Gender dysphoria

Gender dysphoria (GD) is the distress a person experiences as a result of the sex and gender they were assigned at birth. In this case, the assigned sex and gender do not match the person’s gender identity, and the person is transgender. Evidence from studies of twins suggest that people who identify with a gender different from their assigned sex may experience such distress not only due to psychological or behavioral causes, but also biological ones related to their genetics or exposure to hormones before birth.

The diagnostic label gender identity disorder (GID) was used by the DSM until its reclassification as gender dysphoria in 2013, with the release of the DSM-5. The diagnosis was reclassified to better align it with medical understanding of the condition and to remove the stigma associated with the term disorder. The American Psychiatric Association, publisher of the DSM-5, stated that gender nonconformity is not the same thing as gender dysphoria, and 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.” Some transgender people and researchers support declassification of the condition because they say the diagnosis pathologizes gender variance and reinforces the binary model of gender.

The main psychiatric approaches to treatment for persons diagnosed with gender dysphoria are psychotherapy or supporting the individual’s preferred gender through any or all of hormone therapy, gender expression and role, or surgery.

Signs and symptoms
Symptoms of GD in children may include any of the following: disgust at their own genitalia, social isolation from their peers, anxiety, loneliness and depression. 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.

Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem and suicide. 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. Transgender people are also at heightened risk for certain mental disorders such as eating disorders.

Gender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset. Early-onset gender dysphoria is behaviorally visible in childhood. Sometimes, early-onset gender dysphorics identify as gay for a period of time. This group is usually attracted to men in adulthood. Late-onset gender dysphoria does not include visible signs in early childhood, but some report having wishes to be female in childhood that they did not report to others. Those who experience late-onset gender dysphoria will often be attracted to women and may identify as lesbians. Before transition, they will frequently engage in transvestic behavior with sexual excitement. In those assigned female at birth, early-onset gender dysphoria is the most common course.

Causes
GID exists when a person suffers discontent due to gender identity, causing them emotional distress. 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; and that, if society had less strict gender divisions, transsexual people would suffer less.

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 as its origin, in these cases.

Diagnosis
The American Psychiatric Association permits a diagnosis of gender dysphoria if the criteria in the DSM-5 are met. The DSM-5 states that at least two of the following criteria for gender dysphoria must be experienced for at least six months’ duration in adolescents or adults for diagnosis:

A strong desire to be of a gender other than one’s assigned gender
A strong desire to be treated as a gender other than one’s assigned gender
A significant incongruence between one’s experienced or expressed gender and one’s sexual characteristics
A strong desire for the sexual characteristics of a gender other than one’s assigned gender
A strong desire to be rid of one’s sexual characteristics due to incongruence with one’s experienced or expressed gender
A strong conviction that one has the typical reactions and feelings of a gender other than one’s assigned gender
In addition, the condition must be associated with clinically significant distress or impairment.

The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own. The diagnosis was renamed from gender identity disorder to gender dysphoria, after criticisms that the former term was stigmatizing. 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. Other specified gender dysphoria or unspecified gender dysphoria can be diagnosed if a person doesn’t meet the criteria for gender dysphoria but still has clinically significant distress or impairment.

The International Classification of Diseases (ICD-10) list several disorders related to gender identity:

Transsexualism (F64.0): Desire to live and be accepted as a member of the opposite sex, usually accompanied by a desire for surgery and hormonal treatment
Gender identity disorder of childhood (F64.2): Persistent and intense distress about one’s assigned gender, manifested prior to puberty
Other gender identity disorders (F64.8)
Gender identity disorder, unspecified (F64.9)
Sexual maturation disorder (F66.0): Uncertainty about one’s gender identity or sexual orientation, causing anxiety or distress
Significant revision of the ICD’s classification of gender identity-related conditions is expected in the forthcoming ICD-11. As of August 2018, the ICD-11 lists this condition as “gender incongruence”, under “conditions related to sexual health”, coded into three conditions:

Gender incongruence of adolescence or adulthood (HA60): replaces F64.0
Gender incongruence of childhood (HA61): replaces F64.2
Gender incongruence, unspecified (HA6Z): replaces F64.9
In addition, sexual maturation disorder has been removed, along with dual-role transvestism. ICD-11 defines gender incongurence as “a marked and persistent incongruence between an individual’s experienced gender and the assigned sex”, with presentations similar to the DSM-V definition, but does not require significant distress or impairment.

Epidemiology
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 to 0.5% of Massachusetts adults. From a national survey of high-school students in New Zealand, 8,500 randomly selected secondary school students from 91 randomly selected high schools found 1.2% of students responded “yes” to the question “Do you think you are transgender?”. 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. 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.

History
The term gender identity disorder is an older term for the condition in the DSM. The American Psychiatric Association (APA) uses the term gender dysphoria. The APA’s DSM first described the condition in the third publication (“DSM-III”) in 1980.

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.

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.

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