Gender dysphoria

Gender dysphoria/
Gender identity disorder
Classification and external resources
Specialty psychiatry
ICD-10 F64.9, F64.8
ICD-9-CM 302.85
MedlinePlus 001527
MeSH D005783

Gender dysphoria or gender identity disorder (GID) is the formal diagnosis used by psychologists and physicians to describe people who experience significant dysphoria (distress) with the sex and gender they were assigned at birth. Evidence suggests that people who identify with a gender different from the one they were assigned at birth may do so not just due to psychological or behavioral causes, but also biological ones related to their genetics, the makeup of their brains, or prenatal exposure to hormones.[1]

Estimates of the prevalence of gender dysphoria or GID range from a lower bound of 1:2000 (or about 0.05%) in the Netherlands and Belgium[2] to 0.5% of Massachusetts adults[3] to 1.2% of New Zealand high-school students.[4] These numbers are based on those who identify as transgender. It is estimated that about 0.005% to 0.014% of males and 0.002% to 0.003% of females would be diagnosed with gender dysphoria, based on current diagnostic criteria.[5] 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.[6]

GID is classified as a medical disorder by the ICD-10 CM[7] and DSM-5 (called gender dysphoria).[8] Many transgender people and researchers support declassification of GID because they say the diagnosis pathologizes gender variance, reinforces the binary model of gender,[9] and can result in stigmatization of transgender individuals.[8] The official classification of gender dysphoria as a disorder in the DSM-5 may help resolve some of these issues, because the term gender dysphoria applies only to the discontent experienced by some persons resulting from gender identity issues.[8]

The current main psychiatric approaches to treatment for persons diagnosed with GID are psychotherapy or to support the individual's preferred gender through hormone therapy, gender expression and role, or surgery.[10]

Signs and symptoms

Symptoms of GID in children include disgust at their own genitalia, social isolation from their peers, anxiety, loneliness and depression.[11] 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]

Adults with GID are at increased risk for stress, isolation, anxiety, depression, poor self-esteem and suicide.[11] 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 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.[13][14] Transgender people are also at heightened risk for certain mental disorders[15] such as eating disorders.[16][17]

In 2014, a researcher found that the brains of adolescents with gender dysphoria react to the sex hormone androstadienone in a measurable way similar to the brains of people of the gender with which the person identifies.[18]

Causes

GID exists when a person suffers discontent due to gender identity, causing them emotional distress.[11] 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;[19] and that, if the society had less-strict gender divisions, transsexual people would suffer less.[20]

Biological causes

Genetic variation, hormones, and differences in brain functioning and brain structures provide evidence for the biological etiology of the symptoms associated with GID. Twin studies indicate that GID is 62% heritable, evidencing the genetic influence or prenatal development as its origin.[21] In transsexual people who were assigned male at birth, GID is associated with variations in an individual's genes that make the individual less sensitive to androgens.[1] Zhou et al. (1995), in a study of six individuals, found that in one area of the brain, transsexual people who were assigned male at birth have a typically female structure, and transsexual people who were assigned female at birth have a typically male structure.[22] In addition, some aspects of trans women's hypothalamus functioning resemble that typical of cisgender women.[23]

The presence of typically female patterns of white matter and neuron patterns has also been observed in the brains of transsexual people who were assigned male at birth[24][25] and overall longer instances of the androgen receptor gene.[26] However, these markers do not identify every individual who undergoes transition.[27]

Similar brain structure differences have, however, been noted between gay and heterosexual men, and between lesbian and heterosexual women.[28][29] More recent studies have found that circumstance and repeated activities such as meditation modify brain structures in a process called brain plasticity or neuroplasticity. In May 2014, the Proceedings of the National Academy of Sciences reported that for fathers, parenting "rewires the male brain".[30]

Diagnosis

The American Psychiatric Association permits a diagnosis of gender dysphoria if the criteria in the Diagnostic and Statistical Manual of Mental Disorders (5th Edition), or DSM-5, are met. The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own.[31] The DSM-5 states that at least two of the criteria for gender dysphoria must be experienced for at least six months' duration in adolescents or adults for diagnosis.[32] The diagnosis was renamed from "Gender Identity Disorder" to "Gender Dysphoria", after criticisms that the former term was stigmatizing.[33] Subtyping by sexual orientation was deleted. The diagnosis for children was separated from that for adults. 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.[34]

The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):[10] Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10.[35]

Management

Treatment for a person diagnosed with GID 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. 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.[36]

Hormone treatment or surgery for GID is somewhat controversial because of the irreversibility of physical changes. 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.[37][38][39]

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 transsexual transition—is controversial. Some clinicians report that a significant proportion of young children diagnosed with gender identity disorder later do not exhibit the dysphoria.[40]

Professionals who treat gender identity disorder in children have begun to refer and prescribe hormones, known as a puberty blocker, 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.[41]

Psychological treatments

Main article: Psychotherapy

Until the 1970s, psychotherapy was the primary treatment for GID, 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 GID, it may now be used in addition to biological interventions as treatment for GID.[42] 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.[43]:1568

Biological treatments

Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual's physical body and gender identity.[44] 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.[45]

Psychotherapy, hormone replacement therapy, and sex reassignment surgery together can be effective treating GID when the WPATH standards of care are followed.[43]:1570 The overall level of patient satisfaction with both psychological and biological treatments is very high.[42]

History

The term gender identity disorder is an older term for the condition. Some groups, including the American Psychiatric Association (APA), use the term gender dysphoria.[46] The APA's Diagnostic and Statistical Manual first described the condition in the third publication ("DSM-III") in 1980.[47]

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 GID referrals in 2010.[48]

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 GID 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. MP (Member of Parliament) Andrew Percy said "I think many people will be horrified at the thought of a nine-year-old being provided with a drug that effectively stops them developing and maturing naturally."[49] MP (Member of Parliament) Mark Pritchard said, "With competing NHS resources, especially for life-saving cancer drugs, there needs to be an immediate investigation into why these drugs are being prescribed to those so young."[50]

In May 2014, Carmichael said,

Now we’ve done the study--and the results thus far have been positive--we’ve decided to continue with it. So we’ve decided to do “stage not age” (as the criterion) because it’s obviously fairer. Twelve is an arbitrary age. If they started puberty aged nine or ten instead of 12, as long as they’re monitored and the bone density doesn’t suffer, then it is right that the aim is to stop the development of secondary sex characteristics.[50]

Society and culture

Gender as a social construction

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 Western 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.[51] However, research has found that the anxiety associated with the disorder persists in cultures, Eastern or otherwise, which are more accepting of gender nonconformity.[52]

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.[53] However, the Court did not accept that gender was a social construction: it found that sex affirmation "surgery did not resolve her sexual ambiguity".[54]

Classification as a disorder

The psychiatric diagnoses of gender identity disorder (now gender dysphoria) was introduced in the DSM-III in 1980. Some sources have characterized the addition as a political maneuver to re-stigmatize homosexuality.[55][56] (Homosexuality was removed from the DSM-II in 1974.) By contrast, Kenneth Zucker and Robert Spitzer argue that gender identity disorder was included in the 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]

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.[10] Because gender dysphoria is 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.[51] 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.[11][20]

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]

In August 31, 2010, Thomas Hammarberg, Commissioner for Human Rights within the Strasbourg-based Council of Europe, an independent institution, opposed the mental disorder classification and the sterilization of transgender persons as a requirement for legal sex change.[63] The Principle 3 of The Yogyakarta Principles on The Application of International Human Rights Law In Relation to Sexual Orientation and Gender Identity states, "Persons of diverse sexual orientation and gender identities shall enjoy legal capacity in all aspects of life. Each person's self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom," and the Principle 18 states, "Notwithstanding any classifications to the contrary, a person's sexual orientation and gender identity are not, in and of themselves, medical condition and are not to be treated, cured or suppressed."

Intimate relationships

Intimate relationships between lesbians and female-to-male people with GID will sometimes endure throughout the transition process, or shift into 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.[64]

Legislation

In California, Assembly Bill (AB) No. 1266, authored by Assemblyman Tom Ammiano (D-San Francisco), was passed in May 2013 by the State Assembly:

Existing law prohibits public schools from discriminating on the basis of specified characteristics, including gender, gender identity, and gender expression, and specifies various statements of legislative intent and the policies of the state in that regard. Existing law requires that participation in a particular physical education activity or sport, if required of pupils of one sex, be available to pupils of each sex. This bill would require that a pupil be permitted to participate in sex-segregated school programs, activities, including athletic teams and competitions, and use facilities consistent with his or her gender identity, irrespective of the gender listed on the pupil's records.[65]

The California Catholic Conference opposed the bill as unnecessary, as laws exist already to fight discrimination against transgender students. A spokeswoman for the conference said that the issue should be handled by school officials.[65]

Petitions were collected to require a referendum on the legislation in question, but the Secretary of State of California, Debra Bowen, issued a decision determining that, due to disqualified signatures, the threshold of votes had not been reached to force the referendum in question.[66] Pacific Justice and Capitol Resource institutes, representing opponents of AB 1266, dispute this, filing a lawsuit, opposed by the State of California, to have the disqualified signatures validated and petitioners' names made public, which the State argues are confidential. Pro-referendum forces claim votes were mishandled due to malfeasance and incompetence in Tulare and Mono counties, respectively.[66]

See also

References

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  60. ↑ Mallon, Gerald P. (2009). Social Work Practice with Transgender and Gender Variant Youth. New Jersey: Routledge. ISBN 0415994829.
  61. ↑ "Government Policy concerning Transsexual People". People's rights/Transsexual people. U.K. Department for Constitutional Affairs. 2003.
  62. ↑ "La transsexualité ne sera plus classée comme affectation psychiatrique". Le Monde. May 16, 2009.
  63. ↑ Forced divorce and sterilisation - a reality for many transgender persons, commissioner.cws.coe.int; accessed April 11, 2014.
  64. ↑ Barrett, James (2007). Transexual and Other Disorders of Gender Identity: A Practical Guide to Management. RADCLIFFE MEDICAL PRESS LTD. p. 83. ISBN 185775719X.
  65. 1 2 Los Angeles Times, "Assembly approves bill on gender identity in schools" by Chris Megerian, May 9, 2013; accessed April 11, 2014.
  66. 1 2 Suit against State of California over AB 1266, wnd.com, April 2014; accessed April 12, 2014.

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