Gender Dysphoria

What is Gender Dysphoria?

The term ‘gender’ originates from the Old French word “gendre”, meaning “kind, sort, genus”. Usually, when a child is born, they are assigned a gender based on their physical characteristics and chromosomes. For the majority, this assigned gender matches their gender identity – the internal feeling of being male or female. However, some children may feel a mismatch in this assignment, and may grow up to identify as transgender.

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), this feeling of mismatch is called “Gender dysphoria (GD)”. It’s described as a strong disconnect between a person’s experienced or expressed gender and the gender they were assigned at birth. Previously, it was known as “gender identity disorder”.

Children or teens with this feeling often struggle to fit themselves into traditional gender roles of male or female. This mismatch can lead to a feeling of being outcast by society. Additionally, it can spawn various problems such as conflicts with family, friends, and peers, depression, anxiety, substance abuse, poor self-esteem, and even an increased risk of harming themselves or suicide.

It’s important for society to become more aware and consider gender expression as a spectrum, from male to female, rather than strict male or female categories. This understanding can help to lessen the mental health problems caused by societal stigma around gender identity.

One important note is that ‘gender’ should not be confused with ‘sexual orientation’. For example, a transgender man (someone who was assigned female at birth) can identify as heterosexual (attracted to women) and vice versa.

What Causes Gender Dysphoria?

The exact cause of gender dysphoria (a psychological condition where a person feels a mismatch between their biological sex and gender identity) remains unknown, but it’s likely a combination of physical, psychological, and environmental factors.

Children born with conditions like congenital adrenal hyperplasia or androgen insensitivity syndrome, where there’s a disorder in the development of their sexual organs, are often raised as girls. However, they may often cross-dress and feel a sense of belonging to the opposite sex. These feelings usually become more noticeable during puberty, suggesting a biological connection.

There also seem to be certain connections with exposure to chemicals like phthalates, found in plastics, and polychlorinated biphenyls, before birth. These chemicals can interfere with normal sex hormones in a developing fetus. Phthalates may result in elevated fetal testosterone levels, which could increase the risk of disorders like autism and gender dysphoria.

There is a higher rate of gender dysphoria in individuals with certain mental health conditions such as schizophrenia and autism. This suggests a connection in brain structure, though more research is needed. Some evidence indicates that people with autism are more likely to experience gender dysphoria but this claim is still being studied.

Increasing evidence also suggests that childhood trauma such as abuse, neglect, or maltreatment, including physical or sexual abuse, may be linked to gender dysphoria. It has also been observed that individuals with gender dysphoria having a higher risk for depression, suicidal thoughts, and substance use.

Some studies have pointed towards differences in brain structure as a potential cause of gender dysphoria. Specifically, differences have been found in the development of certain brain cells, as well as the structure and connectivity of the amygdala, a part of the brain involved in emotion, according to an individual’s gender.

There have been reports of a link between gender dysphoria and infection with a parasite called toxoplasma in pregnant mothers, but more data is necessary to confirm this association.

Genetic factors are also thought to play a role in gender dysphoria. For example, it’s been observed more frequently in identical twins as compared to non-identical twins, suggesting a potential genetic link. However, the exact relationship and whether it’s causative is still unclear.

Risk Factors and Frequency for Gender Dysphoria

Recent studies have shown a considerable increase in the number of people self-identifying as transgender, ranging from 0.5% to 1.3% across different age groups. This identity was once considered uncommon, however, the reported instances have risen over the years. A 2016 analysis suggested that about 390 per 100,000 adults identified as transgender but also noted that the actual figures might be higher.

A more recent national survey indicated that approximately 1.4 million people, or 0.6% of the population in the United States, identify as transgender. This number is thought to be an underestimation due to societal stigma. Some transgender individuals may avoid participation in surveys out of fear or concern, making the actual prevalence potentially higher than reported. Over the last decade, there has been an increase in individuals from this section of society seeking healthcare.

People who identify as transgender often encounter substance use disorders. Current research indicates that about 28% have reported problems with substance use. Mental health issues are also relatively common in this community.

• In a recent study, nearly half (48.3%) of the participants reported thoughts of suicide, and 23.8% have attempted suicide at least once.
• The study did not show a significant difference in suicidal tendencies between individuals transitioning from male to female (MTF) or female to male (FTM).
• Common mental health conditions among transgender people include anxiety, depression, and personality disorders.
• One 2009 study found that personality disorders were found alongside (comorbid) in 52% of cases, with the Cluster B personality disorder being the most prevalent.

Signs and Symptoms of Gender Dysphoria

Gender dysphoria (GD) is a condition where a person feels discomfort or distress because there’s a mismatch between their biological sex and gender identity. People with GD may look for help from their family doctor, hormone specialist, or mental health provider. The reasons for this can vary – for some, it might be their main concern, while others may have additional mental health issues. With wider societal acceptance and better healthcare access, people with this condition now often start to look for help before puberty, whereas in the past they might have waited until adulthood or late adolescence. It’s important that healthcare providers give these patients the right referrals to ensure they have a strong support system.

When speaking to these patients, healthcare providers need to consider their whole history. This includes their mental health history, history of substance misuse, their social background and family history, as well as their developmental history, including any past trauma. Mental health history might include any previous suicide attempts or self-harming behavior, hospital admissions for mental health, whether they are currently seeing a psychiatrist or psychotherapist, and any past mental health treatments. The social and developmental history gives information about their childhood, education status, academic performance, their social support network, any history of trauma (mental, physical, sexual), any legal history, and their current marital status or if they have children. Family history adds more context with regards to any history of mental health issues, suicide, or substance misuse.

Physical examinations for newborns should include a thorough check of the genitals to look for conditions such as congenital adrenal hyperplasia or androgen insensitivity syndrome, which can result in ambiguous genitalia. Congenital adrenal hyperplasia can show early signs of dehydration, low sodium levels in the blood, and high potassium levels. If it develops late, young females might show signs of male physical traits and irregular periods. Individuals with the severe “salt-losing” type need immediate treatment. Androgen insensitivity syndrome is a condition where males are immune to male hormones in their body. They’re often raised as girls and might have hormone and surgical treatments in their late teens/early adulthood. A careful checkup and genetic testing should be carried out on individuals born with ambiguous genitalia.

Testing for Gender Dysphoria

Gender dysphoria refers to a psychological condition where a person feels a strong incongruence, or mismatch, between their gender identity (how they feel internally) and their assigned gender at birth (typically male or female). This mismatch causes significant distress and could affect a person’s social, school, or occupational functioning.

In children, if this mismatch lasts for at least six months, and the child expresses at least six of the following behaviors consistently (including the first), they might be diagnosed with gender dysphoria:

1. A strong desire or firm belief that they are of a different gender than assigned.
2. Expressing a strong preference for dressing like the opposite gender
3. Expressing a strong preference for playing make-believe or fantasy games as the opposite gender
4. Having a strong preference for toys, games, or activities often related with the opposite gender
5. Having a strong preference for friends of the opposite gender
6. In boys, strongly avoiding traditionally masculine toys, games, and rough play. In girls, the same applies to traditionally feminine toys and games.
7. Disliking their own sexual anatomy and expressing a strong desire to have the physical features that match their experienced gender.

With adolescents and adults, the incongruence between their experienced gender and their physical gender, if it lasts for at least six months, could be a sign of gender dysphoria. This is especially the case if at least two of the following exist:

1. A marked incongruence between their experienced gender and their physical sex characteristics (or expected future characteristics in young adolescents).
2. A strong desire to remove their physical sex characteristics due to their mismatch with their experienced gender
3. A strong desire to have the physical sex characteristics of their experienced gender
4. A strong desire to live as another gender or to be treated as another gender
5. A strong belief that they have the typical feelings and reactions of another gender.

In some cases, a person might show signs of gender dysphoria but not fit the complete criteria for diagnosis. In such instances, a doctor might use categories like ‘other specified gender dysphoria’ or ‘unspecified gender dysphoria’. The former is if the doctor decides to specify why a person doesn’t meet the full criteria, while ‘unspecified’ is used when the doctor chooses not to specify or when the doctor lacks sufficient information for a more specific diagnosis.

Treatment Options for Gender Dysphoria

Patients seeking help for gender dysphoria can come to a range of healthcare professionals, including primary care providers, endocrinologists, or mental health providers. Sometimes, patients may present with mental health issues alongside the primary concern of gender dysphoria. Nowadays, these patients tend to seek help earlier, often before puberty, owing to better societal acceptance, awareness, and accessibility of care.

Depending on the patient’s age and individual circumstances, different professional assessments and treatments may be recommended. For children, therapy can help them understand their gender preferences. For adolescents, considering the approaching changes of puberty, hormone treatment and psychotherapy may be combined. For adults, a variety of treatments encompassing psychotherapy, hormone treatments, and surgeries, may be all available options.

Before starting any kind of treatment, it’s essential for individuals to receive counselling about the following:

1. Care team: Treatment should include a combination of an endocrinologist (a doctor who specializes in hormones) and mental health providers.
2. Expectations: Treatment options aim to help individuals align their physical appearance with their chosen gender identity. It’s key to manage expectations realistically and support from friends and family can be beneficial.
3. Risks and benefits of treatment: Both hormone and surgical therapies come with significant risks, including blood clots, changes in bone density, and an impact on puberty.
4. Fertility preservation: Both hormone and surgical treatments may impact a person’s ability to reproduce in the future, so it’s important to consider options like freezing “gametes” (sperm or eggs) before starting treatment.

Hormone therapy aims to suppress natural hormones and provide cross-sex hormones to help the body align more with a person’s gender identity. Treatment options, criteria for starting treatment, and the benefits and potential side effects can vary for transgender women (male to female/MTF) and transgender men (female to male/FTM).

Transgender women may seek treatments to eliminate facial hair, develop breasts, and acquire a female body shape. A variety of medication options can be used while regularly monitoring the patient’s physical health. Speech/voice therapy can also be offered to aid in matching voice characteristics with the person’s gender identity.

For transgender men, testosterone treatment can bring about changes such as more muscle mass, acne, and a deeper voice. Routine health checks are recommended to monitor potential side effects, such as blood count and cholesterol levels.

Surgical treatment, as referred to as “top surgery” and “bottom surgery”, might be considered to aid in the physical transformation process. This is often a final step of treatment and requires a thorough understanding of the irreversible nature of these procedures, mental health counselling, and adequate social support.

In order to achieve the most satisfying outcome, patients should pursue continuous support from family, community, and peers even after undergoing medical treatment. Continued individual, group therapies, and managing any substance use problems are also crucial for an overall favourable outcome.

What else can Gender Dysphoria be?

When examining an individual’s psychological state or behaviors, it’s crucial for a medical professional to consider several conditions that might affect someone’s mental and emotional wellbeing. These could include:

• Autogynephilia (a condition where a person is aroused by the thought of being the opposite gender)
• Body dysmorphic disorder (a mental disorder where a person is constantly worried about a flaw in their appearance)
• Gynandromorphophilia (a sexual interest in individuals who combine male and female physical characteristics)
• Intersex states (conditions where a person is born with a reproductive system that doesn’t fit typical definitions of male or female)
• Psychosis (a serious mental disorder characterized by a disconnection from reality)
• Paraphilic disorders (sexual interests or behaviours that involve unusual situations, objects, or individuals)
• Self-amputation (a condition where a person is compelled to remove their own body parts)
• Schizophrenia (a mental disorder that affects a person’s thinking, feeling, and behavior)
• Transvestitism (a condition where a person derives pleasure from dressing in clothes of the opposite sex).