Gender dysphoria

Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identity—their personal sense of their own gender—and their sex assigned at birth.

The diagnostic label gender identity disorder (GID) was used until 2013 with the release of the diagnostic manual DSM-5: renamed to remove the stigma associated with the term disorder.

Distress related to one’s assigned gender, sex, and/or sex characteristics.

People with gender dysphoria commonly identify as transgender.

Not all transgender people experience dysphoria.

The critical element of gender dysphoria is clinically significant distress.

The causes of gender dysphoria are unknown.

 A gender identity likely reflects genetic, biological, environmental, and cultural factors.

Treatment for gender dysphoria may include: supporting the individual’s gender expression, desire for hormone therapy or surgery,and may also include counseling or psychotherapy.

Distress from an incongruence between a person’s felt gender and assigned sex/gender is the cardinal symptom of gender dysphoria.

Gender dysphoria in those assigned male at birth (AMAB) generally follows one of two broad trajectories: early-onset or late-onset. 

Early-onset gender dysphoria is behaviorally visible in childhood. 

This group is usually sexually attracted to members of their natal sex in adulthood, commonly identifying as heterosexual. 

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.

Transgender people assigned male at birth who experience late-onset gender dysphoria will usually be attracted to women and may identify as lesbians or bisexual, while those with early-onset will usually be attracted to men.

A similar pattern occurs in those assigned female at birth, with those experiencing early-onset GD being most likely to be attracted to women and those with late-onset being most likely to be attracted to men and identify as gay.

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 playmates of the opposite sex.

Some children experience social isolation, anxiety, loneliness, and depression.

In adolescents and adults, symptoms include the desire to be and to be treated as a different gender.

Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide.

Transgender people are also at heightened risk for eating disorders and substance abuse.

The causes of gender dysphoria remain unknown.

Treatments targeting the etiology or pathogenesis of gender dysphoria do not exist.

Twin studies suggests that genetic factors play a role in the development of gender dysphoria.

Gender identity is thought to likely reflect a complex interplay of biological, environmental, and cultural factors.

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.

Gender disorders:

Transsexualism, the 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 with persistent and intense distress about one’s assigned gender, manifested prior to puberty.

Gender identity disorder, unspecified.

Sexual maturation disorder, with uncertainty about one’s gender identity or sexual orientation, causing anxiety or distress.

Gender incongruence is a marked and persistent incongruence between an individual’s experienced gender and the assigned sex, with no requirement for significant distress or impairment.

Treatment for a person diagnosed with GD may include psychological counseling, supporting the individual’s gender expression, or hormone therapy or surgery. 

This may involve physical transition 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 included reducing problems resulting from the person’s transgender status, counseling the patient in order to reduce guilt associated with cross-dressing.

Treatment generally follow a “harm reduction” model.

Gender dysphoria in children;

Medical, scientific, and governmental organizations have opposed conversion therapy, defined as treatment viewing gender nonconformity as pathological and something to be changed, instead supporting approaches that affirm children’s diverse gender identities.

People are more likely to keep having gender dysphoria the more intense their gender dysphoria, cross-gendered behavior, and verbal identification with the desired/experienced gender are. 

Professionals who treat gender dysphoria in children sometimes prescribe 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 or surgical gender reassignment is in their best interest.

Puberty blockers are fully reversible, and that they are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.

There is a very low certainty of quality of evidence about puberty blocker outcomes in terms of mental health, quality of life and impact on gender dysphoria.

American Academy of Pediatrics suggests pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood.

The American Medical Association, the Endocrine Society, the American Psychological Association, the American Academy of Child and Adolescent Psychiatry and the American Academy of Pediatrics oppose bans on puberty blockers for transgender children. 

Psychotherapy of GD involves helping the patient to adapt to their gender incongruence or to explorative investigation of confounding co-occurring mental health issues. 

Attempts to alleviate GD by changing the patient’s gender identity to reflect assigned sex have been ineffective and are regarded as conversion therapy by most health organizations.

Biological treatments for GD are usually undertaken in conjunction with psychotherapy.

Hormonal treatments have been shown to reduce a number of symptoms of psychiatric distress associated with gender dysphoria.

Gender-affirming hormone therapy may be associated with improvements in quality of life scores and decreases in depression and anxiety symptoms among transgender people; the evidence is low due to methodological limitations of the studies undertaken.

In a two-year study involving transgender and non-binary youth, gender affirming hormones, improved appearance congruence, and psychosocial functioning (Chen D).

Some studies suggests that gender-affirming surgery is associated with improvements in quality of life and decreased incidence of depression: these studies have limitations including risk of bias with lack of randomization, lack of controlled studies, self-reported outcomes and high loss to follow up.

Endocrine Society claims durable evidence for a biological underpinning to gender identity and that pubertal suppression, hormone therapy, and medically indicated surgery are effective and relatively safe when monitored appropriately and have been established as the standard of care. 

There is a decrease in suicidal ideation among youth who have access to gender-affirming care and comparable levels of depression to cisgender peers among socially transitioned pre-pubertal youth.

A review found that puberty blockers are fully reversible, and that they are associated with such positive outcomes as decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life.

More studies are needed to assess the effectiveness, safety, and long-term benefits and risks of hormonal and surgical treatments.

A 2020 Cochrane review found insufficient evidence to determine whether feminizing hormones were safe or effective. 

Several studies have found significant long-term psychological and psychiatric pathology after surgical treatments.

In 2021, a review published in Plastic And Reconstructive Surgery found that less than 1% of people who undergo gender-affirming surgery regret the decision.

Among youth, around 20% to 30% of individuals with gender dysphoria meet the criteria for an anxiety disorder.

Gender dysphoria is also associated with an increased risk of eating disorders in transgender youth.

Children and adolescents and adults with gender dysphoria have found a high prevalence of autism spectrum disorder (ASD) traits or a confirmed diagnosis of ASD. 

It has been estimated that children with ASD were over four times as likely to be diagnosed with GD, with ASD being reported from 6% to over 20% of teens referring to gender identity services.

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 are diagnosable with gender dysphoria.

Some estimate that gender dysphoria occurs in one in 30,000 male births and one in 100,000 female births.

On early 2000s , European studies found that about 1 in 12,000 natal male adults and 1 in 30,000 natal female adults seek out sex reassignment surgery.

Studies of hormonal treatment or legal name change find higher prevalence than sex reassignment: a 2010 Swedish study finding that 1 in 7,750 adult natal males and 1 in 13,120 adult natal females requested a legal name change to a name of the opposite gender.

Studies that measure transgender status by self-identification find even higher rates of gender identity different from sex assigned at birth, although some of those who identify as transgender or gender nonconforming may not experience clinically significant distress and so do not have gender dysphoria.

A survey of Massachusetts adults found that 0.5% identify as transgender.

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.

It id suggested the distress of gender dysphoria is mostly not caused by the cross-gender identity itself, but by difficulties encountered from social disapproval by one’s culture.

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. 

Some hold 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 are often harassed, socially excluded, and subjected to discrimination, abuse and violence, including murder. 

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