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= Gender dysphoria =
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Introduction
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Gender dysphoria (GD) is the distress a person feels due to a mismatch
between their gender identity and their sex assigned at birth. People
who experience gender dysphoria are typically transgender. The
diagnostic label gender identity disorder (GID) was used by the DSM
until it was renamed 'gender dysphoria' in 2013 with the release of
the DSM-5. The diagnosis was renamed to remove the stigma associated
with the term 'disorder'.
Gender nonconformity is not the same thing as gender dysphoria, and
the American Psychiatric Association states that "gender nonconformity
is not in itself a mental disorder. The critical element of gender
dysphoria is the presence of clinically significant distress
associated with the condition."
Evidence from studies of twins suggests that gender dysphoria likely
has genetic causes in addition to environmental ones. Some transgender
people and researchers support declassification of the condition
because they say the diagnosis pathologizes gender variance and
reinforces the binary model of gender.
Treatment for gender dysphoria may involve supporting the person
through changes in gender expression. Hormone therapy or surgery may
be used to assist such changes. Treatment may also include counseling
or psychotherapy.
Signs and symptoms
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Gender dysphoria in those assigned male at birth tends to follow one
of two broad trajectories: early-onset or late-onset. Early-onset
gender dysphoria is behaviorally visible in childhood. Sometimes
gender dysphorics identify as gay for a period of time. This group is
usually attracted to members of their natal sex in adulthood.
Late-onset gender dysphoria does not include visible signs in early
childhood, but some report having had wishes to be the opposite sex in
childhood that they did not report to others. Trans women who
experience late-onset gender dysphoria will often be attracted to
women and may identify as lesbians. They frequently engage in
transvestic behavior with sexual excitement. In those assigned female
at birth, early-onset gender dysphoria is the most common course.
Symptoms of GD in children include preferences for opposite
sex-typical toys, games, or activities; great dislike of their own
genitalia; and a strong preference for playmate of opposite sex
children. Some children may also experience social isolation from
their peers, anxiety, loneliness, and depression. According to the
American Psychological Association, transgender children are more
likely to experience harassment and violence in school, foster care,
residential treatment centers, homeless centers and juvenile justice
programs than other children. Additionally, some child psychologists
continue to use misgendering and pathologizing language and approaches
with transgender children, contrary to APA policy statements.
In adolescents and adults, symptoms include the desire to be and to be
treated as the other gender. Adults with GD are at increased risk for
stress, isolation, anxiety, depression, poor self-esteem, and suicide.
Studies indicate that transgender people have an extremely high rate
of suicide attempts; one study of 6,450 transgender people in the
United States found 41% had attempted suicide, compared to a national
average of 1.6%. It was also found that suicide attempts were less
common among transgender people who said their family ties had
remained strong after they came out, but even transgender people at
comparatively low risk were still much more likely to have attempted
suicide than the general population. Transgender people are also at
heightened risk for eating disorders and substance abuse.
Causes
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A twin study (based on seven people in a 314 sample) suggested that
GID may be 62% heritable, indicating the possibility of a genetic
influence as its origin, in these cases.
Diagnosis
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The American Psychiatric Association permits a diagnosis of 'gender
dysphoria' in adolescents or adults if two or more of the following
criteria are experienced for at least six months' duration:
* A strong desire to be of a gender other than one's assigned gender
* A strong desire to be treated as a gender other than one's assigned
gender
* A significant incongruence between one's experienced or expressed
gender and one's sexual characteristics
* A strong desire for the sexual characteristics of a gender other
than one's assigned gender
* A strong desire to be rid of one's sexual characteristics due to
incongruence with one's experienced or expressed gender
* A strong conviction that one has the typical reactions and feelings
of a gender other than one's assigned gender
In addition, the condition must be associated with clinically
significant distress or impairment.
The DSM-5 moved this diagnosis out of the sexual disorders category
and into a category of its own. The diagnosis was renamed from gender
identity disorder to gender dysphoria, after criticisms that the
former term was stigmatizing. Subtyping by sexual orientation was
deleted. The diagnosis for children was separated from that for
adults, as "gender dysphoria in children". The creation of a specific
diagnosis for children reflects the lesser ability of children to have
insight into what they are experiencing, or ability to express it in
the event that they have insight. 'Other specified gender dysphoria'
or 'unspecified gender dysphoria' can be diagnosed if a person does
not meet the criteria for gender dysphoria but still has clinically
significant distress or impairment. Intersex people are now included
in the diagnosis of GD.
The International Classification of Diseases (ICD-10) lists several
disorders related to gender identity:
* Transsexualism (F64.0): Desire to live and be accepted as a member
of the opposite sex, usually accompanied by a desire for surgery and
hormonal treatment
* Gender identity disorder of childhood (F64.2): Persistent and
intense distress about one's assigned gender, manifested prior to
puberty
* Other gender identity disorders (F64.8)
* Gender identity disorder, unspecified (F64.9)
* Sexual maturation disorder (F66.0): Uncertainty about one's gender
identity or sexual orientation, causing anxiety or distress
The ICD-11, which will come into effect on 1 January 2022,
significantly revises classification of gender identity-related
conditions. Under "conditions related to sexual health", the ICD-11
lists "gender incongruence", which is coded into three conditions:
* Gender incongruence of adolescence or adulthood (HA60): replaces
F64.0
* Gender incongruence of childhood (HA61): replaces F64.2
* Gender incongruence, unspecified (HA6Z): replaces F64.9
In addition, sexual maturation disorder has been removed, along with
dual-role transvestism. ICD-11 defines gender incongruence as "a
marked and persistent incongruence between an individual�s experienced
gender and the assigned sex", with presentations similar to the DSM-5
definition, but does not require significant distress or impairment.
Management
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Treatment for a person diagnosed with GD may include psychotherapy or
to support the individual's preferred gender through hormone therapy,
gender expression and role, or surgery. This may include psychological
counseling, resulting in lifestyle changes, or physical changes,
resulting from medical interventions such as hormonal treatment,
genital surgery, electrolysis or laser hair removal, chest/breast
surgery, or other reconstructive surgeries. The goal of treatment may
simply be to reduce problems resulting from the person's transgender
status, for example, counseling the patient in order to reduce guilt
associated with cross-dressing, or counseling a spouse to help them
adjust to the patient's situation.
Guidelines have been established to aid clinicians. The World
Professional Association for Transgender Health (WPATH) Standards of
Care are used by some clinicians as treatment guidelines. Others use
guidelines outlined in Gianna Israel and Donald Tarver's 'Transgender
Care'. Guidelines for treatment generally follow a "harm reduction"
model.
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 match their assigned sex�or to explore a
transgender transition�is controversial. The follow-up studies of
children with gender dysphoria consistently show that the majority
cease to feel transgender during puberty and identify instead as gay
or lesbian. Others clinicians also report that a significant
proportion of young children diagnosed with gender dysphoria later do
not exhibit any dysphoria.
Professionals who treat gender dysphoria in children have begun to
refer and prescribe hormones, known as puberty blockers, to delay the
onset of puberty until a child is believed to be 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.
Psychological treatments
==========================
Until the 1970s, psychotherapy was the primary treatment for gender
dysphoria, and generally was directed to helping the person adjust to
the gender of the physical characteristics present at birth.
Psychotherapy is any therapeutic interaction that aims to treat a
psychological problem. Though some clinicians still use only
psychotherapy to treat gender dysphoria, it may now be used in
addition to biological interventions. Psychotherapeutic treatment of
GID involves helping the patient to adapt. Attempts to cure GID by
changing the patient's gender identity to reflect birth
characteristics have been ineffective.
Biological treatments
=======================
Biological treatments physically alter primary and secondary sex
characteristics to reduce the discrepancy between an individual's
physical body and gender identity. Biological treatments for GID
without any form of psychotherapy is quite uncommon. Researchers have
found that if individuals bypass psychotherapy in their GID treatment,
they often feel lost and confused when their biological treatments are
complete.
Psychotherapy, hormone replacement therapy, and sex reassignment
surgery together can be effective treating GID when the WPATH
standards of care are followed. The overall level of patient
satisfaction with both psychological and biological treatments is very
high.
In April 2011, the UK National Research Ethics Service approved
prescribing monthly injection of puberty-blocking drugs to youngsters
from 12 years old, in order to enable them to get older before
deciding on formal sex change. The Tavistock and Portman NHS
Foundation Trust (T&P) in North London has treated such children.
Clinic director Dr. Polly Carmichael said, "Certainly, of the children
between 12 and 14, there's a number who are keen to take part. I know
what's been very hard for their families is knowing that there's
something available but it's not available here." The clinic received
127 referrals for gender dysphoria in 2010.
The T&P completed a three-year trial to assess the psychological,
social and physical benefits and risks involved for 12- to 14-year-old
patients. The trial was deemed such a success that doctors have
decided to make the drugs more widely available and to children as
young as 9 years of age. As recently as 2009, national guidelines
stated that treatment for gender dysphoria should not start until
puberty had finished. Ferring Pharmaceuticals manufactures the drug
Triptorelin, marketed under the name Gonapeptyl, at £82 per monthly
dose. The treatment is reversible, which means the body will resume
its previous state upon discontinuation of drugs.
Epidemiology
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Gender dysphoria occurs in one in 30,000 male-assigned births and one
in 100,000 female-assigned births. Estimated rates of those with a
transgender identity range from a lower bound of 1:2000 (or about
0.05%) in the Netherlands and Belgium to 0.5% of Massachusetts adults.
From a national survey of high-school students in New Zealand, 8,500
randomly selected secondary school students from 91 randomly selected
high schools found 1.2% of students responded "yes" to the question
"Do you think you are transgender?". These numbers are based on those
who identify as transgender. It is estimated that about 0.005% to
0.014% of people assigned male at birth and 0.002% to 0.003% of people
assigned female at birth would be diagnosed with gender dysphoria,
based on 2013 diagnostic criteria, though this is considered a modest
underestimate. Research indicates people who transition in adulthood
are up to three times more likely to be male assigned at birth, but
that among people transitioning in childhood the sex ratio is close to
1:1.
History
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The term 'gender identity disorder' is an older term for the condition
in the DSM. The American Psychiatric Association (APA) uses the term
'gender dysphoria'. The APA's DSM first described the condition in the
third publication ("DSM-III") in 1980.
Society and culture
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GD is when a person suffers distress due to gender identity.
Researchers disagree about the nature of distress and impairment in
people with GID. Some authors have suggested that people with GID
suffer because they are stigmatized and victimized; and that, if
society had less strict gender divisions, transsexual people would
suffer less.
Some controversy surrounds the creation of the GD diagnosis, with Davy
et al. stating that although the creators of the diagnosis state that
it has rigorous scientific support, "it is impossible to scrutinize
such claims, since the discussions, methodological processes, and
promised field trials of the diagnosis have not been published."
Gender as a social construction
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Social gender characteristics are created and supported by the
expectations of a culture, and are therefore only partially related to
biological sex. For example, the association of particular colors with
"girl" or "boy" babies begins extremely early in Western
European-derived cultures. Other expectations relate to approved and
allowable behaviors and emotional expression.
Some cultures have three defined genders: man, woman, and effeminate
man. For example, in Samoa, the 'fa'afafine', a group of feminine
males, are entirely socially accepted. The fa'afafine do not have any
of the stigma or distress typically associated in most cultures with
deviating from a male/female gender role. This suggests the distress
so frequently associated with GID in a Western context is not 'caused'
by the disorder itself, but by difficulties encountered from social
disapproval by one's culture. However, research has found that the
anxiety associated with gender dysphoria persists in cultures, Eastern
or otherwise, which are more accepting of gender nonconformity.
In Australia, a 2014 High Court of Australia judgment unanimously
ruled in favor of a plaintiff named Norrie, who asked to be classified
by a third gender category, 'non-specific', after a long court battle
with the NSW Registrar of Births, Deaths and Marriages. However, the
Court did not accept that gender was a social construction: it found
that sex reassignment "surgery did not resolve her sexual ambiguity".
Classification as a disorder
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The psychiatric diagnoses of gender identity disorder (now gender
dysphoria) was introduced in DSM-III in 1980. Arlene Istar Lev and
Deborah Rudacille have characterized the addition as a political
maneuver to re-stigmatize homosexuality. (Homosexuality was removed
from DSM-II in 1974.) By contrast, Kenneth Zucker and Robert Spitzer
argue that gender identity disorder was included in DSM-III because it
"met the generally accepted criteria used by the framers of DSM-III
for inclusion." Some researchers, including Robert Spitzer and Paul J.
Fink, contend that the behaviors and experiences seen in
transsexualism are abnormal and constitute a dysfunction. The American
Psychiatric Association stated that gender nonconformity is not the
same thing as gender dysphoria, and that "gender nonconformity is not
in itself a mental disorder. The critical element of gender dysphoria
is the presence of clinically significant distress associated with the
condition."
Individuals with gender dysphoria may or may not regard their own
cross-gender feelings and behaviors as a disorder. Advantages and
disadvantages exist to classifying gender dysphoria as a disorder.
Because gender dysphoria had been classified as a disorder in medical
texts (such as the previous DSM manual, the DSM-IV-TR, under the name
"gender identity disorder"), many insurance companies are willing to
cover some of the expenses of sex reassignment therapy. Without the
classification of gender dysphoria as a medical disorder, sex
reassignment therapy may be viewed as cosmetic treatment, rather than
medically necessary treatment, and may not be covered. In the United
States, transgender people are less likely than others to have health
insurance, and often face hostility and insensitivity from healthcare
providers.
The DSM-IV-TR diagnostic component of distress is not inherent in the
cross-gender identity; rather, it is related to social rejection and
discrimination suffered by the individual. Psychology professor Darryl
Hill insists that gender dysphoria is not a mental disorder, but
rather that the diagnostic criteria reflect psychological distress in
children that occurs when parents and others have trouble relating to
their child's gender variance. Transgender people have often been
harassed, socially excluded, and subjected to discrimination, abuse
and violence, including murder.
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." In May 2009, the government of France declared that a
transsexual gender identity will no longer be classified as a
psychiatric condition, but according to French trans rights
organizations, beyond the impact of the announcement itself, nothing
changed. Denmark made a similar statement in 2016.
In ICD-11, GID is reclassified as "gender incongruence", a condition
related to sexual health. The working group responsible for this
recategorization recommended keeping such a diagnosis in ICD-11 to
preserve access to health services.
Intimate relationships
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Intimate relationships between lesbians and female-to-male people with
GID will sometimes endure throughout the transition process, or shift
to becoming supportive friendships. Intimate relationships between
heterosexual women and male-to-female people with GID often suffer
once the GID is known or revealed. Researchers say the fate of the
relationship seems to depend mainly on the woman's adaptability.
Problems often arise, with the cisgender partner becoming increasingly
angry or dissatisfied, if her partner's time spent in a female role
grows, if her partner's libido decreases, or if her partner is angry
and emotionally cut-off when in the male role. Cisgender women
sometimes also worry about social stigma and may be uncomfortable with
the bodily feminization of their partner as the partner moves through
transition. The cisgender women who are likeliest to accept and
accommodate their partner's transition, researchers say, are those
with a low sex drive or those who are equally sexually attracted to
men and women.
See also
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* List of transgender-related topics
Further reading
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*
*
*
* Includes a description of ICD-10 criteria.
External links
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*
[
https://web.archive.org/web/20060604060835/http://www.transgendercare.com/guida
nce/resources/ictlep_soc.htm
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.
*
[
https://web.archive.org/web/20030812130936/http://www.lcd.gov.uk/constitution/t
ranssex/policy.htm
The Lord Chancellor's Department Government Policy concerning
Transsexual People]
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=========
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Original Article:
http://en.wikipedia.org/wiki/Gender_dysphoria
