Gender dysphoria

from – AFP > 2015 > November > Gender dysphoria Volume 44, Issue 11, November 2015

Gender Dysphoria and Transgender Care:

• Definition of Gender Dysphoria:
  • Distress or discomfort stemming from a disconnect between a person’s biological sex and their gender identity.
  • Recognized in the DSM-5, replacing the previous term, “gender identity disorder,” to avoid implying that being transgender is pathological.
• Prevalence and Epidemiology:
  • True prevalence in Australia is unknown due to diverse definitions, varying cultural norms, and limited data.
  • New Zealand reported a prevalence of 1 in 6000 with a natal male-to-female ratio of 6:1, though global estimates suggest prevalence is likely higher.
• Vulnerability of Transgender Individuals:
  • Higher risks of discrimination, depression, and suicidality compared with the general population, often attributed to social rejection, mental health challenges, and isolation.
  • Substance misuse, especially anabolic steroids, occurs frequently, often in pursuit of physical changes to match gender identity

definitions

Gender

• Concept: Gender is a social and cultural construct.
• Focus: It encompasses differences in identity, expression, and experience.
• Identities:
  • Man/Woman: Traditional gender identities.
  • Non-Binary: An umbrella term for identities outside the exclusive categories of male and female.

Sex

• Assigned at Birth: Based on observed physical characteristics at birth or infancy.
• Possibility of Change: A person’s sex may differ from their assigned sex at birth over time.

Sex Characteristics

• Definition: Refers to chromosomal, gonadal, and anatomical traits associated with biological sex

Sexual Orientation

• Definition: An umbrella term covering a person’s sexual identity, attraction, and behavior.
  • Sexual Identity: How a person self-identifies their sexuality (e.g., gay, lesbian, bisexual).
  • Attraction: Romantic or sexual interest directed toward another person.
  • Behavior: Actual sexual behaviors or interactions.
• Fluidity: Sexuality may not be fixed; some people identify as sexually fluid, meaning their orientation may change over time or may not fit one specific label.
• Individual Experience: Sexuality can be defined by personal identity, independent of romantic or sexual experiences.

Trans and Cis

• Purpose of Terms: Describes the relationship between one’s gender identity and the sex presumed at birth.
  • Trans (Transgender): Indicates that a person’s gender identity differs from the sex they were assigned at birth.
  • Cis (Cisgender): Indicates that a person’s gender identity aligns with the sex they were assigned at birth.
• Usage: These terms are used as prefixes (transgender, cisgender) to describe gender experience rather than as standalone gender labels.

Innate Variations of Sex Characteristics

• refers to natural differences in a person’s genetic, hormonal, or physical characteristics that don’t fit typical definitions of male or female bodies.
• These variations are present from birth and may affect various aspects of a person’s physical traits associated with sex, including:
  • Genital Anatomy: Variations in the appearance or structure of external genitalia.
  • Hormonal Profile: Differences in the levels or types of sex hormones (like testosterone and estrogen) present in the body.
  • Chromosomal Patterns: Differences in the sex chromosomes, such as having atypical patterns like XXY instead of the usual XX (female) or XY (male).
  • Reproductive Organs: Variations in internal reproductive anatomy, which may not align with typical male or female reproductive structures.
• Key Terms
  • Intersex: Often used as an umbrella term to describe individuals born with these variations.
  • Differences/Disorders of Sex Development (DSD): Medical terms sometimes used to describe these variations.
• Examples
  • Androgen Insensitivity Syndrome (AIS): A condition where an individual has XY chromosomes (typically associated with males) but is resistant to male hormones (androgens), leading to a female appearance.
  • Congenital Adrenal Hyperplasia (CAH): A condition affecting hormone production in the adrenal glands, potentially leading to atypical genital development.

Objectives for General Practitioners (GPs):

• Role of the GP:
  • Create a safe, supportive environment for transgender patients.
  • Familiarize with transgender care principles, including individualized management, and potentially complex psychosocial issues.
  • Establish therapeutic relationships, address basic needs, and be a resource through the gender transition process.

Initial Consultation and Diagnostic Approach:

• Building a Relationship:
  • Begin by establishing the patient’s preferred name and pronouns to foster trust.
  • Emphasize an open, non-judgmental approach to build understanding and therapeutic rapport.
• Initial Assessment:
  • Collect a comprehensive history, focusing on age of onset and any significant events that may have influenced gender identity development.
  • Assess the duration and intensity of gender dysphoria symptoms.
• DSM-5 Diagnostic Criteria:
  • For adults and adolescents, gender dysphoria diagnosis requires two or more of the following criteria over a minimum of six months:
    • Strong desire to change or eliminate one’s secondary sexual characteristics.
    • A profound desire to adopt the secondary sexual characteristics of the opposite gender.
    • Persistent wish to be treated as the opposite gender.
    • Strong conviction of possessing typical feelings/reactions of the opposite gender.
  • Significant Distress: Must impair social, occupational, or other important functional areas.

Risk and Support Assessment:

• HEADSS Psychosocial Assessment:
  • A structured approach to evaluate risk factors and support, particularly useful for adolescents but also applicable to adults.
  • Covers areas like Home life, Education/Employment, Activities/Relationships, Drug use, Sexuality/Suicide/Mental health.
• Mental Health Considerations:
  • Higher prevalence of depressive and anxiety disorders among transgender individuals.
  • Abuse, harassment, and discrimination commonly faced by transgender individuals may exacerbate mental health challenges.
• Substance Use History:
  • Important to assess for any substance misuse, especially steroids for physical transition.
  • Substance misuse is often due to fear of lack of medical access to hormones or reluctance to disclose to healthcare providers.
• Sexual and Support History:
  • Conduct a comprehensive sexual history to assess STI risks and discuss safe sexual practices.
  • Identify family, friends, and community support networks early on, as supportive relationships are crucial during transition.

Physical Examination:

• Body Dysphoria in Physical Exams:
  • Many transgender patients experience discomfort or distress related to their body, especially secondary sexual characteristics.
  • Avoid unnecessary genital or breast exams initially unless medically indicated or requested by the patient.
  • Respect the patient’s preference for androgynous appearance if it aligns with their gender expression.

Differential Diagnosis:

• Conditions to Differentiate from Gender Dysphoria:
  • Transvestic Disorder: Cross-dressing for sexual gratification without identifying as the opposite gender.
  • Body Dysmorphic Disorder: Distressing preoccupation with a specific body part without overall gender misalignment.
  • Psychotic Disorders: Rarely, psychotic delusions may involve gender identity.
  • Borderline Personality Disorder: Can involve identity disturbances, but if suspected, involve mental health professionals.
  • Asperger’s Syndrome: Gender dysphoria-like preoccupations can occur; a skilled mental health evaluation can differentiate.
  • Dissociative Identity Disorder: Can present with gender identity concerns in distinct personalities; involves complex mental health care.

Investigations:

• Baseline for Hormone Therapy:
  • No diagnostic tests for gender dysphoria, but baseline labs (e.g., CBC, lipid profile, liver and kidney function) are essential before initiating hormone therapy to monitor health and side effects.

Management Approach:

• Psychological Counselling:
  • Counselling with experienced mental health professionals is recommended to provide support, manage comorbid conditions, and assist in transitioning.
  • Psychologists can also aid in preparing for surgery and diagnosing any concurrent mental health issues.
• Hormone Therapy:
  • Benefits: Proven to reduce distress related to gender dysphoria.
  • Informed Consent: Educate patients on reversible and irreversible effects.
  • Specialist Referral: Often started by an endocrinologist or sexual health physician, although GPs may manage ongoing monitoring.
• Surgical Transition Options:
  • Many transgender individuals opt for surgery to align physical appearance with gender identity.
  • Generally, regret rates are low, but thorough pre-surgical counselling is essential for decision-making.
• Changing Legal Documents:
  • As per Australian Government guidelines, a letter from a registered doctor or psychologist can facilitate changes in gender on official documents (e.g., Medicare, passports) without needing surgery or hormone therapy.

Ongoing GP Role:

• Monitoring and Holistic Care:
  • Provide preventive care, continuity of support, and a central point for communication among other healthcare providers.
  • Monitor hormone therapy, manage any side effects, and screen for ongoing mental health needs.