gender dysphoria now, in DSM V

1. GENDER IDENTITY DISORDERS
Dr. Srishti Detha
JR 1 PSYCHIATRY

2. INTRODUCTION
• Gender identity, a term first coined by Robert Stoller in the mid-20th century,
came to signify one’s persistent inner sense of belonging to either the male or
female gender category.
• Gender role coined by John Money is thought of as the outward expression of
the inner sense of gender identity.
• However, the terms experienced gender and expressed gender, respectively, are
increasingly replacing gender identity and gender role
• Gender Dysphoria is the discomfort with one’s assigned gender.

3. PREVALENCE
• The prevalence of gender variant identities, is unknown for a variety of reasons
including –
- concealment of these identities due to stigma
- methodological problems in defining the populations of interest and designing
adequate sampling strategies.
• Most such prevalence studies have been conducted in European countries and
figures range from 0.002 to 0.008 percent for natal males and from less than
0.001 to 0.003 percent for natal females.
• Studies that employ more inclusive sampling methods not restricted to
specialty clinics tend to yield higher prevalence figures.

4. 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.
• maleness and masculinity depend on fetal and perinatal androgens.
PSYCHOSOCIAL FACTORS –
• The formation of gender identity is influenced by the interaction of
children's temperament and parents' qualities and attitudes.
• Sex-role stereotypes are the beliefs, characteristics and behaviors of
individual cultures that are deemed normal and appropriate for boys and
girls to possess.

5. GENDER DIAGNOSIS IN ICD AND DSMICD -10 Gender identity disorders • Transsexualism
• Dual-role transvestism
• Gender identity disorder of
childhood
• Other gender identity
disorders
• Gender identity disorder,
unspecified
DSM -4 Sexual and gender identity
disorders
• Gender identity disorder in
adolescents or adults
• Gender identity disorder in
children.
DSM -5 Gender dysphoria • Gender dysphoria in
adolescents and adults
• Gender dysphoria in children
• Other specified gender
dysphoria
• Unspecified gender dysphoria
ICD -11 (anticipated) Conditions related to sexual
health
• Gender incongruence of
adolescents and adults
• Gender incongruence of
children

6. DIAGNOSIS IN DSM 5
1. Gender Dysphoria in Children - CRITERIA- A – 8, of which at least six.
• Persistent and strong desire to be of the other sex or insistence that they belong to
the other sex
• Strong preference for cross-dressing.
• Fantasizing about playing opposite gender roles in make-belief play.
• Preference for toys, games, or activities typical of the opposite sex.
• Preference for playmates of the other sex
• Rejection of toys, games and activities conforming to one’s own sex. In boys
avoidance
of rough-and-tumble play and in girls rejection of typically feminine toys and
activities.
• Dislike for sexual anatomy.
• Desire to acquire the primary and/or secondary sexual characteristics of the opposite

7. Criteria – B
The gender dysphoria leads to clinically significant distress and/or social,
occupational and other functioning impairment. There may be an increased risk of
suffering distress or disability.
The subtypes may be,
ones with or without defects or defects in sexual development.

8. 2. GENDER DYSPHORIA IN ADULTS AND ADOLESCENTS - A definite mismatch
between the assigned gender and expressed gender characterized by at least two or
more –
• Mismatch between experienced or expressed gender and gender manifested by
primary and/or secondary sex characteristics at puberty
• Persistent desire to rid oneself of the primary or secondary sexual characteristics of
the biological sex at puberty.
• Strong desire to possess the primary and/or secondary sex characteristics of the
other gender
• Desire to belong to the other gender
• Desire to be treated as the other gender
• Strong feeling or conviction that he or she is reacting or feeling in accordance with
the identified gender.

9. • The gender dysphoria leads to clinically significant distress and/or social,
occupational and other functioning impairment. There may be an increased risk of
suffering distress or disability.
• The subtypes may be,
ones with or without defects in sexual development.

10. DIAGNOSIS IN ICD-10
F -64 GENDER IDENTITY DISORDERS (GID) –
F64.0 Transsexualism –
A. Desire to live and be accepted as a member of the opposite sex, usually
accompanied by the wish to make one's body as congruent as possible with one's
preferred gender through surgery and hormonal treatment.
B. Presence of the transsexual identity for at least two years persistently.
C. Not a symptom of another mental disorder, such as schizophrenia, or associated
with chromosome abnormality.

11. F64.1 Dual-role transvestism –
A. Wearing clothes of the opposite sex in order to experience temporarily
membership of the opposite sex.
B. Absence of any sexual motivation for the cross-dressing.(f 65)
C. Absence of any desire to change permanently into the opposite sex.

12. F64.2 Gender identity disorder of childhood –
For females:
A. Persistent and intense distress about being a girl, and a stated desire to be a boy
(not merely a desire for any perceived cultural advantages from being a boy), or
insistence that she is a boy.
B. Either (1) or (2):
(1)Persistent marked aversion to normative feminine clothing and insistence on
wearing stereotypical masculine clothing.
(2) Persistent repudiation of female anatomic structures.
C. The girl has not yet reached puberty.
D. The disorder must have been present for at least six months

13. For males:
A. Persistent and intense distress about being a boy and an intense desire to be a girl
or, more rarely, insistence that he is a girl.
B. Either (1) or (2):
(1) Preoccupation with female stereotypical activities, as shown by a preference for
either cross-dressing or simulating female attire, or by an intense desire to participate
in the games and pastimes of girls and rejection of male stereotypic toys, games and
activities.
(2) Persistent repudiation of male anatomic structures.
C. The boy has not yet reached puberty.
D. The disorder must have been present for at least six months.

14. DIFFERENTIAL DIAGNOSIS
IN CHILDREN –
Gender-atypical children –
- For girls, tomboys without GID prefer functional and gender neutral clothing. By
contrast, girls with GID adamantly refuse to wear girls' clothes and reject gender-
neutral clothes.
- For boys, the differential diagnosis must distinguish those who do not conform to
traditional masculine expectations, but do not show extensive cross-gender
identification and are not discontent with being male.
Hermaphroditism - Because the diagnosis of gender GID excludes children with
anatomical intersex, a medical history needs to be taken with the focus on any
suggestion of hermaphroditism in the child.
When in doubt, referral to a pediatric endocrinologist is indicated.

15. In adolescents and adults –
Body Dysmorphic Disorder
Transvestic Disorder
Psychotic Disorder

16. TREATMENT
IN CHILDREN –
At present, no convincing evidence indicates that psychiatric or psychological intervention
for children with GD affects the direction of subsequent sexual orientation.
The treatment of GD in children is directed largely at developing social skills and comfort in
the sex role expected by birth anatomy. To the extent that treatment is successful, transsexual
development may be interrupted.
No hormonal or psychopharmacological treatments for GD in childhood have been
identified.
IN ADOLESCENTS –
Adolescents whose GD has persisted beyond puberty present unique treatment problems.
Treatment 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.
Parents must also be informed. The goal of family intervention is to keep the family stable
and to provide a supportive environment for the teenager.

17. IN ADULTS -
Adult patients coming to a gender identity clinic usually present with straight
forward requests for hormonal and surgical sex reassignment.
No drug treatment has been shown to be effective in reducing cross-gender
When patient GD is severe and intractable, sex reassignment may be the best
solution.
Sex reassignment surgery
- For a person born anatomically male consists principally of removal of the male
genitalia and construction of labia, and vaginoplasty.
- Postoperative complications include urethral strictures, rectovaginal fistulas, vaginal
stenosis, and inadequate width or depth.
- Female-to-male patients typically may undergo bilateral mastectomy and construct
neophallus. Because of increased technical skills in phalloplasty, more female-to-male
patients are now electing these procedures.

18. HORMONAL THERAPY -
• Persons born male are typically treated with daily doses of oral estrogen-
conjugated equine estrogens or ethinylestradiol which leads to - breast enlargement
,testicular atrophy, decreased libido.
-Facial hair removal is required by laser treatment or electrolysis.
• Biological women are treated with monthly or three weekly injections of
testosterone.
-The pitch of the voice drops permanently into the male range as the vocal cords
thicken.
-The clitoris enlarges to two or three times.
-Increased libido.
-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.

19. GENDER IDENTITY DISORDER NOS
This category is included for coding disorders in gender identity that are not
classifiable as a
specific GID. Examples include -
1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital
adrenal
hyperplasia) and accompanying gender dysphoria.
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration without a desire to acquire the sex
characteristics of the other sex

20. Intersexuality:
Person’s biological sex cannot be classified as clearly male or female. It refers to
intermediate or atypical combinations of physical features that usually distinguish
female from male and is usually congenital involving chromosomal, morphologic
genital anomalies.
Management:
1. Treatments: Restore functionality (or potential functionality) – generally
before age 3.
2. Enhancements: Give the ability to identify with “mainstream” – breast enlargement
surgery
• It is easier to assign a child to be female than to assign one to be male, because
male-to-female genital surgical procedures are far more advanced than female-
male procedures.
• The exact procedure of the surgery depends on the cause.
• The goal of treatment is to have genitals concordant with chromosomal, biological,

21. CROSS DRESSERS –
• The DSM-IV-TR lists crossdressing- dressing in clothes of the opposite sex- as a
gender identity disorder if it is transient and related to stress.
• A cross-dresser is a person who has an apparent gender identification with one sex,
and who has and certainly has been birth-designated as belonging to one sex, but
who wears the clothing of the opposite sex. Cross-dressers may not identify with
opposite gender & do not adopt behaviors of the opposite gender, and generally
not want to change their bodies medically.
• Can coexist with paraphilias, such as sexual sadism, sexual masochism, and
• Most common among female impersonators.
MANAGEMENT - A combined approach, using psychotherapy and pharmacotherapy,
often useful.
• Antianxiety and antidepressant agents, medications that reinforce impulse control
may be
helpful, such as fluoxetine.

22. PREOCCUPATION WITH CASTRATION –
• They are clearly uncomfortable with their assigned sex and their lives are driven by
the fantasy of what it would be like to be a different gender.
• They may be asexual and lack sexual interest in either men or women.