Gender dysphoria

Gender Dysphoria, formally known as Gender identity disorder (GID), is the formal diagnosis used by psychologists and physicians to describe persons who experience significant dysphoria (discontent) with the biological sex they were born with. In general the diagnosis is seen as a means to access professional medical treatment, especially surgery.

Gender Dysphoria in Children is usually reported as "having always been there", and is considered clinically distinct from dysphoria which appears in adolescence or adulthood, which has been reported by some as intensifying over time. Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them. In many cases, discomfort is also reported as stemming from the feeling that one's body is "wrong" or meant to be different.

Diagnostic criteria

In the current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) gender dysphoria is in a distinct category in response to criticism of the 4th edition and from no longer using the "five axis" diagnosis system. The change of the name of the diagnosis of "Gender Identity Disorder" to the less pathologizing "Gender Dysphoria" partly in response to concerns regarding the status of issues of gender identity within medical professionals. This change has not yet resulted in increased access to care or insurance coverage for transition related healthcare. Countries and providers who use ICD or DSM-IV coding will continue to use the term "Gender Identity Disorder" and resulting diagnosis/treatment guidelines.

Some trans* people and researchers have criticized gender dysphoria/GID in the DSM for several reasons, including evidence from studies about the brains of transsexual people. The treatment for this condition consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.

DSM-V

In the United States, the American Psychiatric Association permits a diagnosis of gender dysphoria if the diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 5^thEdition are met. The coding used is 302.85 (F64.1) while the criteria are:

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).
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 second­ary 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 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).

B) The condition is associated with clinically significant distress or impairment in social, occupational or other important areas of functioning.

Specify if:
With a disorder of sex development (e.g., a congenital adrenogenital disorder such as 255.2 [E25.0] congenital adrenal hyperplasia or 259.50 [E34.50] androgen insensi­tivity syndrome).
Coding note: Code the disorder of sex development as well as gender dysphoria.

Specify if:
Posttransttion: The individual has transitioned 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, regu­lar 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).

DSM-IV-TR

The 4^thEdition, Text-Revised edition is still used by many practitioners and referenced in absence of an up to date copy of the Diagnostic and Statistical Manual. The diagnosis criteria (were):

1. There must be evidence of a strong and persistent cross-gender identification.
2. This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex.
3. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex.
4. The individual must not have a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia).
5. There must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning.

If the criteria are met, one of the following ICD-9 diagnosis codes are used.

• 302.5 Transsexualism
  • 302.50 … with unspecified sexual history
  • 302.51 … with asexual history
  • 302.52 … with homosexual history
  • 302.53 … with heterosexual history
• 302.6 Gender identity disorder in children
• 302.85 Gender identity disorder in adolescents or adults

Diagnostic code 302.6 is used for Gender identity disorder in children as well as for Gender Identity Disorder, Not Otherwise Specified (GID-NOS). GID-NOS is similar to other "NOS" diagnoses, and can be given for, for example:

1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex, which is known as skoptic syndrome

For some people, GID in the DSM is directly associated with transsexualism; whereas GID-NOS may be more applied towards transgender people in general, especially towards those with a non-binary gender identity. Some trans* people do not feel like the diagnosis criteria describes their condition accurately in any sense while many trans* people feel content with the description provided by the DSM. Occasionally a trans* person will have been diagnosed with "GID-NOS" in presence of other diagnosed non-paraphilia issues of sexuality.
So-called transvestic fetishism has its own code, as a paraphilia rather than a gender identity disorder.

ICD-10

The current edition of the International Statistical Classification of Diseases and Related Health Problems has five different diagnoses for gender identity disorder: transsexualism, Dual-role Transvestism, Gender Identity Disorder of Childhood, Other Gender Identity Disorders, and Gender Identity Disorder, Unspecified. Unlike the DSM, the ICD, retains the diagnosis as primarily psychiatric in nature.

Transsexualism (F64.0) has the following criteria:

• A desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of, one's anatomic sex, and a wish to have surgery and hormone treatment to make one's body as congruent as possible with one's preferred sex.
• The transsexual identity has been present persistently for at least two years.
• The disorder is not a symptom of another mental disorder or a chromosomal abnormality.

Dual-role transvestism (F64.1) has the following criteria:

• The wearing of clothes of the opposite sex for part of the individual's existence in order to enjoy the temporary experience of membership of the opposite sex, but without any desire for a more permanent sex change or associated surgical reassignment, and without sexual excitement accompanying the cross-dressing.

"Gender identity disorder of adolescence or adulthood, nontranssexual type" falls under this diagnosis.

Gender Identity Disorder of Childhood (F64.2) has essentially four criteria, which may be summarized as:

• The individual is persistently and intensely distressed about being a girl/boy, and desires (or claims) to be of the opposite gender.
• The individual is preoccupied with the clothing, roles or anatomy of the opposite sex/gender, or rejects the clothing, roles, or anatomy of his/her birth sex/gender; mere tomboyishness in girls or girlish behaviour in boys is not sufficient.
• The individual has not yet reached puberty. Gender identity disorders in individuals who have reached or are entering puberty should not be classified here but in F66.- (Psychological and behavioural disorders associated with sexual development and orientation).
• The disorder must have been present for at least 6 months.

The remaining two classifications have no specific criteria and may be used as "catch-all" classifications in a similar way to GID-NOS.

• F64.8 Other gender identity disorders
• F64.9 Gender identity disorder, unspecified

Since many people (including doctors, judges etc.) assume that the classifications "transsexual" and "transvestite" can apply only to adults, the F64 section of the ICD-10 is often criticized. One misinterpretation lies in the phrase "usually accompanied by the wish to make his or her body as congruent as possible," by assuming the trans* person seeks (or will require) genital surgery. Some mental health professionals will even refuse a gender identity diagnosis if surgery is not part of the client's transition plan.

Because of the number of trans* people who do not fit neatly into the above categories, there are increasing calls for so-called informed consent treatment models. Those trans* people may be known as "non-op"'s, or have a non-binary gener identity. Unfortunately, the "requirement" for surgery in many places can lead to significant problems with procuring medical treatment and legal change of name and/or gender. In some cases, it may make changes impossible in absence of surgery.

Treatment

Main article: Hormone replacement therapy (male-to-female)

Main article: Hormone replacement therapy (female-to-male)

Access to care

Some medical and psychological professional have tried to dissuade individuals from their transgender behavior/feelings at least since the mid-19th century. While in 1973 the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), and many believed sexual identities were finally freed of medical stigma, today many LGBT and "gender non-conforming" youth and adults remain vulnerable to diagnosis of psycho-sexual disorder under the "Gender Identity Disorder" diagnosis which replaced homosexuality in the DSM version III in 1980.

Formal gender clinics for individuals seeking medical sex reassignment began operating in the 1960s and 1970s, leading to long-term follow-up studies that began appearing in the research literature in the 1980s and 1990s. These studies have examined transsexuals who received clinical approval to undergo reassignment and proceeded to do so. The great majority of patients who met clinics' screening criteria reported being satisfied in the long-term with the results.

Today, most medical professionals who provide transgender transition services to adults now reject conversion therapies as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else. “Transgender transition services”, the various medical treatments and procedures that alter an individual's primary and/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.

The World Professional Association for Transgender Health (WPATH) Standards of Care (Version 7 from 2011) are considered by some as definitive treatment guidelines for providers. Other Standards exist, including the guidelines outlines in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care". Several health clinics in the United States (e.g. Tom Waddell Health Center in San Francisco, Callen-Lorde Community Health Center in New York City, Mazzoni Center in Philadelphia) have developed “protocols” for transgender hormone therapy following a “harm reduction” model which is coming to be embraced by increasing numbers of providers. In their 2005 book Medical Therapy and Hormone Maintenance for Transgender Men, Dr. Nick Gorton et al. suggest a flexible approach based in harm reduction, “Willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.”

Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual's own expression of their identity, regardless of their birth gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.

Medical treatment

Medical body interventions and procedures are often necessary to enable living socially in a gender role that more closely matches one's gender identity, and many assume that being accurately perceived by others is a primary goal of body transformations. However, for those transgender individuals who experience the deep internal distress of body dysphoria, the effects wrought by physical changes â€” hormones, surgeries, or other procedures â€” go much deeper than surface appearances and are far from cosmetic. The primary effects of hormonal and/or surgical interventions are experienced directly by self, internally, increasing a sense of internal harmony and well-being at the deepest psychological and emotional levels, as well as through the physical senses especially proprioception - the body's own knowledge of itself. Many medical professionals have come to consider "post-transition" transsexuals (see “transgender transition”) to be fully cured of their dysphoria or any other disorder.

Therefore, many feel the diagnosis of gender identity disorder is at best only temporarily applicable, if ever. Indeed, through transition many transsexuals are able to bring their body and their lived/expressed gender into alignment with the internal sense of self. Thus, many post-transition transsexuals cease to regard themselves as "trans" in any sense: many trans women (male-to-female) self-describe as "women" and, similarly, many trans men feel themselves to be unequivocally "men." While some of these individuals may require continued hormone replacement therapy (estrogen or testosterone, respectively) throughout their adult life, such HRT is not substantially different from the HRT often prescribed for cisgender females or males (not only are dosage levels similar, so are the effects of lack of treatment). Thus, many medical providers in the United States now routinely prescribe such HRT under the same medical codes used for other women and men.

In prepubescent children

Main article: Gender identity disorder in children

The question of whether to counsel young children to be happy with their biological sex, or to encourage them to continue to exhibit behaviors that do not conform to gender stereotypes â€” or to explore a transsexual transition â€” is controversial. Some clinicians report a significant proportion of young children with gender identity disorder no longer have such symptoms later in life.

There is an active and growing movement since the late 1990s among professionals who treat gender dysphoria in children to refer and prescribe hormones to delay the onset of puberty until a child is old enough to make an informed decision, or has the legal ability to decide on whether (cross-sex) hormonal treatments leading to surgical gender reassignment will be in that person's best interest. This does not preclude the option of ending the hormone blocking treatments and continue in their assigned sex at birth if ongoing mental health assessments conclude that it would benefit the health and well-being of the patient.

Controversy

Classification

Many transgender people do not regard their own cross-gender feelings and behaviors as a disorder. People within the transgender community often question what a "normal" gender identity or "normal" gender role is supposed to be. One argument is that gender characteristics are socially constructed and therefore naturally unrelated to biological sex. This perspective often notes that other cultures, particularly historical ones, valued gender roles that would presently suggest homosexuality or transsexuality as normal behavior. Some people see "transgendering" as a means for deconstructing gender. However, not all transgender people wish to deconstruct gender or feel that they are doing so.

Other transgender people object to the classification of Gender Identity Disorder as a mental disorder on the grounds that there may be a physical cause, as suggested by recent studies about the brains of transsexual people. Many of them also point out that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.

Although evidence suggests that transgender behavior has a neurological basis, critics of Gender Identity Disorder denomination say there is no scientific consensus on whether the cause of transgenderism is mental or physical.

Psychiatric diagnoses will continue to carry authority, and remain useful for medical billing purposes and potentially for the classification of research results, unless those diagnoses are changed. However, little research into transgenderism or transsexualism is actually being conducted. The mental illness diagnoses are also enshrined in the WPATH-SOCs; they persist because no other medical diagnoses are available.

Unfortunately, some youth have been diagnosed with Gender Identity Disorder on the basis of their sexual orientation (because they are viewed as "gender non-conforming" due to their sexual attractions and/or dress/manner) and treated against their will in religious residential treatment centers. One of the more well known cases was that of Lyn Duff, a 15-year-old girl from Los Angeles who was forcibly transported to Rivendell Psychiatric Center in West Jordan, Utah, and subjected to aversion therapy in an attempt to change her sexual orientation.

DSM inclusion

Some people feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the Gender Identity Disorder diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of the opposite sex/gender). People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. As Kelley Winters (pen-name Katharine Wilson), an advocate for GID reform put it, "Behaviors that would be ordinary or even exemplary for gender-conforming boys and girls are presented as symptomatic of mental disorder for gender nonconforming children." However, Zucker and Spitzer argue that Gender Identity Disorder was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion".

The GID controversy figured prominently at the 2009 meeting of the American Psychiatric Association in San Francisco, both in presentations in the meeting and in protests outside the meeting; protesters focused on the attitude of the psychiatric community and tried to make the point that Gender Identity Disorder is not a mental disorder, as well focusing on the role of Kenneth Zucker in leading the DSM-V Task Force on Sexual and Gender Identity Disorders.

Governmental policy

In a landmark publication in December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states "What transsexualism is not...It is not a mental illness." In May 2009 the government of France has also declared that a transsexual gender identity is not a psychiatric condition in France.

The Principle 3 of The Yogyakarta Principles on the application of international human rights law in relation to sexual orientation and gender identity states that "Person of diverse sexual orientation and gender identities shall enjoy legal capacity in all aspects of life. Each person's self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom" and the Principle 18 of this states that "Notwithstanding any classifications to the contrary, a person's sexual orientation and gender identity are not, in and of themselves, medical condition and are not to be treated, cured or suppressed." According to these Principles, any gender identity of a transsexual or transgendered person is neither "disorder" nor mental illness, thus the diagnosis "gender identity disorder" can be contradictory and irreverent.

The official politics in many countries interpret transgenderism as an undesirable behavior that must be prohibited, or as a psychiatric disorder, which should be cured. (See Heteronormativity)

See also

• Gender identity disorder in children

External links

• Standards of Care for Gender Identity Disorders - published by the Harry Benjamin International Gender Dysphoria Association, includes a description of ICD-10 criteria.
• Health Law Standards of Care for Transsexualism An alternative to the Benjamin Standards of Care proposed by the International Conference on Transgender Law and Employment Policy.
• THE LORD CHANCELLOR'S DEPARTMENT Government Policy concerning Transsexual People
• Gender Identity Disorder & Transsexualism - Synopsis of Etiology in Adults provides an alternative to the current classifications of psychiatric disorder and mental illness.
• Conway, Lynn: "Successful Transwomen" and "Successful Transmen" - Lynn Conway's "Success Pages".

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