People’s experiences of dysphoria vary hugely. It is important not to assume what a patient means by this term when they use it, but rather to explore in detail how they experience dysphoria as an individual.
Since gender is a social construct, it follows that gender dysphoria is a complex concept to define. People will often mean different things when they use this term, and sufferers of gender dysphoria may all use this term to describe their difficulties, yet be referring to very different internal experiences. In a clinical setting such ambiguity is unusual, and it takes time and sensitive exploration to be able to understand what a patient is experiencing and describing, and to start to understand why.
Clinicians are expert at unpicking what their patient is experiencing when it comes to relatable symptoms, such as pain. They enquire carefully about the type of pain, the intensity, whether it radiates, what makes it better or worse. Doctors are taught that 80% of diagnoses come from the history alone, so become adept at understanding the differences and nuances in what is being described. This is why when a patient describes a sensation that is difficult to relate to, extra care must be taken to avoid making assumptions or dismissing their ideas. Rather, clinicians should carefully take a history as they usually would, to explore what a patient means by ‘gender’ and how they experience dysphoria. Clinicians would always support the patient, but need to keep a dispassionate, open-minded and professional approach when it comes to diagnoses (if there is one), formulation and therefore treatment.
Transsexualism was originally named in ICD-9 in 1978 as part of the section named “Sexual deviations and disorders”. 1992 saw ICD-10 describing gender identity disorders as an independent group of disorders and were included in the section “Adult personality and behaviour disorders”. The upcoming International Classification of Diseases and Related Health Problems, ICD-11, will lose the term “Transsexualism” and replace it with the term “Gender Incongruence” (WHO, no date). This will no longer be part of the chapter on mental disorders (Chapter 6) but in a new chapter (Chapter 17) entitled “Conditions relating to sexual health”. This creates confusion between the separate concepts of sex and gender. This ambiguity may be due to the fact that this chapter, in addition to including gender incongruence, also describes sexual dysfunctions, which until now have also been considered mental disorders.
Dysphoria is an inner sense of unease, distress, or disgust towards our self – primarily directed towards our body, part of our body or an attribute of our body. Dysphoria is a combination of thoughts, emotions, and physical sensations, and can vary in intensity from low level (easy to ignore), to incapacitating (taking up our whole attention, and preventing us from turning our minds towards other thoughts or activities). People’s experiences of dysphoria vary hugely. It is important not to assume what a patient means by this term when they use it, but rather to explore in detail how they experience dysphoria as an individual.
Dysphoria can also vary in terms of the quality or conviction of the accompanying thoughts. This is more easily understood in the context of body dysphoria, since we can perhaps more readily relate to what someone means when talking about a body part, whereas gender identity can be a difficult concept to relate to; unlike a body part, a person’s inner sense of themselves cannot be physically seen or measured, and many people report not having any gender identity feelings at all.
Some people experience body dysphoria as mild, and the accompanying distressing thoughts as easily soothed. For example, a person may have a fleeting thought that they don’t like the shape of their chin. They may ponder this idea for a few seconds, but quickly move on, telling themselves it doesn’t really matter and thus they don’t feel upset about it, as it is just their chin. The person accepts how it looks.
At other times this thought might come and go quickly, barely interrupting whatever the individual was doing. However, it is a repeated intrusion, and they think about their chin on a more regular basis than others do.
For others, this thought could become more preoccupying. They may start to spend time staring at the mirror and inspecting their chin from different angles. Rather than spending a brief moment considering this body part, the person ruminates, and this preoccupation can take up hours at a time. Instead of critiquing their chin from a dispassionate, unemotional standpoint, the individual’s feelings towards their chin grow more negative, hostile, and their mood slumps. They may spend increasing amounts of time applying make-up to try and change its appearance or browse through websites seeking an image of what could be their perfect chin. The person might consider cosmetic surgery to ‘fix it’. When they go out, they may worry that other people are staring at their chin, and believe these strangers are also harbouring negative thoughts about their chin. The person’s thoughts about their chin are fixed in their mind, and despite many friends or doctors explaining that their chin is fine as it is, the sufferer remains convinced it is deformed.
When the patient’s preoccupation and associated behaviours start to impinge on their general functioning (for example by missing work or not wanting to leave the house), they may be diagnosed with body dysmorphic disorder (BDD). This is a debilitating condition and leads many sufferers to seek cosmetic surgery. However, research has demonstrated that although surgery may relieve a person’s suffering in the short term, the condition can return either focussing on the same body part or shifting to another feature (Sarwer and Spitzer, 2012). This can lead to successive yet futile surgeries, which carry risks and cost a lot of money.
What is generally more helpful for BDD is a course of cognitive behavioural therapy (CBT). During this treatment the sufferer can re-evaluate their thoughts and modify their behaviours, so they become less concerned about any perceived imperfection with the shape of their chin. Treatment does take effort, can be difficult, and requires therapeutic expertise, but the relief of being able to live without this debilitating preoccupation means this effort is generally worth it. Other treatments such as SSRIs (a type of anti-depressant/anti-anxiety medication), often in combination with CBT, have also been shown to be useful (NHS, 2020).
One of the most important psychological concepts that underpins BDD and many other conditions (including gender dysphoria), is how our attention and focus on anything about (or in) ourselves, leads to an increased awareness of the object or sensation in focus. This in turn will unintentionally magnify our sensations and increase the intrusion of thoughts that previously were ‘background noise’.
Whether the focus is your chin, your fatness, your thinning hair, or your gender, attention begets attention, and increases awareness of the aspect one feels is ‘wrong’. So, not only do we magnify sensations that we would previously not have been aware of, our thinking about this part of ourselves becomes more intense, intrusive, and takes up a lot more of our time.
For someone who is concerned about their gender, the ongoing examination of their internal sense of gender is a very personal, individual process. Some people would describe not having an internal sense of gender, or if they do it is of very low importance or interest to them. They then would not need to label it or pay it any more attention than any other aspect of their sense of self. However, someone with gender dysphoria is highly preoccupied with how they feel, what they feel and how others are perceiving them related to their gender role/sexed body.
Not having a gender identity is not the same as being ignorant of gender roles, nor does it mean being unaware of one’s sexed body. Sex differences are one of the first differences between people that children notice, along with noting broad variations associated with people’s ages. Boys and girls notice they have different body parts, but the behaviours (toys, dress etc) associated with these sex differences vary widely and are hugely affected by the child’s socialisation and environment (Martin, 2011). In a class of infant school children, how each child plays can vary enormously. Some girls are drawn to football and running around games, and some boys enjoy dressing up and playing shops. No type of play is considered abnormal from a clinical perspective. As children grow and their personalities develop, they may become drawn to different activities. Yet if a child is made to feel ashamed of what games they like to play, or how they like to dress, this can have a negative impact on the development of their sense of self.
Children with gender dysphoria experience a profound and intense distress directed towards their gender (social role assigned at birth according to their actual sex), and a wish or belief they are in fact the opposite sex. This may be related to early adverse childhood events (Kozlowska et al., 2021), and affect their relationships at school or at home. Gender dysphoria is sometimes associated with other psychological problems such as depression, anxiety or suicidal ideation.
References:
Kozlowska, K. et al. (2021) ‘Attachment Patterns in Children and Adolescents With Gender Dysphoria’, Frontiers in Psychology, 11. doi: 10.3389/fpsyg.2020.582688.
Martin, B. (2011) Children at Play: Learning Gender in the Early Years. Sterling, VA: Trentham Books Limited.
NHS (2020) Body dysmorphic disorder (BDD), NHS.UK. Available at: https://www.nhs.uk/mental-health/conditions/body-dysmorphia/.
Sarwer, D. B. and Spitzer, J. C. (2012) ‘Body Image Dysmorphic Disorder in Persons Who Undergo Aesthetic Medical Treatments’, Aesthetic Surgery Journal, 32(8), pp. 999–1009. doi: 10.1177/1090820X12462715.
WHO (no date) WHO/Europe brief – transgender health in the context of ICD-11. Available at: https://www.euro.who.int/en/health-topics/health-determinants/gender/gender-definitions/whoeurope-brief-transgender-health-in-the-context-of-icd-11.