What is Gender Dysphoria?

An Explanation of Gender Dysphoria  

Thousands of children and adolescents are being referred for medical gender transitioning across Canada. The reasons for seeking medical transitioning go by all sorts of names. Some young people are confused about or questioning their gender. Some are gender non-conforming. Others identify as transgender, non-binary, queer, agender, or gender diverse. None of these are medical terms, yet they often are used to justify going down medical pathways. 

But there are a couple of relevant medical terms for all of this: gender dysphoria and gender incongruence. Both refer to confusion around gender and a sense of disconnect from one’s biological gender. Unfortunately, the two leading medical diagnostic manuals offer hazy criteria for diagnosing gender dysphoria and gender incongruence. That’s a big problem because it makes it easy for minors to be referred for a medical transition.  

What is Gender Dysphoria? 

Gender dysphoria is a diagnosable clinical problem according to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). This manual lists all known mental disorders, conditions, and diseases with descriptions to help clinicians make diagnoses. It is the most comprehensive and definitive resource used by the American Psychiatric Association.  

Gender dysphoria is a diagnosable clinical problem according to the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR).

The general definition of gender dysphoria is “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration… [that] is associated with clinically significant distress in social, school… occupational, or other important areas of functioning.”¹  

In the DSM-5-TR, gender dysphoria falls under its own stand-alone heading and is not grouped with other clinical problems. The DSM-5-TR requires both gender incongruence and significant distress in order for gender dysphoria to be diagnosed.  

There is some ambiguity around whether the incongruence or the distress is the focal point of the clinical problem. The DSM-5 discarded the previous DSM-4 term gender identity disorder to focus “on dysphoria as the clinical problem, not the identity per se,”² implying that there is nothing disordered about gender incongruence. As long as any distress that accompanies gender incongruence is managed, the DSM-5 seems to suggest the underlying gender incongruence needs no treatment. 

Yet, later on, the DSM-5-TR states that “this discrepancy [between birth-assigned gender and a person’s experienced/expressed gender] is the core component of the diagnosis” although “there must also be evidence of distress about this incongruence.”³ This elaboration implies that resolving gender incongruence is a clinician’s primary concern and that the distress will resolve itself if the incongruence is solved. 

The International Classification of Diseases (ICD-11), published by the World Health Organization, is a bit clearer in this regard. While the DSM is used primarily in the United States, the ICD is used around the world. It is broader than the DSM, listing both mental and physical ailments.  

The ICD-11 makes no mention of gender dysphoria. Instead, it focuses on gender incongruence. “Gender incongruence is characterized by a marked and persistent incongruence between an individual’s experienced gender and the assigned sex. Gender variant behaviour and preferences alone are not a basis for assigning the diagnoses in this group.”⁴ The ICD-11 does not mention or require distress for gender incongruence to be clinically diagnosed. It also lists gender incongruence as one of many conditions related to sexual health, rather than its own separate phenomenon as the DSM classifies it. 

Gender Dysphoria in Children 

Both the DSM-5-TR and the ICD-11 distinguish between gender dysphoria in children versus adolescents.  

The diagnostic criteria in the DSM-5-TR for gender dysphoria in children requires “a strong desire to be of the other gender or an insistence that one is the other” and at least five of the remaining seven criteria: 

1. A strong preference for cross-dressing. 

2. A strong preference for cross-gender roles in play. 

3. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender. 

4. A strong preference for playmates of the other gender. 

5. A strong rejection of toys, games, and activities stereotypically used or engaged in by the other gender. 

6. A strong dislike of one’s sexual anatomy. 

7. A strong desire for the primary and/or secondary sex characteristics of the opposite sex.⁵ 

The ICD-11 requires the following to diagnose gender incongruence in children: 

1. Incongruence must be present prior to puberty. 

2. A strong desire to be a different gender. 

3. A strong dislike of his or her sexual anatomy or anticipated secondary sex characteristics and/or a strong desire for the primary and/or anticipated secondary sex characteristics that match the opposite sex. 

4. Make-believe or fantasy play, toys, games, or activities and playmates that are typical of the opposite sex. 

5. The incongruence must have persisted for about 2 years.⁶

Although there are some differences, the diagnostic criteria from the two sources largely overlap. Clinicians relying on either manual when examining a patient probably wouldn’t differ too much on their diagnosis of gender dysphoria or gender incongruence. The only exception would be the requirement for significant distress and how long the incongruence has lasted for (6 months or 2 years). 

Gender Dysphoria in Adolescents 

The diagnostic criteria for gender dysphoria in adolescents in the DSM-5-TR must include at least two of the following criteria: 

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 

3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 

4. A strong desire to be of the other gender. 

5. A strong desire to be treated as the other gender. 

6. A strong desire that one has the typical feelings and reactions of the other gender.⁷ 

The ICD-11 is silent on the diagnostic criteria for gender incongruence in adolescents. While “the diagnosis cannot be assigned prior to the onset of puberty,” the ICD-11 only mentions that it “often leads to a desire to ‘transition’, in order to live and be accepted as a person of the experienced gender, through hormonal treatment, surgery or other health care services to make the individual’s body align, as much as desired and to the extent possible, with the experienced gender” (emphasis added).⁸ Desire to transition is not a required criterion, however. If the gender incongruence is “marked and persistent,” the door is open for clinicians to diagnose a person with gender incongruence. 

Why This Matters 

This diagnostic approach is a problem because it paves the way towards damaging and unnecessary medical interventions for minors and adolescents. 

The ICD is used by medical professionals and clinicians around the world. The World Professional Association for Transgender Health (WPATH) suggests that patients be diagnosed with gender incongruence according to the ICD-11 before progressing to a medical transition.⁹ With such a low bar for diagnosis, many adolescents could be diagnosed with gender incongruence. The ICD would set a higher bar if it had a more expansive list of diagnostic criteria, such as its own criteria for gender incongruence in children like the criteria found in the DSM. 

Further, although both the DSM and ICD help medical practitioners to diagnose ailments, neither gives instruction on how to treat conditions. Instead, most clinicians have looked to WPATH’s Standards of Care for how to treat gender dysphoria and gender incongruence. WPATH’s standards support hormonal and surgical interventions, provided someone has been diagnosed with gender incongruence – a diagnosis that, as we’ve seen, leaves plenty of room for clinical discretion. 

No wonder so many teenagers have medically transitioned in recent years around the world! 

Clarity of terms is not clarity of action 

Gender dysphoria is often mentioned in the popular media, but it is important to know how it is defined in medical diagnostic manuals. Officially, gender dysphoria is a medical term for a mental disorder from a diagnostic manual that is primarily used in the United States. Gender incongruence is the medical term used in the rest of the world for essentially the same condition.  

Biological sex cannot be changed and medical transitions are never the solution to gender dysphoria. 

While these manuals help define the symptoms that characterize gender dysphoria or incongruence, they offer no solutions or way forward for treatment. And while gender dysphoria and gender incongruence are currently listed as diagnosable mental conditions, that could change. Homosexuality also used to be found in the DSM and the ICD but was declassified in newer editions and is no longer considered to be a mental condition. 

Regardless of whether gender dysphoria or gender incongruence continues to be listed and recognized as a mental disorder, our stand remains clear. Biological sex cannot be changed and medical transitions are never the solution to gender dysphoria. 

1. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), 5th TR (Washington (DC), 2022), 513. ↩︎
2. American Psychiatric Association, 512. ↩︎
3. American Psychiatric Association, 513.  ↩︎
4. World Health Organization, “International Statistical Classification of Diseases and Related Health Problems – 11th Edition,” 2024, https://icd.who.int/browse/2024-01/mms/en. ↩︎
5. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), 512. ↩︎
6. World Health Organization, “International Statistical Classification of Diseases and Related Health Problems – 11th Edition.”  ↩︎
7. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), 512–13. ↩︎
8. World Health Organization, “International Statistical Classification of Diseases and Related Health Problems – 11th Edition.”  ↩︎
9. E. Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8,” International Journal of Transgender Health 23, no. sup1 (August 19, 2022): S1–259, https://doi.org/10.1080/26895269.2022.2100644. ↩︎