Gender Dysphoria

13 GENDER DYSPHORIA

KEY CONCEPTS AND TERMINOLOGY

Sex refers to anatomical and genetic characteristics associated with being male or female. For most babies, a natal sex is assigned at birth based on appearance of the genitalia. Gender identity refers to the child or adolescent’s own sense of self as a boy or a girl, which is typically established by age 3 years and consolidated by age 5 or 6 years. Social norms regarding gender expression or gender role behavior are substantially determined by the prevailing culture. Characteristics include mannerisms, gait, clothing, toys, play activities, and preferred playmates. Gender nonconformity (or gender variance) (i.e., gender role behavior that does not conform to culturally defined norms) and gender discordance (i.e., incongruence between anatomical sex and gender identity) may or may not go together in a particular individual. In general, girls are societally permitted more latitude in role behavior than boys are. In nonclinical populations of boys, cross-gender behavior is rare after age 6 years. Gender dysphoria refers to the distress experienced by some (but not all) persons with gender discordance. Transsexual describes individuals who identify as the “opposite” gender and who may seek social, medical, and/or surgical gender reassignment. As there has been increasing awareness of nonbinary and fluid identification and expression, transgender has become the preferred term for people with a gender identity that is discordant with their anatomical sex.

CLINICAL DESCRIPTION

Gender dysphoria was one of the most controversial sections in the development of DSM-5 (American Psychiatric Association 2013), as there have been rapid but divergent changes in societal attitudes toward conventional gender binary concepts, emotions, and behavior. Youth with gay, lesbian, or bisexual sexual orientation or gender nonconformity have a variety of developmental and social issues (see “Additional Reading”), but the only remaining related psychiatric diagnosis is gender dysphoria. DSM-5 renamed this syndrome (previously gender identity disorder) and placed it in its own chapter, rather than with identity disorders. Criteria for gender dysphoria differ for children and for adolescents and adults, but at all ages the lead criterion is “marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration” (American Psychiatric Association 2013, p. 452). In addition, at all ages DSM-5 requires that there be clinically significant distress or impairment in order to make the diagnosis. For child diagnosis, at least six criteria must be met (see Box 13–1), one of which must be Criterion A1 (i.e., a strong desire to be of the other gender or an insistence that one is the other gender). For adolescents, at least two of the eight criteria listed in Box 13–1 must be present.

Box 13–1 DSM-5 Diagnostic Criteria for Gender Dysphoria (Criterion A Only)

Gender Dysphoria in Children

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).
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.
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 and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
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.

Gender Dysphoria in Adolescents and Adults

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 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.
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).