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Other Sexual Disorders: Gender Dysphoria

Lorraine Benuto, Ph.D., edited by C. E. Zupanick, Psy.D.

Previously known in the DSM-IV-TR as Gender Identity Disorder, this condition has become Gender Dysphoria in the DSM-5. This condition is in its own category separate from Sexual Dysfunctions. However, we offer a brief look at the condition here.

The DSM-5 continues to offer a fairly detailed description of Gender Dysphoria with information about what this disorder might look like in childhood, adolescence, and adulthood. In all three stages of life, it includes strong and persistent cross-gender identification. In fact, typically symptoms are apparent in childhood and continue throughout adolescence and adulthood, and are unrelenting. It is important to note that in some cultures a particular gender may be more valued than the other, and therefore more advantageous in terms of status, power, rank, food, job availability, division of labor, etc. Thus, if the reason for the interest in being the opposite sex is merely to have that type of advantage, this disorder would not be diagnosed.

upset teen Children with gender dysphoria may repeatedly state a desire to be the opposite gender, and may even insistent they are the opposite sex. Boys might demonstrate preference for cross-dressing, and girls might insist on only wearing stereotypically, masculine clothing. Play might also be impacted via a strong and persistent preference for cross-sex roles in make-believe play. These children may demonstrate an intense desire to participate in the stereotypical games and pastimes of the other sex, and a strong preference for playmates of the opposite sex. Furthermore, boys may avoid rough-and-tumble play and reject of male stereotypical toys, games, and activities. Children may demonstrate disgust toward their genitals. Girls may insist on urinating standing up and state that they have, or will grow, a penis, and that they do not want to grow breasts or menstruate.

In adolescence and adulthood, the disorder will continue to present itself via symptoms such as a stated desire to be the other sex, a desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex (i.e., "I am a woman trapped in a man's body"). There will also be persistent discomfort with his or her sex, or a sense of inappropriateness in the gender role of that sex. Eventually, there might be a strong preoccupation to get rid of the primary and secondary sex characteristics.

Gender Dysphoria is rare and affects men more often than women. It is important to note the difference between this condition and transvestic fetishism which was discussed earlier. Gender Dysphoria is much more complicated than transvestic fetishism. While dressing in opposite sex clothing may be a component of both disorders, the reason for the behavior is completely different. In fact, in gender dysphoria, the primary goal is not sexual but rather involves a more global desire to live openly as a member of the opposite sex. Moreover, individuals with gender dysphoria have no physical abnormalities as is the case with intersex individuals (i.e., individuals with reproductive organs of both genders such as hermaphrodites). Gender dysphoria should not be confused with homosexual arousal patterns such as homosexual men who behave in feminine ways. People who have gender dysphoria may become depressed as they may face ridicule and rejection by society, and even their own families. They may isolate themselves and only engage in activities where gender has no place.

Possible Causes of Gender Dysphoria

A number of theories have been suggested regarding the cause of gender dysphoria. Gender identity is thought to establish itself early in life. When some children exhibit cross-gender behavior the behavior may be reinforced or even encouraged. Why might such behavior be reinforced? Zucker (1996) uses the term, "pathological gender mourning" and asserts that this may happen when a mother is disappointed with the birth of yet another boy. This mourning may negatively influence her relationship with her younger sons. This might explain why sibling sex ratio and birth order have been found to be related to gender dysphoria. In fact, research has indicated that boys who have gender dysphoria tend to come from families where there are a lot of brothers. Furthermore, Zucker and colleagues (1997) have found that boys with gender dysphoria tend to have a later birth order than boys without gender dysphoria. Thus, it has been suggested that if a mother is expecting (and strongly hoping for) a daughter but has a son, she may unknowingly reinforce cross-gender behaviors.

From a biological perspective, interesting research has happened. The relationship between hormones and fetal development has been considered. It is proposed that higher levels of testosterone or estrogen at certain critical periods of development might masculinize a female fetus, or feminize a male fetus. Females exposed to increased androgens before birth are more likely to display stereotypically male gender roles. Other researchers have suggested that there is an inherited, genetic component to gender identity disorder. Finally, some researchers from a socio-cultural perspective have proposed that Western culture idealizes both men and women according to certain stereotypical variables which may influence gender identify development.

Recommended Treatments for Gender Dysphoria

Clinical approach greatly depends upon the age of the individual. As people with Gender Dysphoria naturally age, the condition becomes more ingrained. Most studies evaluating the effectiveness of sex reassignment surgery indicate psychological improvement following the surgery. Those dissatisfied after surgery tend to focus on unalterable bodily characteristics, such as large hands and feet, the persistence of the Adam's apple, and the quality of their voice. Criteria have been developed to select candidates for surgery to ensure that people seeking sex reassignment are appropriate candidates. To qualify for sex reassignment surgery, individuals must live in the opposite-sex role for 1 to 2 years so that they can become certain they want to change sex. Additionally, they must be stable psychologically, financially, and socially. Reassignment surgery is irreversible.

In male-to-female candidates, hormones are administered to promote gynecomastia (i.e., growth of breasts) and the development of other secondary characteristics. Facial hair is removed via electrolysis, and only later the genitals are removed and a vagina constructed. For female-to-male candidates, an artificial penis is constructed via an often-difficult plastic surgery, and breasts are surgically removed.

Approximately 75% report satisfaction with surgery and good adjustment, with female-to-male conversions adjusting better than male-to-female and 7% of reassignment cases regret surgery. While the use of an artificial penis or vagina may not be the same as having a natural penis or vagina, most people who have sex-reassignment surgery do tend to feel relief in that the outside world begins to view them as they have long-since viewed themselves.