Gender dysphoria
Specialty	Psychiatry, psychology

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Gender identity disorder (GID), also known as gender dysphoria, is a formal diagnosis used by psychologists and physicians to describe people who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex. Affected individuals are commonly referred to as transsexual or transgender. Evidence suggests that people who identify with a gender different from the one they were assigned at birth may do so not just due to psychological or behavioural causes, but also biological ones related to their genetics, the makeup of their brains, or prenatal exposure to hormones.^[1] Estimates of the prevalence of gender dysphoria range up to 1 in 500.^[2] Similarly, little research has been done regarding sex ratios of gender dysphoria, but previous research indicates that people assigned male at birth are three times more likely than those assigned female at birth to be transsexual.^[2]

Gender identity disorder in children is considered clinically distinct from gender dysphoria that appears in adolescence or adulthood. As gender identity develops in children, so do gender role stereotypes: the beliefs, characteristics and behaviors that are deemed culturally normal and appropriate for males and females. These "norms" are influenced by a person's family and friends, media, community and other socializing agents.^[3] Since many cultures have strict expectations about gender, varying from the norm can lead to significant distress for the individual and the people around them. Some transgender individuals also report discomfort stemming from feeling "trapped in the wrong body".^[4]

Controversy exists as to whether GID is a mental disorder.^[5] Gender identity disorder is classified as a medical disorder by the ICD-10 CM^[6] and DSM-5 (called Gender Dysphoria).^[5] Many transgender people and researchers support declassification of GID because they say the diagnosis pathologizes gender variance, reinforces the binary model of gender,^[7] and can also result in stigmatization of transgender individuals.^[5]

The diagnosis has been criticized for not sufficiently distinguishing between anxiety, depression and distress related to the person's experience of their own gender, which is intrinsic to the person, versus that which is related to the social and psychological consequences of having a stigmatized identity and is therefore extrinsic.^[8] Critics say that framing unhappiness about gender as an individual psychological problem risks obscuring the extent to which it may be a broader societal problem.^[9] Treatment for gender dysphoria is also controversial, as changes made are typically irreversible.^[10] The current approach to treatment for people diagnosed with gender dysphoria is to support them in physically modifying their bodies so that they better match their gender identities.^[10]

Causes

Though the exact etiology of gender dysphoria is unknown, there is evidence of biological and sociocultural influences in its development.

Biological causes

Genetic variation, hormones, and differences in brain functioning and brain structures provide evidence for the biological etiology of the symptoms associated with GID. Twin studies indicate that GID is 62% heritable, evidencing the genetic influence in its development.^[11] In male-to-female transsexuals, GID is associated with variations in an individual's genes that make the individual less sensitive to androgens.^[1] Zhou et al. (1995) found that in one area of the brain, male-to-female transsexuals have a typically female structure, and female-to-male transsexuals have a typically male structure.^[12] In addition, some aspects of trans women's hypothalamus functioning resembles that typical of cisgender women.^[13]

Sociocultural causes

David Reimer was a male whose penis was accidentally amputated as an infant, and whose parents decided to raise him as if he were female. David was never comfortable with this assigned femaleness, and he transitioned to living as male later in life. He remained unhappy, however, and committed suicide at age of 38.^[14]

Diagnostic criteria

The American Psychiatric Association permits a diagnosis of gender identity disorder if the criteria in the Diagnostic and Statistical Manual of Mental Disorders (5th Edition), or DSM-5, are met.

The DSM-5 moved this diagnosis out of the sexual disorders category and into a category of its own.^[15] The diagnosis itself was renamed "Gender Identity Disorder" to "Gender Dysphoria," after criticisms that the former term was stigmatizing."^[16]Subtyping by sexual orientation was deleted, and the diagnosis for children was separated from that for adults. The creation of a specific diagnosis for children reflects the supposedly lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight.^[17]

The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):^[10]

Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10.^[18]

Treatment

General

Treatment for GID is generally divided into psychological treatments and biological. Treatment for GID is somewhat controversial, and guidelines have been put in place to aid clinicians in their treatment of transgender individuals. The World Professional Association for Transgender Health (WPATH) Standards of Care, are used as treatment guidelines for GID by some clinicians. Others utilize guidelines outlined in Gianna Israel and Donald Tarver's "Transgender Care". Guidelines for treatment generally follow a "harm reduction" model.^{[citation needed]}

Prepubescent children

The question of whether to counsel young children to be happy with their assigned sex, or to encourage them to continue to exhibit behaviors that do not conform to gender stereotypes—or to explore a transsexual transition—is controversial. Some clinicians report a significant proportion of young children with gender identity disorder no longer have such symptoms later in life.^[19] There is an active and growing movement among professionals who treat gender dysphoria in children to refer and prescribe hormones, known as a puberty blocker, to delay the onset of puberty until a child is old enough to make an informed decision on whether hormonal gender reassignment leading to surgical gender reassignment will be in that person's best interest.^[20]

Psychological treatments

Until the 1970s, psychotherapy was the primary treatment for GID. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Though some clinicians still use only psychotherapy to treat GID, it is now typically used in addition to biological interventions as treatment for GID.^[21] Psychotherapy alone used to 'cure' individuals of GID is highly controversial and largely ineffective.^[21]

Biological treatments

Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual's physical body and gender identity.^[22] Biological treatments for GID without any form of psychotherapy is quite uncommon, but researchers found that when individuals bypass psychotherapy in their GID treatment, they often feel lost and confused when their biological treatments are complete.^[23]

The most effective form of treatment for GID is a combination of psychotherapy, hormone replacement therapy, and sex reassignment surgery.^{[citation needed]} The overall level of satisfaction with both psychological and biological treatments is very high.^[21]

Controversy

Individuals with GID may or may not regard their own cross-gender feelings and behaviors as a disorder. Advantages and disadvantages exist to classifying GID as a disorder.^[10]

Arguments against GID as a disorder

Gender as a social construction

Gender characteristics are socially constructed and therefore naturally unrelated to biological sex. This perspective often notes that other cultures, particularly historical ones, valued gender roles that would presently suggest homosexuality or transgenderism as normal behavior.^{[citation needed]} Some cultures have three defined genders: male, female, and effeminate male. In Samoa, the fa'afafine, a group of feminine males, are entirely socially accepted. The fa'afafine do not experience any of the stigma or distress typically associated with deviating from a male/female gender role, indicating that the distress that is so frequently associated with GID in a Western context is not caused by the disorder, rather it is a secondary result of social disapproval.^[24]

GID as a birth defect

This argument is supported by physiological evidence, such as the presence of typically-female patterns of white matter and neuron patterns observed in the brains of male-to-female transsexuals^[25][26] and overall longer instances of the androgen receptor gene.^[27] (Also see Causes of transsexualism.) One rebuttal to this view is that these markers do not identify every individual who undergoes transition, and that using them to define transsexualism could falsely exclude some people from treatment.^[28]

Distress as a consequence of stigma

The DSM-IV-TR diagnostic component of distress is not inherent in the cross-gender identity, rather it is a result of social rejection and discrimination.^[24] Dr. Darryl Hill insists that GID is not a mental disorder, but rather that the diagnostic criteria reflect psychological distress in children that occurs when parents have trouble relating to their child's gender variance.^[29]

Replacement for homosexuality in the DSM

Some people^[30] feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the GID diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of another sex/gender).^[31] People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. Kenneth Zucker and Robert Spitzer^[32] argue that GID was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion."

International classification

In December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states "What transsexualism is not...It is not a mental illness."^[33] In May 2009, the government of France has also declared that a transsexual gender identity will no longer be classified as a psychiatric condition in France.^[34]

In August 31, 2010, Thomas Hammarberg, Commissioner for Human Rights within the Strasbourg-based Council of Europe, an independent institution, opposed the mental disorder classification and the sterilization of transgender persons as a requirement for legal sex change.^[35]

The Principle 3 of The Yogyakarta Principles on The Application of International Human Rights Law In Relation to Sexual Orientation and Gender Identity states that "Person of diverse sexual orientation and gender identities shall enjoy legal capacity in all aspects of life. Each person's self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom," and the Principle 18 of this states that "Notwithstanding any classifications to the contrary, a person's sexual orientation and gender identity are not, in and of themselves, medical condition and are not to be treated, cured or suppressed."

Arguments in favor of GID as a disorder

GID as dysfunctional

Some researchers, including Dr. Robert Spitzer and Dr. Paul J. Fink, contend that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction.^[29]

Insurance coverage

Because GID is considered a disorder in the DSM-IV-TR, many insurance companies are willing to cover some of the expenses of sex reassignment therapy. Without the classification of GID as a medical disorder, sex reassignment therapy may be viewed as cosmetic treatment, rather than medically necessary treatment, and may not be funded.^[36]

See also

• List of transgender-related topics

References

Further reading

• A Transgender Journey
• Transgender Rights blog
• GID Reform Advocates
• I'm Not Les: A Transgender Story (2012)/ KCTS 9 Documentary

External links

• Standards of Care for Gender Identity Disorders – published by the Harry Benjamin International Gender Dysphoria Association, includes a description of ICD-10 criteria.
• Health Law Standards of Care for Transsexualism An alternative to the Benjamin Standards of Care proposed by the International Conference on Transgender Law and Employment Policy.
• THE LORD CHANCELLOR'S DEPARTMENT Government Policy concerning Transsexual People
• Gender Identity Disorder & Transsexualism – Synopsis of Etiology in Adults provides an alternative to the current classifications of psychiatric disorder and mental illness.
• Conway, Lynn: "Successful Transwomen" and "Successful Transmen" -Lynn Conway's "Success Pages".