Diseases

GENDER DYSPHORIA 

gender dysphoria

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Overview

Gender dysphoria is the feeling of discomfort or distress that might occur in people whose gender identity differs from their sex assigned at birth or sex-related physical characteristics. Transgender and gender-nonconforming people might experience gender dysphoria at some point in their lives. But not everyone is affected. Some transgender and gender-nonconforming people feel at ease with their bodies, either with or without medical intervention. Gender dysphoria is a diagnosis listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a manual published by the American Psychiatric Association to diagnose mental conditions. This term is intended to be more descriptive than the one that was previously used, gender identity disorder. The term gender dysphoria focuses on one’s discomfort as the problem, rather than identity. A diagnosis for gender dysphoria was created to help people get access to necessary health care and effective treatment.[1]https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/symptoms-causes/syc-20475255

Symptoms

Symptoms of gender identity disorder can be observed early in childhood, as young children with this condition often show:

  • Show disgust at seeing or thinking about their genitals.
  • Insist repeatedly that he is a girl if he is a boy and vice versa.
  • Non-compliance with traditional urination practices, such as refusing to sit or stand.
  • Show signs of distress and aggravation in the changes caused by puberty.
  • Isolation and staying away from colleagues and peers.
  • They also show signs of anxiety.
  • Signs of loneliness and depression also appear.

Research shows that individuals with gender identity disorder are at a high risk of suicide, and in fact, 40% of transgender individuals in the United States have attempted suicide at some point in their lives, research also shows that they are more likely to suffer from a number of mental disorders, Including eating disorders that can put their general health at serious risk.[2]https://www.psychiatry.org/patients-families/gender-dysphoria/what-is-gender-dysphoria

Diagnosis

Gender dysphoria in children

  1. A marked incongruence between one’s experience/expressed gender and assigned gender, of at least 6 months’ duration, as manifested but at least six of the following (one of which must be criteria A1)
  2. 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)
  3. 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 as strong resistance to the wearing of typical feminine clothing.
  4. A strong preference for cross-gender roles in make-believe play or fantasy play.
  5. A strong preference for the toys, games, or activities stereotypically used or engaged in by the other gender.
  6. A strong preference for playmates of the other gender.
  7. In boys (assigned gender), a strong rejection of typically masculine toys, games, 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.
  8. A strong dislike of one’s sexual anatomy.
  9. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
  10. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.[3]https://www.nhs.uk/conditions/gender-dysphoria/

Specify if the above criteria are in addition to a disorder of sex development (e.g., a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity disorder).

Gender dysphoria in adolescents and adults

  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:
  2. 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).
  3. 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).
  4. A strong desire for the primary and/or secondary sex characteristics of the other gender.
  5. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
  6. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
  7. 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).
  8. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.[4]https://www.eneuro.org/content/6/6/ENEURO.0183-19.2019

Specify if:

  • With a disorder of sex development (e.g., a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome).
  • Post-transition: 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 natal male; mastectomy or phalloplasty in a natal female).

Other specified gender dysphoria

This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The “other specified gender dysphoria” category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dysphoria” followed by the specific reason (e.g., “brief” gender dysphoria).

Unspecified gender dysphoria

This category applies to presentations in which symptoms characteristic of gender dysphoria that cause clinically significant distress or impairment in social, occupational or other important areas of functioning predominate but do not meet the full criteria for gender dysphoria. The “unspecified gender dysphoria” category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for gender dysphoria and includes presentations in which there is insufficient information to make a more specific diagnosis.

Treatment

Patients can present to their primary care providers, endocrinologists, or mental health provider. Sometimes, it is a primary concern, whereas others might present with confounded mental health problems. Also, due to greater exposure, social acceptance, and greater access to care, this population tends to present earlier before puberty, unlike before, when they might present at adulthood or late adolescence. Necessary referrals should be made according to the patient to provide them with a stronger backbone for support.

It should also be specified according to age. For children, individual, family, and group therapy are important to explore and counsel on gender preference. For adolescents, the added anticipation of puberty is of concern, so hormonal treatment and psychotherapy should be considered simultaneously. For adults, psychotherapy and hormonal and surgical treatments are all available options.

Adequate counseling is necessary for this population before starting treatment:

  1. Care team: a comprehensive approach with an endocrinologist and mental health providers should be made available.
  2. Expectations: transgender hormonal and surgical treatment options will be helpful in addressing the patient’s external appearance to be in congruence with their gender identity. Unrealistic expectations should be addressed adequately. A supportive network of peers, friends, and family is often helpful.
  3. Risks and benefits of treatment: for both hormonal and surgical treatments accompany great risks. Venous thromboembolism, bone mineral density, and pubertal suppression.
  4. Fertility preservation: before initiating hormonal and surgical treatment, the patient might lose the ability to reproduce. So, it is important to discuss the preservation of fertility by freezing the individual’s gametes.
  5. Sexual health: incidence of sexually transmitted infections and HIV was higher in this population.

Also, the practitioner must understand that even with a standardized protocol in place, the approach needs to be individualized to ensure good prognosis post-treatment.

The World Professional Association for Transgender Health (WPATH) currently publishes the Standards of Care (SOC) to provide clinical guidelines for the health care of transsexual, transgender and gender non-conforming persons in order to maximize health and well-being of patients with gender dysphoria. All treatment options should be offered and, depending on an individual’s goals and expectations, the most appropriate surgical technique should be performed. The Standards of Care outlined by WPATH recommends against physical interventions before the age of 16. They recommend that surgery only be performed after the age of 18 and after the individual has lived in their desired gender role for at least two years. In order for people to undergo physical (hormonal or surgical) interventions to make their body more in line with their gender identity, they must be assessed by a mental health professional that has special competence in this area and often recommendations are required from two such mental health professionals.

Hormonal Therapy

The aim is to suppress the internally produced hormones and to administer and maintain cross-sex hormones in their physiological range. There has been a great push to start hormonal therapy in these patients before they hit puberty, but it is still under research, and ethical issues persist.

Criteria for starting treatment

  1. Persistent and well-documented gender dysphoria
  2. Capacity to consent for the treatment.
  3. Mental or medical underlying issues are in control.

Transgender women (MTF):

Elimination of facial hair, induction of breast formation, and a female body contour are the desired goals. They can be a combination of antiandrogens (spironolactone), progestins, medroxyprogesterone acetate (associated with excess cardiovascular and breast cancer risk in older women taking conjugated estrogen), GnRH agonists (long-acting gonadotropin-releasing hormone-suppresses testosterone), finasteride and estrogen (17-beta-estradiol).

Counseling should be provided against cigarette smoking, especially to those on estrogens. Blood pressure, cholesterol, and liver function should be routinely monitored.

Transgender men (FTM):

Their primary treatment measure is testosterone injectables, usually scheduled once a week. During the first few months, increased muscle mass, acne, and libido are seen, along with cessation of menses. Eventually, more permanent changes such as the deepening of the voice and enlarged clitoris occur following 3 to 6 months of therapy. Routine monitoring of hemoglobin, hematocrit, liver function, cholesterol, and screening of diabetes should be done.

Providers in this area of care are encouraged to start hormonal therapy before puberty for maximum results and patient satisfaction. However, involving parental consent for children and young adolescents for initiating hormonal therapy still remains controversial.

 Surgical Therapy

Criterion are needed, in addition to those listed above for initiating hormonal treatment, before opting for surgical treatment. The individual should be on one year of continuous hormone therapy and living in the desired gender role.

This is often the last step of the treatment process. The counseling discussed above should be continued for these patients, and unrealistic expectations should be addressed. Since these are often irreversible procedures, good insight and counseling along with social support is required to predict a favorable outcome.

These surgeries are often referred to as “top surgery” and “bottom surgery.”

For MTF: breast augmentation is common top surgery that trans-women desire. Also, gonadectomy, includes penectomy and vaginoplasty, are desired to remove the main source of testosterone from the body. Vaginal dilators are also routinely used to maintain anatomy if sexual intercourse is a goal.

For FTM: Metoidioplasty, where the clitoris is released from the ligament it is attached to, and tissue is added to increase the length and the girth. Scrotoplasty (testicular implants) and phalloplasty (penile implant) are also methods; however, due to the expense and expertise required for these surgeries, they are not very common procedures.[5]https://raisingchildren.net.au/pre-teens/development/pre-teens-gender-diversity-and-gender-dysphoria/gender-identity

In the end, constant and continued support from family, community, and peers predict favorable outcomes, even after seeking medical and mental health treatment. Individual and group therapies should be continued. Confounding substance use problems should be addressed.

Enhancing Healthcare Team Outcomes

Any mental health illness requires targeting all the three biological, psychological and social aspects of the patient to have the most favorable outcome.

  1. To create more awareness about individuals with gender dysphoria and validate the concerns of this vulnerable population we encourage more active parental and peer support. To understand gender as a scale and not as binary forms can help reduce the stigma in seeking timely help to improve prognosis and outcome. Open discussions and mass level education at school and work environment can help acheive this.
  2. To create more awareness for gender dysphoria among physicians and other health providers and to encourage providers to be more forthcoming and liberal in providing care and treating for this population. To emphasize an inter professional team approach that is already in effect. This gives our patients the opportunity to get treatment within the same loop of providers. Also, understand that this population has a higher incidence of psychiatric illnesses, concomitant substance use and personality disorders can be challenging to deal with.
  3. Along with this innate sense of rejection and desire to be the opposite sex, these patients need treatment with hormones and therapy. These patients should also be screened for mental health problems like depression, anxiety, safety risk assessments, and substance use during all office visits, including those to primary care providers, psychiatrists, psychologists, social workers, endocrinologists to make necessary referrals in case, patient screens positive.
  4. By understanding gender dysphoria as an organic pathology as suggested by available data and not entirely behavioral, as it was previously thought to be, we can try to maximize care and improve outcomes.
  5. As discussed above, even after having protocols written to provide care for these patients, the plan should always be individualized.[6]https://pubmed.ncbi.nlm.nih.gov/23864402/
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