Gender Dysphoria in Adolescents and Adults

Author: Thomas C. Weiss
Published: Tuesday 13th January 2015 - Updated: Tuesday 31st January 2017
Summary: The DSM diagnostic criteria for gender dysphoria includes cross-gender identification that extends beyond desire for perceived cultural advantage.

Gender dysphoria is a diagnosis that refers to people whose gender at the time of their birth is contrary to the one they identify with. It constitutes a new diagnostic class in the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) of Mental Disorders, Fifth Edition. The diagnosis replaces the DSM-IV diagnosis of gender identity disorder. The DSM diagnostic criteria for gender dysphoria include strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage.

Teenagers and adults might have a preoccupation with getting rid of primary and secondary sex characteristics. They may believe they were born as the wrong gender. People with gender dysphoria do not have a concurrent physical intersex condition. People report significant distress or impairment in occupational, social or other important areas of functioning.

Gender Dysphoria in Adolescents and Adults

According to the DSM-V, the first requirement for a diagnosis of gender dysphoria in adolescents and adults is a marked incongruence between the person's experienced or expressed gender and their assigned gender. The incongruence must have lasted for at least 6 months and has to include at least two of the following criteria:

Another requirement is that the condition be associated with clinically significant distress or impaired occupational, social, or other areas of important functioning. A clinician should also specify whether the condition is happening along with a disorder of sex-development. A clinician might also specify whether the person has made the transition to living in the desired gender on a full-time basis.

Gender Dysphoria and Children

Once again, the first requirement for a diagnosis of gender dysphoria in children is a marked incongruence between the person's experienced or expressed gender and their assigned one. The incongruence must have lasted for at least six months and has to include at least six of eight criteria which include the following:

Another requirement is that the condition be associated with clinically significant distress or impairment of school, social, or other important areas of functioning. A clinician should specify whether the condition is happening along with a disorder of sex development.

Psychological Factors and Gender Dysphoria

A publication from the year 1968, rooted in psychoanalytic theory, described a typical background from which a male transsexual might emerge. In the scenario, a woman whose mother did not encourage her daughter's femininity marries a passive man, for a relationship that is unsatisfactory for both, yet is often long-term. The depressed woman has a male child. A happy symbiosis is established between mother and son. The father doesn't attempt to break the symbiosis and often times remains away from home. Excessive physical and emotional closeness to the mother for too long leads to feminine identification and behaviors that secretly please the mother – who then reinforces them.

'Stoller,' the author, perceived this non-conflictual learning process as similar to imprinting. In contrats, Stoller viewed homosexuality and transvestism as end results of defense against the trauma of painful and dangerous interpersonal relationships.

The year of 1974 found a publication by Person and Ovesey postulating a different, but still psychosocial, etiology that was based upon a study of ten primary transexuals. While all ten of the people in the study envied girls and pursued cross-dressing behavior, beginning at age 2-10 years, not one believed he was a girl and nine gave no history of feminine behavior. They were loners with few age mates of either gender. They experienced feelings of depression, anxiety and loneliness. The people in the study were asexual and loathed their male characteristics. Their desire to be female was based on a fantasy of symbiotic fusion with their mothers as a means of dealing with extreme separation anxiety. Stoller described the psychoanalytic etiology of female transsexualism as being, 'unclear,' yet listed some preliminary findings such as:

Please bear in mind that these ideas are preliminary postulates instead of being established facts. Confirming data are not available.

Retrospective studies in adult transsexuals have shown differences in recalled child-rearing patterns between transsexuals and, 'normative,' groups. Male-to-female transsexuals characterized their fathers as less emotionally available, more rejecting, less warm and overly-controlling. Female-to-male transsexuals characterized both of their parents as being more rejecting and less emotionally warm, yet they characterized only their mothers – not their fathers, as being overprotective. It has been argued that the development of transsexualism is the:

"result of a non-conflictual process, where gender identity is precociously fixed [and] ... considered to be an entirely particular phenomenon, so that its aetiology must be clearly distinguished from both perversions and atypical sex change requests."

Basically, the boy has had a happy symbiosis with the mother and develops from early infancy an identity with the female gender. The boy's family then adapts to and supports their child.

Biologic Factors of Gender Dysphoria

Biomedical research into transsexualism has investigated a number of areas. Girls with congenital adrenal hyperplasia (CAH), a condition causing prenatal exposure to a relatively high level of androgens, have been examined to determine whether male gender identity develops even if XX-chromosome persons are raised as females. A few people have been reported. In most instances; however, girls assigned and reared consistently as girls do not become transsexuals.

Transsexualism has not been observed in either males or females exposed to progestogens in utero, which may have antiandrogenic or androgenic qualities, nor has it been found upon exposure to estrogenic drugs such as, 'diethylstilbestrol,' or DES. Despite this, some atypical aspects of gender role behavior have been observed.

In the year of 1983, Dorner found that male-to-female transsexuals, like females, showed a rise in luteinizing hormone (LH) levels after estrogen stimulation as a consequence of prenatal exposure to imbalanced sex steroid levels. The opposite happened in female-to-male transsexuals. Other studies; however, that used more rigorous endocrine methodologies were unable to replicate the study's findings. Several hypothalamic nuclei in people have been reported to be sexually, 'dimorphic,' with respect to shape or size, including the following:

Sex differences in the hypothalamus are believed to underlie sex differences in gender identity, sexual orientation and reproduction. Plainly, more solid and well-designed research into the biology of these disorders is needed. Some studies suggest that male gender identity might be partly mediated through the androgen receptor. The relative contribution of sex hormones and additional non-hormonal factors might be an area where additional research is needed.

Gender Dysphoria Prognosis

Case reports already in existence do not indicate that psychotherapy produces complete and long-term reversal of cross-gender identity. Transsexuals are not a homogeneous group. Some transsexuals do not show severe psychopathology. Diagnosing and treating this disorder early may reduce the chances of emotional distress, depression and suicide. Gender dysphoria is not the same as homosexuality. How the gender conflict happens is different in each person. Some people; for example, might cross-dress, while others desire sex change surgery. Some people of one gender privately identify more with the other gender.

People who are born with ambiguous genitalia, something that might raise questions in their minds concerning their gender, may qualify for gender dysphoria. Sex reassignment surgery may be a viable treatment solution for some. Satisfactory results are reported in 87% of male-to-female and 97% of female-to-male persons. Factors associated with fairly poor post-sex reassignment surgery (SRS) functioning include the following:

Outcome studies suggest that transsexuals without severe psychopathology are better off when treated promptly after achieving a diagnosis. Transsexuals who have severe psychopathology, are not homosexual, or who have a late-onset gender identity disorder should not necessarily be excluded from SRS, yet they require more care and extensive evaluation and therapeutic support before SRS is deemed to be viable.

Patient Education

People should be educated about the differences between true transsexualism and other gender issues such as gender dysphoria, transvestic fetishism, homosexuality and nonconformity to stereotypical sex role behaviors. Both people and their family members need to understand the complexities of gender dysphoria, its enduring nature and the challenges that it usually presents.

Treatment options should be discussed. When SRS is being considered, it should be explained that the procedure does not produce a life free of trouble. In addition, work and social adjustment issues have t be discussed and plans for addressing these concerns must be developed. The importance of continuing family support and understanding should also be approached. The need for long-term therapy and social support should be discussed and encouraged when it is appropriate.

Pharmacologic Therapy

Hormone therapy may be needed. Consequently, an endocrinologist should be involved in multiple phases of the treatment process. In male-to-female persons, original sex characteristics may be suppressed with:

A more feminine body, breasts and increased body fat may be promoted with ethinyl estradiol and conjugated estrogen. In female-to-male persons, facial and body hair growth may be promoted with testosterone cypionate. Pharmacology might also be required for comorbid psychiatric diagnosis. People commonly experience symptoms of anxiety, depression or psychosis. Medications may include anxiolytics, antidepressants and antipsychotics. Clinically referred children and adolescents with gender dysphoria seem to experience a higher incidence of autism spectrum disorder than is found in the overall population.

A controversy exists concerning whether or not adolescents should be allowed to pursue SRS. Many nations deny SRS to adolescents; however, early treatment might be beneficial in adolescents whose secondary sex characteristics have not yet developed fully such as a lowered voice, facial hair or breast development. In such instances, involvement of the adolescent's parents and their approval is essential.

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