Gender DysphoriaDiagnostic CriteriaGender Dysphoria in Children 302.6 (F64.2)A. A marked incongruence between one’s experienced/expressed gender and assignedgender, of at least 6 months’ duration, as manifested by at least six of the following(one of which must be Criterion A1):1. A strong desire to be of the other gender or an insistence that one is the other gender(or some alternative gender different from one’s assigned gender).2. In boys (assigned gender), a strong preference for cross-dressing or simulating femaleattire: or in girls (assigned gender), a strong preference for wearing only typicalmasculine clothing and a strong resistance to the wearing of typical feminineclothing.3. A strong preference for cross-gender roles in make-believe play or fantasy play.4. A strong preference for the toys, games, or activities stereotypically used or engagedin by the other gender.5. A strong preference for playmates of the other gender.6. In boys (assigned gender), a strong rejection of typically masculine toys, games,and activities and a strong avoidance of rough-and-tumble play; or in girls (assignedgender), a strong rejection of typically feminine toys, games, and activities.7. A strong dislike of one’s sexual anatomy.8. A strong desire for the primary and/or secondary sex characteristics that matchone’s experienced gender.B. The condition is associated with clinically significant distress or impairment in social,school, or other important areas of functioning.Specify if;With a disorder of sex development (e.g., a congenital adrenogenital disorder suchas 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivitysyndrome).Coding note: Code the disorder of sex development as well as gender dysphoria.Gender Dysphoria in Adolescents and Adults 302.85 (F64.1 )A. A marked incongruence between one’s experienced/expressed gender and assignedgender, of at least 6 months’ duration, as manifested by at least two of the following:1. A marked incongruence between one’s experienced/expressed gender and primaryand/or secondary sex characteristics (or in young adolescents, the anticipatedsecondary sex characteristics).2. A strong desire to be rid of one’s primary and/or secondary sex characteristics becauseof a marked incongruence with one’s experienced/expressed gender (or inyoung adolescents, a desire to prevent the development of the anticipated secondarysex characteristics).3. A strong desire for the primary and/or secondary sex characteristics of the othergender.4. A strong desire to be of the other gender (or some alternative gender different fromone’s assigned gender).5. A strong desire to be treated as the other gender (or some alternative gender differentfrom one’s assigned gender).6. A strong conviction that one has the typical feelings and reactions of the other gender(or some alternative gender different from one’s assigned gender).B. The condition is associated with clinically significant distress or impairment in social,occupationali^or other important areas of functioning.Specify if:With a disorder of sex development (e.g., a congenital adrenogenital disorder suchas 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensitivitysyndrome).Coding note: Code the disorder of sex development as well as gender dysphoria.Specify if:Posttransttion: The individual has transitioned to full-time living in the desired gender(with or without legalization of gender change) and has undergone (or is preparing tohave) at least one cross-sex medical procedure or treatment regimen—namely, regularcross-sex hormone treatment or gender reassignment surgery confirming the desiredgender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty ina natal female).SpecifiersThe posttransition specifier may be used in the context of continuing treatment proceduresthat serve to support the new gender assignment.Diagnostic FeaturesIndividuals with gender dysphoria have a marked incongruence between the gender theyhave been assigned to (usually at birth, referred to as natal gender) and their experienced/expressed gender. This discrepancy is the core component of the diagnosis. There mustalso be evidence of distress about this incongruence. Experienced gender may include alternativegender identities beyond binary stereotypes. Consequently, the distress is notlimited to a desire to simply be of the other gender, but may include a desire to be of an alternativegender, provided that it differs from the individual's assigned gender.Gender dysphoria manifests itself differently in different age groups. Prepubertal natalgirls with gender dysphoria may express the wish to be a boy, assert they are a boy, or assertthey will grow up to be a man. They prefer boys' clothing and hairstyles, are oftenperceived by strangers as boys, and may ask to be called by a boy's name. Usually, they displayintense negative reactions to parental attempts to have them wear dresses or otherfeminine attire. Some may refuse to attend school or social events where such clothes arerequired. These girls may demonstrate marked cross-gender identification in role-playing,dreams, and fantasies. Contact sports, rough-and-tumble play, traditional boyhood games,and boys as playmates are most often preferred. They show little interest in stereotypicallyfeminine toys (e.g., dolls) or activities (e.g., feminine dress-up or role-play). Occasionally,they refuse to urinate in a sitting position. Some natal girls may express a desire to have apenis or claim to have a penis or that they will grow one when older. They may also state thatthey do not want to develop breasts or menstruate.Prepubertal natal boys with gender dysphoria may express the wish to be a girl or assertthey are a girl or that they will grow up to be a woman. They have a preference fordressing in girls' or women's clothes or may improvise clothing from available materials(e.g., using towels, aprons, and scarves for long hair or skirts). These children may roleplayfemale figures (e.g., playing "mother") and often are intensely interested in femalefantasy figures. Traditional feminine activities, stereotypical games, and pastimes (e.g.,"playing house"; drawing feminine pictures; watching television or videos of favorite femalecharacters) are most often preferred. Stereotypical female-type dolls (e.g.. Barbie) areoften favorite toys, and girls are their preferred playmates. They avoid rough-and-tumbleplay and competitive sports and have little interest in stereotypically masculine toys (e.g.,cars, trucks). Some may pretend not to have a penis and insist on sitting to urinate. Morerarely, they may state that they find their penis or testes disgusting, that they wish them removed,or that they have, or wish to have, a vagina.In young adolescents with gender dysphoria, clinical features may resemble those ofchildren or adults with the condition, depending on developmental level. As secondarysex characteristics of young adolescents are not yet fully developed, these individuals maynot state dislike of them, but they are concerned about imminent physical changes.In adults with gender dysphoria, the discrepancy between experienced gender andphysical sex characteristics is often, but not always, accompanied by a desire to be rid ofprimary and/or secondary sex characteristics and/or a strong desire to acquire some primaryand/or secondary sex characteristics of the other gender. To varying degrees, adultswith gender dysphoria may adopt the behavior, clothing, and mannerisms of the experiencedgender. They feel uncomfortable being regarded by others, or functioning in society,as members of their assigned gender. Some adults may have a strong desire to be of adifferent gender and treated as such, and they may have an inner certainty to feel and respondas the experienced gender without seeking medical treatment to alter body characteristics.They may find other ways to resolve the incongruence between experienced/expressed and assigned gender by partially living in the desired role or by adopting a genderrole neither conventionally male nor conventionally female.Associated Features Supporting DiagnosisWhen visible signs of puberty develop, natal boys may shave their legs at the first signs ofhair growth. They sometimes bind their genitals to make erections less visible. Girls maybind their breasts, walk with a stoop, or use loose sweaters to make breasts less visible. Increasingly,adolescents request, or may obtain without medical prescription and supervision,hormonal suppressors ("blockers") of gonadal steroids (e.g., gonadotropin-releasinghormone [GnRH] analog, spironolactone). Clinically referred adolescents often want hormonetreatment and many also wish for gender reassignment surgery. Adolescents living inan accepting environment may openly express the desire to be and be treated as the experiencedgender and dress partly or completely as the experienced gender, have a hairstyle typicalof the experienced gender, preferentially seek friendships with peers of the other gender,and/or adopt a new first name consistent with the experienced gender. Older adolescents,when sexually active, usually do not show or allow partners to touch their sexual organs. Foradults with an aversion toward their genitals, sexual activity is constrained by the preferencethat their genitals not be seen or touched by their partners. Some adults may seek hormonetreatment (sometimes without medical prescription and supervision) and gender reassignmentsurgery. Others are satisfied with either hormone treatment or surgery alone.Adolescents and adults with gender dysphoria before gender reassignment are at increasedrisk for suicidal ideation, suicide attempts, and suicides. After gender reassignment,adjustment may vary, and suicide risk may persist.PrevaienceFor natal adult males, prevalence ranges from 0.005% to 0.014%, and for natal females,from 0.002% to 0.003%. Since not all adults seeking hormone treatment and surgical reassignmentattend specialty clinics, these rates are likely modest underestimates. Sex differencesin rate of referrals to specialty clinics vary by age group. In children, sex ratios ofnatal boys to girls range from 2:1 to 4.5:1. In adolescents, the sex ratio is close to parity; inadults, the sex ratio favors natal males, with ratios ranging from 1:1 to 6.1:1. In two countries,the sex ratio appears to favor natal females (Japan: 2.2:1; Poland: 3.4:1).Development and CourseBecause expression of gender dysphoria varies with age, there are separate criteria sets forchildren versus adolescents and adults. Criteria for children are defined in a more con-crete, behavioral manner than those for adolescents and adults. Many of the core criteriadraw on well-dofumented behavioral gender differences between typically developingboys and girls. Young children are less likely than older children, adolescents, and adultsto express extreme and persistent anatomic dysphoria. In adolescents and adults, incongruencebetween experienced gender and somatic sex is a central feature of the diagnosis.Factors related to distress and impairment also vary with age. A very young child mayshow signs of distress (e.g., intense crying) only when parents tell the child that he or sheis "really" not a member of the other gender but only "desires" to be. Distress may not bemanifest in social environments supportive of the child's desire to live in the role of theother gender and may emerge only if the desire is interfered with. In adolescents andadults, distress may manifest because of strong incongruence between experienced genderand somatic sex. Such distress may, however, be mitigated by supportive environments andknowledge that biomedical treatments exist to reduce incongruence. Impairment (e.g.,school refusal, development of depression, anxiety, and substance abuse) may be a consequenceof gender dysphoria.Gender dysphoria without a disorder of sex development. For clinic-referred children,onset of cross-gender behaviors is usually between ages 2 and 4 years. This corresponds tothe developmental time period in which most typically developing children begin expressinggendered behaviors and interests. For some preschool-age children, both pervasivecross-gender behaviors and the expressed desire to be the other gender may bepresent, or, more rarely, labeling oneself as a member of the other gender may occur. Insome cases, the expressed desire to be the other gender appears later, usually at entry intoelementary school. A small minority of children express discomfort with their sexual anatomyor will state the desire to have a sexual anatomy corresponding to the experiencedgender ("anatomic dysphoria"). Expressions of anatomic dysphoria become more commonas children with gender dysphoria approach and anticipate puberty.Rates of persistence of gender dysphoria from childhood into adolescence or adulthoodvary. In natal males, persistence has ranged from 2.2% to 30%. In natal females, persistencehas ranged from 12% to 50%. Persistence of gender dysphoria is modestly correlated withdimensional measures of severity ascertained at the time of a childhood baseline assessment.In one sample of natal males, lower socioeconomic background was also modestlycorrelated with persistence. It is unclear if particular therapeutic approaches to genderdysphoria in children are related to rates of long-term persistence. Extant follow-up samplesconsisted of children receiving no formal therapeutic intervention or receiving therapeuticinterventions of various types, ranging from active efforts to reduce genderdysphoria to a more neutral, "watchful waiting" approach. It is unclear if children "encouraged"or supported to live socially in the desired gender will show higher rates of persistence,since such children have not yet been followed longitudinally in a systematicmanner. For both natal male and female children showing persistence, almost all aresexually attracted to individuals of their natal sex. For natal male children whose genderdysphoria does not persist, the majority are androphilic (sexually attracted to males) and oftenself-identify as gay or homosexual (ranging from 63% to 100%). In natal female childrenwhose gender dysphoria does not persist, the percentage who are gynephilic (sexuallyattracted to females) and self-identify as lesbian is lower (ranging from 32% to 50%).In both adolescent and adult natal males, there are two broad trajectories for developmentof gender dysphoria: early onset and late onset. Early-onset gender dysphoria starts inchildhood and continues into adolescence and adulthood; or, there is an intermittent periodin which the gender dysphoria desists and these individuals self-identify as gay or homosexual,followed by recurrence of gender dysphoria. Late-onset gender dysphoria occursaround puberty or much later in life. Some of these individuals report having had a desireto be of the other gender in childhood that was not expressed verbally to others. Others donot recall any signs of childhood gender dysphoria. For adolescent males with late-onsetgender dysphoria, parents often report surprise because they did not see signs of genderdysphoria during childhood. Expressions of anatomic dysphoria are more common andsalient in adolescents and adults once secondary sex characteristics have developed.Adolescent and adult natal males with early-onset gender dysphoria are almost alwayssexually attracted to men (androphilic). Adolescents and adults with late-onset genderdysphoria frequently engage in transvestic behavior with sexual excitement. Themajority of these individuals are gynephilic or sexually attracted to other posttransitionnatal males with late-onset gender dysphoria. A substantial percentage of adult maleswith late-onset gender dysphoria cohabit with or are married to natal females. After gendertransition, many self-identify as lesbian. Among adult natal males with gender dysphoria,the early-onset group seeks out clinical care for hormone treatment and reassignmentsurgery at an earlier age than does the late-onset group. The late-onset group may have morefluctuations in the degree of gender dysphoria and be more ambivalent about and lesslikely satisfied after gender reassignment surgery.In both adolescent and adult natal females, the most common course is the early-onsetform of gender dysphoria. The late-onset form is much less common in natal females comparedwith natal males. As in natal males with gender dysphoria, there may have been aperiod in which the gender dysphoria desisted and these individuals self-identified as lesbian;however, with recurrence of gender dysphoria, clinical consultation is sought, oftenwith the desire for hormone treatment and reassignment surgery. Parents of natal adolescentfemales with the late-onset form also report surprise, as no signs of childhood genderdysphoria were evident. Expressions of anatomic dysphoria are much more common andsalient in adolescents and adults than in children.Adolescent and adult natal females with early-onset gender dysphoria are almostalways gynephilic. Adolescents and adults with the late-onset form of gender dysphoriaare usually androphilic and after gender transition self-identify as gay men. Natal femaleswith the late-onset form do not have co-occurring transvestic behavior with sexual excitement.Gender dysphoria in association with a disorder of sex development. Most individualswith a disorder of sex development who develop gender dysphoria have already come tomedical attention at an early age. For many, starting at birth, issues of gender assignmentwere raised by physicians and parents. Moreover, as infertility is quite common for thisgroup, physicians are more willing to perform cross-sex hormone treatments and genitalsurgery before adulthood.Disorders of sex development in general are frequently associated with gender-atypicalbehavior starting in early childhood. However, in the majority of cases, this does notlead to gender dysphoria. As individuals with a disorder of sex development becomeaware of their medical history and condition, many experience uncertainty about theirgender, as opposed to developing a firm conviction that they are another gender. However,most do not progress to gender transition. Gender dysphoria and gender transitionmay vary considerably as a function of a disorder of sex development, its severity, and assignedgender.Risk and Prognostic FactorsTemperamental. For individuals with gender dysphoria without a disorder of sex development,atypical gender behavior among individuals with early-onset gender dysphoriadevelops in early preschool age, and it is possible that a high degree of atypicalitymakes the development of gender dysphoria and its persistence into adolescence andadulthood more likely.Environmental. Among individuals with gender dysphoria without a disorder of sex development,males with gender dysphoria (in both childhood and adolescence) more commonlyhave older brothers than do males without the condition. Additional predisposingfactors under consideration, especially in individuals with late-onset gender dysphoria (adolescence,adulthpod), include habitual fetishistic transvestism developing into autogynephilia(i.e., sexual arousal associated with the thought or image of oneself as a woman) andother forms of more general social, psychological, or developmental problems.Genetic and physiological. For individuals with gender dysphoria without a disorder ofsex development, some genetic contribution is suggested by evidence for (weak) familialityof transsexualism among nontwin siblings, increased concordance for transsexualismin monozygotic compared with dizygotic same-sex twins, and some degree of heritabilityof gender dysphoria. As to endocrine findings, no endogenous systemic abnormalities insex-hormone levels have been found in 46,XY individuals, whereas there appear to be increasedandrogen levels (in the range found in hirsute women but far below normal malelevels) in 46,XX individuals. Overall, current evidence is insufficient to label gender dysphoriawithout a disorder of sex development as a form of intersexuality limited to the centralnervous system.In gender dysphoria associated with a disorder of sex development, the likelihood oflater gender dysphoria is increased if prenatal production and utilization (via receptorsensitivity) of androgens are grossly atypical relative to what is usually seen in individualswith the same assigned gender. Examples include 46,XY individuals with a history of normalmale prenatal hormone milieu but inborn nonhormonal genital defects (as in cloacalbladder exstrophy or penile agenesis) and who have been assigned to the female gender.The likelihood of gender dysphoria is further enhanced by additional, prolonged, highlygender-atypical postnatal androgen exposure with somatic virilization as may occur in female-raisedand noncastrated 46,XY individuals with 5-alpha reductase-2 deficiency or17-beta-hydroxysteroid dehydrogenase-3 deficiency or in female-raised 46,XX individualswith classical congenital adrenal hyperplasia with prolonged periods of non-adherence toglucocorticoid replacement therapy. However, the prenatal androgen milieu is moreclosely related to gendered behavior than to gender identity. Many individuals with disordersof sex development and markedly gender-atypical behavior do not develop genderdysphoria. Thus, gender-atypical behavior by itself should not be inteφreted as an indicatorof current or future gender dysphoria. There appears to be a higher rate of genderdysphoria and patient-initiated gender change from assigned female to male than from assignedmale to female in 46,XY individuals with a disorder of sex development.Culture-Related Diagnostic issuesIndividuals with gender dysphoria have been reported across many countries and cultures.The equivalent of gender dysphoria has also been reported in individuals living incultures with institutionalized gender categories other than male or female. It is unclearwhether with these individuals the diagnostic criteria for gender dysphoria would be met.Diagnostic iVlaricersIndividuals with a somatic disorder of sex development show some correlation of finalgender identity outcome with the degree of prenatal androgen production and utilization.However, the correlation is not robust enough for the biological factor, where ascertainable,to replace a detailed and comprehensive diagnostic interview evaluation for genderdysphoria.Functional Consequences of Gender DysphoriaPreoccupation with cross-gender wishes may develop at all ages after the first 2-3 years ofchildhood and often interfere with daily activities. In older children, failure to developage-typical same-sex peer relationships and skills may lead to isolation from peer groupsand to distress. Some children may refuse to attend school because of teasing and harass-ment or pressure to dress in attire associated with their assigned sex. Also in adolescentsand adults, preoccupation with cross-gender wishes often interferes with daily activities.Relationship difficulties, including sexual relationship problems, are common, and functioningat school or at work may be impaired. Gender dysphoria, along with atypicalgender expression, is associated with high levels of stigmatization, discrimination, andvictimization, leading to negative self-concept, increased rates of mental disorder comorbidity,school dropout, and economic marginalization, including unemployment, with attendantsocial and mental health risks, especially in individuals from resource-poor familybackgrounds. In addition, these individuals' access to health services and mental healthservices may be impeded by structural barriers, such as institutional discomfort or inexperiencein working with this patient population.Differential DiagnosisNonconfonnity to gender roles. Gender dysphoria should be distinguished from simplenonconformity to stereotypical gender role behavior by the strong desire to be of anothergender than the assigned one and by the extent and pervasiveness of gender-variantactivities and interests. The diagnosis is not meant to merely describe nonconformity tostereotypical gender role behavior (e.g., "tomboyism" in girls, "girly-boy" behavior inboys, occasional cross-dressing in adult men). Given the increased openness of atypicalgender expressions by individuals across the entire range of the transgender spectrum, itis important that the clinical diagnosis be limited to those individuals whose distress andimpairment meet the specified criteria.Transvestic disorder. Transvestic disorder occurs in heterosexual (or bisexual) adolescentand adult males (rarely in females) for whom cross-dressing behavior generates sexualexcitement and causes distress and/or impairment without drawing their primarygender into question. It is occasionally accompanied by gender dysphoria. An individualwith transvestic disorder who also has clinically significant gender dysphoria can be givenboth diagnoses. In many cases of late-onset gender dysphoria in gynephilic natal males,transvestic behavior with sexual excitement is a precursor.Body dysmoφhic disorder. An individual with body dysmorphic disorder focuses onthe alteration or removal of a specific body part because it is perceived as abnormally formed,not because it represents a repudiated assigned gender. When an individual's presentationmeets criteria for both gender dysphoria and body dysmorphic disorder, both diagnosescan be given. Individuals wishing to have a healthy limb amputated (termed bysome body integrity identity disorder) because it makes them feel more "complete" usuallydo not wish to change gender, but rather desire to live as an amputee or a disabled person.Schizophrenia and other psychotic disorders. In schizophrenia, there may rarely bedelusions of belonging to some other gender. In the absence of psychotic symptoms, insistenceby an individual with gender dysphoria that he or she is of some other gender isnot considered a delusion. Schizophrenia (or other psychotic disorders) and gender dysphoriamay co-occur.Other clinical presentations. Some individuals with an emasculinization desire whodevelop an alternative, nonmale/nonfemale gender identity do have a presentation thatmeets criteria for gender dysphoria. However, some males seek castration and/or penectomyfor aesthetic reasons or to remove psychological effects of androgens without changingmale identity; in these cases, the criteria for gender dysphoria are not met.ComorbidityClinically referred children with gender dysphoria show elevated levels of emotional andbehavioral problems—most commonly, anxiety, disruptive and impulse-control, and de-pressive disorders. In prepubertal children, increasing age is associated with having morebehavioral or emotional problems; this is related to the increasing non-acceptance of gender-variantbehavior by others. In older children, gender-variant behavior often leads topeer ostracism, which may lead to more behavioral problems. The prevalence of mentalhealth problems differs among cultures; these differences may also be related to differencesin attitudes toward gender variance in children. However, also in some non-Westem cultures,anxiety has been found to be relatively common in individuals with gender dysphoria,even in cultures with accepting attitudes toward gender-variant behavior. Autism spectrumdisorder is more prevalent in clinically referred children with gender dysphoria thanin the general population. Clinically referred adolescents with gender dysphoria appear tohave comorbid mental disorders, with anxiety and depressive disorders being the mostcommon. As in children, autism spectrum disorder is more prevalent in clinically referredadolescents with gender dysphoria than in the general population. Clinically referredadults with gender dysphoria may have coexisting mental health problems, most commonlyanxiety and depressive disorders.Other Specified Gender Dysphoria302.6 (F64.
This category applies to presentations in which symptoms characteristic of gender dysphoriathat cause clinically significant distress or impairment in social, occupational, or otherimportant areas of functioning predominate but do not meet the full criteria for gender dysphoria.The other specified gender dysphoria category is used in situations in which theclinician chooses to communicate the specific reason that the presentation does not meetthe criteria for gender dysphoria. This is done by recording “other specified gender dysphoria”followed by the specific reason (e.g., “brief gender dysphoria”).An example of a presentation that can be specified using the “other specified” designationis the following:The current disturbance meets symptom criteria for gender dysphoria, but theduration is iess than 6 months.Unspecified Gender Dysphoria302.6 (F64.9)This category applies to presentations in which symptoms characteristic of gender dysphoriathat cause clinically significant distress or impairment in social, occupational, or otherimportant areas of functioning predominate but do not meet the full criteria for genderdysphoria. The unspecified gender dysphoria category is used in situations in which theclinician chooses not to specify the reason that the criteria are not met for gender dysphoria,and includes presentations in which there is insufficient information to make a morespecific diagnosis.