Unpacking the Complexity of Gender Dysphoria in Young Adults Age 18-25!
Due to the increase in gender discussions today and gender vernacular, more young adults are engaging in self-exploration of their gender identity and what it means for them.
This is a great opportunity for many to explore, define, and potentially modify their gender early on vs. living in pain and suffering.
The truth is, not every young adult seeking self-exploration concludes their gender identity is other than the gender assigned at birth. Those who do come to such self-discoveries may or may not engage in gender transition.
The quest is personal and highly individualistic. The path to self-discovery can be straight from what one always knew about themselves to affirmation, to a zigzagging as one unfolds multilayers of gender dysphoria and its complexities.
Given the deep complexities of gender dysphoria and the formation of gender identity, this blog post aims to help readers understand the most important signposts on the path to their self-exploration and gender identity.
Gender Dysphoria describes psychological distress resulting from an incongruence between one’s gender assigned at birth and one’s gender identity. The current DSM-5-TR criteria for gender dysphoria outlines six areas of distress. To meet the diagnosis criteria, a person must experience distress for at least six months and meet two of the six listed criteria.
Many young adults experience gender dysphoria distress early in childhood, while others report experiencing distress pre or post-puberty, and some later in young adulthood.
The idea that gender dysphoria onset must begin at an early age of 3 or 4 is no longer held true as clinicians today understand and witness variability in the age of onset across developmental ages.
The psychological distress stemming from gender dysphoria leads to common symptoms of depression, anxiety, isolation, dissociation, body dysmorphia, and suicidal ideation to name a few.
With symptoms overlapping, it becomes challenging to properly diagnose gender dysphoria, as many symptoms may cover up the root issue. The reverse is also true, what may appear as gender dysphoria is masking a deeper issue(s) that are not being addressed.
For this reason, diagnosing gender dysphoria can be as easy as a single psychological assessment and as complex as a series of ongoing therapy. The goal here is to listen to the patient and to exercise one’s clinical discernment in asking the right questions to help the patient navigate the inner exploration of the Self.
Gender identity is one’s subjective sense of the Self. American Psychological Association Dictionary of Psychology defines the Self as:
the totality of the individual, consisting of all characteristic attributes, conscious and unconscious, mental and physical
If one were to view the Self as a pizza representing one’s personal identity, gender identity would represent a slice of that pie. Thus it is important to note that the Self is composed of various aspects of oneself, gender being one part.
While gender identity is a part of the whole Self, it carries more weight in contrast to the other parts of the Self.
That’s because gender identity is felt internally as one’s relationship to the Self, subject to subject, and externally, how the Self is perceived by others, subject to object. Living in a world where our bodies, behaviors, interests, dress style, and even our patterns of speech are being gendered puts more emphasis on gender identity as a whole.
This is why individuals who struggle with gender dysphoria may also struggle in other areas of their Self-identity, as many facets of who they are being affected by the distress caused by the dysphoria.
Experiencing gender dysphoria and its various manifestations is painful. The most painful part about dysphoria is its unpredictable nature - one day it centers around a particular body part, and the other day it shifts its focus to social interaction. There are many reasons why dysphoria shifts and often lacks in pattern and I have covered the top three reasons in the blog post 3 Reasons Why Gender Dysphoria Shifts Throughout the Body.
As mentioned, gender dysphoria varies in onset: childhood, pre and post-puberty, young adulthood, etc. It further varies in regard to the initial manifestation of distress, often manifesting in three main ways:
Physical: physical distress is felt and experienced as an internal sense of misalignment with one’s secondary sex characteristics and one’s experienced gender identity. Looking at the DSM-5-TR criteria, categories 1-4 demonstrate elements of physical distress.
I refer to physical as experiencing distress primarily concerning secondary sex characteristics or body anatomy.
Social: gender dysphoria distress arises out of experiencing inner incongruence with one’s gender assigned at birth due to the ways one internally experiences their gender identity and the way social environment genders the individual. Social distress is felt and experienced as an internal sense of misalignment with one’s gender identity and how others gender one’s body, gender expression, and gender role. DSM-5-TR criteria express social distress in categories 1, 4, 5, and 6.
I am referring to social as experiencing distress concerning the binary impositions of the world and culture concerning one’s gender identity.
Physical and social: it is inevitable for individuals to experience both a physical and social manifestation of gender dysphoria simultaneously. It is common for individuals who start with physical distress to develop social distress. Vice versa, it is common to start with social distress leading to physical distress.
This is due to experiencing the Self from subject to subject and subject to object, often on an ongoing basis. One cannot divorce the Self from the interactions of the social world. In the DSM-5-TR, the overlap of physical and social is seen in categories 1 and 4.
The manifestations of gender dysphoria further vary in intensity and can range from mild to very severe and can drastically affect one's quality of life. I have written The Most Dangerous Way in Which Gender Dysphoria Affects Your Life! which I highly recommend reading to have a full understanding how dysphoria impacts daily living.
To gain a clear understanding of one’s gender identity, it is important to understand the differences between gender role vs. gender expression vs. gender identity.
Gender identity is your internal sense of who you are in relation to your gender. People develop this internal sense and physical, psychological, and social experiences throughout their lifetime.
For many, their internal sense of gender is aligned with their gender assigned at birth. For others, the incongruence may be felt as early as three or further into their development as young adults. Gender identity may be stable or fixed throughout one's lifespan or fluid and interchangeable.
Gender expression or presentation is a way one prefers to show up in the world in relation to their gender identity or in relation to how they see their gender expression.
For example, a person can identify as a male and have their gender expression correspond to the socially perceived expressions of male identities, such as masculine appearance in clothing and style being one of them.
On the other hand, a person can identify as male and have their gender expression correspond to what is socially perceived as female expression while feeling a stable sense of male identity.
Seen from this view, one’s gender expression does not necessarily has to conform to one’s core gender identity, nor does it have to conform to one's gender role.
A gender role, on the other hand, is a social role of behaviors, attitudes, characteristics, and other qualifiers currently considered socially acceptable or appropriate based on the dichotomy of sexes, male and female. As such, they are seen and defined as masculine or feminine.
For example, a person can identify as a transgender woman and express masculine gender roles while feeling congruent and comfortable with her trans feminine core identity.
On the other hand, a person can identify as a trans man and express a masculine gender role socially considered to correspond to their gender identity.
Similarly to gender expression, gender role does not have to conform to one’s core gender identity or one's gender expression.
It is important to note that many people express variability across gender identity, gender role, and gender expression. The variability may remain stable for some and is mutable for many others.
Consider the following internal and external presentations of the Self regarding gender:
Gender identity male, presentation female, gender role masculine and feminine.
Gender identity trans masculine, presentation masculine, gender role feminine.
Gender identity nonbinary, presentation feminine, gender role masculine.
Because there is so much overlap between gender identity, gender role, and gender expression, it can be challenging to sort out where gender dysphoria distress is coming from. Most importantly as will be discussed later, not every distress a straight line to transgender, nonbinary, or other forms of gender identity other than one assigned at birth.
Developmental history, which accounts for how one grew up, developed, and adapted to life stages, is essential to gender dysphoria assessment. The history of one's socialization, environment, and culture is also integral to developmental history.
When a person demonstrates a persistent physical incongruence with the gender assigned at birth and their gender across the lifespan and across social domains (i.e. at school, at home, with friends, with family) the pattern of suffering is hard to ignore.
Equally, when a person demonstrates social distress stemming from a lack of understanding of what gender identity, gender role, and gender expressions are and the ways they can coexist in various presentations, combined with the prohibitive environment to explore, may lead to the development of gender dysphoria that has little if nothing to do with the core gender identity.
For these reasons, assessment of developmental history helps anchor individuals understanding of their current relationship to their gender assigned at birth and their gender identity.
Similarly, assessing the history of past and present dual diagnoses helps rule out which of the issues are comorbid diagnoses existing alongside gender dysphoria vs. symptoms stemming directly from gender dysphoria masquerading as stand-alone diagnoses vs. symptoms that appear as gender dysphoria but mask a deeper root cause not being addressed.
A comprehensive psychological assessment aimed at developmental history and history of potential past and present comorbid diagnoses, together with an explanation and discussion with the patient, opens a dialogue for the Self to self-explore one's relationship to their gender identity.
Such self-explorations are crucial for young adults seeking to understand the evolution of their gender identity, enabling a sense of autonomy, ownership, and assertive decision-making when considering medical and surgical gender transition.
Gender identity formation is a natural byproduct of mind-body reconciliation via biological, psychological, and social influences and the context one lives in. When one cannot reconcile their mind and body, they experience psychological distress, known as gender dysphoria.
Experiencing gender dysphoria and meeting the diagnostic criteria outlined in the DSM-5-TR does not imply a person is transgender, nonbinary, or has other gender identities. All it demonstrates is that the person is struggling with gender dysphoria.
The distress is a sign to explore parts of the Self that appear or feel incongruent with the gender assigned at birth. The self-exploration leads an individual to discover their core gender identity, whether cisgender, transgender, nonbinary, agender or any other gender identity present today.
Gender transition is essential to gender-affirming care and is lifesaving for many individuals.
Gender transition can encompass anything from social integration and social presentation to legal transition, changing the name and sex marker, to medical and surgical transition aimed at helping modify secondary sex characteristics to align a person with their gender identity.
Those who feel ready for gender transition may encounter numerous fears on the way. Our fears often fall into two categories: internal fears and external ones and you can learn more about them here Afraid to Transition? What Your Fear Might be Telling You!
Many young adults struggling with gender dysphoria enter a consent-informed decision-making process to start the medical transition through hormones and begin the surgical transition to align their bodies with their gender. Examples of factors leading to begin medical and surgical transition are:
to align secondary sex characteristics with their gender identity
to decrease or eliminate psychological distress of gender dysphoria
to achieve congruency
to reconcile mind-body dissonance
Alternatively, many young adults with gender dysphoria decide not to start the medical or surgical transition. Examples of factors leading to abstaining from the medical and surgical transition are:
to avoid potential health side effects of hormone therapy
to avoid potential surgical risks and complications
medical and surgical transition is not in alignment with their goals
they were able to achieve the congruency and/or alignment they sought via modifying their gender presentation and gender role
It is crucial to point out that deciding which elements of gender transition to engage with are highly person-specific and person-centric based on individual needs and goals. Above all, it is important to understand all the pros and cons of gender transition and be grounded in the understanding that, as I have written in 2 Big Reasons Why Transition is Not a Magic Pill! gender transition won’t nor can solve all of your problems.
Gender therapy is a wonderful resource and an opportunity to self-explore one's relationship to their gender identity.
Therapy alone can and does help with gender dysphoria. However, over 17 years of working with transgender and non-binary adults, I have found limitations in how therapy alone can treat gender dysphoria in young adults.
For young adults who exhibit a history of gender dysphoria and demonstrate ongoing persistent gender dysphoria, therapy can aid in confirmation that what they have been struggling with is Gender Dysphoria and further assist with exploring what that means for their gender identity and any decision-making related to transition.
For young adults who exhibit symptoms of gender dysphoria with past or present comorbidity, gender therapy can aid in self-exploration leading to ruling out any diagnosis that may mask a deeper root issue that appears as gender dysphoria.
For young adults who do not exhibit signs of physical dysphoria and express social dysphoria, gender therapy can aid in the self-exploration of ways to alleviate their distress by modifying their gender presentation or gender role.
As such, gender therapy aims at helping young adults gain an inner subjective understanding of the Self in relationship to their gender. If such understanding leads to deciding to undergo medical or surgical transition, gender therapy can help facilitate discussion and aid in decision-making.
Therapy, however, while beneficial, is not capable of fully treating persistent gender dysphoria as such treatment is often highly dependent on modifying secondary sex characteristics via hormones or surgery, something therapy is not capable of providing. Therapy is often the first affirming step anyone can take and as we know, affirming steps are crucial to one’s well-being and confident as described in 3 Main Reasons Affirming Steps are Important to Your Transition.
For this reason, access to gender-affirming care is a medical necessity for many individuals and is not subject to debate.