Gender Dysphoria

12 Key excerpts on "Gender Dysphoria"

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  Sperling Pediatric Endocrinology E-Book

  • Mark A. Sperling(Author)
  • 2020(Publication Date)
  • Elsevier

    (Publisher)

  3 Sexual orientation is one’s sexual attraction toward partners of the opposite sex/gender (heterosexual), same sex/gender (homosexual), or both (bisexual). Gender identity does not predict sexual orientation. A person of any gender may have any sexual orientation.

  “Gender Dysphoria,” listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM) V refers to clinically significant distress of at least 6 months, duration, related to the incongruence between one’s affirmed or experienced gender and one’s “assigned (or natal) gender” (gender incongruence).4 This term replaces gender identity disorder (GID), which was included in the earlier DSM IV. Replacing the term “disorder” with “dysphoria” underscores the concept that a transgender identity, in and of itself, is no longer considered pathological, and focuses clinical concern on the distress that an individual with GI may experience. A summary of terms used in this chapter is detailed in Box 19.1 .

  Box 19.1 Definitions of Terms Used in This Chapter

  • Biological sex, biological male or female: These terms refer to physical aspects of maleness and femaleness. As these may not be in line with each other (e.g., a person with XY chromosomes may have female-appearing genitalia), the terms biological sex and biological male or female are imprecise and should be avoided.
  • Cisgender: This means not transgender. An alternative way to describe individuals who are not transgender is “nontransgender people.”
  • Gender-affirming (hormone) treatment: See “gender reassignment”
  • Gender Dysphoria: This is the distress and unease experienced if gender identity and designated gender are not completely congruent. In 2013 the American Psychiatric Association released the fifth edition of the DSM-5, which replaced “gender identity disorder” with “Gender Dysphoria” and changed the criteria for diagnosis.
  • Gender expression: This refers to external manifestations of gender, expressed through one’s name, pronouns, clothing, haircut, behavior, voice, or body characteristics. Typically, transgender people seek to make their gender expression align with their gender identity, rather than their designated gender.

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  Diagnosing and Treating Children and Adolescents

  A Guide for Mental Health Professionals

  • Brandé Flamez, Carl J. Sheperis(Authors)
  • 2015(Publication Date)
  • Wiley

    (Publisher)

  Gender Dysphoria refers to a condition in which one experiences a marked incongruence between one's expressed and assigned gender (e.g., a child who was assigned female at birth but who identifies his gender as a boy). It is estimated that 0.005 percent to 0.014 percent of biological men and 0.002 percent to 0.003 percent of biological women experience Gender Dysphoria (APA, 2013a). There are no accurate statistics. Gender Dysphoria typically has early onset, which begins during childhood. Although less common, the late onset in adolescence or adulthood is also presented. There are different theories surrounding what causes Gender Dysphoria—atypical gender development. Although some scholars believe psychological factors (e.g., upbringing and mental disorders) significantly contribute to Gender Dysphoria (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker, 2003; de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011), others speculate that biological factors (e.g., brain structure and genetics) play an important role in the development of Gender Dysphoria (Carrillo et al., 2010; Meyer-Bahlburg, 2010). To date, however, there is no conclusive evidence as to what causes Gender Dysphoria. The plausible etiological explanation of Gender Dysphoria is “most likely a multifactorial condition in which psychological as well as biological aspects play some role” (de Vries & Cohen-Kettenis, 2012, p. 304). The clinical presentation of Gender Dysphoria in children differs from the clinical presentation in adolescents and adults (see Table 15.1). In adolescents and adults, Gender Dysphoria is characterized by a strong and persistent desire to become a gender not assigned at birth (e.g., adopting mannerisms and gender roles of the desired gender) and to be free of one's primary and secondary sex characteristics

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  When Harry Became Sally

  Responding to the Transgender Moment

  • Ryan T. Anderson(Author)
  • 2018(Publication Date)
  • Encounter Books

    (Publisher)

  One report from 2016 says that somewhere around 0.6 percent of adults in the United States “identify as a gender that does not correspond to their biological sex.” 7 Another says: “Gender discordance occurs in 0.001% of biological females and in 0.0033% of biological males.” 8 That is a wide statistical spread: more than one in every 200 people at the high end; fewer than one in 20,000 at the low end. According to new clinical guidelines, however, not all of the people who experience a discordant gender identity have “Gender Dysphoria,” a term that refers more specifically to distress associated with a transgender identity. 9 In the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Gender Dysphoria is defined as “incongruence between one’s experienced/expressed gender and assigned gender” in conjunction with “clinically significant distress or impairment in social, occupational, or other important areas of functioning.” 10 Immediately we notice some politicized language, in the reference to assigned gender rather than biological sex. But leave that aside for now. The more pertinent point here is that the APA now says that a patient has Gender Dysphoria only when there is “significant distress or impairment” arising from the disconnection between bodily sex and internal sense of gender. This is a change from the previous edition of the DSM, which listed “gender identity disorder” rather than “Gender Dysphoria,” and said that anyone who persistently manifests an incongruence between biological sex and experienced gender has this disorder. As Dr. McHugh explains, that earlier clinical definition correctly encompassed the dual nature of the disorder: “This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality

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  Selecting Effective Treatments

  A Comprehensive, Systematic Guide to Treating Mental Disorders

  • Lourie W. Reichenberg, Linda Seligman(Authors)
  • 2016(Publication Date)
  • Wiley

    (Publisher)

  DSM-5 has changed important criteria and no longer considers doubts about one's gender to constitute a mental disorder. Rather, Gender Dysphoria is solely concerned with the affective concerns and not the determination of the physical outcome.

  Similar to other DSM-5 disorders, clinically significant distress must be associated with the condition. In other words, doubts about one's gender or gender nonconformity do not constitute a mental disorder. Rather, clinically significant distress or impairment in social, occupational, or other important areas of functioning must be present (American Psychiatric Association [APA], 2013). DSM-5 contains separate sets of criteria for Gender Dysphoria in children, adolescents, and adults.

  By reconceptualizing the disorder to focus on affective or cognitive discontent with one's natal gender, the focus is on the distress that accompanies the dissonance between perceived identity and natal gender.

  To meet the criteria for Gender Dysphoria, the following must be present:

  • A marked difference between the person's expressed gender and the gender he or she is born with.
  • The gender incongruence must cause clinically significant distress in major areas of functioning.
  • The symptoms must be present for at least 6 months.
  • In children, the desire to be another gender must be present and verbalized.

  For children, adolescents, and adults, the specifier “with a disorder of sex development” is added if a congenital condition such as congenital adrenogenital disorder is present.

  For adults who have transitioned to living full-time in the preferred gender and who have undergone or are considering pursuing at least one cross-gender medical procedure (e.g., hormone treatment, gender reassignment surgery), the specifier “Posttransition” can be given. The posttransition specifier is used in the context of continuing treatment procedures that serve to support the new gender assignment.

  Client Characteristics

  Gender identity is a fluid concept that may be questioned many times over the course of a lifetime. The concept encompasses feelings about the body, social roles, gender identification, and sexuality. Gender Identity Disorder was considered to be a pejorative term, and was a controversial diagnosis in DSM-IV

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  Transgender Mental Health

  • Eric Yarbrough(Author)
  • 2018(Publication Date)
  • American Psychiatric Association Publishing

    (Publisher)

  Part II

  Mental Health–Related Topics

  Passage contains an image

  7

  THE Gender Dysphoria DIAGNOSIS

  My problem isn’t that I was born transgender. My problem is that I wasn’t born female. A woman of trans experience

  THE QUOTATION ABOVE was spoken to me by a long-term patient who is a woman of trans experience. It sums up the arguments that go into having or not having a psychiatric diagnosis of Gender Dysphoria. The presence of Gender Dysphoria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013 ) is a controversial one (Drescher et al. 2012 ). There are proponents who would like to see the diagnosis removed altogether, and there are many who would like to see some form of diagnosis remain. Even trying to understand what Gender Dysphoria means is complicated. Understanding the diagnosis of Gender Dysphoria and how to apply it to patient care means knowing it from a historical, cultural, and scientific perspective.

  GENDER VARIANCE IS NOT A MENTAL ILLNESS

  A diagnosis of Gender Dysphoria can and should be used in cases where treatment is necessary. However, the presence of gender variance in itself does not imply the presence of a mental disorder. Further, although Gender Dysphoria is found in psychiatry’s diagnostic manual, DSM, the World Health Organization is preparing to move its gender diagnoses (referred to as gender incongruence ) out of the mental disorders section of the International Classification of Diseases (ICD) and into a new chapter provisionally called “Conditions Related to Sexual Health” (Drescher et al. 2012 ; Reed et al. 2016 ). However, many people still associate the word transgender

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  Complex Disorders in Pediatric Psychiatry

  A Clinician's Guide

  • David I Driver, Shari Thomas(Authors)
  • 2018(Publication Date)
  • Elsevier

    (Publisher)

  We first aim to help providers have a sense of the difference between assigned sex, gender identity, and gender role and how Gender Dysphoria affects children and adolescents. It is important to have a common language to discuss the differences and relationships between sex, gender identity, and gender expression. Biologic sex is defined as the set of anatomic and hormonal differences that have historically defined male and female. These are affected by the individual’s genetic makeup. This is different from an individual’s gender identity, which is an individual’s subjective sense of his/her own gender as male, female, or another gender identification. Gender variance is encompassed within gender identity, as it describes any variability in gender identity or gender role. Gender role is the behaviors and roles learned by an individual as determined by the cultural norms. Gender expression is how an individual presents his/her gender through his/her actions, dress, and demeanor, and how those presentations are based on gender norms.

  Gender Dysphoria is a term created by the Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5 ) to describe the distress that might be present in the context of incongruence between sex assigned at birth and gender identity. There is some controversy around the inclusion of Gender Dysphoria within the diagnostic manuals, as it may inadvertently pathologize gender variance through its inclusion in this manual. Gender variance is a healthy exploration of the gender spectrum. Although we do not believe that gender variance is pathologic, we know that individuals who experience incongruence between biologic sex and gender identity are forced to face intense minority stress, overtly and covertly, and it is unsurprising that transgender adolescents often have alarmingly high rates of mental health issues, including increased suicidal ideation and suicide attempts.1 Minority stress is seen systemically through the chronic violence toward transgender and gender nonconforming individuals, high rates of homelessness, underemployment, and poor medical care for these individuals.

  2 –4

  An individual presenting with Gender Dysphoria might have symptoms that stem from minority stress or might be independent of minority stress; however, the dysphoria is not the result of the individual’s gender identity itself.5

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  The Palgrave Handbook of the Psychology of Sexuality and Gender

  • Christina Richards, Meg-John Barker, Christina Richards, Meg-John Barker, Christina Richards, Meg-John Barker(Authors)
  • 2015(Publication Date)
  • Palgrave Macmillan

    (Publisher)

  There has been enormous debate as to how trans-related issues should be classified, with most people, including psychologists and psychiatrists, agreeing that such states are not indicative of mental illness. Many trans people do not wish to be stigmatised with a mental health diagnosis, and trans activists have long called for the removal of Gender Dysphoria as a psychiatric or psychological diagnosis, arguing that it is harmful and stigmatising and does not fit current aetiological evidence. Parallels have been made with the declassification of homosexuality in the 1970s (Drescher, 2010). However, there was also concern expressed in the run up to the most recent revision of DSM – the DSM-5 – that declassifying trans from the manual might negatively impact on the provision of services such as medicine and surgery by health insurance and taxpayer-funded treatment. There was considerable support for the category of Gender Incongruence, which would have been inclusive of wide varieties of gender identity and expression and does not imply a particular treatment pathway – thereby encompassing those individuals who would not wish to pursue physical treatments. Concerns were raised that, while inclusive, it would encompass individuals for whom no diagnosis was needed, and that some sort of criterion for the distress that individuals experience was needed. The WPATH and APA favoured the diagnostic category Gender Dysphoria (De Cuypere et al., 2010), and Bouman and Richards (2013) have given a critical analysis of the use of the distress criterion in this context.

  The APA have acknowledged that non-conformity to birth-assigned gender is not in and of itself a mental disorder, but have retained the concept of distress as a core criterion for the diagnosis of Gender Dysphoria, which is the term used in DSM-5 (APA, 2013). They have broadened the diagnostic criteria to recognise those individuals who identify as genders other than male or female. The WHO Working Group on the Classification of Sexual Disorders and Sexual Health has recommended a diagnostic change from Transsexualism to Gender Incongruence and removal from the section on mental and behavioural disorders in the forthcoming ICD-11 (Drescher et al., 2012). A separate chapter for Gender Incongruence has been recommended. These are clearly important issues to be resolved, as current health insurance and tax-funded healthcare require a diagnosis to allow access to treatment.

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  Transgender 101

  A Simple Guide to a Complex Issue

  • Nicholas Teich(Author)
  • 2012(Publication Date)
  • Columbia University Press

    (Publisher)

  DSM-5 and how the diagnosis of Gender Dysphoria compares with that of GID.

  Gender Dysphoria: THE NEW DIAGNOSIS8

  The American Psychiatric Association has proposed some major changes in the GID diagnosis for the fifth edition of the DSM. One of these changes is the name of the diagnosis, which will likely be Gender Dysphoria. The group of mental health professionals working on the new diagnosis said that the change in name was due to feedback that the term gender identity disorder was stigmatizing.

  Gender Dysphoria in children constitutes: “A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least 6 of the following indicators (including A1): 1. a strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one’s assigned gender).”9

  Let’s stop there for a moment. The addition of a “marked incongruence” in gender “experience/expression” versus “assigned” gender displays a new understanding by the American Psychiatric Association that (a) people have an “experienced gender” that may or may not be the same as that which is assigned at birth, (b) that the term “assigned” is important because it is not the gender someone is “born as” but the one that is assigned to them at birth by (presumably) the adult delivering the baby, and (c) that there are more than just two genders.

  Criteria 2 through 7 are similar to what they are in GID, though some wording has changed. Criterion 8 reads: “a strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.”10 The assertion that one’s anatomy will spontaneously change, which is in the DSM-IV-TR

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  Gender Dysphoria and Gender Incongruence

  • Walter Bouman, Annelou de Vries, Guy T'Sjoen, Walter Pierre Bouman, Annelou LC de Vries, Guy T'Sjoen(Authors)
  • 2018(Publication Date)
  • Routledge

    (Publisher)

  The point in time that marks the beginning of adolescence might vary depending on whether it is physical pubertal advancement or a youth’s age that one uses to define the precise developmental border (Berenbaum, Beltz, & Corley, 2015). Understanding this distinction is important when considering physical interventions for young people presenting with gender identity concerns, as both physical maturation and psychological maturity associated with age are important determinants of eligibility and readiness for certain treatments as described in the World Professional Association of Transgender Health Standards of Care seventh edition (WPATH SOC7) (Coleman et al., 2011). The potential gap between physical and emotional maturity characterizes the potential dilemmas in assessing and treating transgender adolescents (for example, some individuals enter puberty as young as age nine or even earlier, and some pubertally advanced individuals are not emotionally mature enough to be able to give informed consent at ages as old as 16) (Steinberg, Cauffman, Woolard, Graham, & Banich, 2009).

  In this review we conducted a PubMed search using the terms ‘transgender adolescent’, ‘gender nonconforming youth’, ‘gender identity disorder adolescents’, and ‘Gender Dysphoria adolescent’. Search results were limited to articles within the last 10 years and yielded 70, 3, 42, and 30 articles respectively, with some overlap. Articles that were considered reviews or were out of scope for this review were not included (e.g. not focusing on adolescents, not in English, main scope not related to Gender Dysphoria (GD) or gender nonconformity). The authors also used additional references that were considered to be of great importance or relevance to the current state of affairs in the clinical management of transgender adolescents.

  Terminology

  With terminology constantly evolving, a cursory review of the most widely used definitions is important. ‘Gender identity’ refers to one’s subjective sense of self as male, female, another gender, or a combination of aspects of maleness and/or femaleness. This is distinct from ‘sex’, which refers to anatomical features, including genitalia, that are typically used to assign an individual’s gender at birth. When gender identity and sex are not aligned, the discrepancy has been referred to as ‘gender discordance’ (or incongruence) (Adelson, 2012) that may sometimes result in a negative affective disturbance known as ‘Gender Dysphoria’. The same term describing this phenomenon has also more recently been used as the DSM5 diagnosis Gender Dysphoria (American Psychiatric Association, 2013), with two distinct sets of criteria, one set for children and another for adolescents/adults. In distinguishing the phenomenon from the diagnosis, we will use the acronym GD henceforth only when describing the latter. The International Classification of Diseases (ICD) currently classifies adolescents who desire to be another gender, accompanied by a wish to align their bodies through physical interventions with that gender, as ‘transsexualism’, and details of the history of these diagnoses are better illustrated elsewhere (Drescher, Cohen-Kettenis, & Winter, 2012). Currently, revision proposals of the ICD have suggested replacing the term transsexualism with ‘gender incongruence’. ‘Gender role or expression’ refers to an individual’s outward behavioural demonstration of gender, through mannerisms, clothing, posture, and other factors that a specific culture might associate with a specific gender. ‘Gender nonconformity’ (GNC) refers to gender expression that is non-stereotypical for a particular culture based on an individual’s assigned gender.

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  Rutter's Child and Adolescent Psychiatry

  • Anita Thapar, Daniel S. Pine, James F. Leckman, Stephen Scott, Margaret J. Snowling, Eric A. Taylor, Anita Thapar, Daniel Pine, James F. Leckman, Stephen Scott, Margaret J. Snowling, Eric A. Taylor(Authors)
  • 2015(Publication Date)
  • Wiley-Blackwell

    (Publisher)

  et al., 2012; Giordano, 2013). There is, however, some consensus in considering GD abnormal when it is associated with significant distress with regard to their felt gender. It is more difficult to consider a strong desire to alter the body to conform to the felt psychological state in adolescent or adult GD a form of normative variation.

  GD occurs in many cultures, with remarkable phenomenological similarity. Many non-Western cultures have coined terms to describe what appear to be equivalents to GD and “transsexualism” in modern societies.

  DSM-5 and the ICD

  DSM-5 treats GD substantially differently from the DSM-IV-TR (see Zucker et al., 2013):

  1. The label was changed from gender identity disorder (GID) to GD, which is considered a more accurate term (Fisk, 1973) and which highlights the salience of “distress” (dysphoria) (Knudson et al., 2010). There was considerable support for this change related to a reduction in stigma (Vance et al., 2010).
  2. In DSM-5, GD has its own chapter and thus has been decoupled from the sexual dysfunctions and paraphilias, which also have their own chapters. This reflected incomplete overlap among these conditions. Although GD co-occurs with one paraphilia, transvestic disorder (Blanchard, 2010), the advantages of this change outweighed the disadvantages.
  3. The Point A diagnostic criterion (which lists the symptoms) introduced a conceptual shift by emphasizing “incongruence” between one's experienced/expressed and assigned gender, as opposed to “cross-gender identification” in DSM-IV-TR.
  4. The GD criteria for children require “…a strong desire to be of the other gender or an insistence that he or she is the other gender (or some alternative gender different from one's assigned gender).” This could sharpen distinctions between GD and normative variation (see Zucker, 2010).
  5. Whether individuals born with a physical intersex condition (now termed a disorder of sex development) (DSD) should be eligible for a diagnosis if GD is contentious (see Meyer-Bahlburg, 1994). Recent evidence suggests that some individuals with a DSD experience GD (Richter-Appelt & Sandberg, 2010; Pasterski et al.

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  Perverse Psychology

  The pathologization of sexual violence and transgenderism

  • Jem Tosh(Author)
  • 2014(Publication Date)
  • Routledge

    (Publisher)

  Caplan (1995) observes, public protest can be helpful to those who have been harmed by diagnosis.

  Gender Dysphoria

  The DSM-5 represented a new conceptualization of gender nonconformity within psychiatric discourse. This included several significant changes, such as a name change to ‘Gender Dysphoria’ as well as the inclusion of intersexuality within the criteria (as the controversial term ‘Disorders of Sex Development’, see Diamond (2009) for a critique of this term; see Tosh (2013  a) for a review of the psychiatric discourse related to transgenderism and intersexuality). This change resulted in the diagnosis of ‘Gender Dysphoria with/without a disorder of sex development’. As ‘gender identity disorder’ attracted a wealth of commentary, criticism, and protest since its initial introduction to the DSM, preparations of the fifth edition offered an opportunity to reform and improve the current conceptualization. Unsurprisingly, the proposed changes generated much debate. Texts related to these discussions included a large selection of available articles, webpages, and blog posts. I selected to analyze those that reflected the professional debates regarding the concept, to enable a critique of psychiatric discourse. I included contrasting perspectives due to the lack of consensus within the profession regarding the diagnostic criteria and treatment of transgender people.

  This analysis includes the official DSM-5 produced by the APA and three critical blog posts. These included The Proposed Gender Dysphoria Diagnosis in the DSM-5 by Kelley Winters (2011) of the GID Reform Advocates. This group is described as, ‘medical professionals, caregivers, scholars, researchers, students, human rights advocates, and members of the transgender, bisexual, lesbian and gay communities and their allies who advocate reform of the psychiatric classification of gender diversity as mental disorder’ (GID Reform Advocates, n.d., para. 1). Kelley Winters is a community advocate and author of Gender Madness in American Psychiatry: Essays from the Struggle for Dignity

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  Mental Health Issues in Lesbian, Gay, Bisexual, and Transgender Communities

  • Billy E. Jones, Marjorie J. Hill(Authors)
  • 2008(Publication Date)
  • American Psychiatric Association Publishing

    (Publisher)

  Psychiatric perceptions of transgender persons by American psychiatrists are remarkably parallel to those for gay men and lesbians before the declassification of homosexuality as a mental disorder in 1973. The present diagnostic categories of gender identity disorder and transvestic fetishism, like drapetomania, dysaesthesia aethiopica, and homosexuality in past decades, may or may not meet current definitions of psychiatric disorder, depending on subjective assumptions about “normal” sex and gender roles and the distress of societal prejudice.

  Recent revisions of the Diagnostic and Statistical Manual of Mental Disorders have made the categories of illness related to transgender identity increasingly ambiguous and reflect a lack of consensus within the American Psychiatric Association. The result is that a widening segment of gender-nonconforming youth and adults are potentially subject to diagnosis of psychosexual disorder, stigma, and loss of civil liberty.

  Revising these diagnostic categories will not eliminate transgender stigma, but it may reduce its legitimacy, just as reform of the diagnostic classification in DSM did for homophobia in the 1970s. It is possible to define a diagnosis that specifically addresses the needs of transsexual persons requiring medical sex reassignment and provides criteria that are clearly and appropriately inclusive. It is time for the transgender community to engage the psychiatric profession in a dialogue that promotes medical and public policies that, above all, do no harm to those they are intended to help.

  References

  Adebimpe VR: Race, racism, and epidemiological surveys. Hosp Community Psychiatry 45:27–31, 1994 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 2nd Edition. Washington, DC, American Psychiatric Association, 1968 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. Washington, DC, American Psychiatric Association, 1980 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised. Washington, DC, American Psychiatric Association, 1987

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