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Gender dysphoria OR GENDER IDENDITY DISORDER DSM 5

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UNDER GUIDENCE OF DR SURENDRA PALIWAL
PRESENTER:- DR.K. K.SHARMA

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 Introduction
 Prevalence & sex ratio
 ETIOLOGY- biological ,psychosocial , and
Psychological aspect
 Diagnostic Crite...

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 The term gender dysphoria appears as a
diagnosis for the first time DSM-5to refer to
“those persons with a marked incong...

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Gender dysphoria
Gender dysphoria
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Gender dysphoria OR GENDER IDENDITY DISORDER DSM 5

  1. 1. UNDER GUIDENCE OF DR SURENDRA PALIWAL PRESENTER:- DR.K. K.SHARMA
  2. 2.  Introduction  Prevalence & sex ratio  ETIOLOGY- biological ,psychosocial , and Psychological aspect  Diagnostic Criteria  Course and prognosis  Differential Diagnosis  Treatment
  3. 3.  The term gender dysphoria appears as a diagnosis for the first time DSM-5to refer to “those persons with a marked incongruence between their experienced or expressed gender and the one they were assigned at birth.” It was known as gender identity disorder in the previous edition of DSM.
  4. 4.  Gender identity: the sense one has of being male or being female which corresponds, normally, to the person's anatomical sex.  The affective component of GID is gender dysphoria, discontent with one's designated birth sex and a desire to have the body of the other sex, and to be regarded socially as a person of the other sex.
  5. 5.  Transgender is a general term used to refer to those who identify with a gender different from the one they were born with(sometimes referred to as their assigned gender).  Genderqueer those who feel they are between genders, of both genders, or of neither gender.  Crossdressers who wear clothing traditionally associated with another gender, but who maintain a gender identity that is the same as their birth assigned gender known as cross dressers.
  6. 6.  GID(transexualism in older version of DSM)  Gender identity becomes fixed in most persons by age 2 or 3 years.  The sex ratio of referred children is 4 to 5 boys for each girl.
  7. 7.  Male -0.005 to 0.014, Female-0.002 to 0.003% Sex ratio-child -2:1 to 4.5:1 adol.-1:1 adult-1:1 to 6.1:1 ( Japan 1: 2.2 Poland 1 : 3.4) In Europe male 1:30000 female 1:100,000
  8. 8.  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.  Testosterone can increase libido and aggressiveness in women, and estrogen can decrease libido and aggressiveness in men.  Masculinity, femininity, and gender identity result more from postnatal life events.
  9. 9.  Children usually develop a gender identity consonant with their sex of rearing (also known as assigned sex).  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.
  10. 10.  Mother and child relationship - relationship in the first years of life is paramount in establishing gender identity. During this period, mothers normally facilitate their children’s awareness of, and pride in, their gender: Children are valued as little boys and girls.  Separation individualization process- the separation– individuation process is unfolding. When gender problems become associated with separation–individuation problems, the result can be the use of sexuality to remain in relationships characterized by shifts between a desperate infantile closeness and a hostile, devaluing distance.
  11. 11.  Role of mother- devaluing, hostile mothering can result in gender problems, can also be triggered by a mother’s death, extended absence, or depression, to which a young boy may react by totally identifying with her—that is, by becoming a mother to replace her.  Abused child- Some children are given the message that they would be more valued if they adopted the gender identity of the opposite sex. Rejected or abused children may act on such a belief.  father’s Role - The father’s role is also important in the early years, and his presence normally helps the separation–individuation process. Without a father, mother and child may remain overly close. For a girl, the father is normally the prototype of future love objects; for a boy, the father is a model for male identification.
  12. 12.  Sigmund Freud believed that gender identity problems resulted from conflicts experienced by children within the Oedipal triangle.  In his view, these conflicts are fueled by both real family events and children’s fantasies.  Whatever interferes with a child’s loving the opposite-sex parent and identifying with the same-sex parent, interferes with normal gender identity development.
  13. 13.  These "norms" are influenced by family and friends, the mass- media, community and other socializing agents.  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.
  14. 14. A. strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:  repeatedly stated desire to be, or insistence that he or she is, the other sex  in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing  strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex  intense desire to participate in the stereotypical games and pastimes of the other sex  strong preference for playmates of the other sex
  15. 15. In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.
  16. 16. B.Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or aversion toward rough-and-tumble play and rejection of male games, and activities; in girls, rejection of urinating in a sitting position, she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.
  17. 17. In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
  18. 18. C.The disturbance is not concurrent with a physical intersex condition. D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  19. 19.  A definite difference between experienced/expressed gender and the one assigned at birth of at least 6 months duration. At least six of the following must be present:  Persistent and strong desire to be of the other sex or insistence that they belong to the other sex  In males a strong preference for cross-dressing and in female children a strong preference for wearing typical masculine clothing and dislike or refusal to wear typical feminine clothing  Fantasizing about playing opposite gender roles in make-belief play or activities  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. Boys may hate their penis and testes and girls dislike urinating sitting.  Desire to acquire the primary and/or secondary sex characteristics of the opposite sex.  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.
  20. 20. A definite mismatch between the assigned gender and experienced/expressed gender for at least 6 months duration as characterized by at least two or more of the following features –  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.  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.
  21. 21. 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 sex 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. 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.
  22. 22. 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, e.g. boys' underwear and other accessories. (2) Persistent repudiation of female anatomic structures, as evidenced by at least one of the following: (a) an assertion that she has, or will grow, a penis (b) rejection of urinating in a sitting position (c) assertion that she does not want to grow breasts or menstruate C. The girl has not yet reached puberty. D. The disorder must have been present for at least six months.
  23. 23. 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, as indicated by at least one of the following repeated assertions: (a) that he will grow up to become a woman (not merely in role) (b) that his penis or testes are disgusting or will disappear (c) that it would be better not to have a penis or testes. C. The boy has not yet reached puberty. D. The disorder must have been present for at least six months.
  24. 24.  Child Persistence in male 2.2to 30 % female12to 50% (severe symptoms,low socioeconomic status) Male child 63 to 100 % androphilc Female child 32 to 50 % gynephilic  Adult a.Early onset –in childhood GID –desists –adult GID; androphilic b. Late onset –around puberty, transvestic or gynephilic ,more ambivalent
  25. 25.  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 sex-typed expectations, but do not show extensive cross-gender identification and are not discontent with being male.  Hermaphrodism 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 hermaphrodism in the child. With doubt, referral to a pediatric endocrinologist is indicated.
  26. 26.  BODY DYSMORPHIC DISORDER  TRANSVESTIC DISORDER  PSYCHOTIC DISORDER
  27. 27. Tomboy hermaphrodite
  28. 28.  At present, no convincing evidence indicates that psychiatric or psychological intervention for children with GID affects the direction of subsequent sexual orientation.  The treatment of GID 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 GID in childhood have been identified.
  29. 29.  Adolescents whose GID 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 of the non- pathological nature of same-sex orientation. The goal of family intervention is to keep the family stable and to provide a supportive environment for the teenager.
  30. 30.  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 desires per se.  When patient gender dysphoria is severe and intractable, sex reassignment may be the best solution.
  31. 31.  Sex reassignment surgery for a person born anatomically male consists principally of removal of the penis, scrotum, and testes, construction of labia, and vaginoplasty. Some clinicians attempt to construct a neoclitoris from the former frenulum of the penis. The neoclitoris may have erotic sensation.  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 a neophallus. Because of increased technical skills in phalloplasty, more female-to-male patients are now electing these procedures.
  32. 32.  Persons born male are typically treated with daily doses of oral estrogen- conjugated equine estrogens or ethinylestradiol which produce breast enlargement, testicular atrophy, decreased libido, and diminished erectile capacity.. 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 its pretreatment length and is often accompanied by 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.
  33. 33.  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 or penectomy without a desire to acquire the sex characteristics of the other sex
  34. 34.  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 and genital anomalies.
  35. 35. Intersex condition Description Congenital virilizing adrenal hyperplasia Sex karyotype: XX. Most common cause of sexual ambiguity, overproduction of adrenal androgens and virilization of the female fetus, androgenization can range from mild clitoral enlargement to external genitals that look like a normal scrotal sac, testes, and a penis, but hidden behind these external genitals are a vagina and a uterus. Androgen insensitivity syndrome Sex karyotype: XY. Normal female look at birth and so raised as girl. Cryptorchid testes, clitoromegaly, micropenis co-exist in some. Testosterone do not respond to tissue. Minimal or absent internal sexual organs (uterus, ovary, cervix). Turner’s syndrome Sex karyotype: XO. Children have female genitalia, are short, anomalies like shield-shaped chest and a webbed neck. Tx: exogenous estrogen to develop female secondary sex characteristics. Klinfelter’s syndrome Sex karyotype: XXY. normal male at birth. Excessive gynecomastia may occur in adolescence. Small testes without sperm production. They are tall with reduced fertility. Higher rate of GID. 5-α- Reductase Deficiency Sex karyotype: XY. unable to convert testosterone to dihydrotestosterone (DHT). ambiguous genitalia at birth with some sexual anomaly. Affected person appears to be female. Children are sometimes misdiagnosed as having AIS. Pseudoherm aphroditism Infants born with ambiguous genitals, True hermaphroditism: presence of both testes and ovaries. Male pseudohermaphroditism: incomplete differentiation of the external genitalia even though a Y chromosome is present; testes are present but rudimentary. Female pseudohermaphroditism: presence of virilized genitals in person who is XX
  36. 36.  Management of intersex can be categorized into one of the following two: 1. Treatments: Restore functionality (or potential functionality) – generally undertaken 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-to-male procedures.  The exact procedure of the surgery depends on what is the cause of a less common body phenotype in the first place. There is often concern as to whether surgery should be performed at all.  The goal of treatment is to have genitals concordant with chromosomal, biological, physiological, and other genetic antecedents, thus allowing the development of a person with healthy gender identity.
  37. 37.  If the disorder is not stress related, persons who cross-dress are classified as having transvestic fetishism, which is described as a paraphilia in DSM-IV-TR. An essential feature of transvestic fetishism is that it produces sexual excitement. The DSM-IV-TR lists cross- dressing- 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 do not want to change their bodies medically.  Cross-dressing can coexist with paraphilias, such as sexual sadism, sexual masochism, and pedophilia.  The disorder is most common among female impersonators.
  38. 38.  A combined approach, using psychotherapy and pharmacotherapy, is often useful in the treatment of cross-dressing.  Antianxiety and antidepressant agents, is used to treat the symptoms as cross-dressing can occur impulsively, medications that reinforce impulse control may be helpful, such as fluoxetine (Prozac).
  39. 39.  The category of preoccupation with castration is reserved for men and women who have a persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the opposite sex.  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.

Editor's Notes

  • genital ambiguity: incomplete development of fetal genitalia as a result of excessive androgen action on a female fetus or inadequate amounts of androgen in a male fetus

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