Gender dysphoria

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Gender dysphoria refers to negative feelings arising from some aspect of gender experience, possibly including but not limited to:

  • An assigned gender different from one's gender identity
  • Body dysphoria, where one’s sexual characteristics seem wrong
  • Other’s perceptions of one’s gender
  • Social treatment related to perceived or assigned gender

The term gender dysphoria can be used diagnostically, referring to persistent and clinically significant discomfort with an assigned gender, or to refer to individual instances of gender dysphoria, as in, “Calling someone by the wrong pronouns can evoke gender dysphoria.”

Healthcare professionals typically reference either the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD) in order to confirm a diagnosis of gender dysphoria.

Terminology

Alternate or similar terms include “gender identity disorder,” which was opposed by activists for characterizing the experience as a mental disorder, “gender incongruence,” and “transgenderism” [1].

Gender Dysphoria vs. Gender Identity Disorder

The diagnosis of 'Transsexualism' was introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) compiled by the American Psychiatric Association (APA) in 1980 for individuals who had experienced a minimum of two years discontent with the sex they were assigned at birth and the social role associated with that sex. The criteria of the diagnosis focused on individuals whose identities resembled a male-to-female (MTF) or female-to-male (FTM) paradigm. Others experiencing gender dysphoria but whose identities did not fit the MTF/FTM paradigms could be diagnosed with 'Adulthood Nontranssexual Type', or 'Gender Identity Disorder: Not Otherwise Specified' (GIDNOS).

In 1994 the DSM-IV committee replaced the 'Transsexualism' diagnosis; for individuals with MTF/FTM type identities a diagnosis of 'Gender Identity Disorder' (GID) would be applied instead. The diagnostic criteria of GIDNOS was left undefined, bar that the diagnosis be given to those whose 'gender identity disorder' could not be defined within a MTF or FTM paradigm. The 'Transsexualism' diagnosis also appears in the International Classification of Diseases (ICD-10; F64.0) produced by the World Health Organization (WHO) echoing the DSM-III definition, with a separate diagnosis mirroring the DSM's GIDNOS diagnosis: F64.9 Gender Identity Disorder, Unspecified. Though a gender dysphoric nonbinary individual might use the term 'transsexual' to describe themselves, they would not be considered 'transsexual' within a clinical context.

In early 2013 the American Psychiatric Association published a 'Gender Dysphoria Fact Sheet' on their website which states, "In the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria. This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder and is intended to better characterize the experiences of affected children, adolescents, and adults... DSM not only determines how mental disorders are defined and diagnosed, it also impacts how people see themselves and how we see each other. While diagnostic terms facilitate clinical care and access to insurance coverage that supports mental health, these terms can also have a stigmatizing effect... DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name “gender identity disorder” with “gender dysphoria,” as well as makes other important clarifications in the criteria. It is important to note that gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition... Part of removing stigma is about choosing the right words. Replacing “disorder” with “dysphoria” in the diagnostic label is not only more appropriate and consistent with familiar clinical sexology terminology, it also removes the connotation that the patient is “disordered”". The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published in May 2013 [2].

Kelley Winters, Ph.D., is a writer on issues of trans* medical policy, founder of GID Reform Advocates and an Advisory Board Member for the Matthew Shepard Foundation and TransYouth Family Advocates. She has presented papers on the psychiatric classification of gender diversity at the annual conventions of the American Psychiatric Association, the American Counselling Association and the Association of Women in Psychology. In the GID Reform Weblog she maintains, she writes:-

"The new revisions for the Gender Dysphoria diagnosis in the DSM-5 are mostly positive. However they do not go nearly far enough. The change in title from Gender Identity Disorder (intended by its authors to mean “disordered” gender identity) to Gender Dysphoria (from a Greek root for distress) is a significant step forward. It represents a historic shift from gender identities that differ from birth assignment to distress with gender assignment and associated sex characteristics as the focus of the problem to be treated... In another positive change, the Gender Dysphoria category has been moved from the Sexual Disorders chapter of the DSM to a new chapter of its own. Non-binary queer-spectrum identities and expression are now acknowledged in the diagnostic criteria... However, the fundamental problem remains that the need for medical transition treatment is still classed as a mental disorder. In the diagnostic criteria, desire for transition care is itself cast as symptomatic of mental illness, unfortunately reinforcing gender-reparative psychotherapies which suppress expression of this “desire” into the closet. The diagnostic criteria still contradict transition and still describe transition itself as symptomatic of mental illness. The criteria for children retain much of the archaic sexist language of the DSM-IV-TR that psychopathologizes gender nonconformity. Moreover, children who have happily socially transitioned are maligned by misgendering language in the new diagnosis. More troubling is false-positive diagnosis for those who have happily completed transition. Thus, the GD diagnosis, and its controversial post-transition specifier, continue to contradict the proven efficacy of medical transition treatments. This contradiction may be used to support gender conversion/reparative psychotherapies – practices described as no longer ethical in the current WPATH Standards of Care"[3].

Binary vs. Inclusive Definitions

The term gender dysphoria is typically used in relation to a diagnosis of affected individuals specifically having a male or female identity. For example, the 'Gender Dysphoria Fact Sheet' uses the phrase “the other gender” as if there is only one other gender. However, the symptoms of gender dysphoria are typically applicable to nonbinary as well as binary-identified individuals.

In Childhood and Adolescence

“The symptoms of gender dysphoria usually begin to appear at a very young age. For example, a child may refuse to wear typical boys' or girls' clothes, or dislike taking part in typical boys' or girls' games and activities. In most cases, this type of behaviour is just a normal part of growing up, but in cases of gender dysphoria, it persists into later childhood and through to adulthood.” [4].

The ways in which gender dysphoria affects teenagers and adults differs to the way that it affects children, this is primarily due to the pubertal development of the body and the influence of sexual desire on social relationships. These feelings can often be very difficult to deal with and, as a result, a high percentage of gender dysphoric individuals experience depression, and may feel isolated from their peers; there are high rates of self-abusive behaviours and suicide within the gender dysphoric demographic. Finding a way to interpret and communicate these feelings as a nonbinary individual, at any age, can be profoundly distressing due to the lack of nonbinary reference points within the dominant culture, even more-so when ones nonbinary identity is dismissed by others on that same basis.

Prevalence

“Gender dysphoria is rare, but the number of people being diagnosed with it is increasing due to growing public awareness about the condition. However, although awareness has increased over recent years, many people with gender dysphoria still face prejudice and misunderstanding about their condition. In the UK, it is estimated that 1 in 4,000 people is receiving medical help for gender dysphoria. However, there may be many more people with the condition who have yet to seek help. On average, men are diagnosed with gender dysphoria five times more often than women” 1.

Research

“The exact cause of gender dysphoria is unknown. It is currently classed as a psychiatric condition (relating to the mind), but many recent studies have suggested that it is more to do with biological development (relating to the body). Research into what causes gender dysphoria is ongoing” 1.

Treatment

Main article: Transition

Before the 1960s few countries offered safe, legal medical options for people experiencing gender dysphoria and many criminalized gender-nonconforming behaviours or mandated unproven psychiatric treatments. In response to this problem, the Harry Benjamin International Gender Dysphoria Association now known as the World Professional Association for Transgender Healthcare (WPATH) authored one of the earliest sets of clinical guidelines for the express purpose of ensuring "lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfilment". The WPATH 'Standards of Care' are the most widespread clinical guidelines used by professionals working with transsexual, transgender, or gender variant people, and have undergone several revisions since its initial publication. Traditionally these guidelines have been structured in relation to the Transsexualism diagnosis and as such have presented a dilemma for non-transsexual individuals who have been unable to meet the eligibility criteria for medical treatment.

In 'Archives of Sexual Behaviour (Volume 16), "Heterosexual and homosexual gender dysphoria"' (1987), Dr Ray Blanchard (who served on the DSM-IV Subcommittee on Gender Identity Disorders) wrote, "(there is a) well-recognized tendency of applicants for sex reassignment surgery to distort their histories in the direction of 'classic' transsexualism in an effort to gain approval for such surgery".

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