Gender Dysphoria, Gender Identity, and Related Conditions

Gender Dysphoria, Gender Identity, and Related Conditions

Introduction

• Gender Identity: Refers to one's sense of being male or female, often aligning with their anatomical sex.

• Gender Dysphoria: Expresses discontent with their assigned sex and a desire to have the body or social role of the other sex.

• DSM-5: Introduced gender dysphoria as a diagnosis, replacing gender identity disorder from the previous edition.

• ICD-10: Lists gender identity issues under Disorders of Adult Behavior and Personality, including diagnoses like transsexualism and gender identity disorder of childhood.

• ICD-11 (Proposed): Recommends moving gender identity concerns from psychological sections to a separate chapter, possibly as medical diagnoses or within a new chapter on sexual health and sexual disorders.

• Transgender: A general term for individuals who identify with a gender different from their birth-assigned gender.

Transgender People - Diversity

• Transsexuals: Desire to have the body of another sex.

• Genderqueer: Feel they are between genders, of both genders, or neither gender.

• Cross-Dressers: Wear clothing associated with another gender but maintain a gender identity consistent with their birth-assigned gender.

• Most transgender people do not undergo genital surgery due to choice or financial constraints.

• Transgender people can have any sexual orientation (e.g., a transgender man may identify as gay, straight, or bisexual).

Diagnosis and Clinical Features

Children

• DSM-5 Criteria: Focuses on the incongruence between expressed and assigned gender, with a critical criterion being a desire to be another gender or insistence that one is another gender.

• The diagnosis aims to limit its use to children who clearly express their wish to be another gender.

• Behaviors such as preferring clothing, playmates, toys, and roles of another gender are common.

• Key traits include a strong desire to be the other gender, dislike of one’s sexual anatomy, or desire for the physical characteristics of the desired gender.

• Children may express the desire to have different genitals or state their genitals will change.

• The child must experience clinically significant distress or impairment due to the condition for diagnosis, not just the caregivers.

Adolescents and Adults

• Must show incongruence between expressed and assigned gender.

• Must meet at least two of six criteria, related to their current or desired secondary sex characteristics.

• Other criteria include a strong desire to be another gender, be treated as another gender, or belief that one has the typical feelings and reactions of another gender.

• Most adults seeking help are aware of transgender identity, seeking therapy to explore gender issues and/or request letters for hormone treatment or surgery.

• The idea of being "trapped in the wrong body" does not apply to everyone who identifies as transgender.

• Clinicians should be open and affirming, using language cues from their patients.

• DSM-5 acknowledges that some people may not fit into the traditional gender binary and may desire to be alternative genders like genderqueer.

• Adolescents and adults must be personally distressed or impaired by their feelings.

• A posttransition specifier exists for individuals living in their affirmed gender who have had or are preparing for medical/surgical procedures.

Table 17-1: Gender Dysphoria DSM-5 vs. ICD-10

Other Specified and Unspecified Gender Dysphoria

• Other Specified Gender Dysphoria: Used when the presentation causes clinically significant distress or impairment but doesn't meet the full criteria. Clinicians should specify why the full criteria are not met.

• Unspecified Gender Dysphoria: Applied when full criteria are not met, and the clinician chooses not to specify the reason.

Case Example

• A 27-year-old assigned female at birth reported feeling different as a child, preferring sports with boys, wearing unisex clothing, and disliking breast development and menses.

• Attractions were exclusively to female partners, but she didn't feel like a lesbian; she wanted to be seen as a man by heterosexual women.

• She consulted transsexual websites, joined a female-to-male transsexual support group, and initiated clinical referral.

• She transitioned to living as a man, changed her name, received androgen injections (testosterone), resulting in a deepened voice, facial/body hair growth, cessation of menses, increased sex drive, and clitoral hypertrophy.

• After 2 years, she underwent a bilateral mastectomy and was on the waitlist for phalloplasty and hysterectomy-oophorectomy.

• She continues employment as a man and is in a 3-year relationship with a female partner who has a child from a previous marriage.

Differential Diagnosis

Children

• Children with gender dysphoria likely to identify as transgender as adults are differentiated by statements about desired anatomical changes and the persistence of the diagnosis over time.

• Other gender-nonconforming children may make such statements briefly or prefer clothing/behaviors of another gender but show contentment with their birth-assigned gender.

• The diagnosis no longer excludes intersex people and is coded with a specifier where intersex people are gender dysphoric about their birth-assigned gender.

• Medical history is important to differentiate between children with or without intersex conditions.

• Standards of care for intersex children have changed; historically, surgeries were performed early to create standard male/female appearance, potentially causing sexual dysfunction and sterility.

• Current practices aim to allow intersex people to make decisions about their bodies later in life.

Adolescents and Adults

• Individuals must experience clinical distress or impairment related to their gender identity to be diagnosed with gender dysphoria.

• This excludes transgender or gender-nonconforming individuals not clinically distressed by their gender identities.

• Gender identity issues may be a component of delusional thinking in mental illnesses like schizophrenia, but this is rare and distinct from transgender identity or gender dysphoria, as the gender identity issues diminish with treatment of the psychosis.

• Body dysmorphic disorder may be a differential diagnosis when patients desire to change gendered body parts, but the focus is on the body part looking abnormal, not on gender.

• Transvestic disorder involves recurrent and intense sexual arousal from cross-dressing, causing distress or impairment, differentiated by the patient’s consistent gender identity and sexual excitement linked to cross-dressing interfering with their life.

Course and Prognosis

Children

• Children typically develop a sense of their gender identity around age 3, showing gendered behaviors and interests, and potentially expressing a desire to be another gender.

• Clinical consultations often begin around school age due to interactions with classmates and scrutiny from adults.

• Some adults identifying as transgender recall not showing behaviors consistent with another gender in childhood, either working to appear stereotypical or not recalling gender identity concerns.

• Approaching puberty, children diagnosed with gender dysphoria may show increased anxiety related to anticipated body changes.

• Children diagnosed with gender dysphoria do not necessarily grow up to identify as transgender adults; more than half diagnosed with gender identity disorder (DSM-IV) later identify with their birth-assigned gender.

• Those who identify as transgender adults tend to have more extreme gender dysphoria as children.

• Many studies show increased rates of gay and bisexual identity among those gender nonconforming as children.

Comorbidity

Children

• Children diagnosed with gender dysphoria show higher rates of depressive disorders, anxiety disorders, and impulse control disorders.

• This is likely related to the stigma they face due to their gendered behaviors and identities.

• There are reports of higher rates of autism spectrum disorders among those with gender dysphoria, which some researchers link to intrauterine hormone exposure.

Adults

• Adults diagnosed with gender dysphoria show higher rates of depressive disorders, anxiety disorders, suicidality, self-harming behaviors, and substance abuse.

• The lifetime rate of suicidal thoughts in transgender people is about 40%.

• The minority stress model suggests that stigma, discrimination, harassment, and abuse contribute to increased mental illness in these groups.

• DSM-5 indicates that persons with late-onset gender dysphoria may have more significant fluctuations in distress and ambivalence, and less satisfaction after sex reassignment surgery.

Treatment

Children

• Treatment typically consists of individual, family, and group therapy to explore gendered interests and identities.

• Reparative or conversion therapy aims to change a person’s gender identity or sexual orientation but is considered unethical by the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry.

Adolescents

• As gender-nonconforming children approach puberty, some show intense fear and preoccupation with physical changes.

• Clinicians may use these reactions to consider puberty-blocking medications, such as gonadotropin-releasing hormone (GnRH) agonists, to temporarily block hormones that lead to secondary sex characteristics.

• GnRH agonists are used in other populations (e.g., children with precocious puberty) and are thought to be safe, but such steps require careful consideration.

Adults

• Treatment for adults identifying as transgender may include psychotherapy to explore gender issues, hormonal treatment, and surgical treatment.

• Hormonal and surgical interventions may decrease depression and improve the quality of life.

Mental Health Treatment

• Due to past poor treatment and medicalization of transgender people by mental health providers, there is decreased interest in engaging in mental health care.

• Mental health workers often act as gatekeepers, requiring letters for hormone treatment or surgery.

• Many community clinics are using informed consent models for hormone treatment, reducing the need for mental health providers.

• The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) have become more flexible and open to informed consent models.

• More mental health providers are specializing in working with transgender populations, increasing the engagement in psychotherapy.

Hormones

• Transgender Men: Most often use testosterone, usually by injection weekly or biweekly. Initial changes include increased acne, muscle mass, and libido, with cessation of menses within a few months. Subsequent changes include deepening of the voice, increased body hair, and enlargement of the clitoris. Monitoring includes hemoglobin/hematocrit levels, liver function tests, cholesterol, and screening for diabetes. Individuals are counseled on fertility.

• Transgender Women: May take estrogen, testosterone-blockers, or progesterone. These hormones can cause softening of the skin, redistribution of fat, and breast growth, which rarely exceeds bra cup size B. Hormones should be taken for 18-24 months before breast augmentation. Sex drive, erections, and ejaculation can decrease. Body hair may decrease, though not always as desired. Voice coaching may be sought as hormones do not change the voice. Estrogen users should avoid smoking to reduce the risk of blood clots. Blood pressure, liver function, cholesterol, and prolactin levels are monitored. Reproductive counseling is essential due to permanent sterility.

Surgery

• Fewer people undergo gender-related surgeries than take hormones due to choice or financial constraints.

• “Top surgery” (chest surgery) is the most common surgery for both trans men and trans women.

• Transgender men may have surgery to construct a male-contoured chest.

• Transgender women may have breast augmentation.

• “Bottom surgery” is less common.

• Transgender Men: Metoidioplasty (freeing the clitoris and adding tissue), scrotoplasty (placement of testicular implants), and phalloplasty (creation of a penis) are options, with phalloplasty being less common due to cost and complexity.

• Transgender Women: Vaginoplasty (sex reassignment surgery/SRS) involves removing the testicles, reconstructing the penis to form a clitoris, and creating a vagina. Techniques are improving, but the procedure is expensive. Some women may have orchiectomies (testicle removal) as an in-office procedure to decrease androgen production.

• Facial feminization surgeries are essential, altering facial features to match the affirmed gender and facilitate social interaction and safety.

• Testosterone typically causes the face to appear more masculine, so transgender men rarely undergo facial surgeries.

• Rare cases of self-surgery occur due to inaccessibility, and some have surgeries performed under unsafe conditions.

• Women may inject industrial-grade silicone, leading to body mutilation, infection, and even death due to silicone blood clots and embolism.

Epidemiology

Children

• Most children with gender dysphoria come to clinical attention in early grade school years, though parents report cross-gender behaviors before age 3.

• Among referred boys younger than 12, 10% reported a desire to be the other sex; for girls, it was 5%.

• The sex ratio of children referred for gender dysphoria is 4-5 boys for each girl, likely due to societal stigma toward feminine boys.

• The sex ratio is equal in adolescents referred for gender dysphoria.

• Many children with gender-nonconforming behavior do not grow up to be transgender adults, and vice versa.

Adults

• Estimates of gender dysphoria in adults from European hormonal/surgical clinics show a prevalence of 1 in 11,000 male-assigned and 1 in 30,000 female-assigned people.

• DSM-5 reports a prevalence rate ranging from 0.005 to 0.014% for male- and 0.002 to 0.003% for female-assigned people.

• Most clinical centers report a sex ratio of 3-5 male patients for each female patient.

• Most adults with gender dysphoria report feeling different from other children of their same sex, with the cross-gender identification becoming more profound in adolescence and young adulthood.

• Overall, male to female dysphoria has a higher prevalence than female to male dysphoria.

• There is greater social acceptance of birth-assigned females dressing and behaving as boys (tomboys) than birth-assigned males acting as females (sissies).

• Some researchers speculate that 1 in 500 adults may fall somewhere on a transgender spectrum, based on population data.

Etiology

Biologic Factors

• For mammals, the resting state of tissue is initially female; males develop with androgen introduced by the Y chromosome, leading to testicular development. Without testes and androgen, female external genitalia develop.

• Maleness and masculinity depend on fetal and perinatal androgens.

• Sex steroids govern sexual behavior in lower animals, but this effect diminishes with evolutionary scaling; they influence the expression of sexual behavior in mature men or women (e.g., testosterone can increase libido in women, estrogen can decrease libido in men).

• Masculinity, femininity, and gender identity are more a product of postnatal life events than prenatal hormonal organization.

• Brain organization theory refers to the masculinization or feminization of the brain in utero; testosterone affects brain neurons, contributing to the masculinization of the brain in areas like the hypothalamus.

• Whether testosterone contributes to so-called masculine or feminine behavioral patterns is controversial.

• Genetic causes of gender dysphoria are under study, but candidate genes have not been identified, and chromosomal variations are uncommon.

• Case reports of identical twins include both concordant and discordant pairs for transgender issues.

• Ongoing research includes imaging studies showing changes in white matter tracts, cerebral blood flow, and cerebral activation patterns in patients with gender dysphoria.

• An incidental finding is that transgender persons are likely to be left-handed, the significance of which is unknown.

Psychosocial Factors

• Children usually develop a gender identity consistent with their assigned sex influenced by factors like temperament and interaction with parents’ qualities and attitudes.

• Culturally acceptable gender roles exist; society expects boys to be masculine and girls to be feminine.

• Children learn these roles, though some believe some boys are temperamentally delicate and sensitive and some girls are aggressive and energized.

• Western society has a higher tolerance for “nontraditional” gender role behaviors than in the past.

• Sigmund Freud believed that gender identity problems resulted from conflicts within the Oedipal triangle, fueled by both real family events and children’s fantasies.

• Interference with a child loving the opposite-sex parent and identifying with the same-sex parent interferes with healthy gender identity development.

• Psychoanalysts since Freud have emphasized the mother–child relationship in the first years of life as paramount in establishing gender identity.

• Mothers usually facilitate their children’s awareness of and pride in their gender.

• Devaluing, hostile mothering can result in gender problems.

• Gender problems can become associated with separation–individuation problems, leading to the use of sexuality to remain in relationships of desperate closeness and devaluing distance.

• Children may receive the message that they would be more valued if they adopted the gender identity of the opposite sex, especially rejected or abused children.

• A mother’s death, extended absence, or depression can influence the process, and a young boy may react by identifying with her.

• The father’s role is also vital in the early years for separation–individuation; without a father, the mother and child may remain overly close. For a girl, the father usually is the prototype offuture love objects; for a boy, the father is a model for male identification.

• Learning theory postulates that children may be rewarded or punished by parents and teachers based on gendered behavior, thus influencing the way children express their gender identities. Children also learn how to label people according to gender. Eventually, they also learn that we should not dictate gender based on surface appearances such as clothing or hairstyle.