Gender Dysphoria

Presenter: Yohannes sime (ICCMH-I)

Moderator: Mr. Hailemariam Hailesilassie
(assistant professor)

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 Outlines
• Introduction
• Prevalence and sex ratio
• Etiology – biological, psychological and psycho
social aspect
• Diagnostic criteria
• Course and prognosis
• Treatment

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 DSM V classification
1. Gender dysphoria in children

2. Gender dysphoria in adolescents & adults

3. Other specified/unspecified gender dysphoria

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 Gender Dysphoria
• The term Gender Dysphoria appears as a diagnosis
for the first time DSM-5 refer to
“those persons with a marked incongruence
between their experienced or expressed gender and
the one they were assigned at birth.”

It was known as gender identity disorder in the

previous edition of DSM.

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• Gender identity: the sense one has being male or
being female which corresponds, normally to the
persons anatomical sex.

• Gender identity becomes fixed in most persons by

age 2 or 3 years.

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• The affective component of GI is gender dysphoria,
discontent with ones designated birth sex and a
desire to have the body of the other sex, and to be
regarded socially as a person of the other sex.

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• Transgender: is a general term used to refer to those
who identify with a gender different from the one
they were born with(sometimes referred to as their
assigned gender) and they are diverse groups :-

– Genderqueer: those who feel they are between genders, of

both genders. Or of neither gender

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– Crossdresser: who wear clothing traditionally associated
with another gender, but who maintain a gender identity
that is the same as their birth assigned gender known as
cross dressers.

– Transsexuals: those who want to have the body of another

sex

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 Prevalence and sex ratio
• Male – 0.005 to 0.014%

• Female – 0.002 to 0.003%

• The sex ratio of referred children is 4 to 5 boys for

each girl.

• sex ratio – adolescent 2:1 to 4.5 :1

adult-1:1 to 6.1:1

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 Etiology – biological factors
• Resting state of tissue in mammals is initially female
& as fetus develops, a male is produced only if
androgen is introduced by Y chromosome, which is
responsible for testicular development.

• Maleness and masculinity depend on fetal and

perinatal androgens.

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• Testosterone can increase libido and aggressiveness
in woman, and estrogen can decrease libido and
aggressiveness in men.

• Masculinity, femininity, and gender identity result

more from postnatal life events.

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 Psychosocial aspect
• Children usually develop a gender identity consonant
with their sex of rearing (also known as assigned sex)

• The formation of gender identity is influenced by the

interaction of children's temperament and parents
qualities and attitudes.

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• Sex role stereotypes are the beliefs, characteristics
and behaviors of individual cultures that are deemed
normal and appropriate for boys and girls to possess.

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 Psychological aspect
• Mother and child r/n ship – relation ship in the first
years of life is paramount in establishing gender
identity. During this period, mothers normally
facilitate their children's awareness of and pride in
their gender.

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• Role of mother – devaluating, hostile mothering can be
result in gender problem, can also be triggered by a
mothers death, extended absence, or depression, to
which young boy may react by totally identifying with he
– that is, by becoming a mother to replace her
• Abused child – some children are given the message that
they would be more valued if they adopted the gender
identity of the opposite sex. Rejected or abused children
may act on such a belief

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• Fathers role – the fathers role is also important in
the early years. Without a father, mother and child
may remain overly close. For a girl, father is normally
the prototype of future love objects ; for a boy the
father is a model for male identification.

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• Sigmund Freud believed that gender identity
problems resulted from conflicts experienced by
children within the oedipal triangle.

• In his view, these conflicts are fueled by both real

family events and children's fantasies

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• Since many cultures strongly disapprove of cross-
gender behavior, it often results in significant
problems for affected persons and those in close
relation ships with them.

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 DSM V diagnostic criteria in children
A. A marked 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 gender (or some alternative
gender different from one’s assigned gender).

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2. In boys (assigned gender), a strong preference for
cross-dressing or simulating female attire: or in girls
(assigned gender), a strong preference for wearing
only typical 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.

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4. A strong preference for the toys, games, or activities
stereotypically used or engaged 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 or in girls
(assigned gender), a strong rejection of typically feminine
toys, games, and activities.

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 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.

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• Specifier
With a disorder of sex development

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 DSM V diagnostic criteria in Adolescents and
Adults
A. A marked incongruence 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 primary and/or secondary
sex characteristics (or in young adolescents, the anticipated
secondary sex characteristics).

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2. A strong desire to be rid of one’s primary and/or
secondary sex characteristics because of a marked
incongruence with one’s experienced/expressed
gender (or in young adolescents, a desire to prevent
the development of the anticipated secondary sex
characteristics).

3. A strong desire for the primary and/or secondary

sex characteristics of the other gender.

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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 different from one’s assigned
gender).
6. A strong conviction that one has the typical feelings
and reactions of the other gender (or some alternative
gender different from one’s assigned gender).
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B. The condition is associated with clinically significant
distress or impairment in social, occupational or
other important areas of functioning.

• Specifier
- With a disorder of sex development
- Posttransttion

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 Course and prognosis
• Child

persistence in male 2.2 to 30%, female 12 to 50%

 male child 63 to 100% androphelic

 female child 32 to 50% gynephilic

• Adult –

- early onset in childhood GD; androphelic

- late onset around puberty, gynephilic, more ambivalent

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 Differential diagnosis
• Hermaphrodism

• Body dysmorphic disorder

• Transvestic disorder

• Psychotic disorder

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 Treatment – children
• At present, no convincing evidence indicates that
psychiatric or psychological intervention for children
with GD affects the direction of subsequent sexual
orientation.

• The Rx of GD in children largely at developing social

skills and comfort in the sex role expected by birth
anatomy.

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• To the extent that treatment is successful,
transsexual development may be interrupted

• No hormonal or psychopharmacological treatments

for GD in childhood have been identified

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 Treatment – adolescents
• Adolescents whose GD has persisted beyond puberty
present unique treatment problems.

• Rx management is to slowing down or stopping

pubertal changes expected by anatomical birth sex
and then implementing cross-sex body changes with
cross-sex hormones

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• Puberty-blocking medications are gonadotropin-
releasing hormone (GnRH) agonists that can be used
to temporarily block the release of hormones that
lead to secondary sex characteristics ( e.g.
Leuprorelin).

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 Treatment – adults
• Adult patients usually presents with straight forward
requests for hormonal and surgical sex reassignment.

• No drug treatment has been shown to be effective in

reducing cross-gender desires

• When patient gender dysphoria is severe intractable,

sex reassignment may be the best solution.

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 Sex reassignment surgery
• Sex reassignment surgery for a person born
anatomically male consists principally of removal the
penis, scrotum, and testes, construction of labia, and
vaginoplasty.

• Some clinicians attempt to construct neoclitoris from

the former frenulum of the penis. The neoclitoris
may have erotic sensation.

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• Post operative complications include urethral
strictures, ricto vaginal fistulas, vaginal stenosis and
inadequate width or depth.
• Female to male patients typically may undergo
bilateral mastectomy and construct a neophallus.
• Because of increased technical skills in phalloplasty,
more female to male patients are now selecting
these procedure

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 Hormonal treatment
• Persons born male are typically treated with daily
doses of oral estrogen- conjugated equine estrogens
or ethinylestradiol which produce breast
enlargement, testicular atrophy, decreased libido,
and diminished erectile capacity..

• Facial hair removal is required by laser treatment or

electrolysis

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• Biological women are treated with monthly or three
weekly injection of testosterone.

• The pitch of the voice drops permanently into the

male range as the vocal cords thicken.

• The clitoris enlarges to two to three folds its

pretreatment length and is often accompanied by
increased libido

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• Hair growth changes to the male pattern, and a full
complement of facial hair may grow.

• Cross-sex steroid hormones affect general body fat

and muscle distribution as well as promote breast
development in patients born male.

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 Other Specified Gender Dysphoria
• Symptoms do not meet the full criteria for gender
dysphoria.
• clinician chooses to communicate the specific reason
that the presentation does not meet the criteria for
gender dysphoria
• done by recording “other specified gender dysphoria”
followed by the specific reason (e.g., “brief gender
dysphoria”).

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 Unspecified Gender Dysphoria
• Symptoms do not meet the full criteria for gender
dysphoria.

• clinician chooses not to specify the reason that the

criteria are not met for gender dysphoria.

• includes presentations in which there is insufficient

information to make a more specific diagnosis.

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reference

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Thank you

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