Gender Dysphoria in Children, Adolescents, and Adults

Chapter 8
Gender Dysphoria in Children, Adolescents, and Adults

I was taught early on what I “should” be doing as a boy. I remember asking my mother why God made me a boy when I wanted to be a girl. She took me to a counselor who told me I was too young to know what I wanted. He simply gave me medication for anxiety and suggested I participate in team sports. That was years ago. Since then, I have not admitted to anyone that I want to be a woman. I feel so alone and isolated. —Jacob

Men and women typically display different behaviors related to their assigned genders. These differences in cultural and social behaviors are looked at as constructs and norms in which the two genders are expected to act and behave within the boundaries of society (Diamond, 2002). Identification of these gender differences in behavior starts in early childhood (Balleur-van Rijn, Steensma, Kreukels, & Cohen-Kettenis, 2012). As children age, they develop friendships and participate in activities with other children who are of the same sex. If an individual does not display behaviors considered congruent with his or her natal gender, or the gender assigned at birth, this may cause confusion and discomfort for the individual. This incongruence may lead to a misidentification of one’s gender role and how society expects one to act (Diamond, 2002).

In addition to behavioral differences, gender is also often displayed through physical appearances (Balleur-van Rijn et al., 2012). For example, whether a person has long or short hair is often an indicator of gender. Physical features, such as breasts or facial hair, and clothing are also common determinants. Children learn at a young age how each gender has certain physical attributes as well as different kinds of behaviors (Dragowski, Scharron-del Rio, & Sandigorsky, 2011). If a child is experiencing discrepancies between his or her assigned and expressed gender, the child might likely identify with or adopt physical characteristics (i.e., clothing, hairstyles) of his or her expressed, rather than natal, gender (Perrin, Smith, Davis, Spack, & Stein, 2010).

To help readers better understand both diagnostic categories of gender dysphoria in adults and gender dysphoria in children and adolescents, as well as major changes from the DSM-IV-TR to the DSM-5, we have included major changes and the diagnostic criteria for gender dysphoria at the beginning of this chapter. After presenting the reader with the diagnostic criteria, as with other chapters of this Learning Companion, we then present essential features, special considerations, implications for counselors, differential diagnoses, and two case studies to facilitate a better understanding of gender dysphoria among all age ranges.

Major Changes From DSM-IV-TR to DSM-5

Gender dysphoria replaces the previously termed gender identity disorder in the DSM-IV-TR. Changing from disorder to dysphoria reduces the notion that an individual has a disorder because he or she identifies with a gender other than the one he or she was born into (APA, 2013b, 2013c). Although there was considerable debate from the lesbian, gay, bisexual, and transgender community about keeping gender dysphoria in the DSM, APA advocated that retaining this as a mental disorder will promote treatment: “To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorders Work Group was concerned that removing [gender dysphoria] as a psychiatric diagnosis—as some had suggested—would jeopardize access to care” (APA, 2013b, p. 2). For example, clients can advocate for hormonal and surgical treatments such as gender reassignment surgery because of the clinically significant distress associated with this condition (APA, 2013b; Megeri & Khoosal, 2007).

Counselors must recognize these changes as major symbolic shifts in the nomenclature, intended to better reflect the experience of children, adolescents, and adults struggling with gender identity issues. The clear separation of this chapter from sexual dysfunctions and paraphilias strongly supports the idea that this diagnosis is not a pathological disorder. In the DSM-IV-TR, gender identity disorder, sexual dysfunctions, and paraphilias were classified together under the Sexual and Gender Identity Disorders chapter, which supported the idea that gender dysphoria was a pathological diagnosis. The second symbolic shift is modification of language, which now focuses on “gender incongruence” between biological and expressed gender as opposed to cross-gender identification. The latter, found in the DSM-IV-TR, does not adequately highlight the psychological experience individuals with gender dysphoria encounter.

Although specific criteria changes to this section were not extensive, the separation of criteria sets for children versus adolescents and adults and the inclusion of new specifiers (e.g., with a disorder of sex development and posttransition) to replace the old sexual orientation specifier (i.e., sexually attracted to males, sexually attracted to females, sexually attracted to both, and sexually attracted to neither) are major changes. By separating diagnostic criteria for children, the DSM-5 does not pathologize developmentally appropriate gender nonconformity in children. Moreover, children and adolescents have unique challenges and treatment options (e.g., puberty-delaying hormones). Also, the requirement that individuals experience a strong desire to live as their expressed gender is no longer required for children because children often do not feel comfortable expressing this desire. Finally, the sexual orientation specifier was removed because critics questioned the relevance to a mental health diagnosis, particularly one that remains in the DSM only to assist individuals experiencing persistent and severe internal dysphoria with birth-assigned gender.

To give the reader a better idea of the changes related to gender dysphoria, we list the specific criteria here for gender dysphoria in children, followed by the criteria for adolescents and adults.

Diagnostic Criteria for Gender Dysphoria in Children 302.6 (F64.2)

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 he or she 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.
The condition is associated with clinically significant distress or impairment in social, school, 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.

Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults 302.85 (F64.1)

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 experience/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 alterative gender different from one’s assigned gender).
The condition is associated with clinically significant distress or impairment in social, school, 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:

Posttransition: 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).

Note

Congenital adrenal hyperplasia is a disease that affects the endocrine system, creating a deficiency or overproduction of sex hormones (Dreger, Feder, & Tamar-Mattis, 2012). In effect, this disease can alter the development of primary and secondary sex characteristics. Androgen insensitivity syndrome involves the development of biological sex either before birth or during puberty (Gottlieb, Beitel, Nadarajah, Palioura, & Trifiro, 2012). Sex development disorders such as these must be diagnosed by a medical professional.