GENDER

DYSPHORIA
Introduction
• The area of sex and gender is highly controversial and has led to a
proliferation of terms whose meanings vary over time and within and
between disciplines.
 Key terms

• Gender Identity
• Natal/Assigned Gender
• Gender roles
• Gender expression
• Gender fluidity
• Cisgender
• Transgender
• Gender reassignment
 What is gender?
Gender:
Refers to the attitudes,
feelings, and behaviors
that a given culture
associates with a person’s
biological sex.
A perso
Gender Expression:
How people present themselves
or the way a person
communicates (about gender) to
others through external means
such as clothing, appearance, or
mannerisms
People might present as
feminine, masculine, neutral or a
combination, and this may vary.
Gender Identity:
How people interpret and
view themselves, within
the context of wider
society and culture.
n ’s s ex , ge n der
e n ti t y, a n d gender
id
p re s s i o n m ay vary
e x
n d n o t co rr espond
a
Sex: The biological
characteristics of a
person’s body, i.e.
organs/anatomy and
DNA.
Usually this is male,
female, or intersex.
Gender identity vs.
Assigned gender
Gender is assigned at birth
based on physical sex – i.e.
It’s a girl! or It’s a boy! –
and people are generally
raised in this gender role.
This is called
assigned/natal gender.
Gender Identity:
Gender is how people
interpret and view
themselves. A person
might identify as the
gender they were
assigned at birth
(cisgender) or they may
identify differently
(transgender).
Gender Identity
crystallizes in most
persons by age 2 or 3
years.
Gender identity also differs from sexual orientation…
Sexual and Romantic Attraction:
Who you are sexually and/or
romantically attracted to.

Sexual orientations refers to a person's

interest in people of the same or similar
gender, different gender(s), all genders,
or no genders - include heterosexual,
lesbian, gay, bisexual, queer, and
asexual.

Trans status is not the same as

sexuality/sexual orientation.
For example, someone can be
trans and heterosexual, or trans
and gay.
 So what is transgender?
The term transgender – or trans – refers to people who do not fully identify with the
gender and / or sex they were assigned at birth. In simple terms, this can include:

Non-binary and gender

diverse people
experience our gender
I’m a woman, and I I’m a man, and I was
identity as outside of
was assigned male at assigned female at
the binary of man and
birth. birth.
woman

Gender
fluidity: having
Trans Women Trans Men different gender Non-Binary Gender
identities at people diverse
different times people
Types of non-binary gender
• Agender: Having no specific gender identity or having a gender
identity that is neutral or undefined. Sometimes used
interchangeably with genderless and neutrois.
• Bigender: Having two distinct gender identities, either
simultaneously or alternatively.
• Genderfluid: Moving between two or more gender identities.
• Genderqueer: A catch-all term for individuals with nonbinary
gender identities. Some people identify with it as their main
identity. The term includes a slur, so make sure an individual
explicitly identifies with it before tacking it onto them.
So what is cisgender?
The opposite of transgender
- Term for people whose gender identity matches the sex they were
assigned at birth

Gender roles: the social role as boys/men or as

girls/women
Males – independent, aggressive, dominant,
problem-solvers, should be the main provider in
the family, and should control and suppress
their feelings.
Females – dependent, submissive, domestic,
Cis woman Cis man nurturing carers, emotional.
GENDER DYSPHORIA
• Discomfort or distress caused by discrepancy between gender identity and
natal gender.
• In DSM 5 – Refer to those persons with a marked incongruence between
their experienced or expressed gender and the one they were assigned at
birth
• Previously – known as gender identity disorder
• Person with gender dysphoria express their discontent with their assigned
sex as a desire to have the body of the other sex or to be regarded socially
as a person of the other sex.
• ‘Gender dysphoria’ is currently the clinical diagnosis given to trans and
gender diverse people seeking medical treatment.
Intersex Condition
• A variety of syndromes in
which persons are born
with anatomies that do
not correspond with
typical male or female
bodies
Epidemiology
• Most children with GD are referred for clinical evaluation in early
grade school years.
• Parents – reported the cross gender behaviour were apparent before
3 years of age.
• The sex ratio of children referred for gender dysphoria is 4 to 5 boys
each girl – due to societal stigma directed towards feminine boys.
• The sex ratio is equal in adolescents referred for GD
• DSM-5 reports a prevalence rate ranging from 0.005 to 0.014 percent
for male-assigned and 0.002 to 0.003 percent for female-assigned
people.
Etiology
• Neurobiology Factors
• Psychosocial Factors
Neurobiological Factors
• Gonadal hormones may influence gender identity and sexual
orientation during prenatal and early neonatal development
• Genes, Hormones, Neuroanatomy, Maternal Immune response
factors –inconsistent data but points to strong biological influences
• Brain organization theory refers to masculinization or feminization of the brain in utero. –
Testosterone affects brain neurons that contribute to the masculinization of the brain in such
areas as the hypothalamus.
• For mammals, the resting state of tissue is initially female, as the fetus develops, a male is
produced only if androgen (set off by the Y chromosome, which is responsible for testicular
development) is introduced. Without testes and androgen, female external genitalia develop.
• Thus, maleness and masculinity depend on fetal and perinatal androgen.
• Sex steroid influence the expression of sexual behavior in mature men or women. – Testosterone
can increase libido and aggressiveness in women and estrogen can decrease libido and
aggressiveness in men.
• But masculinity, feminity, and gender identity may result more from postnatal life events than
from prenatal hormonal organization.
• Genetic cause of gender dysphoria are under study, but no candidate genes have been identified,
and chromosomal variations are uncommon in transgender populations.
Kohlberg's
(1966)
Theory
Gender Schema Theory (MARTIN AND
HALVERSON (1981) , BERN (1981)
• They agreed with Kohlberg that a child’s thinking is the basis of gender behavior, but
believed this thinking starts earlier- the process of acquiring gender relevant
information happens before gender consistency/constancy is achieved (aged 6).
• The basic gender identity acquired at the gender labelling stage (aged 2) is sufficient
for an infant to take an interest in and begin identifying with their gender.
• At the core of the theory is the notion of ‘schema’, a mental representation that
guides the processing of information and experiences.
• GST argues that children gain their gender identity between the ages of 2 and 3
when they work out that they are a boy or a girl. At this stage, their gender schema
is extremely simple, consisting of two groups – boys and girls.
• Their own group is viewed as the ‘in group’ and the opposite sex is viewed as the
‘out group’.
• A schema is a mental map of understanding or set of ideas about
the world.
• Gender schemas play an important role in organising and
structuring the infant’s thoughts about information such as what
behaviors or emotional responses are appropriate for
males/females.
• The first schema consists of 2 categories: boy/girl.
• Own sex is considered the in-group, opposite sex is considered
the out-group.
• Once a child identifies with their gender they think of others of
that gender as an in-group, and those who are ‘different’ (i.e.
don’t share their gender) as an out-group.
• Out-groups will be negatively evaluated.
• This identification leads infants to emulate in-group behaviors
and avoid out-group behaviors.
• Infants will actively seek out information about what their in-
group does: i.e. try to acquire schemas of understanding relating
to gender-appropriate behavior, such as it is wrong for boys to
cry.
Freud’s Psychoanalytic Theory
• After passing through the oral and anal psychosexual stages of development, Freud argued that males and
females experience a different complex (or crisis) during the phallic stage aged around 5.
• If the child successfully resolves this crisis they acquire the gender behavior typical of their sex.
• OEDIPOUS COMPLEX: Boys wish to be the sole object of their mother’s attention and experience
immature sexual desire for her. They view their father as a rival for their mother’s attention/affection but
also fear the father and feel guilty about their desires to get rid of him. The fear of the father is
experienced as a fear of castration. This fear is repressed in to the Unconscious.
• To resolve this crisis, boys repress their desires for their mother and enter a period of sexual latency
(which lasts until puberty) where they find a substitute mother in the form of a girlfriend/partner. The
also identify with (identification) and internalise (internalisation) their father’s gender role and adopt
stereotypically masculine behaviors.
• ELECTRA COMPLEX: Girls are initially attracted to their mothers in the same way as boys. Awareness of
the lack of a penis leads to the girl believing she has been castrated and experiencing penis envy. The
girl’s immature sexual desires then focus on the father.
• To resolve this crisis the girl converts her desire for a penis into a desire for a baby. The girl then
identifies with (identification) the mother and internalises (internalisation) stereotypical feminine
behaviors.
• Girls repress their desires for their father and enter a period of sexual latency (which lasts until puberty)
where they find a substitute mother in the form of a boyfriend/partner
Medical Management and Recovery
Outcomes
• Purpose: Treatment of Gender Dysphoria (GD)
• Individuals with GD can choose the direction in which their transition
will proceed
• Social Transition
• Physical Transition/Medical Treatment
• Hormones
• Gender Affirming Surgery (GAS)
 What is ‘transitioning’?

Transitioning is when a person takes steps to socially and /or

physically feel more aligned with their gender identity.
Social Transition Physical Transition

Social transition refers to social Physical transition can involve

interactions and processes, such making changes to your
as ‘coming out’ as trans to appearance, gender
yourself and your friends, family presentation and gender
and peers. expression.

It can also involve changes to: It can also involve access to

• Name, pronouns and medical interventions, such as:
language • Hormone therapy
• How you use gendered • Hair removal
spaces and services • Voice therapy
• Documentation and • Surgeries
identification

Each person’s experience of transition is different …and not everyone uses the term
‘transition’!
Medical management
• Collaborative medical team including PCP, endocrinologist, mental
health providers, and surgeons
• Hormonal Treatment to feminize or masculinize the body
• GAS- change primary and/or secondary sex characteristics (breast,
genitalia, face, body contouring)
• Standards from the World Professional Association of Transgender
Health
• Psychotherapy (individual, family, parents) for purposes such as
exploring gender identity, role, and expression; enhancing social and
peer support; improving body image; or promoting resilience.
Gender Dysphoria
Social Support and Gender Expression Changes
• Peer support
• Support for family/friends
• Voice/communication therapy
• Hair removal
• Breast binding/padding; genital tucking
• Name change and gender change on identity documents
Psychotherapy
(WPATH SOC)1

• Mental health screening REQUIRED for hormonal or surgical

treatment
• Psychotherapy
• Highly recommended
• NOT required
Hormone Therapy
(WPATH SOC)1

• Medically necessary for many individuals with Gender Dysphoria

• Recommended prior to some, not all, surgical treatment
Hormone Therapy Criteria
(WPATH SOC)1

• Referral from one mental health provider

• Persistent, well documented Gender Dysphoria
• Informed consent capacity
• Age of majority
• Reasonably well controlled medical and mental health concerns
Hormone Therapy Informed Consent
(WPATH SOC)1

• May result in irreversible physical changes

• Document
• Comprehensive information provided
• Possible benefits
• Risks
• Impact on reproductive capacity
Hormone Therapy Effects
• Occur over course of 2 years
• Variable timeline
• Variable effects
Hormone Therapy Effects
FtM

• Deep voice
• Variable clitoral enlargement
• Facial/body hair
• Cessation menses
• Breast atrophy
• Decreased body fat %
• Reduction in fertility
Hormone Therapy Effects
MtF

• Breast growth
• Erectile dysfunction
• Decreased testicular size
• Increased body fat %
• Reduction in fertility
 Hormone Therapy Risks1
Risk level MtF FtM
Likely increased Venous thromboembolism Polycythemia
Gallstones Weight gain
Elevated Liver Enzymes Acne
Hypertriglyceridemia Balding
Sleep apnea

Likely increased in the Cardiovascular disease

presence of risk factors
Possible increased Hypertension Elevated liver enzyme
Hyperprolactinemia / prolactinoma Hyperlipidemia

Possible increased in Type 2 Diabetes Destabilization of psychiatric

presence of risk factors disorders
Cardiovascular disease
Hypertension
Type 2 Diabetes

Not increased or Breast Cancer Bone density loss

inconclusive Breast cancer
Cervical cancer
Ovarian cancer
Uterine cancer
Hormone Therapy
follow-up
• 2-3 months initially to stabilize on dose
• Every 2-3 months for first year
• Annual consultation with endocrine after first year
• Potential 1 year non-deployable form initiatation
Sex Reassignment Surgery
(WPATH SOC)1
MtF FtM
Breast/chest Breast augmentation mastectomy
Genital Penectomy Hysterectomy/salpingectomy
Orchiectomy Oophorectomy
Vaginoplasty Metoidioplasty
Clitoroplasty Phalloplasty
Vulvoplasty Vaginectomy
Srotoplasty
Penile prosthesis
Testicular prosthesis
Non-genital/ Facial feminization Voice surgery (rare)
non-breast Liposuction/Lipofilling Liposuction/lipofilling
Voice surgery Pectoral implants
Thyroid cartilage reduction
Gluteal augmentation
Sex Reassignment Surgery Criteria
(WPATH SOC)1

• Breast/chest surgery FtM

• Single referral
• Persistent, well-documented gender dysphoria
• Informed consent capacity
• Age of majority
• Well controlled mental and medical health concerns
• Hormone therapy NOT prerequisite
Sex Reassignment Surgery Criteria
(WPATH SOC)1

• Breast/chest surgery MtF

• Single referral
• Persistent, well-documented gender dysphoria
• Informed consent capacity
• Age of majority
• Well controlled mental and medical health concerns
• Hormone therapy NOT prerequisite
• RECOMMEND at least 12 months prior to breast augment
Sex Reassignment Surgery Criteria
(WPATH SOC)1

• Genital (gonadectomy / hysterectomy)

• Two referrals
• Persistent, well-documented gender dysphoria
• Informed consent capacity
• Age of majority
• Well controlled mental/medical health concerns
• 12 continuous months of hormone therapy
Sex Reassignment Surgery Criteria
(WPATH SOC)1

• Genital (FtM metoidioplasty/phalloplasty; MtF vaginoplasty)

• Two referrals
• Persistent, well-documented gender dysphoria
• Informed consent capacity
• Age of majority
• Well controlled mental/medical health concerns
• 12 continuous months of hormone therapy
• 12 continuous months living in desired gender role (“real life experience”)
Real Life Experience
• Present consistently on day-today basis, across all settings of life in
their desired gender role
• 12 months allows full range of life experiences throughout the year
Transition Timeline
Summary
• Transgender people may develop Gender Dysphoria
• Treatment for Gender Dysphoria may require hormonal or surgical
treatment for gender transition
• Gender transition is highly variable among individuals
• The World Professional Association for Transgender
Health (WPATH)1 is an international,
multidisciplinary, professional association whose
mission is to promote evidence-based care,
education, research, advocacy, public policy, and
respect for transgender health.
• The vision of WPATH is to bring together diverse
professionals dedicated to developing best practices
and supportive policies worldwide that promote
health, research, education, respect, dignity, and
equality for transsexual, transgender, and gender
nonconforming people in all cultural settings