What is Gender Dysphoria?

Firstly, what GD is not. Though cultures sometimes unfairly pick favorites, differences in personality and expression are a normal part of being human. Biological sex is also innately human. Like other mammals, we reproduce by combining male and female genes. So, "male" and "female" are words for these biological reproductive categories, nothing more. Though there are some traits which tend to be more male or female, on average, not everyone is average. It would sadden us if any girl felt like less of a girl just because she likes trucks, sports or short hair; or for a boy to wonder if he's not really a boy at all just because he likes dolls, the colour pink or dancing. Sex stereotypes are not Gender Dysphoria.

Though there’s still a lot we don’t yet know about GD, it has been studied for decades.

The Diagnostic and Statistical Manual Version 5 (DSM-5) outlines three known pathways to the development of GD:

1) Early childhood onset which is highly correlated with homosexuality

2) Late Onset - when Transvestic Disorder with Autogynephilia progresses into GD

3) GD associated with a Disorder of Sex Development (DSD)

We describe these below.

1. Childhood Onset GD

This type of GD is highly correlated with homosexuality, so it is sometimes called homosexual transsexualism (HSTS). Gender non-conformity (GNC), and some degree of cross-sex identification, is quite common among gay and lesbian people, especially in childhood. The degree to which this dimension of homosexuality is expressed is culturally mediated. Distress (dysphoria) associated with gender non-conformity is most likely due to lack of cultural understanding and support for LGB/non-conformity. Gender-related distress isn't common in places like Samoa where gender-nonconformity is expressed openly.

Key features:

Obvious signs of gender-nonconformity from age 2-3
Express a strong desire to be the opposite sex, or believe they are in fact the opposite sex
Occurs in both boys and girls
60-90% of kids who voice a desire to be the opposite sex, desist by or through adolescence without intervention. The remainder may desire medical interventions as adults.
Predictors of persistence: lower socio-economic status, intensity of cross-sex identification, autism

2. Late Onset Gender Dysphoria

The second primary pathway to gender dysphoria described in the DSM-5 and medical literature is related Transvestic Disorders with Autogynephilia. Dr Ray Blanchard, who coined the term Autogynephilia, described it as "a man's propensity to be sexually aroused by the fantasy of being a woman." It's classified as a paraphilia, which is an erotic target location error. Blanchard believed transvestite definition was too narrow, because AGP can be about the body, not just crossdressing. AGP should not be seen as a mere fetish, because that is overly reductive. Like a sexual orientation, AGP is multidimensional and includes a range of feelings and behaviours including romantic love and bonding.

Key features:

Historically, it was estimated that 75% of trans women have AGP
Seen almost exclusively in non-homosexual natal boys/men
Not typically gender-non-conforming as children
Progresses into GD in adolescence or adulthood
There are subcategories and variations
There may be a higher transition regret rate among AGP

Read: The Man Who Would Be Queen by Michael Bailey

Read: Men Trapped in Men's Bodies, by Anne Lawrence

3. Disorder of Sex Development with GD

Disorders of sex development (DSD) are a group of rare congenital medical conditions in which the fetal sex differentiation process has been atypical in some way. For example, one's chromosomal sex may not match one's sex characteristics.

Not all people with DSDs have GD, but a small percentage do, which is more common in certain DSDs such as Ovotesticular DSD and Congenital Adrenal Hyperplasia.

It's been documented that natal females with CAH, for example, are more likely to be same sex attracted, choose male typical occupations and are more likely to experience gender dysphoria.

A dramatically shifting landscape

Natal males have always accounted for the vast majority of the three known types of GD.

Transvestic Disorder with AGP almost exclusively occurs in natal males. Gay men far outnumber lesbians, and butch lesbians with GD are a small subset of homosexual women. DSDs are rare and those who also experience GD even more rare.

A new cohort of trans identified individuals has emerged, especially since about 2015.

Natal females, with no observed history of childhood gender non-conformity, are now the largest group presenting to gender clinics. Little is known about why this shift has occurred.

Dr Lisa Littman was the first to do a preliminary study and develop a hypothesis of socially influenced trans identity, which she termed Rapid Onset Gender Dysphoria (ROGD).

Some traits reported include:

Mostly natal girls, but seen in both boys and girls
Often no signs of gender non-conformity in childhood
First appears in adolescence, quite suddenly
Often very intelligent and sensitive youth
May have conditions that make them more vulnerable (e.g. Borderline Personality Disorder, Autism or ADHD - all of which impact social skills, emotions and processing)
Worsening mental health and behaviour after coming out as trans
Firm and intense focus on gender ideology and subculture
Social media and pornography are believed to be contributers