Gender dysphoria

Gender dysphoria
Synonyms Gender identity disorder
Specialty psychiatry

Gender dysphoria, or gender identity disorder (GID), is the distress a person experiences as a result of the sex and gender they were assigned at birth. In these cases, the assigned sex and gender do not match the person's gender identity, and the person is transgender. There is evidence suggesting that twins who identify with a gender different from their assigned sex may do so not only due to psychological or behavioral causes, but also biological ones related to their genetics or exposure to hormones before birth.[1]

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[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 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.[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]

Gender dysphoria is classified as a disorder under dual role transvestism in the 2017 ICD-10 CM.[7] GID was reclassified to gender dysphoria by the DSM-5.[8] Some 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 reclassification as gender dysphoria 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 American Psychiatric Association, publisher of the DSM-5, 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."[10]

The main psychiatric approaches to treatment for persons diagnosed with gender dysphoria are psychotherapy or supporting the individual's preferred gender through hormone therapy, gender expression and role, or surgery.[11]

Signs and symptoms

Symptoms of GID in children may include any of the following: disgust at their own genitalia, social isolation from their peers, anxiety, loneliness and depression.[12] 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.[13]

Adults with GID are at increased risk for stress, isolation, anxiety, depression, poor self-esteem and suicide.[12] 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][15] Transgender people are also at heightened risk for certain mental disorders[16] such as eating disorders.[17][18]

Causes

GID exists when a person suffers discontent due to gender identity, causing them emotional distress.[12] 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 society had less strict gender divisions, transsexual people would suffer less.[20]

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 or prenatal development as its origin, in these cases.[21]

Diagnosis

The American Psychiatric Association permits a diagnosis of gender dysphoria if the criteria in the DSM-5, are met. The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own.[22] 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.[23] The diagnosis was renamed from "Gender Identity Disorder" to "Gender Dysphoria", after criticisms that the former term was stigmatizing.[24] 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.[25]

The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):[11] Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10.[26]

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.[27]

Hormone treatment or surgery for gender dysphoria 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.[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 transsexual transition—is controversial. Some clinicians report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.[31]

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.[32]

Psychological treatments

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.[33] 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.[34]: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.[35] 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.[36]

Psychotherapy, hormone replacement therapy, and sex reassignment surgery together can be effective treating GID when the WPATH standards of care are followed.[34]:1570 The overall level of patient satisfaction with both psychological and biological treatments is very high.[33]

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.[37] The APA's Diagnostic and Statistical Manual first described the condition in the third publication ("DSM-III") in 1980.[38]

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.[39]

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.

Society and culture

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 colours with "girl" or "boy" babies begins extremely early in Western European-derived cultures. Other expectations relate to approved and allowable behaviors and emotional expression.[40]

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.[41] However, research has found that the anxiety associated with gender dysphoria persists in cultures, Eastern or otherwise, which are more accepting of gender nonconformity.[42]

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.[43] However, the Court did not accept that gender was a social construction: it found that sex reassignment "surgery did not resolve her sexual ambiguity".[44]

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.[45][46] (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."[47] Some researchers, including Robert Spitzer and Paul J. Fink, contend that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction.[48]

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.[11] 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.[49] In the United States, transgender people are less likely than others to have health insurance, and often face hostility and insensitivity from healthcare providers.[50]

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.[41] 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.[48] Transgender people have often been harassed, socially excluded, and subjected to discrimination, abuse and violence, including murder.[12][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."[51] In May 2009, the government of France declared that a transsexual gender identity will no longer be classified as a psychiatric condition.[52]

In the December 2016 draft of the ICD-11, GID is reclassified as gender incongruence.[53]

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.[54]

Legislation

In California, Assembly Bill (AB) No. 1266, the School Success and Opportunity Act, 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.[55]

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.[55]

See also

References

  1. ↑ Heylens, G; De Cuypere, G; Zucker, K; Schelfaut, C; Elaut, E; Vanden Bossche, H; De Baere, E; T'Sjoen, G (2012). "Gender Identity Disorder in Twins: A Review of the Case Report Literature". The Journal of Sexual Medicine. 8 (3): 751–757. doi:10.1111/j.1743-6109.2011.02567.x.
  2. ↑ Olyslager, Femke; Conway, Lynn (2008). "Transseksualiteit komt vaker voor dan u denkt. Een nieuwe kijk op de prevalentie van transseksualiteit in Nederland en België". Tijdschrift voor Genderstudies (in Dutch). Amsterdam: Amsterdam University Press. 11 (2): 39–51. ISSN 1388-3186. Retrieved August 27, 2013. Lay summary – How Frequently Does Transsexualism Occur?. …it is safe to assume that the lower limit for the inherent prevalence of transsexualism in the Netherlands and Flanders is on order of 1:2000 to 1:1000 for transgender females and on the order of 1:4000 to 1:2000 for transgender males.
  3. ↑ Conron, KJ; Scott, G; Stowell, GS; Landers, S (January 2012), "Transgender Health in Massachusetts: Results from a Household Probability Sample of Adults", American Journal of Public Health, American Public Health Association, 102 (1): 118–222, ISSN 1541-0048, OCLC 01642844, doi:10.2105/AJPH.2011.300315, retrieved August 28, 2013, Between 2007 and 2009, survey participants aged 18 to 64 years in the Massachusetts Behavioral Risk Factor Surveillance System (MA-BRFSS; N = 28 662) were asked: "Some people describe themselves as transgender when they experience a different gender identity from their sex at birth. For example, a person born into a male body, but who feels female or lives as a woman. Do you consider yourself to be transgender?" […] We restricted the analytic sample to 28176 participants who answered yes or no to the transgender question (excluding n=364, 1.0% weighted who declined to respond. […] Transgender respondents (n=131; 0.5%; 95% confidence interval [CI]=0.3%, 0.6%) were somewhat younger and more likely to be Hispanic than were nontransgender respondents.
  4. ↑ Clark, Terryann C.; Lucassen, Mathijs F.G.; Bullen, Pat; Denny, Simon J.; Fleming, Theresa M.; Robinson, Elizabeth M.; Rossen, Fiona V. (2014). "The Health and Well-Being of Transgender High School Students: Results From the New Zealand Adolescent Health Survey (Youth'12)". Journal of Adolescent Health. 55 (1): 93–9. PMID 24438852. doi:10.1016/j.jadohealth.2013.11.008. Whether a student was transgender was measured by the question, "Do you think you are transgender? This is a girl who feels like she should have been a boy, or a boy who feels like he should have been a girl (e.g., Trans, Queen, Fa’faffine, Whakawahine, Tangata ira Tane, Genderqueer)?" […] Over 8,000 students (n = 8,166) answered the question about whether they were transgender. Approximately 95% of students did not report being transgender (n=7,731; 94.7%), 96 students reported being transgender (1.2%), 202 reported not being sure (2.5%), and 137 did not understand the question (1.7%).
  5. ↑ Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 454. ISBN 978-0-89042-555-8.
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  7. ↑ "Gender identity disorder in adolescence and adulthood". ICD10Data.com. Retrieved July 3, 2011.
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  20. 1 2 Giordano, Simona (2012). Children with Gender Identity Disorder: A Clinical, Ethical, and Legal Analysis. New Jersey: Routledge. p. 147. ISBN 0415502713.
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  25. ↑ "P 00 Gender Dysphoria in Children". American Psychiatric Association. Retrieved April 2, 2012.
  26. ↑ Potts, S; Bhugra, D (1995). "Classification of sexual disorders". International Review of Psychiatry. 7 (2): 167–174. doi:10.3109/09540269509028323.
  27. ↑ Leiblum, Sandra (2006). Principles and Practice of Sex Therapy, Fourth Edition. The Guilford Press. pp. 488–9. ISBN 978-1-59385-349-5.
  28. ↑ Committee On, Adolescence (2013). "Office-based care for lesbian, gay, bisexual, transgender, and questioning youth". Pediatrics. 132 (1): 198–203. PMID 23796746. doi:10.1542/peds.2013-1282. However, adolescents with multiple or anonymous partners, having unprotected intercourse, or having substance abuse issues should be tested at shorter intervals.
  29. ↑ "www.glma.org Compendium of Health Prof ession Association LGBT Policy & Position Statements" (PDF). GLMA. 2013. Retrieved August 27, 2013.
  30. ↑ "APA Policy Statements on Lesbian, Gay, Bisexual, & Transgender Concerns" (PDF). American Psychological Association. 2011. Retrieved August 27, 2013. BE IT FURTHER RESOLVED that APA recognizes the efficacy, benefit, and necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments;
  31. ↑ Spiegel, Alix (2008-05-08). "Q&A: Therapists on Gender Identity Issues in Kids". NPR. Retrieved 2008-09-16.
  32. ↑ The Transgendered Child: A Handbook for Families and Professionals (Brill and Pepper, 2008)
  33. 1 2 Gijs, L; Brawaeys, A (2007). "Surgical Treatment of Gender Dysphoria in Adults and Adolescents: Recent Developments, Effectiveness, and Challenges". Annual Review of Sex Research. 18 (178–224).
  34. 1 2 George R. Brown, MD (20 July 2011). "Chapter 165 Sexuality and Sexual Disorders". In Robert S. Porter, MD; et al. The Merck Manual of Diagnosis and Therapy (19th ed.). Whitehouse Station, NJ, USA: Merck & Co., Inc. pp. 1567–1573. ISBN 978-0-911910-19-3.
  35. ↑ Bockting, W; Knudson, G; Goldberg, J (January 2006). "Counselling and Mental Health Care of Transgender Adults and Loved Ones".
  36. ↑ Hakeem, Az (2008). "Changing Sex or Changing Minds: Specialist Psychotherapy and Transsexuality". Group Analysis. 41 (2): 182–196. doi:10.1177/0533316408089883.
  37. ↑ "Gender Dysphoria Fact Sheet" (PDF). APA. Retrieved 2 September 2013.
  38. ↑ Koh, J (2012). "The history of the concept of gender identity disorder". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  39. ↑ telegraph.co.uk: "Puberty blocker for children considering sex change", Telegraph (Alleyne) 15 Apr 2011
  40. ↑ Marecek, J., Crawford, M., & Popp, D. (2004). "On the Construction of Gender, Sex, and Sexualities". In A.H. Eagly, A.E. Beall, & R.J. Sternberg. The Psychology of Gender. New York: Guilford Press. pp. 192–216.
  41. 1 2 Vasey, P; Bartlett, N (2007). "What Can the Samoan "Fa'afafine" Teach Us about the Western Concept of Gender Identity Disorder in Childhood?". Perspectives in Biology and Medicine. 50 (4): 481–490. PMID 17951883. doi:10.1353/pbm.2007.0056.
  42. ↑ Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 459. ISBN 978-0-89042-555-8.
  43. ↑ NSW Registrar of Births, Deaths and Marriages v Norrie [2014] HCA 11
  44. ↑ NSW Registrar of Births, Deaths and Marriages v Norrie, 2014 High Court of Australia 11, 11 (High Court of Australia 2 April 2014).
  45. ↑ Arlene Istar Lev (2004). Transgender Emergence: Therapeutic Guidelines for Working with Gender-Variant People and Their Families. Haworth Press. p. 172. ISBN 978-0-7890-2117-5.
  46. ↑ Rudacille, Deborah (February 2005). The Riddle of Gender: Science, Activism, and Transgender Rights. Pantheon. ISBN 978-0-375-42162-4.
  47. ↑ Zucker, KJ; Spitzer, RL (Jan–Feb 2005), "Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note.", Journal of Sex and Marital Therapy, 31 (1): 31–42, PMID 15841704, doi:10.1080/00926230590475251
  48. 1 2 "Controversy Continues to Grow Over DSM's GID Diagnosis". Psychiatric News.
  49. ↑ Ford, Zack. "APA Revises Manual: Being Transgender is No Longer a Mental Disorder". Retrieved April 7, 2013.
  50. ↑ Mallon, Gerald P. (2009). Social Work Practice with Transgender and Gender Variant Youth. New Jersey: Routledge. ISBN 0415994829.
  51. ↑ "Government Policy concerning Transsexual People". People's rights/Transsexual people. U.K. Department for Constitutional Affairs. 2003.
  52. ↑ "La transsexualité ne sera plus classée comme affectation psychiatrique". Le Monde. May 16, 2009.
  53. ↑ "ICD-11 Beta Draft (Mortality and Morbidity Statistics) - Gender incongruence". World Health Organization. Retrieved December 23, 2016.
  54. ↑ Barrett, James (2007). Transexual and Other Disorders of Gender Identity: A Practical Guide to Management. RADCLIFFE MEDICAL PRESS LTD. p. 83. ISBN 185775719X.
  55. 1 2 Los Angeles Times, "Assembly approves bill on gender identity in schools" by Chris Megerian, May 9, 2013; accessed April 11, 2014.

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