Gender Dysphoria 455
crete, behavioral manner than those for adolescents and adults. Many of the core criteria
draw on well-documented behavioral gender differences between typically developing
boys and girls. Young children are less likely than older children, ad olescents, and adults
to express extreme and persistent anatomic dysphoria. In adolescents and adults, incon-
gruence between experienced gender and somati c sex is a central feature of the diagnosis.
Factors related to distress and impairment al so vary with age. A very young child may
show signs of distress (e.g., intense crying) on ly when parents tell the child that he or she
is “really” not a member of the other gender but only “desires” to be. Distress may not be
manifest in social environments supportive of the child’s desire to live in the role of the
other gender and may emerge only if the desi re is interfered with. In adolescents and
adults, distress may manifest because of stro ng incongruence between experienced gender
and somatic sex. Such distress may, however, be mitigated by  supportive environments and
knowledge that biomedical treatments exist to reduce incongruence. Impairment (e.g.,
school refusal, development of  depression, anxiety, and substance abuse) may be a conse-
quence of gender dysphoria.
Gender dysphoria without a disorder of sex development. For clinic-referred children,
onset of cross-gender behaviors is usually betw een ages 2 and 4 years. This corresponds to
the developmental time period in which most  typically developing children begin ex-
pressing gendered behaviors and interests. For some preschool-age children, both perva-
sive cross-gender behaviors and the expressed desire to be the other gender may be
present, or, more rarely, labeling oneself as a member of the other gender may occur. In