Being a teen is hard enough for anyone, but it’s much more difficult if you have gender dysphoria, or discontent with the sex and gender you were assigned at birth. In this essay, I examine some research studies about gender dysphoria in teens and how it relates to gender expression and being transgender.
Gender identity is a topic that has interested me for a long time, so I took this opportunity to learn more about it. I am a proponent of challenging established gender roles, and I believe everyone is unfairly pressured to stay within their expected male or female gender roles in all stages of their lives, from childhood, to adolescence, to adulthood. This pressure comes from myriad sources and affects everyone’s self-concept and self-worth. Those who fit most or all of their expectations are affected positively; those who do not are affected negatively.
It is common, for example, for girls to be labeled negatively as “tomboys,” and for boys to be labeled negatively as “sensitive” (Halderman, 2000). Some people who have been negatively affected or otherwise confused by established gender roles ultimately overcome those factors and emerge with a gender identity that is compatible with their biological sex. But for others, the challenge runs deeper. As some children grow up, they may come to realize their biological sex conflicts with their gender identity (Halderman, 2000). These issues can pose a significant dilemma that affects daily life. This is where gender dysphoria takes shape.
I’ve found that adolescence, the most crucial stage of self-discovery, is the most interesting stage in which to examine gender dysphoria. For the purpose of this essay, I will peruse a series of research studies to analyze how gender dysphoria in adolescents is treated and how the treatment affects them. Before doing so, however, it is important to understand the etiology of gender dysphoria.
The American Psychiatric Association refers to gender dysphoria as “Gender Identity Disorder” in the Diagnostic and statistical manual of mental disorders, or the DSM-IV-TR (2000). Within the DSM-IV-TR, two necessary components are given for diagnosing gender dysphoria. First, there must be evidence of a “strong and persistent cross-gender identification,” and second, there must be “persistent discomfort about one’s assigned sex,” including feeling that one’s biological sex is inappropriate. These conditions only apply if one is not intersex, i.e. if one is male or female biologically; and in order to classify the symptoms as gender dysphoria, there must also be “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (DSM-IV-TR, 2000).
The DSM-IV-TR states that adolescents with gender dysphoria may have variants of typical symptoms seen in both children and adults. Young teens, for example, may be guarded and suspicious, making it more difficult to diagnosis them accurately. Other adolescents may also feel their gender identity is “unacceptable to the family” and suffer problems in their social lives, choosing to isolate themselves, perhaps because of being teased or rejected by their peers. In circumstances such as these, the DSM-IV-TR suggests not to jump to any conclusions about a diagnosis, instead reserving such a diagnosis for adolescents who “appear quite cross-gender identified” and those who “engage in behaviors that suggest significant cross-gender identification” (DSM-IV-TR, 2000).
Despite the components listed in the DSM-IV-TR, correctly diagnosing gender dysphoria may be a struggle in itself. The World Health Organization’s International Classification of Diseases, or ICD-10, insists there must be “a profound disturbance of the normal gender identity,” asserting that “tomboyishness in girls and girlish behaviour in boys is not sufficient” (Arcelus & Bouman, 2001). It seems a fine line is drawn between gender dysphoria and typical conditions. Halderman (2000) suggests the steps for diagnosis are sketchy and poorly examined. He also notes that girls (i.e. those who were assigned female at birth) are much less likely to receive treatment for gender dysphoria, possibly because our society has historically seen masculine characteristics as desirable and has seen feminine characteristics as undesirable (Halderman, 2000).
Further, Richardson (1999) suggests the process of determining an adolescent’s level of “gender atypicality,” or how much the individual appears to reject his or her gender roles, is a gray area at best. He implies that society regards feminine boys and men with the same type of contempt and disgust historically seen for gay men. Ultimately, he says, deciding on the actual “disorder” in “Gender Identity Disorder” may be the hardest part. Controversy has ensued over the fact gender dysphoria is still included in the DSM at all. After all, the DSM used to classify homosexuality as a mental disorder until the 1970s (Richardson, 1999). This debate over the ambiguous methods of diagnosis for gender dysphoria is very important in understanding its etiology. In the future, it is possible that gender dysphoria will be redefined or no longer classified as a disorder.
The studies I chose to examine for this essay each included at least one situation that seemed unambiguous, in which an adolescent clearly identified themselves as a gender that did not match their biological sex (i.e. transgender) and received some form of treatment. The symptoms they expressed were included under the umbrella of gender dysphoria as the DSM defined it in 2000.
As of 2000, there were two categories of treatment available for individuals with gender dysphoria. The first, psychotherapy, attempted to dispel the individual’s wishes to reassign their biological sex to match their gender identity, which may be counterintuitive at best but was considered a form of care at the time. The second is transgender medical treatment, which often but not always resulted in sex reassignment surgery. That procedure, once commonly known as a “sex change,” allows the individual to have a biological sex that matches their gender identity, with the goal of allowing them to live more happily (Meyenburg, 1999).
One research study of adolescents with gender dysphoria took place at the Frankfurt University Child and Adolescent Psychiatric Outpatient Clinic, as summarized by Meyenburg (1999). It includes four case examples of adolescents who sought treatment for gender dysphoria at the clinic throughout the 1990s. All of them came to the clinic with the desire for transgender medical treatment. The objective at the clinic was to “encourage psychotherapy and discourage premature sex reassignment measures” (Meyenburg, 1999), which indicates the clinic had an agenda or bias against transgender patients.
Christa, the study’s first example, was a seventeen-year-old who was a “clear-cut example” of being transgender. Christa had always felt gender dysphoria, was confident about being a boy, and was seeking sex reassignment. After two years of extensive psychotherapy, a desire for sex reassignment was not dispelled, and Christa eventually underwent the surgery. Sandra, a seventeen-year-old girl in a similar situation, was depressed and sad because of her gender identity issues. She unexpectedly stopped coming to therapy sessions and never returned. Later, the clinic learned that she did not undergo sex reassignment surgery, and she instead identified as lesbian (Meyenburg, 1999).
There were also two male-at-birth examples. Martin was a seventeen-year-old boy who was believed to have a “severe case” of gender dysphoria. After his therapy sessions, he indicated that besides feeling like he had female facial features, he was gay, not transgender. Finally, Holger, a thirteen-year-old boy, was beginning to identify as female but also had male-like “heterosexual” desires, in the words of the study, to be with a woman. A few years of psychotherapy appeared to change Holger, as Meyenburg described: he began to identify as male and “he was developing a clearly heterosexual identity” (Meyenburg, 1999).
From these case studies, Meyenburg (1999) argued that patients can find a way to be content through psychotherapy and other life changes that do not involve “irreversible measures” (Meyenburg, 1999). But after reading his study, that is not necessarily the case. Instead, the mixed results indicate that the adolescents’ gender identity was only being suppressed, not “cured” — much in the same way that parents once wanted to “cure” their child’s homosexuality, when we now know that being gay or lesbian is not a disorder and doesn’t need treatment. It has become increasingly apparent since Meyenburg’s study was published that psychotherapy is a treatment that belongs in the past.
Another case study by Arcelus and Bouman (2000) examined the onset of gender dysphoria in a thirteen-year-old boy who also had a history of male-to-female crossdressing in his family. Although the study did not indicate if the boy went on to identify as female or ever received transgender medical treatment after going through psychotherapy, the study suggested there may be some link between gender dysphoria and fetishistic transvestism as an adolescent. The study also discovered there might be a discoverable genetic link for gender dysphoria, because some of the boy’s relatives whom he did not grow up with or around also experienced some symptoms of gender dysphoria (Arcelus & Bouman, 2000).
The last research study I examined was a larger one, conducted by Smith and van Goozen (2001), which studied 47 adolescents who received treatment for gender dysphoria. Among the participants, 20 people chose to undergo transgender medical treatment instead of extensive psychotherapy, 21 received psychotherapy and would not have their sex reassigned, and six others would remain undecided about the various forms of treatment until they became older. Each participant was tested for regular functioning in psychological, social, and sexual areas.
The transgender medical treatment appeared to be successful, as none of the 20 people expressed any regret about their outcome in a survey conducted up to four years later. The study also reported, “The treated group was no longer gender-dysphoric and was psychologically and socially functioning quite well” (Smith & van Goozen, 2001), suggesting that medical treatment and/or sex reassignment is a reasonable form of care for gender dysphoria.
As for the participants who only received psychotherapy, they showed marginal improvement but as a group were not functioning as well psychologically as the group who received medical treatment (Smith & van Goozen, 2001). The trend across this range of studies suggests that psychotherapy should no longer be recommended, and more focus moving forward should be put on establishing a greater understanding of each individual’s case in order to encourage the most appropriate outcome for them fairly and without stigma.
From these studies, it’s clear that treating gender dysphoria in adolescents is a complicated issue. Arcelus and Bouman (2000) propose that there is a broad “spectrum of cross-gender identification” (p. 410), which suggests there is more to gender dysphoria than just “you have it or you don’t.” The etiology of gender dysphoria is immensely complex.
Adolescents face an incredible amount of pressure in their daily lives anyway, and adding gender identity issues to an adolescent’s individual situation makes everything that much more complicated. So, especially for adolescents, I do not necessarily agree with all forms of gender dysphoria being blanket-labeled as the same issue that requires the same care. There is a difference between having a gender expression that falls outside of societal expectations and having a gender identity that differs from one’s biological sex at birth. Both cases are valid, and components of each may overlap in individuals across the gender spectrum, but they are markedly different situations with different outcomes: the former is largely an external issue that would ideally be remedied environmentally, while the latter is often an internal issue that may be treated medically.
Until recent years, adolescents who were gay or lesbian were also told that they had a disorder; they faced even more unnecessary pressure and criticism in those crucial years of their lives and underwent harmful psychotherapy for something that could only be suppressed, not supposedly cured.
Misdiagnosed types of gender dysphoria strike me as a similar scenario. If gender roles were not so ingrained into society, and if children and adolescents were not routinely teased at even the slightest sign of an unexpected gender expression, perhaps some people who are currently suffering would see improvement: those who feel their biological sex is acceptable, but who have an outward expression that exists somewhere else along the spectrum, would be able to identify and express their gender however they see fit, without being led to psychotherapy or other potential harm over an issue that exists primarily in others’ minds.
Of course, even with more evolved attitudes toward gender expression in society, many people who experience gender dysphoria are transgender and know they were born with a conflicting biological sex. Treating their condition like a mental disorder does not help, but neither does doing nothing at all. This is where proper medical treatment comes into play. If medical treatment can help transgender people align their gender identity with their biology so they may feel that they are in the correct body, and if more people who have received that care gain visibility, perhaps our society will come to know transgender people in greater numbers until they are widely understood, validated, and accepted.
Ideally, the entire spectrum of gender identity and expression could be viewed with acceptance. As Richardson (1999) states, it is to some degree a matter of exercising our own “mental freedom — specifically, that we free ourselves from an imaginative conformity with notions of how boys and girls should behave” (p. 50). Combined with the freedom for transgender people to seek medical treatment without stigma, people across the gender spectrum could live happier, healthier lives. If we as a society were to achieve that, it would be one of the greatest paradigm shifts we have ever witnessed.
- American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (revised 4th ed.). Washington, DC.
- Arcelus, J., & Bouman, W. P. (2000). Gender Identity Disorder in a child with a family history of cross-dressing. Sexual and Relationship Therapy. 15(4), 407-411.
- Halderman, D. C. (2000). Gender atypical youth: Clinical and social issues. School Psychology Review. 29(2), 192-200.
- Meyenburg, B. (1999). Gender Identity Disorder in adolescence: Outcomes of psychotherapy. Adolescence. 34(134), 305-313.
- Richardson, J. (1999). Response: Finding the disorder in Gender Identity Disorder. Harvard Review of Psychiatry. 7(1), 43-50.
- Smith, Y. L. & van Goozen, S. H. (2001). Adolescents with Gender Identity Disorder who were accepted or rejected for sex reassignment surgery: A prospective follow-up study. Journal of the American Academy of Child & Adolescent Psychiatry. 40(4), 472-481.