Introduction
The definition of gender and sex is controversial and has resulted in the adoption of various terms with different meanings between distinct disciplines. Confusion chiefly stems from the fact that the English language defines sex as the state of being female or male and also sexuality. Sexuality and sex denote the biological indicators of being female and male which are in the context of an individual’s reproductive capacity. These indicators include sex chromosomes, sex hormones, gonads, and well-defined external and internal genitalia. Gender, on the other hand, refers to legally recognized public roles of individuals as girls or boys, women or men. Biological factors interact with psychological and social factors to contribute to gender development. Gender assignment is the first categorization of a person as female or male that occurs at birth and contributes to the natal gender (Ristori & Steensma, 2016). Gender atypical refers to the presence of behaviors or somatic features that are not statistically typical of persons sharing a commonly assigned gender in society. This leads to the concept of gender identity which is a component of social uniqueness, referring to a person’s notification as female, male, or a category other than these two.
Gender dysphoria is a state of cognitive and affective distress that someone experiences due to the gender and sex that they are assigned at birth (Ristori & Steensma, 2016). In gender dysphoria, the chosen gender and sex of an individual are not in keeping with the individual’s choice of gender. Thus, the individual is considered transgender. The Diagnostic and Statistical Manual previously used gender identity disorder to describe the condition, but it was modified to gender dysphoria in the 5th edition. This was done to create a better understanding of the condition and to eliminate the stigma that resulted from classifying the condition as a disorder. The critical component of gender dysphoria is the presence of significant distress resulting from the condition. The reclassification to remove the word disorder has led to increased support for the declassification of the condition by researchers and transgender individuals since it no longer pathologizes gender variation and does not favor the binary model of gender.
Characteristics of Gender Dysphoria
The conflict present in gender dysphoria affects individuals in different proportions (Zucker, Lawrence & Kreukels, 2016). It changes how a person intends to express their gender and influences self-image, behavior, and dressing (Zucker et al., 2016). Some individuals will cross-dress, others will have strong intentions to transition medically using sex change surgical procedures and hormone treatment while others may want to transition socially. The individuals often assert themselves as belonging to another gender and want to be acknowledged as such (Zucker et al., 2016). Some may even change their names. In adolescents, the individuals experience significant distress as a result of their current or anticipated secondary sexual characteristics and make attempts to suppress them, sometimes going to the extent of acquiring medication that suppresses gonadal function.
Etiology of Gender Dysphoria in Adolescents and Adults
Hormonal causes
Hormones that are coded for by the chromosomal makeup are responsible for regulating the development of gender and sex in the womb (Berenbaum & Meyer-Bahlburg, 2015). The anatomical sex of the fetus is dependent on the chromosomes inherited from the parents. These are a pair of sex chromosomes, one of which is derived from each parent. A typical male has a Y and X sex chromosome while a typical female has a pair of X sex chromosomes. In early pregnancy, all fetuses tend to be female because only the X sex chromosome that is inherited from the mother is active. The sex chromosome inherited from the father becomes active after the eighth week of gestation. Thus, if the male contribution to the pair of sex chromosomes was X, the fetus continues to develop as a female characterized by surging female hormones. The fetus develops female reproductive and accessory organs and features making the gender and sex female. If the male contribution is a Y chromosome, a surge of testosterone and male hormones occurs leading to the acquisition of male features and reproductive organs and making the gender and sex of the fetus male (Berenbaum & Meyer-Bahlburg, 2015).
The hormones that are responsible for gender and sex development may not function appropriately. In androgen insensitivity syndrome, a genetically male individual develops resistance to male hormones leading to the development of all or some of the physical characteristics of a female (Berenbaum & Meyer-Bahlburg, 2015). The effects of androgens on the brain are negated thus producing female psychological characteristics.
In congenital adrenal hyperplasia, the adrenal glands of a genetically female fetus develop rapidly and produce significant amounts of androgens that result in enlargement of the female genitals causing them to resemble male ones.
Psychological factors
According to Stoller, the unbalanced symbiosis between an adolescent and a parent of the opposite sex leads to attenuation of the expression of the adolescent’s assigned gender and sex (Di Ceglie, 2015). The unbalanced symbiosis between a son and his mother eventually results in the child developing feminine behavior and identification that satisfies the mother who in most cases reinforces them. Stroller describes this process as being almost the same as imprinting since it is a non-conflict associated learning process (Di Ceglie, 2015).
Stroller also described a similar process in the development of a female transsexual in which a mother has deep depression, physical illness, or paranoia that limits her functioning during her daughter’s first months or year of life. This leads to the failure of the development of a relationship between the two. The child’s father engages her in activities in which he has an interest, therefore, promoting the adoption of masculine behavior. This results in the girl developing a yearning for anatomic male characteristics due to the conflict resulting from maternal separation early in life that causes significant distress especially during adolescence (Di Ceglie, 2015).
Diagnostic Criteria
The DSM-5 criteria for gender dysphoria in adolescents and adults require the existence of incongruence between a person’s assigned gender and expressed gender lasting at least six months. This incongruence is evidenced by at least two of:
- Significant incongruence between an individual’s current or anticipated primary and secondary sexual features and expressed gender.
- Strong will to discard or prevent the development of someone’s primary and secondary sexual features due to their incongruence with the individual’s expressed gender.
- Significant yearning for the primary and secondary sexual features of another gender.
- A strong will to belong to another gender other than the current one.
- A strong will to be treated as a member of another gender.
- Being convinced he/she has the characteristic reactions and feelings of another gender.
In addition to the above criteria, the individual’s state occurs in association with clinically noteworthy distress or occupational and social dysfunction.
Implications for Treatment
Gender dysphoria that has intensified during puberty and adolescence is managed using guidelines proposed by the Endocrine Society and standards of care determined by the World Professional Association for Transgender Health (Kaltiala-Heino, Bergman, Työläjärvi & Frisen 2018). These guidelines are based on the Dutch Model protocols (Kaltiala-Heino et al., 2018). These protocols propose medical management for gender dysphoria that becomes significantly intense in puberty. Medical treatment is initiated at the age of twelve and above for those that are undergoing or beyond Tanner II and III stages of puberty with persistent gender dysphoria.
Puberty is suppressed using gonadotropin-releasing hormone analogs to alleviate the individual’s psychological distress resulting from the developing secondary sexual characteristics. This provides the adolescent with ample time to make an informed decision on whether to undergo gender-confirming treatment. It also makes the process of social transitioning into the experienced gender easier. Cross-sex hormones are initiated in adolescents aged sixteen and above that continue to have symptoms while individuals aged eighteen and above can undergo sex reassignment surgery.
The chief concern about the Dutch protocol is the question of ethics in pediatrics (Kaltiala-Heino et al., 2018). The use of medication to suppress puberty raises the question of autonomy, the minor’s best interest, and the significance of the social context. There is limited data on the long-term psychological and physical outcomes of treatment yet treatment aims to alleviate the suffering of individuals with gender dysphoria. The available data indicates that long-term outcomes of suppression of puberty are safe and favorable in terms of individual psychosocial function and satisfaction.
References
- Berenbaum, S., & Meyer-Bahlburg, H. (2015). Gender development and sexuality in disorders of sex development. Hormone and Metabolic Research, 47(05), 361-366. doi: 10.1055/s-0035-1548792
- Di Ceglie, D. (2015). Clinical management of gender dysphoria in adolescents. Management of Gender Dysphoria, 61-72. doi: 10.1007/978-88-470-5696-1_8
- Kaltiala-Heino, R., Bergman, H., Työläjärvi, M., & Frisen, L. (2018). Gender dysphoria in adolescence: Current perspectives. Adolescent Health, Medicine and Therapeutics, Volume 9, 31-41. doi: 10.2147/ahmt.s135432
- Ristori, J., & Steensma, T. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13-20. doi: 10.3109/09540261.2015.1115754
- Zucker, K., Lawrence, A., & Kreukels, B. (2016). Gender dysphoria in adults. Annual Review of Clinical Psychology, 12(1), 217-247. doi: 10.1146/annurev-clinpsy-021815-093034