Gender Dysphoria

Gender dysphoria, formerly known as gender identity disorder, is the emotional discomfort felt by a patient because of the incongruence between their experienced gender and the gender they were assigned at birth (continuous inner conflict between gender identity and sexual identity). The 1st signs of cross-gender behaviors begin around age 3, the time when gender identity is established. Management involves a multidisciplinary approach (medical and psychological) to best support the patient.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Introduction

Definitions

  • Sex: biological indicator of one’s male or female reproductive capacity
  • Gender: socially constructed characteristics of men/women
  • Gender assignment: initial assignment as male or female given at birth
  • Gender identity: one’s own identification and acceptance as man, woman, or other
  • Transgender: one who identifies with a gender that is different from that assigned at birth
  • Cisgender: one whose gender assignment and identity are congruent
  • Gender dysphoria: discomfort felt by a patient due to the incongruence between their experienced gender and the gender they were assigned at birth
  • Transsexual:
    • One who wants to have the physical traits or the body of the opposite gender
    • Does not have to have undergone gender reassignment 
  • Queer: one whose sexual orientation or gender identity does not conform to social norms 
  • Cross-dresser: one who maintains their assigned gender but dresses in ways associated with the opposite gender 
  • Transvestism: sexual arousal from wearing clothes of the opposite gender

Epidemiology

  • Reports suggest that 0.3%–0.6% of the adult population are transgender.
  • For every girl referred for clinical evaluation of gender dysphoria, there are 4–5 boys. 
  • Among adults, the prevalence of male to female dysphoria is higher than female to male. 
  • Many children who show gender nonconforming behavior do not grow up to be transgender. 
  • Adults diagnosed with gender dysphoria have higher prevalence of other psychiatric disorders.

Etiology

  • While genetic causes or physiological changes in those with gender dysphoria are not fully understood, gender dysphoria cannot be attributed entirely to behavior. 
  • Psychosocial factors of gender dysphoria may arise from unhealthy relationships or a lack of bond between a child and their mother/father.

Diagnosis

Table: Diagnostic criteria for gender dysphoria
Children Adolescents/adults
Duration at least 6 months; requires at least 6 of the following criteria Duration at least 6 months; requires at least 2 of the following criteria
Desire to be or insistence that one is of another gender (must be present) Incongruence between primary and secondary sexual characteristics of their assigned gender and experienced gender
Dressing in manner typical to the other gender Desire not to be associated with sexual characteristics expected from one’s assigned gender
Preference for playing in the other gender role Desire for sexual characteristics of another gender
Preference for playing with playmates of the other gender Desire to be of another gender
Dislike for playing with toys/activities associated with assigned gender Desire to be treated as another gender
Dislike for one’s own genitals Belief that one’s emotions are that of another gender
Desire for physical maturation to exhibit primary/secondary sexual characteristics associated with one’s experienced gender

Management

Management involves a multidisciplinary approach (medical and psychological) to determine the best treatment plan for the patient.

Before any medical or surgical interventions, patients must meet eligibility criteria outlined by Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

  • Family support, referral for specialist services 
  • The goal of psychotherapy is to achieve comfort in one’s own gender identity to improve chances for social success. 
  • Conversion therapy, which tries to change one’s gender identity or sexual orientation, is against all current practice recommendations. 
  • The lifetime rate of suicidal ideation among those with gender dysphoria is 40%.

Medication

Medications are used based on the patient’s age group and gender:

  • Adolescent patients: 
    • Hormonal treatment using gonadotropin-releasing hormone (GNRH) to delay puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty 
    • While GNRH has been safely used in treating precocious puberty Precocious puberty Precocious puberty (PP) is the appearance of secondary sexual characteristics due to elevated sex hormones before the age of 6-8 in girls and 9 in boys. Excess hormone secretion may occur only at the level of the sex hormone or may involve the whole hypothalamic-pituitary-gonadal axis. Precocious Puberty, use in gender dysphoria among adolescents requires careful clinical evaluation.
  • Adult male-to-female transition: 
    • The goal is to create a female body contour, increase breast formation, and eliminate facial hair. 
    • Antiandrogen (spironolactone or cyproterone acetate)
    • GNRH combined with estrogen therapy (increased risk of venous thromboembolism (VTE))
    • Monitor prolactin levels, which may rise with estrogen therapy. 
    • Side effects include increased risk of blood clots as well as decreased libido. 
  • Adult female-to-male transition:
    • The goal is to increase muscle mass and body hair.
    • Testosterone supplementation
    • Monitor the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver function test, complete metabolic panel, and lipid panel for side effects of liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver disease, stroke, and dyslipidemia. 
    • Testosterone is a teratogen. 

Surgical sex reassignment

  • Offered for patients more than 18 years old
  • Offered only after living 1 year in the desired gender role and after 1 year of continuous hormone therapy
  • Categorized into breast/chest surgery (top surgery), genital surgery (bottom surgery), and non-genital/breast surgery 
  • Adult male to female: 
    • Breast augmentation is a popular top surgery. 
    • Orchiectomy is commonly performed for decreasing the body’s production of testosterone.
    • Facial feminization surgeries are also performed. 
  • Adult female to male: 
    • Top surgery to construct a male-contoured chest 
    • Metoidioplasty
      • Procedure in which the clitoris is released and tissue is added to increase its girth and length to create male-appearing genital
      • Very expensive and not commonly performed 
    • Facial masculinization surgeries are less common, as testosterone therapy can achieve the effect.

Differential Diagnosis

  • Psychotic disorders: psychotic disorders such as delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder or schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia are characterized by delusional thinking and hallucinations. Belief or insistence that one is of another gender should not be considered a delusion. For those who may potentially have gender dysphoria and a psychotic disorder—if the transgender identity diminishes as their psychosis is treated, then they do not have gender dysphoria. 
  • Body dysmorphic disorder Body dysmorphic disorder Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient's preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder ( BDD BDD Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient's preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder): a common psychiatric condition that is characterized by preoccupation with false ideas about one’s own physical appearance. The preoccupation leads to repetitive compulsive behavior that aims to fix the perceived physical defects. Body dysmorphia is different from gender dysphoria since the belief in body dysmorphia is specific to an incorrect body part without any desire to change an assigned gender.
  • Transvestic disorder: part of a larger paraphilic disorder, transvestic disorder is defined as intense sexual pleasure from wearing clothes associated with the other gender. The intensity and recurrence of such fantasies must interact with daily life functioning. Those with transvestic disorder have a gender identity that remains consistent with their assigned gender.

References

  1. Adelson, SL. (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. https://pubmed.ncbi.nlm.nih.gov/22917211/ 
  2. Shechner, T. (2010). Gender identity disorder: A literature review from a developmental perspective. Isr J Psychiatry Relat Sci. https://pubmed.ncbi.nlm.nih.gov/20733256/ 
  3. Rafferty, J. (2018). Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. https://pubmed.ncbi.nlm.nih.gov/30224363/ 
  4. Garg, G, Elshimy, G, & Marwaha, R. Gender dysphoria. [Updated 2020 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK532313/
  5. Sadock, BJ, Sadock, VA, & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 18, Gender Dysphoria, pages 600–607. Philadelphia, PA: Lippincott Williams and Wilkins.
  6. Naghedechi, L. (2018). Gender dysphoria. DeckerMed Medicine.

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