Gender Dysphoria and Gender Incongruence: An evolving inter-disciplinary field

The number of people with gender dysphoria and gender incongruence who seek assessment, support and treatment at gender identity clinic services has increased substantially over the years in Europe and North-America (Aitken et al., 2015; de Vries et al., 2015). There is also a significant increase in people who self-diagnose as having gender dysphoria and gender incongruence. Two recent population studies have aimed to estimate the prevalence of people who identify as such. Kuyper & Wijsen (2014) examined self-reported gender identity and dysphoria in a large Dutch population sample (N = 8064, aged 15–70 years old), and found that 4.6% of people assigned male at birth and 3.2% of people assigned female at birth reported an ‘ambivalent gender identity’ (defined as equal identification with other sex as with sex assigned at birth) and 1.1% of people assigned male at birth and 0.8% of people assigned female at birth reported an ‘incongruent gender identity’ (defined as stronger identification with other sex as with sex assigned at birth). Similarly, Van Caenegem et al. (2015) reported results based on two population-based surveys, one of 1,832 Flemish persons and one of 2,472 sexual minority individuals in Flanders, Belgium examining the prevalence of ‘gender ambivalence’ and ‘gender incongruence’. In the general population, gender ambivalence was present in 2.2% of male and 1.9% of female participants, whereas gender incongruence was found in 0.7% of men and 0.6% of women. In sexual minority individuals, the prevalence of gender ambivalence and gender incongruence was 1.8% and 0.9% in men and 4.1% and 2.1% in women, respectively.

The increase in prevalence of gender dysphoria and gender incongruence in the last decade is likely due to a number of interactively linked factors: the increased visibility of trans* people on television and in cinema, such as for instance Caitlyn Jenner, Transparent, and The Danish Girl. Their screening make trans* enter societal conscience as an increasingly mainstream phenomenon and is likely to contribute to at least a partial de-stigmatization of being trans*; the wide availability of information on the Internet and other communication channels about gender dysphoria and gender incongruence, which also likely contributes to de-stigmatization; the increased awareness of the availability of biomedical treatment (Coleman et al., 2012; Wylie et al., 2014); and the development of societal tolerance towards trans* individuals (FRA, 2014; Keuzenkamp & Kuyper, 2013). Moreover, as being trans* enters societal conscience more people will reflect on their assigned and experienced gender, and some may feel an incongruence and therefore possibly question their assigned cisgender status, which had previously always been taken for granted.

The percentages of people reporting ambivalence and incongruence with their gender identity in the aforementioned population studies are simply staggering. It also highlights the existence of people who explicitly identify as non-binary, that is, those people who identify and/or present in a way which is outside the gender dichotomy of man/woman. It remains unclear how many people will seek assessment and treatment at gender identity clinic services. Nevertheless, many trans* individuals require clinical services as they wish and decide to have cross-sex hormone treatment and surgery in hopes of alleviating their gender dysphoria and gender incongruence. Some people may feel that a certain treatment is necessary for them (Beek et al., 2015), whilst others do not feel the need to feminize or masculinize their body; for those changes in social gender role and expression can be sufficient to alleviate gender dysphoria and gender incongruence. Moreover, many trans* individuals may have socially transitioned with or without various treatment(s) through private means.

We should not underestimate the significance of the increase in prevalence of gender dysphoria and gender incongruence, which is likely to indicate the level of further future demand for clinical services. Governments, health insurance companies, national commissioning bodies of health services should work closely with gender identity clinic services, patient groups and other relevant stakeholders to ensure that adequate resources are allocated, that service planning is developed, and that training of high quality clinical and other staff is initiated. International Organizations, such as the World Professional Association of Transgender Health (WPATH) and the European Professional Association of Transgender Health (EPATH), TransGender Europe (TGEU), Global Action for Trans* Equality (GATE) and the like, could play a vital role in setting minimum standards of care within a legal equality framework at national and supra-national political level. They also have significant lobbying power. In many countries there are no services for trans* people, whilst in others gender identity clinic services have been chronically underfunded, with waiting lists for a first appointment and access to cross-sex hormone treatment and gender-related surgeries excessively long. Prompt access to care and treatment of seamless and interdisciplinary gender identity clinic services for people of all ages are a priority for many trans* people. Clinicians must treat trans* people like any other people; there is no justification to obstruct access to care for adolescent and adult trans* people (Bouman et al., 2014; Richards et al., 2015).

This special issue is dedicated to the 24th Biennial WPATH Symposium in Amsterdam, the Netherlands. In a series of twelve papers, this special issue entitled ‘Gender Dysphoria and Gender Incongruence’ highlights the broad spectrum of clinical and research topics within the evolving interdisciplinary field of transgender healthcare. We chose to focus on mental health across the life span, with relatively little attention to other treatment modalities within our field, including endocrinology and gender-related surgery.

In the first paper, Beek et al. discuss the changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) classification of gender identity-related conditions over time, and indicate how these changes were associated with the changes in conceptualization of gender dysphoria and gender incongruence. They conclude that examining the changes over time of a trans* diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association illustrate that what was once considered a mental disorder may be viewed as a normal variation of human nature. Thus, they cautiously predict that Gender Dysphoria and Gender Incongruence as a diagnosis may at some point be considered a mental health condition in the DSM (as are all diagnoses in this manual) but not in the next version of the International Classification of Diseases of the World Health Organization, which is expected to be published in 2017 (Drescher et al., 2012).

The following three papers by Ristori & Steensma, Leibowitz & De Vries, and Dierckx et al. discuss gender dysphoria and gender incongruence in children, adolescents and within families. The authors acknowledge the difficulties of defining best practice in their specific field regarding clinical interventions given a relative lack of available empirical data. For instance, at what age should one consider early medical intervention in children with gender dysphoria and gender incongruence? In this context, best practice guidelines are often based on expert opinion and consensus between experts, and tend to err on the side of caution, particularly regarding treatments with potentially irreversible consequences. However, some guidelines are debated both for being too liberal and for being too restrictive and paradoxically, increasing numbers of treatment teams around the world embrace early treatment and explore lowering age limits (Vrouenraets et al., 2015). Clearly, more systematic interdisciplinary and (worldwide) multicenter research is required in this area.

The next set of papers focuses on co-existing mental health issues in people with gender dysphoria and gender incongruence. In their review of mental health and gender dysphoria Dhejne et al. show that, although the levels of psychopathology and psychiatric disorders in trans* people attending clinical services at the time of assessment are higher than in the cisgender population, they do improve following gender-confirming medical intervention, in many cases reaching normative values. They emphasise the need for a more robust measurement tool for gender and body dysphoria. Marshall et al. systematically review non-suicidal self-injury (NSSI) and suicidality in trans* people and conclude that they are at a greater risk of NSSI behaviour and suicidality than the cisgender population, and discuss the need to develop effective preventative interventions. Van der Miesen et al. in their narrative review describe a frequent co-occurrence of Gender Dysphoria and Autism Spectrum Disorder, but also state that this co-occurrence does not necessarily preclude gender affirming treatment interventions. Jones et al. systematically review body dissatisfaction and disordered eating in trans* people and show that body dissatisfaction is core to the distress trans* people experience and that this dissatisfaction may increase the risk of disordered eating in some individuals. These four papers thus confirm the vulnerability to mental health problems of this population. Future research must concern itself with the prevention of mental health problems, which predominantly include anxiety, depression and self-harming behaviour. Research must move beyond the narrative that trans* people are a psychologically vulnerable group and focus on design and implementation of treatment programs, which tackle minority stress, discrimination and enhance legal protection and social support. Interventions aiming at improving the life of trans* people, by involving significant others, in order to increase support for this population needs to be developed and evaluated (Arcelus & Bouman, 2015).

In the ninth paper, Richards et al. eloquently reviews the limited literature regarding non-binary or genderqueer genders and consider ways in which (mental) health professionals may assist people who identify as such. The tenth paper, by Nieder et al., found that empirically, there is no link between sexual orientation and outcome of transition-related health care for trans* adults. They do recommend asking for sexual behaviours, attractions and identities, as well as for gender experiences and expressions, and stress that this knowledge should not drive, but simply inform the provision of comprehensive clinical care.

The penultimate paper by De Roo et al. discusses fertility options of trans* people. They expertly discuss the state-of-the-art techniques in the field of fertility preservation and strongly advocate patient’s choice after a process of ongoing explanation of all fertility preserving possible options. The authors rightly point out that many trans* people tend to start potentially irreversible treatments, including cross-sex hormone and surgery at a young age, when reproductive wishes are not yet clearly defined nor fulfilled. Many young trans* people in particular do not wish to defer treatment and often state that they will adopt, without being fully informed and aware of the implications of such a choice. Moreover, in many countries the preservation of fertility for trans* people is not funded. There is a significant risk of future regret of not having preserved one’s reproductive capacity. This pertinent issue must be addressed not only by clinicians in close collaboration with their patients, but also in a broader societal context.

Kreukels & Guillamon conclude this special issue with an exceptional and scholarly review of neuroimaging studies in people with gender incongruence. They describe studies into the etiology of feelings of gender incongruence, and studies that evaluate the effects of cross-sex hormone treatment on the brain. The growing body of research suggests evidence for the role of prenatal organization of the brain in the development of gender incongruence. Most importantly, their findings validate the feelings people with gender incongruence have and experience.

Declaration of interest

The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.