Gender incongruence describes the internal experience of a mismatch between a person’s deeply felt sense of their own gender and the sex they were assigned at birth. This experience is not a mental illness. The World Health Organization (WHO) defines it as a marked and persistent incongruence between an individual’s experienced gender and their assigned sex, recognizing that a person’s internal sense of self is the authority on their gender.
Gender incongruence is distinct from gender expression, which is how a person outwardly presents their gender through clothing, behavior, or appearance. It is also separate from sexual orientation. It is estimated that about 1% of the population may experience some degree of gender incongruence, though determining the exact prevalence is difficult.
Differentiating from Gender Dysphoria
It is important to distinguish gender incongruence from gender dysphoria. While gender incongruence is the state of having a gender identity that does not align with the sex assigned at birth, gender dysphoria refers to the clinically significant distress that can arise from this incongruence, impacting an individual’s quality of life.
Not everyone who experiences gender incongruence will experience gender dysphoria, and the intensity of dysphoria can also vary significantly. The American Psychiatric Association’s diagnostic manual, the DSM-5, uses the term gender dysphoria and specifies that distress is a required component for diagnosis. This separates the identity itself from the distress that may accompany it.
The International Classification of Diseases, 11th Revision (ICD-11), used by the WHO, uses the term gender incongruence and does not require distress for its classification. This reflects a shift in understanding that being transgender is not in itself a disorder. The focus of the ICD-11 is on the incongruence itself, which may lead a person to seek medical transition.
Scientific Understanding of Development
The development of gender identity is a complex process with a strong biological basis, resulting from a combination of genetic, hormonal, and environmental factors. Research in this area is ongoing.
Prenatal hormone exposure is one area of scientific investigation. The theory suggests that the development of gender identity in the brain may be influenced by hormone levels, such as testosterone, during fetal development. Variations in this hormonal environment could lead to a gender identity that differs from the sex assigned at birth. This process is thought to occur separately from the development of physical sex characteristics.
Genetic factors are also considered to play a part. Studies involving twins suggest a genetic component, with higher rates of gender incongruence in identical twins compared to fraternal twins. This research suggests a complex interplay of multiple genetic influences rather than a single “gender gene.”
Neuroanatomical studies have provided insights, showing differences in the brain structure and function of transgender individuals compared to cisgender individuals. Some research has identified variations in brain areas that are sexually dimorphic, meaning they typically differ between males and females. These findings support the idea that gender identity has a biological basis.
The Diagnostic Process
The diagnostic process involves a comprehensive evaluation by a qualified healthcare professional, based on a thorough assessment of an individual’s persistent articulation of their gender identity. For adolescents and adults, the diagnosis is characterized by a marked and persistent incongruence between their experienced gender and assigned sex. This often leads to a desire to transition.
For a diagnosis of gender incongruence in childhood, the ICD-11 specifies a marked incongruence between the child’s experienced gender and their assigned sex, which has persisted for about two years. The criteria include a strong desire to be a different gender and a dislike of one’s sexual anatomy. It is noted that gender-variant behavior and preferences alone are not sufficient for a diagnosis.
Pathways to Gender Affirmation
For individuals who experience gender incongruence, there are various pathways to gender affirmation, which involve aligning their life and external presentation with their internal gender identity. These pathways are highly individualized, and a person may choose to pursue some, all, or none of these options based on their personal needs and goals.
Social affirmation is often one of the first steps and can include changing one’s name, pronouns, and gender expression. This might involve adopting a new hairstyle or changing one’s wardrobe to better reflect one’s gender identity. Using the correct pronouns is a significant part of social affirmation and can help a person feel respected and validated.
Medical affirmation encompasses a range of healthcare interventions. For adolescents, this can include puberty blockers to pause the development of secondary sex characteristics. Hormone therapy, using testosterone or estrogen, is another common form of medical affirmation. Gender-affirming surgeries are also an option for some, which can alter physical characteristics to be more congruent with one’s gender identity.
Legal affirmation involves changing one’s legal documents to reflect their gender identity. This can include updating one’s name and gender marker on identification such as a driver’s license, passport, and birth certificate. The process for legal affirmation varies by location and can be an important step for many in having their gender identity formally recognized by society.