Learning Objectives
By the end of this section, you will be able to:
- Discuss terminology from the APA DSM-5-TR relative to gender identity
- Describe stressors reported by clients due to gender dysphoria
- Outline issues involved in planning nursing care for client with gender dysphoria
- Identify nurses’ potential reactions to clients with gender dysphoria
Gender is a social construct and an individual experience (WHO, 2024b); people learn to act in accordance with the socially constructed expectations of their gender as they grow up. A person's sex is determined by a person's chromosomes, reproductive organs, and other characteristics; we typically determine sex by the genetic makeup of an individual as 46,XX (female) or 46,XY (male). The society in which an individual develops holds specific norms about roles, responsibilities, and behaviors to which individuals are expected to conform. These norms are based on the society’s beliefs about what male and female roles, responsibilities, and behaviors “should” be. A person's gender identity is their deeply held internal perception of their gender. Generally, “cisgender” individuals are those whose gender identity and often their roles and behaviors are congruent with their sex. Other people may identify as both male and female or neither male nor female; some believe that they are not in the right body. Some terms in current use include genderqueer or genderfluid, which fall under the broader term of “nonbinary” (Clark et al., 2018). Transgender is a broad term that can be used to describe people whose gender identity is different from the gender they were thought to be when they were born. A transgender woman is a person who was assigned male at birth but who identifies and/or lives as a woman; a transgender man was assigned female at birth but lives as a man. Some, but not all, transgender or nonbinary people may experience gender dysphoria, a distress or unease that can occur when one's gender identity does not match their sex assigned at birth. The DSM-5-TR defines the term as “a marked incongruence between one’s experienced/expressed gender and assigned gender” (APA, 2022, p. 511). More specifically, gender dysphoria is defined as a condition that must persist for at least six months and leads to significant dissatisfaction or discomfort.
In recent years, the subject of gender dysphoria has come to the forefront. There is greater awareness of children and early adolescents who persistently feel that they are in the “wrong body” (Testa et al., 2015). In a representative sample of high school students living in San Francisco, 3.4 percent reported either being sure they were Transgender or seriously questioning if they were (Johns et al., 2019). Many of these young people experience gender dysphoria and other mental health problems, including suicide attempts (Lowry et al., 2018).
Many parents of children who believe they were assigned the wrong sex at birth seek medical and psychological attention because of the extreme distress experienced by these children. Some children may express their disappointment and frustration associated with gender dysphoria at as young as four years of age; many display clinical depression and suicidal ideation and attempts (Olson et al., 2015). Medical response to this angst has resulted in the increased use of puberty blockers to help early adolescents and their families deal with these mental health issues. Puberty blockers are drugs (usually gonadotropin-releasing hormone agonists [GnRHa]) that are prescribed for those children when they reach Tanner stage 2. The purpose of these drugs is to stop the process of puberty temporarily, giving the child and family more time to determine the authenticity and determination of the child’s desire to transition to the other sex; this is one aspect of a phenomenon known as gender-affirming care (Edwards-Leeper et al., 2016).
The use of puberty blockers is part of the expert guidelines for children with gender dysphoria provided by the Endocrine Society in the United States (Hembree et al., 2017) and the World Professional Association for Transgender Health (Coleman et al., 2022). The use of these drugs is controversial because few longitudinal studies have been done to support the claim that they are reversible and cause no long-term consequences. These drugs have been shown to be safe in treating children with other endocrine disorders, such as precocious puberty (Lee et al., 2014). The limited studies completed to date provide some evidence that these hormones decrease lean body mass and height velocity; they are also credited, however, with providing hope and improved psychological functioning to gender-dysphoric youth (Rew et al., 2021).
The U.S. health-care system has been developed historically within the context of gender as a binary construct (Kilicaslan & Petrakis, 2019). That is, persons were assigned male at birth merely from the appearance of the external genitalia (penis and scrotum with or without descended testicles), or female from the appearance of the vulva and vaginal opening. These birth assignments have generally not been made from analysis of chromosomes that would confirm the male as 46,XY and the female as 46,XX. A cisnormative person has a gender identity that is congruent with their biological sex, or sex assigned at birth (Cicero & Wesp, 2017), whereas others may be identified as gender diverse (i.e., Transgender, Queer, Intersex, agender). Persons who do not identify as cisgender frequently experience health disparities related to stigma and discrimination related to their sexual identity and expression (Puckett et al., 2018).
Many persons who experience gender dysphoria engage in a process of transition from the sex assigned at birth to the sex they believe they are. These people may identify as Transgender or trans. Owing to a lack of understanding on the part of much of society, including those providing health-care services, they often experience a lack of appropriate services and, therefore, frequently avoid seeking routine health-care screenings and other services. The actual meaning of transition is highly individualized, meaning not all trans people take hormones or undergo cosmetic or gender-affirming surgery, especially when considering the cost of these services and lack of available providers.
It is expected that health-care providers will be responsive to the unique needs of Transgender individuals and develop gender-affirming care. WPATH, the World Professional Association for Transgender Health, “is an international, multidisciplinary professional association whose mission is to provide evidence-based care, education, research, public policy, and respect in transgender health” (Coleman, et al., 2022, p. S3). WPATH has published Standards of Care since 1979 to guide health-care professionals in providing safe care for gender-diverse individuals.
Life-Stage Context
Age-Related Matters of Transgender Behaviors
The age at which a child begins to experience the incongruence between assigned gender and preferred gender varies widely. One study indicated the onset of symptoms of gender dysphoria in children as young as four years of age (Olson et al., 2015). Children and adolescents with gender dysphoria exhibit a variety of psychosocial problems that may include illicit drug use, binge drinking, symptoms of depression, and suicidal ideation (Zou et al., 2018). Some of their behavioral problems are responses to perceived parental and/or sibling rejection (Schmitz & Tyler, 2018). The early adolescent, assigned female at birth, with gender dysphoria may bind the breasts during puberty hoping to appear more masculine. Similarly, the young person who was assigned male at birth, may bind the scrotum to appear more feminine. These behaviors emphasize the extreme discomfort the child with gender dysphoria has for their own body.
Gender Identity
Gender identity is a category of social identity that differs from sex (APA, 2022). It is one’s sense of self as being a male, female, or another gender, such as genderfluid or gender neutral. During childhood, children explore gender roles and may try on behaviors more commonly seen in the other sex. Feedback from parents, siblings, and peers helps to shape their sense of identity. In addition, the larger culture in terms of the location of their home, school, and religious affiliation provides enlarged areas in which to experience what it means to be male or female. During puberty, one’s identity is of central importance as the adolescent is in the developmental stage of deciding who they are. This decision process is complex and involves reflection on earlier stages of life and ongoing stages of exploration and experimentation. In emerging adulthood, one ultimately integrates the many possible selves into an identity that strongly influences one’s education, occupation, social relationships, and self as a mature sexual being (Harter, 2015).
It is important to make the distinction between sexual orientation and gender identity. The common acronym LGBTQIA+ refers to both sexual orientation and gender identity. The term queer may be used to describe either sexual orientation or gender identity; Q may also refer to questioning about one’s orientation, identity, or sexual expression (Cicero & Wesp, 2017).
Link to Learning
This link presents a video of several Transgender youth who clarify terminology and indicate that Transgender connotes a wide variety of identities.
The word dysphoria means to feel dissatisfied or very unhappy. For individuals who experience gender dysphoria, they may feel this dissatisfaction and unhappiness in at least three general ways: physical, social, and mental. In terms of the physical domain, people with gender dysphoria are generally unhappy with the sexual parts of their body. For example, a person who was assigned the sex of male at birth may feel very unhappy to have the external genitalia of a penis and scrotum. Some children who were assigned male at birth (AMAB) have even announced that they wanted to or actually tried to cut off their own penis. In terms of the social domain, people with gender dysphoria are generally unhappy or dissatisfied with how they are expected to act or dress. For example, the person AMAB may state that they want to wear dresses and not pants; they may also want to change their name from John to Johanna, for instance. In terms of the mental domain, people with gender dysphoria are generally quite certain that they are inhabiting the wrong body and cannot believe that the sex assigned to them at birth is truly accurate for who they really are.
Stressors Reported by Clients Owing to Gender Dysphoria
Children and adolescents who experience gender dysphoria may find schools to be hostile environments. Harassment, bullying, and discrimination are not uncommon, even in early childhood. As a result, many children, already feeling depressed and lonely because of their confusing gender identity, resort to using tobacco and alcohol. Most schools lack policies that would protect Transgender children and adolescents, which may lead to excessive absenteeism and victimization (Cicero & Wesp, 2017). It is important to note that gender diversity itself is not a psychiatric disorder or diagnosable illness. The child, adolescent, or adult who experiences gender dysphoria may also feel psychosocial distress that may manifest as symptoms of depression, anxiety, or eating disorders, however (Diemer et al., 2015).
The prevalence of gender dysphoria in the general population is relatively low, but the stress experienced by this underrepresented group is relatively enormous, sometimes even leading to and resulting in suicide. Suicidal ideation is particularly high in people of color who also experience discrimination related to their sexual orientation and gender identity (Sutter & Perrin, 2016). Insecurity, inferiority, irritability, shame, fear, loneliness, and hopelessness are among the stressful feelings associated with gender dysphoria (Testa et al., 2015).
Studies have shown that individuals who experience gender dysphoria not only experience heightened anxiety and suicidal ideation, but they experience ongoing concerns about gender-affirming health care (Edwards-Leeper et al., 2016; Reisner et al., 2015). For example, transmasculine individuals, those who are assigned female at birth, do not identify as female and may seek hormone therapy or gender-affirming surgery. In particular, those from racial and ethnic underrepresented populations face unique barriers to reproductive health-care services. They continue to be at high risk for STIs, HIV, and unplanned pregnancy (Agenor et al., 2022). Most health-care services that address gynecological care are provided under labels such as “women’s health,” but this term does not reflect the sensitivity needed to provide similar services to Transgender individuals who were assigned female at birth but identify as males. One participant in a qualitative study of transmasculine persons affirmed that just talking to the doctor “. . . about sexual health stuff always gave me violently bad dysphoria” (Agenor et al., 2022, p. 124).
In its Standards of Care, the World Professional Association for Transgender Health (WPATH) recommends that health-care professionals use the correct terms and language when interacting with gender-diverse individuals that reflect respect, uphold their dignity, and assure their safety. This international organization of multiple disciplines recognizes that persons who experience gender dysphoria or who are in transition from their natal sex (sex assigned at birth) to their expressed sex or gender experience stigma and discrimination, which often leads to health disparities. Many people who transition from their natal sex to their preferred gender do not receive adequate health care because they encounter numerous barriers, including discrimination (Puckett et al., 2018). As a result of such discrimination, many stop having regular health checkups, screening, and vaccinations.
Link to Learning
Watch this video about a trans male who explains gender dysphoria and describes the differences between physical, social, and mental dysphoria.
Nursing Interventions and Management
Political rhetoric in the United States has drawn attention to the experiences of Transgender children and early adolescents. The nation’s health objectives, known as Healthy People 2030, include an objective that is specific to improving “the health, safety, and well-being of lesbian, gay, bisexual, and transgender people” (U.S. Department of Human Services, n.d., para 1). As a result of these forces, researchers have begun to examine the preparation of nursing students in providing care to sexually and gender-diverse persons. To provide safe and culturally appropriate care for sexual minorities, nurses must first recognize and examine their own personal beliefs, biases, and assumptions about those who are different from themselves (Campinha-Bacote, 2007).
McCann and Sharek (2016) analyzed the findings from ten published papers and found that mental health services for Transgender individuals are often missing or inadequate. They recommended that “mental health nurses needed relevant knowledge and skills to be able to deliver culturally competent care that encourages resilience and empowerment in transgender clients” (p. 284). Moreover, they noted that nurses may require additional training about the process of Transgender transition, use of hormones, HIV prevention and care, and other aspects of gender-affirming care.
The American Nurses Association opposes restrictions on Transgender health and calls for nursing advocacy (ANA, 2022). Throughout nursing education and services, nurses are encouraged to be knowledgeable about their clients’ disease/illness processes and treatment. Nurses working with children and adolescents should listen to what they say about their gender, provide support, and refer to other health-care professionals who have more experience or comfort with this subject (Cicero & Wesp, 2017). Nurses should be knowledgeable about community resources that may be available for diverse clients and their families. Nurses should seek to learn from their peers who have different sexual orientations or gender identities from their own; such interactions provide essential social support to all nurses.
Clinical Safety and Procedures (QSEN)
Teamwork and Collaboration to Address Gender Dysphoria
Although there is a paucity of nursing literature addressing gender dysphoria, nurses have the potential to contribute to greater knowledge and understanding of this important area of health care. One of the hallmarks of Quality and Safety Education for Nurses (QSEN) is that of teamwork and collaboration. Nurses who can reach out to other health professionals and seek answers to questions of how best to address the health-care issues of these clients will be making an important contribution to the overall health of society. Interprofessional education that includes social workers, pharmacists, physical therapists, occupational therapists, as well as physicians and nurses should address the unique needs of clients with gender dysphoria. In particular, there is a great need to understand how this phenomenon affects young children and young adolescents. The political climate in some conservative states, however, currently threatens the expansion of knowledge and understanding in this area. Nurses can advocate for citizens in these states to consider the evidence of how treatments, such as using puberty blockers for young adolescents who might otherwise be suicidal, is a good, not immoral, thing to do. Similarly, nurses can advocate for all members of society to learn to accept others who are different from themselves and to bring an end to “hate speech” and discriminatory behavior.
As in all areas of sexual health, the PLISSIT and ExPLISSIT models of sexual communication can be an important component of planning excellent nursing care. Many clients have developed fears related to their sexual health that stem from adverse childhood experiences or from learning from well-meaning adults in their lives that sex and sexual matters are not subjects to be approached in polite company. Nonetheless, communication is essential in developing sexual health. Just giving another permission to talk about a matter that has been long forbidden is often a life-changing first step in managing a sexual health issue.
It’s also important to know one’s own limitations concerning sexual health information. If you don’t know the answer, be willing and ready to refer a client to someone who has more knowledge and experience in this important subject. If you are not certain about the information you are sharing with a client, do not give them misinformation. Be willing to explore professional literature in nursing, medicine, psychology, and sociology to find answers to your questions and those of your clients. Also be willing to start a conversation with a more experienced nurse, whom you trust, and who may have previous experience planning and providing care for persons with gender dysphoria.
Nurses’ Potential Reactions to Clients with Gender Dysphoria
Some nurses may feel conflicted and uncomfortable when assigned to care for a person with gender dysphoria. Religious upbringing, strong beliefs about sexuality, and what is “right” or “wrong” may have resulted in the nurse holding unexamined biases and stereotypes of persons who are “different.” When this is the case, it is important to share this discomfort with the person who has made the assignment so that the nurse can process the feelings and thoughts that come to the surface.
Some nurses may be going through a questioning process or may be in transition themselves. Awareness of one’s own sense of gender identity will influence how the nurse thinks about clients who experience gender dysphoria. Such awareness may enable the nurse to be an ally, offer support, and provide encouragement to the client. Having a safe and supportive group of friends and family will make such a journey healthy (Testa et al., 2015). When nurses are comfortable and secure in their own gender identity and feel confident that they can provide safe and sensitive care, they are then likely to treat the client experiencing gender dysphoria with respect and genuine caring.
Link to Learning
Franklin Covey created a self-assessment tool to help explain what is meant by bias and how it may affect one’s behavior as a professional nurse.