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In transgender persons, assigned sex at birth and gender are not compatible, and the clinical picture created by this incompatibility has been expressed in different terms in the past. But in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association replaced the diagnosis of gender identity disorder (GID) with gender dysphoria (GD).1 Similarly, in the 11th edition of the International Statistical Classification of Diseases and Related Health Problems (ICD-11), the World Health Organization replaced outdated diagnostic categories from ICD-10, such as “transsexualism” and “GID in childhood,” with “gender incongruence of adolescence and adulthood” and “gender incongruence of childhood,” respectively, defining health conditions related to gender identity as “gender incongruence”.2

Although “GD” and “gender incongruence” are still the most commonly used terms to describe the mismatch between sex and gender, I believe these terms are not inclusive—at least for some transgender individuals. This is because sex and gender are distinct concepts, and this distinction is, to some extent, obscured in the expressions “GD/incongruence.” Sex consists of primary components, such as genetic, gonadal, hormonal, and genital characteristics, as well as secondary components, like secondary sexual features. Sex is a multidimensional construct that includes an individual's reproductive/sexual anatomy, sex chromosomes, hormone levels, and secondary sex characteristics, and it is congenital.3 Gender, on the other hand, is defined personally and socio-culturally (ie, psychosocially). However, it is also strictly intertwined with the body and rooted in an individual's perceived gender identity (eg, male, female, transgender man, transgender woman, non-binary). For instance, the terms “transgender” and “non-binary” are often used to describe individuals whose assigned sex at birth does not align with their gender identity (psychological gender). Therefore, sex and gender should be considered separate concepts and not used interchangeably.4

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