Previous article in this series: October 1, 2022, p. 13.

The diagnosis of gender dysphoria

Back to your co-worker. Does she really have feelings of being a boy though she was born a girl? As we will see in future articles, it is not the case that everyone who presents themselves as another gender does so because of genuine (clinical) gender dysphoria. There are other reasons. However, there is no doubt that feelings of gender dysphoria exist for some people. It does not help anyone, including the church, to attempt to deny this. It is important to note though, that these feelings exist on a continuum of lesser to greater. That is, different people who have these feelings, experience them more or less intensely and persistently. Furthermore, for the same individual the feelings can wax and wane at different times, and can even depart altogether. For now, as a description of the experience itself, and as a marker of the greater end of the continuum, the description DSM-5 gives of diagnosable gender dysphoria can be helpful. The manual distinguishes between children and adolescents/adults:

Gender dysphoria in adolescents and adults is a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two 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)

In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Gender dysphoria in children is a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

• A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
• In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
• A strong preference for cross-gender roles in makebelieve play or fantasy play
• A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
• A strong preference for playmates of the other gender
• In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
• A strong dislike of one’s sexual anatomy
• A strong desire for the physical sex characteristics that match one’s experienced gender.

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.1

Of course, determining who has “strong” feelings this way is quite subjective. And whenever something is a fad in society, what is already subjective plays victim to manipulation. Every time a boy plays with his sister’s dolls, he is not manifesting gender dysphoria. Often a child’s imaginative play showcases nothing more than his/her creativity and innocence. Teenagers too (especially under the influence of this age) feel and do and say many things. Some will question who they are for a time perhaps. Some will see that they do not particularly like all the things others of their gender enjoy. These realizations are not necessarily true gender dysphoria. The diagnosis “gender dysphoria” is supposed to be limited to those who feel intensely what is listed above and for whom these feelings persist and cause significant difficulty in all aspects of their lives.

An important comparison

The best way to think about gender dysphoria perhaps is to compare it to anorexia. There are perfectly healthy adolescent girls who look in the mirror and say, “I look so fat.”2 No one concludes from that, or even from the fact that two days later the girl will not eat desert, that the girl has anorexia. However, there is a small fraction of the population who feels fat even though they are skinny, and for whom this notion is persistent and destructive. They begin to starve themselves. That is anorexia. In a similar way, a small portion of people feel genuine persistent distress concerning their gender.

The estimated number for whom this is true is tiny. The DSM-5 manual estimates that it is between .005% and .014% of males, (that is, between 5/100ths of 1 percent and 1.4 tenths of 1 percent of males). For females it is between .002% and .003% of females (that is, between 2/100ths of one percent and 3/100ths of one percent of females).3 To be clear, this is not the amount of people who say they ever have had feelings of incongruence between their physical sex and how they perceive themselves. But, rather, this is the percentage of those with persistent and destructive feelings of incongruence between their sex and how they perceive themselves.

Despite this statistic, the number of people claiming clinical gender dysphoria has skyrocketed. In fact, the number of people claiming any aspect of the so-called LGBTQ+ spectrum has skyrocketed. A couple of decades ago the percentage of the population who claimed to be homosexual or bisexual or the like held steady at between 2-3%. A recent Gallup poll revealed that that number has jumped to 7.1% of the population.4 The majority of this 7.1% are from the youngest American generation. 5 Social contagion is a powerful thing. Regarding gender issues, this social influence apparently affects girls more than boys. In 2016, 46% of sex reassignment surgeries performed in the United States were performed upon women. In 2017, that number jumped to 70%.6 In Britain, the number of youth who claim gender dysphoria has increased 4,000% over a decade. Three-quarters of these are girls.7

A real issue for some

Despite the power of social influence behind these numbers, genuine gender dysphoria does exist for some. And even in many cases where clinical gender dysphoria should not be diagnosed, there are real feelings on the lesser end of the continuum. Another article will address possible explanations for true gender dysphoria. Maybe the co-worker did at one point (perhaps still does) have some feelings of being a boy though she is a girl. And it is important to know that true gender dysphoria is an immensely painful experience, just as anorexia is. As much as we would have compassion on someone who is suffering from the one, we ought to have compassion for someone suffering from the other. People have described gender dysphoria as always putting on layers of clothing when you are cold but never ever being able to get warm. Around 41% of people who affirm their gender dysphoria and identify as transgender will attempt suicide, compared to 4.6% of the general population.8 Certainly this indicates something of the pain, difficulty, and confusion being endured. Certainly, God’s people can and must sympathize deeply with this.

Yet, just as we may not deny the reality of the terribly difficult feelings, we must deny those feelings the right to determine the gender of a person. Feelings can be terribly strong, but they can change over time and under various influences. Feelings are not always mouthpieces for objective truth. And, as most Christians ought to know well, even more rarely are they indicative of God’s will.

1 DSM-5, 452-453.

2 Increasingly, at a younger age due to societal influence.

3 DSM-5, 454.

4 Jeffrey M. Jones, “LGBT Identification in U.S. Ticks Up to 7.1%,”, Gallup Inc, February 17, 2022 ( https://news.gallup.com/ poll/389792/lgbt-identification-ticks-up.aspx).

5 “The increase in LGBT identification in recent years largely reflects the higher prevalence of such identities among the youngest U.S. adults compared with the older generations they are replacing in the U.S. adult population.” J. Jones, “LGBT Identification.”

6 Referenced in Abigail Shrier, Irreversible Damage: The Transgender Craze Seducing Our Daughters (Washington D.C.: Regnery Publishing, 2021), 33.

7 Tony Grew, “Inquiry Into Surge in Gender Treatment Ordered by Penny Mordaunt,” Sunday Times, September 16, 2018 (https:// www.thetimes.co.uk/article/inquiry-into-surge-in-gender-treatment- ordered-by-penny-mordaunt-b2ftz9hfn).

8 Referenced in Ryan T. Anderson, When Harry Became Sally: Responding to the Transgender Moment (New York: Encounter Books, 2019), 93.