Gender Identity Disorders: Concepts, Diagnosis, and Treatment

In international medicine, the old term "gender identity disorder" is gradually falling out of use. In the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnosis of "gender identity disorder" was replaced by "gender dysphoria." The emphasis shifted from "incorrect identity" to the actual distress and impairment that sometimes accompany a discrepancy between a person's gender identity and their assigned sex at birth. [1]

In the International Classification of Diseases, 11th revision (ICD-11), the World Health Organization introduced the concept of "gender incongruence." These conditions were moved from the section on mental disorders to a separate section on sexual health. It is emphasized that transgender or non-binary identity itself is not considered a mental illness; a medical diagnosis is needed to describe the persistent incongruence and associated needs for care. [2]

The modern approach is based on the distinction between identity and suffering. Many transgender and gender-diverse people do not experience significant distress specifically because of their identity, but difficulties are associated with discrimination, rejection, and legal and everyday obstacles. Diagnostic systems strive to preserve access to medical care for those who need it while simultaneously reducing stigma by rejecting the interpretation of identity itself as pathology. [3]

At the same time, various countries continue to use both old and new frameworks in parallel. A number of healthcare systems still use the ICD-10 with the F64 category "gender identity disorders," although professional communities are already focusing on the ICD-11 and the concept of gender incongruity. This creates confusion in terminology, but essentially we are talking about the same phenomenon: a persistent discrepancy between one's internal sense of gender and the sex assigned at birth, which in some people is accompanied by significant distress. [4]

It is important to separate medical categories from public discourse. Medical classifications describe conditions for which a person seeks help and requires support. They do not determine the moral value or "correctness" of a particular gender identity. For this reason, the new guidelines emphasize respect for patient self-determination, the need to avoid stigmatizing language, and reliance on evidence-based approaches in assessment and treatment. [5]

Table 1. Changes in terminology in modern classifications

System	Old term	New term	Key emphasis
DSM-IV	Gender Identity Disorder	Gender Dysphoria	Distress and impairment, not identity itself
DSM-5 and DSM-5-TR	There is no separate "identity disorder"	Gender Dysphoria	The criteria are tied to suffering and functioning
ICD-10	Gender identity disorders (F64)	There are no terms about inconsistency	Classification in the section on mental disorders
ICD-11	Gender incongruence	Gender incongruence	The condition has been moved to the sexual health section.
Professional Standards (WPATH SOC-8)	Different terms in older versions	Gender incongruence, gender dysphoria	Focus on access to support and stigma reduction [6]

How gender identity is formed

Gender identity is a stable internal sense of oneself as male, female, a combination of these categories, or non-binary. It is formed during childhood and adolescence under the influence of biological, psychological, and social factors. Contemporary research shows that for some people, the relationship between the biological sex assigned at birth and gender identity is inconsistent, and this is not simply a matter of upbringing or "fashion." [7]

In studies of populations self-reporting transgender or gender-diverse identities, the proportion of such individuals typically ranges from 0.5% to approximately 1.3%, depending on the country, age, and survey methodology. These figures are significantly higher than estimates from older clinical samples, which only included patients from specialized centers. The increase in numbers is attributed to greater openness, the ability to safely identify oneself, and the expansion of the categories themselves. [8]

Census data and large surveys confirm the existence of a significant group of people whose gender identity does not match their sex assigned at birth. In the 2021 Census of England and Wales, approximately 0.54% of the adult population reported that their current gender identity did not match their sex assigned at birth. Similar estimates are presented in national statistics for Australia, where approximately 1% of the population identifies as gender diverse. [9]

An age-related trend is observed: among adolescents and young adults, the proportion of those who identify as transgender, non-binary, or gender non-conforming is higher than among older generations. This is not attributed to a "spike in the disease," but to greater awareness, access to language for describing their feelings, and a relative increase in the social visibility of such people. A number of studies show that in many studies, girls and young women are more likely to report a non-binary or transmasculine identity, reflecting complex gender and cultural changes. [10]

Gender variance in itself does not constitute a mental disorder. Most people with non-binary or transgender identities do not require psychiatric treatment simply because of their identity. Help is needed for those who experience significant distress, social adaptation difficulties, depression, anxiety, or other mental disorders due to the incongruence between their gender and identity. This fundamentally distinguishes the modern approach from older notions of "gender identity disorders" as an automatic pathology. [11]

Table 2. Gender identity and gender nonconformity

Concept	What does it mean?	Is treatment necessary on its own?
Gender identity	Internal sense of one's gender (male, female, non-binary, and other options)	No, this is a characteristic of a person, not a diagnosis.
Gender variability	Lack of strict conformity to traditional roles and expectations	No, it's part of normal diversity.
Gender incongruity	Persistent discrepancy between sex assigned at birth and gender identity	Medical attention is only needed in cases of distress or requests for changes.
Gender dysphoria	Distress and impairment due to gender incongruity	Yes, this is subject to clinical assessment and support.
The old term "gender identity disorder"	General name in old classifications	Today it is considered outdated and stigmatizing [12]

Modern diagnostic categories

Gender dysphoria in the DSM-5 and DSM-5-TR describes a situation in which an individual experiences a marked incongruity between their experienced gender and their assigned sex at birth, as well as significant distress or impairment in social, occupational, or other important areas of life related to this incongruity. The diagnosis is based on a set of criteria that includes a persistent desire to live and be perceived as a different gender, a desire to change sexual characteristics, and a persistent feeling of alienation about certain aspects of one's body. [13]

The ICD-11 uses the term "gender incongruity" for adolescents and adults, as well as a separate category for children. The key criterion is a persistent, typically for at least two years, discrepancy between one's experienced gender and their assigned sex, often accompanied by a desire for medical and social transition. It explicitly states that gender-nonconforming behavior alone, without persistent internal discrepancy and distress, does not constitute grounds for diagnosis. [14]

It's important to understand that these diagnoses don't describe the "cause" of gender variability, but merely document the presence of clinically significant consequences—suffering and impairment—for which a person seeks help. This is why seeking an identity "cure"—that is, attempts to make a person feel comfortable in their assigned gender—is not considered ethical or effective by leading professional organizations. Guidelines emphasize reducing distress and supporting the individual in finding a comfortable path. [15]

The SOC-8 version of the international standards of care developed by the World Professional Association for Transgender Health (WPATH) offers detailed recommendations for the assessment and care of children, adolescents, and adults with gender dysphoria or gender incongruence. It focuses on an individualized assessment of needs, consideration of the patient's mental state, social context, risks, and expectations, and respect for their autonomy. Hormonal and surgical interventions, psychotherapy, and social support are addressed separately. [16]

At the same time, scientific and political debate surrounds certain types of care, particularly for adolescents. Decisions regarding access to puberty blockers and hormone therapy for minors are made according to different models in different countries, and regulatory bodies assess the balance of benefits and risks differently. Despite this, most professional associations emphasize that any interventions should be based on carefully considered individual assessment and informed consent, rather than on ideological principles. [17]

Table 3. Comparison of the DSM-5 and ICD-11 approaches

Characteristic	DSM-5 (gender dysphoria)	ICD-11 (gender incongruity)
Main focus	Distress and impairment of functioning	Persistent identity-gender inconsistency, need for help
Classification section	Chapter on Mental Disorders	Section on sexual health, outside the mental health section
Criteria for diagnosis	A set of symptoms plus marked distress or impairment	Persistence of non-compliance for at least approximately 2 years, desire for change
Attitude to identity	Identity is not considered a pathology, but distress is pathologized	Gender diversity is recognized as a normal variant, diagnosis is used to describe the clinical situation
Role in access to care	Justifies the need for psychotherapy, hormonal and surgical interventions	Used to organize health care and statistics, reducing stigma [18]

Prevalence and comorbidity of mental disorders

Estimates of the prevalence of gender dysphoria and gender incongruence vary significantly depending on the data analyzed. In clinical samples from adult-specialty centers, early studies reported an estimated prevalence of 0.005–0.01% of the population, which reflects only a small portion of the true diversity, as not all individuals seek medical transition. [19]

Modern population-based studies based on self-reporting show higher figures. In a number of countries, the proportion of people who describe their gender identity as different from the sex assigned at birth reaches approximately 0.5-1.3% of the adult population, and is even higher among young people. These figures do not indicate a similarly high prevalence of clinically significant dysphoria, but they reflect the extent of gender diversity in society. [20]

Numerous studies have documented an increase in the number of adolescents and young adults seeking help for gender dysphoria. In England, for example, between 2011 and 2021, the rate of diagnoses in primary care increased approximately 50-fold, particularly among adolescents assigned female at birth. Analysts attribute this to a combination of factors: increased visibility, reduced stigma, the development of specialized services, and improved data recording. [21]

People with gender dysphoria are more likely to have other mental health disorders. Reviews show a high prevalence of depression, anxiety disorders, post-traumatic stress disorder, eating disorders, and substance abuse. In some samples, comorbid mental health diagnoses are found in 60% or more of patients with gender dysphoria, especially in youth groups.

The increased burden of mental health problems is not explained by transgender or non-binary identity itself, but by the impact of so-called minority stress: discrimination, violence, family rejection, bullying at school, difficulties accessing health care, and legal procedures. Reviews of LGBTQ mental health emphasize that the risk of depression, anxiety, suicidal thoughts, and attempts is higher among gender minorities compared to their cisgender peers precisely because of these external stressors.

Table 4. Prevalence and comorbidity in gender dysphoria

Indicator	Research assessments	Comments
Self-report of transgender or gender diverse identity	Approximately 0.5-1.3% of the population in different studies	Depends on the country, age and survey methodology
Clinical diagnoses of gender dysphoria	From approximately 0.006 to 0.07% according to old clinical data	Only those who seek specialized help are taken into account
Proportion of people with identity and gender inconsistency according to censuses	About 0.5% of the adult population in some countries	Reflects those who have openly communicated their identity
The presence of at least one mental disorder in people with gender dysphoria	Often greater than 60% in clinical samples	Depression, anxiety disorders, post-traumatic stress disorder, eating disorders
Main explanatory factors	Minority stress, discrimination, violence, barriers to accessing care	Not the identity itself, but the social environment and the accompanying pressures

Clinical manifestations and typical difficulties

The clinical presentation of gender dysphoria and gender incongruence varies greatly. For some people, the primary problem is intense internal discomfort from the discrepancy between their body and their gender identity, even to the point of rejection of certain body parts associated with their gender. For others, social aspects take center stage: the inability to live and be recognized as their desired gender, fear of rejection, invisibility, or a constant sense of "role-playing" in everyday situations. [25]

In children and adolescents, manifestations change with age. In childhood, these may include persistent statements about belonging to the opposite sex, a preference for clothing and games associated with the other gender, and a rejection of the anatomical features of one's body. During adolescence, with the onset of puberty, the stress associated with the development of unwanted secondary sexual characteristics increases, and anxiety, depression, and self-injurious behavior often intensify. [26]

In adults, internal conflict is often compounded by difficulties in relationships, work, and family, related to revealing or concealing one's identity. Many describe a feeling of "living a double life": forced to conform to the expectations of others in one context and trying to be oneself in another. This can lead to chronic fatigue, social isolation, and increased mental health symptoms.

Comorbid disorders often form a distinct layer of problems. Depression manifests as persistent low mood, loss of interest in usual activities, sleep and appetite disturbances, while anxiety disorders are characterized by constant internal tension, panic attacks, and avoidance of social situations. Some people develop eating disorders, where control over their body and weight becomes a way to cope with feelings of inadequacy.

Research has focused on the increased risk of suicidal behavior. Adolescents and young adults with gender dysphoria are more likely to experience self-harm, suicidal thoughts, and suicide attempts than the general population. This risk is particularly high when gender dysphoria is combined with depression, anxiety, experiences of violence, and a lack of family support. However, a supportive environment and access to specialized care have been shown to significantly reduce the severity of these risks.

Table 5. Typical clinical manifestations of gender dysphoria

Group of manifestations	Examples	Possible consequences
Internal distress	Rejection of one's own sexual characteristics, a feeling of being "out of one's body"	Anxiety, depression, low self-esteem
Social difficulties	Fear of disclosure, conflicts in the family, at work, at school	Isolation, bullying, loss of support
Behavioral reactions	Avoiding mirrors, showers, intimate contact, and self-harm	Strengthening negative patterns, health risks
Comorbid disorders	Depression, anxiety disorders, eating disorders	Deterioration in quality of life, suicidal thoughts and attempts
Defensive strategies	Concealment of identity, “double life”, overcompensation	Chronic fatigue, burnout, increased stress

Diagnosis and differential diagnosis

Diagnosis of gender dysphoria and gender incongruence begins with a detailed clinical psychological interview. The specialist determines how long the individual has experienced incongruence between their sex and gender identity, how persistent these experiences are, and what specific forms of distress or dysfunction are present. It is important to distinguish stable identity from temporary, experimental forms of self-presentation, typical for some adolescents. [31]

A general mental health assessment is performed to identify depression, anxiety disorders, post-traumatic stress disorder, eating disorders, and substance abuse. Standardized questionnaires and clinical scales are used for this purpose. It is important to understand that the presence of other diagnoses does not negate gender dysphoria, but it does require careful care planning and consideration of the impact of all factors on quality of life.

During childhood and adolescence, the specialist pays special attention to the family system and school environment. Parenting style, the presence of support or violence, and parental awareness are analyzed. A separate task is to distinguish gender incongruity from other conditions, such as severe social anxiety, autism, attachment disorders, or severe depression, where the desire to "disappear" or "be different" may be disguised as a gender issue. [33]

Differential diagnosis involves comparison with a range of conditions that may superficially resemble gender dysphoria but have a different nature. These include body dysmorphic disorder, in which a person is morbidly fixated on perceived defects in appearance without regard to gender; transvestic fetishism, in which the dominant sexual arousal is from clothing and roles of the opposite gender; and psychotic disorders, in which ideas about body alteration may be part of a delusional system. Correctly distinguishing these conditions is crucial for choosing appropriate treatment. [34]

A separate issue is so-called "rapid-onset gender dysphoria" in adolescents, which has generated lively debate. Recent large-scale European studies have not supported the hypothesis that social media "causes" gender dysphoria in adolescents as some kind of mass psychogenic reaction. Rather, it is precisely thanks to access to information and communities that young people find a language to describe their feelings earlier and seek help. [35]

Table 6. Differential diagnosis of gender dysphoria

State	Key features	How is it different from gender dysphoria?
Gender dysphoria/gender incongruence	Persistent identity-gender inconsistency, distress, desire for role and body change	Focus on gender and role, not just appearance
Body dysmorphic disorder	Obsessive preoccupation with appearance defects not related to gender	There is no persistent desire to live in a different gender
Transvestic fetishism	Sexual arousal from clothing and roles of the opposite sex without a stable identity	The motive is sexual arousal, not a feeling of belonging to the opposite sex.
Psychotic disorders	Delusional beliefs about the body, voices, and "substitution"	Ideas change over time and are tied to a delusional system.
A temporary teenage experiment	Exploring roles, style, without persistent distress and required changes	Typically resolves or stabilizes without persistence of severe suffering [36]

Approaches to assistance and support

Modern care for people with gender dysphoria and gender incongruence is based on the principles of respect for self-determination, individual assessment, and evidence-based medicine. International standards of care (WPATH SOC-8) recommend beginning with a comprehensive assessment of the individual's mental and physical health, social circumstances, and expectations. The goal is to identify which specific changes (social, medical, and legal) will help reduce distress and improve quality of life. [37]

Psychotherapy is not viewed as a way to "change identity," but as a means of helping individuals understand their own experiences and cope with anxiety, depression, post-traumatic stress disorder, and family conflict. Cognitive behavioral and supportive approaches based on the minority stress model have been the most studied. They help reduce internalized stigma, learn to cope with discrimination, and build healthy relationships without imposing a predetermined outcome on a person regarding their gender. [38]

Medical interventions include hormonal therapy and surgical procedures to correct sexual characteristics, if desired and there are no contraindications. Guidelines emphasize the need for a thorough risk-benefit assessment, informed consent, and gradualism. For adolescents, the approach is particularly cautious: the possibility of reversible measures (such as puberty blockers) is discussed as a time for evaluation, and decisions on irreversible interventions are made only after a comprehensive assessment by a multidisciplinary team. [39]

Social support plays no less a role than medical support. Research shows that acceptance by family, schools, the medical system, and society as a whole is associated with significantly lower rates of depression, anxiety, and suicidal behavior. This includes basic respect for one's name and pronouns, protection from violence, access to safe education and employment, and the ability to undergo legal procedures to change one's documents without humiliation, if desired.

The ethical consensus of leading professional organizations is to reject so-called conversion practices aimed at "returning" a person to a cisgender or heterosexual identity. Such interventions have no proven effectiveness, are associated with high levels of harm, and are considered a violation of human rights. Instead, the emphasis is on a supportive, affirmative approach, where the professional's task is to work with the client to find the optimal path to reducing suffering and improving quality of life.

Table 7. Main areas of assistance for gender dysphoria

Level of assistance	Examples of interventions	Main objectives
Psychotherapy	Supportive, cognitive behavioral, trauma-focused therapy	Reducing distress, working with depression, anxiety, trauma
Medical assistance	Hormonal therapy, surgical interventions as indicated	Aligning body with identity, reducing suffering
Social support	Family acceptance, safe school and work environment	Reducing minority stress and preventing mental disorders
Legal support	Changing your name and gender marker on documents, protection from discrimination	Simplifying everyday life, reducing conflict and violence
Educational programs	Informing specialists, schools, and society	Reducing stigma and creating realistic perceptions of gender diversity

Social context, myths and ethical issues

Gender dysphoria and gender incongruence do not exist in a vacuum, but rather in a specific social and political context. In countries with more stringent restrictions on LGBTQ rights, transgender and non-binary people are more likely to hide their identity, come out later, and face higher levels of violence and discrimination. This directly impacts mental health, increasing depression, anxiety, and suicidal ideation. [43]

A common myth is the idea that gender dysphoria is a "fashion" or the result of social media influences. Historical accounts of gender non-conforming people long before the advent of the internet, as well as contemporary data on earlier coming out among young people in countries with better information accessibility, suggest the opposite: rather, technology provides an opportunity to find language and community rather than creating the phenomenon itself. European research does not support the hypothesis of "social contagion" as the primary factor in the increase in cases. [44]

Another myth is the notion that all people with gender dysphoria are "obliged" to undergo hormonal and surgical transition. In reality, the range of needs and solutions is much broader: from purely social changes (clothing, name, role) to a combination of hormonal and surgical interventions. The goal of medicine and psychology is not to impose a single scenario, but to help people weigh possible steps based on their goals, health, values, and risks. [45]

Ethical issues are particularly controversial in relation to children and adolescents. On the one hand, data on increased risks of depression and suicidal behavior in gender-diverse youth highlight the importance of early support. On the other hand, there is debate about when and under what conditions certain medical interventions are appropriate. A review of international guidelines shows that most professional bodies insist on thorough assessment, a multidisciplinary approach, and regular review of decisions as the adolescent matures.

Finally, it's important to remember that any classification is a tool, not a sentence. The existence of categories like "gender dysphoria" or "gender incongruity" in medical systems is necessary for organizing care, statistics, and research. For individuals themselves, what matters most is not the diagnosis, but access to respectful, competent, and safe support that allows them to live in harmony with their gender and minimize the suffering associated with external barriers. [47]

Table 8. Common myths about "gender identity disorders" and what the science says

Myth	What the data shows	Practical conclusion
"It's a new internet fad."	Historical sources and modern research confirm the existence of gender variability long before the internet; the rise in gender variability is attributed to visibility and the ability to safely talk about oneself.	It is important to distinguish openness and descriptive language from the alleged “emergence” of a phenomenon
"All trans people are mentally ill."	Increased rates of mental disorders are linked to minority stress and discrimination, not to identity itself.	The focus of assistance is to reduce external pressure and access support
"The diagnosis is made in a couple of visits."	Recommendations require a comprehensive assessment, taking into account the persistence of sensations, comorbidities and social context	High-quality diagnostics are always individual and multi-stage.
"Everyone needs surgery"	The range of solutions is very broad; some people limit themselves to social transition, others prioritize hormone therapy, and still others prefer minimal intervention.	It is important to proceed from the needs and informed choice of a particular person.
"Children just need to be talked out of it."	Conversion practices are ineffective and harmful, and support and respectful attitudes reduce the risks of depression and suicide.	Early acceptance and access to competent care are key protective factors [48]