Gender Identity Disorder

Gender Identity

Gender dysphoria is the distress a person feels due to a mismatch between their gender identity and their personal sense of their own gender and their sex assigned at birth. The diagnostic label gender identity disorder was used until 2013 with the release of the diagnostic manual DSM-5. The condition was renamed to remove the stigma associated with the term disorder.

People with gender dysphoria commonly identify as transgender. Gender nonconformity is not the same thing as gender dysphoria and does not always lead to dysphoria or distress. According to the American Psychiatric Association, not all transgender people experience dysphoria;

The causes of gender dysphoria are unknown but a gender identity likely reflects genetic, biological, environmental, and cultural factors. Treatment may also include counseling or psychotherapy. Without the classification of gender dysphoria as a medical disorder, HRT and gender affirming surgery may be viewed as cosmetic treatments by health insurance, as opposed to medically necessary treatment, and may not be covered.

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 dysphoria will stop for a while in this group and they will identify as gay or homosexual for a period of time, followed by recurrence of gender dysphoria. This group is usually sexually attracted to members of their natal sex in adulthood, commonly identifying as heterosexual or straight.

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.

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 may also experience social isolation from their peers, anxiety, loneliness, and depression. In adolescents and adults, symptoms include the desire to be and to be treated as a different gender and substance abuse.

Gender Identity

Causes

The specific causes of gender dysphoria remain unknown, and treatments targeting the etiology or pathogenesis of gender dysphoria do not exist. Gender identity is thought to likely reflect a complex interplay of biological, environmental, and cultural factors.

Diagnosis

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: 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 if 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.

The International Classification of Diseases lists several disorders related to gender identity:

Transsexualism: 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: Persistent and intense distress about one’s assigned gender, manifested prior to puberty

Other gender identity disorders

Gender identity disorder, unspecified

Sexual maturation disorder: Uncertainty about one’s gender identity or sexual orientation, causing anxiety or distress

The ICD-11, which came into effect on 1 January 2022, significantly revised 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: replaces F64.0

Gender incongruence of childhood: replaces F64.2

Gender incongruence, unspecified: 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 no requirement for significant distress or impairment.

Treatment

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 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.

Guidelines have been established to aid clinicians. The World Professional Association for Transgender Health 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.

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.

The question of adult gender identity outcome is central to the treatment of gender dysphoria in children. The review notes numerous methodological difficulties that arise when measuring desistance, including the variation in intensity of gender dysphoria among the children in the studies. Additionally, the evidence offered has been criticized for citing studies which have been labelled conversion therapy for discouraging social transition and trying to prevent a transgender outcome.

The diagnostic criteria for gender dysphoria used in the studies only required gender-nonconformity, and did not require a child to state a transgender identity or a desire for medical or social transition. Most childhood disasters go on to identify as cisgender and gay or lesbian.

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.

A review published in Child and Adolescent Mental Health 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.

A review commissioned by the UK Department of Health found that there was very low certainty of quality of evidence about puberty blocker outcomes in terms of mental health, quality of life and impact on gender dysphoria. The Finnish government commissioned a review of the research evidence for treatment of minors and the Finnish Ministry of Health concluded that there are no research-based health care methods for minors with gender dysphoria.

Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that “pubertal suppression in children who identify as TGD generally leads to improved psychological functioning in adolescence and young adulthood.”

In the United States, several states have introduced or are considering legislation that would prohibit the use of puberty blockers in the treatment of transgender children. 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. In the UK, in the case of Bell v Tavistock, an appeal court, overturning the original decision, ruled that children under 16 could give consent to receiving puberty blockers.

Psychological treatments

Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to their assigned sex. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Psychotherapy may be used in addition to biological interventions, although some clinicians use only psychotherapy to treat gender dysphoria.

Psychotherapeutic treatment 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

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 GD are typically undertaken in conjunction with psychotherapy; however, the WPATH Standards of Care state that psychotherapy should not be an absolute requirement for biological treatments. It is known that some mental disorders are important to evaluate and treat before proceeding with hormones or surgery, as treatment of these mental disorders can sometimes make the wish for altering one’s body disappear or significantly lessen.

A WPATH commissioned systematic review of the outcomes of hormone therapy “found evidence that gender-affirming hormone therapy may be associated with improvements in scores and decreases in depression and anxiety symptoms among transgender people.” The strength of the evidence was low due to methodological limitations of the studies undertaken.

Some literature suggests that gender-affirming surgery is associated with improvements in quality of life and decreased incidence of depression. Those who choose to undergo sex reassignment surgery report high satisfaction rates with the outcome, though these studies have limitations including risk of bias and high loss to follow up.

For adolescents, much is unknown, including persistence. Disagreement among practitioners regarding treatment of adolescents is in part due to the lack of long-term data found reduction in gender dysphoria, although limitations to these outcome studies have been noted, such as lack of controls or considering alternatives like psychotherapy.

More rigorous studies are needed to assess the effectiveness, safety, and long-term benefits and risks of hormonal and surgical treatments. For instance, a 2020 Cochrane review found insufficient evidence to determine whether feminizing hormones were safe or effective. A 2021 review published in the Journal of the Endocrine Society found hormone therapy was associated with increased quality of life, decreased depression, and decreased anxiety. Associations were similar across gender identity and age. Several studies have found significant long-term psychological and psychiatric pathology after surgical treatments.

Comorbidities

Among youth, around 20% to 30% of individuals attending gender clinics meet the DSM criteria for an anxiety disorder. Gender dysphoria is also associated with an increased risk of eating disorders in transgender youth.

A widely held view among clinicians is that there is an over-representation of neurodevelopmental conditions amongst individuals with GD, although this view has been questioned. Studies on children and adolescents with gender dysphoria have found a high prevalence of autism spectrum disorder traits or a confirmed diagnosis of ASD. Adults with gender dysphoria attending specialist gender clinics have also been shown to have high rates of ASD traits or an autism diagnosis as well. It has been estimated that children with ASD were over four times as likely to be diagnosed with GD,

Epidemiology

Different studies have arrived at different conclusions about the prevalence of gender dysphoria. The DSM-5 estimates 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.

According to Black’s Medical Dictionary, gender dysphoria “occurs in one in 30,000 male births and one in 100,000 female births.” Studies in European countries in the early 2000s 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, with, for example 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.

A national survey in New Zealand of 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?”. Outside of a clinical setting, the stability of transgender or non-binary identities is unknown. The prevalence of gender dysphoria in children is unknown due to the absence of formal prevalence studies.

Society and culture

Researchers disagree about the nature of distress and impairment in people with GD. Some authors have suggested that people with GD suffer because they are stigmatized and victimized; and that, if society had less strict gender divisions, transgender 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.” Overall, it is unclear whether or not gender dysphoria persists in cultures with third gender categories.

Classification as a disorder

The psychiatric diagnosis of gender identity disorder 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. 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 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, In the United States, transgender people are less likely than others to have health insurance, and often face hostility and insensitivity from healthcare providers. Some researchers and transgender people support declassification of the condition because they say the diagnosis pathologies gender variance and reinforces the binary model of gender.

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 the ICD-11, GID is reclassified as “gender incongruence”, a condition related to sexual health. Health line defines it as “feelings of alignment or joy about gender identity or expression,” while Psych Central’s definition is “deep joy when your internal gender identity matches your gender expression.”

In 1979, the term “gender euphoria” was first published; however, it was then used to describe male privilege present in Black cisgender men.

In 1986, the term was first published in a Tran’s context, as part of an interview with a Trans person: “gender dysphoria, and a term of which he seems inordinately proud, gender euphoria.” Similar uses were published in 1988.

In a 1988 interview with a trans man, the subject states, “I think that day administered my first shot of the ‘wonder-drug’ must have been one of the ‘peak-experiences’ of my life — talk about ‘gender euphoria’!” The interview indicates he is referring to testosterone.

In 1990, Virginia Prince used the phrase in trans magazine Femme Mirror, ending an article with, “…from here on you can enjoy GENDER EUPHORIA – HAVE A GOOD LIFE!”

Starting in 1991, a monthly newsletter named Gender Euphoria was released, featuring articles about transgender topics; Leslie Feinberg read the newsletter to better understand the transgender community. In 1993, the blurb of Nan Goldin’s The Other Side read, “The pictures in this book are not of people suffering dysphoria but rather expressing gender euphoria.”

In 1994, Scottish “TV/TS” periodical The Tartan Skirt wrote, “Let’s accentuate the positive, discard the negative, and promote the new condition of ‘Gender Euphoria.'”

In 1997, Patrick Califia described transgender activists picketing using signs that read “Gender Euphoria NOT Gender Dysphoria” and handing out “thousands of leaflets” at protests.

The following year, in 1998, Second Skins: The Body Narratives of Transsexuality reported: The Trans activist group Transsexual Menace is campaigning to have the diagnosis “Gender Identity Disorder” removed entirely from the Diagnostic and Statistical Manual of Mental Disorders. “Gender Euphoria NOT Gender Dysphoria”; its slogans invert the pathologizing of transgender, offering pride in queer difference as an alternative to the psychiatric story. Transgender congruence is also used to ascribe transgender individuals feeling genuine, authentic, and comfortable with their gender identity and external appearance.

In 2019, the Midsumma festival in Australia hosted “Gender Euphoria,” a cabaret focusing on “bliss” in transgender experiences, including musical, ballet, and burlesque performances. A reviewer described it as “triumphant – honest, unpretentious, touching, and a vital celebration.”

References

Byne, W., Karasic, D. H., Coleman, E., Eyler, A. E., Kidd, J. D., Meyer-Bahlburg, H., Pleak, R. R., & Pula, J. (2018). Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgender health3(1), 57–70. https://doi.org/10.1089/trgh.2017.0053

de Vries, A. L., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of homosexuality59(3), 301–320. https://doi.org/10.1080/00918369.2012.653300

Ettner, R. (2020). Etiology of Gender Dysphoria. In: Schechter, L. (eds) Gender Confirmation Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-29093-1_2

Hewitt, J. K., Paul, C., Kasiannan, P., Grover, S. R., Newman, L. K., & Warne, G. L. (2012). Hormone treatment of gender identity disorder in a cohort of children and adolescents. The Medical journal of Australia196(9), 578–581. https://doi.org/10.5694/mja12.10222

Steensma, T. D., Kreukels, B. P., de Vries, A. L., & Cohen-Kettenis, P. T. (2013). Gender identity development in adolescence. Hormones and behavior64(2), 288–297. https://doi.org/10.1016/j.yhbeh.2013.02.020

Zucker, K.J. (2015). The DSM-5 Diagnostic Criteria for Gender Dysphoria. In: Trombetta, C., Liguori, G., Bertolotto, M. (eds) Management of Gender Dysphoria. Springer, Milano. https://doi.org/10.1007/978-88-470-5696-1_4

 

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