Gender Incongruence/Gender Dysphoria

What is Gender Dysphoria?

The term "transgender" refers to a person whose sex assigned at birth (i.e,. the sex assigned at birth, usually based on external genitalia) does not align with their gender identity (i.e., one's psychological sense of their gender). Some people who are transgender will experience "gender dysphoria," which refers to psychological distress that results from an incongruence between one's sex assigned at birth and one's gender identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.

People who are transgender may pursue multiple domains of gender affirmation, including social affirmation (e.g., changing one's name and pronouns), legal affirmation (e.g., changing gender markers on one's government-issued documents), medical affirmation (e.g., pubertal suppression or gender-affirming hormones), and surgical affirmation (e.g., vaginoplasty, facial feminization surgery, breast augmentation, masculine chest reconstruction, etc.). Of note, not all people who are transgender will desire all domains of gender affirmation, as these are highly personal and individual decisions.

It is important to note that gender identity is different from gender expression. Whereas gender identity refers to one's psychological sense of gender, gender expression refers to the way in which one presents to the world in a gendered way. For example, in much of the U.S., wearing a dress is considered a "feminine" gender expression, and wearing a tuxedo is considered a "masculine" gender expression. Such expectations are culturally defined and vary across time and culture. One's gender expression does not necessarily align with their gender identity. Diverse gender expressions, much like diverse gender identities, are not indications of a mental disorder.

Gender identity is also different from sexual orientation. Sexual orientation refers to the types of people to which one is sexually attracted. As with people who are cisgender (people whose sex assigned at birth aligns with their gender identity), people who are transgender have a diverse range of sexual orientations.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)1 provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children, adolescents, and adults.

The DSM-5-TR defines gender dysphoria in adolescents and adults as a marked incongruence between one's experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:

  • A marked incongruence between one's experienced/expressed gender and primary and secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
  • A strong desire to be rid of one's primary and 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)
  • A strong desire for the primary and secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one's assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one's assigned gender)
  • 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)

In order to meet the criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The DSM-5-TR defines gender dysphoria in children as a marked incongruence between one's experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

  • 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)
  • 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
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender
  • A strong preference for playmates of the other gender
  • 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
  • A strong dislike of one's sexual anatomy
  • A strong desire for the physical sex characteristics that match one's experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Treatment

Support for people with gender dysphoria may include open-ended exploration of their feelings and experiences of gender identity and expression, without the therapist having any pre-defined gender identity or expression outcome defined as preferable to another. Psychological attempts to force a transgender person to be cisgender (sometimes referred to as gender identity conversion efforts or so-called "gender identity conversion therapy") are considered unethical and have been linked to adverse mental health outcomes.

Support may also include affirmation in various domains. Social affirmation may include an individual adopting pronouns, names, and various aspects of gender expression that match their gender identity. Legal affirmation may involve changing name and gender markers on various forms of government identification. Medical affirmation may include pubertal suppression for adolescents with gender dysphoria and gender-affirming hormones like estrogen and testosterone for older adolescents and adults. Medical affirmation is not recommended for prepubertal children. Some adults (and less often adolescents) may undergo various aspects of surgical affirmation.

Family and societal rejection of gender identity are some of the strongest predictors of mental health difficulties among people who are transgender. Family and couple couples therapy can be important for creating a supportive environment that will allow a person's mental health to thrive. Parents of children and adolescents who are transgender may benefit from support groups. Peer support groups for transgender people themselves are often helpful for validating and sharing experiences.

Challenges/Complications

Transgender people suffer from high levels of stigmatization, discrimination, and victimization, contributing to negative self-image and increased rates of other mental health disorders. Transgender individuals are at higher risk of victimization and hate crimes than the general public. Suicide rates among transgender people are markedly higher than the general population.

Transgender children and adolescents are often victims of bullying and discrimination at school, which can contribute to serious adverse mental health outcomes. Interventions are often needed to create safe and affirming school environments.

Transgender individuals may also face challenges in accessing appropriate health care and insurance coverage of related services.

Terminology

Important terms related to Gender Dysphoria:

  • Cisgender: Describes a person whose gender identity aligns in a traditional sense with the sex assigned to them at birth.
  • Gender diverse: An umbrella term describing individuals with gender identities and expressions and includes people who identify as multiple genders or with no gender at all.
  • Gender dysphoria: A concept designated in the DSM-5-TR as clinically significant distress or impairment related to gender incongruence, which may include a desire to change primary and secondary sex characteristics. Not all transgender or gender-diverse people experience gender dysphoria.
  • Gender expression: The outward manifestation of a person's gender, which may or may not reflect their inner gender identity based on traditional expectations. Gender expression incorporates how a person carries themselves, their dress, accessories, grooming, voice/speech patterns con,versational mannerisms, and physical characteristics.
  • Gender identity: A person's inner sense of being a girl/woman, boy/man, some combination of both, or something else, including having no gender at all. This may or may not correspond to one's sex assigned at birth.
  • Nonbinary: A term used by some individuals whose gender identity is neither girl/woman nor boy/man.
  • Sex/gender assigned at birth: Traditional designation of a person as "female," "male," or "intersex" based on anatomy (e.g., external genitalia and internal reproductive organs) and other biological factors (e.g., sex chromosomes). "Sex" and "gender" are often used interchangeably, but they are distinct entities. It is best to distinguish between sex, gender identity, and gender expression and to avoid making assumptions about a person regarding one of these characteristics based on knowledge of the others. This is sometimes abbreviated as AFAB (assigned female at birth) or AMAB (assigned male at birth).
  • Sexual orientation: Describes the types of individuals toward whom a person has emotional, physical, and romantic attraction.
  • Transgender: An umbrella term describing individuals whose gender identity does not align in a traditional sense with the gender they were assigned at birth. It may also be used to refer to a person whose gender identity is binary and not traditionally associated with that assigned at birth.

Source From psychiatry.org 

FAQs

Transgender is a non-medical term that has been used increasingly since the 1990s as an umbrella term describing individuals whose gender identity (inner sense of gender) or gender expression (outward performance of gender) differs from the sex or gender to which they were assigned at birth. Some people who use this term do not consider themselves as matching a binary gender category of either strictly male or female. In addition, new terms such as gender non-conforming, genderqueer, bigender, and agendered are increasingly in use.

Transsexual is a historic medical term that refers to individuals who have undergone some form of medical and surgical treatment for gender affirmation or confirmation (historically referred to as sex reassignment). Some transsexual individuals may identify as transgender, although many primarily identify as the male or female gender to which they have transitioned.

People who identify as transgender but who do not seek medical or surgical treatment are not transsexual.

Not all transgender people suffer from gender dysphoria, and that distinction is important to keep in mind. Gender dysphoria and coming out as transgender can occur at any age.

The DSM-5-TR* distinguishes between Gender Dysphoria in Childhood for those who experience Gender Dysphoria before puberty. The diagnosis of Gender Dysphoria in Adolescents and Adults can occur at any age. Those who experience gender dysphoria later in life often report having secretly hidden their gender dysphoric feelings from others when they were younger.

*Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), Fifth edition, Text Revision. American Psychiatric Association. 2013

Many transgender people who take feminizing or masculinizing hormones, estrogen or testosterone, respectively, report improvement of emotions as their gender dysphoria lessens or resolves. In general, a person transitioning from male to female (MTF, transwoman) takes feminizing hormones that may reduce libido. A person transitioning from female to male (FTM, transman) takes masculinizing hormones that may increase libido. Less commonly, masculinizing hormones may provoke anxious, hypomanic, manic, or psychotic symptoms in patients who have an underlying psychiatric disorder that includes such symptoms. This adverse event appears to be associated with higher doses or greater than average blood levels of testosterone.

As with any medical treatment, the anticipated risks and benefits should be considered by a patient and prescribing doctor on an individual basis.

Not all individuals with gender dysphoria choose to undergo medical or surgical treatment. For one, gender-affirming surgeries are very expensive and are sometimes not covered by insurance. People with gender dysphoria decide which treatment options are right for them. Some are satisfied with taking hormones alone. Some are satisfied with no medical or surgical treatment but prefer to dress as the felt gender in public. Some people make use of Trans affirming social networks online and in local supportive communities to cope with gender dysphoria and claim a gender identity and forms of expression that do not require medical treatments. Some individuals choose to express their felt gender in private settings only because they are either uncomfortable or fearful of publicly expressing their felt gender. People who are denied or have no access to gender-affirming treatments can become anxious, depressed, socially withdrawn, and suicidal.

No. Such a desire is called transvestitism, and it is not a psychiatric disorder. DSM-5-TR does have a diagnosis of Transvestic Disorder that specifically states it “does not apply to all individuals who dress as the opposite sex, even those who do so habitually.” It is only considered a disorder if “cross-dressing or thoughts of cross-dressing are always or often accompanied by sexual excitement.”

Source From psychiatry.org 

Start your journey to Mental Wellness with Dr. Vatsal Suchak.

Book a Consultation