Living with Gender Dysphoria*

* Until recently the DSM addressed gender identity issues using the label “gender identity disorder.” However, the word “disorder” was seen as shaming and stigmatizing. To rectify this, the DSM-5 has removed the offending language, replacing it with the already commonly used and more easily accepted term, “gender dysphoria.”

Zach is a 37-year-old married father of three. He has been in recovery for alcohol and cocaine abuse for more than a decade, but he has never managed more than a few months of continuous sobriety. He recently completed substance abuse treatment at The Ranch, where for the first time ever he discussed and began dealing with his “core issue” of gender dysphoria.

Gender Identity Issues and AddictionI’d seen half a dozen outpatient therapists and been to multiple rehabs, but I’d never told anyone my deepest, darkest secret – that I feel more like a woman than a man. I’ve hated myself for my entire life because of the way I feel. For a while I thought I might be gay because I was sneaking around having sex with men, but that “diagnosis” never felt right. I figured that if I got married and had kids everything would be okay, but that didn’t fix things. Instead, it made me more miserable than ever. I was completely terrified that if anyone ever found out who I really am, then I’d lose my wife and kids and everything else I thought was important. Finally, during intake at the Ranch they posed some gender identity questions – the first time anyone ever asked me anything like that. My first instinct was to lie, but I knew that wouldn’t do me any good, so I gave up and told them the truth.

As Zach’s story illustrates, there is a great deal of confusion about gender dysphoria, not just among the general population but among the individuals who are actually dealing it and even among mental health clinicians (who are typically not trained  to assess and identify gender identity issues). Making matters worse is that a lot people seem to think that if a person doesn’t act on gender dysphoric feelings, then the individual does not have an issue and therefore the subject need not be discussed – even if it’s causing severe emotional distress. Unfortunately, when left buried inside someone gender dysphoria can be devastating, typically manifesting sideways with extremely negative results (addiction, social isolation, suicide attempts, etc.)

Gender Identity vs. Sexual Orientation

Some people think that being gay, lesbian, or bisexual is a gender identity issue. It is not. Most gay and bisexual men are perfectly happy being male, and most lesbian and bisexual women are equally content being female. Gender identity issues have little to do with sexual orientation. Instead, gender dysphoria is evidenced by a significant, longstanding level of discontent with one’s birth sex and/or the gender roles associated with that sex.

Some forms of gender dysphoria are relatively mild; others not so much. The spectrum is actually rather wide. For instance, certain men feel sexy or more confident when wearing women’s panties under their business attire. Other men are not emotionally comfortable unless they’re dressed like a woman and wearing makeup, even though they are just fine with their male genitalia. Still others say they are a woman trapped in a man’s body, and they won’t ever be happy unless their physical gender can be transformed to match their internal identity. This last category is commonly referred to as transgender or transsexual. Many transgendered people – it is difficult to know how many – actively seek gender reassignment surgery.

What Makes Me, Me?

Over the years, a wide variety of potential causes for gender dysphoria have been posited, though few hold water. The best research suggests these issues are mostly biological in nature. For instance, in male-to-female transsexuals gender identity issues have been linked to a gene that makes a person less sensitive to androgens (steroidal hormones that control the development and maintenance of male characteristics).[i] Other studies have found that in male-to-female transsexuals certain areas of the brain have a typically female structure, with the opposite holding true for female-to-male transsexuals.[ii] Some people believe that in addition to nature, nurture may also play a role – childhood trauma, molestation, nontraditional parental gender role modeling, and the like – but this concept is not supported by research.

Gender Dysphoria = Easy Route to Addiction

Most individuals who struggle with gender identity issues experience great personal distress. Usually this starts early in childhood, worsening during adolescence and early adult life. In part this discomfort arises because children are almost constantly exposed to cultural stereotypes regarding gender – blue for boys, pink for girls – and they are expected to conform to these societal norms. In other words, boys are supposed to roughhouse and play sports, girls are supposed to enjoy frilly dresses and make-believe tea parties. These norms are modeled (and enforced) not only at home, but at school, in the media, in churches and other social organizations, and just about everywhere else a child may travel.

Sadly, gender dysphoric children usually have few places to turn for support and insight, as society generally (and usually rather strongly) disapproves of gender-atypical behaviors. Even children whose “differences” are embraced and supported at home are likely to encounter serious resistance elsewhere. Their inability or unwillingness to conform to societal norms can and nearly always does create external strife and shaming, which can easily become internalized to the point of toxicity. Unsurprisingly, many if not most people with gender dysphoric issues are riddled with anger, fear, depression, anxiety, low self-esteem, and numerous other debilitating psychological conditions. They begin to feel as if there is something inherently wrong with who and what they are.

Sometimes these individuals turn to alcohol or drugs as a way to disinhibit themselves so they can engage in the behaviors/lifestyle they so desperately desire. Other times they drink or use to self-medicate the self-hatred they feel about what they are doing and/or who they truly are. Either way, they engage in addictive behaviors to escape the pain and discomfort that radiates endlessly from their toxic shame core. Over time, dissociating in this way can develop into an ongoing pattern (i.e., addiction) that is usually just as destructive as the underlying psychological issues.

What We Can Do to Help

A significant percentage of the men and women dealing with gender identity issues have never spoken about what they’re feeling. Instead, they have compartmentalized and secretly carried the pain and shame caused by their unacceptable (to them) desires. Because of this, Elements Behavioral Health treatment facilities routinely ask about and openly discuss gender related issues. We find at our addiction treatment centers that, if queried, about 1 in 10 clients reports some form of gender dysphoria. (At Elements, we use inclusive and welcoming language on our websites and in our ads, and this may raise the percentage of addicts we see who report gender related issues.)

When working with gender dysphoric clients, regardless of whether they are addicted, a primary part of the therapeutic process is helping them to accept what they are feeling and craving as a natural and satisfactory part of who they are. If you are not trained to do this or do not feel comfortable facilitating such a process, it is best to refer such clients to a fellow clinician who might better serve them. Most large cities have LGBT centers that can help with referrals. The American Association of Sexuality Educators, Counselors, and Therapists is another excellent resource.

When dealing with addicted gender dysphoric clients it is important to relate the client’s gender identity issues to the addiction. In other words, it is vital that these individuals fully understand that their gender-related issues, be they repressed or active, can and probably do fuel some if not most of their addictive behaviors. Once they understand that their gender-related guilt and toxic shame creates the emotional discomfort that drives their addiction, they can learn to recognize these feelings as a trigger and to implement healthier, non-addictive coping mechanisms.


He contributes regularly to, writing primarily about sex addiction, and The Huffington Post, writing primarily about the intersection of technology with sex and intimacy. He has developed clinical programs for The Ranch in Nunnelly, Tennessee, Promises Treatment Centers in Malibu, and the aforementioned Sexual Recovery Institute in Los Angeles. He has also provided clinical multi-addiction training and behavioral health program development for the US military and numerous other treatment centers throughout the United States, Europe, and Asia.


[i] G Heylens, G De Cuypere, K Zucker, C Schelfaut, E Elaut, H Vanden Bossche, E De Baere, and G T’Sjoen, “Gender Identity Disorder in Twins: A Review of the Case Report Literature,” The Journal of Sexual Medicine (2012) 8: 751–757.

[ii] Jiang-Ning Zhou, Michel A Hofman, Jouis JG Gooren, and Dick F Swaab, “A Sex Difference in the Human Brain and its Relation to Transsexuality,” (1995) Nature 378 (6552): 68–70.