Gender identity disorder: Difference between revisions

Jump to navigation Jump to search
VisualWikitext
No edit summary
 
(104 intermediate revisions by 3 users not shown)
Line 1: Line 1:
__NOTOC__
__NOTOC__
'''For patient information, click [[Gender identity disorder (patient information)|here]]'''
'''For patient information, click [[Gender identity disorder (patient information)|here]]'''
{{SI}}
{{SI}}
{{CMG}}; {{AE}} {{KS}}
{{CMG}}; {{AE}} {{Sharma}} {{KS}}


{{SK}} Gender dysphoria  
{{SK}} Gender dysphoria  


==Overview==
==Overview==
'''Gender identity disorder''', as identified by [[psychologist]]s and [[physician]]s, is a condition in which a person has been born one [[gender]], usually on the basis of their [[sex]] at birth (compare [[intersexuality|intersex disorders]]), but identifies as belonging to another gender, and feels significant discomfort or the inability to deal with this condition. It is a psychiatric classification and describes the problems related to [[transsexualism|trans sexuality]], [[transgender]] identity and more rarely [[transvestism]]. It is the diagnostic classification most commonly applied to [[transsexualism|transsexuals]].  The core symptom of '''gender identity disorders''' is [[gender]] [[dysphoria]], literally being uncomfortable with one's assigned gender. This feeling is usually reported as "having always been there" since childhood, although in some cases, it appears in [[adolescence]] or adulthood, and has been reported by some as intensifying over time. 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. In many cases, discomfort is also reported as stemming from the feeling that one's body is "wrong" or meant to be different.  
Gender identity disorder or gender dysphoria is a condition characterized by the disparity between the gender one is born with and the gender one desires to live as. Gender dysphoria literally means 'being uncomfortable with one's assigned gender'. These individuals experience severe distress and impairment in overall functioning. Gender dysphoria can be broadly categorized into [[Transsexuality|transsexualism]], dual-role [[transvestism]], and gender identity disorder of childhood. Since many cultures strongly disagree with cross-gender behavior, it often results in significant problems for affected individuals as well as their families. In many instances, discomfort is also due to the feeling that one's body is "wrong" or is meant to be different from the present state. This condition may arise at any age and intensify over time. Management is complex but early [[treatment]] is associated with lesser [[distress]] and better outcomes.


==Historical Perspective==
==Historical Perspective==
* The concept of gender dysphoria is not recent but has been the center of objection in many cultures. Since ancient times as mentioned in the mythology, people have existed who wish to lead a life of the opposite gender.<ref>[http://www.gendertalk.com/articles/oped/gid_tnt.shtml Dorlands Medical Dictionary]</ref>
 
* A Greek tale mentions about a woman raised as a man, who fell in love with another woman and before the wedding, she was [[Metamorphosis|metamorphosed]] into a male. They both lived together thereafter. <ref name="pmid22844818">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*The concept of gender identity disorder is not recent but has been the center of objection in many cultures. Since ancient times as mentioned in mythology, people have existed who wish to lead a life of the opposite gender.<ref>[http://www.gendertalk.com/articles/oped/gid_tnt.shtml Dorlands Medical Dictionary]</ref>
* Another evidence of gender diversity in history is from Hatshepsut, the Egyptian female pharaoh (1478-1458 BCE) who was portrayed as a bearded emperor. <ref name="PoteatRachlin2019">{{cite journal|last1=Poteat|first1=Tonia|last2=Rachlin|first2=Katherine|last3=Lare|first3=Sean|last4=Janssen|first4=Aron|last5=Devor|first5=Aaron|title=History and Prevalence of Gender Dysphoria|year=2019|pages=1–24|issn=2523-3785|doi=10.1007/978-3-030-05683-4_1}}</ref>
*A Greek tale mentions a woman raised as a man, who fell in love with another woman, and before the wedding, she was [[Metamorphosis|metamorphosed]] into a male. They both lived together thereafter. <ref name="pmid22844818">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* A Roman king Elagabalus (218- 222 CE) was well-known for his beauty, his feminine dressing manner and extensive use of cosmetics. As he wanted the people to remember him as a woman and wished to have female genitalia, he had approached a [[surgeon]] who could transform him. <ref name="PoteatRachlin20192">{{cite journal|last1=Poteat|first1=Tonia|last2=Rachlin|first2=Katherine|last3=Lare|first3=Sean|last4=Janssen|first4=Aron|last5=Devor|first5=Aaron|title=History and Prevalence of Gender Dysphoria|year=2019|pages=1–24|issn=2523-3785|doi=10.1007/978-3-030-05683-4_1}}</ref>
*Another evidence of gender diversity in history is from Hatshepsut, the Egyptian female pharaoh (1478-1458 BCE) who was portrayed as a bearded emperor. <ref name="PoteatRachlin2019">{{cite journal|last1=Poteat|first1=Tonia|last2=Rachlin|first2=Katherine|last3=Lare|first3=Sean|last4=Janssen|first4=Aron|last5=Devor|first5=Aaron|title=History and Prevalence of Gender Dysphoria|year=2019|pages=1–24|issn=2523-3785|doi=10.1007/978-3-030-05683-4_1}}</ref>
* The first [[sex reassignment surgery]] was by [[World Professional Association for Transgender Health|Harry Benjamin]], who published a case of a 'woman trapped in the body of a man'. It was later known as transsexualism. <ref name="pmid228448182">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*A Roman king Elagabalus (218- 222 CE) was well-known for his beauty, his feminine dressing manner, and extensive use of [[cosmetics]]. As he wanted the people to remember him as a woman and wished to have female [[genitalia]], he had approached a [[surgeon]] who could transform him. <ref name="PoteatRachlin20192">{{cite journal|last1=Poteat|first1=Tonia|last2=Rachlin|first2=Katherine|last3=Lare|first3=Sean|last4=Janssen|first4=Aron|last5=Devor|first5=Aaron|title=History and Prevalence of Gender Dysphoria|year=2019|pages=1–24|issn=2523-3785|doi=10.1007/978-3-030-05683-4_1}}</ref>
* Gender Identity Disorder and several other conditions like [[fetishism]], homosexuality etc had no clear-cut classification margins and were overlapping till 1950s.  
*The first [[sex reassignment surgery]] was by [[World Professional Association for Transgender Health|Harry Benjamin]], who published a case of a woman trapped in the body of a man. It was later known as [[Transsexuality|transsexualism]]. <ref name="pmid228448182">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* In 1957, John William Money proposed the concept of gender and focused on the conditions associated with sex development.<ref name="pmid228448183">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*Gender identity disorder and several other conditions such as [[fetishism]], and [[Homosexual|homosexuality]] had no clear-cut classification margins and were overlapping until the 1950s.
*In 1957, John William Money proposed the concept of gender and focused on the conditions associated with sex development.<ref name="pmid228448183">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>


==Classification==
==Classification==
*There are multiple classification systems for Gender Identity Disorder.
* In 1980, the notion of this disorder was first mentioned in [[DSM-III]]. <ref name="pmid228448184">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* [[DSM-III-R]] divided it into 3 broad types- 'non-transsexualism', 'transsexualism' and 'not otherwise specified'. <ref name="pmid228448185">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* [[Diagnostic and statistical manual of mental disorders|DSM- IV]] combined the former two into Gender Identity Disorder.<ref name="pmid228448186">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* [[ICD-10]] categorized Gender Identity Disorder into four main groups.<ref name="pmid228448187">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
* DSM-5 has changed the terminology of Gender Identity Disorder to Gender Dysphoria.<ref name="pmid228448188">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>


*There are multiple classification systems for gender identity disorder.
*In 1980, the notion of this disorder was first mentioned in [[DSM-III]]. <ref name="pmid228448184">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*[[DSM-III-R]] divided it into 3 broad types 'transsexualism','non-transsexualism', and 'not otherwise specified'. <ref name="pmid228448185">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*[[Diagnostic and statistical manual of mental disorders|DSM-IV]] combined the former two into gender identity disorder.<ref name="pmid228448186">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*[[ICD-10]] categorized gender identity disorder into five main groups.<ref name="pmid228448187">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>
*[[Diagnostic and statistical manual of mental disorders|DSM]]-5 has changed the terminology of gender identity disorder to gender dysphoria.<ref name="pmid228448188">{{cite journal| author=Koh J| title=[The history of the concept of gender identity disorder]. | journal=Seishin Shinkeigaku Zasshi | year= 2012 | volume= 114 | issue= 6 | pages= 673-80 | pmid=22844818 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22844818  }}</ref>


==Pathophysiology==
==Pathophysiology==
*The exact pathogenesis of Gender Identity Disorder is not fully understood.
 
*Gender identity disorder is hypothesized to be due to a combination of biologic and cultural factors, the former having a predominant role.
*The exact [[pathogenesis]] of gender identity disorder is not fully understood.
*Multiple studies have demonstrated an admixture of hormonal, neuroanatomical, and genetic factors in the development of this disorder. However, a single candidate gene has not been isolated in relation with this condition.<ref name="FisherRistori2018">{{cite journal|last1=Fisher|first1=Alessandra D.|last2=Ristori|first2=Jiska|last3=Morelli|first3=Girolamo|last4=Maggi|first4=Mario|title=The molecular mechanisms of sexual orientation and gender identity|journal=Molecular and Cellular Endocrinology|volume=467|year=2018|pages=3–13|issn=03037207|doi=10.1016/j.mce.2017.08.008}}</ref>  
*Gender identity disorder is hypothesized to be due to a combination of [[biological]] and cultural factors, the former having a predominant role.
*It has been found that prenatal and postnatal neurohormonal factors also have a role in this condition.  
*Multiple studies have demonstrated an admixture of [[hormonal]], neuroanatomical, and [[genetic]] factors in the development of this disorder. However, a single candidate [[gene]] has not been isolated.<ref name="FisherRistori2018">{{cite journal|last1=Fisher|first1=Alessandra D.|last2=Ristori|first2=Jiska|last3=Morelli|first3=Girolamo|last4=Maggi|first4=Mario|title=The molecular mechanisms of sexual orientation and gender identity|journal=Molecular and Cellular Endocrinology|volume=467|year=2018|pages=3–13|issn=03037207|doi=10.1016/j.mce.2017.08.008}}</ref>
*Brain derived neurotrophic factor (BDNF) levels have been found to be significantly decreased in patients with Gender Identity Disorder.<ref name="FontanariAndreazza2013">{{cite journal|last1=Fontanari|first1=Anna-Martha V.|last2=Andreazza|first2=Tahiana|last3=Costa|first3=Ângelo B.|last4=Salvador|first4=Jaqueline|last5=Koff|first5=Walter J.|last6=Aguiar|first6=Bianca|last7=Ferrari|first7=Pamela|last8=Massuda|first8=Raffael|last9=Pedrini|first9=Mariana|last10=Silveira|first10=Esalba|last11=Belmonte-de-Abreu|first11=Paulo S.|last12=Gama|first12=Clarissa S.|last13=Kauer-Sant'Anna|first13=Marcia|last14=Kapczinski|first14=Flavio|last15=Lobato|first15=Maria Ines R.|title=Serum concentrations of brain-derived neurotrophic factor in patients with gender identity disorder|journal=Journal of Psychiatric Research|volume=47|issue=10|year=2013|pages=1546–1548|issn=00223956|doi=10.1016/j.jpsychires.2013.04.012}}</ref>
*It has been found that [[prenatal]] and [[postnatal]] neurohormonal factors also have a role.
*[[Brain-derived neurotrophic factor]] ([[Brain-derived neurotrophic factor|BDNF]]) levels are significantly decreased in patients with gender identity disorder.<ref name="FontanariAndreazza2013">{{cite journal|last1=Fontanari|first1=Anna-Martha V.|last2=Andreazza|first2=Tahiana|last3=Costa|first3=Ângelo B.|last4=Salvador|first4=Jaqueline|last5=Koff|first5=Walter J.|last6=Aguiar|first6=Bianca|last7=Ferrari|first7=Pamela|last8=Massuda|first8=Raffael|last9=Pedrini|first9=Mariana|last10=Silveira|first10=Esalba|last11=Belmonte-de-Abreu|first11=Paulo S.|last12=Gama|first12=Clarissa S.|last13=Kauer-Sant'Anna|first13=Marcia|last14=Kapczinski|first14=Flavio|last15=Lobato|first15=Maria Ines R.|title=Serum concentrations of brain-derived neurotrophic factor in patients with gender identity disorder|journal=Journal of Psychiatric Research|volume=47|issue=10|year=2013|pages=1546–1548|issn=00223956|doi=10.1016/j.jpsychires.2013.04.012}}</ref>


==Differential Diagnosis==
==Differential Diagnosis==


*[[Body dysmorphic disorder]]
*[[Body dysmorphic disorder]]
*Non conformity to gender roles
*Nonconformity to gender roles
*Other clinical presentations
*Other clinical presentations
:*[[Castration]]
:*[[Castration]]
:*[[Penectomy]]
:*[[Penectomy]]
*[[Schizophrenia]]<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Other [[psychotic disorder]]s
*Other [[psychotic disorder]]s
*[[Schizophrenia]]
*Transvestic disorder<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>


==Epidemiology and Demographics==
==Epidemiology and Demographics==
===Prevalence===
===Prevalence===
The prevalence of gender dysphoria is:
The [[prevalence]] of gender dysphoria among adults is:<ref name="DSMV" /><ref name="pmid28838353">{{cite journal| author=Zucker KJ| title=Epidemiology of gender dysphoria and transgender identity. | journal=Sex Health | year= 2017 | volume= 14 | issue= 5 | pages= 404-411 | pmid=28838353 | doi=10.1071/SH17067 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28838353  }}</ref><ref name="pmid30335346">{{cite journal| author=| title=StatPearls | journal= | year= 2020 | volume=  | issue=  | pages=  | pmid=30335346 | doi= | pmc= | url= }}</ref>
* 5-14 per 100,000 (0.005%-0.014%) among natal adult males
 
* 2-3 per 100,000 (0.002%-0.003%) among natal females<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*5-14 per 100,000 (0.005%-0.014%) in natal males
*2-3 per 100,000 (0.002%-0.003%) in natal females
*In 2016, approximately 1.4 million individuals in the United States identified themselves as transgender.
*The [[prevalence]] of gender dysphoria is thought to be much higher than the actual numbers as most people don't want to participate in the studies due to social stigma.
 
===Age===
===Age===
*Patients of all age groups may develop Gender identity Disorder.
 
*It has been observed that most children with Gender Dysphoria do not continue to have the condition after puberty.<ref name="WallienCohen-Kettenis2008">{{cite journal|last1=Wallien|first1=Madeleine S.C.|last2=Cohen-Kettenis|first2=Peggy T.|title=Psychosexual Outcome of Gender-Dysphoric Children|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=47|issue=12|year=2008|pages=1413–1423|issn=08908567|doi=10.1097/CHI.0b013e31818956b9}}</ref>
*Patients of all age groups can develop gender identity disorder.
*Homosexual men have been found to have later than expected birth order.<ref name="BlanchardZucker1996">{{cite journal|last1=Blanchard|first1=Ray|last2=Zucker|first2=Kenneth J.|last3=Cohen-Kettenis|first3=Petty T.|last4=Gooren|first4=Louis J. G.|last5=Bailey|first5=J. Michael|title=Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males|journal=Archives of Sexual Behavior|volume=25|issue=5|year=1996|pages=495–514|issn=0004-0002|doi=10.1007/BF02437544}}</ref>
*It has been observed that most children with gender dysphoria do not continue to have this condition after [[puberty]].<ref name="WallienCohen-Kettenis2008">{{cite journal|last1=Wallien|first1=Madeleine S.C.|last2=Cohen-Kettenis|first2=Peggy T.|title=Psychosexual Outcome of Gender-Dysphoric Children|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=47|issue=12|year=2008|pages=1413–1423|issn=08908567|doi=10.1097/CHI.0b013e31818956b9}}</ref>
*Feminine homosexual men tend to have more than expected number of brothers.<ref name="BlanchardZucker1996">{{cite journal|last1=Blanchard|first1=Ray|last2=Zucker|first2=Kenneth J.|last3=Cohen-Kettenis|first3=Petty T.|last4=Gooren|first4=Louis J. G.|last5=Bailey|first5=J. Michael|title=Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males|journal=Archives of Sexual Behavior|volume=25|issue=5|year=1996|pages=495–514|issn=0004-0002|doi=10.1007/BF02437544}}</ref>


===Gender===
===Gender===
* The relationships of children with gender dysphoria have been observed to be better with children of opposite-sex as compared to that of same-sex at the level of elementary school.<ref name="WallienVeenstra2009">{{cite journal|last1=Wallien|first1=Madeleine S. C.|last2=Veenstra|first2=René|last3=Kreukels|first3=Baudewijntje P. C.|last4=Cohen-Kettenis|first4=Peggy T.|title=Peer Group Status of Gender Dysphoric Children: A Sociometric Study|journal=Archives of Sexual Behavior|volume=39|issue=2|year=2009|pages=553–560|issn=0004-0002|doi=10.1007/s10508-009-9517-3}}</ref>
 
*In adults, the [[prevalence]] of male-to-female transsexualism is higher than female-to-male transsexualism.<ref name="ZuckerLawrence2016">{{cite journal|last1=Zucker|first1=Kenneth J.|last2=Lawrence|first2=Anne A.|last3=Kreukels|first3=Baudewijntje P.C.|title=Gender Dysphoria in Adults|journal=Annual Review of Clinical Psychology|volume=12|issue=1|year=2016|pages=217–247|issn=1548-5943|doi=10.1146/annurev-clinpsy-021815-093034}}</ref>
*The relationships of children with gender dysphoria have been found to be better with children of opposite-sex as compared to that of same-sex at the level of elementary school.<ref name="WallienVeenstra2009">{{cite journal|last1=Wallien|first1=Madeleine S. C.|last2=Veenstra|first2=René|last3=Kreukels|first3=Baudewijntje P. C.|last4=Cohen-Kettenis|first4=Peggy T.|title=Peer Group Status of Gender Dysphoric Children: A Sociometric Study|journal=Archives of Sexual Behavior|volume=39|issue=2|year=2009|pages=553–560|issn=0004-0002|doi=10.1007/s10508-009-9517-3}}</ref>
*[[Homosexual men|Homosexual]] men have been found to have later than expected birth order.<ref name="BlanchardZucker1996">{{cite journal|last1=Blanchard|first1=Ray|last2=Zucker|first2=Kenneth J.|last3=Cohen-Kettenis|first3=Petty T.|last4=Gooren|first4=Louis J. G.|last5=Bailey|first5=J. Michael|title=Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males|journal=Archives of Sexual Behavior|volume=25|issue=5|year=1996|pages=495–514|issn=0004-0002|doi=10.1007/BF02437544}}</ref>
*Feminine [[homosexual]] men usually have more than the expected number of brothers.<ref name="BlanchardZucker1996">{{cite journal|last1=Blanchard|first1=Ray|last2=Zucker|first2=Kenneth J.|last3=Cohen-Kettenis|first3=Petty T.|last4=Gooren|first4=Louis J. G.|last5=Bailey|first5=J. Michael|title=Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males|journal=Archives of Sexual Behavior|volume=25|issue=5|year=1996|pages=495–514|issn=0004-0002|doi=10.1007/BF02437544}}</ref>


===Race===
===Race===
*Gender dysphoria is a multifactorial condition and the studies performed for determining racial predominance have presented variable results.
*[[Race]] and ethnicity play an important role in the management of gender dysphoria and the cross-cultural training of [[mental health]] professionals can result in better treatment outcomes. <ref name="StanfordBois1992">{{cite journal|last1=Stanford|first1=E. Percil|last2=Bois|first2=Barbara C. Du|title=Gender and Ethnicity Patterns|year=1992|pages=99–117|doi=10.1016/B978-0-12-101277-9.50008-5}}</ref>


==Risk Factors==
==Risk Factors==
*High degree of atypicality
 
*Habitual fetishistic transvestism<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*The high degree of atypicality
*High birth weight<ref name="VanderLaanLeef2014">{{cite journal|last1=VanderLaan|first1=Doug P.|last2=Leef|first2=Jonathan H.|last3=Wood|first3=Hayley|last4=Hughes|first4=S. Kathleen|last5=Zucker|first5=Kenneth J.|title=Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children|journal=Journal of Autism and Developmental Disorders|volume=45|issue=6|year=2014|pages=1742–1750|issn=0162-3257|doi=10.1007/s10803-014-2331-3}}</ref>
*Habitual fetishistic [[transvestism]]<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>
*Genetic factors <ref name="HeylensDe Cuypere2012">{{cite journal|last1=Heylens|first1=Gunter|last2=De Cuypere|first2=Griet|last3=Zucker|first3=Kenneth J.|last4=Schelfaut|first4=Cleo|last5=Elaut|first5=Els|last6=Vanden Bossche|first6=Heidi|last7=De Baere|first7=Elfride|last8=T'Sjoen|first8=Guy|title=Gender Identity Disorder in Twins: A Review of the Case Report Literature|journal=The Journal of Sexual Medicine|volume=9|issue=3|year=2012|pages=751–757|issn=17436095|doi=10.1111/j.1743-6109.2011.02567.x}}</ref>
*High [[birth weight]]<ref name="VanderLaanLeef2014">{{cite journal|last1=VanderLaan|first1=Doug P.|last2=Leef|first2=Jonathan H.|last3=Wood|first3=Hayley|last4=Hughes|first4=S. Kathleen|last5=Zucker|first5=Kenneth J.|title=Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children|journal=Journal of Autism and Developmental Disorders|volume=45|issue=6|year=2014|pages=1742–1750|issn=0162-3257|doi=10.1007/s10803-014-2331-3}}</ref>
*Cigarette Smoking <ref name="HoffmanDelahanty2018">{{cite journal|last1=Hoffman|first1=Leah|last2=Delahanty|first2=Janine|last3=Johnson|first3=Sarah E.|last4=Zhao|first4=Xiaoquan|title=Sexual and gender minority cigarette smoking disparities: An analysis of 2016 Behavioral Risk Factor Surveillance System data|journal=Preventive Medicine|volume=113|year=2018|pages=109–115|issn=00917435|doi=10.1016/j.ypmed.2018.05.014}}</ref>
*[[Genetic]] factors <ref name="HeylensDe Cuypere2012">{{cite journal|last1=Heylens|first1=Gunter|last2=De Cuypere|first2=Griet|last3=Zucker|first3=Kenneth J.|last4=Schelfaut|first4=Cleo|last5=Elaut|first5=Els|last6=Vanden Bossche|first6=Heidi|last7=De Baere|first7=Elfride|last8=T'Sjoen|first8=Guy|title=Gender Identity Disorder in Twins: A Review of the Case Report Literature|journal=The Journal of Sexual Medicine|volume=9|issue=3|year=2012|pages=751–757|issn=17436095|doi=10.1111/j.1743-6109.2011.02567.x}}</ref>
*Autism Spectrum disorder (ASD)<ref name="VanderLaanLeef2014">{{cite journal|last1=VanderLaan|first1=Doug P.|last2=Leef|first2=Jonathan H.|last3=Wood|first3=Hayley|last4=Hughes|first4=S. Kathleen|last5=Zucker|first5=Kenneth J.|title=Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children|journal=Journal of Autism and Developmental Disorders|volume=45|issue=6|year=2014|pages=1742–1750|issn=0162-3257|doi=10.1007/s10803-014-2331-3}}</ref>
*[[Cigarette smoking]] <ref name="HoffmanDelahanty2018">{{cite journal|last1=Hoffman|first1=Leah|last2=Delahanty|first2=Janine|last3=Johnson|first3=Sarah E.|last4=Zhao|first4=Xiaoquan|title=Sexual and gender minority cigarette smoking disparities: An analysis of 2016 Behavioral Risk Factor Surveillance System data|journal=Preventive Medicine|volume=113|year=2018|pages=109–115|issn=00917435|doi=10.1016/j.ypmed.2018.05.014}}</ref>
*[[Autism spectrum disorder]](ASD)<ref name="VanderLaanLeef2014">{{cite journal|last1=VanderLaan|first1=Doug P.|last2=Leef|first2=Jonathan H.|last3=Wood|first3=Hayley|last4=Hughes|first4=S. Kathleen|last5=Zucker|first5=Kenneth J.|title=Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children|journal=Journal of Autism and Developmental Disorders|volume=45|issue=6|year=2014|pages=1742–1750|issn=0162-3257|doi=10.1007/s10803-014-2331-3}}</ref>
 
==Comorbidities==
It is controversial if the conditions are coexistent with or develop as a result of gender dysphoria. Some of the [[comorbidities]] observed in various studies are:
 
*[[Borderline Personality Disorder]]<ref name="Lothstein2010">{{cite journal|last1=Lothstein|first1=Leslie M.|title=Psychological Testing With Transsexuals: A 30-Year Study|journal=Journal of Personality Assessment|volume=48|issue=5|year=2010|pages=500–507|issn=0022-3891|doi=10.1207/s15327752jpa4805_9}}</ref>
*[[Avoidant personality disorder|Avoidant Personality Disorder]]<ref name="DuišinBatinić2014">{{cite journal|last1=Duišin|first1=Dragana|last2=Batinić|first2=Borjanka|last3=Barišić|first3=Jasmina|last4=Djordjevic|first4=Miroslav L.|last5=Vujović|first5=Svetlana|last6=Bizic|first6=Marta|title=Personality Disorders in Persons with Gender Identity Disorder|journal=The Scientific World Journal|volume=2014|year=2014|pages=1–7|issn=2356-6140|doi=10.1155/2014/809058}}</ref>
*[[Schizoid personality disorder|Schizoid Personality Disorder]]<ref name="DuišinBatinić2014">{{cite journal|last1=Duišin|first1=Dragana|last2=Batinić|first2=Borjanka|last3=Barišić|first3=Jasmina|last4=Djordjevic|first4=Miroslav L.|last5=Vujović|first5=Svetlana|last6=Bizic|first6=Marta|title=Personality Disorders in Persons with Gender Identity Disorder|journal=The Scientific World Journal|volume=2014|year=2014|pages=1–7|issn=2356-6140|doi=10.1155/2014/809058}}</ref>
*[[Paranoid Personality Disorder]]<ref name="DuišinBatinić2014">{{cite journal|last1=Duišin|first1=Dragana|last2=Batinić|first2=Borjanka|last3=Barišić|first3=Jasmina|last4=Djordjevic|first4=Miroslav L.|last5=Vujović|first5=Svetlana|last6=Bizic|first6=Marta|title=Personality Disorders in Persons with Gender Identity Disorder|journal=The Scientific World Journal|volume=2014|year=2014|pages=1–7|issn=2356-6140|doi=10.1155/2014/809058}}</ref>
*[[Psychotic disorders]]<ref name="HeppKraemer2005">{{cite journal|last1=Hepp|first1=U.|last2=Kraemer|first2=B.|last3=Schnyder|first3=U.|last4=Miller|first4=N.|last5=Delsignore|first5=A.|title=Psychiatric comorbidity in gender identity disorder|journal=Journal of Psychosomatic Research|volume=58|issue=3|year=2005|pages=259–261|issn=00223999|doi=10.1016/j.jpsychores.2004.08.010}}</ref>
*[[Anxiety disorders]]<ref name="HeppKraemer2005">{{cite journal|last1=Hepp|first1=U.|last2=Kraemer|first2=B.|last3=Schnyder|first3=U.|last4=Miller|first4=N.|last5=Delsignore|first5=A.|title=Psychiatric comorbidity in gender identity disorder|journal=Journal of Psychosomatic Research|volume=58|issue=3|year=2005|pages=259–261|issn=00223999|doi=10.1016/j.jpsychores.2004.08.010}}</ref>
 
==Prognosis==
The factors associated with poor [[prognosis]] are:
 
*[[Personality Disorder]]<ref name="BodlundKullgren1996">{{cite journal|last1=Bodlund|first1=Owe|last2=Kullgren|first2=Gunnar|title=Transsexualism—General outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex|journal=Archives of Sexual Behavior|volume=25|issue=3|year=1996|pages=303–316|issn=0004-0002|doi=10.1007/BF02438167}}</ref>
*[[Psychiatric]] [[comorbidity]]<ref name="HeppKraemer2005">{{cite journal|last1=Hepp|first1=U.|last2=Kraemer|first2=B.|last3=Schnyder|first3=U.|last4=Miller|first4=N.|last5=Delsignore|first5=A.|title=Psychiatric comorbidity in gender identity disorder|journal=Journal of Psychosomatic Research|volume=58|issue=3|year=2005|pages=259–261|issn=00223999|doi=10.1016/j.jpsychores.2004.08.010}}</ref><ref name="TeradaMatsumoto2012">{{cite journal|last1=Terada|first1=Seishi|last2=Matsumoto|first2=Yosuke|last3=Sato|first3=Toshiki|last4=Okabe|first4=Nobuyuki|last5=Kishimoto|first5=Yuki|last6=Uchitomi|first6=Yosuke|title=Factors predicting psychiatric co-morbidity in gender-dysphoric adults|journal=Psychiatry Research|volume=200|issue=2-3|year=2012|pages=469–474|issn=01651781|doi=10.1016/j.psychres.2012.07.018}}</ref>
*Negative self-image<ref name="BodlundKullgren1996">{{cite journal|last1=Bodlund|first1=Owe|last2=Kullgren|first2=Gunnar|title=Transsexualism—General outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex|journal=Archives of Sexual Behavior|volume=25|issue=3|year=1996|pages=303–316|issn=0004-0002|doi=10.1007/BF02438167}}</ref>
*Mental instability<ref name="HeppKraemer2005">{{cite journal|last1=Hepp|first1=U.|last2=Kraemer|first2=B.|last3=Schnyder|first3=U.|last4=Miller|first4=N.|last5=Delsignore|first5=A.|title=Psychiatric comorbidity in gender identity disorder|journal=Journal of Psychosomatic Research|volume=58|issue=3|year=2005|pages=259–261|issn=00223999|doi=10.1016/j.jpsychores.2004.08.010}}</ref>
*Sex reassignment at an older age<ref name="WålinderLundström2018">{{cite journal|last1=Wålinder|first1=Jan|last2=Lundström|first2=Bengt|last3=Thuwe|first3=Inga|title=Prognostic Factors in the Assessment of Male Transsexuals for Sex Reassignment|journal=British Journal of Psychiatry|volume=132|issue=1|year=2018|pages=16–20|issn=0007-1250|doi=10.1192/S0007125000282895}}</ref>


==Diagnostic criteria==
==Diagnostic criteria==
{| border="1"
 
|+ The table's caption
===DSM-5 Diagnostic Criteria:===
! Column heading 1 !! Column heading 2 !! Column heading 3
 
|-
*According to [[Diagnostic and statistical manual of mental disorders|DSM]]-5, gender dysphoria has been divided into:
! Gender
 
| Cell 2 || Cell 3
#Gender dysphoria in children
|-
#Gender dysphoria in adolescents and adults
! Row heading A
#Other specified gender dysphoria
|Cell B
#Unspecified gender dysphoria
|Cell C
 
|-
===Gender Dysphoria in Children<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
! Row heading A
|Cell B
|Cell C
|}
===DSM-V Diagnostic Criteria for Gender Dysphoria in Children<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
{{cquote|
{{cquote|


*A. 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):
*A. A major incongruence between the assigned gender and the experienced/expressed gender for a minimum of 6 months' duration and should include at least six of the following (Criterion A1 must be included):


:*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).
:*1. The insistence that one belongs to the opposite gender or having a strong desire to be of the other gender (or any gender, different from the one assigned).
:*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.
:*2. In boys ( the assigned gender), a strong preference for cross-dressing or in girls (the assigned gender), a strong desire for wearing only typically masculine clothing, and exhibiting resistance to the wearing of typical feminine clothing.
:*3. A strong preference for cross-gender roles in make-believe play or fantasy play.
:*3. A very strong preference for cross-gender roles in fantasy play.
:*4. A strong preference for the toys, games, or activities stereo typically used or engaged in by the other gender.
:*4. A strong preference for the toys, games, or activities used or engaged in by the opposite gender.
:*5. A strong preference for playmates of the other gender.
:*5. Preference to play with the children 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.
:*6. In boys (the assigned gender), a strong rejection of typically masculine toys, games, and activities; or in girls (the assigned gender), a very strong rejection of feminine toys, games, and activities.
:*7. A strong dislike of one’s sexual anatomy.
:*7. A clear dislike of one’s sexual anatomy.
:*8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender.
:*8. A strong wish for the primary or secondary sex or both characteristics that match one’s experienced gender.


'''''AND'''''
'''''AND'''''


*B. The condition is associated with clinically significant distress or impairment in social,school, or other important areas of functioning.
*B. The condition causes clinically significant distress or impairment in social, school, or other important domains of functioning.


Specify if;
Specify if;


With a disorder of sex development (e.g., a congenital adreno genital disorder such as [[congenital adrenal hyperplasia]] or [[androgen insensitivity syndrome]]).
With a disorder of sex development (like [[congenital adrenal hyperplasia]] or [[androgen insensitivity syndrome]]).
}}
}}


===DSM-V Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===
===Gender Dysphoria in Adolescents and Adults<ref name="DSMV">{{cite book | title = Diagnostic and statistical manual of mental disorders : DSM-5 | publisher = American Psychiatric Association | location = Washington, D.C | year = 2013 | isbn = 0890425558 }}</ref>===


{{cquote|
{{cquote|


*A. 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:
*A. A major incongruence between one’s assigned gender and  experienced/expressed gender, of at least 6 months' duration, involving 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).
:*1. A marked incongruence between one’s experienced/expressed gender and primary or secondary or both sexual characteristics.
:*3. A strong desire for the primary and/or secondary sex characteristics of the other gender.
:*2. A strong desire to be devoid of one’s primary and/or secondary sexual characteristics because of the incongruence with one’s experienced/expressed gender.
:*4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
:*3. A very strong desire for the primary and/or secondary sexual characteristics of the opposite gender.
:*5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
:*4. A desire to be of 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).
:*5. A very strong desire to be treated as the other gender (or some alternative gender different from the assigned gender).
:*6. A firm belief that one has the typical feelings and reactions of the other gender (or some alternative gender different from the assigned gender).


'''''AND'''''
'''''AND'''''


*B. The condition is associated with clinically significant distress or impairment in social,occupational or other important areas of functioning.
*B. The condition is associated with clinically significant distress or impairment in occupational, social, and/or other important areas of functioning.


Specify if:
Specify if:


With a disorder of sex development (e.g., a congenital adrenogenital disorder such [[congenital adrenal hyperplasia]] or [[androgen insensitivity syndrome]]).
*With a disorder of sex development (like [[congenital adrenal hyperplasia]] or [[androgen insensitivity syndrome]]).


*Specify if:
*Post transition: The individual has transitioned to full-time living in the desired gender and has undergone a minimum of one cross-sex medical procedure or treatment regimen like regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, [[vaginoplasty]] for a natal male; [[mastectomy]] or phalloplasty for a natal female).
}}


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 a natal male; [[mastectomy]] or phalloplasty in a natal female).
===Other Specified Gender Dysphoria===
}}
=== ICD-10 ===


{{Infobox_Disease |
*Symptoms of gender dysphoria cause clinically significant distress in social, occupational, and/or other domains of functioning but do not meet the full criteria for gender dysphoria.
  Name          = Gender Identity Disorder  |
  Image          = |
  Caption        = "Transsexualism"|
  ICD10          = {{ICD10|F|64||f|60}} |
  ICD9          = {{ICD9|302.5}} |
  ICDO          = |
  OMIM          =  600952 |
  MedlinePlus    = |
  eMedicineSubj  = med |
  eMedicineTopic = 3439 |
  MeshName      = Transsexualism |
  MeshNumber    = F03.800.800.800 |
}}
The current edition of the [[ICD|International Statistical Classification of Diseases and Related Health Problems]] has five different diagnoses for gender identity disorder: ''transsexualism'', ''Dual-role Transvestism'', ''Gender Identity Disorder of Childhood'', ''Other Gender Identity Disorders'', and ''Gender Identity Disorder, Unspecified''.<ref>[http://www.wpath.org/Documents2/socv6.pdf HBIGDA Standards Of Care For Gender Identity Disorders, Sixth Version]</ref>


Transsexualism has the following criteria:
===Unspecified Gender Dysphoria===
* The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through [[Gender reassignment therapy|surgery and hormone treatment]].
* The [[gender identity|transsexual identity]] has been present persistently for at least two years.
* The disorder is not a symptom of another [[mental disorder]] or a chromosomal abnormality.


Dual-role transvestism has the following criteria:
*This category is used in the circumstances where the clinician chooses not to specify the reason that the full criteria for gender dysphoria are not met or have insufficient information to formulate a more specific diagnosis.
* The individual wears clothes of the opposite sex in order to experience temporary membership in the opposite sex.
* There is no sexual motivation for the cross-dressing.
* The individual has no desire for a permanent change to the opposite sex.  


Gender Identity Disorder of Childhood has essentially four criteria, which may be summarised as:
* The individual is persistently and intensely distressed about being a girl/boy, and desires (or claims) to be of the opposite gender.
* The individual is preoccupied with the clothing, roles or anatomy of the opposite sex/gender, or rejects the clothing, roles, or anatomy of his/her birth sex/gender.
* The individual has not yet reached puberty.
* The disorder must have been present for at least 6 months.


The remaining two classifications have no specific criteria and may be used as "catch-all" classifications in a similar way to GIDNOS.
===ICD-10 Diagnostic Criteria===
[[ICD|International Statistical Classification of Diseases and Related Health Problems]] has five categories for gender identity disorder: ''transsexualism'', ''Dual-role [[Transvestism]]'', ''Gender Identity Disorder of Childhood'', ''Other Gender Identity Disorders'', and ''Gender Identity Disorder, Unspecified''.<ref>[http://www.wpath.org/Documents2/socv6.pdf HBIGDA Standards Of Care For Gender Identity Disorders, Sixth Version]</ref>


Since, very often, many people (including doctors, judges etc.) assume that the classifications "transsexual" and "transvestite" can apply only to adults, the F64 section of the ICD-10 is often criticised, especially since the "usually" in "usually accompanied by the wish to make his or her body as congruent as possible " is often ignored as well, and wish for sexual reassignment surgery (SRS) is seen as a requirement for the diagnosis of "transsexualism". However, an increasing number of physicians and therapists are treating transsexual people who have no desire for surgery, sometimes known as "non-op" transsexuals.
Transsexualism has the following criteria:


Many transgender people, however, do not fit into either of these two categories; for example, transgender people who wish to change their social gender completely, but who do not bother with SRS. This can lead to significant problems with things such as procuring medical treatment and legal change of name and/or gender; in some cases, it may make them completely impossible.
*The desire to be accepted as or live as a member of the opposite gender, mostly accompanied by the wish to make one's body as congruent as possible with the preferred gender by the process of [[Gender reassignment therapy|surgery and hormone treatment]].
*The [[transsexual identity]] has been present continuously for a minimum of two years.
*The disorder is not secondary to a [[mental condition]] or a [[chromosomal]] abnormality.


== Controversy ==
Dual-role [[transvestism]] is characterized by:
{{Refimprove|section|date=February 2007}}
{{Original research|section|date=September 2007}}
Many transgender people do not regard their cross-gender feelings and behaviours as a [[mental illness|disorder]].<ref>[http://www.lgbtcenter.northwestern.edu/support-transgender.html#disability LGBT Resource Center - Support Articles]</ref> People within the transgender community often question what a "normal" [[gender identity]] or "normal" [[gender role]] is supposed to be. One argument is that gender characteristics are socially constructed and therefore naturally unrelated to biological sex. This perspective often notes that other cultures, particularly historical ones, valued gender roles that would presently suggest [[homosexuality]] or transsexuality as normal behavior.<ref>[http://www.apiwellness.org/article_tg_issues.html Issues of Transgendered Asian Americans and Pacific Islanders]</ref> Some people see "transgendering" as a means for ''[[deconstruction|deconstructing]]'' gender. However, not all transgender people wish to deconstruct gender or feel that they are doing so.


Other transgender people object to the classification of GID as a mental disorder on the grounds that there may be a physical cause, as suggested by recent studies about the brains of transsexual people. Many of them also point out that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.{{Fact|date=May 2007}}
*The individual wearing clothes of the opposite sex in order to experience temporary membership in the other sex.
*No sexual motivation has been found for the cross-dressing.
*No desire for permanent sex transformation.


Although evidence suggests that transgender behaviour has a neurological basis, there is no scientific consensus on whether the etiology of transgenderism is mental or physical.{{Fact|date=May 2007}} Psychiatric diagnoses will continue to carry authority, and remain useful for medical billing purposes and potentially for the classification of research results, unless those diagnoses are changed. However, little research into transgenderism or transsexualism is actually being conducted. The mental illness diagnoses are also enshrined in the [[WPATH]]-[[Standards of care for gender identity disorders|SOC]]s; they persist because no other medical diagnoses are available.
Gender identity disorder of childhood has four criteria, which may be summed up as:


In a landmark publication in December 2002, the British Lord Chancellor's office published a ''Government Policy Concerning Transsexual People'' document that categorically states "What transsexualism is not...It is not a mental illness." Nonetheless, existing psychiatric diagnoses of gender identity disorder or the now obsolete categories of homosexual disorder, gender dysphoria syndrome, true transsexual, etc., continue to be accepted as formal evidence of transsexuality.  
*The individual is persistently and severely distressed about being a girl/boy, and desires (or claims) to be a member of the opposite gender.
*The individual is preoccupied with the clothing, [[anatomy]], and roles of the opposite gender, or rejects the clothing, [[anatomy]], and roles of one's birth gender.
*[[Puberty]] has not been attained yet.
*The disorder must have been present for a minimum of 6 months.


The official politics in many countries interpret transgenderism as an undesirable behavior that must be prohibited, or as a psychiatric disorder, which should be cured. {{Fact|date=May 2007}}  See [[Heteronormativity]].
The remaining two classifications have no specific criteria.


Additionally, some youth have been diagnosed with GID on the basis of their sexual orientation (because they are viewed as "gender non-conforming" due to their sexual attractions and/or dress/manner) and treated against their will in religious residential treatment centers. One of the more well known cases was that of [[Lyn Duff]], a 15-year-old girl from Los Angeles who was forcibly transported to Rivendell Psychiatric Center in West Jordan, Utah, and subjected to [[aversion therapy]] in an attempt to change her sexual orientation.
Many people assume that the classifications "[[transsexual]]" and "[[Transvestism|transvestite]]" can apply only to adults and therefore, the F64 section of the ICD-10 is often criticized, for example, the wish for [[sexual reassignment surgery]] (SRS) is perceived as a requirement for the diagnosis of "transsexualism".


Many people feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the GID diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of the opposite sex/gender).<ref>{{cite book | last = Rudacille | first = Deborah | title = The Riddle of Gender: Science, Activism, and Transgender Rights | publisher = Pantheon |date=February 2005) | isbn = 978-0375421624}}</ref> People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. As Kelley Winters PhD (pen-name Katharine Wilson), an advocate for GID reform put it, "Behaviors that would be ordinary or even exemplary for gender-conforming boys and girls are presented as symptomatic of mental disorder for gender nonconforming children."<ref>[http://www.transgender.org/gidr/gid3026.html "GID Reform Advocates"]</ref>  However, Zucker and Spitzer<ref>Zucker KJ, Spitzer RL, 2005, "Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note."''Journal of Sex and Marital Therapy'' 2005 Jan-Feb;31(1):31-42</ref> argue that GID was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion".
== Treatment ==
==Treatment==
==Treatment==
{{Refimprove|date=February 2007}}
{{Main|Hormone replacement therapy (male-to-female)|Hormone replacement therapy (female-to-male)}}


Some medical and psychological professional have tried to 'dissuade individuals from their [[transgender]] behaviour/feelings at least since the mid-[[19th century]]. Only occasionally have such cures been reported, and almost all such reports lack substantiation.{{Fact|date=May 2007}} (Overlapping reports suggest some in fact were cured several times, implying that these individuals were not cured at all.{{Fact|date=May 2007}}) While in 1973 the [[American Psychiatric Association]] (APA) removed homosexuality from the [[Diagnostic and Statistical Manual of Mental Disorders]] (DSM)<ref>Zucker KJ, Spitzer RL, 2005, "Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note."''Journal of Sex and Marital Therapy'' 2005 Jan-Feb;31(1):31-42</ref>, and many believed sexual identities were finally freed of medicalized stigma, today many LGB and "gender non-conforming" youth and adults remain vulnerable to diagnosis of psychosexual disorder under the GID diagnosis which replaced homosexuality in the DSM version III in 1980.  Thus many LGB and [[Gender variance|gender variant]] youth and adults, including transgender individuals, are still directed to [[conversion therapies]].{{Fact|date=May 2007}}
*Management of gender dysphoria is often challenging and requires a multidisciplinary approach.
*Previously the management was primarily focused on [[sex reassignment surgery]] or [[psychotherapy]] but with the inundation of medical advances, a wide spectrum of treatment modalities are available now.
*Many factors have to be considered and [[treatment]] should be initiated in a step-wise manner emphasizing the detailed assessment, management of [[comorbid]] [[psychiatric]] conditions, facilitation of identity formation, management of [[sexual identity]], and finally, the aftercare.<ref name="BocktingColeman1993">{{cite journal|last1=Bockting|first1=Walter|last2=Coleman|first2=Eli|title=A Comprehensive Approach to the Treatment of Gender Dysphoria|journal=Journal of Psychology & Human Sexuality|volume=5|issue=4|year=1993|pages=131–155|issn=0890-7064|doi=10.1300/J056v05n04_08}}</ref>
*For the [[treatment]] of gender dysphoria, there is a requirement of an expert team consisting of the diagnosing clinicians (including an [[endocrinologist]]), a mental health provider for adolescents, and a mental health professional for adults.<ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>


Today, most medical professionals who provide [[transgender transition]] services now reject conversion therapies as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else (e.g. Lynn Conway’s “Success Pages” in External Links below).{{Fact|date=May 2007}}  “[[Transgender transition]] services”, the various medical treatments and procedures that alter an individual's primary and/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria.  (See discussion of [[body dysphoria]] for how this concept relates to the misnomer "gender dysphoria". Similarly, see [[Transgender transition]] for a critical discussion of the concept of “reassignment” as in [[sex reassignment therapy]] and for a discussion of related medical services and procedures.)
===Management of Children and Adolescents===


The [[World Professional Association for Transgender Health]] (WPATH, formerly HBIGDA) [[Standards of care for gender identity disorders|Standards of Care]] (Version 6 from 2001) are considered by some as definitive treatment guidelines for providers.  Other Standards exist (see those discussed in [[Standards of care for gender identity disorders]], including the guidelines outlines in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care". Several health clinics in the United States (e.g. Tom Waddell in San Francisco, Callen Lorde in New York City, Mazzoni in Philadelphia) have developed “[[Guideline (medical)|protocols]]” for transgender hormone therapy following a “[[harm reduction]]” model which is coming to be embraced by increasing numbers of providers.  In their 2005 book ''Medical Therapy and Hormone Maintenance for Transgender Men'', Dr. Nick Gorton et al suggest a flexible approach based in harm reduction, “Willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.” (See External Links below.)
*While treating children and adolescents, the center of focus should be ethical values of informed consent, harm avoidance or minimization, full disclosure, and life options maximization.<ref name="Stein2012">{{cite journal|last1=Stein|first1=Edward|title=Commentary on the Treatment of Gender Variant and Gender Dysphoric Children and Adolescents: Common Themes and Ethical Reflections|journal=Journal of Homosexuality|volume=59|issue=3|year=2012|pages=480–500|issn=0091-8369|doi=10.1080/00918369.2012.653316}}</ref>
*There should be special consideration to patient autonomy and confidentiality, wherever the adolescent is competent to make the decisions. <ref name="SwannHerbert2008">{{cite journal|last1=Swann|first1=Stephanie|last2=Herbert|first2=Sarah E.|title=Ethical Issues in the Mental Health Treatment of Gender Dysphoric Adolescents|journal=Journal of Gay & Lesbian Social Services|volume=10|issue=3-4|year=2008|pages=19–34|issn=1053-8720|doi=10.1300/J041v10n03_02}}</ref>
*[[Hormone]] [[treatment]] is generally not recommended for prepubertal gender dysphoric individuals. Treatment by [[Gonadotropin-releasing hormone agonist|gonadotropin-releasing hormone agonists]]([[Gonadotropin-releasing hormone|GnRH]]) is considered only if the adolescents have entered [[puberty]] at Tanner Stage 2.<ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>
*[[Gonadotropin-releasing hormone agonist|Gonadotropin-releasing hormone agonists]] suppress [[puberty]] in adolescents with gender dysphoria. <ref name="SchagenCohen-Kettenis2016">{{cite journal|last1=Schagen|first1=Sebastian E.E.|last2=Cohen-Kettenis|first2=Peggy T.|last3=Delemarre-van de Waal|first3=Henriette A.|last4=Hannema|first4=Sabine E.|title=Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents|journal=The Journal of Sexual Medicine|volume=13|issue=7|year=2016|pages=1125–1132|issn=17436095|doi=10.1016/j.jsxm.2016.05.004}}</ref>
*They pose threats in the form of adverse effects of the [[metabolic]] as well as [[endocrine]] nature. Their side effects are through the inability to increase the bone mass and significant interference with brain development. <ref name="Cohen-KettenisSchagen2011">{{cite journal|last1=Cohen-Kettenis|first1=Peggy T.|last2=Schagen|first2=Sebastiaan E. E.|last3=Steensma|first3=Thomas D.|last4=de Vries|first4=Annelou L. C.|last5=Delemarre-van de Waal|first5=Henriette A.|title=Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up|journal=Archives of Sexual Behavior|volume=40|issue=4|year=2011|pages=843–847|issn=0004-0002|doi=10.1007/s10508-011-9758-9}}</ref>
*However, the routine monitoring of [[gonadotropins]], [[sex steroids]], [[liver]], and [[renal function]] in adolescents on [[Gonadotropin-releasing hormone agonist|gonadotropin-releasing hormone agonists]] is not necessary.<ref name="SchagenCohen-Kettenis2016">{{cite journal|last1=Schagen|first1=Sebastian E.E.|last2=Cohen-Kettenis|first2=Peggy T.|last3=Delemarre-van de Waal|first3=Henriette A.|last4=Hannema|first4=Sabine E.|title=Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents|journal=The Journal of Sexual Medicine|volume=13|issue=7|year=2016|pages=1125–1132|issn=17436095|doi=10.1016/j.jsxm.2016.05.004}}</ref>
*There is limited evidence about the beginning of [[hormonal]] [[treatment]] before 13.5 to 14 years of age and therefore, is generally not recommended. <ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>


Medical body interventions and procedures are often necessary to enable living socially in a gender role that more closely matches one's gender identity, and many assume that being accurately perceived by others is a primary goal of body transformations.  However, for those transgender individuals who experience the deep internal distress of body dysphoria, the effects wrought by physical changes -  hormones, surgeries, or other procedures - go much deeper than surface appearances and are far from cosmetic.{{Fact|date=May 2007}}  The primary effects of hormonal and/or surgical interventions are experienced directly by self, internally, increasing a sense of internal harmony and well-being at the deepest psychological and emotional levels, as well as through the physical senses especially [[proprioception]] - the body's own knowledge of itself.  Many medical professionals have come to consider "post-transition" transsexuals (see “[[transgender transition]]”) to be fully cured of their dysphoria or any other disorder.{{Fact|date=May 2007}}
===Management of Adults===


Therefore, many feel the diagnosis of gender identity disorder is at best only temporarily applicable, if ever.{{Fact|date=April 2007}} Indeed, through transition many transsexuals are able to bring their body and their lived/expressed gender into alignment with the internal sense of self.  Thus, many post-transition transsexuals cease to regard themselves as "trans" in any sense: many [[transwomen]] (male-to-female) self-describe as "women" and, similarly, many [[transmen]] feel themselves to be unequivocally "men." While some of these individuals may require continued [[hormone replacement therapy]] ([[estrogen]] or [[testosterone]], respectively) throughout their adult life, such HRT is not substantially different from the HRT often prescribed for [[cisgender]] females or males (not only are dosage levels similar, so are the effects of lack of treatment). Thus, many medical providers in the United States now routinely prescribe such HRT under the same medical codes used for other women and men.{{Fact|date=May 2007}}
*For adults with gender dysphoria, the treating clinicians should be well-trained in transgender-related diagnostic criteria, maintenance of mental health, optimum primary care, precise hormonal treatment, and timely [[surgery]]. <ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>
*When endogenous sex steroid suppression requires high doses of extrinsic [[sex steroid]] hormones, the clinicians should consider surgically removing natal gonads to reduce the [[sex steroid]] related [[adverse effects]]. The side effects of [[Sex steroid|sex steroids]] should be vigilantly monitored by the clinicians in these patients.<ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>
*Both transgender males and females should be monitored for [[gonadal]] cancer when surgical removal is incomplete.<ref name="HembreeCohen-Kettenis2017">{{cite journal|last1=Hembree|first1=Wylie C|last2=Cohen-Kettenis|first2=Peggy T|last3=Gooren|first3=Louis|last4=Hannema|first4=Sabine E|last5=Meyer|first5=Walter J|last6=Murad|first6=M Hassan|last7=Rosenthal|first7=Stephen M|last8=Safer|first8=Joshua D|last9=Tangpricha|first9=Vin|last10=T’Sjoen|first10=Guy G|title=Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline|journal=The Journal of Clinical Endocrinology & Metabolism|volume=102|issue=11|year=2017|pages=3869–3903|issn=0021-972X|doi=10.1210/jc.2017-01658}}</ref>
*It has been observed that the adults who undergo [[sex reassignment surgery]] consider their sexual life as dissatisfactory. Adequate [[hormonal]] treatment, management of the underlying [[psychological]] issues, and having a partner resulted in a better subjective perception of sexual [[Quality of Life]](QoL).<ref name="BartolucciGómez‐Gil2015">{{cite journal|last1=Bartolucci|first1=Constanza|last2=Gómez‐Gil|first2=Esther|last3=Salamero|first3=Manel|last4=Esteva|first4=Isabel|last5=Guillamón|first5=Antonio|last6=Zubiaurre|first6=Leire|last7=Molero|first7=Francisca|last8=Montejo|first8=Angel L.|title=Sexual Quality of Life in Gender‐Dysphoric Adults before Genital Sex Reassignment Surgery|journal=The Journal of Sexual Medicine|volume=12|issue=1|year=2015|pages=180–188|issn=17436095|doi=10.1111/jsm.12758}}</ref>


Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual's own expression of their identity, regardless of their birth gender or social role expectations.  However, for those transgender individuals who experience the internal distress of [[body dysphoria]], social acceptance of variation, while vastly important, will not be sufficient.  For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated. 
*Irrespective of the age of the patient, all the individuals with gender dysphoria live in a dilemma, worsened by societal disapproval. The treating team should utilize a holistic approach to cut down their misery.
 
Gorton et al. underscore the importance of medical interventions for some transgender individuals, warning that “Providers must however consider not only the adverse effects of providing hormones but the adverse consequences of denying access to medically supervised hormonal therapy. […] Non-treatment of transgender patients can result in significantly worse psychological outcomes.”  Failure to treat and/or delayed access to transition may have tragic, indeed catastrophic, results for some transgender individuals. It is well-known that the rate of [[teen suicide]]s is highest for LGBT youth.{{Fact|date=May 2007}}  Recent studies now suggest that [[suicide]] rates are highest for transgender youth and adults, especially those unable to live their gender identity and those unable to access transgender transition services.  Gorton et al. suggest rates as high as 20% for untreated transsexuals. (See also “transgender health priorities”).  However, even when transition services are available, suicide rates are still higher than for the general population.


==References==
==References==
Line 211: Line 226:


[[Category:Gender]]
[[Category:Gender]]
[[Category:Sexual and gender identity disorders]]
[[Category: Sexual and gender identity disorders]]
 
[[Category:Psychiatry]]
[[Category:Psychiatry]]
 
[[Category: Up-To-Date]]
{{WS}}
[[Category: Up-To-Date]]
{{WikiDoc Sources}}

Latest revision as of 19:38, 21 January 2021


For patient information, click here

WikiDoc Resources for Gender identity disorder

Articles

Most recent articles on Gender identity disorder

Most cited articles on Gender identity disorder

Review articles on Gender identity disorder

Articles on Gender identity disorder in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Gender identity disorder

Images of Gender identity disorder

Photos of Gender identity disorder

Podcasts & MP3s on Gender identity disorder

Videos on Gender identity disorder

Evidence Based Medicine

Cochrane Collaboration on Gender identity disorder

Bandolier on Gender identity disorder

TRIP on Gender identity disorder

Clinical Trials

Ongoing Trials on Gender identity disorder at Clinical Trials.gov

Trial results on Gender identity disorder

Clinical Trials on Gender identity disorder at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Gender identity disorder

NICE Guidance on Gender identity disorder

NHS PRODIGY Guidance

FDA on Gender identity disorder

CDC on Gender identity disorder

Books

Books on Gender identity disorder

News

Gender identity disorder in the news

Be alerted to news on Gender identity disorder

News trends on Gender identity disorder

Commentary

Blogs on Gender identity disorder

Definitions

Definitions of Gender identity disorder

Patient Resources / Community

Patient resources on Gender identity disorder

Discussion groups on Gender identity disorder

Patient Handouts on Gender identity disorder

Directions to Hospitals Treating Gender identity disorder

Risk calculators and risk factors for Gender identity disorder

Healthcare Provider Resources

Symptoms of Gender identity disorder

Causes & Risk Factors for Gender identity disorder

Diagnostic studies for Gender identity disorder

Treatment of Gender identity disorder

Continuing Medical Education (CME)

CME Programs on Gender identity disorder

International

Gender identity disorder en Espanol

Gender identity disorder en Francais

Business

Gender identity disorder in the Marketplace

Patents on Gender identity disorder

Experimental / Informatics

List of terms related to Gender identity disorder

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vatsala Sharma; M.B.B.S[2] Kiran Singh, M.D. [3]

Synonyms and keywords: Gender dysphoria

Overview

Gender identity disorder or gender dysphoria is a condition characterized by the disparity between the gender one is born with and the gender one desires to live as. Gender dysphoria literally means 'being uncomfortable with one's assigned gender'. These individuals experience severe distress and impairment in overall functioning. Gender dysphoria can be broadly categorized into transsexualism, dual-role transvestism, and gender identity disorder of childhood. Since many cultures strongly disagree with cross-gender behavior, it often results in significant problems for affected individuals as well as their families. In many instances, discomfort is also due to the feeling that one's body is "wrong" or is meant to be different from the present state. This condition may arise at any age and intensify over time. Management is complex but early treatment is associated with lesser distress and better outcomes.

Historical Perspective

  • The concept of gender identity disorder is not recent but has been the center of objection in many cultures. Since ancient times as mentioned in mythology, people have existed who wish to lead a life of the opposite gender.[1]
  • A Greek tale mentions a woman raised as a man, who fell in love with another woman, and before the wedding, she was metamorphosed into a male. They both lived together thereafter. [2]
  • Another evidence of gender diversity in history is from Hatshepsut, the Egyptian female pharaoh (1478-1458 BCE) who was portrayed as a bearded emperor. [3]
  • A Roman king Elagabalus (218- 222 CE) was well-known for his beauty, his feminine dressing manner, and extensive use of cosmetics. As he wanted the people to remember him as a woman and wished to have female genitalia, he had approached a surgeon who could transform him. [4]
  • The first sex reassignment surgery was by Harry Benjamin, who published a case of a woman trapped in the body of a man. It was later known as transsexualism. [5]
  • Gender identity disorder and several other conditions such as fetishism, and homosexuality had no clear-cut classification margins and were overlapping until the 1950s.
  • In 1957, John William Money proposed the concept of gender and focused on the conditions associated with sex development.[6]

Classification

  • There are multiple classification systems for gender identity disorder.
  • In 1980, the notion of this disorder was first mentioned in DSM-III. [7]
  • DSM-III-R divided it into 3 broad types 'transsexualism','non-transsexualism', and 'not otherwise specified'. [8]
  • DSM-IV combined the former two into gender identity disorder.[9]
  • ICD-10 categorized gender identity disorder into five main groups.[10]
  • DSM-5 has changed the terminology of gender identity disorder to gender dysphoria.[11]

Pathophysiology

  • The exact pathogenesis of gender identity disorder is not fully understood.
  • Gender identity disorder is hypothesized to be due to a combination of biological and cultural factors, the former having a predominant role.
  • Multiple studies have demonstrated an admixture of hormonal, neuroanatomical, and genetic factors in the development of this disorder. However, a single candidate gene has not been isolated.[12]
  • It has been found that prenatal and postnatal neurohormonal factors also have a role.
  • Brain-derived neurotrophic factor (BDNF) levels are significantly decreased in patients with gender identity disorder.[13]

Differential Diagnosis

Epidemiology and Demographics

Prevalence

The prevalence of gender dysphoria among adults is:[14][15][16]

  • 5-14 per 100,000 (0.005%-0.014%) in natal males
  • 2-3 per 100,000 (0.002%-0.003%) in natal females
  • In 2016, approximately 1.4 million individuals in the United States identified themselves as transgender.
  • The prevalence of gender dysphoria is thought to be much higher than the actual numbers as most people don't want to participate in the studies due to social stigma.

Age

  • Patients of all age groups can develop gender identity disorder.
  • It has been observed that most children with gender dysphoria do not continue to have this condition after puberty.[17]

Gender

  • In adults, the prevalence of male-to-female transsexualism is higher than female-to-male transsexualism.[18]
  • The relationships of children with gender dysphoria have been found to be better with children of opposite-sex as compared to that of same-sex at the level of elementary school.[19]
  • Homosexual men have been found to have later than expected birth order.[20]
  • Feminine homosexual men usually have more than the expected number of brothers.[20]

Race

  • Gender dysphoria is a multifactorial condition and the studies performed for determining racial predominance have presented variable results.
  • Race and ethnicity play an important role in the management of gender dysphoria and the cross-cultural training of mental health professionals can result in better treatment outcomes. [21]

Risk Factors

Comorbidities

It is controversial if the conditions are coexistent with or develop as a result of gender dysphoria. Some of the comorbidities observed in various studies are:

Prognosis

The factors associated with poor prognosis are:

Diagnostic criteria

DSM-5 Diagnostic Criteria:

  • According to DSM-5, gender dysphoria has been divided into:
  1. Gender dysphoria in children
  2. Gender dysphoria in adolescents and adults
  3. Other specified gender dysphoria
  4. Unspecified gender dysphoria

Gender Dysphoria in Children[14]

“
  • A. A major incongruence between the assigned gender and the experienced/expressed gender for a minimum of 6 months' duration and should include at least six of the following (Criterion A1 must be included):
  • 1. The insistence that one belongs to the opposite gender or having a strong desire to be of the other gender (or any gender, different from the one assigned).
  • 2. In boys ( the assigned gender), a strong preference for cross-dressing or in girls (the assigned gender), a strong desire for wearing only typically masculine clothing, and exhibiting resistance to the wearing of typical feminine clothing.
  • 3. A very strong preference for cross-gender roles in fantasy play.
  • 4. A strong preference for the toys, games, or activities used or engaged in by the opposite gender.
  • 5. Preference to play with the children of the other gender.
  • 6. In boys (the assigned gender), a strong rejection of typically masculine toys, games, and activities; or in girls (the assigned gender), a very strong rejection of feminine toys, games, and activities.
  • 7. A clear dislike of one’s sexual anatomy.
  • 8. A strong wish for the primary or secondary sex or both characteristics that match one’s experienced gender.

AND

  • B. The condition causes clinically significant distress or impairment in social, school, or other important domains of functioning.

Specify if;

With a disorder of sex development (like congenital adrenal hyperplasia or androgen insensitivity syndrome).

”

Gender Dysphoria in Adolescents and Adults[14]

“
  • A. A major incongruence between one’s assigned gender and experienced/expressed gender, of at least 6 months' duration, involving at least two of the following:
  • 1. A marked incongruence between one’s experienced/expressed gender and primary or secondary or both sexual characteristics.
  • 2. A strong desire to be devoid of one’s primary and/or secondary sexual characteristics because of the incongruence with one’s experienced/expressed gender.
  • 3. A very strong desire for the primary and/or secondary sexual characteristics of the opposite gender.
  • 4. A desire to be of the other gender (or some alternative gender different from one’s assigned gender).
  • 5. A very strong desire to be treated as the other gender (or some alternative gender different from the assigned gender).
  • 6. A firm belief that one has the typical feelings and reactions of the other gender (or some alternative gender different from the assigned gender).

AND

  • B. The condition is associated with clinically significant distress or impairment in occupational, social, and/or other important areas of functioning.

Specify if:

  • Post transition: The individual has transitioned to full-time living in the desired gender and has undergone a minimum of one cross-sex medical procedure or treatment regimen like regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty for a natal male; mastectomy or phalloplasty for a natal female).
 ”

Other Specified Gender Dysphoria

  • Symptoms of gender dysphoria cause clinically significant distress in social, occupational, and/or other domains of functioning but do not meet the full criteria for gender dysphoria.

Unspecified Gender Dysphoria

  • This category is used in the circumstances where the clinician chooses not to specify the reason that the full criteria for gender dysphoria are not met or have insufficient information to formulate a more specific diagnosis.


ICD-10 Diagnostic Criteria

International Statistical Classification of Diseases and Related Health Problems has five categories for gender identity disorder: transsexualism, Dual-role Transvestism, Gender Identity Disorder of Childhood, Other Gender Identity Disorders, and Gender Identity Disorder, Unspecified.[31]

Transsexualism has the following criteria:

  • The desire to be accepted as or live as a member of the opposite gender, mostly accompanied by the wish to make one's body as congruent as possible with the preferred gender by the process of surgery and hormone treatment.
  • The transsexual identity has been present continuously for a minimum of two years.
  • The disorder is not secondary to a mental condition or a chromosomal abnormality.

Dual-role transvestism is characterized by:

  • The individual wearing clothes of the opposite sex in order to experience temporary membership in the other sex.
  • No sexual motivation has been found for the cross-dressing.
  • No desire for permanent sex transformation.

Gender identity disorder of childhood has four criteria, which may be summed up as:

  • The individual is persistently and severely distressed about being a girl/boy, and desires (or claims) to be a member of the opposite gender.
  • The individual is preoccupied with the clothing, anatomy, and roles of the opposite gender, or rejects the clothing, anatomy, and roles of one's birth gender.
  • Puberty has not been attained yet.
  • The disorder must have been present for a minimum of 6 months.

The remaining two classifications have no specific criteria.

Many people assume that the classifications "transsexual" and "transvestite" can apply only to adults and therefore, the F64 section of the ICD-10 is often criticized, for example, the wish for sexual reassignment surgery (SRS) is perceived as a requirement for the diagnosis of "transsexualism".

Treatment

  • Management of gender dysphoria is often challenging and requires a multidisciplinary approach.
  • Previously the management was primarily focused on sex reassignment surgery or psychotherapy but with the inundation of medical advances, a wide spectrum of treatment modalities are available now.
  • Many factors have to be considered and treatment should be initiated in a step-wise manner emphasizing the detailed assessment, management of comorbid psychiatric conditions, facilitation of identity formation, management of sexual identity, and finally, the aftercare.[32]
  • For the treatment of gender dysphoria, there is a requirement of an expert team consisting of the diagnosing clinicians (including an endocrinologist), a mental health provider for adolescents, and a mental health professional for adults.[33]

Management of Children and Adolescents

Management of Adults

  • For adults with gender dysphoria, the treating clinicians should be well-trained in transgender-related diagnostic criteria, maintenance of mental health, optimum primary care, precise hormonal treatment, and timely surgery. [33]
  • When endogenous sex steroid suppression requires high doses of extrinsic sex steroid hormones, the clinicians should consider surgically removing natal gonads to reduce the sex steroid related adverse effects. The side effects of sex steroids should be vigilantly monitored by the clinicians in these patients.[33]
  • Both transgender males and females should be monitored for gonadal cancer when surgical removal is incomplete.[33]
  • It has been observed that the adults who undergo sex reassignment surgery consider their sexual life as dissatisfactory. Adequate hormonal treatment, management of the underlying psychological issues, and having a partner resulted in a better subjective perception of sexual Quality of Life(QoL).[38]
  • Irrespective of the age of the patient, all the individuals with gender dysphoria live in a dilemma, worsened by societal disapproval. The treating team should utilize a holistic approach to cut down their misery.

References

  1. ↑ Dorlands Medical Dictionary
  2. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  3. ↑ Poteat, Tonia; Rachlin, Katherine; Lare, Sean; Janssen, Aron; Devor, Aaron (2019). "History and Prevalence of Gender Dysphoria": 1–24. doi:10.1007/978-3-030-05683-4_1. ISSN 2523-3785.
  4. ↑ Poteat, Tonia; Rachlin, Katherine; Lare, Sean; Janssen, Aron; Devor, Aaron (2019). "History and Prevalence of Gender Dysphoria": 1–24. doi:10.1007/978-3-030-05683-4_1. ISSN 2523-3785.
  5. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  6. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  7. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  8. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  9. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  10. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  11. ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
  12. ↑ Fisher, Alessandra D.; Ristori, Jiska; Morelli, Girolamo; Maggi, Mario (2018). "The molecular mechanisms of sexual orientation and gender identity". Molecular and Cellular Endocrinology. 467: 3–13. doi:10.1016/j.mce.2017.08.008. ISSN 0303-7207.
  13. ↑ Fontanari, Anna-Martha V.; Andreazza, Tahiana; Costa, Ângelo B.; Salvador, Jaqueline; Koff, Walter J.; Aguiar, Bianca; Ferrari, Pamela; Massuda, Raffael; Pedrini, Mariana; Silveira, Esalba; Belmonte-de-Abreu, Paulo S.; Gama, Clarissa S.; Kauer-Sant'Anna, Marcia; Kapczinski, Flavio; Lobato, Maria Ines R. (2013). "Serum concentrations of brain-derived neurotrophic factor in patients with gender identity disorder". Journal of Psychiatric Research. 47 (10): 1546–1548. doi:10.1016/j.jpsychires.2013.04.012. ISSN 0022-3956.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
  15. ↑ Zucker KJ (2017). "Epidemiology of gender dysphoria and transgender identity". Sex Health. 14 (5): 404–411. doi:10.1071/SH17067. PMID 28838353.
  16. ↑ "StatPearls". 2020. PMID 30335346.
  17. ↑ Wallien, Madeleine S.C.; Cohen-Kettenis, Peggy T. (2008). "Psychosexual Outcome of Gender-Dysphoric Children". Journal of the American Academy of Child & Adolescent Psychiatry. 47 (12): 1413–1423. doi:10.1097/CHI.0b013e31818956b9. ISSN 0890-8567.
  18. ↑ Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. (2016). "Gender Dysphoria in Adults". Annual Review of Clinical Psychology. 12 (1): 217–247. doi:10.1146/annurev-clinpsy-021815-093034. ISSN 1548-5943.
  19. ↑ Wallien, Madeleine S. C.; Veenstra, René; Kreukels, Baudewijntje P. C.; Cohen-Kettenis, Peggy T. (2009). "Peer Group Status of Gender Dysphoric Children: A Sociometric Study". Archives of Sexual Behavior. 39 (2): 553–560. doi:10.1007/s10508-009-9517-3. ISSN 0004-0002.
  20. ↑ 20.0 20.1 Blanchard, Ray; Zucker, Kenneth J.; Cohen-Kettenis, Petty T.; Gooren, Louis J. G.; Bailey, J. Michael (1996). "Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males". Archives of Sexual Behavior. 25 (5): 495–514. doi:10.1007/BF02437544. ISSN 0004-0002.
  21. ↑ Stanford, E. Percil; Bois, Barbara C. Du (1992). "Gender and Ethnicity Patterns": 99–117. doi:10.1016/B978-0-12-101277-9.50008-5.
  22. ↑ 22.0 22.1 VanderLaan, Doug P.; Leef, Jonathan H.; Wood, Hayley; Hughes, S. Kathleen; Zucker, Kenneth J. (2014). "Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children". Journal of Autism and Developmental Disorders. 45 (6): 1742–1750. doi:10.1007/s10803-014-2331-3. ISSN 0162-3257.
  23. ↑ Heylens, Gunter; De Cuypere, Griet; Zucker, Kenneth J.; Schelfaut, Cleo; Elaut, Els; Vanden Bossche, Heidi; De Baere, Elfride; T'Sjoen, Guy (2012). "Gender Identity Disorder in Twins: A Review of the Case Report Literature". The Journal of Sexual Medicine. 9 (3): 751–757. doi:10.1111/j.1743-6109.2011.02567.x. ISSN 1743-6095.
  24. ↑ Hoffman, Leah; Delahanty, Janine; Johnson, Sarah E.; Zhao, Xiaoquan (2018). "Sexual and gender minority cigarette smoking disparities: An analysis of 2016 Behavioral Risk Factor Surveillance System data". Preventive Medicine. 113: 109–115. doi:10.1016/j.ypmed.2018.05.014. ISSN 0091-7435.
  25. ↑ Lothstein, Leslie M. (2010). "Psychological Testing With Transsexuals: A 30-Year Study". Journal of Personality Assessment. 48 (5): 500–507. doi:10.1207/s15327752jpa4805_9. ISSN 0022-3891.
  26. ↑ 26.0 26.1 26.2 Duišin, Dragana; Batinić, Borjanka; Barišić, Jasmina; Djordjevic, Miroslav L.; Vujović, Svetlana; Bizic, Marta (2014). "Personality Disorders in Persons with Gender Identity Disorder". The Scientific World Journal. 2014: 1–7. doi:10.1155/2014/809058. ISSN 2356-6140.
  27. ↑ 27.0 27.1 27.2 27.3 Hepp, U.; Kraemer, B.; Schnyder, U.; Miller, N.; Delsignore, A. (2005). "Psychiatric comorbidity in gender identity disorder". Journal of Psychosomatic Research. 58 (3): 259–261. doi:10.1016/j.jpsychores.2004.08.010. ISSN 0022-3999.
  28. ↑ 28.0 28.1 Bodlund, Owe; Kullgren, Gunnar (1996). "Transsexualism—General outcome and prognostic factors: A five-year follow-up study of nineteen transsexuals in the process of changing sex". Archives of Sexual Behavior. 25 (3): 303–316. doi:10.1007/BF02438167. ISSN 0004-0002.
  29. ↑ Terada, Seishi; Matsumoto, Yosuke; Sato, Toshiki; Okabe, Nobuyuki; Kishimoto, Yuki; Uchitomi, Yosuke (2012). "Factors predicting psychiatric co-morbidity in gender-dysphoric adults". Psychiatry Research. 200 (2–3): 469–474. doi:10.1016/j.psychres.2012.07.018. ISSN 0165-1781.
  30. ↑ Wålinder, Jan; Lundström, Bengt; Thuwe, Inga (2018). "Prognostic Factors in the Assessment of Male Transsexuals for Sex Reassignment". British Journal of Psychiatry. 132 (1): 16–20. doi:10.1192/S0007125000282895. ISSN 0007-1250.
  31. ↑ HBIGDA Standards Of Care For Gender Identity Disorders, Sixth Version
  32. ↑ Bockting, Walter; Coleman, Eli (1993). "A Comprehensive Approach to the Treatment of Gender Dysphoria". Journal of Psychology & Human Sexuality. 5 (4): 131–155. doi:10.1300/J056v05n04_08. ISSN 0890-7064.
  33. ↑ 33.0 33.1 33.2 33.3 33.4 33.5 Hembree, Wylie C; Cohen-Kettenis, Peggy T; Gooren, Louis; Hannema, Sabine E; Meyer, Walter J; Murad, M Hassan; Rosenthal, Stephen M; Safer, Joshua D; Tangpricha, Vin; T’Sjoen, Guy G (2017). "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline". The Journal of Clinical Endocrinology & Metabolism. 102 (11): 3869–3903. doi:10.1210/jc.2017-01658. ISSN 0021-972X.
  34. ↑ Stein, Edward (2012). "Commentary on the Treatment of Gender Variant and Gender Dysphoric Children and Adolescents: Common Themes and Ethical Reflections". Journal of Homosexuality. 59 (3): 480–500. doi:10.1080/00918369.2012.653316. ISSN 0091-8369.
  35. ↑ Swann, Stephanie; Herbert, Sarah E. (2008). "Ethical Issues in the Mental Health Treatment of Gender Dysphoric Adolescents". Journal of Gay & Lesbian Social Services. 10 (3–4): 19–34. doi:10.1300/J041v10n03_02. ISSN 1053-8720.
  36. ↑ 36.0 36.1 Schagen, Sebastian E.E.; Cohen-Kettenis, Peggy T.; Delemarre-van de Waal, Henriette A.; Hannema, Sabine E. (2016). "Efficacy and Safety of Gonadotropin-Releasing Hormone Agonist Treatment to Suppress Puberty in Gender Dysphoric Adolescents". The Journal of Sexual Medicine. 13 (7): 1125–1132. doi:10.1016/j.jsxm.2016.05.004. ISSN 1743-6095.
  37. ↑ Cohen-Kettenis, Peggy T.; Schagen, Sebastiaan E. E.; Steensma, Thomas D.; de Vries, Annelou L. C.; Delemarre-van de Waal, Henriette A. (2011). "Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up". Archives of Sexual Behavior. 40 (4): 843–847. doi:10.1007/s10508-011-9758-9. ISSN 0004-0002.
  38. ↑ Bartolucci, Constanza; Gómez‐Gil, Esther; Salamero, Manel; Esteva, Isabel; Guillamón, Antonio; Zubiaurre, Leire; Molero, Francisca; Montejo, Angel L. (2015). "Sexual Quality of Life in Gender‐Dysphoric Adults before Genital Sex Reassignment Surgery". The Journal of Sexual Medicine. 12 (1): 180–188. doi:10.1111/jsm.12758. ISSN 1743-6095.
Retrieved from "https://www.wikidoc.org/index.php?title=Gender_identity_disorder&oldid=1684583"