Is gender dysphoria a mental disorder? Here’s what you should know

By Kristen Rogers, CNN

(CNN) — Schuyler Bailar was assigned female at birth. But as a child, he couldn’t shake the sense that he wouldn’t grow up to be a woman.

“One of my earliest gender memories was that I was going to grow up to be a dad,” Bailar said. “I was going to grow up to be Grandpa. I was going to grow up to be a man.”

Despite his clarity, Bailar — now a 27-year-old transgender man living in New York City — didn’t know how to express it as a child. From as early as age 5 or 6, he rejected the clothing and other trappings associated with girlhood: As a swimmer, he refused to wear girls’ swimsuits, instead opting for a full-body wetsuit. He was adamant that he was a tomboy.

Thinking about puberty changing his body filled him with fear and dread — leading him to focus even more on swimming as a respite from his thoughts. But when he broke his back during a bicycling accident the summer before 11th grade, “everything sort of fell apart,” he said.

The gender-related psychological turmoil that had been quieted by swimming surfaced as an eating disorder, depression and self-harm, which made Bailar feel out of control.

Bailar was experiencing gender dysphoria, the psychological distress and discomfort some people feel when there’s a difference between their sex assigned at birth and their gender identity, said Jonah DeChants, senior research scientist at The Trevor Project, a suicide prevention and crisis intervention organization for LGBTQ youth.

This discomfort can arise in social settings if others refer to the person with the wrong gender pronoun, for example, or as in Bailar’s case, if the person’s body doesn’t align with their gender identity, DeChants said.

Sex describes the biological sex a person was assigned at birth. An individual’s sex is based on biological characteristics of maleness or femaleness as indicated by chromosomes, gonads, hormones and genitals. Gender, on the other hand, pertains to the behaviors, attitudes and feelings a culture ties to someone’s biological sex — it’s a social identity and a social construct, according to the American Psychological Association.

Gender identity, an aspect of gender, is a person’s “psychological sense of their gender,” the American Psychological Association says.

Less than 0.1% of the population, or 1 in 1,000 people, has been diagnosed with gender dysphoria, according to the American Psychiatric Association. But this figure is based on only the number of people who have sought gender-affirming treatment at clinics.

Gender dysphoria typically begins in childhood, sometimes as early as 3 years old, according to the American Psychiatric Association. But symptoms can occur anytime in life, said Dr. Jack Drescher, a clinical professor of psychiatry at Columbia University in New York City.

Symptoms of gender dysphoria

For an adolescent or adult to be diagnosed with gender dysphoria, they must be experiencing certain criteria for gender dysphoria, along with clinically significant distress or functional impairment, according to the American Psychiatric Association. Not every person who doesn’t identify with their assigned gender experiences gender dysphoria, particularly the distress and impairment.

Some of those criteria differ based on age, but generally, they involve conflict between one’s gender identity and primary and/or secondary sex characteristics. (Primary sex characteristics refer to the ovaries or testes and related hormones, while secondary sex characteristics are features that come with maturation of the body — such as voice, facial hair, breast size and height.)

People with gender dysphoria might really want to get rid of those primary or secondary sex characteristics or have those characteristics that match their gender identity. These individuals might also prefer clothing, activities, toys, play or social treatment traditionally associated with a gender different than their assigned gender.

Distress associated with gender dysphoria can involve anxiety, depression, low self-esteem, self-harm, suicidality or trauma responses — such as hypervigilance — from being mistreated in society, said Dr. Amir Ahuja, director of psychiatry at the Los Angeles LGBT Center and president of The Association of LGBTQ+ Psychiatrists. Someone’s distress can become significant enough that it interferes with their ability to function: Maybe they can’t sleep, concentrate at school or work, eat well, pay bills on time, socialize, or clean their house, he added.

If you or someone you know is struggling with suicidal thoughts or mental health matters, please call the National Suicide Prevention Lifeline at 988 (or 800-273-8255) to connect with a trained counselor or visit the NSPL site.

Is gender dysphoria a mental disorder?

Because gender dysphoria is included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, also called the DSM, it is diagnosed as a mental disorder, experts said. (The DSM is the handbook used by health care professionals as the authoritative guide in diagnosing mental disorders.)

But the gender incongruence — having a gender identity that’s not the one assigned at birth — isn’t what makes gender dysphoria a mental disorder. Having clinically significant dysphoria around the incongruence is what makes it a disorder, Ahuja said.

“Like all DSM illnesses, one key component of depression, anxiety, schizophrenia, all of that, is that you have to be functionally impaired by it, otherwise it doesn’t count as a diagnosis,” he added.

Gender dysphoria’s inclusion in the DSM is also necessary for access to gender-affirming care — so for The Trevor Project’s DeChants, whether gender dysphoria is in the DSM is partly a pragmatic issue.

“We do need to do more to destigmatize and help folks understand that being trans is not being mentally ill,” he said. “I would like to see moving away from the DSM.”

But for people to get care in the US health care system, the DSM having a diagnostic code for gender dysphoria means that people can get insurance to pay for their care, DeChants said.

Alleviating gender dysphoria

People address gender dysphoria in different ways that typically fall into a few categories, and the American Psychiatric Association says that not everyone needs all the various types of support.

People may try exploring their experiences of gender identity and expression with a therapist.  When Bailar received help for his eating disorder at a residential treatment center for over four months, his therapist there helped him realize he’s transgender.

A person’s loved ones may try family or couples therapy or support groups to share their experiences and help foster a supportive environment for the person with gender dysphoria.

Affirmation of one’s gender identity by others can also be critical, as “family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender,” according to the American Psychiatric Association.

Bailar’s family and Harvard University swim coach supported him, leading Bailar to become the first openly transgender athlete to compete in any sport on a National Collegiate Athletic Association Division 1 men’s team.

What the American Psychiatric Association calls social affirmation can look like someone adopting different gender pronouns and other aspects of gender expression, such as the way one dresses — something Bailar had been doing since childhood.

Someone could legally affirm oneself by changing their name and gender markers on government identification forms.

What’s called medical affirmation includes puberty blockers for adolescents, which pause puberty, giving the adolescent time to think about their identity and their guardians time to consider options, DeChants said. Hormones for older teens and adults can help develop features such as facial hair (using testosterone) or a softer voice (using estrogen).

Some adults opt for surgical affirmation to remove, add or alter the appearance of some sex characteristics. Bailar underwent top surgery (a double mastectomy) in March 2015 and began hormone therapy a few months later.

Nearly a decade later, Bailar is happy, he said. He’s newly married, an author and a speaker, and spends most of his time educating others about gender. His upcoming book “He/She/They: How We Talk About Gender and Why It Matters” releases in October.

“Gender-affirming care was a big part of alleviating gender dysphoria,” he said. “I am so in love with being trans, and I have so much joy, because the love, the support, the freedom I experience in my transness far outweighs any kind of negativity. And the negativity exists because people are transphobic, not because I’m trans.”

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