Patient information from BMJ

Gender incongruence and gender dysphoria in adults

Last published:Aug 06, 2024

For some people, their internal sense of gender identity may not match their birth sex. This is known as gender incongruence. When this causes a person distress, it's known as gender dysphoria.

People with gender incongruence and gender dysphoria may take steps to live and be accepted as a person of their experienced gender. This is called gender transition.

Gender transition might involve medical or surgical treatment, but this varies and not every person will choose to have treatment.

This patient information will focus on gender incongruence and gender dysphoria in adults only.

Gender, gender identity, and birth sex

Gender is defined as the qualities and behaviours associated with being a man or a woman. This is based on how society sees males and females.

But gender identity is how you see yourself - as being a man, a woman, or neither (also known as non-binary or agender).

Your internal sense of gender identity may not be the same as the sex you were born into. For example, you might see yourself as a woman even though you were born with male sex organs. For some people, this can cause distress.

What is gender incongruence and gender dysphoria?

Gender incongruence is when your internal sense of gender identity does not match your birth sex. When you feel distress because of this, it’s known as gender dysphoria.

Transgender (trans) is a term that describes someone whose internal sense of gender identity is different from their birth sex. So a ‘transgender man’ is someone who was born female, but who identifies as a man. And a ‘transgender woman’ is someone who was born male, but who identifies as a woman.

There is a lot of debate about the terms gender incongruence and gender dysphoria and when it’s best to use them. That’s because there is no single term that can capture the experiences of all people whose internal sense of gender identity does not match their birth sex.

It’s important to know that gender identity and sexual orientation are completely separate; transgender people may identify as straight, gay, lesbian, bisexual, or none of these.

What causes gender incongruence and gender dysphoria?

It’s not clear what causes gender incongruence and gender dysphoria.

Gender identity is very complex; some research has suggested it may be linked to genetics and social factors. But much more research is still needed.

Studies have shown there may be a slightly higher chance of having gender incongruence and gender dysphoria in people with Kleinfelter syndrome (a condition where males are born with an extra X chromosome) and congenital adrenal hyperplasia (an inherited condition which affects how some hormones are made in the body).

Some research also suggests that people with gender incongruence and gender dysphoria are more likely to show features of autism.

What are the signs of gender incongruence and gender dysphoria?

The main sign of gender incongruence and gender dysphoria is that your internal sense of gender identity and birth sex don’t match. But for a doctor to agree, there are specific signs, or criteria, they need to look out for.

So, for a doctor to agree that you have gender incongruence, you need to be experiencing:

• a big and persistent difference between your internal sense of gender identity and your birth sex

• a desire to transition in order to live and be accepted as a person of your experienced gender through treatment (with hormones or surgery) or other health care services.

Your doctor will agree that you also have gender dysphoria if:

• you have been experiencing gender incongruence for more than 6 months

• you are feeling distressed and struggling in your work and social life because of your experiences.

Your doctor will have a discussion with you to understand your situation better. They may ask you, or your family and friends, what you were like as a child. For example, you may have role-played or had fantasies about being the other gender.

Your doctor will also ask about your experiences as an adult. If you were born male and have gender incongruence or gender dysphoria, you may be shaving your facial, body, or leg hair, and binding your genitals too. And if you were born female and have gender incongruence or gender dysphoria, you may be binding your breasts. You may also be wearing baggy shirts to hide your breasts, or speaking less because you may be unhappy with the pitch of your voice.

The most common sign in people born male who have gender incongruence or gender dysphoria is cross-dressing. This is when you wear the clothes of the other gender to feel like you are part of that group. You may also use a first name that is associated with that gender.

Although gender incongruence and gender dysphoria are not mental health disorders, transgender people may experience symptoms of worsening mental health. This is because they are at increased risk of:

• depression

• anxiety

• post-traumatic stress disorder

• suicidal thoughts

• substance-use disorder (addiction to drugs or alcohol).

Your doctor will discuss your mental health with you, alongside talking about your experiences.

Gender-affirming care

Treatment for gender incongruence and gender dysphoria varies and not every person will choose to have it.

But you may decide you do want gender-affirming care to help you transition so you can live as a person of your experienced gender all the time.

The two main treatments that can help people transition are hormone treatments and surgery.

It’s important to remember that gender-affirming care depends on the individual person. There is no ‘one size fits all’ approach. You can choose to have all, some, or none of the treatments available to you.

Some of these treatments involve major changes that cannot be reversed. So making the decisions that are right for you is extremely important.

There are also other treatments to consider such as hair removal, speech and language therapy, and supportive counselling.

If you are considering gender-affirming care, your doctor will explain all the options available to you and their side effects. They can also answer any questions you have.

For more information on these treatments, see our patient information titled: Gender-affirming care in adults: hormone treatment, and Gender-affirming care in adults: surgery.

What will happen?

Your decision about treatment is an important, personal choice. If you do choose to have gender-affirming care, you will have further support from a team of gender identity specialists. Waiting times for treatment can be long, usually because of high demand.

Transgender people may experience stigma and discrimination. This can affect mental health and make some personal and professional relationships difficult to deal with. If you would like to talk to other people about their experiences, there is a lot of support. For example, in the UK, transunite.co.uk - a directory of more than 100 local support groups - is available.

Your doctor might be able to put you in touch with a support group in your area, or you could search online.