Gender dysphoria in adults - Symptoms, Causes, Images, and Treatment Options

Diseases

Highlights & Basics

Key Highlights

"Transgender" is an umbrella term that is used to describe people whose gender identity is different from their birth-assigned sex (known as gender incongruence/gender dysphoria). Differences and debates about appropriate terminology exist, and there is no single term which effectively and uncontroversially describes all people experiencing gender incongruence/dysphoria.
Many transgender adults will not seek specialist medical intervention, and prevalence is likely underestimated; UK census data from 2021 suggest prevalence to be about 0.5%.
For those seeking gender-affirming medical or surgical treatment, the diagnosis should be confirmed by a medical professional with appropriate experience. Treatment is complex and should only be undertaken as part of a package of care provided by a multidisciplinary team with extensive experience in this area.
Options for gender-affirming care include hormone therapies and surgeries. Adjunctive options include hair removal, speech and language therapy and supportive counseling. Management is highly individualized, and that there is no "one size fits all" approach to treatment. Transgender people may choose to undergo all, some, or none of the above interventions to support their gender affirmation.
Although gender incongruence is not in itself a mental disorder, transgender people are at increased risk of certain mental health conditions, for example, depression and anxiety, compared with the general population; rates of autism spectrum disorder are also elevated.

Quick Reference

History & Exam
- Key Factors
- Other Factors
More information...
Diagnostics Tests
More information...
Treatment Options
More information...

Definition

Epidemiology

Etiology

Pathophysiology

Citations

Key Articles

World Health Organization. International statistical classification of diseases and health related problems (ICD). 11th revision. Jan 2022 [Internet publication].[Full Text]
American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2022.
Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(suppl 1):S1-S259.[Abstract][Full Text]
Richards C, Barrett J. Trans and Non-binary Gender Healthcare for Psychiatrists, Psychologists, and Other Health Professionals. Cambridge, UK: Cambridge University Press; 2020.
Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.[Abstract]
The American College of Obstetricians and Gynecologists. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-88.[Abstract][Full Text]

Other Online Resources

WHO: International Classification of Diseases 11th Revision
WHO: FAQs Gender incongruence and transgender health in the ICD
APA: gender dysphoria

Referenced Articles

1. World Health Organization. International statistical classification of diseases and health related problems (ICD). 11th revision. Jan 2022 [Internet publication].[Full Text]
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric Publishing; 2022.
3. Winter S, Diamond M, Green J, et al. Transgender people: health at the margins of society. Lancet. 2016 Jul 23;388(10042):390-400.[Abstract]
4. Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(suppl 1):S1-S259.[Abstract][Full Text]
5. Practice Committee of the American Society for Reproductive Medicine. Inclusive language and environment to welcome lesbian, gay, bisexual, transgender, queer, questioning, intersex, and asexual+ patients. Fertil Steril. 2024 Jun;121(6):954-60.[Abstract]
6. Centers for Disease Control and Prevention. Transgender persons. Apr 2023 [internet publication].[Full Text]
7. Drummond KD, Bradley SJ, Peterson-Badali M, et al. A follow-up study of girls with gender identity disorder. Dev Psychol. 2008 Jan;44(1):34-45.[Abstract]
8. Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23.[Abstract]
9. Singh D, Bradley SJ, Zucker KJ. A Follow-up study of boys with gender identity disorder. Front Psychiatry. 2021;12:632784.[Abstract][Full Text]
10. Collin L, Reisner SL, Tangpricha V, et al. Prevalence of transgender depends on the "case" definition: a systematic review. J Sex Med. 2016 Apr;13(4):613-26.[Full Text]
11. UK Parliament. 2021 census: what do we know about the LGBT+ population? 16 Jan 2023 [internet publication].[Full Text]
12. Van Der Miesen AI, Hurley H, De Vries AL. Gender dysphoria and autism spectrum disorder: a narrative review. Int Rev Psychiatry. 2016;28(1):70-80.[Abstract][Full Text]
13. Glidden D, Bouman WP, Jones BA, et al. Gender dysphoria and autism spectrum disorder: a systematic review of the literature. Sex Med Rev. 2016 Jan;4(1):3-14.[Abstract]
14. Terada S, Matsumoto Y, Sato T, et al. Factors predicting psychiatric co-morbidity in gender-dysphoric adults. Psychiatry Res. 2012 Dec 30;200(2-3):469-74.[Abstract]
15. Bockting WO, Miner MH, Swinburne Romine RE, et al. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013 May;103(5):943-51.[Abstract][Full Text]
16. Swaab DF, Chung WC, Kruijver FP, et al. Sex differences in the human hypothalamus in the different stages of human life. Neurobiol Aging. 2003 May-Jun;24(suppl 1):S1-16.[Abstract]
17. American Psychiatric Association. Assessment and treatment of gender dysphoria and gender variant patients. 2018 [internet publication].[Full Text]
18. Diamond M, Watson LA. Androgen insensitivity syndrome and Kleinfelter's syndrome: sex and gender considerations. Child Adolesc Psychiatr Clin N Am. 2004 Jul;13(3):623-40.[Abstract]
19. Peterson RE, Imparato-McGinley J, Gautier T, et al. Male pseudohermaphroditism due to steroid 5 alpha reductase deficiency. Am J Med. 1977 Feb;62(2):170-91.[Abstract]
20. Meyer-Bahlburg HF. Hormones and psychosexual differentiation: implications for the management of intersexuality, homosexuality and transsexuality. Clin Endocrinol Metab. 1982 Nov;11(3):681-701.[Abstract]
21. Dittmann RW, Kappes MH, Kappes ME, et al. Congenital adrenal hyperplasia II: gender-related behavior and attitudes in female salt-wasting and simple virilizing patients. Psychoneuroendocrinology. 1990;15(5-6):421-34.[Abstract]
22. Dittmann RW, Kappes MH, Kappes ME, et al. Gender related behavior and attitudes in female patients and sisters. Psychoneuroendocrinology. 1990;15(5-6):401-20.[Abstract]
23. Cohen-Kettenis PT, van Goozen SH, Doorn C, et al. Cognitive ability and cerebral lateralization in transsexuals. Psychoneuroendocrinology. 1998 Aug;23(6):631-41.[Abstract]
24. Heylens G, De Cuypere G, Zucker KJ, et al. Gender identity disorder in twins: a review of the case report literature. J Sex Med. 2012 Mar;9(3):751-7.[Abstract]
25. Bentz EK, Hefler LA, Kaufmann U, et al. A polymorphism of the CYP17 gene related to sex steroid metabolism is associated with female-to-male but not male-to-female transsexualism. Fertil Steril. 2008 Jul;90(1):56-9.[Abstract][Full Text]
26. Pasterski V, Gilligan L, Curtis R. Traits of autism spectrum disorders in adults with gender dysphoria. Arch Sex Behav. 2014 Feb;43(2):387-93.[Abstract]
27. Richards C, Barrett J. Trans and Non-binary Gender Healthcare for Psychiatrists, Psychologists, and Other Health Professionals. Cambridge, UK: Cambridge University Press; 2020.
28. Le Vay S. The sexual brain. Boston, MA: MIT Press;1993.
29. Rametti G, Carrillo B, Gómez-Gil E et al. The microstructure of white matter in male to female transsexuals before cross-sex hormonal treatment. A DTI study. J Psychiatr Res. 2011 Jul;45(7):949-54.[Abstract]
30. Luders E, Sánchez FJ, Gaser C, et al. Regional gray matter variation in male-to-female transsexualism. Neuroimage. 2009 Jul 15;46(4):904-7.[Abstract]
31. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2017 Nov 1;102(11):3869-903.[Abstract]
32. Royal College of Psychiatrists. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Oct 2013 [internet publication].[Full Text]
33. Nuttbrock L, Hwahng S, Bockting W, et al. Lifetime risk factors for HIV/sexually transmitted infections among male-to-female transgender persons. J Acquir Immune Defic Syndr. 2009 Nov 1;52(3):417-21.[Abstract][Full Text]
34. Sevelius JM. Gender Affirmation: A framework for conceptualizing risk behavior among transgender women of color. Sex Roles. 2013 Jun 1;68(11-12):675-89.[Abstract]
35. Rotondi NK, Bauer GR, Scanlon K, et al. Nonprescribed hormone use and self-performed surgeries: "do-it-yourself" transitions in transgender communities in Ontario, Canada. Am J Public Health. 2013 Oct;103(10):1830-6.[Full Text]
36. Becerra Fernández A, de Luis Román DA, Piédrola Maroto G. Morbidity in transsexual patients with cross-gender hormone self-treatment [in Spanish]. Med Clin (Barc). 1999 Oct 23;113(13):484-7.[Abstract]
37. American Psychological Association. Guidelines for psychological practice with transgender and gender nonconforming people. Am Psychol. 2015 Dec;70(9):832-64.[Abstract][Full Text]
38. Nik-Ahd F, Jarjour A, Figueiredo J, et al. Prostate-specific antigen screening in transgender patients. Eur Urol. 2023 Jan;83(1):48-54.[Abstract][Full Text]
39. Chen H, Wiepjes CM, van Schoor NM, et al. Changes of vitamin D-binding protein, and total, bioavailable, and free 25-hydroxyvitamin D in transgender people. J Clin Endocrinol Metab. 2019 Jul 1;104(7):2728-34.[Abstract][Full Text]
40. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):1911-30.[Abstract][Full Text]
41. The American College of Obstetricians and Gynecologists. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021 Mar 1;137(3):e75-88.[Abstract][Full Text]
42. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position statement "assessment and hormonal management in adolescent and adult trans people, with attention for sexual function and satisfaction". J Sex Med. 2020 Apr;17(4):570-84.[Abstract]
43. Murad MH, Elamin MB, Garcia MZ, et al. Hormonal therapy and sex reassignment: a systematic review and meta-analysis of quality of life and psychosocial outcomes. Clin Endocrinol (Oxf). 2010 Feb;72(2):214-31.[Abstract]
44. Baker KE, Wilson LM, Sharma R, et al. Hormone therapy, mental health, and quality of life among transgender people: a systematic review. J Endocr Soc. 2021 Apr 1;5(4):bvab011.[Abstract][Full Text]
45. Fisher AD, Castellini G, Ristori J, et al. Cross-sex hormone treatment and psychobiological changes in transsexual persons: two-year follow-up data. J Clin Endocrinol Metab. 2016 Nov;101(11):4260-9.[Abstract][Full Text]
46. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes. 2016 Apr;23(2):168-71.[Abstract]
47. Schuster MA, Reisner SL, Onorato SE. Beyond bathrooms--meeting the health needs of transgender people. N Engl J Med. 2016 Jul 14;375(2):101-3.[Abstract]
48. British Medical Association. Managing patients with gender dysphoria. Wed 2023 [internet publication].[Full Text]
49. Rosendale N, Goldman S, Ortiz GM, et al. Acute Clinical Care for Transgender Patients: A Review. JAMA Intern Med. 2018 Nov 1;178(11):1535-43.[Abstract]
50. Weyers S, Elaut E, De Sutter P, et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med. 2009 Mar;6(3):752-60.[Abstract]
51. Haupt C, Henke M, Kutschmar A, et al. Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database Syst Rev. 2020 Nov 28;11:CD013138.[Abstract]
52. Vinogradova Y, Coupland C, Hippisley-Cox J. Use of hormone replacement therapy and risk of venous thromboembolism: nested case-control studies using the QResearch and CPRD databases. BMJ. 2019 Jan 9;364:k4810.[Abstract][Full Text]
53. Dittrich R, Binder H, Cupisti S, et al. Endocrine treatment of male-to-female transsexuals using gonadotropin-releasing hormone agonist. Exp Clin Endocrinol Diabetes. 2005 Dec;113(10):586-92.[Abstract]
54. Patel KT, Adeel S, Rodrigues Miragaya J, et al. Progestogen use in gender-affirming hormone therapy: a systematic review. Endocr Pract. 2022 Dec;28(12):1244-52.[Abstract]
55. Traish AM, Gooren LJ. Safety of physiological testosterone therapy in women: lessons from female-to-male transsexuals (FMT) treated with pharmacological testosterone therapy. J Sex Med. 2010 Nov;7(11):3758-64.[Abstract]
56. Joint R, Chen ZE, Cameron S. Breast and reproductive cancers in the transgender population: a systematic review. BJOG. 2018 Nov;125(12):1505-12.[Abstract]
57. General Medical Council. Trans healthcare. Jan 2024 [internet publication].[Full Text]
58. Barrett J. Transsexualism and other disorders of gender identity: a practical guide to management. Abingdon, UK: Radcliffe Medical Publishing; 2007.
59. de Blok CJ, Wiepjes CM, van Velzen DM, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol. 2021 Oct;9(10):663-70.[Abstract]
60. Trum HW, Hoebeke P, Gooren LJ. Sex reassignment of transsexual people from a gynecologist's and urologist's perspective. Acta Obstet Gynecol Scand. 2015 Jun;94(6):563-7.[Abstract][Full Text]
61. British Medical Association. Inclusive care of trans and non-binary patients. Mar 2022 [internet publication].[Full Text]
62. UCSF Transgender Care. Guidelines for the primary and gender-affirming care of transgender and gender nonbinary people. Jun 2016 [internet publication].[Full Text]