Gender Dysphoria

Gender dysphoria is a diagnosis that refers to people whose gender at birth is contrary to the one they identify with. It constitutes a new diagnostic class in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), replacing the DSM-IV diagnosis of gender identity disorder. ^[1]

The DSM-5-TR diagnostic criteria for gender dysphoria include strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage. Adolescents and adults may have a preoccupation with getting rid of primary and secondary sex characteristics, and they may believe that they were born as the wrong sex. People with gender dysphoria do not have a concurrent physical intersex condition. Patients report significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic criteria (DSM-5)

Adolescents and adults

According to DSM-5-TR, the first requirement for the diagnosis of gender dysphoria in adolescents and adults is a marked incongruence between the patient’s experienced or expressed gender and his or her assigned gender. ^[1] This incongruence must have lasted for at least 6 months and must include at least 2 of the following 6 criteria:

• Marked incongruence between the patient’s experienced or expressed gender and his or her primary or secondary sex characteristics

• Strong desire to be rid of his or her primary or secondary sex characteristics (or, in young adolescents, to prevent the development of the anticipated secondary characteristics)

• Strong desire for the primary or secondary sex characteristics of the other gender

• Strong desire to be of the other (or some alternative) gender

• Strong desire to be treated as the other (or some alternative) gender

• Strong conviction of having the typical feelings and reactions of the other (or some alternative) gender

The second requirement is that the condition be associated with clinically significant distress or impairment of social, occupational, or other important areas of functioning.

In addition, the clinician should specify whether the condition is occurring in conjunction with a disorder of sex development and, if so, should code that disorder as well.

The clinician may also specify whether the individual has made the transition to living in the desired gender on a full-time basis.

Children

The first requirement for the diagnosis of gender dysphoria in children is, again, a marked incongruence between the patient’s experienced or expressed gender and his or her assigned gender. ^[1] This incongruence must have lasted for at least 6 months and must include at least 6 of the following 8 criteria (with the first criterion being mandatory):

• Strong desire to be of the other (or some alternative) gender or insistence that one already is

• Strong preference for cross-dressing or simulating female attire (boys); strong preference for typical masculine clothing and resistance to typical feminine clothing (girls)

• Strong preference for cross-gender roles in make-believe or fantasy play

• Strong preference for the stereotypical toys, games, or pastimes of the other gender

• Strong preference for playmates of the other gender

• Strong rejection of typically masculine toys, games, and activities, with strong avoidance of rough play (boys); strong rejection of typically feminine toys, games, and activities (girls)

• Strong dislike of one’s sexual anatomy

• Strong desire for the primary or secondary sex characteristics that match one’s experienced gender

The second requirement is that the condition be associated with clinically significant distress or impairment of social, school, or other important areas of functioning.

In addition, the clinician should specify whether the condition is occurring in conjunction with a disorder of sex development and, if so, should code that disorder as well.

Psychological factors

In a 1968 publication, rooted in psychoanalytic theory, Stoller described a typical background from which a male transsexual might emerge. ^[4]

In this scenario, a woman whose mother did not encourage her daughter’s femininity marries a passive man, for a relationship that is unsatisfactory for both but is often lasting. ^[4] This depressed woman has a male child. A blissful symbiosis is established between mother and son. The father does not try to break the symbiosis and tends to stay away from home. Excessive physical and emotional closeness to the mother for too long a time leads to feminine identification and behaviors that secretly please the mother, who reinforces them.

Stroller viewed this nonconflictual learning process as similar to imprinting. In contrast, he viewed homosexuality and transvestism as end results of defense against the trauma of dangerous and painful interpersonal relationships.

In a 1974 publication, Person and Ovesey postulated a different, yet still psychosocial, etiology that was based on a study of 10 primary transsexuals (individuals with gender dysphoria). ^[5]

Although all 10 subjects in the study envied girls and engaged in cross-dressing behavior, starting at age 3-10 years, none believed he was a girl, and 9 gave no history of feminine behavior. ^[5] They were loners, with few age mates of either sex, and they had feelings of anxiety, depression, and loneliness. They were asexual and loathed their male characteristics. Their wish to be female was based on a fantasy of symbiotic fusion with the mother as a way of dealing with extreme separation anxiety.

Stoller described the psychoanalytic etiology of female transsexualism as unclear but listed some preliminary findings, as follows:

• Neither the mother nor the father of the girl has a gender disorder

• The mother is unable to function in the first months or year of the daughter’s life, because of deep depression (or, in a minority of cases, paranoia or physical illness)

• The child knows that the mother is present but beyond emotional reach

• The father does not minister to his wife; rather, he has the daughter minister to her

• The daughter is described as vigorous, ungraceful, and unattractive in infancy

• The father engages the daughter in activities that interest him, thus promoting masculine behavior

• By the age of 4-5 years, the daughter already yearns to have the anatomic insignias of maleness, a yearning born out of pain and conflict from premature maternal separation

It should be kept in mind that these ideas are preliminary postulates rather than established facts; confirming data are unavailable.

Retrospective studies in adult transsexuals have shown differences in recalled child-rearing patterns between transsexuals and normative groups. Male-to-female transsexuals characterized their fathers as less emotionally available, less warm, more rejecting, and overly controlling. Female-to-male transsexuals characterized both parents as more rejecting and less emotionally warm, but they characterized only their mothers, not their fathers, as overprotective.

It has been argued that the development of transsexualism is the “result of a non-conflictual process, where gender identity is precociously fixed [and] ... considered to be an entirely particular phenomenon, so that its aetiology must be clearly distinguished from both perversions and atypical sex change requests.” ^[6] Essentially, the boy has had a happy symbiosis with the mother and develops from early infancy an identity with the female gender, which the family adapts to and supports. ^{[7, 8]}

Biologic factors

Biomedical research into transsexualism has investigated several areas. Girls with congenital adrenal hyperplasia (CAH), a condition causing prenatal exposure to a relatively high level of androgens, have been examined to determine whether male gender identity develops even if XX-chromosome individuals are raised as females. A few such cases have been reported. In most cases, however, girls assigned and reared consistently as girls do not become transsexuals.

Transsexualism has not been observed in males or females exposed to progestogens in utero, which might have antiandrogenic or androgenic qualities, nor has it been found upon exposure to estrogenic drugs, such as diethylstilbestrol (DES). Nevertheless, some atypical aspects of gender role behavior have been observed.

In 1983, Dörner et al found that male-to-female transsexuals, like females, showed a rise in luteinizing hormone (LH) levels after estrogen stimulation as a consequence of prenatal exposure to imbalanced sex steroid levels ^[9] ; the opposite occurred in female-to-male transsexuals. However, other studies that used more rigorous endocrine methodologies were unable to replicate this study’s findings.

Several hypothalamic nuclei in humans have been reported to be sexually dimorphic with respect to size or shape, including the following:

• A sexually dimorphic nucleus (SDN) of the preoptic area of the hypothalamus (SDN-POA61)

• Two cell groups in the anterior hypothalamus (isonicotinic acid hydrazide [INAH]-262-64 and INAH-362)

• The darkly staining posteromedial component of the bed nucleus of the stria terminalis (BNST-dspm)

• The suprachiasmatic nucleus (SCN) and the central subdivision of the bed nucleus of the stria terminalis (BSTc)

These sex differences in the hypothalamus are believed to underlie sex differences in gender identity, reproduction, and sexual orientation. Clearly, more solid well-designed research into the biology of these disorders is needed.

Some studies suggest that male gender identity may be partly mediated through the androgen receptor. ^[10] The relative contribution of sex hormones and other nonhormonal factors may be an area where further research is needed. ^[11]

According to DSM-5-TR, the prevalence of gender dysphoria is 0.005–0.014% for adult natal males and 0.002-0.003% for adult natal females. ^[1] In Europe, 1 per 30,000 adult males and 1 per 100,000 adult females seek sexual reassignment surgery (SRS).

In children, gender dysphoria is 2–4.5 times more common among natal boys than among natal girls. In adolescents, the male-to-female ratio is closer to parity. In adults, the male-to-female ratio is generally weighted toward natal males, ranging from 1:1 to 6.1:1; however, it tends toward natal females in both Japan (1:2.2) and Poland (1:3.4).

Transgender adults may be more likely to have unhealthy habits and medical issues than cisgender individuals. A study of 3075 transgender adults and 719,567 cisgender adults found that transgender individuals were more likely to smoke, to be sedentary, and to not have health insurance.Transgender individuals were also 30% more likely to report their health as "fair" or "poor" and 66% more likely to experience severe mental distress. ^[12]

Existing case reports do not indicate that psychotherapy produces complete and long-term reversal of cross-gender identity. Transsexuals are not a homogeneous group. Some transsexuals do not show severe psychopathology. Diagnosing and treating this disorder early can reduce the chances of depression, emotional distress, and suicide. Gender dysphoria is not the same as homosexuality. How the gender conflict occurs is different in each person. For example, some people may cross-dress, while others want sex change surgery. Some people of one gender privately identify more with the other gender. ^[13]

People who are born with ambiguous genitalia, which can raise questions about their gender, may qualify for the diagnosis of gender dysphoria. ^[13]

SRS may be a viable treatment solution for some. Satisfactory results are reported in 87% of male-to-female and 97% of female-to-male SRS patients. Factors associated with relatively poor post-SRS functioning include the following:

• Transvestic disorder

• Effeminate homosexuality

• SRS performed late in life

• Bad surgical results

• Suicidal intentions

• Inadequate social functioning

• Loss of work and family

• Uncooperative attitude toward clinicians

• Enduring resistance towards being transsexual

Outcome studies suggest that transsexuals without severe psychopathology are better off when treated promptly after diagnosis. Transsexuals who have severe psychopathology, are not homosexual, or have a late-onset gender identity disorder should not necessarily be excluded from SRS; however, they require more care and extensive evaluation and therapeutic support before SRS is deemed viable.

Patients should be educated about the differences between true transsexualism and other gender issues, such as transvestic fetishism, nonconformity to stereotypical sex role behaviors, gender dysphoria, and homosexuality. Both patients and their families need to understand the complexities of gender dysphoria, its enduring nature, and the challenges that it typically presents.

Treatment options should be discussed. When SRS is being considered, it should be explained that the procedure does not produce a trouble-free life. Additionally, work and social adjustment issues must be discussed, and plans for addressing these concerns must be developed. The importance of continuing family support and understanding should also be addressed. Finally, the need for long-term therapy and social support should be discussed and encouraged when appropriate.

Patient and family education remains an important aspect of treatment. An extensive summary of standards of care for transsexual, transgender, and gender-nonconforming people is available from the World Professional Association for Transgender Health (WPATH). ^[3]