The difference in diagnosing a delusion or deception is in discerning the distress.

The history and differential

Criteria: Gender Dysphoria in Adolescents and Adults 1

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least two or more of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)

• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)

• A strong desire for the primary and/or secondary sex characteristics of the other gender

• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)

• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)

• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Caveats

• The Gender Dysphoria diagnosis functions as a double-edged sword. It provides an avenue for treatment, making medical and surgical options available to TGNC people. However, it also has the potential to stigmatize TGNC people by categorizing them as mentally ill.

• The ultimate goal would be to categorize TGNC treatment under an endocrine/medical diagnosis.

• In the past, TGNC patients were disproportionally diagnosed with psychotic/mood disorders to explain their gender variance. Because of this, many in the community are understandably skeptical of mental health and psychiatric care.

• There are some genetic explanations for gender dysphoria, categorized in DSM–5 by using the diagnostic specifier “with a disorder of sex development.” Parents and physicians of these patients are typically aware of the genetic anomaly from birth, with treatment beginning in childhood.

Ruling out Psychiatric Illness

• It is common for TGNC people who have grown up in an unsupportive environment to express symptoms characteristic with personality disorders. Impulsivity, mood lability, and suicidal ideation occur commonly. This does not necessarily qualify them for a personality disorder diagnosis because personality disorders are typically lifelong and pervasive. TGNC people typically show a reduction or disappearance of these symptoms once they are in a supportive gender-affirming environment.

• There are no studies indicating that psychiatric illness causes gender dysphoria as a consistent condition over time, although delusions or unstable personality characteristics may manifest as intermittent thoughts or feeling of gender incongruity. Additionally, TGNC people can have other psychiatric disorders (e.g., psychotic, bipolar, depressive, substance use disorders) just as anyone else that is not related to their gender variance.

• Gender dysphoric symptoms may be the primary focus of treatment, but don’t overlook the possibility that other psychiatric symptoms may need to be treated first depending on severity.

• TGNC people can have psychiatric symptoms of psychotic, anxiety, and mood disorders just like any other part of the population.

References

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing

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