458 Gender Dysphoria
ment or pressure to dress in attire associated  with their assigned sex. Also in adolescents
and adults, preoccupation with cross-gender w ishes often interferes with daily activities.
Relationship difficulties, including sexual relationship problems, are common, and func-
tioning at school or at work may be impa ired. Gender dysphoria, along with atypical
gender expression, is associated with high le vels of stigmatization , discrimination, and
victimization, leading to nega tive self-concept, increased ra tes of mental disorder comor-
bidity, school dropout, and economic marginalization, including unemployment, with at-
tendant social and mental health risks, especially in individuals from resource-poor family
backgrounds. In addition, these individuals’ access to health services and mental health
services may be impeded by structural barriers,  such as institutional discomfort or inex-
perience in working with this patient population.
Differential Diagnosis
Nonconformity to gender roles. Gender dysphoria should be distinguished from sim-
ple nonconformity to stereotypical gender role behavior by the strong desire to be of an-
other gender than the assigned one and by th e extent and pervasivene ss of gender-variant
activities and interests. The diagnosis is not meant to mere ly describe nonconformity to
stereotypical gender role behavior (e.g., “t omboyism” in girls, “girly-boy” behavior in
boys, occasional cross-dressing in adult men). Given the increased openness of atypical
gender expressions by individuals across the entire range of the transgender spectrum, it
is important that the clinical diagnosis be lim ited to those individuals whose distress and
impairment meet the specified criteria.
Transvestic disorder. Transvestic disorder occurs in he terosexual (or bisexual) adoles-