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Gender Dysphoria & Its Association With Chronic Illness

Written by Leo Gorgatti, Edited by Olivia McCollum, Edited by Courtney Coleman

 

Gender dysphoria is defined as a form of psychological distress that may come with feelings of gender incongruence, often heightened during puberty as secondary sex characteristics begin to develop.₁ Gender incongruence is a marked and persistent conflict between an individual’s gender identity and assigned sex. It often produces a desire to transition (socially and/or medically) and be accepted as one’s experienced gender. Gender dysphoria most prominently affects transgender individuals, or people whose gender identity (an individual’s innate sense of their gender) differs from the one they were assigned at birth.₂ ₃ Based on data extracted from the Behavioral Risk Factor Surveillance Study (BRFSS), 0.5% of adults in the US identify as transgender.₄ In the past decade (2013-2023), reported gender dysphoria among young people has increased exponentially worldwide due to increased social acceptance and visibility of transgender individuals. This increase is a result of more widespread disclosure of gender dysphoria symptoms from transgender individuals to their healthcare providers and communities.₅ ₆ ₇ The 2017 Youth Risk Behavior Survey (YRBS) found that 1.8% of US high school students— across 10 states and 9 large urban areas— identified as transgender, while another 1.6% were unsure of their gender identity.₈


Gender dysphoria often highly impacts an individual’s mental health. It is also important to note that gender dysphoria— a psycho-emotional response to gender incongruence (a mismatch between one’s gender identity and assigned sex)— is exacerbated by discrimination, stigma, violence, and other adverse experiences.₉ Common mental health impacts of gender dysphoria include depression, suicidal ideation, anxiety, and overall low mood. Numerous studies show that gender-diverse individuals with high levels of gender incongruence are more likely to meet the diagnostic criteria for major depressive disorder.₁₀ Comorbidity studies in young people have shown that having gender dysphoria is associated with a higher likelihood of having a mental health disorder.₇ ₁₁ Another study analyzed medical data collected from the entire Swedish population over 10 years (2005-2015)— 2,679 of them having received a gender incongruence diagnosis. The analysis found that gender incongruence diagnosis was associated with a six times higher likelihood of having a mood/anxiety disorder, a three times higher likelihood of being prescribed antidepressants and antianxiety medications, and a six times higher likelihood of attempting suicide resulting in hospitalization (compared to the general population).₁₂


Some common physiological health impacts of gender dysphoria are activation of the hypothalamic-pituitary-adrenal axis, activation of the autonomic nervous system, and various pro-inflammatory responses.₁₃ ₁₄ Gender dysphoria may also increase stress, activating the central and peripheral nervous systems.₁₃ During chronic stress, the central nervous system is decoupled from the feedback loop that normally controls its activity, leading to chronic cortisol elevation.₁₂ ₁₅ Chronic cortisol elevation is additionally associated with abnormal development during childhood/adolescence, anxiety, anorexia, and sleep disturbances.₁₅ Chronic stress can cause the immune system to become dysregulated. Immune system dysregulation is attributed to the activation of cytokines and C-reactive proteins (CRP), working in combination to promote cardiovascular disease, growth suppression, hypogonadism, hypertension, and visceral fat accumulation.₁₆ ₁₇ ₁₈ Long-term, chronic stress may lead to osteoporosis, cardiovascular disease, obesity, and metabolic syndrome.₁₇ 


The standard treatment for gender dysphoria is gender-affirming care. The World Professional Association for Transgender Health (WPATH) Standards of Care Version 8 (2022) provides guidance on assessing gender dysphoria and determining eligibility for gender-affirming treatment. The guidance emphasizes that the assessor’s (psychologist, therapist, endocrinologist, surgeon, etc.) role in treating a patient presenting with gender dysphoria is not to determine their gender identity. The assessor is meant to identify the presence of gender dysphoria, assess any co-existing mental health concerns, offer information about gender-affirming treatments, support the patient in considering the risks/effects of the treatment/procedure, determine if the patient would likely benefit from the treatment/procedure, and verify if the patient is able to understand the treatment/procedure being offered.₁₉


The main forms of gender-affirming care include mental health care, hormone and surgical treatments, feminizing/masculinizing voice therapy, hair removal/transplant, and reproductive/sexual health care. Patients who would benefit from physically transitioning are linked to endocrinologists and mental health specialists to proceed with coordinated care. This ensures proper support of the patient’s psychosocial well-being and allows for individualized treatment that aligns with their corresponding gender identity.₁₉ 


Common medical interventions include puberty suppression, gender-affirming hormone therapy (GAHT), and gender-affirming surgeries. Puberty suppression is accomplished by gonadotropin-releasing hormone (GnRH) analogues. Adolescents experiencing gender dysphoria, but not yet undergoing GAHT, are recommended GnRH analogues to prevent/stall the development of secondary sex characteristics. Various circumstances may lead to the use of puberty suppression to treat gender dysphoria in place of or before GAHT. These include parental preferences, legislation/policies that restrict GAHT for adolescents, or the patient needing or wanting to further explore their gender identity with a mental health professional before deciding. For transfeminine people— those assigned male at birth who experience a feminine gender identity — estrogens, and sometimes progestins, are prescribed in feminizing hormone therapy. For transmasculine people — those assigned female at birth who experience a masculine gender identity — testosterone is prescribed as a masculinizing hormone therapy. Throughout these treatments, preliminary and ongoing monitoring are required to keep hormones at safe levels and ensure the patient is content with the physical and emotional developments induced by treatment.₁₉ Gender-affirming hormone therapy has been shown to reduce sexual distress, lower dysregulated cortisol levels to a normal range, alleviate distress/depression/anxiety, and improve quality of life.₂₀ ₂₁ ₂₂ ₂₃


There is a wide range of gender-affirming surgeries. Examples include genital reconstruction surgeries like vaginoplasty or phalloplasty and procedures such as voice feminization/masculinization surgeries. Again, each treatment is specific to the patient, and specific surgeries are recommended if they may alleviate a patient’s gender dysphoria. Multiple studies regarding gender-affirming mastectomy or breast reduction in transmasculine individuals have shown a consistent and direct increase in health-related quality of life, a significant decrease in gender dysphoria, and a consistent increase in satisfaction with body and appearance.₂₄₋₄₀ Studies regarding gender-affirming breast surgery in transfeminine individuals have shown consistent and direct improvement in patient satisfaction with body image.₃₉ ₄₁₋₄₄ Gender-affirming vaginoplasty, the construction of a vagina in transfeminine people, reported high levels of patient satisfaction and satisfaction with sexual function. It was also associated with a low incidence of patient regret.₃₈ ₃₉ ₄₂ ₄₅₋₆₇ In studies reporting post-gender-affirming facial surgeries, it was found that patients were very satisfied with their surgical results. Patients also reported being significantly more satisfied with the appearance of their faces than individuals who had not had gender-affirming facial surgery.₃₉ ₆₈₋₇₄


One of the main challenges in gender-affirming care today is inaccessibility/non-utilization of treatment. This is often caused by scarcity of trans-knowledgeable providers, untimely access, cost barriers, and previous stigmatizing experiences in healthcare. One of the main consequences of this challenge is the use of non-prescribed hormone therapy. Unregulated use of unprescribed hormone replacement can be dangerous because it can result in supratherapeutic doses and possibly unsafe injection practices; the latter holds a severe risk for exposure to blood-borne illness. Still, it is important to understand that the use of non-prescribed hormones is oftentimes a way to mitigate the burden of unmet gender-affirming medical needs. A harm-reduction lens may be required in addressing this medical challenge: people should not be expected to stop taking non-prescribed hormones if prescribed treatment isn’t made accessible to them. Two methods that have been used to improve accessibility to hormone therapy are decentralization of gender-affirming care in primary care settings and the establishment of telehealth services.₁₉


Gender dysphoria is a unique topic due to the hyper-politicization of transgender healthcare and the complicated history of classification and diagnosis. Though gender dysphoria is not a chronic illness itself, it can produce chronic illness, especially when left untreated. In the past decade, population trends have shown that reported gender dysphoria has increased substantially thanks to increased acceptance and visibility of transgender identities.₅₋₇ With more gender-diverse individuals seeking treatment for gender dysphoria, the need for advancement and expansion in gender-affirming care becomes all the more evident. With interdisciplinary gender-affirming interventions— mental health services, endocrinology, plastic surgery, fertility services, otolaryngology, etc.— the lives of individuals affected by gender dysphoria can be greatly improved. Still, to fully reinforce the health and well-being of gender dysphoric patients, policy, medicine, and society at large must continue progressing towards support for transgender individuals.₁₉

 

Works Cited

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This post is not a substitute for professional advice. If you believe that you may be experiencing a medical emergency, please contact your primary care physician, or go to the nearest Emergency Room. Results from ongoing research is constantly evolving. This post contains information that was last updated on March 14, 2024.

 

Leo Gorgatti is a fourth year majoring in molecular cell biology with an emphasis in biochemistry at UC Berkeley.


Olivia McCollum is a second-year MPH student at the University of Washington (UW) in the Department of Epidemiology and a student in the UW’s Department of Environmental and Occupational Health Graduate Certificate Program.


Courtney Coleman is a master's degree candidate in biology at Harvard and Co-President of Students vs Pandemics.

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