Gender dysphoria: what it is, symptoms, and diagnosis

Gender dysphoria is one of the most searched terms when it comes to transgender experiences. Yet, significant misunderstandings cluster around this expression: some confuse it with being transgender, some consider it a mental illness, some think all trans people suffer from it in the same way. In reality, gender dysphoria describes a specific experience — the distress linked to the discrepancy between one’s gender identity and the sex assigned at birth — and understanding it correctly is the first step toward approaching the topic with respect and awareness.

What “gender dysphoria” means

The term dysphoria derives from ancient Greek: dys (difficult, painful) and phoria (to bear, to endure). Literally, it indicates a condition difficult to bear, a deep malaise. In psychiatric terminology, dysphoria is the opposite of euphoria and describes a state of discomfort, dissatisfaction, or suffering.

The expression gender dysphoria was officially introduced in 2013 with the publication of the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) by the American Psychiatric Association [1]. It replaced the previous “gender identity disorder,” used in the DSM-IV, a terminological change that was far from cosmetic. The shift from the concept of “disorder” to “dysphoria” marked a first recognition that transgender identity is not in itself a pathology: the clinical problem is not the identity, but the distress that may accompany it [1].

In common language, the term is often used imprecisely to generically indicate the transgender condition. In clinical settings, however, it has a more specific meaning: it refers specifically to the clinically significant distress that some people experience due to the incongruence between the felt gender and the assigned gender. This distinction is fundamental, because not all transgender people experience dysphoria, and its intensity varies enormously from individual to individual.

How it manifests

Gender dysphoria does not take a single form. It expresses itself through a set of emotional, cognitive, and physical experiences that can vary in intensity, frequency, and modality depending on the person, age, and life context.

In adults and adolescents

In adults and adolescents, dysphoria can manifest as persistent discomfort with one’s primary or secondary sexual characteristics. For example, a trans woman may experience profound distress due to the presence of facial hair or a masculine body structure; a trans man may live in anguish over the presence of breasts or menstruation. This discomfort is not simple aesthetic dissatisfaction: it is the feeling that one’s body does not correspond to who one truly is.

Dysphoria also manifests in the social dimension: the suffering of being perceived, called, and treated as the wrong gender. Being called by a name that does not correspond to one’s identity, being referred to with pronouns one does not recognize, being assigned social roles incongruent with one’s gender — these are all experiences that can generate profound and constant distress [1][4].

On the emotional level, dysphoria can translate into anxiety, depression, dissociation from one’s body, difficulties in interpersonal relationships, and, in the most severe cases, suicidal ideation [7]. It is important to emphasize that this suffering is not caused by gender identity itself, but by the unresolved discrepancy between identity and body, and by the impact of social stigma.

In children

In children, gender dysphoria presents differently. A child may insistently express belonging to a gender different from the one assigned, prefer games, clothing, and playmates typically associated with the felt gender, reject their given name or assigned pronouns, and show discomfort with their own anatomical characteristics. These manifestations must be distinguished from the normal variability of childhood gender expression: gender dysphoria in children is characterized by the persistence, consistency, and intensity with which the child expresses their identity [1][4].

Intensity is not constant

An often overlooked aspect is that dysphoria is not a static experience. Its intensity can vary over time, go through phases of greater or lesser severity, be amplified by external factors such as social stress or discrimination, and diminish in contexts of acceptance and affirmation. Some people experience peaks of dysphoria at specific moments — adolescence, certain social situations, confrontation with their own body — and periods of relative well-being at other times.

Diagnostic criteria

The DSM-5-TR, in its most updated version from 2022, defines specific diagnostic criteria for gender dysphoria, distinct for adults and adolescents on one hand and for children on the other [1].

For adults and adolescents

The diagnosis requires a marked incongruence between the experienced or expressed gender and the gender assigned at birth, lasting at least six months, manifesting through at least two of the following aspects: incongruence between the experienced gender and primary or secondary sexual characteristics; desire to be rid of one’s sexual characteristics due to incongruence with the felt gender; desire to possess the sexual characteristics of the gender one identifies with; desire to belong to the felt gender; desire to be treated as a person of the felt gender; conviction of having the feelings and reactions typical of the gender one identifies with. Additionally, the condition must be associated with clinically significant distress or impairment of social, occupational, or other important areas of life [1].

For children

The criteria for children are formulated differently, taking into account developmental characteristics. They require a marked incongruence between the experienced or expressed gender and the assigned gender, lasting at least six months, manifesting through at least six criteria including: strong desire to belong to the other gender, preference for clothing of the other gender, preference for roles typically associated with the other gender in play, preference for playmates of the other gender, rejection of games and activities typically associated with the assigned gender, and aversion to one’s own sexual anatomy [1].

It is essential to understand that these criteria do not serve to “label” people, but to provide a framework that allows mental health professionals to identify who needs support and ensure access to appropriate care pathways.

Gender dysphoria and gender incongruence

Two terms that are often confused or used as synonyms, but which actually describe distinct concepts: gender dysphoria from the DSM-5 and gender incongruence from the ICD-11.

The DSM-5, published by the American Psychiatric Association, uses the term gender dysphoria and still places it within the classification of mental disorders, although with the clarification that it is not the transgender identity itself that constitutes a disorder, but the distress that may accompany it [1].

The ICD-11, adopted by the World Health Organization in 2019, took a further and conceptually different step [2]. The chosen term is gender incongruence, and its placement is in Chapter 17, dedicated to “Conditions related to sexual health,” outside the chapter on mental and behavioral disorders. The ICD-11 definition does not require the presence of distress or functional impairment as a necessary criterion: it simply describes the marked and persistent incongruence between the experienced gender and the assigned sex [2].

This is not merely a terminological difference. It is a paradigm shift. The DSM-5 focuses on distress (dysphoria) as the clinically relevant element. The ICD-11 recognizes the condition (incongruence) regardless of the presence of distress, implicitly affirming that a person can be transgender without necessarily suffering [2][3]. The WHO’s choice reflects decades of research demonstrating that the distress experienced by transgender people is largely the product of external factors — stigma, discrimination, lack of access to care — rather than an intrinsic characteristic of gender incongruence [3][7].

The maintenance of a diagnostic code in the ICD-11, despite the removal from the mental disorders section, has an important practical reason: without a recognized code, transgender people would risk losing access to health coverage for gender-affirming care [2].

It is not a mental illness

The history of the classification of transgender identities in psychiatric nosography is a story of progressive depathologization, similar to that of homosexuality, which was removed from the DSM in 1973.

Until 1980, the DSM did not contain a specific diagnosis for transgender identities. With the DSM-III, “gender identity disorder” was introduced, a formulation that explicitly placed transgender identity among mental pathologies. The DSM-IV maintained this approach. Only with the DSM-5 in 2013 did the shift to “gender dysphoria” mark a first conceptual change: the problem is not the identity, but the distress [1].

The most significant change came with the ICD-11 in 2019, when the WHO removed gender incongruence from the chapter on mental disorders [2][3]. This decision was motivated by solid scientific evidence: studies conducted in various countries demonstrated that gender incongruence, in itself, is not associated with psychological distress or functional impairment when the person lives in a welcoming context and has access to necessary care [3].

The distress that many transgender people experience is real and should not be minimized. But its origin lies largely in minority stress — the chronic stress arising from belonging to a stigmatized social group [7]. Discrimination, family rejection, social exclusion, verbal and physical violence, difficulties in accessing healthcare: these are the factors that fuel psychological distress, not gender identity itself [7][8]. A 2013 study on a sample of transgender Americans found a direct correlation between experiences of stigma and worsening mental health, confirming the central role of social context in the genesis of suffering [7].

Biological foundations

Research on the biological foundations of gender identity, and consequently of gender dysphoria, has made significant progress in recent decades. Although the mechanisms are not yet fully understood, the evidence points in a clear direction: gender identity has a significant biological component.

Twin studies have demonstrated that gender identity has a significant heritability index, with concordance for transgender identity much higher in monozygotic (identical) twins than in dizygotic (fraternal) twins. This suggests an important, though not exclusive, genetic component.

Neuroimaging research has revealed differences in brain structure. A 2021 mega-analytic study conducted by the ENIGMA Transgender Persons Working Group found that certain structural brain characteristics of transgender people fall in an intermediate position between those typical of the assigned sex and those of the felt gender, suggesting a neuroanatomical basis for gender identity [9].

More recent studies have explored the role of epigenetics — modifications in gene expression that do not alter the DNA sequence — finding significant associations between epigenetic patterns and gender incongruence [10]. These studies suggest that the interaction between genetic factors and prenatal environment (particularly hormonal exposure during fetal development) may contribute to the development of gender identity.

For a deeper exploration of this topic, see the article on the biological bases of gender identity.

How it is addressed

Gender dysphoria is not “cured” in the sense of eliminating the person’s gender identity. The pathways recognized by the international scientific community aim to alleviate distress by allowing the person to live consistently with their identity [4][6].

Social transition

Social transition is often the first step and consists of adopting the name, pronouns, clothing, and presentation consistent with the felt gender. It does not require medical interventions and can be, for some people, the only necessary step. Research shows that social transition, when supported by the family and social environment, is associated with significant improvement in psychological well-being [8].

Psychological support

Psychological support does not aim to modify gender identity, but to support the person in exploring their identity, managing dysphoria, and facing the social challenges related to transition. Mental health professionals also play a role in the diagnostic process and in guiding people toward appropriate care pathways [4][5].

Hormone therapy

Hormone therapy (testosterone for trans men, estrogens and anti-androgens for trans women) enables the development of secondary sexual characteristics consistent with the felt gender [6]. Studies demonstrate significant improvement in quality of life and a reduction in dysphoria in people who undertake hormone therapy [8]. For more details, see the hormone therapy guide.

Surgical procedures

Gender-affirming surgical procedures encompass a wide range of operations, from mastectomy to vaginoplasty, from phalloplasty to facial feminization surgery [4]. Not all trans people desire or need surgical procedures, and the choice is always individual. For more information, see the article on gender-affirming surgery.

Conversion therapies do not work

So-called conversion therapies, which aim to change a person’s gender identity to match the sex assigned at birth, are considered ineffective and harmful by all major scientific and health organizations [5]. The American Psychological Association has explicitly stated that such practices are associated with an increased risk of depression, anxiety, and suicide, and that transgender identities are normal variations of human experience that do not require any attempt at modification [5].

For a complete overview of available pathways, see the article on how to start transition.

Dysphoria is not the same for everyone

One of the most important aspects to understand is that the experience of gender dysphoria is not universal among transgender people, nor does it present uniformly.

Not all trans people experience dysphoria. Some transgender people describe their experience not in terms of suffering, but of gender euphoria: the joy and sense of completeness felt when they are recognized in the correct gender, when their body changes thanks to hormone therapy, when they can finally live authentically. Dysphoria and euphoria are not mutually exclusive: many people experience both at different times.

The experience is non-linear. Dysphoria can emerge strongly at certain periods of life and diminish at others. Some people report having experienced signs since childhood; others become aware of it only in adolescence or adulthood, sometimes after decades of distress not fully understood. There is no “right” age to recognize one’s gender identity.

Dysphoria is not only about the body. For some people, the main discomfort is related to physical characteristics; for others, it is the social dimension that weighs more — the way they are perceived, called, treated. Some people experience intense dysphoria related to specific body parts, while feeling less discomfort in other areas. This variability explains why gender-affirming pathways are so different from person to person.

The absence of dysphoria does not invalidate identity. A person who does not suffer intensely because of the discrepancy between felt gender and assigned gender is not “less trans” than someone who experiences debilitating dysphoria. Gender identity is not measured by suffering, and the ICD-11 recognized precisely this principle by choosing not to include distress among the necessary criteria for gender incongruence [2].

In Italy

In Italy, the pathway for people experiencing gender dysphoria involves access to specialized centers that offer assessment, psychological support, hormone therapy, and, when indicated, surgical procedures.

The Italian National Health Service (SSN) covers gender-affirming pathways, including hormone therapy and surgery, although actual access varies significantly from region to region. Waiting times can be long, and not all areas have specialized centers with adequate expertise.

The first step is generally to contact one’s general practitioner or directly contact one of the gender identity centers in the area. These centers offer a multidisciplinary pathway involving psychologists, psychiatrists, endocrinologists, and specialized surgeons. The diagnosis of gender dysphoria is made by mental health professionals with specific experience in gender identity, through an assessment process that respects the person’s timing and needs [4].

For detailed information about available centers and concrete steps to follow, see the articles on transgender centers in Italy and how to start transition.

The Italian reference law is Law 164 of 1982, which allows for the rectification of sex on civil registry documents. In recent years, case law has progressively recognized the possibility of obtaining legal gender recognition even without surgical procedures, a significant evolution in the landscape of transgender rights in Italy.

Gender dysphoria in children and adolescents

Gender dysphoria manifests differently depending on age. Understanding these differences is essential to avoid both underestimating real distress and pathologizing the normal variability of gender expression.

In prepubertal children

In younger children, gender dysphoria typically expresses itself through verbal statements (“I am a girl,” “I am a boy”), a marked and persistent preference for clothing, games, and playmates typically associated with the felt gender, and discomfort with one’s anatomy. It is essential to distinguish between gender non-conforming behavior and gender dysphoria: a child who plays with dolls or a girl who prefers games considered masculine does not necessarily have gender dysphoria. Dysphoria is characterized by the persistence, consistency, and insistence with which the child expresses an identity different from the one assigned [1][13].

A longitudinal study by Olson and colleagues, published in 2022, followed children who had undergone a social transition and found that 94% maintained their gender identity at five years [11]. This finding contradicts the narrative that gender dysphoria in children is almost always “just a phase.”

In adolescents

Adolescence often represents a critical moment for gender dysphoria. Puberty brings bodily changes that can intensify distress significantly: breast development, facial hair growth, voice changes, menstruation — each of these changes can become a source of intense suffering for an adolescent whose gender identity does not correspond to the assigned sex. Some adolescents describe puberty as a “betrayal” by their own body.

Not all adolescents who experience dysphoria have manifested it since childhood. Some people become aware of their gender incongruence only in adolescence, and this does not make their experience less valid. Gender identity can emerge with clarity at different moments in life.

When to seek help

The framework used by experts to assess gender incongruence in children is based on three criteria: persistent (the identification with a different gender lasts over time, it is not episodic), consistent (it manifests in different contexts — at home, at school, with friends), and insistent (the child expresses their identity with conviction and shows distress when it is not recognized) [11][13].

If a child or adolescent shows these signs, it is advisable to consult a mental health professional with experience in gender identity, not to “confirm” or “disprove” the dysphoria, but to offer a safe space for exploration and support.

For more on the topic of transgender children and adolescents, see the articles my child is trans: what to do and gender expression in children.

The increase in diagnoses

Over the past ten to fifteen years, the number of people seeking specialist services for gender incongruence has increased significantly worldwide. This is a real phenomenon and deserves to be understood in context, without alarmism or minimization.

The numbers

Globally, specialized clinics have recorded an increase in referrals, particularly among adolescents. In Italy, gender identity centers have observed a steady increase in visits in recent years. A change in the demographic profile of people presenting to services has also been noted: while in the past the majority were trans women (people assigned male at birth), today there is a growing number of trans men and non-binary people (people assigned female at birth) among adolescents [13].

Why the numbers are increasing

The increase in diagnoses does not necessarily mean there are “more trans people” than in the past. The most effective parallel is with left-handedness: when schools stopped forcing left-handed children to write with their right hand, the percentage of left-handed people in the population increased rapidly, then stabilized. There were not more left-handed people than before — people could simply finally be themselves.

Similarly, the increase in referrals to gender identity services most likely reflects a combination of factors: reduced stigma, greater awareness of the existence of transgender identities through information and media visibility, broader diagnostic criteria (the ICD-11, for example, has a wider definition than before), and greater accessibility of services [2].

The “social contagion” theory

Facing this increase, some voices have proposed the theory of “social contagion”: the idea that young people “become trans” through the influence of peers or social media. This hypothesis, often associated with the concept of ROGD (Rapid-Onset Gender Dysphoria) proposed by Littman in 2018, is not supported by scientific evidence [12]. The original study had significant methodological limitations — it was based exclusively on reports from parents recruited from websites openly critical of transgender people — and ROGD is not recognized as a diagnosis by either the DSM-5 or the ICD-11.

Subsequent studies conducted directly on transgender youth have found no evidence of “social contagion.” Gender identity is not something that is “caught”: it is a deep aspect of human experience, with documented biological foundations [9][10].

For an in-depth analysis of the social contagion theory and the evidence that disproves it, see the article on transgender social contagion.