Prepubertal natal boys with gender dysphoria may express the wish to be a girl or as- sert they are a girl or that they will grow up to be a woman. They have a preference for (e.g., using towels, aprons, and scarves for long hair or skirts). These children may role- play female figures (e.g., playing "mother”) and often are intensely interested in female fantasy figures. Traditional feminine activities, stereotypical games, and pastimes (e.g., ”playing house”; drawing feminine pictures; watching television or videos of favorite fe- male characters) are most often preferred. Stereotypical female-type dolls (e.g., Barbie) are often favorite toys, and girls are their preferred playmates. They avoid rough-and-tumble play and competitive sports and have little interest in stereotypically masculine toys (e.g., cars, trucks). Some may pretend not to have a penis and insist on sitting to urinate. More rarely, they may state that they find their penis or testes disgusting, that they wish them re- moved, or that they have, or wish to have, a vagina.
In young adolescents with gender dysphoria, clinical features may resemble those of children or adults with the condition, depending on developmental level. As secondary sex characteristics of young adolescents are not yet fully developed, these individuals may not state dislike of them, but they are concerned about imminent physical changes.
In adults with gender dysphoria, the discrepancy between experienced gender and physical sex characteristics is often, but not always, accompanied by a desire to be rid of primary and / or secondary sex characteristics and / or a strong desire to acquire some pri- mary and / or secondary sex characteristics of the other gender. To varying degrees, adults with gender dysphoria may adopt the behavior, clothing, and mannerisms of the experi- enced gender. They feel uncomfortable being regarded by others, or functioning in soci- ety, as members of their assigned gender. Some adults may have a strong desire to be of a different gender and treated as such, and they may have an inner certainty to feel and re- spond as the experienced gender without seeking medical treatment to alter body char- acteristics. They may find other ways to resolve the incongruence between experienced/ expressed and assigned gender by partially living in the desired role or by adopting a gen- der role neither conventionally male nor conventionally female.
When visible signs of puberty develop, natal boys may shave their legs at the first signs of hair growth. They sometimes bind their genitals to make erections less visible. Girls may bind their breasts, walk with a stoop, or use loose sweaters to make breasts less visible. In- creasingly, adolescents request, or may obtain without medical prescription and supervi- sion, hormonal suppressors (“blockers") of gonadal steroids (e.g., gonadotropin—releasing hormone [GnRH] analog, spironolactone). Clinically referred adolescents often want hor- mone treatment and many also wish for gender reassignment surgery. Adolescents living in an accepting environment may openly express the desire to be and be treated as the experi- enced gender and dress partly or completely as the experienced gender, have a hairstyle typ- ical of the experienced gender, preferentially seek friendships with peers of the other gender, and/ or adopt a new first name consistent with the experienced gender. Older adolescents, when sexually active, usually do not show or allow partners to touch their sexual organs. For adults with an aversion toward their genitals, sexual activity is constrained by the preference that their genitals not be seen or touched by their partners. Some adults may seek hormone ment surgery. Others are satisfied with either hormone treatment or surgery alone.
Adolescents and adults with gender dysphoria before gender reassignment are at in- creased risk for suicidal ideation, suicide attempts, and suicides. After gender reassign- ment, adjustment may vary, and suicide risk may persist.