Evidence
Alert

New research provides insights into the distress experienced by transgender adults

Transgender people have a mismatch between their sex assigned at birth and the gender they identify as. This can lead to sense of unease, dissatisfaction or distress (gender dysphoria) which can be intense. Social factors also cause negative feelings.

Treatment at gender clinics is only available to those who have gender dysphoria. How gender dysphoria is defined therefore has a direct impact on the care available to transgender people. The current definition is limited to internal distress. Expanding this definition to include distress as a result of difficult social experiences could allow gender clinics to support more people.

The first systematic review of adults with gender dysphoria confirms that many experience significant distress. The review explored the causes of distress and how different types of distress interact. It revealed a complex relationship between an individual's feelings about their body, their gender identity, how they express their gender, and how other people interact with them.

Not all transgender people experience gender dysphoria. But overall, transgender people need better support from the healthcare system and from society. Greater understanding and acceptance from others could improve their wellbeing.

What’s the issue?

Around 1% of UK adults are transgender but it is not known how many experience distress related to their gender identity.

How we define gender dysphoria is of great importance to transgender people. It has a huge impact on the healthcare they receive. In most countries, an individual must have an assessment of gender dysphoria before they can get treatment at a gender clinic.

Researchers wanted to review research featuring the viewpoints of people who experience gender dysphoria, rather than the perspective of clinicians.

What’s new?

This study is the first systematic review of research about transgender peoples’ experiences of gender dysphoria.

The researchers included 20 papers. These papers included more than 1600 transgender adults with any experience of negative emotions related to their gender identity. Most were conducted in Western Europe or the US and all were published between 2009 and 2019.

They analysed the data to reveal four key causes of distress:

  • the mismatch between gender identity and body led participants to have negative feelings such as unease, hatred and disgust towards their bodies
  • conflict between this mismatch and the expectations of society
  • the social consequences of gender identity, such as being isolated
  • personal reactions to rejection and transphobia.

Participants in the study described significant distress, including depression, anxiety, and suicidal thoughts.

The findings show the complex relationships between an individual's feelings about their body, their gender identity, gender expression, and how other people interact with them.

Why is this important?

The definition of gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) focusses on internal distress caused by differences between someone’s body and their gender identity.

But many of the experiences identified in this review go beyond this formal definition. Transgender people also experience confusion, denial, and fear of the future. They experience distress from their interactions with others and from society at large.

The researchers suggest that the DSM definition of gender dysphoria should include more causes and types of distress. This is especially important because the DSM definition is used to assess individuals for treatment.

The findings provide further evidence that transgender people need better support within the healthcare system and in society more broadly. More understanding and acceptance from outsiders would improve their wellbeing.

What’s next?

Future studies could compare:

  • the distress of transgender people living in more accepting cultures to those in less accepting cultures
  • the distress experienced by people who physically transition to those who do not
  • the experiences of individuals who identify as male or female (binary) to those who do not (non-binary).

The researchers would like to explore the experience of gender dysphoria in children and young people. This would reveal if and how their experiences differ from those of adults.

You may be interested to read

The full paper: Cooper K, and others. The phenomenology of gender dysphoria in adults: A systematic review and meta-synthesis. Clinical Psychology Review. 2020;80:101875

Funding

Kate Cooper is funded by an NIHR Clinical Doctoral Research Fellowship.

Commentaries

Study author

I was interested in how recently researchers had started asking transgender people directly about their experiences of gender dysphoria. I was also surprised that none of the papers set out to explore the experience of gender dysphoria.

Our study shows the complex relationships between an individual’s own experience of their body and gender. It reveals the interplay between these experiences and being a person who lives in a society with gender norms.

We need to find ways to reduce the stigma of people with different gender experiences to help reduce their distress. This needs to go alongside the support already offered in gender clinics.

Kate Cooper, Clinical Psychologist, University of Bath

Psychologist

A strength of the review is that it provides a comprehensive summary of research about the long-term outcomes of gender transitioning. This research challenges myths that have been used to attempt to limit access to gender affirming healthcare.

A question for future research is how providers like clinical psychologists, psychiatrists, and other medical specialists can move away from relying on pathology-based models of care for transgender people. How could novel models of healthcare better shape the experiences of transgender people?

Exciting possibilities exist when funders support research with input from transgender people. Research needs to focus on their own experiences of living through distress and on positive outcomes of care.

Gareth Treharne, Associate Professor of Psychology, University of Otago, New Zealand

Conflicts of Interest

None declared.