Gender dysphoria(Gender Identity disorder).pdf

Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics.
Whole gender spectrum seems to getting more and more divers eveyday.Lot of new terms and norms has come to the use.Psychology also should harmonize with these new trends.So do the people who are in the psychology and clinical psychiatry fields.
This presentation discusses about gender dysphoria, also known as the gender identity disorder.This includes deep and wide range of knowledge in both graphical and text versions which makes them easy to understand.I think this will help to doctors,medical students,nurses and nursing students,psychology students,general public and specially for those who try to understand themselves while suffering from distress with their birth gender.

1. Dysphoria
Gender
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Sankalpa Gunathilaka
MBBS (Sri Lanka)
Dip. In Psychology and Counselling

2. Content
•Introduction and Classification(ICD-10 and DSM-5)
•Important terminologies
•Clinical features and diagnostic criteria
•Subtypes
•Classification based on Onset and relevant features
•Course of Gender dysphoria
•Aetiology
•Risk factors
•Differential diagnosis
•Comorbidities
•Management
•References

3. ❑Persistent discomfort with one’s biological sex or assigned gender.(natal sex)
❑Gender identity disorder (ICD-10) = Gender dysphoria (DSM-5)
❑The future ICD-11 has proposed the new term ‘Gender incongruence’ to describe GID and
consider not as a disease.
ICD - 10 DSM-5
Transsexualism (F64.0) Gender dysphoria in children (F64.2)
Dual-role transvetism (F64.1) Gender dysphoria in Adolescents and Adults (F64.1)
Gender identity disorder of childhood(F64.2)
Other gender identity disorders(F64.3)
Other gender identity disorders, unspecified(F64.4)
Classification differences in ICD-10 and DSM-5
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4. ▪Cisgender: someone who identifies with the gender they were assigned at birth.
▪Expressed gender(Gender identity): the subjective experience of being male, female,
genderqueer or otherwise.
▪Transgender: an umbrella term for people whose gender(identity, expression, general
sense of self) is different from the sex they were assigned at birth
▪Transgender woman(Trans-woman): someone who has assigned male at birth but living as
a woman(male to female)
▪Transgender man(Trans-man):Someone who was assigned female at birth but living as a
man(female to male)
Important terms in Gender dysphoria :
LGBTQ+
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5. ▪Non-binary(Transqueer): someone who does not identify with either gender, or
has a gender that changes over time, or feels in between genders.
▪Transsexualism: Desire to live and be accepted as a member of opposite sex,
accompanied by sense of discomfort with or inappropriateness of one’s
anatomic sex. They wish to have a congruous body with preferred sex.
▪Transsexual: someone who has transitioned from one sex to the other through
the use of hormones and/or surgical procedure
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6. ▪Marked incongruence between natal gender and expressed gender
▪Distress about the incongruence
▪Factors related to distress may vary
▪In childhood distress(cry) may not manifest if beging supportive to child’s desire
▪In adults distress in reduced by supportive environment
▪Expressed gender may include alternative gender identities beyond the binary
stereotypes.
▪Clinically manifest differently in different age groups.
oChildhood, Adolescent, Adult life
In Gender Dysphoria
▪More in male than females
▪Occurs before 12 years of age – mostly 2-4 years of age
▪Prepubertal children assert they belong to opposite gender and will grow up to be the
opposite gender.
❖Gender Dysphoria in childhood :
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7. Diagnostic criteria : According to DSM-5
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8. ❖Adults with Gender dysphoria:
▪To varying degree adults adopt to the behaviors, clothes and manners of expressed gender
▪Feel uncomfortable when treated as assigned gender(use expressed gender pronouns)
▪Try to resolve incongruousness by partially living in the desired role(sexual transvetism)
▪If married to a opposite gender; resist when partner try to touch or see the person’s
genital organs.
❖Young Adolescent with gender dysphoria : clinical picture resembles with
either children or with adults depending on the developmental level
Childhood AdolescentAdult life
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9. Diagnostic criteria: According to DSM-5
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10. Classification:❑Based on the time of onset
Early Onset Late Onset
Before 12 years of age (mostly 2-4 years) Around puberty or much later in life
Becomes homosexual in later life Majority – Heterosexual
•Natal males -Gynophilic
•Natal females - Adrophilic
OR attracted to post-transitional persons with
same natal gender
Seek for clinical advise earlier and undergo
surgery earlier at earlier age
More fluctuating in degree of dysphoria
May be less satisfied after reassignment surgery
More common in natal females More common in natal males
Anatomic dysphoria more common in adults but
silent
(with development of secondary sexual characteristics)
If married to opposite gender; after surgery identify
themselves as Lesbian or Gay
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11. Course of Gender Dysphoria
Puberty
Childhood Adulthood
2 yrs
Early onset
Late onset
Anatomic dysphoria
▪Early onset dysphoria sometime may subsides
without persisting into the adult life
▪Persistent is affected by various factors
▪So the persistent rate may vary
▪Persistent is more in females
▪Among who does not persist – majority become
Homosexual
oLesbians / Gays
oMales > Females
▪Minority of children express discomfort with
their sexual anatomy(anatomic dysphoria)
▪Anatomic dysphoria markedly elevates during
puberty
▪Anatomic dysphoria more common with Gender
dysphoria.
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12. Aetiology
▪Genetic causes
▪Prenatal sex hormones
- But this is more closer to gender atypical behavior than gender dysphoria
▪Sex dimorphic brain structure and function
▪Psychological processes
- In some people gender identity is more fluid like and less trait like.
Risk factors
▪Temperamental: Atypical gender behavior seen in early preschool age (Early onset gender dysphoria)
▪Environmental: Influence from close contacts with similar conditions (Late onset gender dysphoria)
▪Genetic and physiological : (Early onset gender dysphoria)
oDisorders of sex development - 46,XY individual with inborn nonhormonal genital
defect(penile agenesis) may have been assigned to female gender.
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13. Differential diagnosis
▪Nonconformity of gender roles
➢Tomboys and Girly-boy
➢Differ from dysphoria by strong desire to be opposite gender and pervasiveness of gender variant
activities, interests
▪Transvestic disorder
➢Mostly in heterosexual and bisexual males – rare in females
➢Cross-dressing generates sexual excitement
➢Accompanied by gender dysphoria
➢Risk factor for Late onset dysphoria in gynophilic natal males
▪Body dismorphic features
➢Individual focuses on alterating/removing of particular body part as they perceive them as dismorphic;
not due to it represents assigned gender
▪Schizophrenia and other psychiatry disorders
➢Delusion of belonging to another gender is rare
➢If no psychiatry symptoms –not consider as delusion
➢Dysphoria and Schizophrenia can co-exist
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14. Comorbidities
▪Elevated level of emotional and behavioral problems
➢Anxiety
➢Depressive disorder
➢Disruptive and impulse control
oThese increase with age
▪In children with gender dysphoria –Autism Spectum disorder
▪In older children peer ostracism leads to more behavioral problems
▪Adults with gender dysphoria may co-exist with Anxiety/ Depressive disorder
▪Suicide
▪Sexual transmitted diseases
AIDS was first
spread among gay
communities
eventually giving it
the name ‘gay virus’
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15. Management
1.Referral to the gender-confirming clinics
A.Make the diagnosis
•Guideline: The standards of Care for the Health of Transexual, Trangender and Gender
non-confirming people-Volume 07 (SOC-7)
•With this any trained health professional can make the diagnosis.
B.Psychiatric assessment – to rule out and treat any significant comorbid mental illness
2. Management should be carried out with multidisciplinary manner
•Psychiatry
•Endocrinology
•Surgery
➢Steps to climb :
Counselling and Psychotherapy
Real life experiences in the preferred gender
Hormonal therapy
Gender reassignment Surgery
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16. Counselling and Psychotherapy
▪Inform the full range of options available
▪Consider the full consequences of any contemplated changes, both for the person and for the
family
▪Don’t focus on therapeutic work as a goal because it would worsen the congruousness with
assigned gender
Real life experience in preferred gender role
▪All individuals with gender dysphoria should live in their new gender role for 1 year
▪Hormone therapy continue parallelly.
▪After one year particular person’s degree of adjustment is assessed by a assessment panel
▪If adjustment is satisfactory – can consider surgery
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17. Hormonal therapy
▪Effective and Safe
Male to Female transition Female to Male transition
- Testosterone suppression
•Spironolactone
•Cyproterone acetate/GnRH agonist
- Androgens
•IM testosterone ester preparations
- Demasculization
- Breast enlargement (Gynecomastia)
- Hair density reduces
- Voice deepens
- Hair increases on face and body
- The clitoris enlarges
- Sex drive increase
Pc: www.dailymail.co.uk
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18. Gender confirming surgery (sex reassignment surgery)
Male to Female Female to Male
- Mammoplasty - Mastectomy (breast removal)
- Penectomy (penis removal) - Ovariectomy (ovaries removal)
- Orchidectomy (testes removal) - Phalloplasty (penis reconstruction)
- Creating of vagina-like structure
Phalloplasty
First successful gender confirming
surgery in Sri Lanka was done in Jaffna
Teaching Hospital(2021)
After mastectomy
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19. Reference
•Oxford shorter textbook of Psychiatry 7
th

Edition
•ICD-10 classification of mental and behavioral
disorders
•Diagnostic and statistical manual of mental
disorders -5
th
Edition
•SAGE encyclopedia of abnormal and clinical
Psychology : Phase of human sexual response
•‘What we can learn from sexual response
cycle’ by Kristen Mark, Ph.D
(https://www.psychologytoday.com/us/blog/the
-power-pleasure/201211/what-we-can-learn-
sexual-response-cycles)
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20. Thank you !
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“ Vikriti Evam Prakriti ”
विकृत िः एिम प्रकृत
( What seems unnatural is also Natural )
-Bhagavat Gita-