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Gender dysphoria issues in male female..
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- 2. Definition Gender dysphoria refersto the distress that may accompany the incongruence between one`s experienced or expressed gender and one`s assigned gender.
- 3. Changes from DSM4 • GID first introduced in 1980 (DSM III). • DSM-5 replaces the diagnostic name “gender identity disorder” with “gender dysphoria”. • In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilia's. • Gender dysphoria has its own chapter in DSM-5 and separated from Sexual dysfunctions and Paraphilic disorders. • A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender.
- 4. Gender Dysphoria inChildren 302.6 (F64.2)
- 5. Diagnostic Criteria A. Amarked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gen der (or some alternative gender different from one’s assigned gender). 2. In boys (assigned gender), a strong preference for cross-dressing or simulating fe male attire: or in girls (assigned gender), a strong preference for wearing only typ ical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereotypically used or en gaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (as signed gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. B. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.
- 6. Gender Dysphoria inAdolescents and Adults 302.85 (F64.1 )
- 7. A. A markedincongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: 1. A marked incongruence between one’s experienced/expressed gender and pri mary and/or secondary sex characteristics (or in young adolescents, the antici pated secondary sex characteristics). 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics be cause of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated second ary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender dif ferent from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gen der (or some alternative gender different from one’s assigned gender). B. The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning. Diagnostic Criteria
- 8. Specifiers Posttransition The individual hastransitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen —namely, regu lar cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).
- 9. Prevalence For natal adult males •0.005% -0.014% For natal adult females • 0.002%- 0.003% •In children • 2:1 to 4.5:1 •In adolescents • Close to equivalence •In adults • Favors natal males • 1:1 to 6.1:1 Sex ratios
- 10. Causes • The exactcause of gender dysphoria is unknown and there is much debate over the possible causes of gender dysphoria. • Psychiatric and biological causes • Genetic causes of biological sex • Hormonal causes • Rare conditions • Other causes of gender dysphoria
- 11. Psychiatric condition meaninga mental ailment and the disease may not have origins in the brain alone. •Development that determines biological sex happens in the mother’s womb. •Anatomical sex is determined by chromosomes that contain the genes and DNA. Androgen insensitivity syndrome (AIS) is when a person who is genetically male (who has one X and one Y chromosome) is resistant to male hormones (called androgens). As a result, the person has some or all of the physical traits of a woman, but the genetic makeup of a man. •In congenital adrenal hyperplasia (CAH) a female fetus has adrenal glands (small caps of glands over the kidneys) that produce high level of male hormones. This causes the genitals to become more male in appearance and, in some cases, the baby may be thought to be biologically male when she is born. • chromosomal abnormalities • Sometimes defects in normal human bonding and child rearing
- 12. Associated Features SupportingDiagnosis ❑When visible signs of puberty develop: • Boys shave their legs • Girls bind their breasts ❑Clinically referred adolescents often want: • Hormone treatment • Gender reassignment surgery ❑Before GRS are at increased risk for suicidal ideation, suicide attempts and suicides. ❑Adolescents living in an accepting environment may openly express the desire to be as the experienced gender.
- 13. Development and Course •Young children are less likely than older children, adolescents and adults to express extreme and persistent anatomic dysphoria. • Factors related to distress and impairment also vary with age (e.g., intense crying). • In adults such distress reduce by supportive environments and biomedical treatments. • Impairments (school refusal, development of depression, anxiety and substance abuse) may be a consequence of gender dysphoria.
- 14. Gender Dysphoria withouta disorder of sex development • Onset of cross gender behaviors is usually between ages 2 and 4 years, usually at entry into elementary school. ❑Rates of persistence of gender dysphoria: • In natal males, ranged from 2.2% to 30% • In natal females, ranged from 12% to 50% ❑whose gender dysphoria does not persist • In natal male children, androphilic (sexually attracted to males) • In natal female children, gynephilic (sexually attracted to females)
- 15. Continue • In bothadolescent and adult natal males, there are two broad trajectories for develop ment of gender dysphoria: ❑ Early-onset gender dysphoria • starts in childhood and continues into adolescence and adulthood; or, there is an irregular pe riod in which the gender dysphoria stops and these individuals self-identify as gay or ho mosexual, followed by recurrence of gender dysphoria. ❑Late-onset gender dysphoria • occurs around puberty or much later in life. Some of these individuals report having had a desire to be of the other gender in childhood that was not expressed verbally to others. Others do not recall any signs of childhood gender dysphoria.
- 16. Gender Dysphoria inassociation with a disorder of sex development • Most individuals have already come to medical attention at an early age. • Infertility is quite common for this group. • Disorders of sex development in general are frequently associated with gender-atypi cal behavior starting in early childhood.
- 17. Risk and PrognosticFactors • Temperamental • Atypical gender behavior among individuals with early onset gender dysphoria develops in early preschool age • Environmental • Males commonly have older brothers than do males without the condition. • Late onset GD include habitual fetishistic transvestism developing into autogynephilia (i.e., sexual arousal associated with the thought or image of oneself as a woman).
- 18. Genetic and physiological •Increased concordance for transsexualism in monozygotic compared with dizygotic same-sex twins, and some degree of heritability of gender dysphoria. • Androgen insensitivity syndrome (AIS) • congenital adrenal hyperplasia (CAH) • Many individuals with disorder of sex development and markedly gender atypical behavior do not develop gender dysphoria.
- 19. Culture-Related Diagnostic Issues •Reported across many countries and cultures. • Reported in Individuals living in cultures with institutionalized gender categories other than male or female.
- 20. Functional consequences ofGender Dysphoria ❑Cross gender wishes may develop after the first 2-3 years of childhood: • Interfere with daily activities • Failure to develop peer relationships and lead to isolation and distress. • Refuse to attend school ❑In adolescents and adults interferes with daily activities and relationship difficulties: • Leading to negative self-concept, unemployment, increased rates of mental disorder comorbidity • Access to health services and mental health services may be hindered by structural barriers.
- 21. Case study Sarah (Bornmale with the given name Lucas) • Sarah is a 10-year-old self-identified female, although she was assigned the gender of male at birth. She was referred to the clinical psychologist after a teacher noticed some self-injurious behavior. Sarah also told her teacher there were a few students at the school who had been calling her names and bullying her on Facebook. Sarah’s parents noticed their child (born male) by about age three was insistent she was a girl. Sarah played with stereotypical female toys, and most of her peers in the daycare were girls rather than boys. Sarah does not have a disorder of sex, and therefore no biological/medical treatment is needed at this time. Sarah and her parents have been working closely with their pediatrician, who has recently set them up with a support group for families with transgendered children. Sarah is also seeing her school counselor since the self-injury incident, to address depression and anxiety symptoms.
- 22. Case study A 45-year-oldman, dressed as a woman, requests a prescription for estrogens and a rapid referral for gender reassignment surgery on the grounds of self-diagnosed transsexualism. He gives a history of lifelong cross-dressing, which became sexually exciting at puberty. The sexual excitement diminished in his 20s, to be replaced by a sense of relaxation and comfort when in a female role, described as being able to express his feminine side. He is married, but separated, and has 2 children. The sexual content of his marriage (never very great) diminished after their birth. He hid his cross-dressing from his wife until she discovered his female clothes and assumed that he was having an affair. Although initially tolerant of his cross-dressing, she became increasingly dissatisfied as he spent more time in a female role and suggested that they might live together as sisters. Moving away from his wife and children, he began to purchase estrogens from the internet. He lived as a woman for all purposes aside from his work, where nothing was known of his female life outside. He began to feel increasingly unhappy in his male work life, feeling that he is only truly himself when living as a woman.
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- 24. ❑ Nonconformity togender roles: - An example of nonconforming behavior is a girl who prefers to dress in boys’ clothes. She may exhibit behaviors that are more culturally typical of boys, too.
- 25. ❑Transvestic disorder: • Transvesticdisorder occurs in heterosexual (or bisexual) adoles cent and adult males (rarely in females) for whom cross-dressing behavior generates sex ual excitement and causes distress and/or impairment without drawing their primary gender into question. It is occasionally accompanied by gender dysphoria. ❑ Body dysmorphic disorder: • An individual with body dysmorphic disorder focuses on the alteration or removal of a specific body part because it is perceived as abnormally formed, not because it represents a repudiated assigned gender. When an individual's presenta tion meets criteria for both gender dysphoria and body dysmorphic disorder, both diag noses can be given.
- 26. ❑ Other clinicalpresentations: • Some individuals with an emasculinization desire who develop an alternative, nonmale/nonfemale gender identity do have a presentation that meets criteria for gender dysphoria. • However, some males seek castration and/or penec tomy for aesthetic reasons or to remove psychological effects of androgens without chang ing male identity; in these cases, the criteria for gender dysphoria are not met. ❑ Schizophrenia and other psychotic disorders: • In schizophrenia, there may rarely be delusions of belonging to some other gender. In the absence of psychotic symptoms, in sistence by an individual with gender dysphoria that he or she is of some other gender is not considered a delusion. • Schizophrenia (or other psychotic disorders) and gender dys phoria may co-occur.
- 27. Comorbidity • Anxiety anddepressive disorders • Autism spectrum disorder •Disruptive and impulse control
- 28. Other Specified Gender Dysphoria302.6 (F64.8) * This category applies to presentations in which symptoms characteristic of gender dys phoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dys phoria. * The other specified gender dysphoria category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dys phoria” followed by the specific reason (e.g., “brief gender dysphoria”). ●An example of a presentation that can be specified using the “other specified” desig nation is the following: ●The current disturbance meets symptom criteria for gender dysphoria, but the duration is less than 6 months.
- 29. Unspecified Gender Dysphoria 302.6(F64.9) ●This category applies to presentations in which symptoms characteristic of gender dys phoria that cause clinically significant distress or impairment in social, occupational, or oth er important areas of functioning predominate but do not meet the full criteria for gender dysphoria. ●The unspecified gender dysphoria category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for gender dyspho ria, and includes presentations in which there is insufficient information to make a more specific diagnosis.