Gender Dysphoria

By Ahmad Yadak
Terminology
Sex (Sexual identity)
defined by chromosomes, hormonal profile, external and internal sex organs
(biological)
Gender identity
the sense one has of being male or female, which corresponds most often to the
person’s anatomical sex.
Gender roles
the behaviors, values, and attitudes that a society considers appropriate for both
male and female.
Sexual orientation
the types of individuals toward whom a person has emotional, physical, and/or
romantic attachments. (Heterosexuality, Homosexuality, Bisexuality)
Gender dysphoria
The term gender dysphoria appears as a diagnosis for the first time in the fifth
edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to
refer to those persons with a marked incongruence between their experienced or
expressed gender and the one they were assigned at birth.
It was known as gender identity disorder in the previous edition of DSM.
• Persons with gender dysphoria express their discontent with their assigned sex as a
desire to have the body of the other sex or to be regarded socially as a person of the
other sex.

• Gender identity crystallizes in most persons around age 3 corresponding to anatomical

sex.
DSM-5 Diagnostic Criteria for Gender Dysphoria
DSM-5 Diagnostic Criteria for Gender
Dysphoria in children
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 (one of which must be Criterion A1):
1. A strong desire to be of the other gender or an insistence that one is the other gender (or some
alternative gender different from one’s assigned gender).

2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls
(assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to
the wearing of typical feminine clothing.

3. A strong preference for cross-gender roles in make-believe play or fantasy play.

4. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other
gender

5. A strong preference for playmates of the other gender

6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and
activities and a strong avoidance of rough-and tumble play; or in girls (assigned gender),
a strong rejection of typically feminine toys, games, and activities.

7. A strong dislike of one’s sexual anatomy.

8. A strong desire for the primary and/or secondary sex characteristics that match one’s
experienced gender.

B. The condition is associated with clinically significant distress or impairment in social,

school, or other important areas of functioning
DSM-5 Diagnostic Criteria for Gender
Dysphoria in adolescents and adults
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of
at least 6 months’ duration, as manifested by at least two of the following:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or

secondary sex characteristics (or in young adolescents, the anticipated secondary sex
characteristics).

2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a
marked incongruence with one’s experienced/expressed gender (or in young adolescents, a
desire to prevent the development of the anticipated secondary sex characteristics).

3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
4. A strong desire to be of the other gender (or some alternative gender different from
one’s assigned gender).

5. A strong desire to be treated as the other gender (or some alternative gender
different from one’s assigned gender).

6. A strong conviction that one has the typical feelings and reactions of the other
gender (or some alternative gender different from one’s assigned gender).

B. The condition is associated with clinically significant distress or impairment in social,

occupational or other important areas of functioning
Gender Dysphoria/ Homosexuality
Example :

Homosexuality
Born as Male  sense of being male and act as male (Intact sense of self)
 attractive to males )attraction to same sex).

Gender Dysphoria
Born as Male  sense of being female and act as female (Impaired sense of self)
 attractive to males (attraction to same sex).
 EPIDEMIOLOGY
Children
Most children with gender dysphoria are referred for clinical evaluation in early grade school years. Parents,
however, typically report that the cross-gender behaviors were apparent before 3 years of age.
The sex ratio of children referred for gender dysphoria is 4 to 5 boys for each girl (4-5:1).
The sex ratio is equal in adolescents referred for gender dysphoria.
Researchers have observed that many children considered to have shown gender nonconforming behavior
do not grow up to be transgender adults.

Adults
Most clinical centers report a sex ratio of three to five male patients for each female patient (3-5:1).
Overall the prevalence of male to female dysphoria is higher than female to male dysphoria.
An important factor in diagnosis is that there is greater social acceptance of birth-assigned females
dressing and behaving as boys (so-called tomboys) than there is of birth-assigned males acting as females
(so-called sissies).
ETIOLOGY
Biological Factors
Sex
For mammals, the resting state of tissue is initially female; as the fetus develops, a male is produced
only if androgen (set off by the Y chromosome, which is responsible for testicular development) is
introduced. Without testes and androgen, female external genitalia develop. Thus, maleness and
masculinity depend on fetal and perinatal androgens.

Gender identity
Masculinity, femininity, and gender identity may result more from postnatal life events than from
prenatal hormonal organization.
Brain organization theory refers to masculinization or feminization of the brain in utero.
Testosterone affects brain neurons that contribute to the masculinization of the brain in such areas
as the hypothalamus. Whether testosterone contributes to so-called masculine or feminine
behavioral patterns remains a controversial issue.
Genetic causes of gender dysphoria are under study but no candidate genes have been identified,
and chromosomal variations are uncommon in transgender populations.
A variety of approaches to understand gender dysphoria are underway.
Psychosocial Factors
1- The formation of gender identity is influenced by the interaction of
children’s temperament and parents’ qualities and attitudes.
2- Culturally acceptable gender roles exist: Boys are not expected to be
effeminate, and girls are not expected to be masculine. There are boys’ games
(e.g., cops and robbers) and girls’ toys (e.g., dolls and dollhouses).
3-Childhood conflicts; mother-child relationship, mother’s death.
 COURSE AND PROGNOSIS

Children
Children typically begin to develop a sense of their gender identity around age 3.
It is often around school age that children are first brought for clinical consultations, as this
is when they begin to interact heavily with classmates and to be scrutinized by adults other
than their caregivers.
Approaching puberty, many children diagnosed with gender dysphoria begin to show
increased levels of anxiety related to anticipated changes to their bodies.
Children diagnosed with gender dysphoria do not necessarily grow up to identify as
transgender adults. A number of studies have demonstrated that more than half of those
diagnosed with gender identity disorder, based on the DSM-IV, later identify with their
birth-assigned gender once they reach adulthood.
Those children who do identify as transgender as adults have been shown to have more
extreme gender dysphoria as children.
Comorbidity in Children
Children diagnosed with gender dysphoria show higher rates than other children of :
depressive disorders
anxiety disorders
impulse-control disorders
There are also reports that those diagnosed with gender dysphoria are more likely
than others to fall on the autism spectrum.
Adults
1- Most adults with gender dysphoria report having felt different from other children of their same
sex, although, in retrospect, many could not identify the source of that difference.

2- Many report feeling extensively cross-gender identified from the earliest years, with the cross-
gender identification becoming more profound in adolescence and young adulthood.

3- Some people diagnosed with gender dysphoria as adults recall the continuous development of
transgender identity since childhood. In these cases, some have periods of hiding their gender
identity, many entering into stereotypical activities and employment in order to convince
themselves and others that they do not have gender nonconforming identities.

4-Others do not recall gender identity issues during childhood.

Comorbidity in Adults
Adults diagnosed with gender dysphoria show higher rates than other
adults of :
depressive disorders
anxiety disorders
suicidality and self-harming behaviors
substance abuse (The lifetime rate of suicidal thoughts in transgender
people is thought to be about 40%).
TREATMENT

Children
Treatment of gender identity issues in children typically consists of individual,
family, and group therapy that guides children in exploring their gendered interests
and identities. There are some providers who practice reparative, or conversion
therapy, which attempts to change a person’s gender identity or sexual orientation.
Adolescents
As gender-nonconforming children approach puberty, some show intense fear and
preoccupation related to the physical changes they anticipate or are beginning to
experience.

1- Psychotherapy
2- Puberty-blocking medications: gonadotropin-releasing hormone (GnRH) agonists
 that can be used to temporarily block the release of hormones that lead to
secondary sex characteristics, giving adolescents and their families time to reflect
on the best options moving forward.
Adults
Treatment of adults who identify as transgender may include
psychotherapy to explore gender issues, hormonal treatment, and surgical
treatment.
Hormonal and surgical interventions may decrease depression and improve
quality of life for such persons.

**The patient should live at least 2 years as the other sex before
undergoing the surgery (1 year in the desired gender role and after 1 year
of continuous hormone therapy).
Hormones
Hormone treatment of transgender men is primarily accomplished with
testosterone, usually taken by injection every week or every other week.
Transgender women may take estrogen, testosterone-blockers, or progesterone,
often in combination.
Surgery
Many fewer people undergo gender-related surgeries than take hormones.
Some people do not desire gender-related surgeries. Others cannot afford them,
or are not convinced that they will be satisfied with currently available results.
The most common type of surgery for both trans-men and trans-women is “top
surgery,” or chest surgery.
Transgender men may have surgery to construct a male contoured chest. Trans-
women may have breast augmentation.
“Bottom surgery” is less common.
Differential Diagnosis of Adolescents and Adults

1- There are certain mental illnesses in which transgender identity may

be a component of delusional thinking, such as in schizophrenia.

2- Body dysmorphic disorder

3- Transvestic disorder, which is defined as recurrent and intense sexual

arousal from cross-dressing that causes clinically significant distress or
impairment.
Thank you