10.5 Gender Dysphoria

In 2013, the term gender identity disorder (GID) was renamed to gender dysphoria (GD) after criticisms that the former term was stigmatizing.
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) reclassified GD, moving it out of the sexual disorders category into a unique category.

To be diagnosed with GD, a person must:

Experience a noticeable difference for at least six months between their expressed gender and sex assigned at birth.
Exhibit symptoms which may include:
- A desire for others to treat them as another gender.
- Discomfort with their genitals or sex characteristics.
- A wish for their genitals or sex characteristics to align with a different gender.
- A strong sense of belonging to another gender despite external perceptions.
The gender incongruence causes significant impairment in functioning across social, occupational, school, or daily life.

The primary symptom of GD is distress stemming from incongruence between a person's experienced gender and assigned sex/gender.

Common indicators of GD in children:
- Preference for opposite-sex typical toys, games, or activities.
- Strong dislike of their own genitals.
- A preference for playmates of the opposite sex.
Children with GD may also experience:
- Social isolation, anxiety, loneliness, and depression.
The diagnosis for children is considered separately from that for adults, cognizant of their typically limited insight and ability to articulate their experiences.

Symptoms include:
- A desire to be and be treated as the other gender.
- Increased risk for:
- Stress
- Isolation
- Anxiety
- Depression
- Poor self-esteem
- Suicide
Studies highlight high rates of suicide attempts among transgender individuals:
- Approximately 41% of a sample of 6,450 transgender individuals in the U.S. had attempted suicide.
- Comparatively low rates for the general population show a national average of 1.6%.
Results suggest that individuals with strong family support post-transition experience lower suicide attempts, yet overall risks remain elevated for transgender persons.
Transgender individuals also face heightened risks for:
- Eating disorders
- Substance abuse

Transgender refers to individuals whose internal sense of gender does not align with their sex assigned at birth.
Genderfluid indicates a gender identity that varies over time.
Gender non-conforming encompasses anyone whose demeanor and behavior defy traditional gender roles.

Transitioning involves actions taken by a transgender person to make their external presentation align with their experienced gender, which may include:
- Changes in name and pronouns
- Alterations in dress or appearance
- Medical procedures including hormone therapy or surgery.
Types of transition include:
- Social Transition: Changing name, pronouns, attire.
- Legal Transition: Changes to legal documents (e.g., name change).
- Medical Transition: Hormonal treatments or surgeries to alter physical characteristics.

A newly added specifier for individuals who have transitioned to their gender identity (through surgeries or hormonal treatments) to ensure ongoing access to necessary treatments.

Early-Onset Gender Dysphoria:
- Observable behaviors during childhood.
- May decrease as individuals identify as gay or homosexual during a period before potentially re-experiencing GD.
- Typically, adults from this group are attracted to the sex assigned at their birth.
Late-Onset Gender Dysphoria:
- No visible signs in early childhood; may have unreported wishes to be of the opposite sex.
- Trans women may identify as lesbians.
- Individuals assigned female at birth typically experience early-onset GD.

Occurrence rates:
- 1 in 30,000 individuals assigned male at birth
- 1 in 100,000 individuals assigned female at birth
Estimated prevalence rates:
- 0.005% to 0.014% of individuals assigned male
- 0.002% to 0.003% of individuals assigned female
Greater likelihood of being assigned male at birth among those transitioning in adulthood, while childhood transitions present a closer ratio of 1:1.
2016 analysis: 390 per 100,000 adults identified as transgender, with anticipated future surveys reflecting increased prevalence.
Recent data indicated that approximately 1.4 million individuals (0.6%) in the U.S. identify as transgender, with underrepresentation likely due to stigma and reluctance to participate in surveys.
Notable increases in the population seeking healthcare in recent years.

Substance Use Disorders:
- Approximately 28% report substance abuse issues.
Suicidal Ideation:
- Around 48.3% reported suicidal thoughts; 23.8% had attempted suicide.
Common comorbidities include:
- Anxiety
- Depression
- Personality Disorders (with 52% prevalence cited in specific cases).

Unclear origins; suggested links to a biopsychosocial model.
Congenital adrenal hyperplasia and androgen insensitivity syndrome can influence gender identity and development.
In-utero exposure to chemicals such as phthalates and polychlorinated biphenyls linked to gender dysphoria.

Higher prevalence noted in individuals with Schizophrenia and Autism Spectrum Disorder, indicating possible neuroanatomical links requiring further study.
Childhood trauma may correlate with reports of GD as well as poor mental health outcomes among affected individuals.
Neuroanatomical studies have indicated links to faulty development in certain brain regions, particularly in the hypothalamus.

Evidence of heritability; higher prevalence observed among monozygotic twins compared to dizygotic twins.
Certain alleles linked to gender dysphoria (e.g., CYP17 and CYP17T-34C), though distinction between causation and correlation remains challenging.