Beyond and through the body: Subjective experiences of gender dysphoria across bodily and social dimensions

Abstract

Background

Traditional definitions of gender dysphoria (GD) reflect a binary, body-centered understanding of distress, often neglecting the influence of social and cultural contexts and failing to capture the lived experiences of transgender and nonbinary (TNB) individuals—especially nonbinary people.

Aim

The present study aimed at exploring TNB young adults’ subjective experiences of GD across bodily and social dimensions, while also attending to the interaction between these experiences and their fluctuations over time and context, moving beyond binary and transnormative assumptions.

Methods

Four focus group discussions were conducted with 13 participants (aged 18–27 years), exploring their lived experiences of GD. A thematic analysis was applied to the verbatim transcripts, guided by the central question: “How do TNB individuals experience gender dysphoria?”

Results

Three overarching themes and 11 subthemes were identified: (1) inhabiting the body, detailing visceral somatic sensations, the avoidance of mirrors and touch, alienation from specific body parts, and discomfort shaped by sociocultural meanings; (2) inhabiting the world, capturing distress arising from conflicts with binary gender norms and transnormativity, experiences of misgendering and invalidation, and persistent gender-related rumination; (3) changes in the subjective experience of GD, highlighting the variability of GD across social contexts, life stages, and gender-affirming interventions.

Discussion

The findings conceptualize GD as a multidimensional and dynamic experience, encompassing bodily discomfort and distress, social recognition, interpersonal dynamics, and minority stress. The results challenge body-centric, binary clinical models and advocate for more nuanced, experience-near frameworks for care and assessment that are better attuned to the clinical realities and therapeutic needs of TNB individuals.

Introduction

In the literature on transgender and nonbinary (TNB) individuals, the term gender dysphoria is often used ambiguously—at times referring to a diagnostic category, and at other times to the subjective experience of dysphoric symptoms—making it difficult to fully understand how it manifests and affects the psychological well-being of those who experience it (Davy & Toze, 2018). Introduced as a diagnostic label in the DSM-5 (APA, 2013), gender dysphoria describes the distress that may accompany the incongruence between one’s assigned and experienced or expressed gender. However, its history has much deeper roots, marked by misconceptions and biases stemming from the longstanding pathologization and medicalization of gender nonconforming identities (Davy, 2015; Giovanardi et al., 2025; Johnson, 2016; Rosenberg et al., 2024).

For many years, clinical research focused almost exclusively on the experiences of transgender individuals with binary gender identities (particularly trans women), while largely neglecting nonbinary identities and experiences. Moreover, although gender dysphoria is not universally experienced by all trans individuals, it has long represented the dominant framework through which their experiences have been understood, both clinically and theoretically (Galupo et al., 2021).

Early definitions of gender dysphoria were shaped by the “wrong body” narrative (Engdahl, 2014). Within this one-dimensional framework, distress is construed as an intrapsychic experience resulting from a disconnection between biological anatomy and gender identity, implying that a medicalized gender affirmation pathway is inherent to being trans. As Engdahl (2014) noted: “The body is assumed wrong in relation to an inner, real, and authentic gender identity, thus giving the impression of an essence that the body constrains, producing a reified image of both body and self as static and separate entities” (p. 267). This ideal of authenticity still upholds normative ideas of what is considered “real” in relation to gender, reinforcing binary gender norms and contributing to the marginalization of nonconforming bodies and identities, thereby exposing them to misrecognition, exclusion, and social stigma.

Transnormativity—the cultural framework in which transgender identities are deemed valid only when aligned with binary, medicalized standards (Bradford & Syed, 2019; Johnson, 2016; Mize & Lindley, 2025)—has significant repercussions in clinical practice with TNB individuals. Within healthcare systems, TNB individuals often feel pressured to conform to normative accounts of gender dysphoria, framing their experiences in ways that align with eligibility criteria for a formal diagnosis and access to gender-affirming care (Bradford & Syed, 2019; Davy, 2010, 2015; Lorusso et al., 2025; Pulice-Farrow et al., 2020). Although the current diagnostic formulation of gender dysphoria is less explicitly pathologizing and binary than its predecessor, its criteria continue to emphasize physical distress as a central element and uphold a medicalized model of trans identity (Johnson, 2016). For this reason, the scientific understanding of gender dysphoria is self-reinforcing, as individuals are prone to tailor their narratives to meet clinical expectations, ultimately limiting recognition of the complexity and diversity of TNB experiences.

Informed by the minority stress framework (Hendricks & Testa, 2012; Testa et al., 2015), including its recent extension to stressors specific to nonbinary people (Matsuno et al., 2024), recent research has expanded the conceptualization of gender dysphoria beyond a sole focus on bodily experience, emphasizing the critical role played by social context (Cooper et al., 2020; Di Giannantonio et al., 2025; Galupo et al., 2020b; Pulice-Farrow et al., 2020).

This broadening of perspective has been largely made possible by qualitative research, which has amplified the voices of trans individuals—particularly those with nonbinary identities—whose experiences have long been overlooked (Galupo et al., 2021; Murawsky, 2023; Rosati et al., 2025). Interpersonal interactions, sociocultural norms, and institutional structures—alongside bodily factors—play a significant role in shaping the development and experience of gender dysphoria among TNB individuals. For example, Galupo et al. (2020) demonstrated that gender dysphoria can be actively triggered or intensified by social interaction, particularly through experiences of misgendering (i.e. not being recognized in one’s own gender identity). Gender-related distress often arises in environments in which individuals must navigate binary and cisnormative expectations, especially in relation to how others perceive their gender. Dysphoric feelings, therefore, are increasingly understood as emerging not only from internal discomfort, but also from socially mediated experiences (Cooper et al., 2020; Galupo et al., 2020; Goldbach & Knutson, 2023; Pulice-Farrow et al., 2020). Nonbinary individuals often report dysphoria related to social invisibility and lack of recognition (Galupo et al., 2021), and some express discomfort with dominant gender narratives that lead them to question the legitimacy of their identities (Bradford & Syed, 2019).

In this context, Lindley et al. (2022) proposed a distinction between body gender dysphoria and social gender dysphoria, with the former referring to distress related to the incongruence between one’s experienced gender and one’s physical characteristics, and the latter referring to distress arising from the mismatch between one’s experienced gender and its perception or recognition in social contexts. However, the authors also acknowledged that, for many TNB individuals, these categories of distress are not easily separable. Building on this, Perger (2024) cautioned that such a conceptual distinction risks suggesting that bodily dysphoria exists independently of social influence. However, according to Perger, the role of society in shaping bodily discomfort extends far beyond interpersonal interactions: sociocultural norms are not merely external pressures but are actively internalized and embodied. From this perspective, Di Giannantonio et al. (2025) found that, among nonbinary participants, bodily discomfort was often linked not to a sense of alienation from sex characteristics per se, but to the symbolic and social meanings attributed to them. For instance, some assigned female at birth (AFAB) participants associated breast-related discomfort with experiences of objectification and sexualization, while some assigned male at birth (AMAB) participants described their genitalia as embodying male toxicity and patriarchal power.

Because the construct of gender dysphoria has historically been defined by cisgender clinicians with no direct experience of the phenomenon (Pulice-Farrow et al., 2020), it fails to capture the complexity and diversity of TNB individuals’ lived experiences. In a similar vein, diagnostic labels and commonly used assessment tools frequently reflect narrow, binary-based understandings that do not adequately represent the range of TNB identities, making it more difficult for individuals to access appropriate care and gender-affirming pathways (Austin et al., 2022; Elliot, 2001; Galupo & Pulice-Farrow, 2020; Goldbach et al., 2023).

Within this framework, the present study adopted a qualitative, phenomenological approach to explore how gender dysphoria is described and experienced by TNB individuals. The aim was to move beyond fixed diagnostic categories and understand gender dysphoria as a subjective, multidimensional experience. Accordingly, the voices of individuals with firsthand experience of gender dysphoria—free from transnormative assumptions or clinical preconceptions—were foregrounded, via the question: “How would you describe your experience of gender dysphoria?” This approach sought to foster a more nuanced, experience-near understanding that could support more inclusive and individualized care.

Methods

Study design

A qualitative, phenomenologically oriented design was adopted to explore the ways in which TNB individuals experience bodily and social gender dysphoria. Participants were recruited through online announcements (posted on, e.g. Instagram), the personal networks of the research team, and direct contact with local queer associations. The study inclusion criteria required that participants: (a) identified as transgender and/or nonbinary, (b) were aged 18 years or older, and (c) were fluent in Italian. A formal diagnosis of gender dysphoria (APA, 2022) or gender incongruence (WHO, 2019) was not required. Focus group discussions (FGDs) were chosen as the research method, to allow participants to share their perspectives and engage with each other’s experiences freely (Balasubramaniam, 2019; Hennink, 2014). In general, FGDs enable researchers to observe how individual perspectives are structured through interaction with others (Bradford & Syed, 2019), offering access to more complex and nuanced insights than individual interviews typically yield (MacDougall & Fudge, 2001). In the present study, each FGD was audio recorded, transcribed verbatim, and subsequently analyzed. Thematic analysis (Braun & Clarke, 2006) was selected as the most appropriate analytic approach, as it offers a rich and detailed account of the data, capturing a wide range of experiences. The study received ethical approval from the Ethical Committee of the Department of Dynamic and Clinic Psychology and Health Studies, Sapienza University of Rome (protocol number: CERT_18FD0344D0A; date of approval: 26/06/2024).

Participants

Thirteen young adults self-identifying as transgender (n = 6) and/or nonbinary (n = 7), with an average age of 21.8 years (SD = 2.8), were recruited. Among the nonbinary participants, two also identified as demigirls, one as a demiboy and bigender, and one as agender; two expressed a preference for not using any label. Eight participants were AFAB, two were AMAB, and three did not disclose this information. Almost all participants were White, except for one Latin American individual. Regarding gender-affirming medical care (GAMC), 54% (n = 7) had undergone some form of treatment, including hormonal blockers (n = 1), gender-affirming hormone therapy (GAHT) (n = 5), and chest surgery (n = 2). Only one participant had neither received nor intended to pursue GAMC. The remaining participants expressed a range of desires for future interventions. Table 1 reports participant characteristics. The pseudonyms used to refer to participants are names of transgender, nonbinary, and gender nonconforming figures drawn from historical, mythological, and artistic traditions.

Table 1.

Demographics.

Pseudonym	Age	Gender identity	Ethnicity	GAMC	Future GAMC
Agrado	24	trans woman	White	oestrogens	/
Bilal	21	nonbinary, no labels	Latin American	/	/
Bujar	18	nonbinary, no labels	White	/	testosterone, chest surgery
Cal	20	trans man	White	testosterone	chest surgery
Caeneus	23	man	White	testosterone	chest surgery
Elliot	22	trans man	White	chest surgery	/
Frida	21	demigirl	White	/	testosterone
Lana	25	nonbinary, demiboy, bigender	White	/	testosterone, chest surgery
Magnus	27	trans man	White	testosterone, chest surgery	testosterone
Orlando	20	trans man	White	testosterone	chest surgery
Ranma	25	nonbinary, agender	White	/	chest surgery
Sylvia	19	demigirl	White	/	oestrogens
Tiresias	19	nonbinary	White	hormonal blockers, low dose GAHT	hormonal blockers

Research team and positionality

The research team consisted of members with diverse positionalities regarding age, academic role (i.e. full professor, researcher, PhD student, master’s degree student), gender identity (i.e. cisgender, nonbinary), and sexual orientation (i.e. queer, bisexual, gay, heterosexual). All team members were Italian, White, and able-bodied. Research and data analysis were conducted by trained students and researchers. To foster a safe and welcoming environment, team members disclosed their gender identities and sexual orientations to participants, intentionally positioning themselves within the research process.

Procedure and measures

All participants completed an ad hoc questionnaire to collect sociodemographic data, including age, ethnicity, gender identity, assigned sex at birth (optional), and past or desired GAMC. Prior to data collection, participants were informed about the study procedures and data confidentiality, and provided informed consent. Subsequently, they took part in a semi-structured FGD lasting approximately 90–120 min, conducted in the presence of two facilitators and one observer. For this discussion, the research team structured a tailored discussion guide (Hennink, 2014), based on the existing literature on gender dysphoria. The guide consisted of a semi-structured list of questions designed to explore the bodily and social aspects of gender dysphoria, the interaction between these experiences, and the ways in which they vary over time and across contexts. A total of 17 main questions, alongside optional follow-up prompts, were structured to investigate five thematic areas: (1) identity and gender (e.g. “How would you briefly define your relationship with gender, gender identity, and the use of labels and definitions related to your gender identity?”), (2) gender dysphoria (e.g. “Throughout your life, have you experienced or are you currently experiencing gender dysphoria? How would you describe it?”), (3) relationship with the body (e.g. “Could you describe your relationship with your body?”), (4) relationship between the body and social contexts/interactions (e.g. “Some people have reported not feeling body dysphoria in all contexts or all the time. Are there any specific social contexts in which your discomfort with your body is particularly intense?”) and (5) social gender dysphoria (e.g. “Based on your experience, how would you describe social gender dysphoria?”).

Facilitators ensured that questions were posed flexibly and responsively, encouraging broad participation while preventing domination by a few vocal participants. The observer managed technical aspects (e.g. audio recording) and took field notes on nonverbal behavior and group dynamics.

A total of four FGDs were conducted: two with trans men and women, and two with nonbinary individuals. The first two served as pilot sessions to refine the discussion guide and setting. Only the first was conducted online via Zoom, while the remaining three were held in a private room at the Department of Dynamic and Clinical Psychology and Health Studies, Sapienza University of Rome. To ensure sample homogeneity within the FGDs, the research team chose to separate trans men and women from nonbinary participants. This decision was informed by Bradford and Syed (2019) concept of “intracommunity conflict,” which arises from differing experiences and varying degrees of adherence to transnormativity between these groups. Nonbinary identities that deviate from normative prescriptions may be perceived by some trans men and women as threatening to the recognition and validation of transgender identities. Conversely, trans men and women who embody transnormative ideals may be perceived by nonbinary participants as overly assimilative and compliant with the cisgender gaze and dominant cultural norms.

The discussion excerpts presented in the Results section were originally in Italian. They were translated into English and then back-translated into Italian by two of the authors, both fluent in Italian and English. The translation into English made it possible to move beyond the binary constraints of the Italian language, which is highly gendered: nouns have a grammatical gender (e.g. masculine “-o” or feminine “-a”) with gender concordance expressed by articles or adjectives (Mirabella et al., 2024). While the translation facilitated a more respectful representation of participants with nonbinary identities, it is important to note that it may not fully reflect the gendered linguistic reality of Italian nor the alternative strategies used to circumvent it.

Data analysis

The data were analyzed using thematic analysis following the six-step approach developed by Braun and Clarke (2006), which provides a structured and flexible method to capture a wide range of experiences. The phases are: (1) familiarization with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report. The data corpus consisted of the four focus group transcripts, and the analytic data set was examined in relation to the exploratory question: “How do TNB individuals experience gender dysphoria?”

The analytic process began with repeated readings of the transcripts to achieve familiarization. In the coding phase, two independent raters (AG, LG) generated synthetic labels to capture key features of the data. Their coding was compared and integrated under the supervision of two additional team members (BDG, GG), ensuring consensus. During this process, some codes were merged, others refined or discarded to maximize consistency and relevance. Codes were then organized into themes and subthemes. Team discussions refined the hierarchical relationships among them and clarified overlaps and distinctions across levels.

Results

As illustrated in Table 2, the thematic structure consisted of three overarching themes—inhabiting the body, inhabiting the world, and changes in the subjective experience of gender dysphoria—along with 11 subthemes capturing distinct yet interconnected, overlapping, and mutually influencing aspects of dysphoric experience. While thematic overlaps and contradictions were inevitable, each theme and subtheme was developed to highlight specific aspects of gender dysphoria.

Table 2.

Thematic structure.

Theme	Subtheme	Quotation
Inhabiting the body	Somatic feelings	The feeling that I always felt about my chest, aside from discomfort, was always a very physical nausea, a nausea that would start from my brain and take over everything. (Lana, 25, nonbinary)
	Touching and looking at the body	In moments of strong dysphoria, I kind of avoid all possible mirrors. (Elliot, 22, trans man)
	Disconnection from the body	I would call it precisely a feeling of detachment, of disconnection. There’s like, this alien perception in the mirror, you know? (Agrado, 24, trans woman)
	Embodiment of sociocultural meanings	Even if I rationally know that the fact that having a certain body part does not make me somehow part of this cultural attitude, however the association is there, and depending on the day it is stronger or weaker. (Tiresias, 19, nonbinary)
	Corporeality and sexuality	How do you share something that you don’t feel is yours? How do you put into play something that you feel is fake? (Agrado, 24, trans woman)
Inhabiting the world	Conflicts with gender norms and transnormativity	I felt some kind of reversed discomfort because I was coming out of what is the socially acceptable way of being trans, that is, being medicalized. (Tiresias, 19, nonbinary)
	Invalidation and misgendering	They get the pronouns wrong and so that’s where the dysphoria kicks in, because it’s like a confusion, isn’t it? (Lana, 25, nonbinary)
	Rumination and worry about gender	I feel resignation because most of the time I have my brain telling me: “Whatever you try to do there is no way to hide the fact that you are physically in a certain way […] There is no way not to be seen as female […] It is a constant rumination about how resigned I am. (Bujar, 18, nonbinary)
Changes in the subjective experience of gender dysphoria	Moving across social contexts	There’s just so much anxiety in these male contexts, the men’s locker room at the gym and places like that. I always try to avoid them, but it’s a source of dysphoria for me to want to avoid them, because I think: “Why can’t I just live them normally?” (Elliot, 22, trans man)
	Becoming aware	The active suffering, the embedded suffering, is more in the moment in which you can face something that you know how to name. (Ranma, 25, nonbinary)
	Minding the body	Dysphoria is something that destroyed me: despite the various changes you may have, there is always something that will simply remind you that you are not cis. (Orlando, 20, trans man)

Inhabiting the body

This theme explored the ways in which participants experienced and described gender dysphoric feelings concerning their bodies. While certain recurring narratives and modalities emerged, body-related gender dysphoria was articulated idiosyncratically by each participant. Inhabiting one’s body—understood as an expression of existence and a point of contact with the world—was often experienced as a complex process. Bodily discomfort was not limited to body image alone, but often stemmed from the interplay between bodily and social dimensions. The theme thus encompassed the ways in which gender-related discomfort was embodied by participants, and was organized into five subthemes: (1) somatic feelings, (2) touching and looking at the body, (3) disconnection from the body, (4) embodiment of sociocultural meanings, and (5) corporeality and sexuality.

Somatic feelings

All participants reported experiencing gender-related bodily discomfort, with varying degrees of intensity. Dysphoric feelings could involve the entire body (e.g. when it failed to align with the idealized body image corresponding to one’s gender identity) or specific body parts associated with masculinity, femininity, or one’s assigned gender. The chest and genitals were most frequently cited as significant sources of distress.

Discomfort often manifested physically, ranging from mild unease to intense reactions such as disgust, anguish, apathy, nausea, or a sensation of asphyxiation:

The feeling that I always felt about my chest, aside from discomfort, was always a very physical nausea, a nausea that would start from my brain and take over everything. (Lana, 25, nonbinary)

At some point, I could no longer wear bras. They gave me a terrible sense of suffocation, as if a snake were coiled tightly around my body. (Ranma, 25, nonbinary).

Some participants also reported “phantom limb” sensations in body parts they did not possess, particularly in the genital area.

Touching and looking at the body

Participants often described the challenges they experienced when looking at, physically handling, and interacting with their own bodies. Discomfort often arose during routine activities such as showering or shaving, or more generally when seeing their reflection in a mirror or viewing photographs of themselves. To cope with dysphoric feelings, participants reported engaging in avoidance behaviors that could become prohibitive in everyday life:

It weighs me down, it weighs me down on a mental level, that is, from the brain it starts, it takes over my stomach, it’s all amplified. In that moment I look, there is the image that is hammering in my brain and there it is, there I am showering with the light off or I just don’t look. (Lana, 25, nonbinary)

In moments of strong dysphoria, I kind of avoid all possible mirrors. (Elliot, 22, trans man)

Disconnection from the body

When I have to take a shower there is no mirror for me, in the sense that I avoid looking at myself in any way, so it is as if my body does not exist, there is only a floating head, I feel a bit like the floating head in Courage the Cowardly Dog. (Cal, 20, trans man)

Body dysphoria could manifest as a feeling of disconnection or detachment from one’s body or specific body parts—most frequently the genitals—which were often perceived as foreign or as “something that doesn’t belong to me”:

I have a strong genital dysphoria […] The penis gives me that sensation that it seems to me as if it were a prosthesis, that they have stuck on me, I can’t perceive it as an […] integrated element. (Agrado, 24, trans woman)

This sense of disconnection referred to a perceived mismatch between one’s body and its mental representation, as well as an inability to integrate certain characteristics into one’s body image. In other cases, dysphoric feelings were described as a complete absence of bodily sensation, as if “everything was switched off” (Ranma, 25, nonbinary).

Embodiment of sociocultural meanings

Some participants perceived certain body parts as culturally signified, and cited expectations and prescriptions associated with societal norms, roles, and gender stereotypes. For these participants, the body—and specifically the sexed body—became a source of suffering as a symbolic vehicle of sociocultural meanings and expectations that were incompatible with their own identities. With pubertal development and the emergence of secondary sexual characteristics, the perceived assumption of an alignment between body and social role became more pronounced, at times becoming deterministic. For example, having a penis was described as not only meaningful in terms of gender identity, but as also carrying behavioral expectations. Tiresias (19, nonbinary) described:

The genital area causes some trouble […] There is this very cultural expectation of conquering and aggressiveness, even in human relationships, which then on many occasions, near and far to me, results in violence and precisely, even if I rationally know that the fact that having a certain body part does not make me somehow part of this cultural attitude, however the association is there, and depending on the day it is stronger or weaker.

In some cases, societal mandates overrode personal desires. For AFAB participants in particular, body parts associated with reproduction, pregnancy, and breastfeeding were often experienced as particularly burdensome.

My desire to remove it is also linked to the fact that I don’t want to have this cultural vision imposed on me that if you have it then you have to use it and use it to contribute to society, to the demographic decline and whatever other reasons […] It is as if some of my expressions or body parts were not really only mine but were also something communal. (Frida, 21, demigirl)

Corporeality and sexuality

Participants described sexuality as a potential source of discomfort, with dysphoria acting as a barrier to sexual exploration—both individually and with others. As Agrado (24, trans woman) reflected: “How do you share something that you don’t feel is yours? How do you put into play something that you feel is fake?”

Dysphoric feelings related to the genitals imposed significant limitations. Participants often reported intense frustration, and at times anger, at being unable to engage with sexuality in a peaceful or affirming way. In some cases, dysphoria led to interruptions during sexual activity or the avoidance of situations that might become erotic.

Now everything goes well until the end with her most of the time. It’s just that it’s tiring that to make this happen there’s exhausting mental work to do, I mean: “So you’re touching yourself, think it’s a penis, think that…” all the time and I can visualize myself from the male point of view, only then I can really stay on track. If I get lost for a moment it’s over, but I can do this automated thing and that’s it. But yeah, maybe when you’re a bit more tired, you can’t stay as focused and you get lost, it takes a while. (Magnus, 27, trans man)

Another key factor linking bodily and social dimensions was the role played by partners. An unsupportive or invalidating partner could exacerbate body dysphoria—particularly for nonbinary participants, who often faced microaggressions, identity invalidations, and pressure to conform to binary gender norms. Conversely, a supportive partner and open, assertive communication around sexuality served as protective factors, helping to alleviate bodily discomfort. Nevertheless, dysphoria management required substantial cognitive and emotional effort, which was not always available.

Inhabiting the world

As with descriptions of body-related dysphoria, social dysphoria rarely emerged in clear separation from the bodily dimension. Some participants explicitly stated that the two experiences—body and social dysphoria—were extremely similar but triggered by different factors. Thus, the dimensions constantly interacted, shaping and influencing one another.

The descriptions within this theme primarily pertained to the relational, interpersonal, and sociocultural spheres. They encompassed participants’ discomfort in social interactions or specific contexts, mostly related to the ways in which their gender identity was perceived by others. The theme consisted of three subthemes: (1) conflict with gender norms and transnormativity, (2) invalidation and misgendering, and (3) rumination and worry about gender.

Conflicts with gender norms and transnormativity

This subtheme encompassed participants’ described relationships with gender norms and expectations. Confronting gender-stereotypical behavioral prescriptions emerged as a key factor contributing to dysphoria, with participants navigating between internalization and rejection of these norms. Many reported lifelong pressure to conform to gender expectations, often feeling constrained in their attempts to express themselves outside of cis- and heteronormative binary frameworks. For nonbinary participants, gender normativity was described as particularly limiting, given the absence of sociocultural reference points beyond binary models during their development:

At first, I think there is an age when one is conditioned to take one’s place within the hetero-binary norm, and that was the moment of collapse for me, as I have always felt a very androgynous identity […] I have always felt as if there were two rooms: one for the masculine, for the boys, and another for the girls. Perhaps they even have a porthole, a window through which one can peer into the other room, but they remain separated by a wall. I have always felt as though I lived in the cracks, in the hallways between these two rooms. A place yet to be mapped out, but at the same time, not necessarily one to be categorized. (Tiresias, 19, nonbinary)

For binary trans participants, the conflict with norms and stereotypes emerged in a more ambivalent form. On the one hand, they reported conforming to gendered attitudes and behaviors to gain recognition, feel a sense of belonging, and pass as cisgender. On the other hand, they expressed internal conflict with these norms, experiencing them as restrictive or misaligned with their senses of self:

I experience the male stereotype heavily. I mean, I’m trying to break away from that, but I realize that there’s still a strong urge to display machismo if there are other men, especially cis men, next to me. (Cal, 20, trans man)

Moreover, transnormative social representations of what a trans person “should” be were reported to create challenges, particularly when the body—whether medicalized or not—failed to align with these expectations. Participants reported that such representations, often internalized, obstructed self-understanding and free expression of their identity. They could become a source of suffering, exacerbating both bodily and social dysphoria. Likewise, feeling compelled to conform to medicalized standards that did not reflect their true desires and identity was described as a significant source of discomfort:

I also experienced this moment of profound uncertainty, almost a second wave of reversed dysphoria the moment I chose to stop hormone therapy […] I felt some kind of reversed discomfort because I was coming out of what is the socially acceptable way of being trans, that is, being medicalized. (Tiresias, 19, nonbinary)

Invalidation and misgendering

For participants, social dysphoria often stemmed from a lack of recognition of their gender identity. Identity invalidation manifested in various forms, with misgendering being among the most frequently discussed and deeply distressing. Misgendering ranged from explicit acts of violence to subtle microaggressions, including the imposition of expectations and stereotypes associated with the assigned gender. In general, participants described these experiences as undermining to their self-esteem and sense of self:

What triggers my dysphoria is precisely when I simply feel good and I think I look fine, perhaps it may even happen that I am euphoric, I leave the house, I go into any shop… boom! They get the pronouns wrong and so that’s where the dysphoria kicks in, because it’s like a confusion, isn’t it? (Lana, 25, nonbinary)

The constant risk of invalidation led many individuals to internalize the gaze of others, fostering expectations of rejection and discrimination, and ultimately restricting freedom of expression:

Basically, for me, social dysphoria is like my bodily dysphoria, but instead of stemming from me, it simply starts with other people, precisely because I see myself in a certain way, people see me in another way, and there’s something wrong there, so I am the one who’s making a mistake, and then it happens that my vision adapts to that of other people, and so I make that dysphoria my own, that’s the problem. (Sylvia, 19, demigirl)

Rumination and worry about gender

Participants frequently reported a tendency to ruminate on negative gender-related experiences and to worry about how others might perceive their identity—particularly regarding others’ reactions and the possibility of “passing.” These anxieties frequently manifested as intrusive, repetitive thoughts with obsessive, anxious, or depressive undertones.

At home I get ready, when I’m about to go out I have many internal voices telling me: “Your breasts are showing, your breasts are showing, you don’t have enough moustache,” everything, and so there’s this constant stress, anxiety, sweating. (Lana, 25, nonbinary)

Such concerns were often triggered by social interactions, especially in public or unfamiliar environments. In these contexts, participants described enacting hypervigilance through a constant monitoring of others’ reactions. This mental state could become tense, pervasive, and deeply ingrained in their cognitive and emotional processing. To navigate social relationships with some degree of ease, participants reported having to exert considerable mental and emotional effort to counteract these intrusive thoughts and the associated discomfort:

I feel resignation because most of the time I have my brain telling me: “Whatever you try to do there is no way to hide the fact that you are physically in a certain way […] There is no way not to be seen as female […] It is a constant rumination about how resigned I am. (Bujar, 18, nonbinary)

If I’m on the subway, for example, and I’m sitting with my legs open, I’m like: oh god, maybe that guy in front of me sees me as a man, and then he looks down and notices that, weirdly, there’s no bulge—what’s he going to think? He’ll figure it out right away. (Cal, 20, trans man)

Changes in the subjective experience of gender dysphoria

This final theme focused on the fluctuating nature of gender dysphoria, encompassing its described variability across time and space. Such fluctuations ranged from micro-changes throughout the day to deeper, long-lasting shifts linked to life stages, evolving self-awareness, or bodily changes—whether general or resulting from GAMC. The theme was organized into three subthemes: (1) moving across social contexts, (2) becoming aware, and (3) minding the body.

Moving across social contexts

Participant accounts in this subtheme highlighted the ways in which gender dysphoria varied depending on social context. Dysphoric feelings could be triggered by specific settings and interactions, while diminished or absent in others. These fluctuations often related to the perceived level of safety. Public spaces were frequently mentioned—large or unfamiliar environments, or those requiring engagement with registry-based identification, tended to heighten the risk of misgendering or discrimination and amplify concerns about how one was being perceived, often triggering strong feelings of dysphoria. Nonbinary participants, in particular, described feeling compelled to conform to specific norms of gender presentation, leading at times to a sense of performance or inauthenticity. Many participants reported feeling at ease with their bodies in private but experiencing dysphoria in social settings. Moreover, contexts involving bodily exposure or spaces that were rigidly binary and cisnormative were described as particularly challenging:

There’s just so much anxiety in these male contexts, the men’s locker room at the gym and places like that. I always try to avoid them, but it’s a source of dysphoria for me to want to avoid them, because I think: “Why can’t I just live them normally?” (Elliot, 22, trans man)

Perceived discomfort led some participants to limit their social interactions and avoid particularly stressful contexts and activities. However, such social withdrawal often significantly impaired their daily functioning, sometimes in a pervasive manner.

Relationships with family, friends, and partners were experienced differently depending on whether participants felt safe being out and on the level of perceived support and validation in their social contexts. Supportive environments enabled participants to express themselves more freely and to lower their vigilance:

Where they know I’m trans and I know it’s accepted and I’m like, I’m really relaxed. Sometimes it gives me euphoria because I feel very affirmed in my gender, not just as a guy but as a trans guy which is also a source of pride for me. (Elliot, 22, trans man)

Becoming aware

“Maybe everyone feels this way, don’t they?” (Lana, 25, nonbinary)

Identity construction is a deeply personal process. Some participants described it as gradual and progressive, while others recounted epiphany-like moments of sudden realization that brought previously latent experiences into focus and opened up new possibilities for reflection. This non-linear, complex journey could be shaped by various factors, including bodily changes (often linked to puberty), which some individuals experienced with particular intensity.

Participants’ narratives revealed a strong correlation between shifts in gender dysphoria and changes in body fat distribution and shape. A conflicted relationship with the body often contributed to the development of disordered eating behaviors and, in some cases, diagnosable eating disorders. For some, early feelings of body dissatisfaction during the process of self-discovery were not immediately recognized as gender-related, but were instead misinterpreted as body dysmorphic:

There was a period when I suffered from anorexia, and I distinctly remember that the psychiatrist on duty asked me: “What parts of your body do you see as fat?” The question caught me off guard because I saw myself as excessively thin, I didn’t see anything fat. That’s when I realized that my attempt to erase myself was due to the presence of my chest, which I couldn’t eliminate, and so… I understood that it was gender dysphoria. (Lana, 25, nonbinary)

Identity exploration could also be facilitated by specific events or encounters, or by playful experimentation with gender expression. Discomfort with one’s gender often served as a catalyst for self-understanding. At times, the recognition and naming of one’s gender identity coincided with the emergence or intensification of dysphoric feelings. In other cases, self- awareness enabled individuals to reinterpret their personal histories, assigning new meanings to past experiences through the lens of deeper self-knowledge:

I used to put so many things that were part of my life and perhaps gave me pain and I couldn’t give a name to in an almost inaccessible place, and somehow, I thought: “Everyone feels this way”. […] When I realized that instead it could be something that has a name, a whole critical mass of experiences, of pains that had been put away came in, […] I then realized that there are people who really feel like a man, feel like a woman. […] The active suffering, the embedded suffering, is more in the moment in which you can face something that you know how to name. (Ranma, 25, nonbinary)

Minding the body

This subtheme concerned fluctuations in dysphoria linked to bodily changes brought about by gender-affirming care, the re-signification and mentalization of the body, and the process of embracing a trans identity. Participants revealed that, at times, their inability to accept the structure and build of their given body became central to their dysphoric experience. This often entailed a process of mourning the fantasy of having a body that fully reflected their internal ideal—a task that was both cognitively and emotionally demanding. Comparison with others’ bodies frequently contributed to shaping their idealized body image. For nonbinary participants, this ideal often involved androgyny, fluidity, or neutrality—ideals that are inherently difficult to attain. In contrast, participants with binary gender identities often described their bodily ideal as aligning with cisnormative standards—a socially and culturally constructed model, albeit interpreted through a personal lens.

A desire to modify the body through surgery or hormone therapy was not expressed by all participants. Among those who had received GAMC (n = 7), only one was nonbinary. This participant initially underwent hormonal blockers and low-dose gender-affirming hormone therapy (GAHT), but later decided to discontinue the GAHT. Gender-affirming pathways are not necessarily linear but may involve deviations that are nevertheless part of the self-discovery process. The decision to retransition, therefore, can be a meaningful aspect of this journey, where different identification stages can provide a transitional space in which the person can elaborate and discover their gender identity.

Overall, participants reported a significant reduction in dysphoric feelings following GAMC. Many described a shift from perceiving their body image as a pervasive source of pain to beginning to inhabit a body that felt recognizable and affirming. However, some also expressed fears that physical changes might not align with their pre-intervention expectations. In these cases, the focus of dysphoria often shifted to smaller physical features or to immutable parts of the body:

Dysphoria is something that destroyed me: despite the various changes you may have, there is always something that will simply remind you that you are not cis […] It’s like I even have it about my childhood, because I didn’t live it as a boy, I lived it as a girl. […] It’s as if I had a completely wrong life. […] There are things that hormones, therapy, whatever, cannot change, unfortunately […] The biggest dysphoria I have is that of height. I think it’s literally the only thing I can never change, neither with hormones nor with operations, and it’s the only thing that really drives me crazy. (Orlando, 20, trans man)

However, the ideal body could be challenged, thereby softening dysphoric feelings. For instance, Tiresias (19, nonbinary) described a personal resolution to the conflict between their ideal of fluidity and their limited possibilities for expressing it:

My identity lies in my fluidity and to have this fluidity I don’t need to demonstrate, I don’t need to constantly prepare, pose, express myself, dress in a way that constantly leaves people confused about my gender, although it gives me a lot of satisfaction when it just happens. It is simply me embodying this priority regardless of the elements of my body […] My fluidity remains, because it is just in my being.

In this regard, psychotherapy may play a valuable role by offering a space to process dysphoric feelings and providing significant gender-affirming support to complement medical gender-affirming care:

One thing that has somehow helped me to lessen the confrontation and that I am still doing in a psychotherapy I have been going to for years now, is not looking so much at the: “Ok, I’m not a cis guy.” I mean, I will never be, it’s something I basically have to accept. It’s more, “Okay, I can’t have those experiences, but I have just as many that are equally valid, though, and that I appreciate and that have made me the person that I am […] Shifting the focus on these things helps me and gives me a sense of euphoria sometimes. (Elliot, 22, trans man)

A common thread across these diverse narratives was the ongoing process of reclaiming the body—of moving beyond the pursuit of often unattainable ideals and painful comparisons with others. This process also involved accepting one’s personal history, which served as a bridge between the body as given and its evolution over time. Moreover, the process could help to alleviate dysphoric experiences while also facilitating the construction of one’s identity as a dynamic interplay between one’s body, psyche, and relationships with others.

Discussion

The present findings align with recent literature repositioning gender dysphoria as a multidimensional, dynamic phenomenon, shaped also by social contexts, interpersonal dynamics, and minority stress factors. At the core of this perspective lies the embodied, first-person experience of the body—its somatic sensations, its perception in the world, its status as the object of one’s own and others’ gazes, and its investment with deeply rooted sociocultural meanings. Such an approach allows for a more profound and nuanced understanding of gender dysphoria, moving beyond transnormative and binary models. By adopting a phenomenologically oriented framework that foregrounds the subjective accounts of TNB individuals, a more complex and situated comprehension of dysphoric experiences may emerge (Cooper et al., 2020; Galupo et al., 2020; Goldbach et al., 2023; Perger, 2024).

Participant narratives reflected a high degree of individual variability, each articulating unique configurations of dysphoric experiences and coping strategies. When given space to narrate their experiences outside normative clinical scripts (Bradford & Syed, 2019), participants described gender dysphoria as a deeply subjective phenomenon. Nevertheless, their narratives revealed points of convergence with traditional conceptualizations of gender dysphoria. This was particularly evident in accounts of bodily discomfort, which manifested in various ways, including detachment or disconnection from the body or from specific body parts perceived as alien to the self (Pulice-Farrow et al., 2020); “phantom limb” sensations associated with the genitals or chest; and coping strategies involving the avoidance of one’s bodily image or minimal interaction with certain body parts (Pulice-Farrow et al., 2020). In the present study, such accounts were further enriched by participants’ descriptions of dysphoria as a visceral experience, conveyed through somatic sensations of disgust, anguish, apathy, nausea, and asphyxiation.

However, the present results challenge existing diagnostic criteria, moving beyond the dominant focus on the disjunction between one’s assigned and one’s desired body. Instead, they situate trans and nonbinary bodies—and the experience of bodily discomfort—within the broader cis-heteronormative context that shapes and constrains gendered subjectivities. From this perspective, the body is a lived body—a body-in-situation—embedded in specific social, cultural, and relational dynamics (Engdahl, 2014; Young, 2005).

Across the FGDs, participants emphasized that gender-related distress was not solely rooted in corporeal experience, but frequently triggered or intensified by external, interpersonal conditions. These findings confirm and extend previous research (Galupo et al., 2020; Goldbach et al., 2023), highlighting the central role of social context in shaping the subjective experience of gender dysphoria. In particular, moments of misgendering, invalidation of one’s identity, and pressure to conform to binary and normative gender expectations were described as key sources of distress. Moreover, perceived safety within social environments was consistently identified as a critical determinant in both the experience and the modulation of gender dysphoria (Goldbach et al., 2023). In line with the minority stress perspective (Galupo et al., 2020; Hendricks & Testa, 2012), participants described pervasive anticipatory anxiety and preoccupation with the way in which their body, presentation, and gender identity might be perceived—or rejected—by others. These concerns often gave rise to states of hypervigilance and rumination, frequently marked by anxiety or depressive content, which significantly impaired their social functioning and, in some cases, led to pervasive forms of social withdrawal. This result is consistent with Lindley and Galupo’s (2020) conceptualization of gender dysphoria as a proximal stressor, emphasizing that dysphoric experiences are not solely intrapsychic, but dynamically shaped by the internalization of social stressors and cisnormative expectations. This perspective also echoes the theoretical reflections advanced by Devor (1996), who proposed broadening the definition of gender dysphoria—particularly for individuals socialized as female—beyond strictly clinical and individual frameworks. Drawing on the etymology of dysphoria (“hard to bear”), Devor conceptualized it as a condition in which certain or all aspects of one’s gender status become difficult to bear for fundamentally social or political reasons, as well as psychological ones. Unease arising from the dissonance between individual subjectivities and normative gender expectations embedded in dominant Western cultures may thus be understood as a socially produced response to restrictive and inadequate models of sex and gender.

In line with—and extending—previous research (e.g. Lindley et al., 2022), the present findings suggest that the subjective experience of gender dysphoria involves both physical and social dimensions. While some participant narratives emphasized corporeal sensations and discomfort, others highlighted social dynamics such as recognition, visibility, and conformity. However, for most participants, these dimensions were not easily separable. This was particularly evident in narratives concerning embodiment-related discomfort, which suggested that, beyond being triggered by specific social interactions and contextual dynamics (Galupo et al., 2020), bodily dysphoria may also be deeply shaped by the sociocultural meanings attributed to the body. In particular, participants often attributed the discomfort they experienced as rooted in dominant cultural significations of bodily features, attributes, or functions. For AFAB individuals, reproductive capacity emerged as a central point of tension. Some participants expressed a deep conflict with body parts and physiological functions symbolically associated with femininity and motherhood, often linked to a sense of external control over their bodies—as if the female body was seen as something communal or socially owned, rather than belonging exclusively to the individual. Conversely, the penis—culturally signified as a marker of masculinity—was associated by some participants with violence, aggression, and domination. Taken together, these findings underscore that, although the body is undoubtedly implicated in gender dysphoria, it is also a socialized body (Perger, 2024), profoundly shaped by sociocultural meanings. The role of the body thus appears complex and mediated, rather than linear, as suggested by medicalized and transnormative frameworks.

Participant accounts also revealed that dysphoria may stem from the perceived impossibility of attaining an “ideal” body. While many reported that medical gender-affirming interventions significantly reduced their overall distress and allowed them to inhabit their bodies with greater ease, the benefits of these interventions remains limited, as they may merely shift the focus of dysphoria to smaller physical details or immutable traits (e.g. height, bone structure, hand and foot size). This aspect is consistent with the literature showing that GAMC, while of utmost importance to those who seek it, is often overly burdened with potentially unrealistic expectations that are likely to be disappointed. Rosenberg et al. (2024) emphasize that TNB individuals may not always be fully prepared to inhabit a “reconfigured body,” and that GAMC is still commonly construed as an antidote to gender dysphoria, according to which a TNB person may achieve well-being only by inhabiting a medicalized body that is socially read as cisgender. Medicalization, however, should instead be understood as a point of departure for further, deeper elaborations.

This resonates with Saketopoulou’s (2014) notion of mourning the body, describing the process of mentalizing one’s body by acknowledging the unresolvable conflict between gender identity and the material reality of the body. Clinical engagement with the mourning of the idealized body and its associated pain may be essential for processing dysphoric feelings.

The present findings also underscore the importance of identity integration. Acceptance of one’s gender identity and the capacity to “claim one particular kind of history” (Gozlan, 2018) appear to support more adaptive responses to dysphoria. Conversely, when individuals are unable to assert their TNB identity and instead pursue cisnormative passing as an ultimate goal, they may gain protection from external stigma (e.g. transphobic violence or discrimination) but forfeit access to affirming resources within queer communities. In some cases, this lack of identity assertion—potentially linked to internalized transphobia—may limit opportunities for social support and mirroring (Hendricks & Testa, 2012). This suggests that the psychological containment of dysphoric experiences involves both an acceptance of the body and an exploration of its meanings (Saketopoulou, 2014), as well as an affirmation of one’s particular life story (Gozlan, 2018). Accordingly, these processes may be crucial for sustaining psychological well-being in TNB individuals. It is nevertheless important to stress that the decision not to assert one’s identity can also take the form of a self- protective strategy aimed at preventing possible physical or verbal aggression. The current political climate and the increasing attacks on trans rights in Italy (Rosati et al., 2025) and across Western countries (e.g., Pease & Galupo, 2024) reinforce such dynamics. Expectations of rejection and discrimination thus play a crucial role in the emergence of this stance, sometimes pushing people to conform to normative expectations to avoid repercussions, even at the cost of inhibiting their own gender affirmation (Hendricks & Testa, 2012; Testa et al., 2015)

Finally, the complexity highlighted in the FGDs exposed the limits of the current transition–detransition–retransition framework. A simplistic view—prevalent in both public discourse and, at times, the scientific literature—conceives of any deviation from the linear gender affirmation path as a form of detransition marked by regret (Irwig, 2022; Jorgensen, 2023). However, the lived experience of gender dysphoria is far less linear than commonly portrayed by diagnostic criteria. Drawing on Laplanche’s theory (Laplanche, 2007), Saketopoulou and Pellegrini (2023) described dysphoria as an ongoing re-translation of a deep enigma—one that may take unexpected turns and directions. In this view, gender affirmation pathways may move forward, reverse, branch out, or be rearticulated in new languages and definitions. Therefore, clinical practice must be capable of engaging with diverse and non-linear trajectories, moving beyond deterministic and reductionist perspectives.

Limitations and future directions

The study presents several limitations that should be addressed in future research. First, although a diagnosis of gender dysphoria was not required for participation, the recruitment process explicitly referenced this construct. This may have introduced self-selection bias, whereby individuals experiencing bodily dysphoria were more likely to participate, potentially leading to an overrepresentation of this dimension. Second, the sample was demographically narrow: all participants were aged 18–27 years and predominantly White, with only one Latin American, one trans woman, and one person living in a rural area. Given the well-documented impact of social isolation and intersecting minority stressors (e.g. ethnicity, geography, disability) on TGNB mental health (Hendricks & Testa, 2012; Matsuno et al., 2024; Testa et al., 2015), future research should adopt a more intersectional approach. To our knowledge, no intersex individuals were included in the sample. Considering the parallels between the invisibilization and systemic pathologization faced by intersex and nonbinary individuals (van de Grift et al., 2024), future research should explore the ways in which intersex experiences of gender dysphoria differ, particularly in relation to sociocultural dynamics. Lastly, this was a cross-sectional study, with each participant contributing to a single focus group session. While retrospective narration is essential for making sense of gender identity development (Saketopoulou & Pellegrini, 2023), longitudinal designs would enable a deeper understanding of the evolution of gender dysphoria over time and in relation to key milestones in gender affirmation.

Conclusions

The present study offered privileged access to the inner landscape of gender dysphoria, as narrated in the first-person voices of those experiencing it. Moving beyond pathologizing and binary paradigms, participants’ accounts revealed gender dysphoria to be a multifaceted and shifting experience—one that cannot be reduced to diagnostic categories or linear developmental trajectories. Rather, it emerged as an affective and embodied experience, deeply shaped by the interplay between bodily self-awareness, sociocultural meaning systems, and the intersubjective negotiation of identity. In line with contemporary theories of embodiment (Butler, 2025; Fausto-Sterling, 2019; Lemma, 2013), the body was framed as a complex psychic and symbolic space: not merely a site of dysphoric sensation, but also a medium through which selfhood was constituted, mentalized, and socially negotiated.

These findings suggest that gender dysphoria may reflect not a disconnection from the body per se, but rather a rupture in the meaningful integration of the body within a coherent and validated self-narrative. Moreover, the results highlight the profoundly intersubjective nature of gender dysphoria. As theorized by Benjamin (1995, 2018), recognition is not simply an individual achievement, but a relational process through which subjectivity is constituted and sustained. Participants’ accounts demonstrated that the presence or absence of recognition—whether through misgendering, invalidation, or affirmation—deeply affected not only their dysphoric states, but also their possibilities for inhabiting their bodies and identities with continuity and coherence. Consistent with Scandurra et al. (2020), the ability to mentalize stigma—that is, to understand experiences of rejection and internalized transphobia as expressions of external prejudice rather than reflections of one’s identity—can protect the self-concept and relational expectations, thereby helping to reduce psychological distress. By extension, this capacity may mitigate the social and interpersonal dimensions of gender dysphoria.

Within this framework, the therapeutic relationship may serve as a critical site of rupture or repair. With regard to the former, psychotherapy may problematically reproduce normative scripts and non-recognition, particularly when clinicians approach TNB experiences through pathologizing or prescriptive lenses (Giovanardi et al., 2025; Rosati et al., 2022). However, when grounded in epistemic humility and emotional availability, therapy may hold space for transformative recognition, whereby the embodied self is mentalized, narrated, and reclaimed (Salamon, 2010). As participants suggested, therapeutic work that attends to the embodied dimensions of dysphoria and the sociocultural meanings inscribed in the body may play a vital role in supporting personal agency, affirming subjectivity, and fostering the psychological integration of identity.

Finally, the present findings prompt critical reflection on what is being measured in assessments of gender dysphoria in research contexts. Recent studies (e.g. Galupo et al., 2020) have shown that existing instruments often fail to capture lived dysphoric experience—particularly for nonbinary individuals. This underscores the need for assessment frameworks that are phenomenologically grounded and sensitive to the diverse dimensions and expressions of this construct. Ultimately, the present findings invite clinicians and researchers to move beyond static conceptions of gender and dysphoria. They call for a model of care that honors the fluidity, complexity, and relational embeddedness of gendered experience—one in which the body is not merely treated or modified, but listened to, made thinkable, and recognized in its singularity.

Funding Statement

This study was funded by the European Union – NextGenerationEU, PNRR project “Benessere psicologico in popolazioni a rischio,” Mission 4, Component 1, Investment 1.4 (CUP B83C22003120006).

Author contributions

Conceptualization: BDG, GG; Methodology: BDG; Investigation: BDG, LG, AG; Writing—original draft: BDG, LG, AG; Writing—review & editing: GG, VL; Supervision: GG, VL.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data supporting the study findings are available from the corresponding author (BDG), upon reasonable request. Due to privacy concerns, the data are not publicly available.