Chapter 16

Gender Dysphoria

Description

• The term gender dysphoria (GD) denotes distress or discomfort with one’s biological sex or assigned gender

• Most widely recognized and most severe GD is transsexualism, in which affected persons express an intense and persistent desire to live and be recognized as members of the other sex and to make their bodies resemble those of the other sex through hormonal and surgical treatment

• Transsexualism is not a DSM-5 diagnosis per se

Background

• Individuals who wish to live as members of the other sex have been recognized since antiquity in many different societies worldwide

• Christine Jorgensen’s widely reported sex reassignment in 1952 brought the phenomenon of transsexualism to public attention in Western countries

• American medical centers began offering sex reassignment in the 1960s

• GD was first recognized as a psychiatric diagnosis in 1980 in DSM-III

Terminology• Recent definitions of GD have deemphasized discomfort with

biological sex characteristics and have focused almost exclusively on discordance between assigned sex and gender identity (individual’s identification as male, female, or other)

• Transsexualism: Term used by clinicians (remains an official diagnosis in the International Classification of Diseases that appears to be synonymous with “severe GD”

• Transgender/transgenderism: Terms used informally to describe persons who report or exhibit significant cross-gender identity or behavior, whether or not they meet full diagnostic criteria for GD

Typical Clinical Presentation

• Dislike for one’s primary or secondary sex characteristics, discomfort with one’s assigned gender or associated gender role, identification with the other gender, and requests for approval for hormonal and surgical sex reassignment are the most frequent presenting complaints of adult patients with GD

• Adults with GD sometimes present initially with other clinical concerns, however, including paraphilias, sexual dysfunctions, depression, or other general psychiatric conditions

Less Common Clinical Presentation

• Rarely, persons with GD may identify with what the DSM-5 calls “some alternative gender” that corresponds to neither their assigned sex nor the other sex

• Examples would include males who desire castration and who identify as eunuchs and persons who want some combination of the secondary sex characteristics of both sexes who identify as she-males, trans persons, or transgender persons

Subtypes of GD in Male Adults• Adult males with GD or transsexualism whose sexual

orientation is characterized by exclusive attraction to men are called homosexual (or androphilic) gender dysphoric males, or MtF transsexuals, because they are homosexual relative to their biologic sex

• Adult males with GD or transsexualism whose sexual orientation is characterized by attraction to women, to women and men, or to neither sex, are called nonhomosexual gender dysphoric males or MtF transsexuals

• In adult males with GD or transsexualism, homosexual and nonhomosexual subtypes appear to represent distinctly different clinical spectra and plausibly reflect entirely different etiologies

Subtypes of GD in Female Adults

• The great majority of adult females with GD or transsexualism are exclusively attracted to women and are called homosexual (or gynephilic) gender dysphoric females or FtM transsexuals

• Although these gender dysphoric females differ in important ways from their nonhomosexual counterparts, the differences between subtypes based on sexual orientation in females with GD are less pronounced and less well-documented

• The great majority of adult females with GD or transsexualism are exclusively attracted to women and are called homosexual (or gynephilic) gender dysphoric females or FtM transsexuals

Diagnosing GD: DSM-5• A marked incongruence between gender identity

(“experienced/expressed gender”) and assigned sex, manifesting as some combination of discomfort with anatomic sex, desire for the anatomy of the other sex, desire to live or be treated as a member of the other sex, or perceived psychological similarity to the other sex

• There is also a requirement of clinically significant distress or impairment in functioning

• Like past editions of the DSM, the DSM-5 has one principal diagnosis—GD—and one or more residual diagnoses

• Two residual diagnoses in the DSM-5:– Other Specified GD is used where symptoms of gender dysphoria are

present and there is clinically significant distress or impairment but the full criteria are not met and the clinician wishes to state why the presentation does not meet full diagnostic criteria

– Unspecified GD is the same as Other Specified GD except that the clinician does not wish to communicate a reason

Differential Diagnosis• Differential diagnostic considerations for the diagnosis of GD

in adults include transvestic disorder; schizophrenia, bipolar disorder, and other psychotic conditions; dissociative identity disorder; some personality disorders (PDs); body dysmorphic disorder; and gender nonconformity

• Although transvestic disorder is one of the differential diagnoses for GD, the two conditions can and do co-occur

• In persons with transvestic disorder, the absence of a marked incongruence between gender identity and assigned sex would exclude the diagnosis of GD

• Many cross-dressing men who meet diagnostic criteria for transvestic disorder, however, describe cross-gender identities of some strength and some express a desire to use feminizing hormone therapy

Differential Diagnosis cont.

• Patients with schizophrenia, bipolar disorder, and other psychotic disorders sometimes experience delusional beliefs of being or becoming the other sex

• Treatment of the psychotic condition usually leads to resolution of the cross-gender identification

• In rare cases, GD and psychosis can co-occur• Cross-gender ideation can also occur with

dissociative identity disorder and antisocial personality disorder

Epidemiology• There is evidence to suggest that GD is becoming more

prevalent• In a large, population-base survey, prevalence was 1.1% for

males and 0.8% for females (Netherlands)• In most Western countries, MtF is 2 to 3 times as prevalent as

FtM transsexualism• Autogynephilic cross-dressers appear to be the most

numerous transgender subgroup• Most transsexuals report being aware of transgender feelings

in early childhood• Nonhomosexual MtF transsexuals typically report that they

experienced their first desire to be the other sex or to change sex in middle childhood or even as late as adolescence or adulthood

Psychological Assessment

• Diagnosis involves determining the presence or absence of a GD, evaluating the nature and severity of the GD, and assessment of comorbid psychopathology

• The clinician should obtain information about the client's psychosexual development, gender identification, sexual orientation, and feelings concerning sexed body characteristics and assigned gender role

• In adults, GDs are diagnosed primarily on the basis of self-report– No objective or medical tests exist– Questionnaires exist but are not widely used clinically

Biological Assessment

• Physical examination could help ascertain the presence or absence of a disorder of sex development (specifier)

• Karyotyping (a test to examine chromosomes in a sample of cells, which can help identify genetic problems as the cause of a disorder or disease) may be used

• Polycystic ovary syndrome (PCOS) has been found in female GD but results are inconsistent

Clinical Course

• The clinical course of GD is variable, not easily predictable, and not well understood, even in persons who have been carefully evaluated and diagnosed

• Four recognized outcomes of severe GD:1. Unresolved or unknown2. Acceptance of natal gender3. Part-time cross-gender expression4. Full-time cross-living and sex reassignment

Treatment• Four main treatment modalities for GD:

1. Psychotherapy2. Cross-sex hormone therapy3. Real-life experience in the desired gender role4. Sex reassignment surgery

• Psychotherapy is not intended to cure gender dysphoria but to allow the client to explore his or her evolving identity, discuss relationship and employment issues, and consider treatment options

• Persons with GD can also benefit from group psychotherapy, which can reduce feelings of isolation and provide opportunities to receive and give support, including advice about grooming and social presentation

Treatment cont.• Cross-sex hormone therapy suppresses or minimizes the

secondary sex characteristics of a person's natal sex and promotes the development of the secondary sex characteristics of the other sex

• Hormone therapy for males with GD and MtF transsexuals usually involves a combination of estrogens and antiandrogens– This feminizing hormone therapy typically results in breast growth,

decreased muscle mass, reduction in the growth of facial and body hair, slowing of scalp hair loss, and decreased sexual interest

• Hormone therapy for females with GD and FtM transsexuals usually involves only testosterone– This masculinizing hormone therapy causes increased facial and

body hair, increased muscle mass, male pattern scalp hair loss, deepening of the voice, clitoral enlargement, and suppression of menses

Treatment cont.

• Real-life experience in the desired gender role helps clients decide whether cross-living offers a better quality of life

• Clients can undertake a real-life experience without professional help, and some clients will already be living full time in a cross-gender role when they are first seen by clinicians

• Improvement in social and psychological functioning in the desired gender role is one possible measure of success, but such improvement can be difficult to demonstrate if negative social and economic consequences of prejudice and discrimination overshadow the psychological benefits of living in the desired gender role

Treatment cont.

• Sex reassignment surgery (SRS)– Feminizing genitoplasty in males with GD– Reduction mammaplasty and chest reconstruction in females with

GD– Masculinizing genitoplasty in females with GD

• Most studies of the outcomes of the sex reassignment process have involved MtF transsexuals who have undergone genital SRS, or FtM transsexuals who have undergone chest reconstruction

• Nearly all such studies have concluded that sex reassignment generally, and SRS specifically, results in substantial relief of GD, high levels of patient satisfaction, favorable (or at least not worsened) psychosocial outcomes, and a low prevalence of regret

Etiology

• It is important to recognize the limitations of theories and research findings relevant to understanding the etiology of GD and transsexualism in adults

• Much of the relevant research has addressed the etiology of GD as it manifests in children

• Most cases of GD remit before adulthood• Recent study showed that some children who had

transitioned socially to live as members of the other gender “reverted” to living in the gender role that matched their natal sex

Etiology cont.

• Behavioral Genetics– Among 23 pairs of monozygotic twins, 9 pairs (39%) were

concordant for GID, whereas among 21 pairs of same-sex dizygotic twins, none were concordant for GID, a statistically significant difference. In a study of 96 MZ and 61 DZ twin pairs (ages 4–17), heritability accounted for 62% of the variance in GID scores and nonshared environment accounted for 38%

– The prevalence of GID in the children was 2.3%, which may suggest that the authors’ threshold for ascertaining the condition was too low: Their conclusions about heritability arguably addressed childhood gender nonconformity rather than true GID

Etiology cont.• Molecular Genetics

– Researchers have hypothesized that abnormalities in genes that code for sex hormone receptors or for enzymes that catalyze the synthesis or metabolism of sex hormones might show associations with GD/transsexualism

– Candidate genes include those coding for androgen receptor (AR), estrogen receptor alpha (ERα), estrogen receptor beta (ERβ), and progesterone receptor (PR), and for the enzymes aromatase (CYP19), 17-alpha-hydroxylase (CYP17), and 5-alpha-reductase, type II (SRD5A2)

• There is little or no evidence at present that abnormalities related to molecular genetics account for GD or transsexualism– Most investigations have yielded negative results, and the few

positive results have not been replicated by other investigators

Etiology cont.• Neuroanatomy

– The central subdivision of the bed nucleus of the stria terminalis (BSTc), a hypothalamic or limbic nucleus, is sexually dimorphic; it is significantly larger and contains a larger number of neurons in men than in women

– A postmortem study of six MtF transsexuals found that mean BSTc size was small and female-typical, a sex-reversed pattern

– However, the BSTc does not become sexually dimorphic until adulthood, long after the symptoms of MtF transsexualism typically appear

– Magnetic resonance imaging (MRI) studies demonstrated that hormone therapy in MtF transsexuals was associated with significant reductions in the volume of the brain globally and the hypothalamus particularly

– Male pedophiles, too, had a lower than expected BSTc volume; noting the similar findings in MtF transsexuals, they proposed that these alterations may not be specific to pedophilia but may rather be a feature of sexual abnormalities in general

Etiology cont.

• Cognitive schemas of gender• Cognitive factors appear to play a limited role in the

etiology of GD in adults• Most research has focused on:

– Childhood development of cognitive schemas concerning gender– Cognitive comparisons of self and others during transgender

coming out– Cognitive contributions to cross-gender identity formation in

transvestism and nonhomosexual MtF transsexualism• The process of reconciling core gender identity and the

emergent cross-gender identity has been described as an attempt to resolve cognitive dissonance

Etiology

• Sex and ethnicity considerations– Adult GD is 2 to 3 times more common in males than in females– Males with GD are diverse with respect to sexual orientation, age

at clinical presentation, and congruence between physical appearance and desired gender role; females with GD are more homogeneous with respect to these variables

– Cross-sex hormone therapy is highly effective in masculinizing the appearance of FtM transsexuals but much less effective in feminizing the appearance of MtF transsexuals

– In Asian, Polynesian, and Latin American countries, most MtF transsexuals are homosexual in orientation; whereas in the United States, Canada, and most western European countries, the majority of MtF transsexuals are currently nonhomosexual in orientation