENTREQ guidelines ( Tong, Flemming, McInnes, Oliver, & Craig, 2012 ), which aim to standardize the reporting of qualitative syntheses. A protocol for this study was pre-registered on PROSPERO (CRD42019140899). The theoretical basis for the qualitative synthesis was interpretive constructivism ( Rubin & Rubin, 2012 ). Interpretive constructivism acknowledges that the findings regarding the phenomenology of gender dysphoria from the studies reviewed will have multiple and at times conflicting perspectives, which can exist alongside one another.

A meta-ethnography approach was selected for the current study ( Noblit & Hare, 1988 ). This entailed conducting a structured analysis for synthesising research about the phenomenology of gender dysphoria in transgender individuals. This methodology allowed for a” line-of-argument” synthesis, which allowed for the development of an integrating scheme which furthered understanding of the phenomena under investigation. A systematic search and screening against pre-defined criteria preceded a thorough synthesis of qualitative studies investigating the experience of gender dysphoria.

2.1. Inclusion criteria

The inclusion criteria were developed in order to identify in-depth qualitative data about the experience of gender dysphoria in transgender individuals (see Table 2 ). Gender-related distress was operationally defined as any negative emotions directly related to gender identity in transgender individuals. This broad definition of gender dysphoria was selected rather than attempting to apply diagnostic criteria in order to include a wide range of studies, and also in acknowledgement of the rapidly changing cultural understanding of gender diversity.

Inclusion and exclusion criteria.

2.2. Search strategy

We developed a pre-planned search strategy, using MEDLINE, PsycINFO, Embase and Web of Science and the search terms in Table 3 . A preliminary search on PubMed with the following terms: (((((((qualitative) OR interview) OR "focus group") OR experience) OR phenomenolog*)) AND (((((((((distress) OR "mental health") OR depression) OR "low mood") OR discomfort) OR dysphoria)) AND (((((((Transgender) OR "gender nonconforming") OR “gender atypical”) OR “gender variant”) OR non-binary) OR genderqueer))) OR (((transsexual*) OR "gender identity disorder") OR "gender dysphoria"))).

Planned search terms and criteria for review.

The searches were conducted in July 2019, and 1741 records were identified, reducing to 1370 once duplicates were removed. The searches were updated and run again in October 2019. This identified 121 new papers since the July search. Non-published “grey” literature was not included in the present study. The reference sections of included papers were scanned for further published studies that might meet inclusion criteria.

2.3. Screening

A total of 85 studies went to full text review. See Fig. 1 for further details of the identification, screening, and eligibility assessment of papers in this study. The first round of screening involved reading the title and abstract of identified references to assess whether papers met the above criteria. Where further information was required, the full text was assessed in the second screening round using the same method.

Identification, screening and eligibility of studies in the systematic review.

Twenty studies were included in the analysis, which included 1606 transgender participants in total. All studies which met the inclusion criteria were published from 2009 onwards. See Appendix A for details of each included study.

2.4. Inter-rater reliability

The first author screened studies using the inclusion and exclusion criteria, and a second researcher screened 10% of these. Discrepancies were resolved using a pre-defined strategy. Any disagreements between the two screeners were resolved by discussion. Where an agreement could not be reached, the final author was consulted. Agreement between the two researchers was measured; there was 99.3% agreement between the two researchers (Cohen's Kappa = 0.85), indicating near perfect agreement.

2.5. Data extraction

A data table was developed for the purpose of this study. As well as including data for the qualitative synthesis, the following data were collected: Author name(s); Year published; Title; Journal; Setting; Participant group (i.e. binary or non-binary participants, transgender women etc.); Number of participants; Qualitative methodology; Interview type (see Appendix A ). Data in the results and discussion section of the study pertaining to the inner experience of gender dysphoria were extracted. Specifically, data regarding the thoughts, feelings, and sensations that come with having a transgender identity and being distressed about this were included, but not broader data about the experience of accessing healthcare or education experiences. Once analysis had begun and the initial concepts were identified, a table was constructed to look at whether and how each study represents data pertaining to each concept ( Britten et al., 2002 ).

2.6. Quality assessment

The widely used CASP checklist ( Critical Appraisal Skills Programme, 2018 ) was used to assess the quality of studies included in the review (see Appendix B ). All studies were included in the synthesis irrespective of quality, but the CASP checklist results were considered carefully when conducting the data coding and synthesis. The CASP checklist was used to assess whether each included study had a clear statement of aims; used an appropriate methodology; had an appropriate research design and recruitment strategy; considered data collection, research relationships and ethical issues; analyzed data rigorously; stated findings clearly; and had value. Each item was given a score of 0–2 dependent on the quality of information provided in each category, see Duggleby et al. (2010) , with 2 representing higher quality and 0 lower quality. 10% of the studies were inter-rated by the final author, following the process outlined in the “screening” section, and inter-rater reliability was good (Cohen's Kappa = 0.67).

2.7. Data analysis

Data were coded and translated inductively based on Noblit and Hare (1988) , commencing with familiarization with each of the papers. The experiences of gender dysphoria in transgender individuals were the focus of the analysis. It is important to note at this stage the relationship between the following concepts:

• • First order constructs, or participant responses
• • Second order constructs, or how the original authors interpreted these responses
• • Third order constructs, or how the review authors interpret the second order constructs

Line-by-line coding was conducted to search for first order and second order concepts related to the target phenomena, i.e. inner experiences of gender dysphoria (e.g. Rice, 2002 ). Each study was analyzed in this way until the concepts from each paper were identified. This was done by the first author and the final author coded a subset of included papers. The second order constructs were used for the meta-synthesis, but the first order constructs were noted in order to ensure that the second order constructs accurately represented what the participants had said and demonstrated significant depth of description. In cases where the first order construct was not thought to align well with the corresponding second order construct, the second order construct was not included in the analysis.

Next concepts which recurred across multiple studies were used to translate the findings between each study (e.g. Britten et al., 2002 ). Concepts which were shared among studies were grouped together when their themes were similar to one another. This was done through an iterative process of grouping concepts together and reading and re-reading the included studies to ensure that concepts that were grouped together were done so in a meaningful way ( Toye et al., 2014 ). A summary of the concept from each relevant paper was written in the format of either a quote from the source paper or a summary written by the research team. Summaries used the original authors' words where possible.

A translational synthesis was undertaken, whereby included papers had sufficiently similar themes to be grouped together and resulted in a line of argument synthesis. At this stage, third order constructs were created to synthesize the findings of all the papers. The third order constructs were developed by the first author and then discussed in depth with the other authors. The authors discussed any differences in their understanding of the concepts and second order constructs of the included papers, and the third order constructs were refined until the authors reached agreement. Third order constructs would be divided into two types; subordinate themes and overarching themes which shaped the overall synthesis and findings. These over-arching themes represented the line of argument stage of the synthesis. At this point the synthesis was written in narrative form by the first author, and this synthesis described the concepts, second order, and third order constructs identified in the meta-synthesis. The narrative synthesis was then read and agreed upon by all the authors.

We identified four key concepts in the analysis, with twelve sub-themes. The overarching concepts identified were” distress due to dissonance of assigned and experienced gender”‘, “interface of assigned gender, gender identity, and society”,” negative social consequences of gender identity” and” internal processing of rejection and transphobia”. See Table 4 for an overview of the third order constructs we identified.

Overarching concepts and sub-themes.

3.1. Distress due to dissonance of assigned and experienced gender

The first concept we identified was participants' negative feelings about the mismatch between their gender identity and body. These feelings included gender-focused and body-focused distress which were interrelated. Participants experienced distress, conflict, confusion, and denial related to their gender identity, and as well as body dysphoria and disconnection. These feelings had consequences such as suicidal ideation and fear for the future.

The most prominent sub-theme we identified was body dysphoria, which included the unease, dysphoria, hatred, and disgust participants felt towards their bodies. The focus was frequently on the genitals and secondary sex characteristics such as the chest and body and facial hair, with some attempts to suppress these features. Studies identified a range of negative feelings towards the body from being troubled, experiencing discomfort, a destabilized sense of self, to disgust, hatred, and existential crisis. These feelings sometimes led to participants' attempts to suppress their femininity or masculinity, for example through restricting food intake to minimize the appearance of breasts. Some individuals also experienced detachment from the body. This referred to the sense of disconnection from the physical self which resulted from body and gender dissonance. The word” disembodiment” was used in two of the three studies which referred to detachment, and underlines the force of this feeling for participants, who felt such a powerful sense of gender dissonance that they experienced a total break between their sense of self and physical body. For some participants, this feeling of disgust towards their body led to suicidal thoughts or self-harm; individuals felt that death was preferable to continuing to live in their body.

The next subtheme was gender distress, which refers to distress relating to participants' gender identity, which in some participants extended to thoughts of death and suicide. Multiple papers described distress following conflict between participants' gender assigned at birth and self-concept, with the sense that this could be destabilizing and cause an existential crisis. Emotions reported included depression, anxiety, disappointment, and self-hatred, and these feelings could be overwhelming and tumultuous. One paper looked at the experience of transgender individuals undergoing transition and found that negative emotions were particularly experienced pre- and during transition, becoming less prominent post-transition.

The sense of conflict between participants' body and gender was a prominent sub-theme, with studies describing a mismatch between individuals' gender identities and anatomy, leading to feelings of dissonance, conflict, and distress. A range of vocabulary was used to describe this dissonance, demonstrating a spectrum of feelings from discomfort to significant distress and struggle. This use of the words” struggle” and” conflict” suggests that some people experienced the difference between their gender identity and bodies as something to be struggled against and overcome, with the implication that an internal conflict could lead to changes that would resolve the struggle. One paper highlighted that the distance between a person's gender identity and their experiences of their own body contributed to the intensity of gender dysphoria. Some papers conceptualized the dissonance as being between body and mind, whereas other focused more specifically on body and sense of self or gender identity. This dissonance was identified by non-binary participants as well as binary-identified participants.

The next subtheme we identified was confusion or uncertainty about gender identity which is experienced as distressing. Participants reported that they needed more support from society or from family members in order to understand their feelings about their gender. There was an implication that there are societal norms around being "certain” of one's gender identity or that one should conform to gender norms, and that transgressing societal expectations was therefore experienced as confusing and disorientating. It is of note that even a sense of uncertainty was experienced as distressing in contexts where the dominant narrative is that gender identity is fixed and in line with one's sex, and therefore certain.

Denial and suppression were another prominent feature of the studies, with denial of an individual's true gender identity leading to attempts to suppress it. This brought participants feelings of stress and of not being true to one's identity. In all the studies which discussed this theme there was the sense that transgender identities caused feelings of shame in participants due to negative views of transgender identities in society, or that suppressing one's gender identity was necessary to be accepted by others. Participants also felt shame around the suppression of their gender identity, implying that they felt caught between two contradictory ways of conceptualizing and expressing their gender identity, on the one hand conforming to traditional gender norms and suppressing their identity, and on the other hand fully embracing their gender identity.

The last sub-theme we identified within this concept was fear of the future. This referred to participants' difficulties envisaging how to navigate their gender identities, with a sense of hopelessness or fear for the future. This theme encapsulated the lack of control and anxiety transgender individuals felt about making life-altering decisions when they became more certain about their gender identity. Considering the earlier themes of death sometimes feeling preferable to continuing in one's current body, and the confusion or denial and suppression that comes with dissonance of assigned and experienced gender, huge emotional weight was associated with future-decision making for this group. While many participants were desperate to change their bodies and gender expression, for some this was associated with a fear of stepping into the unknown and of transgressing social norms.

3.2. Interface of assigned gender, gender identity, and society

The second concept we identified was the interface of assigned gender, gender identity, and society. This concept acknowledges the social nature of gender identity. Gender norms are culturally defined expectations about how gender-related behaviors and gender expression are interpreted. An individual's gender expression is interpreted by others using gender norms to work out their likely gender identity. The dissonance that the transgender individual experiences around their assigned gender and gender identity may be experienced by those they interact with, who may be unsure how to label the transgender person. The transgender individual who is undergoing transition wants to be seen as belonging to their experienced gender group and treated as such. In order to achieve this aim, individuals may wish to change others' perceptions of their body, and therefore others' perceptions of their gender expression. This concept underscores the effect of binary gender norms (i.e. the idea that gender is binary, either male or female) on the transgender individual, who may struggle with having a different gender journey to the dominant narratives around gender. These experiences of the interface of body, personal identity, and societal norms and responses to the individual led to a sense of not fitting in and transgressing societal norms, and a fear of others shaming or misgendering the individual. There are reciprocal relationships between feelings about the body, gender expression, and reactions of others. For example, an individual who is misgendered may then begin to feel higher levels of body dysphoria and conflict between their assigned and experienced gender. Moreover, feelings of anxiety or confusion around one's gender identity could affect an individual's gender expression, thereby shaping the social responses of people the transgender individual interacts with.

The first sub-theme was distress due to misgendering. This related to participants' fear of others misreading their gender identity and experiencing distress when this occurred, with a feeling of responsibility to ensure misgendering did not occur. A number of the studies identified feelings of fear, distress, embarrassment, anxiety, and stress at the thought or reality of being identified as belonging to a gender group which does not align with one's identity. Studies identified anticipatory fear of being misgendered or placing pressure on oneself to “pass” as one's gender identity, with some participants reporting suicidal ideation if they were not successful in this aim. This was linked with the earlier theme of body dysphoria and conflict of body and gender, as participants would measure their success in changing their bodies or gender expression by the reactions of others. Participants expressed fear of being labelled as transgender by others, with an implicit sense that this is a shameful, negative label. Moreover, participants wanted to be affirmed in their gender identity by others. This theme linked with the sense of struggle identified within the first theme, with misgendering being something that participants aimed to overcome. This demonstrates the complex interplay between gender identity, gender expression, and social interactions with others, with an individual's own sense of dissonance and negative feelings about their bodies and gender identity potentially being exacerbated by the reactions of other people. This theme has an emphasis on emotions linked to anxiety, suggesting that participants would spend time trying to predict and control the reactions of others.

The second sub-theme was the mismatch between participants' gender identity and societal expectations. This theme captured the dissonance between the individual's gender and societal expectations, rather than dissonance around the individual's own body and gender identity. Dominant social narratives that gender identity and biological sex should align did not fit the transgender person, which resulted in conflict and sadness. This links to the earlier theme of confusion, whereby participants were unsettled by their gender identity not aligning with societal expectations. Studies described participants' experience that they had been socialized to the incorrect gender, which caused dissonance and distress. This relates to the earlier theme of participants' suppression or denial of their gender identity, which happened as a result of not fitting societal norms. Furthermore, social interactions triggered gender dysphoria, and participants experienced shame and self-hatred when they perceived that others were looking at them and assessing their gender. Transgender individuals expected to be rejected due to the prevalence of binary gender norms, and so did not feel able to share their thoughts and feelings about their gender, even with close family members. Transgender men who chose to become pregnant felt isolated by the gender binary, as they did not conform to gender norms around parenthood. Therefore, societal expectations that assigned gender and gender identity should align, and that others should act in a gender conforming way, led participants to experience more negative feelings about their own gender identity, with shame being an important emotion in this process.

3.3. Negative social consequences of gender identity

The third concept was the social consequences of gender identity, primarily a sense of isolation due to the individual's gender identity. Transgender individuals felt and were cut-off from society and communities due to their gender identity. Participants reported that they felt outside of society due to their differences in gender identity, and the lack of acceptance in society for people who do not conform to traditional gender norms. Studies referred to a lack of community, reduced sense of belonging, invisibility, invalidation, and loneliness. Participants were clear that this was associated with their gender identity and that this caused distress, particularly loneliness. This concept highlights the loneliness of belonging to a group which can be ostracized by society. It is worth noting that some studies also referred to positive social consequences of gender identity, such as becoming close to other transgender people, however the negative social consequences came alongside these. The positive consequences are not reported here due to this paper's focus on distress in relation to gender identity.

3.4. Internal processing of rejection and transphobia

The final concept was the internal processing of rejection and transphobia, with hypervigilance for rejection due to gender identity and an internalized sense of shame and fear about one's gender. The focus of this concept was on the individual's internal cognitive processes and making meaning of their negative experiences as a transgender person in the world, with the difficult feelings that come with this including sadness, loss, and anxiety. This theme is conceptualized as resulting from the earlier theme of negative social consequences of gender identity; if participants had not either experienced or seen examples of rejection due to being transgender or transphobia, then they would not have developed internal narratives and processes to make sense of these experiences.

The most prominent sub-theme for this concept was fear of rejection, and sadness following rejection. This theme focused on how participants feared future rejection and ruminated on previous incidents of rejection, and these experiences were heightened by a high rate of previous rejections and awareness of negative societal attitudes towards transgender people. A high number of included studies discussed participants' fears of rejection, judgement or other negative responses from others, including family and friends. The range of emotions included fear, anxiety, loneliness, discomfort, frustration, pain, anger and depression. Participants experienced a sense of loss when rejected by people close to them such as friends or family. Participants wanted to fit in and hoped that others would not judge them, fearing rejection and judgement of others.

The next sub-theme was hypervigilance for transphobia, where an individual's expectation that they would be discriminated against or harmed due to being transgender was associated with attentional biases for threat and danger when out in public, with an understandable fear about leaving the home. Studies described participants' feelings of being unsafe due to fears of discrimination, violence or harassment. Such fears led to individuals looking out for signs of danger when out in public, in the hope of keeping themselves safe, presumably resulting in individuals spending long stretches of time in a state of high psychological arousal and anxiety, even at times when no threat is present. This was associated with a range of negative feelings such as anxiety, embarrassment, and depression.

The final sub-theme for this concept was internalized transphobia, or feelings of shame as negative external narratives about transgender people were internalized. Studies identified that individuals were highly aware of social stigma about their gender identity, and of transphobic narratives, and that for some people these became internalized, resulting in a sense of shame about their gender. One study highlighted that social messages about transgender people directly led to self-hate, confusion, and shame ( Rood et al., 2017 ). These feelings had consequences such as difficulties affirming gender identity, finding satisfaction with physical body, and hiding at home.

4. Discussion

This systematic review and meta-ethnographic study synthesized all the available qualitative studies about the lived experience of gender dysphoria in transgender adults. Twenty studies were included, all published since 2009, providing a rich dataset for the synthesis. Four overarching concepts were identified; distress due to dissonance of assigned and experienced gender, interface of assigned gender, gender identity, and society, social consequences of gender identity and internal processing of rejection and transphobia. These concepts demonstrated that distress caused by the dissonance of assigned and experienced gender is closely intertwined with distress due to the reactions of others to one's gender identity, whether that is reflected by strangers misgendering the individual, or rejection by close family or friends. This can then feed into the individual's thinking pattern and behaviors, for example through hypervigilance for transphobia, and fear of rejection due to being transgender. This demonstrates the complex relationships between an individual's feelings about their body, their gender identity, gender expression, and how outsiders interact with the individual, often guided by cultural gender norms and lack of awareness or acceptance of the transgender individual's experience. These findings are concordant with the quantitative literature available in this field. Participants described experiencing significant psychological distress in this study, in line with previous quantitative work ( Downing & Przedworski, 2018 ). Participants frequently reported experiencing anxiety and low mood in relation to their gender, and anxiety and depression are the most commonly reported conditions in this group ( Dhejne et al., 2016 ). While not a focus of this study, some studies included in this review did highlight the improved psychological wellbeing post-transition, in line with quantitative reviews about the effects of physical transition ( Nobili et al., 2018 ).

The first overarching theme we identified was dissonance of assigned and experienced gender. This concept aligns most closely with the DSM-5 definition of gender dysphoria ( American Psychiatric Association, 2013 ), particularly the sub-themes of body dysphoria, gender distress, and conflict of body and gender. These clearly align well with the criteria such as incongruence between gender identity and sex, the desire to be rid of one's sex characteristics and to have those of the other gender, a desire to be the other gender and the conviction that one has the feelings and responses of the other gender. This finding of significant distress in relation to the body supports the findings of quantitative outcome studies which find high levels of distress in those with gender dysphoria pre-transition ( Nobili et al., 2018 ). This is further supported by studies demonstrating that transgender people identify more with images of their body which are edited to be in line with their gender identity, compared to cisgender people who identify with unedited images of their body (e.g. Majid et al., 2019 ). The only part of the DSM-5 criteria which fits with another theme is the desire to be treated as the other gender, which aligns with the interface to assigned gender, gender identity, and society concept. The sub-themes which do not fit with the DSM-5 criteria are confusion, denial, and suppression and fear of the future. These features also contribute to distress but are not captured by the current DSM criteria, due to the focus of the DSM on intra-individual rather than societal and inter-individual processes. One explanation for these discrepancies is that they are not indicators of gender dysphoria, and rather are associated features. Another possible explanation for these discrepancies is the different types of gender related distress. The experience of gender distress which is alleviated through physical transition may diverge from the experience of gender distress which does not lead to a physical transition. There is limited research available in the adult population to further explore this at present.

This study provides further evidence for the concepts of negative social consequences of gender dysphoria and internal processing of rejection and transphobia, which fit within the framework of gender minority stress ( Meyer, 2015 ; Testa et al., 2015 ), as well as the rejection sensitivity model ( Downey & Feldman, 1996 ; Feinstein, 2019 ). Testa et al. (2015) developed a measure of gender minority stress in the transgender and gender nonconforming community. In their paper they highlight the role of difficult social experiences in the experience of psychological distress in gender nonconforming and transgender individuals. As well as experiences of discrimination, rejection and victimization, they measured internalized transphobia and gender non-affirmation, or misgendering, as well as negative expectations for future events, and nondisclosure. Their scale measuring these constructs was found to be valid for use with transgender people, providing quantitative support for the utility of these constructs. Our study has found a number of overlapping sub-themes, such as misgendering, isolation, internalized transphobia, and fear of rejection and sadness following rejection and so provides support for the gender minority stress framework. Further, Feinstein (2019) proposes an extension to minority stress theory using the rejection sensitivity model, which includes "anxious expectations of rejection", "perceptions of rejection", and "cognitive affective reactions" which contribute to distress following adverse social experiences ( Downey & Feldman, 1996 ). While Feinstein applied this model to sexual minority groups, other authors have proposed its potential relevance to the transgender population, if adapted to this group and supported by rigorous research evidence (e.g. Wells, Tucker, & Kraines, 2019 ). Our findings provide some support for these cognitive factors contributing to distress in the transgender population, with the “internal processing of rejection and transphobia” theme highlighting pre-emptory and post-hoc emotional responses to rejection due to transgender identity which are in line with components of the rejection sensitivity model. These similarities provide preliminary support for Feinstein's proposal that internal processing of rejection is central to distress, and suggests that this occurs in the transgender population as well as in sexual minority groups. While rejection sensitivity as a model to account for emotional distress has intuitive appeal and some evidence to support it, fluctuations in the level of rejection sensitivity in other groups, perhaps with social and interpersonal contexts playing a role, highlights the need for careful longitudinal research to establish rejection sensitivity as a valid theoretical framework for transgender people.

Our paper further extends the established understanding of gender dysphoria, and gender minority stress, to better understand the relationship between these two experiences. We found that societal expectations and gender norms caused participants to experience gender dysphoria when comparing their own gender experiences to those of others, or when sensing that their body and gender expression were being judged by others. On top of these factors, experience of actual rejection and social isolation due to gender caused significant distress. This led to increased body dysphoria, gender distress, conflict of body and gender, confusion, denial, and suppression and fear of the future, alongside internalized transphobia. All of these experiences in turn increased difficulties in leaving the home and hypervigilance when interacting with others. A strength of this study was the relatively recent publication of all the included studies; the oldest was from 2009. While the searches were not constrained by year, it appears that researchers have only recently begun investigating the lived experience of adults who experience gender dysphoria. Older studies were often excluded due to using quantitative or case study methods, rather than employing systematic qualitative methods. This means that this synthesis is highly relevant to current presentations of gender dysphoria and given the rapidly shifting context of this field (e.g. Aitken et al., 2015 ). A limitation was the relatively low number of studies that recruited non-binary participants, and none of the studies analyzed these data separately. Therefore, it was not possible to understand the similarities or differences in the experience of gender dysphoria between these groups. A further limitation is that our inclusion criteria restricted the synthesis to peer-reviewed, qualitatively analyzed studies. This means that the rich narratives of transgender individuals included in books or other non-peer reviewed sources were not included in the current study. This may have led to selection bias for the narratives which researchers have chosen to focus upon. Finally, we included papers which investigated the experiences of adults, and so the findings may not be transferrable to children. Systematic reviews focused on the experiences of children with gender dysphoria are therefore warranted.

We propose that the DSM definition of gender dysphoria requires increased conceptual clarity in its definition of distress. This is particularly important given the role of gender dysphoria diagnosis in current gender clinic practice ( Coleman et al., 2012 ). Our review demonstrates that significant distress is experienced by those with gender dysphoria as a result of social factors, which vary over time and age cohorts. Future quantitative research could compare the experience of gender dysphoria in individuals within more accepting cultural contexts versus less accepting contexts. This would help unpack the effects of the social environment on distress in gender dysphoria. Further research should investigate the relationships between distress due to dissonance of assigned and experienced gender, as well as processes such as: internal processing of rejection and transphobia including internalized transphobia; the interface of assigned gender, gender identity, and society, including misgendering or non-affirmation of gender; and negative social consequences of gender or discrimination, rejection, and victimization. Longitudinal studies investigating these processes over the course of coming out as transgender or transitioning would be well placed to elucidate the relationships between these concepts. Furthermore, research into the experience of non-binary individuals of gender dysphoria to understand how this relates to the experience of binary-identified transgender individuals is needed. This is particularly important given the flexibility of gender identities included in the DSM-5 criteria for gender dysphoria. Finally, the experience of distress in those who choose to physically transition versus those who choose another option is currently not known. This study provides further evidence for the need for society to accommodate people with different gender identities and journeys. It is clear from our findings that such societal shifts will improve the well-being of transgender people. Furthermore, societal responses to transgender people such as misgendering can exacerbate their negative feelings towards their body and their gender, adding further distress to the existing experience of gender dysphoria. Significantly, additional experiences of dysphoria than those in the DSM-5 came from the analysis. It is worth noting that confusion around gender identity, and suppression and denial of gender identity were often reported in relation to distress around gender identity. This study provides support for both the DSM-5 criteria for gender dysphoria and gender minority stress theory, while providing an important insight into how these experiences of distress are related to one another.

Kate Cooper is funded by a National Institute for Health Research (NIHR) Clinical Doctoral Research Fellowship for this research project.

Role of funding sources

Kate Cooper is funded by a National Institute for Health Research (NIHR) Clinical Doctoral Research Fellowship for this research project. The NIHR had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication. This publication presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Contributors

KC, AR, WM and CB designed the study and KC wrote the protocol. KC conducted literature searches and screening. All authors contributed to the analysis. KC wrote the first draft of the manuscript and all authors contributed to and have approved the final manuscript.

Declaration of Competing Interest

Acknowledgements.

Thank you to Anna Lawes for her support with screening papers for this review.

Kate Cooper is a Research Fellow at the University of Bath and Clinical Psychologist in Oxford Health. Ailsa Russell is a Reader at the University of Bath and Director of the MSc in Applied Clinical Psychology. William Mandy is an Associate Professor and Research Director of the UCL Clinical Psychology Course. Catherine Butler is a Senior Lecturer/Clinical Director on the Doctorate in Clinical Psychology and Deputy Head of the Psychology Department at the University of Bath.

1 An original stated aim of this systematic review, as published on PROSPERO, was to compare the experiences of binary and non-binary transgender individuals' experiences of gender dysphoria. Following searches and screening, there were not enough data regarding the non-binary experience of gender dysphoria to keep this as an aim of this review.

Appendix A. Studies included in the meta-ethnography

Appendix b. casp quality assessment for included papers.

Gender Dysphoria: A Review Investigating the Relationship Between Genetic Influences and Brain Development

Affiliation.

• 1 University of Exeter, Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
• PMID: 32801984
• PMCID: PMC7415463
• DOI: 10.2147/AHMT.S259168

Gender dysphoria (GD) is a facet of modern human biology which is believed to be derived from the sexual differentiation of the brain. GD "involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify", as defined in the DSM-5. Individuals report feeling uncomfortable and faced with prejudice from those around them, affecting their mental health. Elucidating the relationship between genetic influences on gonadal and brain development could give an insight into understanding this clinical condition. To explore this issue, a review of the literature database was carried out. Evidence suggests that abnormal biological processes, including mutations in certain genes, can lead to abnormal gonadal development, causing some fetuses to present with indifferent gonads and to be reassigned at birth to the default female sex. This disparity in genetic influences relates to an increased likelihood of a diagnosis of GD. An investigation into complete androgen insensitivity syndrome, involving androgen receptor (AR) gene mutation, suggests that such individuals also experience GD. It is known that the brains of males and females are different. Evidence further suggests that brain anatomy and neuronal signaling pathways are more closely aligned with a person's perceived gender identity. Individuals who present with discordant gonadal and brain developments experience psychological challenges that may contribute to a state of unease or generalized dissatisfaction with their biological sex. These point to a possible biological and genetic underpinning of GD as stemming from a discordance between gonadal and brain development. However, not enough evidence has associated these differences with GD. Further research is required to elucidate the true mechanisms and possible inheritance pattern of GD for a better education and greater understanding by clinicians and the general public on perceptions regarding GD.

Keywords: brain development; gender; gender dysphoria; gonadal development; sex.

© 2020 Boucher and Chinnah.

Publication types

• Open access
• Published: 21 September 2023

A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours

• Elisa Marconi   ORCID: orcid.org/0000-0001-6722-8390 1   na1 ,
• Laura Monti   ORCID: orcid.org/0000-0001-8339-265X 1   na1 ,
• Angelica Marfoli   ORCID: orcid.org/0009-0007-7324-577X 2 ,
• Georgios D. Kotzalidis   ORCID: orcid.org/0000-0002-0281-6324 3 , 4 , 7 ,
• Delfina Janiri   ORCID: orcid.org/0000-0003-2485-6121 4 , 7 ,
• Cecilia Cianfriglia   ORCID: orcid.org/0009-0000-6777-7007 2 ,
• Federica Moriconi   ORCID: orcid.org/0000-0003-1593-0043 1 ,
• Stefano Costa   ORCID: orcid.org/0000-0002-0137-2370 5 ,
• Chiara Veredice   ORCID: orcid.org/0000-0003-2267-8077 6 ,
• Gabriele Sani   ORCID: orcid.org/0000-0002-9767-8752 4 , 7 &
• Daniela Pia Rosaria Chieffo   ORCID: orcid.org/0000-0002-0130-6584 1 , 8  

Child and Adolescent Psychiatry and Mental Health volume  17 , Article number:  110 ( 2023 ) Cite this article

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Introduction

Gender dysphoria (GD) is characterized by the incongruence between one’s experienced and expressed gender and assigned-sex-at-birth; it is associated with clinically significant distress. In recent years, the number of young patients diagnosed with GD has increased considerably. Recent studies reported that GD adolescents present behavioural and emotional problems and internalizing problems. Furthermore, this population shows a prevalence of psychiatric symptoms, like depression and anxiety. Several studies showed high rates of suicidal and non-suicidal self-injurious thoughts and behaviour in GD adolescents. To increase understanding of overall mental health status and potential risks of young people with GD, this systematic review focused on risk of suicide and self-harm gestures.

We followed the PRISMA 2020 statement, collecting empirical studies from four electronic databases, i.e., PubMed, Scopus, PsycINFO, and Web of Science.

Twenty-one studies on GD and gender nonconforming identity, suicidality, and self-harm in adolescents and young adults met inclusion criteria. Results showed that GD adolescents have more suicidal ideation, life-threatening behaviour, self-injurious thoughts or self-harm than their cisgender peers. Assessment methods were heterogeneous.

A standardised assessment is needed. Understanding the mental health status of transgender young people could help develop and provide effective clinical pathways and interventions.

Gender dysphoria (GD) is a condition characterized by a marked incongruence between one’s experienced and expressed gender and the one assigned at birth and is often associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, especially when reported early [ 1 ]. In recent years, the number of young patients diagnosed with GD or and gender-diverse identity—including nonbinary and questioning sexual identities—has considerably increased [ 2 , 3 , 4 , 5 ]. Current studies document that this population may be exposed to a higher risk of adverse events affecting health status and well-being [ 6 , 7 ]. This further impacted this vulnerable population, with the most negative consequences for those who experience a gender not congruent with the one they were assigned at birth [ 8 , 9 , 10 ]. Indeed, children and adolescents with GD and transgender or transgender and gender nonconforming (TGNC) are described as a psychologically and socially vulnerable population, facing a wide range of physical and mental health concerns that could benefit from early intervention [ 11 , 12 , 13 ]. GD during adolescence develops in individuals whose brain is still developing to reach full maturity only some years later, hence the need to dedicate special attention to this population.

As a population perceiving gender minority stress [ 14 ], adolescents with GD are likely to lack social acceptance and suffer stigma laid upon them by others [ 15 ], but also tend to internalisation [ 16 ]. A corollary may be that several studies found adolescents with GD, compared to their age-matched cisgender peers, to show more often behavioural and emotional problems and higher levels of individual distress-generating internalising problems, rather than environment-perturbing externalising problems [ 17 , 18 , 19 ]. Consequently, adolescents with GD show a higher prevalence of psychiatric issues, such as depression and anxiety disorders [ 17 , 20 , 21 ], likely due to social stigma.

Adolescents and young adults with GD and gender-diverse identity report higher suicidal thinking, planning, and attempts as well as non-suicidal self-harming thoughts and behaviours (NSSI) than the general population [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Suicidality is an umbrella term including suicidal ideation, suicidal behaviours, and suicide attempts and plans which are correlated to the desire to die [ 33 ]; we will use suicidality sparingly in this paper and focus instead upon the above-mentioned specific terms, when possible. Non-suicidal self-harming behaviours and thoughts, however, refer to self-injurious acts without intending to end one’s own life, but involve self-punishment or negative emotion regulation [ 34 ]. In both cases, early age at onset has been identified as an important vulnerability factor, with onset during childhood and adolescence being associated with a poorer prognosis [ 17 ], based on different surveys of high-school students [ 31 ]. For example, in New Zealand, 20% of students with GD reported attempting suicide in the past 12 months, compared to 4% of all students [ 35 ]. Similarly, in the United States, 15% of students with GD reported a suicide attempt requiring medical treatment in the last 12 months, compared to 3% of all students [ 36 , 37 , 38 ]. In another American survey, 41% of students with GD reported having attempted suicide during their lifetime, compared to 14% of all students [ 39 ]. Moreover, Surace and her colleagues [ 40 ] found a mean prevalence of 28.2% for NSSI, 28.0% for suicidal ideation, and 14.8% for suicide attempts in young TGNC clinical populations up to 25 years old.

Besides aspects of GD like body dysmorphic disorder, feeling uncomfortable in one’s own body, and hopelessness about obtaining gender-affirming medical procedures, a possible contribution to elevated suicidal risk and behaviours in the GD population might lie within the social stigma experienced by TGNC adolescents, such as discrimination, prejudice, social stress, and ostracism within the peer group and/or family [ 41 ]. Suicidal ideation and self-injurious behaviours generally relate to significant emotional problems, such as depressive and anxiety symptoms, which in turn trigger psychosocial and biological imbalance, could increase the wish to die [ 42 , 43 , 44 , 45 ], thus adding to the above.

In summary, several studies have shown higher rates of suicidal and non-suicidal self-harming thoughts and behaviours in adolescents and young adults with GD and gender-diverse identity—such as nonbinary and questioning sexual identity—compared to their male and female cisgender peers. However, the evidence heretofore is piecemeal, probably due to social stigma currently associated with GD and the concern of stigmatising individuals suffering from this condition. To better understand the mental state of adolescents and young adults with TGNC, we conducted a systematic review focusing on the risk for suicide and self-harming gestures in the GD population. The aim of this review was to estimate the frequency of suicidal and self-harm behaviour in adolescents and young adults with GD, comparing them with cisgender adolescents where possible.

We performed a systematic review in compliance with the 2020 PRISMA guidelines for systematic reviews and meta-analyses [ 46 ] to increase comprehensiveness and transparency of reporting.

Information sources and database search

To systematically collect empirical studies on the possible relation between suicidality/self-harming and GD in adolescents and young adults, several keywords were used to search for appropriate publications in four electronic databases, i.e., PubMed, Scopus, PsycINFO, and Web of Science since their inception and no date or language restriction.

Authors conducted the search separately in each database using the following agreed upon search strategy for PubMed and adapting the search for the other databases: (suicid* OR self-injur* OR self-harm* OR self-inflict* OR self-lesion*) AND (gender dysphori* OR transgender) AND (child* OR adolesc* OR "young adult*" OR youth* OR "school age"). Since the terms GD and transgender are used by many people as synonymous, in our searches we used both terms to identify possible eligible articles.

Eligibility criteria

Inclusion criteria were a study published in a peer-reviewed journal, reporting data on suicide and related behaviours (thinking, planning, and attempts) and/or non-suicidal self-harming thoughts and acts (using methods that reliably obtain the desired result) in adolescent and young adult (14–27 years old) samples with GD/transgender status/gender diverse identity.

Exclusion criteria were studies conducted on children or adult samples and those with mixed populations not providing data for adolescents and young adults separately. Also, opinion papers, such as editorials, letters to the editor, and hypotheses without providing data were excluded, as well as case reports or series, reviews/meta-analyses, animal studies, studies with inadequate/poor methodology and inadequate reporting of data, unfocused, or unrelated to the subject matter. All inter- and intra-database duplicates were removed, as well as abstracts, meeting presentations and studies presenting incomplete data.

Although reviews and meta-analyses were not included, their reference lists were screened to identify additional eligible publications. Eligibility for each study was decided with Delphi rounds among all authors until complete consensus was reached.

Data extraction

The analysis was conducted by all authors, who applied the eligibility criteria on each database. Each author conducted the selection process separately from others; at a final step, all authors compared their results in Delphi rounds (either in-person or remotely) aimed at obtaining full consensus.

Data collection and risk of bias assessment

Data collected for each study included country of origin, number of paediatric patients, demographic information (age and biological sex), presence/absence of GD and if present, type of GD, and clinical symptoms focused on self-harm (suicide behaviour, suicidal ideation, suicidal intent and planning, non-suicidal self-harm, and other self-injurious behaviour).

The evaluation of the risk of bias was conducted by a quality index derived from the Qualsyst’ Tool [ 47 ]. The quality of selected studies was assessed independently by all investigators and disagreements were resolved by consensus (results of risk-of-bias for all studies in the Additional file 1 ).

Identified studies

On February 7, 2023, we located 1416 articles (Fig.  1 , PRISMA flowchart) [ 39 ], of which 128 articles were assessed for eligibility. Of these papers, 107 articles were excluded according to eligibility criteria; 21 dealing with the relationship between GD and gender non-conforming identity, and suicidality and self-harm in adolescents and young adults met inclusion criteria.

PRISMA2020 flow diagram for new systematic reviews: Search findings and selection with detailed reasons for exclusion

For the purpose of this systematic review, we have focused our analyses on these 21 studies. Figure  1 provides a PRISMA flow diagram showing search results.

Due to the breadth of the topic and the variety of variables included in this systematic review, the subject matter was organized according to the categories of psychopathological symptoms of interest in the study (Tables 1 and 2 ) and a final mixed category (Table 3 ). Of 21 studies meeting the inclusion criteria, there were 2 studies where self-harming behaviours and thoughts was the outcome in TGNC adolescents (Table 1 ), 6 studies where suicide was the outcome (Table 2 ), and 13 studies where the outcome was committing suicide combined to self-injurious attitudes (Table 3 ).

The 21 studies were mainly from the United States, the United Kingdom and Europe. Included studies were also conducted in China, Iran, Turkey, Canada and Australia. Studies were non-interventional and observational, with 17 being cross-sectional or retrospective and 4 longitudinal.

GD and non-suicidal self-harming ideation and behaviours were investigated by two studies [ 48 , 49 ], GD and suicidality by six studies [ 6 , 17 , 24 , 29 , 39 , 51 ], and GD and both suicidality and non-suicidal self-harm by 13 [ 11 , 21 , 22 , 25 , 30 , 50 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]; of these studies, four [ 11 , 21 , 55 , 58 ] detected the presence of internalizing problems (depressive and anxiety disorders) in GD adolescents and young adults. Detailed results are provided in the Additional file 1 .

Summary results

Detailed results of each study are shown in Tables 1 – 3 and in the Additional file 1 . We will here summarise results in GD and transgender populations regarding studies of (1) non-suicidal self-harm, (2) suicidal ideation and attempts, and (3) non-suicidal self-harm, suicidal ideation, and suicide attempts combined.

- Non-suicidal self-harming was explored in two studies [ 48 , 49 ]; transgender adolescents showed higher tendency toward self-harm ideation than cisgender adolescents, while non-suicidal self-inflicted behaviours were more common in cisgender males and females than among transgender adolescents [ 49 ]. AFAB adolescents showed nominally more lifetime and current NSSI than AMAB, but this did not reach statistical significance [ 48 ] (Table 1 ).

- Suicidal thinking and attempts only were examined in six studies [ 6 , 17 , 24 , 29 , 39 , 51 ] and generally identified a high prevalence in GD/transgender populations of suicide behaviours and attempts, ranging from 14.3% of severe suicidal ideation in Heino et al. [ 29 ] to a cumulative “high risk” of 80.9% in Alizadeh Mohajer et al. [ 6 ]; however, studies used different assessment instruments, so it becomes difficult to draw conclusions as to the real extent of suicidality in our target population. Gender-diverse adolescents displayed high suicidal ideation (Table 2 ). Transgender/GD adolescents displayed more suicidal behaviour than cisgender adolescents, either males or females [ 39 ]. Suicidality did not differ between AMAB and AFAB transgender adolescents/younger adults [ 51 ].

- Suicidality and non-suicidal self-harm combined were explored in thirteen studies [ 11 , 21 , 22 , 25 , 30 , 50 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. Both NSSI and suicidality were higher in transgender/GD youths than in cisgender participants. AMAB and AFAB showed higher NSSI and suicidality rates than cisgender boys and girls [ 11 ] (Table 3 ).

Additional considerations will be detailed further on.

The last decade has seen an increase in cases of GD in adolescents worldwide and our knowledge of the epidemiological and clinical features continues to evolve [ 59 ]. An adequate understanding of the phenomenon and any related symptoms is important for the early management and possible prevention of distress. Indeed, the literature has highlighted the existence of a high association of psychological and psychiatric symptoms in adolescents with GD.

Several studies used different methods to investigate whether transgender identity and clinical outcomes in the general adolescent population are related [ 6 , 17 , 21 , 22 , 24 , 25 , 29 , 30 , 39 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ]. The present review focused particularly on high-severity psychological symptoms in young people, such as self-harm and suicidal symptomatology. Indeed, the results of the studies underline a statistically significant correlation between youth TGNC—including gender dysphoric, non-binary and questioning adolescents—and prevalence of suicidal thinking and plans/attempts and self-harming thoughts and behaviours compared to cisgender populations [ 20 , 29 , 60 , 61 , 62 , 63 , 64 , 65 ]. Currently, there is a dearth of results from population-based samples, hence generalizing current findings is still very premature [ 59 ]. Despite progress and availability of resilience factors to face stigma and discrimination in some societies and social groups, there are considerable anti-LGBT attitudes in some countries and other social groups, ensuing in GD adolescents showing more mental symptoms and distress compared to cisgender peers [ 52 , 66 , 67 ]. Gender dysphoric adolescents show higher rates of depression leading to suicidal risk and engage in more self-injurious behaviours than their cisgender peers, confirming that a significant proportion of this population experience severe suicidal ideation and almost one third attempt suicide [ 4 ]. Other studies highlight that half of transgender youths are diagnosed with depression and anxiety disorders as well as poorer overall health and sleep quality [ 11 , 66 , 68 ]. Furthermore, puberty appears to exacerbate mental health problems in people with GD [ 30 ].

The main theoretical models, such as the gender minority stress model [ 69 ], identify potential risk factors among transgender individuals, link exposure to stigma, discrimination, and lack of social support. Previous research identified sexual minority status as a fundamental risk factor for own life-threatening behaviours [ 70 ]. In fact, adolescents diagnosed with GD experience victimization from their peers, negative parental reactions to their gender-nonconforming expression and identity, and family violence. These exogenous factors often lead transgender individuals to experience personal distress and isolation, which might elicit higher rates of own-life-threatening behaviours, such as suicidal attempts and ideation and self-harm thoughts than their heterosexual peers [ 70 , 71 , 72 , 73 ].

Overall, results of the studies included in this systematic review confirmed that, compared to cisgender adolescents, TGNC adolescents reported a significantly higher frequency of suicidal attempts, suicidal thoughts, making suicide plans, self-harm ideation and deliberately participating in self-harm acts. Higher depressive and anxiety symptoms and lower overall physical health were also positively associated with GD [ 11 , 55 , 57 , 58 , 74 ].

However, results were heterogeneous. Specifically, Wang and colleagues [ 11 ] indicated that among the gender minority groups transgender girls had the greater risk of planning and attempting suicide, transgender boys had the highest risk of performing deliberate self-harm, and questioning youth AFAB had the highest risk of suicidal ideation. Similar results were obtained in another study [ 24 ], with the risk ratios analysis highlighting the greater rate of suicidality among birth-assigned females. This pattern is consistent with many other studies showing that suicidality is more common among AFAB adolescents than it is among AMAB youth [ 75 ]. Some studies found possible gender differences between AFAB and AMAB and possible consequences for their mental health, suggesting that although AMAB might experience more stigmatization and preconceptions, AFAB youth seem to cope differently with distress [ 17 , 25 , 48 ]. Nevertheless, this outcome was different from Toomey and colleagues’ work [ 39 ], which found that transgender boys had a higher rate of attempted suicide than transgender girls.

At any rate, despite these within-group discrepancies, general findings emerging from quantitative studies provide evidence that a large proportion of adolescents referred for GD and other transgender youth, whether “AFAB” or “AMAB”, have a substantial co-occurring history of psychosocial and psychological vulnerability, causing a higher risk for suicidal ideation and life-threatening behaviours, such as self-harm thoughts and self-injurious gestures [ 70 , 76 ].

Since society is becoming increasingly liquid according to Zygmunt Bauman [ 77 ], more cases of transgender states and GD are anticipated to occur; this will mean that we will have more of the general population at enhanced risk for self-harming acts, suicidal thinking, and suicidal behaviour. Under this perspective, it should be important to develop a comprehensive psychological assessment aimed at identifying people at risk of the above behaviours so to enforce preventive programmes [ 78 , 79 , 80 ].

For this reason, results provided by this systematic review may enhance the knowledge of health professionals about adolescents referred for GD. Furthermore, a better understanding of the mental health status of transgender youth and the associated risks could help to develop and provide effective interventions. The need for more knowledge and tools is also a key aspect of supporting each individual properly [ 30 , 81 ]. Finally, increasing social awareness and scientific knowledge can also help target support programs for parents. Indeed, parents could benefit from interventions dedicated to understanding the impact of attitudes, behaviours and decisions, as well as assisting them in the therapeutic paths they take with their children with GD [ 70 ].

Limitations . This review contains heterogeneous data that could not be subjected to a meta-analysis. Heterogeneity regarded the instruments used to assess the populations included and the variables examined. To add to the high heterogeneity, the population under study belonged to multiple categories, such as cisgender males, cisgender females, individuals assigned female at birth whose experienced gender was male (so-called female-to-male transgender), individuals assigned male at birth whose experienced gender was female (so-called male-to-female transgender), and nonbinary. Often studies did not differentiate possible transgender from nonbinary identities. We attempted at focusing on GD only, but had to deal also with other populations as well, since the literature treats these populations as they were one and the same, which of course is not the case. Furthermore, a distinction between self-harm and suicide attempts was not always possible. Moreover, the social stigma laid upon gender diverse populations and current cultural trends may have directly or indirectly affected the writing of this review and its final results and conclusions.

Conclusions

In conclusion, the overall findings emerging from this review provide evidence that a large proportion of adolescents with GD have a substantial concomitant history of psychosocial and psychological vulnerability, with a higher risk of suicidal ideation, life-threatening behaviour, and self-injurious thoughts or self-harm. Understanding the mental health status of transgender young people could help developing and providing effective clinical pathways and interventions. The relatively new issue of suicide in adolescent/young adult populations currently suffers from poor assessment standardization. There is a need for standardized assessment, culturally adapted research, and destigmatisation of this socially vulnerable population to address the issue of increased suicidal thinking and attempts.

Availability of data and materials

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Acknowledgements

We greatly appreciate the help Drs. Alessio Simonetti and Evelina Bernardi provided in statistical issues.

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Elisa Marconi and Laura Monti are first authors as they equally contributed to the manuscript.

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Clinical Psychology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy

Elisa Marconi, Laura Monti, Federica Moriconi & Daniela Pia Rosaria Chieffo

Catholic University of the Sacred Heart—Rome, Largo Francesco Vito 1, 00168, Rome, Italy

Angelica Marfoli & Cecilia Cianfriglia

NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), University of Rome “La Sapienza”, Via Di Grottarossa1035-1039, 00198, Rome, Italy

Georgios D. Kotzalidis

Department of Psychiatry, Department of Neuroscience, Head, Neck and Thorax, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 1, 00168, Rome, Italy

Georgios D. Kotzalidis, Delfina Janiri & Gabriele Sani

UOSD Operative Unit Psychiatry and Psychotherapy for Adolescents, Azienda USL Di Bologna, Ospedale MaggioreLargo Bartolo Nigrisoli, 2, 40133, Bologna, Italy

Stefano Costa

Pediatric Neuropsychiatry Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy

Chiara Veredice

Institute of Psychiatry, Department of Neuroscience, Catholic University of the Sacred Heart—Rome, Largo Francesco Vito 1, 00168, Rome, Italy

Departement of Life Sciences and Public Health Department, Catholic University of Sacred Heart, 00168, Rome, Italy

Daniela Pia Rosaria Chieffo

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EM, LM, AM, CC, and DPRC. conceived the review. EM, LM, AM, CC, and GDK. organized and collected the material and wrote the first draft of the manuscript. AM, EM, GDK, DJ, FM, and SC. performed literature searches. EM, LM, AM, CC and GDK. wrote the Methods and decided eligibility criteria. DPRC, GDK. and GS. supervised the writing of the manuscript. DPRC, CV, AM, GDK. and GS. revised the final version of the manuscript. All authors contributed to the writing of the manuscript, read, and approved the submitted version.

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Marconi, E., Monti, L., Marfoli, A. et al. A systematic review on gender dysphoria in adolescents and young adults: focus on suicidal and self-harming ideation and behaviours. Child Adolesc Psychiatry Ment Health 17 , 110 (2023). https://doi.org/10.1186/s13034-023-00654-3

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• Winter 2024 | VOL. 22, NO. 1 Reproductive Psychiatry: Postpartum Depression is Only the Tip of the Iceberg CURRENT ISSUE pp.1-142

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Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists

• William Byne ,
• Dan H. Karasic ,
• Eli Coleman ,
• A. Evan Eyler ,
• Jeremy D. Kidd ,
• Heino F.L. Meyer-Bahlburg ,
• Richard R. Pleak , and

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Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.

(Copyright © William Byne et al. 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License ( http://creativecommons.org/licenses/by/4.0 ), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Introduction

Individuals who would likely be considered transgender today are evident throughout the historical record ( 1 ). The historical and sociocultural conceptualizations of gender variance, and their evolution within mental health professions over the past century and a half are reviewed elsewhere ( 2 ).

Nineteenth and 20th century theories of gender variance and views of appropriate treatment were pathologizing and highly stigmatizing to transgender people ( 2 ). While mainstream psychiatry is now more affirming of gender variance, transgender individuals often are aware of the history in this area and many are likely to have encountered providers who adhere to outdated stigmatizing theories and approaches to treatment ( 3 ). Today’s mental health professionals should, therefore, be familiar with the history in this area as it is not unusual for gender-variant patients to have apprehensions about seeking mental healthcare or to raise questions about their providers’ views and approach to treatment considering that history.

Between 1963 and 1979, over 20 university-based gender identity clinics opened in the United States ( 2 , 4 ). These clinics provided interdisciplinary care that included psychiatrists and other mental health professionals and played an important role in the provision of medical services to transgender people and in promoting research to improve their care ( 2 , 4 ). The majority of these clinics closed following a 1981 decision of the U.S. Department of Health and Human Services (HHS) that labeled sex reassignment surgery as experimental ( 5 ), a decision what was overturned by HHS in 2014 in a determination that concluded that the 1981 decision was ‘‘unreasonable and contrary to contemporary science and medical standards of care ( 6 ).’’

With the closure of the academic gender clinics, transgender people in the United States came to rely on a loose network of medical and mental health providers, often affiliated with the Harry Benjamin International Gender Dysphoria Association (HBIGDA), which was subsequently renamed the World Professional Association for Transgender Health (WPATH). HBIGDA/WPATH developed and successively revised standards of care (SOC) for gender transition, which are currently in their seventh revision as the WPATH SOC7 ( 7 ). In the WPATH SOC7, mental health professionals are tasked with determining whether those interested in gender-affirming treatments meet eligibility criteria, have capacity for informed consent, and have adequately anticipated the psychosocial impacts of their transition.

The WPATH SOC also provide clinical guidance for health professionals to assist transgender people in their search for psychological well-being in their gendered selves. In the absence of other comprehensive English language guidelines, U.S. providers and their professional associations came to rely heavily on the HBIDGA/WPATH SOC ( 8 – 10 ). Similarly, insurance carriers and tax courts employ WPATH SOC criteria in evaluating the medical necessity of transition treatments for determination of reimbursable and tax-deductible medical expenses ( 11 – 14 ).

With transition services offered outside of university-based clinics, U.S. medical schools and residency training programs offered little exposure to the provision of transition services, leaving psychiatrists and other physicians poorly prepared for the growth in demand for these services seen in recent years ( 15 ). This article aims to assist adult psychiatrists and other mental health professionals who are not gender specialists in the care of these individuals. Detailed information on the assessment and treatment of gender dysphoria in children and adolescents can be found elsewhere ( 16 – 19 ).

A glossary of transgender-related terms is found in Table 1 . Providers should be respectful of their patients’ identity labels; however, due to the rapid evolution of gender terminology, they may need to clarify how both their patients and colleagues employ particular terms.

*On official documents such as birth certificates, driver’s licenses, and passports, the traditional category ‘‘sex’’ is equivalent to ‘‘gender’’ in current psychological terminology.

**‘‘Trans’’ (also ‘‘Trans*’’) More recent umbrella terms being increasingly used to avoid distinguishing between transgender and transsexual individuals. DSM, Diagnostic and Statistical Manual of Mental Disorders; GD, Gender Dysphoria; GID, Gender Identity Disorder; ICD, International Classification of Diseases.

TABLE 1. Glossary

Diagnostic and Statistical Manual of Mental Disorders and Transgender-Related Nosology

The first two editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952 and 1968, respectively, did not include any gender diagnosis ( 20 ). The diagnosis, ‘‘Transsexualism’’ (sic), first appeared in 1975 in the ninth revision of the International Classification of Diseases (ICD)-9(21) and subsequently, in the DSM-III in 1980 under the parent category, Sexual Deviations ( 22 ). The defining characteristics of this diagnosis were as follows: ( 1 ) discomfort about one’s assigned sex; ( 2 ) ‘‘cross-dressing,’’ in reality or fantasy, as the other sex, but not for the purpose of sexual excitement; and ( 3 ) the desire to get rid of one’s primary and secondary sex characteristics and to acquire those of the other sex. DSM-III also included ‘‘Gender Identity Disorder of Childhood’’ (GIDC).

Both transsexualism and GIDC were carried over into DSM-IIIR, but were no longer categorized as sexual deviations. Instead, they were placed within the parent category, Disorders Usually First Evident in Infancy, Childhood, or Adolescence ( 23 ). This category also included disruptive behavior disorder, eating disorders, and tic disorders. Under this parent category, DSM-IIIR added a new diagnosis, Gender Identity Disorder of Adolescence and Adulthood Nontranssexual Type (GIDAANT). These changes recognized that gender identity disorder (GID) often begins in childhood, may or may not persist into adolescence and adulthood, and when it does persist, it may not entail a desire for the primary or secondary sexual characteristics of the other sex.

With DSM-IV, the diagnoses of Transsexualism and GIDAANT were discontinued, but GIDC and GIDAA were retained and placed under a new parent category, Sexual and Gender Identity Disorders, a category that also included the unrelated sexual dysfunctions and paraphilias ( 24 ). Individuals with somatic intersex conditions, who experienced dysphoria attributable to dissatisfaction with their gender assigned at birth, could be diagnosed with Gender Identity Disorder Not Otherwise Specified.

Retention of the diagnosis by the DSM and its new name, including the word ‘‘disorder,’’ was perceived by many as stigmatizing and contributing to societal discrimination against transgender individuals ( 25 ). By analogy to homosexuality, much of the distress and functional impairment associated with being transgender, and required for the diagnosis of GID, could derive from social stigmatization rather than from being transgender, per se . On the other hand, removal of a coded diagnosis for medical classification and billing purposes would limit access to transition care, deny the full impact of gender dysphoria, and prove harmful to transgender individuals ( 2 , 26 ).

Ultimately, the diagnosis was retained by DSM-5(27), but its name was changed to Gender Dysphoria (GD), simultaneously removing the stigmatizing ‘‘disorder’’ from its name and shifting the focus to dysphoria as the target symptom for intervention and treatment, rather than gender identity itself ( 27 , 28 ). GD was also moved out of the parent category that included sexual dysfunctions and paraphilias, with which it has nothing in common, and into a separate parent category, also named Gender Dysphoria.

Use of the diagnostic label, GD, requires that a person meets the full criteria specified in DSM-5. This is distinctly different from the historical generic use of the term, gender dysphoria, which refers to the distress caused by a discrepancy between one’s experienced gender and assigned gender, whether or not full DSM criteria for GD are met. For clarity here, references to the diagnosis will be capitalized or abbreviated (i.e., Gender Dysphoria or GD) while references to the symptom will not be capitalized or abbreviated (i.e., gender dysphoria).

The DSM is a manual on mental disorders and, therefore, despite the name change, GD retains its classification as a mental disorder. In contrast, the ICD is not limited to only mental disorders. In its forthcoming eleventh iteration, ICD-11, the diagnosis of Gender Incongruence (GI) (corresponding to GD in DSM-5 terminology) will most likely be moved out of the section on mental disorders. Instead, it has been proposed to place it in a separate section tentatively named Conditions Related to Sexual Health or Sexual and Gender Health ( 29 ). Placing GI in this section will declassify it as a mental disorder, while maintaining a diagnosis that will facilitate access to care through third party reimbursement, and could eventually lead to American Psychiatric Association (APA) removing GD from the DSM.

Importantly, the GD diagnosis does not apply automatically to people who identify as transgender but is given only to those who either exhibit clinically significant distress or impairment associated with a perceived incongruence between their experienced/expressed gender and their assigned gender or who, after transition, no longer meet full criteria, but require ongoing care (e.g., hormonal replacement therapy). In DSM-5, this latter group is given a ‘‘post-transition’’ specifier.

Unlike previous versions of the DSM, in DSM-5, gender-dysphoric individuals with somatic intersex conditions, who were previously excluded from the diagnosis, can now receive the diagnosis with a specifier to indicate the presence of the intersex condition. DSM-5 is also the first DSM to recognize the legitimacy of gender identities outside the gender binary such that individuals with GD are no longer described as identifying simply as ‘‘the other gender,’’ but as ‘‘the other gender (or some alternative gender different from one’s assigned gender).’’ Examples of alternative genders include eunuch, genderqueer, and nonbinary.

Epidemiology

Epidemiological research has employed different measures of transgender populations, resulting in varying estimates of prevalence ( 30 , 31 ). Some studies assessed the fraction of a population, which had received the DSM-IV diagnosis of GID or the ICD 10 diagnosis of transsexualism, both of which were limited to clinical populations who sought binary transition (male-to-female or female to-male). For example, the prevalences reported in DSM-5 (0.005–0.014% for birth-assigned males; 0.002–0.003% for birth-assigned females) are based on people who received a diagnosis of GID or transsexualism, and were seeking hormone treatment and surgery from gender specialty clinics ( 25 ), and, therefore, do not reflect the prevalence of all individuals with gender dysphoria or who identify as transgender.

The prevalence of transgender people receiving gender specialty care in the Netherlands has been estimated at 0.008% for transgender women and 0.003% for transgender men ( 32 ). More recent data for those obtaining surgery in Belgium were similar ( 33 ). In Sweden, point prevalence in 2010 was estimated to be 0.013% for transgender women and 0.008% for transgender men ( 34 ). A higher percentage, 0.023%, received a diagnosis of GID recorded in the health records of the U.S. Veteran’s Administration ( 35 ).

Other studies, rather than measuring the proportion of a population that received a clinical diagnosis, have reported on those who self-identified as transgender or gender incongruent, and found that measuring self-identity yields much higher numbers. In 2016, data from the Center for Disease Control’s Behavioral Risk Factor Surveillance System suggested that 0.6% of U.S. adults identify as transgender, double the estimate utilizing data from the previous decade ( 36 ).

In a large Massachusetts population-based phone survey, 0.5% of the population (age 18–64 years) identified as transgender ( 37 ). In another large population-based survey in the Netherlands, 1.1% of those assigned male at birth (age 15–70 years) reported an incongruent gender identity (stronger identification with a gender other than the one assigned at birth), as did 0.8% of those assigned female at birth ( 38 ).

Recent surveys of youth showed even higher numbers. In New Zealand, 1.2% of high school students surveyed identified as transgender ( 39 ). In a survey of San Francisco middle school students (grades 6–8), 1.3% identified as transgender ( 40 ). More study is needed, but these larger numbers indicate that many transgender people have not been counted in clinical studies, including those with nonbinary identities, those not seeking transition care, those receiving hormones outside of clinics specializing in transgender care or by self-administration, and others who identify as transgender when surveyed, but do not report gender dysphoria to clinicians.

Gender Development

Biological considerations.

Animal research has established that sex differences in the phenotype of both body and brain as well as behaviors are the result of multiple, sex-biasing factors. These include hormonal, sex-chromosomal ( 41 ), genetic, and epigenetic contributions ( 42 ). The sensitivity of brain tissues to organizational effects of sex hormones appears to be particularly high at prenatal/perinatal stages of development and gradually declines toward young adulthood ( 43 ). The timing of hormonal secretions in the course of development, however, gives the impression of three discrete sensitive periods: (1 ) pre/perinatal; ( 2 ) pubertal ( 44 ); and ( 3 ) for females, the first pregnancy ( 45 ).

In humans, statistical sex differences in brain structure are well documented ( 46 ), and findings of sensitive periods for sexual differentiation of the brain appear to parallel those seen in other mammals ( 47 , 48 ). The evidence for brain/behavior effects of prenatal androgenization is particularly strong ( 49 – 51 ), much of which derives from studies of individuals with somatic intersex conditions and varying degrees of functional androgen exposure ( 51 – 53 ).

Androgenization of the brain depends not only upon the level of androgen to which a fetus is exposed but also upon numerous other factors, including the presence of enzymes to convert androgens to the specific metabolites required by particular brain cells, their steroid receptors, and their postreceptor mechanisms that are involved in the full response to androgens. Receptor structure, which can influence sensitivity, is genetically determined, while the activity of genes for receptors and postreceptor mediators is subject to epigenetic modulation ( 54 ).

As the period of genital differentiation largely precedes the sexual differentiation of the brain ( 55 ), it is conceivable that GD in individuals without somatic intersex conditions could reflect a brain-limited intersex condition (i.e., a lack of concordance between the sexually differentiated state of the brain and body). That hypothesis has been tested in a variety of ways, including searching for features of the brain in individuals with GD that more closely match their experienced gender than their birth-assigned gender ( 56 ). Investigations in this regard have included postmortem morphometric and stereological studies ( 57 ), as well as in vivo morphometric ( 58 ), functional magnetic resonance imaging ( 59 ), and diffusion tensor imaging studies of the brain ( 60 – 62 ), and examination of otoacoustic emissions ( 63 ).

As reviewed elsewhere ( 53 , 56 , 64 ), while some positive findings in the predicted direction have been reported ( 56 , 64 ), inferences are currently limited. This is because few findings have been replicated and few studies have adequately controlled for potentially confounding variables such as age, sexual orientation, transition status (including history of gender-affirming hormonal treatment, if any), and hormonal status at the time of study (or of death in the case of postmortem studies) ( 53 ).

Much of what is known about the role of early hormonal exposure on the development of gender identity in humans derives from studies of gender outcomes in individuals with somatic intersex conditions. Early guidelines for initial gender assignment for such infants relied heavily on the surgical potential to achieve concordance between the gender assigned and the appearance and functional potential of the external genitalia, in particular, the capacity of penile-vaginal intercourse ( 9 ). Current guidelines, however, emphasize what is known about the longterm gender outcomes of individuals with intersex conditions on a syndrome by syndrome basis ( 52 ).

Overall, these data suggest that regardless of genetic constitution, or gonadal or genital development at birth, individuals prenatally exposed to a full complement of masculinizing hormonal influences (i.e., androgen exposure and the cellular mechanisms for responding fully to androgens as described above) have an increased likelihood of GD when assigned female ( 51 , 52 ). Conversely, most reported 46,XY individuals with complete androgen insensitivity syndrome (and hence no functional androgenization of the brain) have developed a female gender identity, despite having a Y chromosome as well as normally developed and functioning testes ( 51 , 52 ). To date, however, no brain marker of sexual differentiation has been validated to guide the initial gender assignment of infants with intersex conditions.

Psychosocial Factors Influencing Gender Expression

In mammals, and particularly in humans, psychological and social factors have a major additional influence on behavioral outcome ( 65 ). In humans, these psychosocial processes include verbal labeling (e.g., ‘‘boy’’ and ‘‘girl’’) and nonverbal gender-cuing (e.g., gender-specific clothing and haircuts) of children by parents and others in their social environment, as well as the shaping of children’s gendered behavior by positive and negative reinforcement and later by explicit statements of gender-role expectations. Related processes in developing children include gender-selective observational learning/imitation, the formation of gender stereotypes and of related self-concepts, and self-socialization. The effects on gender development have been documented in a vast body of research in developmental psychology ( 65 ).

The impact of such psychosocial factors, however, is not determinative. This is evidenced by individuals in whom gender identity is discordant with the initial gender assignment and gender of rearing, for example, transgender individuals and a higher than expected proportion of individuals with particular intersex conditions (i.e., 46,XY individuals with high degrees of somatic hypomasculinization and 46,XX individuals with high degrees of somatic hypermasculinization) ( 66 , 67 ).

Factors in Gender-Identity Development

Systematic data on gender identity development are much more limited than those on gendered behavior. Yet, the data available, especially for those with intersex conditions, lead to the conclusion that, while early androgenization plays a role, a definitive biological predetermination of gender identity seems unlikely. Not a single biological factor, but multiple factors (i.e., biological, psychological, and social) appear to influence the development of gender identity ( 50 ).

The need to transition gender is even less understood in individuals without, compared to those with, intersex conditions ( 68 ). Along with the dramatically increased referrals of gender-variant individuals to specialized clinics in Western Europe and North America over the last two decades ( 69 , 70 ), there has been a diversification of presentations beyond the original ‘‘transsexual’’ who sought (or was perceived by providers to seek) change to the ‘‘other’’ gender through treatment with gender-affirming hormones and genital surgeries. Currently, many transgender people seek chest, but not genital surgery, or only gender-affirming hormones, or only a social transition without any medical changes. Others may simply desire flexibility in gender expression without transition to ‘‘the other gender,’’ identifying, for example, as nonbinary or genderqueer ( 71 , 72 ).

Prospective follow-up studies of children, who before puberty had met criteria for the DSM-IV diagnosis of GID, showed that the majority of those diagnosed with GID in early or early middle childhood ‘‘desisted,’’ meaning that they subsequently identified as their birth-assigned gender and did not meet criteria for GID. As adults, many identified as lesbian, gay, or bisexual ( 73 – 75 ). Some ‘‘desisters,’’ however, subsequently transitioned later in life ( 73 ).

The data available do not allow a clear prediction before puberty of which child will persist and transition permanently, and which child will not ( 75 ). With the introduction of stricter criteria for the diagnostic category of Gender Dysphoria in DSM-5, the persistence rate likely will be higher ( 73 ), but this needs to be tested by future long-term follow-up studies. For example, the degree of gender nonconformity and whether a child believes they are , as opposed to wishes to be , ‘‘the other’’ gender have been proposed as predictors of persistence ( 76 , 77 ). Those in whom GD persists from childhood into adolescence are likely to experience an exacerbation of dysphoria with the emergence of (or with the anticipation of) undesired secondary sexual characteristics at puberty, in which case pubertal suspension should be considered ( 10 ).

Regardless of their initial sexual orientation, during and after transitioning to express their experienced gender, some individuals retain their pretransition sexual attraction patterns, while others change ( 7 ). In some transgender women, the desire to transition gender is preceded by fantasizing themselves as women, sometimes with sexual arousal ( 78 ). This phenomenon has been controversially interpreted by some as fetishism ( 79 ). Importantly, neither a history of fetishistic arousal nor one’s sexual orientation precludes one from meeting the criteria for the diagnosis of GD ( 27 ) or eligibility for gender transition services ( 7 , 80 ).

Mental Health Assessment and Treatment

This section addresses the assessment and treatment of adults with gender identity or expression concerns in the absence of an intersex condition. GD in individuals with intersex conditions is addressed in the Appendix. Treatment of GD in prepubescent children, where there is currently less consensus ( 81 ), is addressed elsewhere as is treatment of adolescents, including selection of candidates for pubertal suspension ( 81 , 82 ). The primary roles of the mental health professional in assessing and treating patients with GD are based on expert consensus ( 7 , 8 , 10 , 20 ), summarized in Table 2 and described more fully below in the broader context of gender variance.

TABLE 2. Roles of the Psychiatrist

Expert consensus regarding the treatment of adults has been arrived at after many years of clinical experience. Attempts to engage individuals in psychotherapy to change their gender identity or expression are currently not considered fruitful by the mental health professionals with the most experience working in this area ( 7 , 9 , 83 ) and legal bans of therapies aimed at changing sexual orientation have recently been extended to therapies aimed at changing gender identity or expression in a number of U.S. states and Canadian provinces ( 84 , 85 ). Currently, psychotherapeutic involvement with adults with GD is primarily used to assist in clarifying their desire for, and commitment to, changes in gender expression and/or somatic treatments to minimize discordance with their experienced gender, and to ensure that they are aware of and have considered alternatives ( 7 ).

Gender questioning, gender-variant, and transgender adults present to mental health services for a variety of reasons. Some presentations may relate explicitly to gender. For example, patients may wish to explore their gender identity, consider transition options and concerns (e.g., coming out to family or coworkers), or request evaluation for hormonal or surgical treatments. The latter may include requests for referrals for such treatments, including requests for mental health referral letters as specified by the WPATHSOC7 or required by their providers of transition treatments and/or insurance carriers ( 7 , 11 – 13 ).

According to WPATH SOC7, as an alternative to an evaluation by a mental health professional, primary care providers who are competent in the assessment of GD may evaluate patients for hormone therapy, particularly in the absence of significant coexisting mental health concerns and when working in the context of a multidisciplinary specialty team ( 7 ).

Patients may also seek couples or family therapy before, during, or after transition to address the impact of the transition on interpersonal or family dynamics. Alternatively, many transgender patients seek or are referred to psychiatric services for reasons that are either unrelated to gender identity or expression (e.g., management of primary psychiatric illnesses), or only partially related (e.g., sequela of childhood trauma as a result of minority stress due to gender nonconformity).

A careful evaluation for a history and psychological sequela of gender-related stigma and abuse, from childhood on, is crucial given the high rates of violence and bullying experienced by gender-variant individuals, as well as the high rates of discrimination, unemployment, homelessness, sex work, and HIV infection ( 3 , 86 ). High rates of depressive, anxiety, and substance use disorders, as well as suicidal ideation and completed suicide have been linked to such gender minority stress ( 87 – 89 ). In addition to these mental health disparities, the transgender population also exhibits marked general health disparities ( 90 ). Few of these disparities are linked to sexually transmitted infections or hormonal or surgical transition treatments ( 7 , 10 , 90 ), but are instead linked to financial barriers to care as well as avoidance of healthcare due to experienced and/or anticipated stigma and discrimination in healthcare settings, and the widespread belief among transgender individuals that medical professionals are poorly trained to meet their needs ( 3 ), a belief that appears to be well founded ( 15 ). Extensive guidance on overcoming these barriers to care, including creating a welcoming clinical environment, can be found elsewhere ( 91 ).

Assessment of Gender Concerns

Treatment should be patient centered and tailored to the needs and individuality of each patient. Patients should be asked what names and pronouns they use and should be addressed by those names and pronouns regardless of their stage of transition. Those who transitioned many years ago and are seeking treatment for another problem typically need much less focus on gender history than those who are questioning their gender identity, just beginning gender transition, or exploring options for gender expression. When gender is not the primary concern, devoting the appropriate amount of attention to gender-related issues is important, balancing against an overemphasis on gender that can feel inadvertently stigmatizing to the patient or distract from adequate focus on the chief complaint.

While it is important to avoid the assumption that coexisting psychiatric symptoms are due to gender variance, the impact of past and present gender-related stigma should be considered in the biopsychosocial evaluation. This is particularly important in light of the stress diathesis model of psychiatric illness and its exacerbations ( 8 , 92 ). Suicidality should always be assessed, as should protective factors such as social and family supports ( 93 ). Suicidal ideation ( 3 , 94 ) and completed suicide ( 90 ) are dramatically increased in this population and GD may be a risk factor for suicidality, independent of other psychiatric conditions ( 94 , 95 ). Up to 47% of transgender adults have considered or attempted suicide ( 93 ). Assessment of suicide risk is especially important during periods of heightened vulnerability, such as when transgender identity is disclosed to family and more broadly ( 9 , 83 ).

The gender assessment should include the age and circumstances when the patient first became aware of a sense of difference from peers of the same sex assigned at birth as well as experiences of negative affect or self-perception related to that sense of difference ( 8 , 20 ). Any history of peripubertal and/or pubertal distress due to the anticipation and/or emergence of unwanted secondary sex characteristics should also be explored, as should past experiences of gender-related stigmatization, discrimination, harassment, and violence ( 8 , 20 ).

The patient’s history of coping mechanisms and support systems should also be examined ( 8 , 20 ). Gender expression (e.g., pronoun use, name changes, manner of dress, and bodily modifications) over time should be explored as well as what has and has not been helpful in improving the sense of well-being. It is important to clarify each patient’s goals and plans for social and/or medical transition, degree of commitment, and expectations ( 7 , 96 ). For those who do not wish to transition, assessing current psychosocial challenges and formulating with the patient how to best address them (e.g., psychotherapy, group therapy, and social support) should not be neglected.

Recommendations regarding psychiatric assessment of individuals with GD have focused largely on assessment of eligibility for and decision-making capacity related to medical and surgical gender transition services ( 7 , 8 , 10 ) Eligibility for both gender-affirming hormone therapy and surgeries requires persistent gender dysphoria, a documented diagnosis of GD based on DSM-5 criteria, and the capacity to give informed consent ( 7 ). In addition, any significant medical or psychiatric concerns must be sufficiently controlled so that they do not interfere with the patient’s ability to safely adhere to the treatment regimen. The current standard of care in major clinics, the WPATH SOC7, and insurance requirements for reimbursement of services follow a flexible progression of transition steps, which may begin with completely reversible steps (e.g., change of pronouns, name, and manner of dress), followed by partially reversible changes (e.g., gender-affirming hormones), and then irreversible gender-affirming surgeries ( 7 , 10 – 14 , 97 ). There is flexibility in this process given that some people do not pursue all of these interventions or may prefer to do so in a different sequence. For example, transgender men may wish to undergo mastectomy or male breast construction before initiating masculinizing hormones ( 7 ).

Before gonadectomy, 12 months of continuous hormone therapy consistent with the patient’s gender goals are recommended, unless hormones are clinically contraindicated for the individual. The aim of hormone therapy before gonadectomy is primarily to allow the individual to experience a period of gender-affirming hormones, before irreversible surgical intervention ( 7 ). Before masculinizing or feminizing genital reconstructive surgeries, the WPATH SOC7 also recommend 12 continuous months of living in a gender role that is congruent with the patient’s gender identity ( 7 ).

Diagnosis of gender dysphoria.

The DSM-5 diagnostic criteria for GD in adolescents and adults are shown in Table 3 . Diagnosing GD in adults by these criteria is usually straightforward, especially for those with overt manifestations in childhood, exacerbation of distress with pubertal changes, and persistence into adulthood in the absence of significant coexisting mental health concerns ( 8 , 9 ).

Adapted from DSM-5 ( 27 ).

TABLE 3. Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults

Assessment of patients who are seeking transition services, but do not clearly meet criteria for GD, may require more time and exploratory therapy ( 9 ) (e.g., a patient desiring hormonal or surgical treatment to transition to another gender, who does not clearly experience incongruence between their experienced gender and their gender assigned at birth). The same is true for those with the onset of gender dysphoria in the context of a psychiatric disturbance (e.g., psychosis, dissociative disorder, and autism spectrum disorder) or recent trauma ( 9 , 98 , 99 ); those who are ambivalent about their gender identity or desired sex characteristics; and those who exhibit marked exacerbations and remissions of dysphoria over time.

The psychiatrist must assess whether some factor other than GD accounts for the expressed desire to transition. If not, coexisting mental illness is not a contraindication to supporting transition if it is sufficiently controlled to not interfere with the patient’s capacity for decision-making or ability to safely adhere to the demands of the desired treatment ( 7 , 9 , 98 ).

Differential diagnosis.

Few conditions can be mistaken for GD. Simple nonconformity to gender roles can be differentiated from GD based on the degree of associated distress and whether or not the individual identifies as the sex assigned to them at birth. GD can be differentiated from body dysmorphic disorder (BDD), in which an individual may wish a body part to be removed or altered because it is viewed as deformed ( 27 ). In contrast, in GD alterations are sought for anatomical characteristics that are incongruent with one’s gender identity. BDD and GD can, however, coexist and the presence of BDD is not an absolute contraindication for gender-confirming surgery ( 27 ). Transvestic disorder is characterized by significant distress or impairment due to sexual arousal in the context of cross-dressing fantasies, urges, or behavior. It may exist independently or co-occur with GD ( 27 ), and is not a contraindication to supporting transition in those who meet criteria for GD ( 7 ).

Gender-themed delusions have been reported to occur in up to 20% of those with psychotic disorders ( 100 ). Such delusions can usually be easily differentiated from GD by their content (i.e., if they do not entail the belief that one’s gender differs from that assigned at birth), as well as by their presence only during psychotic phases of illness, and the absence of other DSM criteria required for the diagnosis of GD ( 98 ). Importantly, GD and psychotic disorders may coexist and patients with both diagnoses can benefit from gender-affirmative treatment and appropriate hormonal and/or surgical gender interventions ( 98 ). Timely diagnosis of GD may be impeded when it is first overtly expressed in adolescence or early adulthood coincident with, or shortly following, the first psychotic episode ( 98 ).

Mental Health Treatment

Statements in this section are based on the cited studies supplemented by the authors’ cumulative clinical experience treating patients with GD. Psychotherapy can be useful for patients with GD; however, many successfully transition or decide against transition with little or no psychotherapy. Psychotherapy may be helpful at different times and for different reasons across the lifespan ( 7 ). Many transgender people seek mental health treatment on an intermittent basis, while contemplating gender transition, at key points in the transition process, or post-transition if symptoms recur or worsen.

Participation in transgender support groups, including peer-led groups, and other interactions with transgender individuals or the transgender community are often useful in clarifying the goals of those who experience ambivalence about transition. With patients who are otherwise eligible for transition treatments, but express ambivalence about transition, the therapist should maintain a stance of neutrality, creating a safe therapeutic space in which the patient can weigh all options and arrive at a decision in their own time. Many transgender adults need some combination of hormonal treatment and/or surgical procedures for relief of GD, but some experience relief with a change in gender expression without any medical treatment ( 7 ). Strengthening resilience factors identified in the transgender population ( 93 ) should be a focus, particularly, in patients with suicidal ideation.

Although treatment with exogenous estrogen or testosterone carries a risk for medical side effects ( 10 ), both have been associated with improvement with respect to anxiety, mood, and mood stability, as well as overall satisfaction and quality of life for both transgender women and transgender men ( 101 – 104 ). Similarly, review of the available literature ( 9 ) demonstrates the benefits of surgery in alleviating GD and the rarity of postsurgical regret. Emotional changes may occur with use of either androgen or estrogen supplementation, although these are usually subtle ( 9 ). An increase in libido usually occurs with androgen use with female to male transition ( 10 ). Although decreased libido due to antiandrogen and/or estrogen treatment in individuals transitioning male to female is common ( 10 ), some may experience a stronger interest in sex, perhaps due to the affirming aspects of attaining desired bodily changes.

Safer sex information and instruction in self-protective negotiation in sexual settings should be provided and tailored to the anatomy, needs, and experiences of transgender persons ( 9 ). Masculinizing hormones have been associated with a possible destabilization of psychotic and bipolar disorders, especially with supraphysiological blood levels of testosterone ( 7 ) in both cisgender and transgender men ( 105 – 106 ). The likelihood of such episodes can, therefore, be minimized by careful dosing and monitoring.

Detailed information on specific gender-affirming surgical procedures can be found elsewhere ( 7 , 107 ). Psychiatrists should collaborate with other providers (e.g., endocrinologists, surgeons, psychotherapists, primary care providers, social workers, and other mental health professionals) to ensure that patients have the knowledge required to adequately evaluate the benefits, risks, and limitations of desired treatments and their alternatives. This is necessary not only for informed consent but also to ensure adequate preparation for surgery and postsurgical needs (e.g., convalescent period, period of sexual abstinence, and vaginal dilatation in the case of vaginoplasty).

Helping the patient anticipate and prepare for psychosocial impacts of treatment (e.g., impact on social relationships and employment) is also essential. Importantly, transition treatments target GD, not coexisting psychiatric diagnoses, and coexisting diagnoses are likely to require ongoing attention after transition, although symptom severity may be ameliorated ( 98 , 100 , 102 ).

Referrals for hormones and surgery

Whether the initial evaluation for hormones is done by the hormone prescriber or by a mental health professional, criteria for starting hormones are the same: the presence of persistent GD, the ability to give informed consent, and relative mental health stability ( 7 ). Insurance carriers and surgeons require mental health evaluation before transition-related surgeries to assess and document eligibility, readiness, and medical necessity of the requested procedure ( 7 , 10 – 14 ).

The specific requested content of referral letters varies among surgical providers and insurance plans. To avoid unnecessary delays in treatment, letter writers should be aware of such differences and ensure that their letters meet the requirements of all relevant parties. The content requested by most providers and insurance carriers is similar to that outlined in the WPATH SOC7. Genital and gonadal surgeries usually require documentation from two licensed mental health professionals, while chest surgeries generally require just one evaluation and referral ( 7 , 108 ). Although not requirements of WPATH SOC7, some insurers require one letter from a psychiatrist or other doctoral level mental health provider, or may specify a minimal duration of mental healthcare ( 13 ). Such requirements vary by health system, insurance carrier, and state, and raise challenges for those without access to reimbursement for mental healthcare.

Current Social Issues: Stigmatization and Access to Care

Transgender health advocates have worked to address societal discrimination against transgender people, including stigmatization of identity, discrimination in schools, workplaces, and healthcare, and to improve access to care. Increasingly, this advocacy has been embraced by major institutional and governmental agencies. One large online survey, the National Transgender Discrimination Survey ( 88 ) found that rejection, discrimination, victimization, and violence against transgender people occur in a multitude of settings and negatively affect transgender people across the life span. Transgender youth are often harassed and assaulted in schools, which is associated with dropping out and subsequent impoverishment. Many transgender people are harassed at work or lose jobs due to their gender identity and expression. Discrimination extends to healthcare settings, where patients may be refused care or treated disrespectfully, or do not have access to care ( 88 ).

U.S. public policy has contributed to the lack of access to care. A report by the National Center for Health Care Technology of the HHS Public Health Service issued in 1981, titled ‘‘Evaluation of Transsexual Surgery,’’ deemed these procedures ‘‘experimental,’’ and recommended that Medicare not cover transition-related care. This was formalized in a 1989 Health Care Financing Administration National Coverage Determination ( 5 ). Exclusion of transgender healthcare in private insurance as well as Medicaid and Medicare was near universal in the decades to come. A lack of funding for clinical care and research led to the closing of transgender care programs at academic institutions in the years following the 1981 report.

Many transgender health insurance exclusions have been removed recently. This trend started with increasing numbers of employers in the last 15 years adding transition care to health coverage. Starting in 2013, some states have ruled that transgender healthcare exclusions are discriminatory and have banned them from state-regulated health insurance plans. In 2014, the 1981 Medicare policy was reversed, removing categorical exclusions for transgender care ( 6 ). In 2015, the HHS moved to end categorical exclusions for transgender care from all insurance and care providers who accept federal funding or reimbursement ( 109 ); and since 2016, insurers in the Federal Employees Health Benefits Program must include transition-related coverage for transgender federal employees ( 110 ).

During this same period, executive orders and other guidance from the Obama administration conferred increased protection against discrimination to transgender individuals in workplace and educational settings ( 111 ), the ban on open military service of transgender individuals was lifted ( 112 ), and changes at the HHS and the National Institutes of Health (NIH) facilitated research to better define and address the health needs of transgender individuals ( 111 ). Much work remains, however, to fully actualize these policy changes. In addition, progress has been slowed on the federal level by the change in presidential administrations and legal actions ( 113 ).

WPATH SOC7 (7) has attempted to improve access to care by including the informed consent model for hormone administration. In multidisciplinary clinics providing transgender care, primary care providers can assess for and diagnose longstanding GD that might benefit from treatment with hormones and administer hormones without referral from a mental health professional. However, patients with cooccurring mental health conditions should be referred to mental health providers when appropriate. WPATH has advocated for the depathologization of transgender identity, the medical necessity of transgender care, and improved access to legal gender change ( 7 ).

The APA has also attempted to reduce stigma and improve access to care. As discussed previously, the DSM-IV diagnosis of GID, regarded as stigmatizing by many transgender health and advocacy groups, was replaced with GD in DSM-5 ( 114 ). In addition, the APA approved position articles on discrimination and access to care. Its statement on discrimination against transgender and gender-variant individuals ( 115 ) opposes all private and public discrimination against transgender individuals, and its statement on access to care for transgender and gender-variant individuals ( 116 ) urged the removal of all categorical healthcare exclusions for transgender people and advocated for the expansion of access to care.

Increased access to care must be accompanied by culturally competent research in transgender health, recommended by the Institute of Medicine ( 86 ) and outlined in the NIH’s Strategic Plan to Advance Research on the Health and Well-being of Sexual and Gender Minorities ( 117 ). Expanded and improved education of healthcare providers is necessary, and the American Association of Medical Colleges has produced guidelines for curricular and climate change to improve transgender health ( 118 ). Principles of culturally competent care for transgender and nonbinary patients should be included in residency training as well, including psychiatric residency programs.

Conclusions

Transgender, nonbinary, and gender questioning people are sufficiently common that even psychiatrists whose practice does not focus on gender are likely to encounter patients who have transitioned gender, are planning or considering transition, or are questioning their gender identity. Gender concerns are only one of the reasons these individuals may seek psychiatric care and, regardless of their area of specialization, psychiatrists should be adept at conducting respectful, culturally sensitive, and affirming gender assessments without placing an undue emphasis on gender when it is not the patient’s presenting concern. Mental health professionals must fully appreciate that the focus of treatment for GD is on the dysphoria, not the gender identity. At the same time, they must appreciate the role of minority stress in gender minority mental health disparities, screen for related manifestations, including anxiety disorders, depression, and suicidality, and consider resilience factors in treatment planning.

Psychiatrists should also be competent in the provision of routine psychiatric care that is gender affirming to gender variant patients with serious mental illnesses without assuming that the gender variance is a manifestation of the illness. They should not expect coexisting serious mental illness, especially in the context of strong genetic loading, to fully resolve with successful treatment of GD and should assist the patient in formulating realistic expectations.

If not included in their residency or fellowship training, or supervised clinical experience, psychiatrists should familiarize themselves with the standards of care for gender transition as described in the WPATH SOC7 and outlined in this article, as well as the roles and minimal competencies of mental health professionals working with adults with GD ( 7 ). In addition to the minimal competencies, WAPTH SOC7 recommends that health professionals take steps to sustain or augment their cultural competency to work with transgender and other gender minority patients by participating in continuing education and becoming knowledgeable about community, advocacy, and public policy issues that affect transgender individuals and their families ( 7 ).

All providers should work within their sphere of competency and refer patients when necessary. Board-certified psychiatrists should be competent in the diagnosis of GD by the criteria of the most current DSM and in assuring that any coexisting psychiatric disorder is appropriately diagnosed and adequately controlled ( 118 ). In the absence of additional training, they should refer to other providers or seek supervision in fulfilling the other tasks of mental health professionals in addressing the gender concerns of transgender and other gender diverse patients. Providers from all disciplines should work within their professional organizations to ensure that training in gender-affirmative care is integrated throughout all levels of the training curriculum ( 119 ).

Gender Dysphoria in Patients with Intersex Conditions

As reviewed elsewhere ( A1 ), Gender Dysphoria (GD) and patient-initiated gender transition occur with increased frequency in individuals with intersex conditions. Because Diagnostic and Statistical Manual of Mental Disorders-5 now allows gender-dysphoric individuals with somatic intersex conditions to receive the diagnosis of GD, psychiatrists need to be aware of assessment and treatment-relevant characteristics of such individuals that differ from gender-dysphoric individuals without somatic intersexuality ( A2 ).

Intersex conditions are a subset of conditions relatively recently designated as ‘‘disorders of sex development’’ ( A3 ) or ‘‘differences of sex development’’ (DSD) ( A4 ). We use the term ‘‘intersex’’ in this document as our focus is on that subset of individuals with DSDs who were born with atypical external genitalia or lack of concordance among various sex characteristics such as sex chromosomes, gonads, or external genitalia so that questions often arise as to which gender should be assigned at birth. GD may develop from late preschool age through late adulthood with a range from 0% to ~ 70% depending on the specific intersex syndrome, its severity (degree of androgen insensitivity, degree of 21-hydroxylase deficiency, degree of genital atypicality, etc.), the gender originally assigned, and the postnatal history of exposure to both endogenous and exogenous sex hormones ( A5 ).

Persons with the combination of GD and intersex condition encounter fewer barriers to legal gender reassignment, and the barriers to hormonal and surgical treatments are much lower ( A1 ). This is because, depending on the particular condition, individuals with an intersex condition may have been gonadectomized (often due to concern about risk of malignancy) before puberty so that administration of exogenous hormones is required as part of routine care to induce puberty. In addition, infertility is quite common whether due to the condition itself or to gonadectomy, and genital surgery has often been done in infancy or childhood with the intent of affirming, both to the patient and the parents, the gender to which the individual was assigned. Furthermore, such early procedures may have been followed by additional surgical modifications in adolescence or young adulthood.

Decisions regarding hormonal and surgical procedures are complicated by the highly variable somatic presentations of the various intersex conditions. Thus, to be fully effective, the mental health provider needs to be informed about the medical and surgical history of the individual (A6, A7), the available data on long-term gender development (e.g., contentment vs. dysphoria in the assigned gender), and other psychological outcomes of patients on a syndrome by syndrome basis ( A5, A8 ). Moreover, intersex conditions are frequently associated with stigma, even in medical settings, which may result in shame and maladaptive coping mechanisms on the part of the patients as well as their parents ( A9–A12 ).

Providers need to be aware of the many ways in which some individuals with intersex conditions report having been stigmatized by their treatment by clinicians and parents (e.g., failure of age-appropriate disclosure of their condition, attempts to modify their gender expression, and repeated genital examinations) (A9–A13 ). Efforts are under way to develop decision-making tools and clinical checklists to ensure that parents and affected children are adequately assessed and informed as active participants in decision-making processes and that the intersex condition and its ramifications are disclosed to the affected individual in an age-appropriate manner ( A14 ).

Gender Evaluation

The questionnaires and interview schedules developed for the assessment of gender development in transgender individuals who do not have an intersex condition ( A15, A16 ) apply to those with intersex conditions as well, but need to be complemented by detailed medical, surgical, and related psychosocial histories, including the histories of disclosure to the patient of her/his medical condition, efforts made to reinforce the initial gender assignment, and responses by parents and providers to behaviors perceived as atypical with respect to the gender assignment. Mental health providers should also assess the patient’s knowledge of their surgical history, their understanding of the implications with respect to fertility and gender-affirming hormonal and surgical procedures, and any history of shaming or other stigma due to their condition, or perceived gender atypicality with respect to their gender assigned at birth.

Decisions Regarding Gender Transition

For individuals with intersex conditions, GD usually raises the question of transition to a different gender, and all issues of relevance to transgender persons without these conditions should also be considered here. Yet, the situation is often more complex than in GD in the absence of an intersex condition. Factors contributing to the desire to transition may include the awareness of the discrepancy between assigned gender and genetic factors such as the karyotype, anatomic factors such as the type of gonads, and secondary sex characteristics like breast development in men or hirsutism and masculine habitus in women. Related psychosocial influences may derive from being misidentified as the ‘‘other’’ gender or from frank stigmatization due to gender-atypical physical features.

Different cultures and even subcultures within a given countrymaydifferintheroles(includingrights) associated withone’sgender,andinthesalienceandweightofcriteria used in decision-making on gender reassignment ( A17, A18 ). When discussing gender options, clinicians need to consider the legal regulations of the country in which they work as well as the religious and other ideologies that can influence the gender perspectives of patients (and of caregivers for minors). These considerations are also very important when doing clinical work with visitors or immigrants from foreign countries. Thus, the viewpoints of patients (and caregivers) within their cultural contexts should be explored in detail and taken into consideration when these individuals are provided with psychoeducation about gender and other issues related to their intersex conditions ( A19 ).

As with other transgender patients, when working with patients with an intersex condition and GD, clinicians should engage the patient in a detailed discussion of their expectations from the gender transition: the social effects of public gender change as well as the medical and social effects of the attendant change in hormone treatment and, if desired, of genital or chest surgery. Some of their expectations may be unrealistic, and after detailed discussion, some patients may modify the hormonal and/or surgical treatments they desire or decide against medical treatments or legal gender change, and pursue other ways of finding authenticity in their gender expression. Patients may be happy with their gender-atypical bodies and/or adapt a nonbinary gender identity such as ‘‘intersex.’’ Mental health providers should not assume that patients would benefit from conforming to fit within a gender binary, physically or with respect to gender identity.

Empathic listening is especially important in working with intersex individuals, perhaps particularly with those who have inadvertently discovered their intersex status in adolescence or adulthood, and may have been stigmatized for gender nonconformity or homosexuality, or subjected to irreversible hormonal or surgical treatments consistent with their assigned rather than their experienced gender. Upon discovery of their biological status, such patients may feel betrayed by their parents and physicians, feeling they colluded to keep them in ignorance of their medical condition, damaged their bodies, or punished or stigmatized them for their gendered behaviors. Such patients need empathic validation of their feelings. Assurance that parents and providers had their best intentions at heart, while usually true, is likely to be experienced as an empathic failure and negatively impact the formation of a therapeutic alliance.

As is often seen in many individuals with uncommon medical conditions, many people with intersex conditions experience varying degrees of isolation and loneliness ( A1 ). Therefore, linking them to existing intersex support groups by internet or face-to-face meetings can be very beneficial. Despite the emotional relief that support groups can provide, such contacts may sometimes cause additional concerns. For instance, the composition of the group (e.g., the syndromes represented within the group, the personalities of some group members, or the goals of the group) may not meet the individual’s expectations, and the information provided may not always be accurate. Thus, some monitoring of the patient’s experience with the chosen group is recommended.

Hormonal and Surgical Treatments

As reviewed elsewhere ( A1 ), many individuals with both an intersex condition and GD will be agonadal in later adolescence or adulthood, either because they were born that way (e.g., in syndromes involving gonadal dysgenesis) or due to surgery, for instance, for the prevention of gonadal malignancy. In those with intact gonads (especially 46,XX congenital adrenal hyperplasia raised female), loss of fertility may be another issue of concern. Persons who are agonadal are usually on hormone replacement therapy by the time of late adolescence. Cessation of that treatment, change to treatment with hormones congruent with their gender identity, patient education for informed consent, and the monitoring of treatment effects are tasks of the endocrinologist.

Also, the technical aspects of genital surgery are more complex than in patients receiving gender‐confirming genital surgeries, who do not have intersex conditions. Both the external genitalia and the internal reproductive tract in intersex conditions typically differ from what most surgeons are familiar with in transgender patients without these conditions. In addition, many patients with intersex conditions have already undergone one or more genital surgeries by late adolescence. The resulting postsurgical anatomy constitutes an additional challenge for the surgeon performing gender-confirming surgery, and a good sexfunctional outcome may be more difficult to achieve.

Mental health providers should also be aware that not all individuals who identify their gender or gender identity as intersex have a somatic intersex condition, and should ensure that those who do have an intersex condition are receiving adequate medical care, including hormones (to prevent osteoporosis) and cancer screenings, as appropriate to their particular condition ( A3 ). Without challenging a patient’s identity label, this distinction can usually be made by inquiring about the name of the patient’s condition, when and how they learned of it, and any history of related surgeries, hormonal replacement, or ongoing follow-up evaluations. If there is any doubt, appropriate referrals should be made to ensure that the patient is receiving adequate follow-up and treatment.

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RETRACTED ARTICLE: Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases

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• Published: 29 March 2023
• Volume 52 , pages 1031–1043, ( 2023 )

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• Suzanna Diaz 1 &
• J. Michael Bailey   ORCID: orcid.org/0000-0003-4756-1705 2  

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This article was retracted on 14 June 2023

This article has been updated

During the past decade there has been a dramatic increase in adolescents and young adults (AYA) complaining of gender dysphoria. One influential if controversial explanation is that the increase reflects a socially contagious syndrome: Rapid Onset Gender Dysphoria (ROGD). We report results from a survey of parents who contacted the website ParentsofROGDKids.com because they believed their AYA children had ROGD. Results focused on 1655 AYA children whose gender dysphoria reportedly began between ages 11 and 21 years, inclusive. These youths were disproportionately (75%) natal female. Natal males had later onset (by 1.9 years) than females, and they were much less likely to have taken steps toward social gender transition (65.7% for females versus 28.6% for males). Pre-existing mental health issues were common, and youths with these issues were more likely than those without them to have socially and medically transitioned. Parents reported that they had often felt pressured by clinicians to affirm their AYA child’s new gender and support their transition. According to the parents, AYA children’s mental health deteriorated considerably after social transition. We discuss potential biases of survey responses from this sample and conclude that there is presently no reason to believe that reports of parents who support gender transition are more accurate than those who oppose transition. To resolve controversies regarding ROGD, it is desirable that future research includes data provided by both pro- and anti-transition parents, as well as their gender dysphoric AYA children.

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Introduction

The demographics of gender dysphoria have changed dramatically during the past two decades. Specifically, the proportion of cases among adolescent natal females has sharply increased, both absolutely and relatively (Aitken et al., 2015 ; Steensma et al., 2018 ; Zucker, 2019 ). This change has been noted in clinic-referred samples across North America and Western Europe (Zucker, 2019 ; Zucker & Aitken, 2019 ). The causes of these changes are difficult to know. Two main hypotheses have been proposed:

Hypothesis 1

There has not been an increase in the actual number of gender dysphoric adolescents, but more of them are being recognized and referred to gender clinics.

Those who believe this hypothesis view the increase in referrals to gender clinics favorably, because gender dysphoric youth are getting treatment they need rather than suffering in silence (e.g., Turban & Ehrensaft, 2018 ). People who hold this view also tend to support gender transition for gender dysphoric youth.

Hypothesis 2

There has been an increase in gender dysphoria among adolescents, especially adolescent females.

This hypothesis is associated with Rapid Onset Gender Dysphoria (ROGD) (Littman, 2018 ; Marchiano, 2017 ; Shrier, 2020), a recent and controversial theory. ROGD theory proposes that common cultural beliefs, values, and preoccupations cause some adolescents (especially female adolescents) to attribute their social problems, feelings, and mental health issues to gender dysphoria. That is, youth with ROGD falsely believe that they are transgender, and that they must undergo social and medical gender transition to resolve their issues. A sharp increase in such false beliefs among adolescents and young adults has led to the recent “epidemic” in ROGD.

ROGD is believed to be a culture-bound syndrome, which did not exist until recently, when transgender issues began to attract considerable cultural attention (Allen, 2015 ). Furthermore, ROGD has been hypothesized to be socially contagious (Littman, 2018 ). Adolescents who know others with ROGD are more likely to acquire ROGD themselves.

Advocates of the ROGD theory view the dramatic increase in referrals to gender clinics with alarm. They are concerned that adolescents with ROGD are at risk of unnecessary, harmful, and irreversible psychological and medical interventions (e.g., Marchiano, 2017 ; Shrier, 2020).

The surge in referrals for adolescent-onset gender dysphoria is so recent that neither hypothesis has much support in the mainstream academic literature. This is understandable in the early stages of research on any human clinical phenomenon, especially one as controversial as gender dysphoria.

Parents of Gender Dysphoric Youth as Influential Stakeholders

A new development in the history of gender dysphoria has been the formation of Internet communities of concerned parents. These communities appear to be centered around the two opposing viewpoints we have described. Some of these communities comprise parents concerned that their AYA children have ROGD and are pursuing gender transition unnecessarily. Examples include the Gender Critical Support Board, ParentsofROGDKids.com, and Genspect.org. Other communities are more supportive of gender transition for gender dysphoric youth. These include the Facebook group, Parents of Transgender Children, among others. Some of these groups are quite large, with Gender Critical Support Board exceeding 3500 registered members, and Parents of Transgender Children exceeding 8000 members (both numbers taken from their respective websites on April 12, 2022).

Parents of gender dysphoric youth have had an especially important role in the controversies regarding adolescent-onset gender dysphoria. For example, the blogger who writes as 4thwavenow became interested in the issue when her daughter “suddenly announced she was a trans man after a few weeks of total immersion in YouTube transition vlogs and other trans-oriented social media” (4thwavenow.com, n.d.). (Her daughter’s gender dysphoria has subsequently subsided.) Littman ( 2018 ), who originated the theory of ROGD, was strongly influenced by accounts of parents like this (Kay, 2019). ROGD is a controversial idea and has been challenged by both activists (e.g., Ashley, 2020 ) and scientific studies (Bauer et al., 2022 ; but see Littman, 2022 ). Careful empirical study is sorely needed.

Parents who disagree with the concept of ROGD and who believe that their children are gender dysphoric in the conventional sense (i.e., having a strong feeling of incongruence between their physical body and the gender they identify with) have also played an important role in the controversy. Until recently it was rare for parents to acquiesce to their children’s wish to transition, but this has been changing. Parents have become much more likely to allow their gender dysphoric children to socially and/or medically transition (see, e.g., de Graaf & Carmichael, 2019 ; Olson et al., 2016 ). For example, minor children may be given puberty-delaying hormones with parents’ permission. In some cases, youth years away from legal adulthood may even receive gender-confirming surgery, such as mastectomy in natal females (Olson-Kennedy et al., 2018 ). Thus, parents supporting gender transition have dramatically altered acceptable social, psychological, and medical practice.

One relevant issue concerns the potentially differing motivations of parents who believe, and those who disbelieve, the idea that their gender dysphoric adolescent children have ROGD. The former have been accused of being prejudiced against transgender persons and other sexual minorities (Restar, 2020 ; “Why are so,” 2018). However, Littman’s ( 2018 ) study found that most such parents held tolerant views regarding the rights of sexual minorities. An alternative explanation of these parents’ endorsement of ROGD is that it describes the trajectory of their children’s gender dysphoria better than conventional explanations of gender dysphoria do.

ROGD has been studied primarily in adolescents and young adults (Littman, 2018 ). By definition, these youth were not gender dysphoric prior to puberty. In contrast, early-onset gender dysphoria begins prior to puberty, often during early childhood (Bailey & Blanchard, 2018; Zucker & Bradley, 1995 ). It is possible that parents of children with early-onset gender dysphoria and parents of youth with ROGD have different preferences for their children. The current study focuses on AYA children believed by their parents to have ROGD.

Parents of Gender Dysphoric Children as Sources of Information

Research on children’s development in many domains has long depended on parent reports. Google Scholar reports 78,800 citations for the search term “parent reports,” as of April 12, 2022. Research on gender dysphoria has also often included parent reports (e.g., Arnoldussen et al., 2020 ; Olson, 2016 ; Wallien & Cohen-Kettenis, 2008 ; Zucker & Bradley, 1995 ). Researchers have also long acknowledged the imperfections—including both incomplete information and biases—associated with parent reports (Achenbach et al., 1987 ). Parent reports are especially controversial when parent and child reports differ dramatically, as they often do in cases considered to be ROGD (Littman, 2018 ).

We expect that parents’ and children’s reports are more similar for families in which parents support their children’s transition, although this has not been studied directly. However, this does not mean that parents who support transition are correct. These parents and their gender dysphoric children could both be mistaken, especially if there is social pressure to accept children’s claims of transgender status. The increasing number of people who have reidentified with their natal gender (detransitioners) raises questions about the desirability of transition (Littman, 2021 ; Marchiano, 2020 ).

Given the recent surge of cases of gender dysphoria in adolescents and young adults whose demographic profile is unlike those from previous generations, it is important to seek data from all sources and premature to reject any of them. As we learn more, we may come to prefer some sources of information over others, but there is not yet any guide to this preference. In the meantime, it is desirable—even urgent—to collect data from all available sources.

The Current Study

We analyzed data from a survey of parents who contacted a website for parents concerned that their AYA children have ROGD. Parents provided data regarding their AYA children’s adjustment before gender dysphoria onset, children’s gender dysphoria, and children’s social and medical transition steps. We discuss potential biases in the data due to subject self-selection and survey framing.

Participants

Participants were parents or other caretakers of gender dysphoric children who contacted the website ParentsofROGDKids.com. This website provides information and support to parents who believe their children may have ROGD and who are skeptical about “affirmative” therapeutic approaches (i.e., those encouraging gender transition). ParentsofROGDKids.com did not actively recruit parents. Rather, parents discovered the website via Internet searches or mentions on Internet forums. After contacting the website, parents were asked to provide more information about their gender dysphoric children, via email. This was done to ensure that those engaging with the website were not attempting mischievous deception. Those whose information was sufficiently detailed and credible received the following survey solicitation:

Rapid Onset Gender Dysphoria (ROGD) is a new phenomenon that is only now beginning to be recognized. The so-called gender clinics are not forthcoming with information about demographics or mental health issues of clients who seek out their services. Nor do they publish information on patient outcomes. The task is left up to us, the parents, to seek out this information on our own. Please help us gain a better understanding of this emotionally devastating and physically traumatizing, yet increasingly common phenomenon. Who Should Complete this Survey If your child: Had a relatively normal childhood without showing any signs of discomfort with their gender, and Suddenly, seemingly out of the blue, decided they identified as the opposite gender, or some other “gender” Please take the time to fill out this survey. It takes about 10–15 min to complete, a bit longer if you write comments (which are very helpful!). *Don’t worry if the survey skips over some questions. It is designed to skip over questions that do not apply to you. All responses will be kept strictly confidential.

The authors acknowledge that the framing of the survey is biased toward belief in, and concern about, ROGD. This may have influenced responses, although it is likely that a more important bias was self-selection due to the website’s name and purpose. The initial purpose of the survey was not for scientific publication, but information gathering for a community of parents with shared concerns. In the Discussion, we consider which results are more or less likely to be biased.

Parent informants provided information about their gender dysphoric children. The data analyzed herein include parents’ reports on the following variables: timing and early signs of children’s gender dysphoria; children’s mental health (including formal diagnoses) and social adjustment prior to the onset of gender dysphoria; and children’s steps taken toward both social and medical transition. The survey can be viewed in the supplementary materials.

Survey Respondents

Participants of the current study completed surveys from December 1, 2017 (the beginning of the survey), through October 22, 2021, a total of 46 months. In total 1774 responses were received. (The number of potential participants who contacted the website was not recorded.)

The large majority of survey respondents ( N  = 1496; 84.3%) were mothers reporting on their own children. Fathers ( N  = 223) comprised 12.6% of the respondents, and persons with some other relationship to the gender dysphoric youth, such as stepparent, grandparent, or adoptive parent ( N  = 55; 3.1%), were the remaining respondents. For ease of presentation, we refer to respondents as “parents.”

To illuminate the general political/ideological orientation among the parents who responded, the first author examined a subset of email correspondence in which some parents provided details about their gender dysphoric children and family situation. Emails were chosen systematically, by taking the first ten of every consecutive fifty. (Parents were not queried to provide this information until after the project had commenced, and so not all parents provided emails.) A total of 280 emails were examined for statements indicating either supportive/progressive attitudes or unsupportive/conservative attitudes. Statements were coded as supportive/progressive if they indicated that parents were politically progressive, including supportive of LGBT rights and people. This included evidence that they were at least partially supportive of their child’s gender-related choices. Emails were coded as unsupportive/conservative if they indicated that parents were conservative or religious in ways that may not be supportive of LGBT rights or people. (Statements indicating either conservative or religious beliefs were not, by themselves, coded as the latter.) The number of coded statements indicating supportive/progressive sentiments was 70, and the number indicating unsupportive/conservative sentiments was 5. Table 1 contains 7 examples of the supportive/progressive statements (every tenth statement starting at the first) and all 5 unsupportive/conservative statements. All deidentified coded statements are included as a supplement.

Characteristics of Gender Dysphoric Youths

Current age, age of onset, and duration of gender dysphoria.

The survey included the following description of gender dysphoria: “feeling unhappy or uncomfortable with your gender. It can include wishing to be the opposite gender, or to be a different ‘gender’ altogether. It can also include simply rejection of your own gender.” It then listed several “signs of gender dysphoria,” focusing on displaying cross-sex behavior (e.g., “changing your posture or way of moving”). Respondents were asked to estimate when their child “began to exhibit signs of gender dysphoria.” On average, the youths were reported to be 14.8 years ( SD  = 3.1) when they became gender dysphoric. Onset ages ranged from 3 to “greater than 25 years,” with a median of 14 years.

Because ROGD is hypothesized to begin during puberty through early adulthood (Littman, 2018 ), we limited subsequent analyses to parent reports on youths whose gender dysphoria was reported to begin between ages 11 and 21, inclusive. This left 93.3% ( N  = 1,655) of the original sample, of whom 75% ( N  = 1249) were natal females and 25% ( N  = 406) natal males. Mean current age of gender dysphoric youths was 15.7 (SD = 2.7) years for females and 17.2 (SD = 2.7) for males, t (1653) = 9.9, p  < 0.001, d  = 0.56.

Figure  1 shows the distribution of age of gender dysphoria onset, separately for natal females and males. Reported onset was significantly later for natal males ( M  = 16.0, SD = 2.2) than for natal females ( M  = 14.1, SD = 2.2), t (1653) = 15.5, p  < 0.001, d  = 0.84. Duration of gender dysphoria, from onset to the present, was briefer for the natal males ( M  = 1.2 years, SD = 1.6) than for the natal females ( M  = 1.6 years, SD  = 1.6), t (1772) = 5.3, p  < 0.001, d  = 0.25.

Distribution of parent reports of children’s age of onset of gender dysphoria (in years), separately for natal females and males

Demographics

Ethnic backgrounds of the youths were European ( N  = 1276; 78.9% of those who answered this question), ethnically mixed ( N  = 262; 16.2%), Asian ( N  = 45; 2.8%), Indigenous ( N  = 13; 0.8%), African–American ( N  = 10; 0.6%), Middle Eastern ( N  = 6; 0.4%), and East Indian ( N  = 6, 0.4%). Although the survey did not ask where respondents lived, it did include one question regarding where the gender clinic the youth attended (if any) was located. The most common location was in the USA ( N  = 357; 74.2% of those who provided any location), followed by Canada ( N  = 49; 10.2%), Europe ( N  = 46; 9.6%), and Australia ( N  = 25; 5.2%). Thus, it is likely that most respondents were from North America.

Prior Social Adjustment

Table 2 provides several ratings of gender dysphoric youths’ social adjustment prior to the onset of gender dysphoria. Ratings were similar for natal females and males, with only two showing statistically significant sex differences. Parents reported that natal males were more likely to have been bullied and less likely to have had many good friends.

Informants rated the relationships between the youths and their mothers and fathers both prior to gender dysphoria onset, and after social transition (if any), on a 6-point scale from 1 (estranged) to 6 (extremely close). Pre-dysphoria relationships with mothers had a mean rating of 5.2 (with 5 representing “fairly close” and 6 representing “very close”), and relationships with fathers a mean of 4.6 (with 4 representing “neutral”). For a subsequent analysis of change after social transition, we computed a composite score of parental relationship quality by averaging mothers’ and fathers’ ratings at each time period.

Mental Health History

Asked whether the gender dysphoric youth have a history of “mental health issues,” 57% ( N  = 944) of informants responded affirmatively, 42.5% ( N  = 703) negatively, and 0.4% ( N  = 8) did not respond. The percentage of affirmative responses was slightly higher for natal females (59.4%) than for natal males (51%), χ 2 (1, N  = 1647) = 8.7, p  = 0.003. Figure  2 presents the distribution of the onset of children’s mental health issues relative to the onset of their gender dysphoria. On average, mental health problems began at 10.5 years (SD = 3.6; Mdn  = 11) and preceded gender dysphoria by 3.8 years, paired t (940) = 32.0, p  < 0.0001, d  = 1.31.

Parent reports of relative timing of gender dysphoria and mental health issues, in units of years. Negative numbers indicate that mental health issues preceded gender dysphoria, and positive numbers indicate that gender dysphoria preceded mental health issues

Informants were asked about several possible “first symptoms” of mental health issues. Table 3 provides the frequency of each initial symptom, separately by natal sex. More frequent responses, averaged across natal sex, are higher in the table. The most common problem mentioned was “anxiety,” and this was significantly more common among natal females than among natal males. Other problems producing relatively large and significant sex differences included self-injury (more common in natal females) and addiction to video games (more common in natal males). In contrast, addiction to the Internet did not produce a significant sex difference.

Asked whether the youth had ever received “a formal psychological diagnosis,” 42.5% ( N  = 703) of informants said “yes.” Responses to this question were highly correlated with responses to the previously mentioned question whether the gender dysphoric youth had a history of mental illness, r (1653) = 0.74. (For some later analyses, a variable was constructed by summing the dichotomous responses to both items. The summed composite should have greater reliability than either of its component items. We refer to the composite as “mental health issues,” and higher scores indicated more problems with mental health.) The percentage of youths with formal diagnoses was similar for natal females, 43.4% ( N  = 542) and natal males, 39.7% ( N  = 161), χ 2 (1, N  = 1665) = 1.75, p  = 0.19. Furthermore, older youths were slightly more likely to have diagnoses, with the correlation between current age and diagnostic status r (1653) = 0.07, p  = 0.006. Diagnoses had been provided mainly by psychiatrists (41.6%; N  = 294) and psychologists (30.0%; N  = 212). Table 4 provides the frequencies of specific diagnoses that were queried, separately by natal sex. Youths with formal diagnoses averaged 2.2 diagnoses (SD = 1.1). This variable did not differ significantly by sex.

Asked whether any stressful events in their AYA child’s life may have contributed to the onset of gender dysphoria, 72.6% ( N  = 1,161) of parents said “yes.” Inspection of specific responses suggested that these stressful events varied considerably in both their nature and severity. For example, a number of parents noted that the family had moved recently. Others mentioned the youth’s romantic difficulties. But a few said that the youth had suffered severe physical or sexual abuse, and several mentioned that a friend or relative had committed suicide. Respondents rated youths with these experiences higher on the composite variable mental health issues, compared with other youths, t (1597) = 3.9, p  < 0.001, d  = 0.22.

Intelligence

Informants rated the youths’ intelligence using a 5-point scale from 1 (exceptionally low–mentally handicapped) to 5 (exceptionally high intelligence). In general, ratings were high, with only 15.5% ( N  = 255) of youths rated as average or below average, and 35.6% ( N  = 587) rated as having exceptionally high intelligence. Natal males ( M  = 4.38) were rated slightly higher than natal females ( M  = 4.13), t (1645) = 6.1, p  < 0.0001, d  = 0.36.

Social and Medical Transition

Asked whether their gender dysphoric AYA child had “come out” as the “opposite gender or some other gender,” 89.3% ( N  = 1,458) of those who answered responded affirmatively. Of these cases, 81.6% of the youths came out as the opposite gender, but in 18.4% another gender was specified, such as “gender fluid,” “non-binary,” and “trans” or “transgender.” Coming out as a different, rather than opposite, gender was more common among natal females ( N  = 235; 20.9%) than among natal males ( N  = 31; 9.8%), χ 2 (1, N  = 1442) = 20.3, p  < 0.0001. Of youths who had “come out,” 22% ( N  = 321) were out “everywhere.” Being out everywhere was more common for natal females ( N  = 273, 21.9%) than for natal males ( N  = 48, 11.8%), χ 2 (1, N  = 1655) = 19.7, p  < 0.0001.

The survey included questions about social transition, which was explained as follows:

Social transition means taking formal steps to live as the opposite gender (or some other gender) officially. This can include:

legally changing their name, gender, and pronouns on government ID, expecting everyone to refer to them with their new name and pronouns, constantly trying to “pass” as the opposite gender in manner of dress, posture, tone of voice, mannerisms, and interests

Social transition formalizes "coming out" as transgender, and the two often occur together.

Of 1436 youths for whom informants provided relevant information, 65.3% ( N  = 937) had socially transitioned, 33.8% ( N  = 485) had not socially transitioned, and 1% ( N  = 14) no longer wished to transition (i.e., had desisted). Mean age at social transition was reported as 15.4 years (SD = 2.6). Current social transition was much more common among natal females, 65.7% ( N  = 821) of whom were rated as socially transitioned, compared with 28.6% ( N  = 116) of the natal males, χ 2 (1,  N  = 1655) = 172.3, p  < 0.0001. Furthermore, natal females tended to socially transition earlier (15.1 years) than natal males (17.4 years), t (932) = 9.1, p  < 0.0001. Of those who had desisted, 13 of 14 were natal females, out of 1120 females and 316 males for whom parents provided this information.

Table 5 presents rates of several aspects of social transition, separately for natal males and females. Natal females were substantially more likely than natal males to have taken most of the social transition steps. Table 6 presents rates of several aspects of medical transition, separately by natal sex. In general, steps toward medical transition were unusual. For example, hormone blockers were reported for only 0.8% of natal females and 2.0% of natal males (test of the sex difference, χ 2 (1,  N  = 1655) = 3.9, p  = 0.048). The most frequently reported medical intervention was cross-sex hormones, received by 6.5% of females and 8.4% of males (the test of the sex difference was not significant, p  = 0.193). Surgical intervention was assessed using the question “Has your child surgically transitioned?” Surgical transition was especially rare, reported for 1% of males and 0.7% of females (the test of the sex difference was not significant, p  = 0.604).

Parents were also asked to rate the separate effects of social transition on their AYA child’s gender dysphoria, anxiety, and depression. These ratings were substantially correlated and were averaged to provide an overall rating from 1 = much worse to 5 = much better, with 3 indicating no change. Coefficient alpha for this 3-item scale was 0.73. Figure  3 shows the distribution of this variable for the 556 parents who answered all three questions. Parents were much more likely to say that the youth had worsened than improved. The one-sample t- test comparing the sample mean 2.1 with 3, the score signifying no change, was highly significant, t (566) = − 24.6, p  < 0.0001, d  = − 1.0.

Parent reports of change in functioning after social transition. 1 = much worse; 2 = somewhat worse; 3 = no change; 4 = somewhat better; 5 = much better

The change in the quality of parental relationships (from prior to gender dysphoria to after social transition) was also strongly negative, declining from an average of 4.8 (indicating “fairly close”) to 3.6 (between “neutral” and “don’t get along very well”), paired t (891) = − 32.0, p  < 0.0001, d  = − 1.2. This decline was especially severe for mothers, a 1.5-point decrease compared with fathers’ 0.9-point decrease, paired t (891) = 10.4, p  < 0.0001, d  = 0.4.

Parents were asked whether they had felt pressure from a “gender clinic or specialist” to transition their child socially or medically. Of the 390 parents who answered this question, 51.8% ( N  = 202) answered “yes,” 23.6% ( N  = 92) were unsure, and 24.6% ( N  = 96) said “no.” Treating this item as a 3-point scale (from 1 = “no” to 2 = “unsure” to 3 = “yes”), parents who felt pressured were more likely to believe their children had deteriorated after transition, r (197) = 0.22, p  = 0.002.

Correlates of Social and Medical Transition

We examined correlates of current social transition (i.e., contrasting youths who are currently socially transitioned with those who have not socially transitioned; these analyses ignored those who have desisted). Table 7 contains the results of univariate and multivariate tests for the correlates we explored. Univariate tests are for the associations between each single correlate and current social transition. (These were tested either via logistic regression, for numeric correlates or via contingency analyses for dichotomous correlates.) Socially transitioned youths were significantly more likely to be natal female (see above). They tended to be older: 72.7% of females 16 or older had transitioned, compared with 60.1% of those younger than 16; for males the respective figures were 31.2% and 21.3%. They tended to have had gender dysphoria longer: females who had been gender dysphoric for longer than one year had a 75.5% rate of social transition, compared with 58.6% for those gender dysphoric for one year or less; for males the respective figures were 45.7% and 22.6%. They tended to have a history of mental health issues: 74.1% of females with both a history of mental health issues and a formal diagnosis had socially transitioned, compared with 57.2% of those with neither; for males the respective figures were 31.5% and 24.2%. Finally, we examined associations between social transition and contact with gender specialists. Of the 1,396 parents who answered the relevant question, 37.8% (527) had received a referral to a gender specialist and 52.3% (737) had not. (The remaining 9.5% [132] did not know.) These referrals were associated with a greater chance of social transition: 82.3% of females with a referral had socially transitioned compared with 58% of other females; the respective figures for males were 44.3% and 21.1%. The table also contains multivariate tests for the association between each correlate and current social transition, controlling for the other correlates. (These were tested via multiple logistic regression.) In every case, the direction of associations was identical for univariate and multivariate analyses, and the predictors remained statistically significant.

Table 8 contains analogous results for having received any hormonal treatment. The pattern of results was similar to that for social transition, with the aforementioned exception of natal sex: males were more likely than females to have received hormonal treatment. Males 16 and older had a 11.4% rate of hormonal treatment, compared with 0% for those 16 or younger; respective figures for females were 14.3% and 0.3%. Males whose gender dysphoria had persisted longer than one year had a 23.8% rate of hormonal treatment, compared with a 3.0% rate for those with a shorter duration; for females these figures were 13.6% and 1.3%, respectively. Males with both indicators of mental health issues (see above) had a hormonal treatment rate of 8.8%, compared with 7.6% for those with neither indicator; for females these figures were 8.7% and 3.7%. Finally, males who had contact with gender specialists had a hormonal treatment rate of 12.2%, compared with 6.6% for those without such contact; for females these rates were 10.1% and 4.8%.

Possible Social Influences on Gender Dysphoria and Transition

Asked whether the youths were friends with others who “came out as transgender around the same time,” 55.4% of parents ( N  = 917) said “yes.” That response was significantly higher regarding natal females (60.9%, N  = 760) than natal males (38.7%, N  = 157), χ 2 (1, N  = 1655) = 61.0, p  < 0.0001. Among those who answered “yes,” the mean number of transgender friends was 2.4 ( Mdn  = 2). Having friends come out as transgender contemporaneously was significantly related to the likelihood of social transition, statistically adjusting for natal sex, χ 2 (1, N  = 1655) = 63.5, p  < 0.0001. Among females, 73.3% with contemporaneous transgender friends had taken steps toward social transition, compared with 54% without such friends; for males, respective figures were 39.5% and 21.7%.

Informants estimated that before developing gender dysphoria, their children spent an average of 4.5 h per day “on the Internet and social media” ( Mdn  = 5). The estimate for natal males ( M  = 5.6) was significantly higher than for natal females ( M  = 4.1), t (1455) = 8.6, p  < 0.0001, d  = 0.6. This variable (hours per day using the Internet and social media) was not significantly related to the likelihood of social transition, statistically adjusting for natal sex, χ 2 (1, N  = 1457) = 1.0, p  = 0.30.

Changes in Characteristics of Gender Dysphoric Youths

We examined whether any of the following variables have changed in a consistent manner across the 3 years and 10 months of data collection for this article: natal sex, age of gender dysphoric youths, years with gender dysphoria, mental health issues, and social or medical transition status. This was done by regressing each variable on the continuous measure of survey completion date. Table 9 shows that most of these variables have shown statistically significant changes. To clarify these changes, we provide separate numbers for youths reported on prior to 2020 (first cohort) with those reported on in 2020 and 2021 (second cohort). The former was 20.2% male, and the latter 28.3% male. Ages of gender dysphoric youths at the time of the survey decreased from 16.3 to 15.9 years. Estimated age of gender dysphoria onset decreased from 14.7 to 14.5 years. Years with gender dysphoria at the time of survey decreased from 1.6 to 1.4 years. The likelihood of referral to a gender specialist decreased from 35.3 to 28.9%.

Results of our study are generally consistent with other recent research about the current surge of gender dysphoria among youth with onset during adolescence or young adulthood. Natal females were affected more often than natal males. Preexisting mental health issues were common, but so was high intelligence. Most youths had changed their pronouns, and most of these changes were cross-sex rather than gender-neutral. Social transition was far more prevalent than medical transition. There was evidence of immersion both in social media and in peer groups with other transgender-identifying youths.

Two sex differences are potentially important. These included the findings that natal males’ gender dysphoria was reported to be 1.9 years later than females’ and that natal males were much less likely than females to have taken steps toward social transition. This difference contrasts with findings from a study of clinic-referred gender dysphoric adolescents in Toronto and Amsterdam, which did not show a sex difference in referral age (Aitken et al., 2015 ). That study included adolescents regardless of when their gender dysphoria began, whereas youths reported on in the present study were believed to have adolescent or young adult onset. The current study’s results are consistent with the existence of different causes for gender dysphoria in natal females and males, at least in some cases. Specifically, one kind of gender dysphoria, stemming from autogynephilia—a natal male’s sexual arousal at the idea of being female—occurs only in adolescent and post-adolescent natal males and does not appear to have an analogue among natal females (Bailey & Blanchard, 2017). Unfortunately, the survey did not assess youths’ sexuality. An alternative potential explanation is that females begin puberty earlier than males. To the extent that pubertal changes contribute to the onset of gender dysphoria, earlier onset would be predicted for females (Aitken et al., 2015 ).

One statistically robust finding was both disturbing and seemingly important. Youths with a history of mental health issues were especially likely to have taken steps to socially and medically transition. This relationship held even after statistically adjusting for likely confounders (e.g., age). The finding is concerning because youth with mental health issues may be especially likely to lack judgment necessary to make these important, and in the case of medical transition permanent, decisions. The finding supports the worries of parents whose preferences differ from their gender dysphoric children. It is consistent with another finding of this study that parents believed gender clinicians and clinics pressured the families toward transition. The finding is particularly concerning given that parents tended to rate their children as worse off after transition.

Limitations

At least two related issues potentially limit this research. First, parents were recruited via a website for parents who believe their children have ROGD, rather than a more conventional and less problematic form of gender dysphoria. Such parents are unlikely to be representative of all parents with gender dysphoric adolescents. However, it is unclear how one might recruit a representative sample of parents reporting on their gender dysphoric adolescents. National gender clinics such as those found in Canada, the Netherlands, the UK, Sweden, and Finland may have especially large caseloads. But without large community epidemiological studies, we cannot know whether the patients seen at the clinics are representative of the population of gender dysphoric youth. More than twice as many parents in our sample reported that they had not received a referral for a gender specialist for their children as parents who had received a referral. Thus, it is uncertain what proportion of gender dysphoric adolescents like those reported on in our study are seen at national clinics. The ROGD phenomenon (or more cautiously, the ROGD concept) is so new that nothing is known with much confidence regarding this population.

Second, because parents in our sample were self-selected for concern that their children have ROGD, parent reports could be biased and inaccurate. Why would parents be biased to believe in ROGD, and to oppose their children’s gender transition? One hypothesis is that parents with these attitudes are socially conservative and thus “transphobic.” However, the limited research on such parents has shown the opposite that such parents tend to be politically progressive and to hold tolerant attitudes toward sexual and gender minorities (Littman, 2018 ; Shrier, 2020). Our results also support the view that parents concerned that their AYA children have ROGD are not motivated by intolerance or conservative ideology (Table 1 ). The possibility remains that it is parents who reject the ROGD explanation who are incorrect and thus, biased. At present, it is uncertain why some parents believe their children have ROGD and oppose their gender transition, while other parents reject the ROGD concept and facilitate their children’s gender transition. It is possible, of course, that the ROGD hypothesis and the alternative hypothesis are both correct in certain cases, leading their parents to form different beliefs and attitudes.

Assuming for now that parents in our study were apt to provide responses biased in favor of ROGD explanations and opposed to transition, which findings are most suspect, and which are least so? Simple ratings averaged over all parents are especially likely to be due to bias. For example, the finding that parents tended to view their children’s mental health and parental relationships as worsening after transition could reflect a biased tendency to associate negative outcomes with transition. In contrast, findings that depend on comparisons between parents in this study are less likely to be due to bias. For example, it is unclear how bias could cause parents of natal males to report a later age of onset for their children’s gender dysphoria compared with parents of natal females. Nor is it clear how bias could cause parents to report a higher rate of transition steps among youth with mental health issues compared with other youth.

Future Directions

Our study relies on information provided by parents who believe their children have ROGD and are thus unlikely to be supportive about their children’s transgender status and intentions to transition. Obviously, it would be highly desirable for future studies also to include parents with differing beliefs and attitudes. Furthermore, responses from gender dysphoric adolescents and young adults, themselves, would be extremely important. None of these informants is guaranteed to provide accurate information. But examining the extent and domains of their agreement versus disagreement will be crucial to addressing the ongoing controversies concerning ROGD and the “epidemic” of adolescent gender dysphoria. Longitudinal data will be especially valuable, because all stakeholders in this controversy ultimately have the same goal: the long-term happiness of gender dysphoric youth.

Availability of Data and Materials

These data are available upon reasonable request. A copy of the survey instrument is available to those who contact the corresponding author.

Code Availability

Not applicable.

Change history

10 may 2023.

Publisher’s Note: readers are alerted that concerns have been raised regarding methodology as described in this article. The publisher is currently investigating this matter and a further response will follow the conclusion of this investigation.

16 May 2023

Publisher's Note: the Supplementary Information has been removed due to a lack of documented consent by study participants.

14 June 2023

This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1007/s10508-023-02635-1

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Diaz, S., Bailey, J.M. RETRACTED ARTICLE: Rapid Onset Gender Dysphoria: Parent Reports on 1655 Possible Cases. Arch Sex Behav 52 , 1031–1043 (2023). https://doi.org/10.1007/s10508-023-02576-9

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DOI : https://doi.org/10.1007/s10508-023-02576-9

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Clinicians should stop the routine prescribing of puberty blockers to children attending gender identity clinics with gender dysphoria, NHS England has said. 1

The decision was announced on 12 March as part of NHS England’s ongoing overhaul of children’s gender identity services in England.

In new guidance NHS England said, “We have concluded that there is not enough evidence to support the safety or clinical effectiveness of PSH [puberty suppressing hormones] to make the treatment routinely available at this time.” Instead, drugs that block puberty hormone receptors to arrest the progress of puberty and delay the development of secondary sexual characteristics will be approved only for people taking part in clinical research trials.

However, the new guidance does not apply to children with precocious (early) puberty, for whom puberty blockers will remain available on the NHS. Nor does it apply to prescribing hormones for natal males aged 16 or older who are seeking to transition, as “oestrogen alone is insufficient to suppress testosterone levels into the normal range for natal females,” said NHS England.

In 2020 NHS England established a policy working group to review published evidence on the use of puberty blockers, as did the National Institute for Health and Care Excellence. That same year NHS England commissioned Hilary Cass, a former president of the Royal College of Paediatrics and Child Health, to carry out an independent review of gender identity services for under 18s.

At that time these services were provided nationally solely by the Gender Identity Development Service (GIDS) at the Tavistock and Portman NHS Foundation Trust in London, although GIDS has a base in Leeds and outreach clinics in other locations such as Exeter.

Cass’s interim report recommended that the sole service treating children and adolescents for gender dysphoria should be closed and replaced with a network of regional centres, and it argued that evidence to support routine use of puberty blockers was lacking. 2 A final report from the review is expected next month.

Best interests

The GIDS service is due to close in April, but several similar services are set to be created around the country, starting with two centres: a partnership between Great Ormond Street Hospital and Evelina London Children’s Hospital, with South London and Maudsley NHS Foundation Trust providing specialist mental health support; and a partnership between Alder Hey Children’s NHS Foundation Trust in Liverpool and the Royal Manchester Children’s Hospital, with both trusts also providing mental health services.

A public consultation also took place last year on the proposal to end routine prescribing of puberty blocking hormones, just after NHS England issued interim guidance on the issue. 3 The number of young people currently taking puberty blockers is estimated at fewer than 100.

Maria Caulfield, health minister, said, “We welcome this landmark decision by the NHS to end the routine prescription of puberty blockers and this guidance which recognises that care must be based on evidence, expert clinical opinion, and in the best interests of the child.

“The NHS must ensure its gender identity services protect, support, and act in the best interests of children, and we will continue to work with NHS England to protect children in this area.”

• ↵ NHS England. Clinical policy: Puberty suppressing hormones. 12 Mar 2024. https://www.england.nhs.uk/publication/clinical-policy-puberty-suppressing-hormones/
• ↵ NHS England. Interim clinical policy: Puberty suppressing hormones for children and adolescents who have gender incongruence/dysphoria. 3 Aug 2023. https://www.engage.england.nhs.uk/consultation/puberty-suppressing-hormones/

A trans woman harmed herself while in a Utah prison. Now the DOJ may file a lawsuit.

If the state doesn’t comply with changes requested by federal officials, the u.s. attorney general’s office ‘may initiate a lawsuit.’.

(Leah Hogsten | The Salt Lake Tribune) A housing unit at the Utah State Correctional Facility, April 7, 2023.

A transgender woman incarcerated in Utah faced a deepening mental health crisis as she was discriminated against in a state correctional facility, the U.S. Department of Justice found in a new report .

After being denied gender-affirming care and other accommodations for her identity, the woman’s gender dysphoria worsened to the point that “she performed dangerous self-surgery and removed her own testicles” nearly two years after entering custody, the department wrote on Tuesday.

During their investigation, federal officials interviewed Utah Department of Corrections’ medical director and Americans with Disabilities Act coordinator, as well as other staff and contractors. They also requested and reviewed policies provided by the department.

The Utah Department of Corrections said Tuesday afternoon that it disagreed with the Justice Department’s finding and had been “blindsided” by the report.

“We have been working to address this complex issue, and were blindsided by today’s public announcement from the Department of Justice. We have also taken steps on our own, and as a state, to address the needs of inmates while maintaining the highest safety standards,” executive director Brian Redd said in a statement. “We fundamentally disagree with the DOJ on key issues, and are disappointed with their approach.”

A spokesperson for Utah Department of Health and Human Services — which is in the process of taking over health care in correctional facilities following past scrutiny — told The Salt Lake Tribune Wednesday morning that it stands by Redd’s statement.

Gender dysphoria is a condition that is covered under the ADA . While being transgender is not considered a disability, some trans people experience the medical condition which causes severe mental and emotional distress when a person’s assigned sex at birth and their gender identity don’t align.

“By not allowing me this opportunity to live my life as a woman, who I believe I am and have lived life for many years, the prison is causing me such mental stress in the form of anxiety, depression ... ,” the incarcerated woman wrote in ADA requests and grievances, according to the Justice Department.

As the woman sought gender-affirming care, such treatment had to be approved by a committee, the report found. That process “unnecessarily delayed and restricted” her access to care as members of the committee reportedly “expressed bias against individuals who are transgender and reluctance to prescribe medically appropriate treatment for gender dysphoria.”

Once the woman did receive access to care, her physician at the prison reportedly tried to talk her out of the hormone therapy she had been asking for over the previous 15 months. When that therapy started being administered, her physician “failed to take basic steps to ensure that it was provided safely and effectively,” according to the Justice Department.

She also asked for makeup and female clothing, including bras and women’s underwear, from the commissary. Except for one sports bra, investigators found, her requests were denied.

In its denial, Utah corrections officials wrote, “female underwear and cosmetics are approved for incarcerated persons assigned to female housing units.” After the woman appealed, the department issued a second denial, writing, “prison incarcerated persons shall be dressed in the approved clothing for the incarcerated persons designated housing classification.”

The incarcerated woman has been assigned to male housing since she entered the Utah correctional system.

“Despite its policy to ensure appropriate and safe housing, UDOC assigns incarcerated persons, including those with gender dysphoria, to either male or female housing based solely on sex at ‘commitment,’ as determined by staff conducting a visual search of genitals,” the Justice Department wrote in its report.

In the ADA requests and grievances she filed, the woman also complained about being subjected to cross-gender pat and visual searches. To avoid being pat down by male correctional officers, which is required every time incarcerated people exit the dining hall, the woman eats alone in her cell, according to the report.

The Justice Department urged the Utah Department of Corrections to “remedy these violations, and to protect the civil rights of other individuals with gender dysphoria” by revising policies to allow incarcerated people with gender dysphoria an equal opportunity to participate in and benefit from ... services, programs, and activities.” Those policies should also outline providing health care for gender dysphoria “consistent with UDOC’s treatment of other medical conditions.”

It is also requesting that all correctional employees be trained on ADA requirements. Federal officials are asking that the department allow it to access its facilities and files, as well as provide reports “delineating all steps taken to comply with these requirements, including the dates on which each step was taken, and, where applicable, information sufficient to demonstrate compliance.”

An attorney overseeing the Disability Rights Section of the Justice Department’s Civil Rights Division in wrote in a letter to Redd and the Utah attorney general’s office that the state should also pay compensatory damages to the woman.

The Justice Department aims to work with the Utah Department of Corrections to draw up a “court- enforceable consent decree.”

“If we are unable to reach such a resolution, the Attorney General may initiate a lawsuit,” the letter says.

The crackdown on ADA compliance in this case is part of a broader effort by President Joe Biden’s Justice Department to address discrimination against trans people in correctional settings, the statement said. It pointed to a statement of interest the department filed in a case in Georgia in which a trans woman incarcerated there is seeking gender-affirming care that the state has so far denied.

Could recently passed laws lead to more federal scrutiny?

Multiple bills passed in Utah’s most recent legislative session could get in the way of the Utah Department of Corrections meeting the Justice Department’s demands.

One already signed by Gov. Spencer Cox, “ Sex-based Designations for Privacy, Anti-bullying and Women’s Opportunities ,” more widely known as HB257, changes the legal definitions of “female” and “male” to categorize Utahns by the reproductive organs of their birth.

It’s criminal for anyone who doesn’t meet those definitions to use locker rooms, showers or dressing rooms in government-owned or -controlled buildings. There are limited exceptions for transgender people who have amended their birth certificates and had invasive and costly gender-affirming surgeries.

Another bill that awaits the governor’s signature would provide additional guidance to the Utah Department of Corrections when incarcerated transgender people request housing and accommodations that align with their gender identity.

That bill, “ Inmate Assignment Amendments ,” would require trans people to undergo an “individualized security analysis” to assess a number of factors — including their physical characteristics, whether they are sincere in expressing their identity, social behavior and “any other factor determined to be relevant” — before being moved to spaces that align with their identity.

Editor’s note • This article discusses a mental health crisis. If you or people you know are at risk of self-harm, call or text 988 to reach the Suicide & Crisis Lifeline for 24-hour support.

This story is developing and may be updated.

Donate to the newsroom now. The Salt Lake Tribune, Inc. is a 501(c)(3) public charity and contributions are tax deductible

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Breaking news, britain bans puberty blockers for transgender teens while voodoo ‘science’ still rules us.

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Britain’s National Health Service on Wednesday banned the use of puberty blockers for the treatment of gender dysphoria in transgender minors — while the US medical establishment and the Biden administration remain committed to deadly junk science.

Crucially, US “science” here is dominated by the claims of the supposedly expert World Professional Association for Transgender Health, though internal WPATH communications show it ignores science to push not just hormone treatments for kids, but life-altering surgery — even as its own members privately acknowledge devastating and permanent side effects.

The leaked messages show WPATH doctors admitting that some patients given puberty-blocking drugs are too young or mentally ill to understand, for example, that they risk never being able to have kids as a consequence of their treatment — utterly violating basic medical ethics when it comes to informed consent.

As the premier advocacy group for “gender-affirming” care , WPATH for years set the line for the World Health Organization, European agencies like Britain’s NHS, and top US medical organizations including the American Academy of Pediatrics.

But the United Kingdom and much of Europe have moved away from the junk science, especially on pediatric gender transition — because independent research disproves virtually all the claims that supposedly make it a no-brainer, including the idea that it’s vital to preventing suicide.

We now know that when WPATH adopted its 2022 Standards of Care guidelines, it scrapped a chapter about ethics and removed minimum-age requirements for children starting puberty blockers or undergoing sexual modification surgeries.

Yet the US medical establishment remains in the grip of WPATH, with the AAP still recommending hormones and surgery for kids and the American Medical Association supporting rules to keep parents in the dark about the social transitions of minors.

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Meanwhile, Scarsdale’s public schools just added “discussion of gender expression and gender identity” to the 5th-grade sex-ed curriculum, citing “guidance from the  American Academy of Pediatrics’  inclusive approach to puberty education.”

And a WPATH member, trans woman Dr. Rachel Levine, serves as US assistant secretary for health — not just advocating for pseudo-science, but symbolizing the Biden administration’s commitment to it.

Envy the Brits, Swedes, and so on for having public health establishments that can heed the science and reject this trendy nonsense.

And worry about what other snake oil the guardians of American medicine are buying.

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