|Year : 2022 | Volume
| Issue : 1 | Page : 4-11
Gender dysphoria in adults: Concept, critique, and controversies
Abdul Faheem, Ilambaridhi Balasubramanian, Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
|Date of Submission||30-Apr-2022|
|Date of Decision||08-Jun-2022|
|Date of Acceptance||09-Jun-2022|
|Date of Web Publication||8-Jul-2022|
Dr. Vikas Menon
Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Gender dysphoria (GD) is a condition where one feels distressed about one's assigned gender at birth. The construct has undergone successive revisions in understanding and terminology in contemporary classificatory systems. Currently, the terms “GD” and “gender incongruence” are used in the Diagnostic and Statistical Manual of Mental Disorders-5 and International Classification of Diseases-11, respectively. However, there continues to be a lack of clarity on terminologies used in describing related concepts. Sex is an inflexible categorical concept, whereas gender is a social construct. It is vital to understand and distinguish between sexual orientation and gender identity. Clarity in understanding and usage of these and other related terms in the field is central to addressing the issue of stigma faced by the members of the lesbian, gay, bisexual, transgender, queer, intersex, asexual+ (LGBTQIA+) community, an umbrella term used to denote individuals with nonconformative gender identity and orientation. Several clinical and ethical issues exist with diagnosing and managing GD such as optimal treatment of minors, fertility after gender affirming treatments, and dissatisfaction following gender reassignment. To clarify these issues and facilitate access to care for LGBTQIA+ individuals, the GD category has been retained in the classificatory systems despite activists calling for dropping the term from diagnostic manuals to minimize associated stigma. Other controversies in the area include inclusion of childhood GD diagnosis on the grounds of uncertainty of longitudinal trajectory of the clinical phenomenon and use of nonevidence-based, potentially harmful, treatments such as “conversion therapies.” There is a need to sensitize clinicians about these issues and mainstream them in the assessment and management of GD. Such an approach would aid development of culturally sensitive and evidence-based treatments for gender variance.
Keywords: Gender dysphoria, gender identity, gender incongruence, gender orientation, gender-affirming surgery, LGBT, lesbian, gay, bisexual, transgender, queer, intersex, asexual+, transgender
|How to cite this article:|
Faheem A, Balasubramanian I, Menon V. Gender dysphoria in adults: Concept, critique, and controversies. J Curr Res Sci Med 2022;8:4-11
|How to cite this URL:|
Faheem A, Balasubramanian I, Menon V. Gender dysphoria in adults: Concept, critique, and controversies. J Curr Res Sci Med [serial online] 2022 [cited 2022 Aug 19];8:4-11. Available from: https://www.jcrsmed.org/text.asp?2022/8/1/4/350138
| Introduction|| |
Gender dysphoria (GD) is defined as the distress that may accompany the incongruence between one's experienced or expressed gender and one's assigned gender. The intense emotional pain associated with GD may cause functional impairment in people's lives. Awareness about GD has been increasing with time and more and more people are now opening up about their gender non-conformity. Simultaneously, many reforms designed to safeguard rights of transgender individuals have also been designed and executed. The past decade has witnessed many adaptations in GD terminology. Of most importance, perhaps, is the replacement of the term gender identity disorder (GID) in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV with GD in DSM-5 and, more recently, gender incongruence in the International Classification of Diseases (ICD)-11.,,,
Members of the lesbian, gay, bisexual, transgender, queer, intersex, asexual+ people undergo discrimination in personal, occupational, and health domains. They also suffer various forms of physical and psychological abuse and are a stigmatized subpopulation.,,,, Various studies report that members of the LGBTQIA+ population are at risk for mental distress due to experienced discrimination and stigma. The transgender population are at two to three times higher risk of suffering from psychiatric illnesses such as depression, anxiety, adjustment disorders, social phobia, substance use disorder, suicidal behaviors, and risk of human immunodeficiency virus infections compared to cisgender peers.,,, In this review, we discuss the basic terminologies around gender, the evolution of GD in the classificatory system since its inception, and issues related to labeling of diagnoses.
| Search Strategy, Study Selection, and Data Extraction|| |
In April 2022, we performed an electronic MEDLINE (through PubMed) search with keywords such as GD, gender incongruence, gender identity disorder, transgender, gender orientation, transsexualism, disorders of sex development, and gender reaffirming surgery combined with relevant Boolean operators. The searches were done by two qualified psychiatrists without any restriction on dates or search filters. Selected studies were classified under the broad themes of history, epidemiology, etiopathogenesis, concept and definition, nosology, comorbidity, critique, and controversies in GD. As this was not intended to be a systematic review, we did not perform a risk of bias appraisal for included studies. Instead, below we present a narrative summary of the results in line with the aforementioned themes. Ethics approval and informed consent were not required for this narrative review.
| History of Gender Dysphoria|| |
The term “gender dysphoria syndrome” was coined in 1973 and includes transsexualism apart from other related gender identity disorders. Transsexualism is an age-old phenomenon. There have been various examples of this phenomenon in different cultures such as a female-bodied pharaoh named Hatshepsut, a French woman named Jean D'Arc who dressed and lived as a man, and a Spanish Catholic named Catalina de Erauso who was allowed by the Pope to live as a man although her assigned gender was female.
Medical and psychiatric theorizing about these phenomena began late in the 19th century. Until the middle of the 20th century, transsexualism was seen as “pathological.” For example, the noted German lawyer and pioneering gay activist Karl Ulrichs proposed that men's spirits in women's bodies (urningen) and women's spirits in male bodies (urnings) were the reason for homosexuality. Magnus Hirschfeld from Germany was the first to distinguish homosexuality (to have partners of the same sex) from transsexualism (to live as the other sex) in the 1920s. He was also involved in gender reassignment surgeries in Europe during this period.,
The gender transition of Jorgensen from a natal man to a trans-woman in 1952 created a large sensation in the United States and engendered discussions around gender reassignment and gender identity in both public and medical forums. In the 1950s, John Money studied children with disorders of sexual development (DSD) and proposed that gender identity was acquired by 3 years of age and was primarily determined by external factors. He also suggested that it was impossible to change one's gender identity later in life.
In the 1960s, American endocrinologist Harry Benjamin popularized the term “transsexual” in its current usage. He gave hormone therapy to transgender individuals and published “The transsexual phenomenon” based on his observations. In 1979, the Harry Benjamin International Gender Dysphoria Association was founded in honor of the eminent endocrinologist Dr Harry Benjamin, known for his influential clinical work on transsexualism; soon, this body started providing guidelines for the treatment of people with gender dysphoria. The organization was later renamed as World Professional Association for Transgender Health.,
| Epidemiology|| |
The prevalence of GD in children and adolescents is 1.2%–2.7%.,, The DSM-5 prevalence in adults of GD for birth-assigned males ranges between 0.005% and 0.014%, and for birth-assigned females, it is between 0.002% and 0.003%. The estimated prevalence rates are assumed to underestimate true prevalence owing to bias in the way data are collected. In many of these studies, only those individuals who seek treatment in a specialist center were included leaving out individuals who do not seek help. Furthermore, varied definitions are used to describe GD (transgender individuals/transsexual individuals/GID/GD). A study has noted geographical differences in the prevalence of GD reiterating the cultural influence and varied diagnostic criteria used across countries.
Recently, there has been a surge in the number of individuals with GD seeking help from specialist clinics. This might be due to a rise in public awareness along with increased media reporting, more number of LGBTQ support groups, campaigns for transsexual individuals rights, reduced discrimination, and greater awareness of GD among health professionals.,,,,
| Etio-Pathogenesis of Gender Dysphoria|| |
Freud associated homosexual development with oedipal frustration which states intense mother attraction in childhood coupled with distancing oneself from a father figure. Unresolved separation anxiety during the separation-individuation phase in infancy gives origin to male transsexualism.
Associations between polymorphism of CYP17, particularly the CYP17-34C gene and female to male (FtM) but not male to female (MtF) transsexual individuals have been observed and proposed as a putative genetic marker of GD. A review of case reports found 40% concordance for GD in 23 monozygotic female and male twin pairs.
There is conflicting evidence regarding neuroanatomical resemblance of transgender individuals with their natal sex or gender identity prior to undergoing hormonal therapy with majority of studies favoring brain morphology resemblance to their gender identity than natal sex. On the one hand, among the transgender individuals who meet the criteria for GD, the cortical thickness, gray matter volume, and white matter microstructure have been found to be similar to that of cisgender control subjects of the perceived gender than that of natal sex.,,, On the other hand, few studies among MtF and FtM transsexual individuals have reported that the gray matter distribution and the regional brain volumes are in line with their natal sex counterparts., Thicker cortex was noted in both the hemispheres of the brain in male to female transgender individuals compared to the control males. Transgender individuals were more likely to have their callosal shapes in sync with patterns observed in the perceived gender than their assigned gender. Gender dysphoria is also proposed to be associated with variants in signaling of sex hormone signaling genes. There is a potential role of androgens especially prenatal exposure to testosterone in gender development.
Notwithstanding above theories, a clear etiology for GD remains elusive. Moreover, the literature focusses on the gender identity issue rather than the distress associated with it. And, such studies are usually done on clinically referred population who more commonly endorse associated distress. More evidence is based on cross-sectional studies rather than longitudinal studies. Clearly, there exists a subgroup of individuals who do not have distress and are not being evaluated. This affects the generalizability of literature on the etiopathogenesis of GD.
| Concept and Definition|| |
Gender versus sex
Sex is assigned at birth (or before, using imaging techniques such as ultrasound) depending on the appearance of external genitalia. It is a nonflexible categorical concept. It is based on the status of biological variables that are typical of males and females (genes, chromosomes, gonads, internal, and external genitalia). In contrast, gender is a social construct that refers to attributes of biological sex, but is not necessarily influenced by it. It refers to the social categories of males (i.e., boys, men) and females (i.e., girls, women) and also refers to attributes of living in the social role of a man or a woman.
Sexual orientation vs. gender identity
Gender identity refers to a person's inner inherent sense of being a man or woman or alternate category that may or may not correspond to the sex assigned at birth.
Sexual orientation refers to a person's pattern of sexual or romantic attraction to others of the same, other, both, or neither sex. Sexual orientation cannot be inferred from one's gender identity. Cross-gender identification does not necessarily reveal a person's sexual orientation.
The following terms are used to denote sexual orientation:
- Androphilia: Attracted to men
- Gynephilia: Attracted to women
- Bisexual: Attracted to both
- Analophilic: Attracted to neither.
An umbrella term used to refer to those members in whom the experienced or expressed gender does not align with normative social expectations of the gender assigned at birth.
[Table 1] enumerates definitions of basic terms used in gender dysphoria literature.
| Nosology|| |
International classification of diseases
Transvestitism was first included in ICD-8. But what was included as transvestitism was not clearly defined. Transvestitism was subsequently replaced by transvestism. A new diagnosis called transsexualism was added in ICD-9. The category of Gender Identity Disorder (F64) was introduced in ICD-10. It included transsexualism, dual-role transvestism, gender identity disorder of childhood, other gender identity disorders, and gender identity disorder, unspecified. In the ICD-11, gender identity disorders are removed from the mental disorders chapter (chapter 6). They are now part of a new chapter on “conditions related to sexual health” (chapter 17) and are called “gender incongruence”. Therefore, gender incongruence is no longer a mental illness according to ICD-11.
Diagnostic and statistical manual of mental disorders
“Transsexualism” as a diagnosis was introduced in DSM-III (1980) in the category of “psychosexual disorders.” DSM-III-revised R made few changes from DSM III. It included 3 gender diagnoses: “transsexualism,” “gender identity disorder of adolescence and adulthood, nontranssexual type” (GIDAANT), and “gender identity disorder not otherwise specified.” “Psychosexual disorders” was removed as a category, and these diagnoses were moved to “sexual disorders.”
In DSM-IV, a separate category called “gender identity disorders” was created. GIDAANT was removed as a diagnosis from DSM-IV. In DSM-IV, importance was given more to cross-gender behavior, while in revised version of DSM III (DSM-III-R), cross-gender identity emphasized. In DSM-5, GID was changed to “gender dysphoria” to minimize associated stigma. They were placed in the gender dysphoria section, which was separated from paraphilias and sexual dysfunctions. An effort was made to differentiate between transient and persistent gender dysphoria by including a duration criterion. Criteria for cross-gender identification and not feeling comfortable in the assigned gender were merged in DSM-5.
The recent DSM-5 Text Revision (DSM-5-TR) published in March 2022 has not changed any diagnostic categories in the section on gender dysphoria but has tried to change the language to help reduce stigma by clarifying that these aspects of a person are not selected by choice. This includes the more accurate and inclusive changes below:
- “Desired gender” to “experienced gender”
- “Cross-sex medical procedure” to “gender-affirming medical procedure”
- “Natal male/natal female” to “individual assigned male/female at birth”
| Comorbidities in Gender Dysphoria|| |
Members suffering from GD are at risk of developing a range of psychiatric disorders due to the stigma and discrimination associated with their condition. Common comorbidities in this group include major depressive disorder, anxiety spectrum disorder, and substance use disorders. Suicide ideas and attempts are higher among this group compared to general population. The relation between gender dysphoria and stress may be mediated by several variables such as social support, contact with other LGBT people, and internalized homophobia. [Table 2] lists common psychiatric comorbidities seen in GD.
| Critique Related to the Diagnosis of Gender Dysphoria|| |
Considering the dysphoria associated with assigned gender as a variation in normal gender representation against the existing binary classification of gender and stigmatizing such individuals by labeling them with a mental disorder diagnosis have been criticized by various activists' groups. Prevailing antitransgender attitudes in various cultures and the belief that one is born transgender are considered to be the theories behind normalizing gender dysphoria. Nevertheless, addition of gender dysphoria into classificatory system enables psychiatrists to act as gate keepers for ensuring medical services for transgender individuals. It is of note that many people who are availing mental health services do not otherwise have mental disorders or do not desire mental health treatment which creates an unnecessary burden on psychiatrists. Psychiatrists are a key part of the multidisciplinary team involved in assessment and treatment of transgender individuals; in this regard, parallels can be drawn with procedures such as assessment of organ transplant individuals.
Any clinician needs to delineate the target population for offering appropriate care. However, it is evident from the literature that various diagnostic terms have been used in the context of gender nonconformity with little consensus regarding the definition of these terms. This leads to confusion in demarcating the target population and results in false-positive diagnoses. Therefore, a proper and uniform definition with clarity is required to avoid confusion and disparity in practice. The change of diagnostic terminologies in recent versions of classificatory systems to gender dysphoria/incongruence is intended to reduce pathological connotation. However, retaining these terms may further add to the stigma that the community members are already experiencing.
DSM-5 includes a specifier “with a disorder of sex development” under the diagnosis of GD to include those with intersex conditions. However, it should be noted that not all individuals with DSD experience GD. Only around 8.5%–20% of individuals with DSD are affected by gender dysphoria. The GD experience in DSD varies according to the gender assignment and the type of DSD syndrome., The context in which a child with DSD is reared, the severity of DSD, and the treatment provided contribute to gender dysphoria. There are no reports of gender change in individuals with 46XY and micropenis, who were assigned as females at birth.,
The “post-transition” specifier is added under the diagnosis of GD to include members who have undergone any medical or surgical procedure. This specifier ensures that the members have access to medical care without difficulty and benefit from insurance claims for ongoing hormonal treatment. An unanswered question, however, is whether to include members who had undergone surgeries, before the onset of gender transition, in the post-transition specifier.
Application of the “post-transition” specifier does not make sense for those who are not experiencing dysphoria as it would result in a false-positive diagnosis of GD. As intersex people have biological characteristics that do not fully align with either the male or female gender, the distress that arises from gender incongruence is unclear. According to the available literature, assigning gender to intersex people at birth does not address the possibility of distress with the assigned gender in the future. Moreover, diagnosing GD in intersex people raises the basic question of propriety of original assignment of gender by doctors/parents at birth.
| Controversies|| |
Controversies related to the diagnosis of gender dysphoria
Gender-based diagnoses have created many controversies since their inclusion in the diagnostic classificatory system such as ICD and DSM. The difference of opinion between mental health professionals, transgender advocacy groups, and the LGBT community is centered on whether gender identity-related diagnostic categories should be included in classification systems. Over the past decade, the debate regarding gender identity diagnoses and their exclusion from the classification system has been ongoing. The inclusion of the diagnoses in the classificatory system would help these individuals to get access to medical care and enable them to be beneficiaries of insurance policies that require diagnostic codes for availing medical and surgical benefits. On the other hand, advocacy groups argue that including diagnoses would add further stigma to a community already afflicted by the same while excluding diagnoses would depathologize the issue.,
Thus, the exclusion of these diagnoses would help reduce the stigma experienced by this group of people. The DSM-5 and ICD-11 revision teams have attempted to strike a balance between reducing stigma and permitting adequate access to care for this community. Hence, the diagnosis was changed from gender identity disorder to gender dysphoria and gender incongruence in DSM-5 and ICD-11, respectively. It implies that one's identity has not been disordered but rather, the experienced distress is the result of mismatching assigned gender and gender identity. While neither DSM nor ICD entirely negates stigma, they attempt to reconcile this issue with less stigmatizing terminology than before. The transition of gender has been likened to uncomplicated pregnancy, a normal life phenomenon that needs medical attention.
The inclusion of gender diagnoses in children has been criticized as well. However, it was argued that the inclusion of this diagnosis in children facilitates evaluation and management of the condition in childhood. However, this inclusion ignores the uncertainty surrounding the condition's outcome in adulthood.,
Controversies related to the management of gender dysphoria
Members of the LGBT community may resort to psychotherapy at a higher rate compared to non-LGBT population., Psychotherapists and clinicians should realize that their attitudes and knowledge about the experiences of the LGBT community are relevant to the therapeutic process with these clients. The therapist's heterosexist bias and microaggressions toward their LGBT clients can be detrimental to the therapeutic process and outcomes. They should undergo appropriate training under supervision to provide appropriate and sensitive clinical care to the concerned clients., Even though research suggests that efforts to change sexual orientation are unlikely to be successful and, on the contrary, carry some legitimate risk of harm, some mental health professionals still attempt to change LGBT individuals to become heterosexual through what is referred to as “conversion therapy” or “reparative therapy”,
Various ethical concerns remain regarding the treatment of GD. One of them is the time of initiation of therapy for children and adolescents. At a young age, children's autonomy is questionable, and they cannot fully comprehend the outcomes of medical and surgical interventions. Delaying treatment can aggravate dysphoria leading to depression, anxiety, and suicidal ideation., Secondly, there are reports of regret after surgery due to incorrect diagnosis of GD, dissatisfaction with the procedure and outcome of newly created organs, or the irreversibility of surgical procedures in comparison to hormonal therapy. In addition, for GD individuals, the decision of choosing between sex transition and maintaining the ability to reproduce can be a difficult one. Hormonal treatments temporarily impair one's ability to procreate, whereas surgery permanently eliminates this ability. Hence, opting for surgery is an ethical dilemma too, not only for GD patients, but also for their families and surgeons.
| Conclusion|| |
Gender dysphoria/incongruence is the new term for individuals with gender nonconformity in the recent iterations of major diagnostic classificatory systems such as ICD and DSM; these changes reflect the decreasing focus on pathology and increasing focus on distress associated with one's gender nonconformity. Members of the LGBT community are at risk of developing various psychiatric disorders, such as depression and anxiety, due to inherent discrimination and stigma experienced by these individuals. Various terminologies are used in understanding the gender dysphoria entity and defining them clearly is essential for avoiding confusion in practice and research. Controversies in views around inclusion of gender-based diagnoses in classificatory systems between the various stakeholders suggest a need to evolve consensus. Further research efforts are needed to frame assessment and management guidelines in GD; such guidelines also need to be culturally sensitive and ethically balanced.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]