‘Gender dysphoria’: What it is, what it isn’t and how history has changed its view

A growing chorus of online voices claim that gender dysphoria — a condition of distress sometimes experienced by transgender people — is a mental illness or disorder.  

"Trans-anything where does it end? Let’s call it for what is…a serious mental illness," read one tweet shared hundreds of times. 

"Gender dysphoria is a mental illness and should be treated as such," read another.

Republican presidential primary candidate Vivek Ramaswamy echoed the sentiment during an April 30 interview on NBC’s "Meet the Press."

"I think that when a kid says that I’m born into the wrong body, that my gender doesn’t match my biological sex, more often than not that is a case of a mental health disorder," Ramaswamy said. "That doesn’t mean you disrespect that person. It means they are crying out for help."

Vivek Ramaswamy on NBC's Meet the Press on April 30, 2023

But experts say this is not correct: Being transgender and having gender dysphoria are not mental illnesses. Historically the diagnosis has carried the term "disorder," but experts no longer view it as a pathology and are working to destigmatize the diagnosis while continuing to ensure access to gender-affirming healthcare.

The American Psychiatric Association defines gender dysphoria as "psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity." 

Let’s break down what that means. Although most people don’t give their "M" or "F" much thought, medical experts and most major medical organizations agree that sex and gender are not the same thing. 

Sex (not the bedroom kind) is a biological category determined by physical features such as genes, hormones and genitalia. People are male, female or intersex, which means they were born with reproductive or sexual anatomy that doesn’t fit the typical definitions of male or female. 

Gender is different, experts say. Gender identity refers to someone’s internal sense of being a man, woman, something in-between or neither, and it can change over someone’s lifetime. 

For many people, their sex and gender are the same, but people who are transgender have a mismatch between the two. This incongruence can cause distress called gender dysphoria.

People experiencing gender dysphoria may feel uncomfortable with their bodies, specifically parts that signal biological sex. They may feel anxious when called by the wrong name or treated as a person of a gender that doesn’t match their identity. Some may feel their bodies have betrayed them and, in some cases, discomfort with their bodies can lead to self-harm or depression. 

Having gender dysphoria is not the same thing as being trans. It’s an "emotional response to being trans," said Michael Hendricks, a Washington, D.C.-based clinical psychologist focused on gender diversity. "Being trans is who you are." 

And all experts we talked to agreed: Being trans is not a mental illness or disorder. 

Not all trans or gender-diverse people experience gender dysphoria. For example, nonbinary people, whose gender identity is neither male or female, may not feel uncomfortable with their bodies. Or trans people who have medically transitioned may rarely feel dysphoria because they feel their sex characteristics are now in alignment with their gender. 

People can know who they are and feel their bodies do not reflect that without suffering extreme distress, explained Dr. Michelle Forcier, a professor of pediatrics at the Alpert School of Medicine at Brown University who specializes in sex, gender and reproductive health.

Cisgender people, whose gender aligns with societal expectations based on their sex assigned at birth, can experience feelings of gender dysphoria, too, said Dr. Alex Keuroghlian, director of the Massachusetts General Hospital Psychiatry Gender Identity Program. Cisgender men who develop breast tissue or cisgender women who have undergone mastectomies may experience feelings of dysphoria from their bodies not matching their gender identities. 

The distress of gender dysphoria can be treated by affirming a person’s gender identity through social support and sometimes medical or surgical treatment, experts say. 

On "Meet the Press," Ramaswamy said that the term "gender identity disorder" was clinically accepted language for many years in the U.S. 

"Gender dysphoria for most of our history all the way through the DSM-5 has been characterized as a mental health disorder," Ramaswamy said.

Gender dysphoria was called "gender identity disorder" until 2013, when the new Diagnostic and Statistical Manual of Mental Disorders, or DSM-5, was released. Prior to that it was called "transsexualism."

But Dr. Jack Drescher, a distinguished life fellow of the American Psychiatric Association and past president of the Group for Advancement of Psychiatry, said the DSM is less like a bible and more like a user’s manual.

"The DSM is a tool that grows and changes as our understanding in science changes," Forcier said. It reflects the social constructs and opinions of a particular time in history. Homosexuality was also in the DSM until 1973, when it was removed because of activism from the LGBTQ+ community. 

So, when preparing to switch from DSM-IV to DSM-5, its publisher, the American Psychiatric Association, reevaluated its definition of gender identity disorder. Drescher, who worked on the official revision of that section, recalled advocates’ requests to strike the diagnosis of gender identity disorder from the manual. 

Although gender dysphoria did not exactly fit the criteria of a mental disorder, removing it from the manual would jeopardize access to gender-affirming care because without a diagnostic code, most insurance plans wouldn’t cover it, and incarcerated trans people could be denied health care. "So, the challenge to our work group was how to reduce the stigma of having a diagnosis while maintaining access to care," said Drescher.

Part of the solution was switching the name to "gender dysphoria."

This change also made gender dysphoria a temporary condition that could be resolved with treatment, not a permanent diagnosis, said Hendricks. 

A similar change was made to the latest edition of the World Health Organization’s International Classification of Diseases. The WHO renamed the diagnosis "gender incongruence" and moved it from the chapter on mental health disorders to a new section titled "conditions related to sexual health."  

But the legacy and stigma of previous diagnostic terms persist. "I think it seeps into the culture within health care and medicine," Keuroghlian said. "There's a false subtext that trans and gender-diverse people inherently have pathology based on who they are." 

The line can also blur because the persistent distress of gender dysphoria can cause other mental health issues. 

"If you have masculinizing or feminizing body parts that aren't a part of your gender identity, psychically living in a body that doesn't reflect who you are or living in a body that's betrayed you can cause anxiety, depression and all these other things," Forcier said. 

Other research suggests that higher rates of mental health struggles among trans people can be attributed to the social stigma and discrimination they experience as a minority group. But Hendricks said these secondary mental health problems can sometimes be resolved when a person is able to get gender-affirming care. 

A few years ago, a new term emerged in the transgender health discourse — "rapid-onset gender dysphoria." Researcher Dr. Lisa Littman coined the term in a study that surveyed parents in online forums who reported their child had "a sudden or rapid onset of gender dysphoria." Littman recruited parents from online groups for parents concerned about gender-affirming care and "transgenderism."

The study did not survey the children experiencing gender dysphoria but instead relied on parental observation. PolitiFact contacted Littman but did not hear back.

Several experts told PolitiFact that rapid-onset gender dysphoria, sometimes referred to as ROGD, was not a medically recognized diagnosis and expressed concerns about the design and conclusions of Littman’s study. 

"It comes from parents commenting on what they perceive to be their child's experience, which may have nothing to do with their child's experience," said Forcier.

Recent research has challenged Littman’s hypothesis, finding that among a survey of 27,497 transgender participants, 40.8% realized their identities after age 10, and those who knew as children didn’t share that with anyone until they were 20 years old, on average. And the median time between realizing one’s identity and sharing it was 14 years.

Despite concerns, this term has gained traction among people concerned with expanding access to gender-affirming medical care, especially among youth.