psychiatric disorders
Gender Incongruence and Gender Dysphoria
Symptoms and Signs of Gender Incongruence and Gender Dysphoria
Although this section is called symptoms and signs, it also discusses experiences and characteristics of gender-diverse individuals who do not have gender dysphoria. Childhood gender diversity is a frequent occurrence in general human development ( Symptoms and signs references ) and is not itself a mental disorder nor necessarily an indication that a child has a transgender identity ( Childhood gender dysphoria is a clinical diagnosis that often manifests as early as age 2 to 3 years but may become apparent at any age. Most children with gender dysphoria are not evaluated until they are age 6 to 9. Children with gender dysphoria commonly present with the following for at least a 6-month period ( Symptoms and signs references ): Prefer cross-dressing Insist that they are of the other sex Wish that they would wake up as the other sex Prefer participating in the stereotypical games and activities of the other sex Prefer playmates of the other gender Have a strong dislike of their sexual anatomy For example, a young girl may insist she will grow a penis and become a boy, and she may stand to urinate. A boy may fantasize about being female and avoid rough-and-tumble play and competitive games. He may also wish to be rid of his penis and testes. For boys, if distress at the physical changes of puberty is present, this is often followed by a request during adolescence for feminizing somatic treatments. The gender trajectory for gender-incongruent prepubescent children cannot be reliably predicted in advance. Some studies have found that a majority of study participants with childhood gender incongruence remained stable in this gender identity as adolescents ( Symptoms and signs references ). In other studies, among study participants diagnosed with gender dysphoria as children, a minority continued to meet diagnostic criteria for gender dysphoria as adults ( There is considerable controversy over whether or at which age to support the social and/or medical gender transition of young prepubertal children with gender dysphoria. There is no conclusive research to guide this decision ( Symptoms and signs references The current World Professional Association for Transgender Health (WPATH) Standards of Care, version 8 ( Symptoms and signs references ) provide guidance for experts working in this sensitive area. These guidelines recommend that parents/caregivers and health care professionals respond supportively to children who desire to be acknowledged as the gender that matches their internal sense of gender identity. They also recommend that parents/caregivers and health care professionals support children to continue to explore their gender throughout the pre-pubescent years, regardless of social transition ( Gender-diverse children and adolescents as a group are more likely to experience trauma, bullying, isolation, and mental health difficulties than their cisgender peers ( Symptoms and signs references ). The increase in suicidality and depression in adolescents who identify as transgender or gender diverse has garnered substantial attention and study ( Some transgender children or adolescents make a social transition. This may involve one or more of the following changes during childhood: name change, pronoun change, changing sex markers on documents and school records; participation in "other" gender sports, recreational clubs, camps; changing the bathroom and locker room used to be consistent with experienced gender; communication of experienced/affirmed gender to other people publicly; and personal expression changes (eg, hair styles, clothing, jewelery choices) ( Symptoms and signs references ). Many adults diagnosed with gender dysphoria have early gender dysphoria symptoms or experience a sense of being "different" in early childhood, but some do not present until adulthood and had no evidence of childhood gender incongruence. Transwomen may first identify as cross-dressers and only later in life come to embrace their transgender identity. Some gender-dysphoric persons initially make choices consistent with their sex assigned at birth (eg, marriage, military service), and frequently admit, in retrospect, that they were not comfortable with their emerging transgender/gender-diverse feelings and made life decisions to try to avoid dealing with them. For those assigned male at birth, this has been described as a "flight into hypermasculinity" ( Symptoms and signs references ). Once they accept their transgender identity and publicly transition gender, many transgender people blend seamlessly into the fabric of society in their preferred gender identity—with or without gender-affirming hormone therapy or gender-affirming surgery. Transgender people may feel comfortable with a variety of methods of expressing their gender identity. Some transwomen are satisfied with mastering a more feminine appearance and obtaining female identification documents (eg, driver’s license, passport) to help them work and live in society as women. Likewise, many patients assigned female at birth choose to proceed with a social transition, and with the assistance of gender-affirmingtestosteronetherapy (whether or not mastectomies and/or chest reconfiguration are performed) appear and sound quite masculine. Other gender-diverse people experience problems, which may include Overview of Anxiety Disorders , 1.Endocrine Society, Pediatric Endocrine Society: Position statement: Transgender health. Endocrine Society. Accessed May 19, 2023. 2.Ehrensaft D: Exploring gender expansive expressions. InThe gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children, edited by Keo-Meier C, Ehrensaft D, American Psychological Association, Washington, DC. 3.American Psychiatric Association:Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Text Revision (DSM-5-TR). Washington, DC, American Psychiatric Association, 2022. 4.Olson KR, Durwood L, Horton R, et al: Gender identity 5 years after social transition.Pediatrics150 (2): e2021056082, 2022. https://doi.org/10.1542/peds.2021-056082 5.Singh D, Bradley S, Zucker K: A follow-up study of boys with gender identity disorder.Front PsychiatryVolume 12, 2021. https://doi.org/10.3389/fpsyt.2021.632784 6.Wallien MSC, Cohen-Kettenis PT: Psychosexual outcome of gender-dysphoric children.J Am Acad Child Adolesc Psychiatry47(12)1413-1423, 2008. doi: 10.1097/CHI.0b013e31818956b9 7.Chen D, Edwards-Leeper L, Stancin T, et al: Advancing the practice of pediatric psychology with transgender youth: State of the science, ongoing controversies, and future directions.Clin Pract Pediatr Psychol6(1):73-83, 2018. doi: 10.1037/cpp0000229 2 8.Travers A:The Trans Generation: How Trans Kids (and Their Parents) Are Creating a Gender Revolution.New York, New York University Press, 2018. 9.World Professional Association for Transgender Health: Standards of Care Version 8. 10.Barrow K, Apostle D: Addressing mental health conditions often experienced by transgender and gender expansive children. InThe gender affirmative model: An interdisciplinary approach to supporting transgender and gender expansive children, edited by Keo-Meier CE, Ehrensaft DE. American Psychological Association. 2018. 11.Ristori J, Steensma TD: Gender dysphoria in childhood.Int Rev Psychiatry28(1),13-20, 2016. https://doi.org/10.3109/09540261.2015.1115754 12.Turban JL, King D, Carswel JM, et al: Pubertal suppression for transgender youth and risk of suicidal ideation.Pediatricse20191725, 2020. https://doi.org/10.1542/peds.2019-1725 13.Turban JL, King D, Kobe J, et al: Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults.PLoS One17(1): e0261039, 2022. https://doi. org/10.1371/journal.pone.0261039 14.Brown GR: Transsexuals in the military: flight into hypermasculinity.Arch Sex Behav17(6):527-537, 1988. doi: 10.1007/BF01542340 15.McDuffie E, Grown GR: 70 U.S. veterans with gender identity disturbances: A descriptive study.J Transgenderism12(1):21-30, 2010. https://doi.org/10.1080/15532731003688962 16.Brown GR, Jones KT: Mental health and medical outcome disparities in 5135 transgender veterans receiving health care in the Veterans Health Administration: A case-control study.LGBT Health3(2):122-131, 2016. doi: 10.1089/lgbt.2015.0058 