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GENDER DYSPHORIA (Gender Identity Disorder)
DIAGNOSIS
The diagnosis of gender dysphoria (formerly gender identity disorder) emphasizes the
incongruence between one's perceived gender and one’s anatomical sex particularly in
older children, adolescents, and adults. In all ages a strong desire to be the other gender
must be present and will reduce the possibility of over-diagnosing individuals who have
extreme gender-variant behavior. Although some advocate the removal of “transgendered”
conditions from diagnostic nomenclature, gender identity disorders are recognized
disorders because they almost always cause significant distress, or as one patient said,
“How would you like to go through life as a woman trapped in a man’s body?” Dysphoria
rather than disorder captures how the incongruence feels. With gender dysphoria there
exists a determination and motivation for change but conversely a lack of flexibility and
willingness to entertain other options. That rigidity may interfere with treatment and the
most satisfactory resolution. Increased age, duration of cross-gender behaviors, and
resistance to change these behaviors are more likely to be associated with real gender
dysphorias. Formerly called “transsexualism” in adult cases, gender dysphoria is such a
persistent feeling of severe discomfort with one’s own anatomical sex, that there is a strong
wish to be rid of one’s genitals, and wish to live as the opposite sex.
TABLE 1
Diagnostic Criteria for Childhood Gender Identity Disorder (Gender Dysphoria)
A. An intense and persistent cross-gender identification as manifest by the following (DSM-5 requires at least six):
1. the pervasive and persistent desire to be (or insistence that he or she is of) the opposite sex to that
assignedepeatedly stated desire to be, or insistence that he or she is, the other sex
2. an intense rejection of the attire of the assigned gender and persistent preoccupation with the dress of the
opposite gender
3. an intense rejection of the attributes and behavior (roles) of the assigned gender
4. a very strong desire to participate with the games, toys and pastimes stereotypically of the other gender
5. preferred playmates are of the opposite gender
6. an intense rejection of participation with the games, toys, and pastimes stereotypically of the same gender
7. repudiation of the anatomical structures specific to their own gender
8. a strong desire for the sexual anatomy of the other gender
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex,
frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that one has the
typical feelings and reactions of the other sex.
B. Persistent and intense distress about ones assigned gender or significant impairment in personal, family, social,
educational, occupational or other important areas of functioning.
Note. Adapted from ICD-10 (pp. 168-170) and DSM-5 (pp. 452-459)
EPIDEMIOLOGY
Gender dysphoria is rare but may be increasing, with an estimated prevalence
among men of 1 in 25,000; among women, 1 in 100,000. Heightened awareness and
increased openness in today's society has resulted in more referrals for gender
dysphoria.
DIFFERENTIAL DIAGNOSIS
Those with gender dysphoria usually, but not always, cross-dress to be in accord
with their own gender identity. The patient’s family members typically recollect that
as a child he wanted to be a she, or vice versa, even as early as 3 years old. While
growing up, these children often experience correction, criticism, ostracism, and/or
marginalization by peers and some relatives. These interpersonal difficulties,
combined with the person’s own strong and disturbing intrapsychic cross-gender
conflicts, result in high rates of oppositional and antisocial behavior, self-mutilation
(frequently of the genitals), attempted suicide, and completed suicide.
If a gender non-conforming youth experiences erotic pleasure and sexual arousal
from engaging in cross-gender role behaviors, the diagnosis would more likely be a
paraphilia (transvestitic fetish). In adolescents it is difficult to know whether this is
a permanent situation or just an experimental phase in someone who will never
seek gender reassignment.
The gender dysphoria may reflect an individual’s lack of acceptance of
homosexuality. Also, there are those who believe that cross-gender behavior is a
normal developmental pathway to homosexuality. However, gender non-conformity
is clearly not a precondition of homosexuality and does not necessarily lead to the
same.
In rare cases of gender dysphoria there is a wish for genital ablation in
persons who preferred to be sexless but have no cross gender identity for example
in a male to eunuch identity disorder in males who seek castration voluntarily
without wanting to acquire the female sex characteristics. Similarly there are teens
who attempt to integrate masculine and feminine aspects of the self and adopt an
androgynous or gender queer form of expression. This may signify incomplete
gender identity development. With a history of sexual abuse such a wish may be an
avoidance of traumatic reminders.
Post-traumatic gender dysphoria and associated gender variant behaviors
may be a repetition compulsion of sexual abuse to relieve the anxiety associated
with the anticipation (likelihood) of future trauma.
Family stress whether a major change, loss, or some other trauma may cause
brief periods of cross-gendered behaviors.
To make the diagnosis of gender dysphoria, the intrapsychic gender conflict
must not be the product of psychosis. Psychotic delusions may be present in mood
disorders (mania or depression), delusional disorders, and schizophrenia. With a
psychotic delusion, an individual may truly believe he or she is a member of the
other sex, but an individual with a gender dysphoria strongly feels like a member of
the other sex rather than believing it is factually true.
Neurologic impairments across a spectrum of parietal lobe dysfunction could
cause a variety of syndromes leading to dissatisfaction with one's physical body.
Comorbid psychiatric problems may be a driving factor of gender dysphoria
and desire for gender reassignment. One study revealed over half of GD children
met criteria for at least one other psychiatric diagnosis. Perhaps 30% have an
anxiety disorder. GD is also significantly associated with measures of parental
psychopathology.
Prenatal sex hormones (androgen exposure) may affect gender role behavior and
sexual orientation in adulthood.
Those individuals with ambiguous genitalia have a higher rate of gender dysphoria
and patient initiated gender change than the general population. Such intersex
conditions are most often caused by congenital adrenal hyperplasia or 5-alphareductase deficiency. See Guevote note in references.
It is important to consider an underlying diagnosis of Autistic Spectrum Disorder
(ASD) when encountering patients with gender dysphoria. Autistic spectrum
disorders are present in 10% of individuals with gender dysphoria. This association
is possibly explained by the propensity for obsessions and restricted interests.
When individuals with ASD realize their uniqueness and differences compared to
others, they may develop confusion of identity which could be exhibited as gender
dysphoria. Some autistic individuals assert gender dysphoria symptoms in response
to social isolation at school. Many of the clinical symptoms related to gender
dysphoria might be explained by the cognitive characteristics and psychopathology
of ASD.
Although the comorbid psychopathology may be the result rather than the
underlying problem of gender dysphoria, being transgender may also be sought as a
solution to non-gender problems. Even experienced interdisciplinary teams find it
is more complicated to accurately diagnose gender dysphoria in youth who are not
functioning well in multiple domains. The validity of the evaluation in the face of
self-presentation biases can be improved by interviewing multiple informants and
by employing various methods to collect accurate clinical data.
ETIOLOGY AND PATHOGENESIS
Gender identity development is complex and the mechanism of geneenvironment interactions of mechanisms poorly understood with unclear outcomes.
There are no associations with systemic hormone levels in adolescents and adults
and GD or homosexuality. It has been hypothesized that prenatal androgen
exposure promotes the development of attraction to females whereas insensitivity
or lack of exposure to androgens leads to male attraction. Antibodies to
testosterone from previous pregnancies with a male fetus, may lead to incomplete
androgenation of the brain (consistent with the later birth order and more older
male siblings). Also androgen insufficiency may occur with fetal stress. There are
epigenetic explanations for same-sex partner preference, ambiguous genitalia, and
transgender identity. Homosexuality does occur more frequently in families but no
studies implicate a specific gene. Epigenetics is the study of heritable changes in
gene expression caused by mechanisms other than the underlying DNA sequence.
DNA methylation and histone modification do not alter the underlying nulceotide
sequence but may persist for multiple cell divisions and are sometimes passed to
the next generation. These epi-marks may regulate the expression of certain genes
involving androgen production or response to androgens during fetal development.
Sex-specific epi-marks produced early in embryogenesis may protect each sex from
the substantial natural variation in testosterone that occurs later in fetal
development i.e. girl fetuses are not masculinized even under high testosterone
conditions and boy fetuses are still masculinized even under low testosterone
conditions. However, if these same epi-marks are transmitted to the next
generation from fathers to daughters or mothers to sons they would cause the
reverse effects i.e. masculinized girls and feminized boys.
Father absence may contribute to GD. Mother’s of boys with GD have high
levels of emotional involvement and lower criticism. Mother’s anxiety about
violence from men, poor management of stress, and ambivalent or hostile
relationships with the fathers could lead to parenting that promotes cross-gender
behavior in sons. Sons may be anxious about maternal withdrawal and
abandonment. There may be a lack of parental discouragement of cross-sex
behaviors.
The concept of what is male or female in most societies is deeply ingrained in
culture and largely dichotomous. There are individual variations in maleness or
femaleness that challenge this dichotomy and as with many of our diagnostic
categories the suggestion of a spectrum. Over time society can accept these
individual variations. Extreme deviations from the norm are not by themselves
pathologic but can lead to psychopathology (functional impairment). Substantial
and unusual variation (outside the norm) in maleness or femaleness in behavior or
identity is generally designated as cross gender, gender variant, gender atypical,
gender non-conforming youth, or transgender. Gender nonconformity is not always
accompanied by discordant gender identity. In the societal context these variations
may lead to gender dysphoria.
A desire to become a girl may have been an effort to avoid the bullying from
male peers or greater identification with non-masculine traits. It may be a result of
a life-long avoidance of exploration because of an anxious temperament (association
of less risk-taking and strong attachment to the female gender). Also negative
feelings about self may lead to gender dysphoria as an effort to cope with these
feelings. If there was a history of abuse by a male perpetrator, the cross-gender
identification may be post-traumatic avoidance as opposed to identification with the
aggressor.
DEVELOPMENT OF GENDER IDENTITY
Gender constancy is established between the ages of two and seven years
when the child is able to discriminate different gender roles and identifies
accordingly. Children learn about boys or girls from authority figures and from
social cues and they apply this knowledge to themselves. As the child matures he or
she becomes increasingly motivated to observe, incorporate, and respect gender
roles. Although the idea of gender spectrum and gender fluidity has merit, it is
easier for most children to have some clear sense of gender consistent with being
either a boy or girl because our culture depends on gender to explain sexuality,
society, and self.
By two years of age parents begin to notice gender deviant behaviors such as
feminine interests in their boys. At this age children may have idiosyncratic ideas of
what it means to be a boy or girl. By the time they enter preschool they have highly
conventional, concrete, and rigid notions of boy versus girl behaviors. These gender
classifications may generate confusion in someone not interested in the activities
typical of other kids with the same anatomical sex. He or she does not realize that
there are different kinds of boys or girls who prefer things of the opposite gender
because they are uncommon. It is common for the expression of gender variant
behavior to decrease later in childhood around age 9 or 10 years although it may
emerge again during adolescence.
In essence the diagnosis of gender dysphoria may represent a medical
accommodation of a social prejudice, where the distress and dysfunction are the
result of that prejudice. Gender dysphoria theoretically would abate with more
acceptance of androgyny versus the current societal preference for a rigid gender
dichotomy.
The vast majority of pre-pubertal gender dysphoric children do not become
transgender in adolescence or adulthood. Although at least 80% of childhood GD
desists by adulthood, GD rarely desists after the onset of puberty. In fact, when GD
persists into adolescence, puberty is often associated with a worsening of dysphoria
and distress. Gender dysphoric girls referred in childhood are less likely to remit
than boys. Both gender nonconformity and gender dysphoria are believed by some
to be developmentally related to homosexuality.
Adolescents with gender dysphoria may vastly differ in their ability to handle
the complexities and adversities that often accompany gender variance. Some have
such intense distress that they expect clinicians to immediately provide them with
hormones and gender reassignment surgery as quickly as possible. Others are
simply trying to find ways to live with these feelings of confusion or some unease.
The gender dysphoria may have started long before puberty or be more recent. The
environment can be accepting and supporting or rejecting. These individuals may
present with a broad range of coexisting psychiatric problems. Gender variant
behavior and even the desire to be of another gender can be either a phase or a
variation of normal development without any adverse consequences for a child's
current functioning. Prospective studies show that gender variance in clinical
populations is associated with later homosexuality or bisexuality as well as gender
dysphoria in adulthood. Nonetheless even in clinical populations the vast majority
cases of gender dysphoria do not persist from childhood into adulthood. When
presenting during adolescence it seems much less likely that gender dysphoria will
desist. Gender dysphoria can lead to such high-risk behaviors during adolescence
as soliciting illicit hormones or silicone injections, drug and alcohol abuse, or
suicide.
Peer rejection can be a major issue for the child or adolescent with gender
nonconformity leading to poorer social relationships in general. In childhood this is
more of a problem for feminine boys than for masculine girls (tomboys). There
seems to be a contemporary need for society to acquiesce to the desires of children
with GD (or to normalize children with ambiguous genitalia). This may be
motivated by the apparent fundamental human need to appear normal, perhaps to
fill the social need of belonging to a group. Ironically, the desire to “fit in” survives
despite telling our children to “be themselves” when the need to be accepted into
the group is the issue and being like others is the goal. After adolescence this
belonging to the majority group seems less important.
There is no single clinical course for children with gender dysphoria although
most children do not persist in their gender dysphoria. There is some evidence to
suggest that those with more extreme measures of cross gender behavior and
gender dysphoria are more likely to persist. Perhaps two-thirds of children with GD
develop a homosexual orientation in adolescence.
Anxiety may be related to real or perceived rejection, hostility, and abuse
because of the teen’s transgender status or fear of being discovered. Transgendered
teens have committed suicide, perhaps 50% have serious suicidal thoughts, and one
third have actually made a suicide attempt. Gender non-conforming adolescents
seem to have better psychological health than transgender adults. It could be that
the stress associated with the desire to be of the other gender leads to socioemotional problems including depression and anxiety. Also there may be social
ostracism and rejection by same-sex peers. Concurrent conditions such as ADHD,
bipolar disorder, anxiety disorders, and autistic spectrum disorders may make a
child more vulnerable to social ostracism or gender confusion. This helps explain
some disturbing reactions such as emotional hypersensitivity, severe mood swings,
oppositional behavior, temper tantrums, attention problems, anxiety, and
depression.
TREATMENT OPTIONS
Children, adolescents, and adults manifesting such gender variation are referred
to mental health professionals for assessment and treatment. However, few
providers have much experience with these rare disorders. Other identified
barriers to caring for gender nonconforming and transgender youth include
variability in clinical approach by community providers, a general lack of comfort in
and knowledge of gender identity issues, and multiple clinician (and from various
disciplines) involvement with poor coordination and disagreement as to what
constitutes competent and comprehensive care. The latter relates to the lack of
solid evidence to inform practice.
Prior to treatment of gender dysphoria directly, there must be exclusion of
psychiatric conditions that are similar to or contribute to gender dysphoria. As the
most basic initial step a comprehensive psychiatric evaluation is necessary to
carefully assess and treat any underlying comorbidities that may be impacting
gender identity and dysphoria. The gender dysphoria may have been caused by cooccurring psychopathology, family and social rejection, psychological distress due to
the real discrepancy between psychological and anatomic gender, or by family
psychopathology. Although psychopathology may be the result rather than the
underlying problem of GD, sexual reassignment may also be sought as a solution to
non-gender problems. Even for experienced clinical teams, it is more complicated to
make an accurate diagnosis of gender dysphoria in adolescents who are not
functioning well. It is a challenge to disentangle the gender and autistic spectrum
disorders. There should be assessment of any comorbid psychiatric diagnoses as
well as environmental influences on a child's gender development including school,
peers, extended family members, siblings, popular culture, and patterns of the
individual's coping strategies and resilience capacities. An ongoing treatment
relationship will expand the opportunities to understand the dynamic interactions
between psychiatric comorbidities and various external influences on the
individual.
There are three general approaches to management and treatment of gender
dysphoria: 1) No active intervention 2) Attempt to lessen gender dysphoria by
helping the child accept his biological sex and the associated gender identity 3)
Encourage a transition to the cross-gender role. No systematic data are available on
the effectiveness of these different treatment approaches. As one would expect,
without strong evidence to guide clinical interventions, there are diverse and
controversial opinions.
The first approach offers no active intervention to lessen gender dysphoria
or cross gender behavior. This hands-off approach is based on the assumption that
80 to 90% of children even without treatment will have resolution of gender
dysphoria upon reaching adolescence. The downside to this strategy is that the 1020% who persist upon reaching adolescence are more firmly established in their
diagnosis and less responsive to interventions.
Especially early in development one should avoid definitive labels on a person’s
cross-gender identity because it is yet evolving. It would probably not best serve
the child to refer to him or her by an alternate gender name or pronoun. Many
transgender children do not express or experience distress or dysfunction with their
assigned gender, despite some having the desire to be the other sex. And the
overwhelming majority of gender nonconforming children desist from their cross
gender identifications and behaviors by adolescence. The outcome may relate to
severity of symptoms. However, if present after puberty gender dysphoria rarely
resolves.
Another approach attempts to lessen gender dysphoria by helping the
child accept his biological sex and the associated gender identity. It just makes
sense that the individual is best served by accepting one’s biology instead of
rejecting it. The child is assisted with expanding sex-role stereotypes and flexibility
in both directions. Dysphoria may be reduced by broadening the more narrow
societal definitions of gender to allow for the patient's specific variation in gender
role attitudes, preferences, and behaviors. This helps the person accept his
biological sex through expanding the sex-role stereotypes to accommodate his
preferences. The clinician should offer education and resources toward that end.
For example, it can be instructive to demonstrate changes in societal gender norms
over the course of human history in regard to care, clothing, and jewelry. Most
children express relief when they can have a way of defining and understanding
themselves as just a different kind of boy or girl. Educating parents and
communities about expanding gender role and accepting cross-gender behaviors
may complement this individual treatment goal.
The matter of gender identity is patiently explored in psychotherapy. Selfacceptance and expanding gender role behavior are encouraged. The therapist
attempts to increase the child's comfort by expressing behaviors and identifications
consistent with his or her natal sex. The clinician best not rush to collude
with young patients in the idea that unease and uncertainty are all related to an
unclear vision of the most correct gender. Identity diffusion is a normal part of
adolescent development. While it may be that a broader conception of gender would
be advantageous to some, and that any one individual may over the course of a life
come to see him or herself as more masculine or feminine, making a narrow
determination of an incorrect gender in adolescence is shortsighted.
The benefits of assuming a cross gender social role in the school setting is
controversial. It is not realistic to expect that everyone will accommodate cross sex
dress and behavior and it may be best to help the transgendered child fit better into
his environment. It is adaptive to figure out how to negotiate between expressing
one's real self and acclimating to the real world so we submerge aspects of
ourselves depending on the context. So it is helpful to create safe spaces for the child
to play, explore same-gender activities, and reinforce congruent gender role
behaviors. This is sometimes accomplished through activities in art, theater, music,
and creative play. Paying special attention (even negative attention) to either
gender role behaviors may serve to reinforce them. It is generally a good practice to
provide positive attention independent of any gender-specific behavior. Strategies
to reduce peer rejection and ostracism can improve the social isolation and
alienation that contribute to emotional distress.
Reducing dependence and enmeshment with the caregivers addresses the
typical imbalance between attachment and exploration. Families are discouraged
from overtly or inadvertent reinforcing cross-gender behaviors. Minimizing family
punishment, ridicule, and criticism helps reduce the risk for depression, suicide and
substance abuse. Families are encouraged to have more tolerance of gender
discordance while setting limits on expression of gender discordant behavior to the
extent that these limits are necessary to decrease risk for peer or community
harassment. Increased levels of harassment and victimization by peers are related
to increased levels of depression and anxiety and decreased levels of self-esteem.
The focus of these interventions is more on reducing the dysphoria than the gender
role behaviors. However, hastening the desistence (i.e. fading) of gender
discordance, is still an overarching treatment goal.
Adolescents may resist therapy because of perceptions that they are
psychosocially well-adjusted except for their gender issues. General
psychotherapeutic interventions that improve the individual’s adaptive ego strength
and resilience, expand the repertoire of coping skills, and enhances understanding
are potentially helpful. The frequency of treatment is guided by the severity of
associated psychopathology and the degree of functioning. Collaborative treatment
with other provider’s patients and families often view the mental health component
of treatment as a means to achieving the medical interventions. Once achieving the
primary goal, mental health follow-up is poor. Acute safety issues are dressed
through psychiatric hospitalization. Play (psychomotor) therapy may help youth
who do not easily verbalize feelings. Treatment roadmaps and narrative medicine
(writing and telling a story with drawings and pictures) may assist with the
impatient adolescent.
Ongoing support of the youth and parents through the therapeutic treatment
relationship is highly desirable. There are few experienced clinicians and little
prospective evidence to guide treatment. Most parents initially question the
diagnosis and whether the child is going through a phase or has been influenced by
peers or social media or is otherwise exploring sexuality. There is also the concern
that improvements in psychopathology following diagnosis and early treatment are
transient and will return when experiencing ongoing discrimination, rejection, or
disappointments. A more cautious clinical approach as opposed to strongly
advocating for the presence and maintenance of the disorder is appreciated by most
parents.
Family therapy may be necessary to help resolve conflicts between
family members. Parents may need guidance on how to relate to their child in a way
that does not contribute to more gender dysphoria. Healthy boundaries and limits
must still be provided by parents and will be tested by the gender variant
adolescent.
Parents often struggle with the conflict between validating the child's current
stated wishes versus succumbing to the stigma that environmental influences may
impose. Dealing with recommendations of other providers such as pediatricians,
school psychologists, teachers, therapists involved in the child's treatment may
reflect inadvertent or blatant opposing ideas and biases. With adolescents who are
gender nonconforming, standards for establishing patient eligibility and readiness
for treatment may be inconsistent across providers. Improving adaptation to the
multiple external and internal challenges is necessary psychosocial treatment.
Support groups may be helpful but online and other resources cannot be relied
upon to give the best advice for any specific individual. Additionally this area has
been highly politicized. A listserv through the CNMC helps families to know that they
are not alone.
The social challenges for both the child and the parents are the hardest because
our culture expects and is designed to support extremely binary gender roles.
Parents are encouraged to be straightforward and share the fact that my child is
nonconforming in gender role behavior and has been that way since an early age.
The message is conveyed in a way that communicates love and support for their
child. They should be discouraged from openly sharing the associated emotional
difficulties along the way. Instead of converting others it is best to be surrounded
by people who are not rejecting.
Families often deal with grief and loss around losing a son or daughter and
the normative hopes and dreams and expectation for their child's future. They
grieve the loss of anticipated stability as their child grows older and progresses
through normal development. They worry about reducing the reproductive
possibilities. They are concerned about their child's succeeding at school, work,
interpersonal relationships, and family formation. They worry about the physical
and emotional safety of their child. They may respond with reduced expectations of
the child's achievements and expectations around the household and fail to set
appropriate structure and limits that all adolescents need. They may withdraw and
fail to give the adolescent needed support. Most parents have encouraged their child
to limit cross dressing and other cross gender behaviors that may be focus of
negative attention in public and rather practice them in the privacy of their own
home. Some parents believe that group participation may prematurely validate and
actually promote a course of action that the child would not otherwise take.
However listening to the stories of others and talking about personal struggles
contribute to developing insight, adaptive strategies, and collective problem-solving.
For those with persistence of gender dysphoria into adulthood, a third
approach encourages a transition to the cross-gender role. Gender discordance
presenting in adolescents or adults is more likely to persist than when presenting in
childhood, so treatment approaches often assume persistence of gender
discordance. As adults, those with gender dysphoria try to live as if they belong to
the opposite sex. Many successfully hide their sex from coworkers and friends.
Sexual intimacy is restricted; a majority of transsexuals don’t marry, and when they
do, the marriages usually fail. Because they experience themselves as members of
the opposite sex, they prefer normal heterosexual partners of the same biological
sex, but they do not view themselves as “homosexual” because of their cross-gender
identity. At this point the goal of psychotherapy becomes the alleviation of
emotional problems arising from the transsexualism.
Sex reassignment (also referred to as normalizing or gender-conforming
procedures) is controversial and includes real-life experience as the other gender
with prescribed hormones, and surgery to change the genitals and other sex
characteristics. Gender atypical behavior by itself should not be taken as an
indicator for sex reassignment. A comprehensive psychological evaluation and an
opportunity to explore feelings about gender with a qualified clinician are required
over a period of time. It is important to remember that transient periods of
uncertainty about one's gender are common but should not be interpreted as a clear
indication for sex reassignment. Once the adult with cross-gender identity clearly
decides to switch sexes, some professionals support the patient in seeking hormonal
and surgical sex reassignment. Other clinicians have ethical qualms about
supporting the individual’s desire for surgical sex reassignment and remove
themselves from the case and refer the person to another clinician.
Much of the distress that transgender adolescents experience in puberty is
related to the emergence of secondary sex characteristics. Sex hormone suppression
through the use of gonadotropin-releasing hormone analogues can be used to
reversibly delay development of secondary sex characteristics to minimize the later
need for surgery and until maturity allows for informed consent. Most importantly
puberty suppression will inhibit the spontaneous formation of a gender identity
corresponding to natal sex. Another drawback would be insufficient penile and
scrotal tissue to construct labia and a vaginal vault in the future. Suppressing
puberty does not give the adolescent the choice of freezing sperm prior to fertility.
Of course delaying treatment until adulthood may have its own psychological
drawbacks including the development of depression, suicidality, anxiety, and
oppositional defiant disorders accompanied by school dropout and social
withdrawal. So the rationale for early treatment is that transgendered youth may be
spared the burden of having to live with irreversible signs of what they perceive to
be the wrong secondary sex characteristics and more surgical procedures. This is
often considered when GD intensifies instead of decreases during early puberty and
there are no serious psychosocial problems interfering with diagnosis or treatment.
Medical treatment to suppress puberty is expensive and not routinely covered by
insurance and provides logistical hurdles that may not be affordable by the family.
This may contribute to the adolescent’s perception that his or her parents are
unsupportive or rejecting. Protective laws may preclude such treatment in certain
states or countries and of course parents must be involved in treatment decisions
prior to the age of legal consent. Most gender dysphoric youths choose to live in the
desired gender roles simultaneously with the beginning of puberty suppression.
Hormone therapy is the next step in sex reassignment and is considered at
around the age of 16 years when there is sufficient maturity for independent
medical decision-making. It is an absolute requirement that the social gender role
change will occur simultaneously. It is desirable that gender dysphoric patients
undergo a prolonged period of living in the desired gender in most or all domains of
everyday life as appropriate for the patient's age before undergoing any poorly
reversible or irreversible medical treatment such as cross gender hormone
treatment or gender confirming genital surgery. Hormone therapy is easier and
safer when following suppressed puberty. The resulting physical changes and
impact on fertility are only partially reversible. Most adolescents who have received
hormonal therapy report persistent cross gender identity and improved
psychological functioning.
A majority of adults with cross-gender identity express the strong desire to
change their sexual anatomy permanently. In the United States, two to eight times
more men than women seek surgical sex reassignment. To qualify for a surgical sex
transformation, surgeons typically require that patients live as the opposite sex for
at least 2 years, during which time they should demonstrate minimally adequate
social and occupational functioning, be able to sustain enduring friendships, and be
free of major psychopathology. Some surgeons in private practice perform sex
reassignment surgery without any psychiatric evaluation but this would be unusual.
Some individuals with gender dysphoria seek surgery in foreign countries at a lower
cost, where psychiatric evaluations are rare. Surgical procedures are accompanied
by prescriptions for estrogen or testosterone to induce the secondary sex
characteristics of the other sex.
Education about the short-term and long-term costs and benefits of sex
reassignment will help the individual have a balanced view. Achieving congruence of
gender identity and anatomical sex through reassignment surgery is an expensive
and extreme intervention that potentially inflicts harm and dysfunction. Realistic
expectations of the neo-vagina, neo-phallus, and sexual functioning (e.g. loss of
orgasm and the ability to reproduce) are necessary. There is the real possibility of
aggressive reactions when engaged in sexual encounters where the partner is not
aware of the person’s natal sex. The surgical procedure and hormone therapy may
not achieve the acceptance or validation of gender identity that the person may be
seeking. Identity is not really about appearance so changing physical attributes
does not change the identity, the genetic material, or the essence of the individual.
This sex reassignment approach is inconsistent with the treatment of similar
psychopathology such as Body Dysmorphic Disorder or Body Integrity Identity
Disorder where noninvasive strategies are exclusively employed to reduce the
patient’s suffering (see below). Patients and their families perceive that they have
almost no choice if they are choosing between a guaranteed low quality of life and
the possibility of a more fulfilling life through sex reassignment. Based on the
existing evidence, the clinician is ethically bound to avoid giving, even inadvertently,
such an impression. Clinician neutrality regarding outcomes is often recommended
in order to allow the youth to openly explore gender dysphoric feelings and
treatment wishes. This recommendation sounds good on the surface but with the
current evidence may not be on solid ethical ground. With all these problems, it
seems that all other treatment options should be exhausted before a surgical
solution is entertained to relieve psychological distress.
With a few exceptions, those who have had sex reassignment surgery do not
express regrets, no longer report dysphoria, and claim to be functioning well
socially and psychologically. However, those patients selected for this treatment
were the best-functioning from the start and may have done equally well with
alternative treatment. There is little evidence to demonstrate actual improvement
in overall functioning. In fact, psychological, relational, and vocational adjustment of
individuals with gender dysphoria who obtain sex reassignment surgery are not
significantly different from those who do not. In terms of a cost–benefit analysis,
surgical sex reassignment is difficult to justify. However, for the gender satisfaction
they anticipate, many adults with gender dysphoria continue to work for years to
save up money to pay for this surgery since it is not typically covered by health
insurance.
ETHICAL ISSUES
Perhaps the major ethical dilemma for gender reassignment surgery is the
potential for doing harm where evidence is lacking. The more popular treatment
options may lead to permanent irreversible harm and are inconsistent with
approaches to similar clinical conditions. For example, the treatment of non-gender
related body dysmorphic disorder seeks to minimize surgical interventions and
promote self-acceptance. There are those who express concern that sex
reassignment is a form of sanctioned self-mutilation supported by the politics
surrounding sexual identity and orientation and by a dichotomous societal
preference regarding gender. They argue that a different approach would prevail
for other similar but non-politicized clinical situations. For example, Body Integrity
Identity Disorder (BIID) denotes a syndrome in which a person is preoccupied with
the desire to amputate a healthy limb. The desire to amputate seems related to a
disturbance in the person's perception that the limb is not a genuine part of himself.
Limb amputation can relieve temporarily the patient's feeling of distress without
necessarily adjusting the patient's own identity misperception. Persons with this
disorder seek surgical correction but the medical community is generally united in
pursuing noninvasive treatment strategies to reduce the patient’s suffering. The
patient retains the most function and is thus best served by incorporating the limb
as part of a fully integrated and unified whole identity. As with gender dysphoria the
persons receiving the surgery express no regrets afterward, but have clearly lost
some degree of functioning. They may also initially report less distress although the
ambulation difficulties will undoubtedly provide new challenges with social and
emotional consequences. Because of the reduction in functioning, this lack of regret
seems insufficient for physicians to support the process of relieving psychological
distress through surgery. Gender reassignment can be clearly distinguished from
surgeries that are cosmetic, restorative, or reconstructive.
References and Resources
Guevote – The Way I Feel is How I Am (1996) is a documentary film portraying the daily lives of a
significant percentage of girls born in a Caribbean village who change into men at puberty because of
a genetic variation that conveys androgen insensitivity.
The Gender and Sexuality Development Program at Children’s National Medical Center (CNMC) in
Washington, DC (www.childrensnational.org/gendervariance) provides psychosexual evaluations
and therapeutic services on an outpatient basis.
The World Professional Association for Transgender Health (WPATH) is an international and
multidisciplinary professional organization devoted to the understanding and treatment of gender
identity disorders by promoting evidence based care, education, research, advocacy, public policy
and respect in transgender health. www.wpath.org
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th
ed.) Washington, DC: American Psychiatric Association.
Barlow, D.H., Reynolds, E.J., & Agras, W.S. (1973). Gender identity change in a transsexual. Archives of
General Psychiatry, 28, 569–576.
Kilgus, M.D. (2014) Dysphoria about gender. In M.D. Kilgus and W.S. Rea (Eds.), Essential
Psychopathology Casebook (pp. 367-399), New York: Norton.
Rekers, G.A., Kilgus, M.D., & Rosen, A.C. (1990). Long-term effects of treatment for childhood gender
disturbance. Journal of Psychology and Human Sexuality, 3(2), 121–153.
Rekers, G.A. (1995). Handbook of child and adolescent sexual problems (pp. 255–271). New York:
Lexington Books.
World Health Organization. (2007). International statistical classification of diseases and related
health problems (10th ed.). Available at
http://www.who.int/classifications/apps/icd/icd10online/.