Gender dysphoria

Gender dysphoria (GD) is the distress a person feels due to a mismatch between their gender identity and their sex assigned at birth. People who experience gender dysphoria are typically transgender. The diagnostic label gender identity disorder (GID) was used by the DSM until it was renamed gender dysphoria in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.[4]

Gender dysphoria
Other namesGender identity disorder
SpecialtyPsychiatry, psychology 
SymptomsDistress related to one's assigned gender or sex[1][2]
ComplicationsEating disorders, suicide, depression, anxiety, social isolation[3]
Differential diagnosisVariance in gender identity or expression that is not distressing[1][2]
TreatmentTransitioning, psychotherapy[2]
MedicationHormones (e.g., androgens, antiandrogens, estrogens)
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Gender nonconformity is not the same thing as gender dysphoria,[5] and the American Psychiatric Association states that "gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition."[1]

Evidence from studies of twins suggests that gender dysphoria likely has genetic causes in addition to environmental ones.[6][7] Some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender.[4][8][9]

Treatment for gender dysphoria may involve supporting the person through changes in gender expression. Hormone therapy or surgery may be used to assist such changes.[2] Treatment may also include counseling or psychotherapy.[2]

Signs and symptoms

Gender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset. Early-onset gender dysphoria is behaviorally visible in childhood. Sometimes gender dysphoria will desist in this group and they will identify as gay or homosexual for a period of time, followed by recurrence of gender dysphoria. This group is usually sexually attracted to members of their natal sex in adulthood. Late-onset gender dysphoria does not include visible signs in early childhood, but some report having had wishes to be the opposite sex in childhood that they did not report to others. Trans women who experience late-onset gender dysphoria will often be sexually attracted to women and may identify as lesbians. Those with late-onset gender dysphoria frequently engage in transvestic behavior with sexual excitement. In those assigned female at birth, early-onset gender dysphoria is the most common course. This group is usually sexually attracted to women. Trans men who experience late-onset gender dysphoria will often be sexually attracted to men and may identify as gay.[10]

Symptoms of GD in children include preferences for opposite sex-typical toys, games, or activities; great dislike of their own genitalia; and a strong preference for playmate of opposite sex children.[11] Some children may also experience social isolation from their peers, anxiety, loneliness, and depression.[3] According to the American Psychological Association, transgender children are more likely to experience harassment and violence in school, foster care, residential treatment centers, homeless centers and juvenile justice programs than other children.[12] Additionally, some child psychologists continue to use misgendering and pathologizing language and approaches with transgender children, contrary to APA policy statements.[13]

In adolescents and adults, symptoms include the desire to be and to be treated as the other gender.[11] Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide.[3] Studies indicate that transgender people have an extremely high rate of suicide attempts; one study of 6,450 transgender people in the United States found 41% had attempted suicide, compared to a national average of 1.6%. It was also found that suicide attempts were less common among transgender people who said their family ties had remained strong after they came out, but even transgender people at comparatively low risk were still much more likely to have attempted suicide than the general population.[14] Transgender people are also at heightened risk for eating disorders[15] and substance abuse.[16]

Causes
Main article: Causes of transsexuality

A twin study (based on seven people in a 314 sample) suggested that GID may be 62% heritable, indicating the possibility of a genetic influence as its origin, in these cases.[17]

Diagnosis

The American Psychiatric Association permits a diagnosis of gender dysphoria in adolescents or adults if two or more of the following criteria are experienced for at least six months' duration:[11]

  • A strong desire to be of a gender other than one's assigned gender
  • A strong desire to be treated as a gender other than one's assigned gender
  • A significant incongruence between one's experienced or expressed gender and one's sexual characteristics
  • A strong desire for the sexual characteristics of a gender other than one's assigned gender
  • A strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed gender
  • A strong conviction that one has the typical reactions and feelings of a gender other than one's assigned gender

In addition, the condition must be associated with clinically significant distress or impairment.[11]

The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own.[11] The diagnosis was renamed from gender identity disorder to gender dysphoria, after criticisms that the former term was stigmatizing.[18] Subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults, as "gender dysphoria in children". The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.[19] Other specified gender dysphoria or unspecified gender dysphoria can be diagnosed if a person does not meet the criteria for gender dysphoria but still has clinically significant distress or impairment.[11] Intersex people are now included in the diagnosis of GD.[20]

The International Classification of Diseases (ICD-10) lists several disorders related to gender identity:[21][22]

  • Transsexualism (F64.0): Desire to live and be accepted as a member of the opposite sex, usually accompanied by a desire for surgery and hormonal treatment
  • Gender identity disorder of childhood (F64.2): Persistent and intense distress about one's assigned gender, manifested prior to puberty
  • Other gender identity disorders (F64.8)
  • Gender identity disorder, unspecified (F64.9)
  • Sexual maturation disorder (F66.0): Uncertainty about one's gender identity or sexual orientation, causing anxiety or distress

The ICD-11, which will come into effect on 1 January 2022, significantly revises classification of gender identity-related conditions.[23] Under "conditions related to sexual health", the ICD-11 lists "gender incongruence", which is coded into three conditions:[24]

  • Gender incongruence of adolescence or adulthood (HA60): replaces F64.0
  • Gender incongruence of childhood (HA61): replaces F64.2
  • Gender incongruence, unspecified (HA6Z): replaces F64.9

In addition, sexual maturation disorder has been removed, along with dual-role transvestism.[25] ICD-11 defines gender incongruence as "a marked and persistent incongruence between an individual’s experienced gender and the assigned sex", with presentations similar to the DSM-5 definition, but does not require significant distress or impairment.

Management

Treatment for a person diagnosed with GD may include psychotherapy or to support the individual's preferred gender through hormone therapy, gender expression and role, or surgery. This may include psychological counseling, resulting in lifestyle changes, or physical changes, resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries.[26] The goal of treatment may simply be to reduce problems resulting from the person's transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing, or counseling a spouse to help them adjust to the patient's situation.[27]

Guidelines have been established to aid clinicians. The World Professional Association for Transgender Health (WPATH) Standards of Care are used by some clinicians as treatment guidelines. Others use guidelines outlined in Gianna Israel and Donald Tarver's Transgender Care. Guidelines for treatment generally follow a "harm reduction" model.[28][29][30]

Prepubescent children

The question of whether to counsel young children to be happy with their assigned sex, or to encourage them to continue to exhibit behaviors that do not match their assigned sex—or to explore a transgender transition—is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.[31][32][33] Others clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.[34]

Professionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender reassignment leading to surgical gender reassignment will be in that person's best interest.[35]

Psychological treatments
Main article: Psychotherapy

Until the 1970s, psychotherapy was the primary treatment for gender dysphoria, and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions.[36] Psychotherapeutic treatment of GID involves helping the patient to adapt. Attempts to cure GID by changing the patient's gender identity to reflect birth characteristics have been ineffective.[37]:1741

Biological treatments
Main article: Sex reassignment therapy

Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual's physical body and gender identity.[38] Biological treatments for GID without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GID treatment, they often feel lost and confused when their biological treatments are complete.[39]

Psychotherapy, hormone replacement therapy, and sex reassignment surgery together can be effective treating GID when the WPATH standards of care are followed.[37]:1570 The overall level of patient satisfaction with both psychological and biological treatments is very high.[36]

In April 2011, the UK National Research Ethics Service approved prescribing monthly injection of puberty-blocking drugs to youngsters from 12 years old, in order to enable them to get older before deciding on formal sex change. The Tavistock and Portman NHS Foundation Trust (T&P) in North London has treated such children. Clinic director Dr. Polly Carmichael said, "Certainly, of the children between 12 and 14, there's a number who are keen to take part. I know what's been very hard for their families is knowing that there's something available but it's not available here." The clinic received 127 referrals for gender dysphoria in 2010.[40]

The T&P completed a three-year trial to assess the psychological, social and physical benefits and risks involved for 12- to 14-year-old patients. The trial was deemed such a success that doctors have decided to make the drugs more widely available and to children as young as 9 years of age. As recently as 2009, national guidelines stated that treatment for gender dysphoria should not start until puberty had finished. Ferring Pharmaceuticals manufactures the drug Triptorelin, marketed under the name Gonapeptyl, at £82 per monthly dose. The treatment is reversible, which means the body will resume its previous state upon discontinuation of drugs.

Epidemiology

Gender dysphoria occurs in one in 30,000 male-assigned births and one in 100,000 female-assigned births.[41] Estimated rates of those with a transgender identity range from a lower bound of 1:2000 (or about 0.05%) in the Netherlands and Belgium[42] to 0.5% of Massachusetts adults.[43] From a national survey of high-school students in New Zealand, 8,500 randomly selected secondary school students from 91 randomly selected high schools found 1.2% of students responded "yes" to the question "Do you think you are transgender?".[44] These numbers are based on those who identify as transgender. It is estimated that about 0.005% to 0.014% of people assigned male at birth and 0.002% to 0.003% of people assigned female at birth would be diagnosed with gender dysphoria, based on 2013 diagnostic criteria, though this is considered a modest underestimate.[45] Research indicates people who transition in adulthood are up to three times more likely to be male assigned at birth, but that among people transitioning in childhood the sex ratio is close to 1:1.[46]

History

The term gender identity disorder is an older term for the condition in the DSM. The American Psychiatric Association (APA) uses the term gender dysphoria.[47] The APA's DSM first described the condition in the third publication ("DSM-III") in 1980.[48]

Society and culture
A sign at a trans rights rally: "Gender is like that old jumper from my cousin: It was given to me and it doesn't fit."

GD is when a person suffers distress due to gender identity.[3] Researchers disagree about the nature of distress and impairment in people with GID. Some authors have suggested that people with GID suffer because they are stigmatized and victimized;[49] and that, if society had less strict gender divisions, transsexual people would suffer less.[50]

Some controversy surrounds the creation of the GD diagnosis, with Davy et al. stating that although the creators of the diagnosis state that it has rigorous scientific support, "it is impossible to scrutinize such claims, since the discussions, methodological processes, and promised field trials of the diagnosis have not been published."[20]

Gender as a social construction

Social gender characteristics are created and supported by the expectations of a culture, and are therefore only partially related to biological sex. For example, the association of particular colors with "girl" or "boy" babies begins extremely early in Western European-derived cultures. Other expectations relate to approved and allowable behaviors and emotional expression.[51]

Some cultures have three defined genders: man, woman, and effeminate man. For example, in Samoa, the fa'afafine, a group of feminine males, are entirely socially accepted. The fa'afafine do not have any of the stigma or distress typically associated in most cultures with deviating from a male/female gender role. This suggests the distress so frequently associated with GID in a Western context is not caused by the disorder itself, but by difficulties encountered from social disapproval by one's culture.[52] However, research has found that the anxiety associated with gender dysphoria persists in cultures, Eastern or otherwise, which are more accepting of gender nonconformity.[53]

In Australia, a 2014 High Court of Australia judgment unanimously ruled in favor of a plaintiff named Norrie, who asked to be classified by a third gender category, 'non-specific', after a long court battle with the NSW Registrar of Births, Deaths and Marriages.[54] However, the Court did not accept that gender was a social construction: it found that sex reassignment "surgery did not resolve her sexual ambiguity".[54]:para 11

Classification as a disorder

The psychiatric diagnoses of gender identity disorder (now gender dysphoria) was introduced in DSM-III in 1980. Arlene Istar Lev and Deborah Rudacille have characterized the addition as a political maneuver to re-stigmatize homosexuality.[55][56] (Homosexuality was removed from DSM-II in 1974.) By contrast, Kenneth Zucker and Robert Spitzer argue that gender identity disorder was included in DSM-III because it "met the generally accepted criteria used by the framers of DSM-III for inclusion."[57] Some researchers, including Robert Spitzer and Paul J. Fink, contend that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction.[58] The American Psychiatric Association stated that gender nonconformity is not the same thing as gender dysphoria,[5] and that "gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition."[1]

Individuals with gender dysphoria may or may not regard their own cross-gender feelings and behaviors as a disorder. Advantages and disadvantages exist to classifying gender dysphoria as a disorder.[2] Because gender dysphoria had been classified as a disorder in medical texts (such as the previous DSM manual, the DSM-IV-TR, under the name "gender identity disorder"), many insurance companies are willing to cover some of the expenses of sex reassignment therapy. Without the classification of gender dysphoria as a medical disorder, sex reassignment therapy may be viewed as cosmetic treatment, rather than medically necessary treatment, and may not be covered.[59] In the United States, transgender people are less likely than others to have health insurance, and often face hostility and insensitivity from healthcare providers.[60]

The DSM-IV-TR diagnostic component of distress is not inherent in the cross-gender identity; rather, it is related to social rejection and discrimination suffered by the individual.[52] Psychology professor Darryl Hill insists that gender dysphoria is not a mental disorder, but rather that the diagnostic criteria reflect psychological distress in children that occurs when parents and others have trouble relating to their child's gender variance.[58] Transgender people have often been harassed, socially excluded, and subjected to discrimination, abuse and violence, including murder.[3][50]

In December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states, "What transsexualism is not ... It is not a mental illness."[61] In May 2009, the government of France declared that a transsexual gender identity will no longer be classified as a psychiatric condition,[62] but according to French trans rights organizations, beyond the impact of the announcement itself, nothing changed.[63] Denmark made a similar statement in 2016.[64]

In ICD-11, GID is reclassified as "gender incongruence", a condition related to sexual health.[24] The working group responsible for this recategorization recommended keeping such a diagnosis in ICD-11 to preserve access to health services.[25]

Intimate relationships

Intimate relationships between lesbians and female-to-male people with GID will sometimes endure throughout the transition process, or shift to becoming supportive friendships. Intimate relationships between heterosexual women and male-to-female people with GID often suffer once the GID is known or revealed. Researchers say the fate of the relationship seems to depend mainly on the woman's adaptability. Problems often arise, with the cisgender partner becoming increasingly angry or dissatisfied, if her partner's time spent in a female role grows, if her partner's libido decreases, or if her partner is angry and emotionally cut-off when in the male role. Cisgender women sometimes also worry about social stigma and may be uncomfortable with the bodily feminization of their partner as the partner moves through transition. The cisgender women who are likeliest to accept and accommodate their partner's transition, researchers say, are those with a low sex drive or those who are equally sexually attracted to men and women.[65]

See also
  • List of transgender-related topics

References
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