Gender dysphoria

Gender dysphoria
Specialty	Psychiatry, psychology

Gender identity disorder (GID), also known as gender dysphoria, is a formal diagnosis used by psychologists and physicians to describe people who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex. Affected individuals are commonly referred to as transsexual or transgender. 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.

Estimates of the prevalence of gender identity disorder range from a lower bound of 1:2000 (or about 0.05%) in the Netherlands and Belgium to 0.5% in Massachusetts to 1.2% in New Zealand. 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.

Gender identity disorder is classified as a medical disorder by the ICD-10 CM and DSM-5 (called gender dysphoria). Many transgender people and researchers support declassification of GID because they say the diagnosis pathologizes gender variance, reinforces the binary model of gender, and can also result in stigmatization of transgender individuals. Treatment for gender identity disorder is also controversial, as changes made are typically irreversible.

The current approach to treatment for people diagnosed with gender identity disorder is to support them in physically modifying their bodies so that they better match their gender identities, an approach that conceptualizes them as having a medical problem that is corrected through various forms of medical intervention.

Signs and symptoms

Symptoms of GID in children include disgust at their own genitalia, social isolation from their peers, anxiety, loneliness and depression. According to the American Psychological Association, transgender children are likelier than other children to experience harassment and violence in school, foster care, residential treatment centers, homeless centers and juvenile justice programs.

Adults with GID are at increased risk for stress, isolation, anxiety, depression, poor self-esteem and suicide. Transgender women are likelier than other people to smoke cigarettes and abuse alcohol and other drugs. In the United States, transgender women have a higher suicide rate than others, both before and after gender reassignment surgery, and are at heightened risk for certain mental disorders.

Transgender people are often harassed, socially excluded, subjected to discrimination, abuse, violence and murder. In the United States, transgender people are less likely than others to have health insurance, and often face hostility and insensitivity from healthcare providers.

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, and 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 feminisation 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.

Causes

Main article: Causes of transsexualism

Gender Identity Disorder exists when a person's gender identity causes him or her emotional distress. Researchers disagree about the nature of distress and impairment in people with GID, with some believing people with GID suffer solely because they are stigmatized and victimized, and saying that in societies with less-strict gender divisions, transsexuals suffer less.

Though the exact etiology of gender dysphoria is unknown, there is evidence of biological and sociocultural influences in its development.

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 in its development. In male-to-female transsexuals, GID is associated with variations in an individual's genes that make the individual less sensitive to androgens. Zhou et al. (1995) found that in one area of the brain, male-to-female transsexuals have a typically female structure, and female-to-male transsexuals have a typically male structure. Zhou et al. (1995) had a sample size of only six male-to-female transgender individuals. There may, for example, be some non-transgender heterosexual men with some brain structures one would usually expect in a female, as the sample size in Zhou et al. (1995) is far from sufficient to exclude such possibilities. In addition, some aspects of trans women's hypothalamus functioning resemble that typical of cisgender women.

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. The diagnosis itself was renamed from "Gender Identity Disorder" to "Gender Dysphoria," after criticisms that the former term was stigmatizing. Subtyping by sexual orientation was deleted, and the diagnosis for children was separated from that for adults. The creation of a specific diagnosis for children reflects the supposedly lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.

The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):

Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10.

Management

Treatment has typically either aimed to change the person's body to match their identity, or the opposite. Today, treatment is generally driven by the patient's desired outcome. It may include psychological counselling 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 cosmetic surgeries. The goal of treatment may simply be to reduce problems resulting from the person's transgender status, for example counselling the patient in order to reduce guilt associated with cross-dressing, or counselling a spouse to help him or her adjust to the patient's situation.

Treatment for GID is somewhat controversial, and guidelines have been put in place to aid clinicians. The World Professional Association for Transgender Health (WPATH) Standards of Care, are used as treatment guidelines for GID by some clinicians. Others utilize guidelines outlined in Gianna Israel and Donald Tarver's "Transgender Care". Guidelines for treatment generally follow a "harm reduction" model.

Prepubescent children

Main article: Gender identity disorder in 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 sex—or to explore a transsexual transition—is controversial. Some clinicians report a significant proportion of young children with gender identity disorder no longer have such symptoms later in life. There is an active and growing movement among professionals who treat gender identity disorder in children 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.

Psychological treatments

Main article: Psychotherapy

Until the 1970s, psychotherapy was the primary treatment for GID. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Though some clinicians still use only psychotherapy to treat GID, it is now typically used in addition to biological interventions as treatment for GID. Psychotherapy alone used to 'cure' individuals of GID is highly controversial and sometimes considered ineffective;

"However, up to 2007 no randomized controlled studies evaluated the efficacy or the effectiveness of psychotherapeutic interventions to cure gender dysphoria ... Very few reports describe some form of psychological intervention to cure gender dysphoria in a systematic way...

"Even if a psychological "cure" did exist, an interesting ethical question remains: Does an individual with a gender identity disorder or gender variance still have the right to choose [Sex Reassignment Surgery] without first undergoing the psychological intervention that would "cure" [their] gender variance"

(Gijs & Brewaeys, 2007, pg. 182-183)

Biological treatments

Main articles: Sex reassignment therapy, Sex reassignment surgery, Hormone replacement therapy (male-to-female), and Hormone replacement therapy (female-to-male)

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

The most effective form of treatment for GID is a combination of psychotherapy, hormone replacement therapy, and sex reassignment surgery. The overall level of satisfaction with both psychological and biological treatments is very high.

History

The term Gender Identity Disorder is an older term for the condition. Some groups, including the American Psychological Association (APA), use the term Gender Dysphoria. The APA's Diagnostic and Statistical Manual first described the condition in the third publication ("DSM-III") in 1980.

Society and culture

Individuals with GID may or may not regard their own cross-gender feelings and behaviors as a disorder. Advantages and disadvantages exist to classifying GID as a disorder.

Gender as a social construction

Social "gender" characteristics are created and supported by the expectations of a culture, and are therefore not or 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. More significantly, expectations regarding (for example) display of emotion continue throughout one's entire life in these cultures.

Some cultures have three defined genders: male, female, and effeminate male. For example, in Samoa, the fa'afafine, a group of feminine males, are entirely socially accepted. The fa'afafine do not experience any of the stigma or distress typically associated with deviating from a male/female gender role, suggesting that the distress that is so frequently associated with GID in a Western context is not caused by the disorder, but may instead result from the disapproval of one's culture of residence.

GID as a birth defect

This argument is supported by physiological evidence, such as the presence of typically-female patterns of white matter and neuron patterns observed in the brains of male-to-female transsexuals and overall longer instances of the androgen receptor gene. (Also see Causes of transsexualism.) However, these markers do not identify every individual who undergoes transition, and using them to define transsexualism could falsely exclude some people from treatment.

Distress as a consequence of stigma

The DSM-IV-TR diagnostic component of distress is not inherent in the cross-gender identity, rather it is a result of social rejection and discrimination. Dr. Darryl Hill insists that GID is not a mental disorder, but rather that the diagnostic criteria reflect psychological distress in children that occurs when parents have trouble relating to their child's gender variance.

Replacement for homosexuality in the DSM

Some people feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the GID diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of another sex/gender). People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. Kenneth Zucker and Robert Spitzer argue that GID was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion."

International classification

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." In May 2009, the government of France has also declared that a transsexual gender identity will no longer be classified as a psychiatric condition in France.

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.

The Principle 3 of The Yogyakarta Principles on The Application of International Human Rights Law In Relation to Sexual Orientation and Gender Identity states that "Person 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 of this states that "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."

GID as dysfunctional

Some researchers, including Dr. Robert Spitzer and Dr. Paul J. Fink, contend that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction.

Insurance coverage

Because GID is considered a disorder in the DSM-IV-TR, many insurance companies are willing to cover some of the expenses of sex reassignment therapy. Without the classification of GID as a medical disorder, sex reassignment therapy may be viewed as cosmetic treatment, rather than medically necessary treatment, and may not be funded.

See also

• List of transgender-related topics
• Ego-dystonic sexual orientation

Further reading

• A Transgender Journey
• Transgender Rights blog
• GID Reform Advocates
• I'm Not Les: A Transgender Story (2012)/ KCTS 9 Documentary

External links

• Standards of Care for Gender Identity Disorders – published by the Harry Benjamin International Gender Dysphoria Association, includes a description of ICD-10 criteria.
• Health Law Standards of Care for Transsexualism An alternative to the Benjamin Standards of Care proposed by the International Conference on Transgender Law and Employment Policy.
• THE LORD CHANCELLOR'S DEPARTMENT Government Policy concerning Transsexual People
• Gender Identity Disorder & Transsexualism – Synopsis of Etiology in Adults provides an alternative to the current classifications of psychiatric disorder and mental illness.
• Conway, Lynn: "Successful Transwomen" and "Successful Transmen" -Lynn Conway's "Success Pages".