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Gender Dysphoria in Adolescents and Adults

  • Synopsis: Published: 2017-07-29 (Rev. 2017-07-31) - Information regarding gender dysphoria, a diagnosis that refers to people whose gender at the time of their birth is contrary to the one they identify with. For further information pertaining to this article contact: Sexual Diversity at sexualdiversity.org.

Main Document

Quote: "According to the DSM-V, the first requirement for a diagnosis of gender dysphoria in adolescents and adults is a marked incongruence between the person's experienced or expressed gender and their assigned gender"

Gender dysphoria is a diagnosis that refers to people whose gender at the time of their birth is contrary to the one they identify with. It constitutes a new diagnostic class in the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) of Mental Disorders, Fifth Edition. The diagnosis replaces the DSM-IV diagnosis of gender identity disorder. The DSM diagnostic criteria for gender dysphoria include strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage.

Teenagers and adults might have a preoccupation with getting rid of primary and secondary sex characteristics. They may believe they were born as the wrong gender. People with gender dysphoria do not have a concurrent physical intersex condition. People report significant distress or impairment in occupational, social or other important areas of functioning.

Understanding Gender Terminology

Gender dysphoria is a complex condition that might be hard to understand. Due to this, it helps to distinguish between the meanings of some different gender-related terminology. What follows are descriptions of the terms.

  • Transvestism: Transvestism involves a person who occasionally wears clothing usually associated with the opposite gender for a number of reasons.
  • Gender Dysphoria: Gender dysphoria involves distress or discomfort caused by a mismatch between a person's gender identity and their biological gender which was assigned at the time of their birth.
  • Transsexualism: Transsexualism involves the desire to live and be accepted as a member of the opposite gender, often times accompanied by the desire to receive treatment to make their physical appearance more consistent with their gender identity.
  • Genderqueer: 'Genderqueer,' is an umbrella term used to describe gender identities other than male and female; for example, people who are neither male nor female, who are both female and male, or people who are transitioning between genders.

Causes of Gender Dysphoria

To be plain, the precise cause of gender dysphoria is not clear. It was traditionally believed to be a form of psychiatric condition, with causes believed to originate in the person's mind. More recent research; however, suggests the condition might actually be the result of the unusual development of a baby while it is in the womb, potentially as a result of hormonal or genetic factors, which causes the person's brain to develop a gender identity that is different from the baby's genitals.

Gender Dysphoria Signs

The first signs of gender dysphoria may appear while a child is still very young. For example; a child might refuse to wear common girls' or boys' clothing, or the child may not like participating in common girls' or boys' activities or games. In most instances, the behavior is simply an average part of growing up and will pass with time. Yet for people with gender dysphoria, the behavior persists into later childhood and on through adulthood.

Adults with gender dysphoria might feel trapped inside a body that does not match their gender identity. They may feel so unhappy about social expectations they live in accordance with their anatomical gender instead of the gender they feel themselves to be. They might also experience a strong desire to change or rid themselves of physical signs of their biological gender, such as breasts or facial hair.

Gender Dysphoria in Adolescents and Adults

According to the DSM-V, the first requirement for a diagnosis of gender dysphoria in adolescents and adults is a marked incongruence between the person's experienced or expressed gender and their assigned gender. The incongruence must have lasted for at least 6 months and has to include at least two of the following criteria:

  • Strong desire to be of the other (or some alternative) gender
  • Strong desire to be treated as the other (or some alternative) gender
  • Strong desire for the primary or secondary sex characteristics of the other gender
  • Strong conviction of having the typical feelings and reactions of the other (or some alternative) gender
  • Marked incongruence between the patient's experienced or expressed gender and his or her primary or secondary sex characteristics
  • Strong desire to be rid of his or her primary or secondary sex characteristics (or, in young adolescents, to prevent the development of the anticipated secondary characteristics)

Another requirement is that the condition be associated with clinically significant distress or impaired occupational, social, or other areas of important functioning. A clinician should also specify whether the condition is happening along with a disorder of sex-development. A clinician might also specify whether the person has made the transition to living in the desired gender on a full-time basis.

Gender Dysphoria and Children

Once again, the first requirement for a diagnosis of gender dysphoria in children is a marked incongruence between the person's experienced or expressed gender and their assigned one. The incongruence must have lasted for at least six months and has to include at least six of eight criteria which include the following:

  • Strong dislike of one's sexual anatomy
  • Strong preference for playmates of the other gender
  • Strong preference for cross-gender roles in make-believe or fantasy play
  • Strong preference for the stereotypical toys, games, or pastimes of the other gender
  • Strong desire to be of the other (or some alternative) gender or insistence that one already is
  • Strong desire for the primary or secondary sex characteristics that match one's experienced gender
  • Strong preference for cross-dressing or simulating female attire (boys); strong preference for typical masculine clothing and resistance to typical feminine clothing (girls)
  • Strong rejection of typically masculine toys, games, and activities, with strong avoidance of rough play (boys); strong rejection of typically feminine toys, games, and activities (girls)

Another requirement is that the condition be associated with clinically significant distress or impairment of school, social, or other important areas of functioning. A clinician should specify whether the condition is happening along with a disorder of sex development.

Psychological Factors and Gender Dysphoria

A publication from the year 1968, rooted in psychoanalytic theory, described a typical background from which a male transsexual might emerge. In the scenario, a woman whose mother did not encourage her daughter's femininity marries a passive man, for a relationship that is unsatisfactory for both, yet is often long-term. The depressed woman has a male child. A happy symbiosis is established between mother and son. The father doesn't attempt to break the symbiosis and often times remains away from home. Excessive physical and emotional closeness to the mother for too long leads to feminine identification and behaviors that secretly please the mother - who then reinforces them.

'Stoller,' the author, perceived this non-conflictual learning process as similar to imprinting. In contrats, Stoller viewed homosexuality and transvestism as end results of defense against the trauma of painful and dangerous interpersonal relationships.

The year of 1974 found a publication by Person and Ovesey postulating a different, but still psychosocial, etiology that was based upon a study of ten primary transexuals. While all ten of the people in the study envied girls and pursued cross-dressing behavior, beginning at age 2-10 years, not one believed he was a girl and nine gave no history of feminine behavior. They were loners with few age mates of either gender. They experienced feelings of depression, anxiety and loneliness. The people in the study were asexual and loathed their male characteristics. Their desire to be female was based on a fantasy of symbiotic fusion with their mothers as a means of dealing with extreme separation anxiety. Stoller described the psychoanalytic etiology of female transsexualism as being, 'unclear,' yet listed some preliminary findings such as:

  • Neither the mother nor the father of the girl has a gender disorder
  • The child knows that the mother is present but beyond emotional reach
  • The daughter is described as vigorous, ungraceful, and unattractive in infancy
  • The father does not minister to his wife; rather, he has the daughter minister to her
  • The father engages the daughter in activities that interest him, thus promoting masculine behavior
  • The mother is unable to function in the first months or year of the daughter's life, because of deep depression (or, in a minority of cases, paranoia or physical illness)
  • By the age of 4-5 years, the daughter already yearns to have the anatomic insignias of maleness, a yearning born out of pain and conflict from premature maternal separation

Please bear in mind that these ideas are preliminary postulates instead of being established facts. Confirming data are not available.

Retrospective studies in adult transsexuals have shown differences in recalled child-rearing patterns between transsexuals and, 'normative,' groups. Male-to-female transsexuals characterized their fathers as less emotionally available, more rejecting, less warm and overly-controlling. Female-to-male transsexuals characterized both of their parents as being more rejecting and less emotionally warm, yet they characterized only their mothers -- not their fathers, as being overprotective. It has been argued that the development of transsexualism is the:

"result of a non-conflictual process, where gender identity is precociously fixed [and] ... considered to be an entirely particular phenomenon, so that its aetiology must be clearly distinguished from both perversions and atypical sex change requests."

Basically, the boy has had a happy symbiosis with the mother and develops from early infancy an identity with the female gender. The boy's family then adapts to and supports their child.

Biologic Factors of Gender Dysphoria

Biomedical research into transsexualism has investigated a number of areas. Girls with congenital adrenal hyperplasia (CAH), a condition causing prenatal exposure to a relatively high level of androgens, have been examined to determine whether male gender identity develops even if XX-chromosome persons are raised as females. A few people have been reported. In most instances; however, girls assigned and reared consistently as girls do not become transsexuals.

Transsexualism has not been observed in either males or females exposed to progestogens in utero, which may have antiandrogenic or androgenic qualities, nor has it been found upon exposure to estrogenic drugs such as, 'diethylstilbestrol,' or DES. Despite this, some atypical aspects of gender role behavior have been observed.

In the year of 1983, Dorner found that male-to-female transsexuals, like females, showed a rise in luteinizing hormone (LH) levels after estrogen stimulation as a consequence of prenatal exposure to imbalanced sex steroid levels. The opposite happened in female-to-male transsexuals. Other studies; however, that used more rigorous endocrine methodologies were unable to replicate the study's findings. Several hypothalamic nuclei in people have been reported to be sexually, 'dimorphic,' with respect to shape or size, including the following:

  • Two cell groups in the anterior hypothalamus (isonicotinic acid hydrazide
  • A sexually dimorphic nucleus (SDN) of the preoptic area of the hypothalamus
  • The darkly staining posteromedial component of the bed nucleus of the stria terminalis
  • The suprachiasmatic nucleus (SCN) and the central subdivision of the bed nucleus of the stria terminalis

Sex differences in the hypothalamus are believed to underlie sex differences in gender identity, sexual orientation and reproduction. Plainly, more solid and well-designed research into the biology of these disorders is needed. Some studies suggest that male gender identity might be partly mediated through the androgen receptor. The relative contribution of sex hormones and additional non-hormonal factors might be an area where additional research is needed.

Gender Dysphoria Prognosis

Case reports already in existence do not indicate that psychotherapy produces complete and long-term reversal of cross-gender identity. Transsexuals are not a homogeneous group. Some transsexuals do not show severe psychopathology. Diagnosing and treating this disorder early may reduce the chances of emotional distress, depression and suicide. Gender dysphoria is not the same as homosexuality. How the gender conflict happens is different in each person. Some people; for example, might cross-dress, while others desire sex change surgery. Some people of one gender privately identify more with the other gender.

People who are born with ambiguous genitalia, something that might raise questions in their minds concerning their gender, may qualify for gender dysphoria. Sex reassignment surgery may be a viable treatment solution for some. Satisfactory results are reported in 87% of male-to-female and 97% of female-to-male persons. Factors associated with fairly poor post-sex reassignment surgery (SRS) functioning include the following:

  • Suicidal intentions
  • Bad surgical results
  • Transvestic disorder
  • Loss of work and family
  • SRS performed late in life
  • Effeminate homosexuality
  • Inadequate social functioning
  • Uncooperative attitude toward clinicians
  • Enduring resistance towards being transsexual

Outcome studies suggest that transsexuals without severe psychopathology are better off when treated promptly after achieving a diagnosis. Transsexuals who have severe psychopathology, are not homosexual, or who have a late-onset gender identity disorder should not necessarily be excluded from SRS, yet they require more care and extensive evaluation and therapeutic support before SRS is deemed to be viable.

Patient Education

People should be educated about the differences between true transsexualism and other gender issues such as gender dysphoria, transvestic fetishism, homosexuality and nonconformity to stereotypical sex role behaviors. Both people and their family members need to understand the complexities of gender dysphoria, its enduring nature and the challenges that it usually presents.

Treatment options should be discussed. When SRS is being considered, it should be explained that the procedure does not produce a life free of trouble. In addition, work and social adjustment issues have t be discussed and plans for addressing these concerns must be developed. The importance of continuing family support and understanding should also be approached. The need for long-term therapy and social support should be discussed and encouraged when it is appropriate.

Treating Gender Dysphoria

The goal for treating gender dysphoria is to help reduce or remove the distressing feelings of a mismatch between the person's biological gender and their gender identity. Treatment can mean different things for individuals. For some people, it may mean dressing and living as their preferred gender.

For other people, it might mean taking hormones, or having surgery to change their physical appearance. Many transsexual people receive treatment to change their bodies permanently, so they are more consistent with their gender identity. The vast majority are satisfied with the eventual results.

Pharmacologic Therapy

Hormone therapy may be needed. Consequently, an endocrinologist should be involved in multiple phases of the treatment process. In male-to-female persons, original sex characteristics may be suppressed with:

  • Flutamide
  • Spironolactone
  • Cyproterone acetate
  • Progestational compounds
  • Luteinizing hormone--releasing hormone (LHRH) agonists

A more feminine body, breasts and increased body fat may be promoted with ethinyl estradiol and conjugated estrogen. In female-to-male persons, facial and body hair growth may be promoted with testosterone cypionate. Pharmacology might also be required for comorbid psychiatric diagnosis. People commonly experience symptoms of anxiety, depression or psychosis. Medications may include anxiolytics, antidepressants and antipsychotics. Clinically referred children and adolescents with gender dysphoria seem to experience a higher incidence of autism spectrum disorder than is found in the overall population.

A controversy exists concerning whether or not adolescents should be allowed to pursue SRS. Many nations deny SRS to adolescents; however, early treatment might be beneficial in adolescents whose secondary sex characteristics have not yet developed fully such as a lowered voice, facial hair or breast development. In such instances, involvement of the adolescent's parents and their approval is essential.

Is Gender Identity Disorder a Disability Under the ADA?

Gender identity disorder (GID) on its own does not make you eligible for Social Security disability (SSD) benefits. In fact the ADA specifically excludes gender identity disorder as a "disability" within the meaning of the law. For a condition to be covered under SSD, it must prevent a person from working enough to support his or herself, and GID itself does not cause physical or mental disabilities severe enough to impact your ability to work. So, someone with GID would not be eligible for SSD if this was the only issue they had. However, a person with GID may qualify for SSD because of certain conditions that may develop alongside, or as the result of, being transgender. People who have GID tend to have depression, anxiety, and similar mental illnesses due to experiences they may have living as transgender individuals. For instance, depression can negatively impact a person's ability to maintain employment; therefore, you may be eligible for social security disability payments if your depression is severe enough to prevent you from working. Contact your local Department of Social Security to determine if you are eligible for SSD payments for Gender Dysphoria and associated conditions.

Gender Dysphoria Awareness

The numbers of people who experience gender dysphoria is not exactly known because many people with the condition never pursue assistance. One study pursued in Scotland in 1999 discovered that approximately 1 in every 12,500 people might have the condition, although some people are of the belief that this is a notable underestimate. A survey of 10,000 people was undertaken in the year 2012 by the Equality and Human Rights Commission discovered that 1% of the population was gender variant to some degree.

Even though gender dysphoria seems to be rare, the numbers of people being diagnosed with the condition is increasing due in part to increasing public awareness of gender dysphoria. Many people with gender dysphoria; however, continue to face misunderstanding or outright prejudice.

Related Information:

  1. Males with Disabilities 4 Times More Likely to be Sexually Abused - Researchers report men with disabilities more than four times more likely to be victimized by sexual assaults compared to men without disabilities - Elsevier Health Sciences
  2. What Makes a Man Sexually Attractive - The Answer May Surprise You - Dramatic gender differences in how men and women rank sexual attractiveness of non-verbal expressions of commonly displayed emotions including happiness pride and shame - University of British Columbia




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