Gender Dysphoria Flashcards
what criterion MUST be present for a diagnosis of gender dysphoria in children
a STRONG DESIRE to be of the other gender or an INSISTENCE that one if the other gender (or some alternative gender different from one’s assigned gender)
how many symptoms are required, amongst those listed in criterion A for gender dysphoria, to meet criteria for gender dysphoria in children
6 (out of a possible 8)
what is criterion A for gender dysphoria in children
a MARKED INCONGRUENCE between one’s experienced/expressed gender and assigned gender, of at least SIX MONTH duration, as manifested by at least SIX of the following (of which one must be number 1)
- a STRONG DESIRE to be of the other gender or an INSISTENCE that one if the other gender (or some alternative gender different from one’s assigned gender)
- in boys (assigned gender),a. strong preference for CROSS DRESSING or simulating female attire; or in girls (assigned gender), a strong preference for wearing only TYPICAL MASCULINE clothing and a strong resistance to the wearing of typical feminine clothing
- a strong preference for CROSS GENDER ROLES in make believe play or fantasy play
- a strong preference for the TOYS, games, or activities stereotypically used or engaged in by the other gender
- a strong preference for PLAYMATES of the other gender
- in boys (assigned gender), a strong rejection of typically masculine toys, games and activities and a strong avoidance of rough and tumble play; in girls (assigned gender), a strong rejection of typically feminine toys, games and activities
- a strong DISLIKE of ones SEXUAL ANATOMY
- a strong desire for the primary and/or secondary SEX CHARACTERISTICS that match one’s experienced gender
what is criterion B for gender dysphoria in children
the condition is associated with clinically significant distress or impairment in school, social, or other areas
what specifier is there for gender dysphoria in children
with a disorder of sex development (i.e a congenital adrenogenital disorder such as congenital adrenal hyperplasia or androgen insensivitity syndrome)
how many symptoms are listed in criterion A for gender dysphoria in adolescents/adults? how many are required for diagnosis?
6 total listed
2 required
what is criterion A fro gender dysphoria in adolescents/adults
a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least SIX MONTHS duration, as manifested by at least TWO of the following:
- a marked incongruence between ones experienced/expressed gender and primary and/or secondary sex characteristics
- a strong desire to BE RID of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender
- a strong desire for primary/secondary sex characteristics sex characteristics of the other gender
- a strong desire to of the other gender (or some alternative gender)
- a strong desire to be TREATED AS the other gender
- a STRONG CONVICTION that one has the TYPICAL FEELINGS and reactions of the other gender
what specifiers are available for gender dysphoria in adolescents/adults
- with a disorder of sex development
- posttransition
what does the gender dysphoria in adolescents/adults specifier “posttransition” indicate
the individual has transitioned to FULL TIME LIVING in the desired gender (with or without legalization of gender change) and has undergone or is preparing to undergo at least ONE CROSS SEX MEDICAL PROCEDURE or treatment regimen (namely, regular cross sex hormone treatment or gender reassignment surgery confirming desired gender)
what is the core component of the diagnosis of gender dysphoria
the discrepancy between experienced/expressed gender and assigned/natal gender
+
evidence of DISTRESS about this
list two hormone suppressors /”blockers” of gonadal steroids that may be requested or used without Rx for the suppression of secondary sex characteristics in gender dysphoria
gonadotropin releasing hormone analog (GnRH analog) or spironolactone
how does gender dysphoria affect suicide risk
adolescents and adults with gender dysphoria before gender reassignment are at increased risk for SI, SAs and suicides
after gender reassignment, ADJUSTMENT MAY VARY, and suicide risk may persist
what are prevalence rates for gender dysphoria
natal males–> 0.005%-0.014%
natal females–> 0.002%-0.003%
*likely modest underestimates
what are the sex ratios of the rate of referrals to speciality clinics for gender dysphoria
more natal males than females referred in childhood (2:1-4.5:1)
teens–> about equal
adults–> more natal males than females referred (1:1-6.1:1 range)
in which two countries are more adult natal females referred to specialty clinics for gender dysphoria
poland and japan
for clinic-referred children, the onset of cross-gender behaviours usually occurs at what age
between 2-4 years old
*corresponds to developmental time period in which most typically developing children begin expressing gendered behaviours and interests
in what % of natal males does gender dysphoria persist from childhood into adolescence
2.2-30%
in what % of natal females does gender dysphoria persist from childhood into adolescence
12-50%
do we know why gender dysphoria persists in some kids and not others?
modest correlation with SEVERITY at time of baseline assessment
modest correlation between lower SES and persistence in natal males
UNCLEAR if children “encouraged” or supported to live socially in the desired gender will show higher rates of persistence as such children have not yet been followed longitudinally in a systematic manner
what feature do both natal female and male persons with persistent gender dysphoria share
almost all are sexually attracted to individuals of their natal sex
what is the most common sexual orientation in natal males whose gender dysphoria does NOT persist
majority are sexual attracted to males and often self ID as gay/homosexual
what is the most common sexual orientation in natal females whose gender dysphoria does NOT persist
only about 32-50% are sexually attracted to females and go on to ID as lesbian
what are the two broad trajectories for development of gender dysphoria
early and late onset
what is early onset gender dysphoria
begins in childhood and persists into adolescence and adulthood
what is late onset gender dysphoria
occurs around puberty or much later in life
(some recall long hx of wanting to be other gender, some do not recall any signs of childhood gender dysphoria… for teen males with late onset gender dysphoria, parents often report surprise because they did not see signs of gender dysphoria during childhood)
how does sexual orientation tend to vary between those natal males with early vs late onset gender dysphoria
early onset–> almost always attracted to men
late onset–> frequently engage in transvestic behaviour with sexual excitement; majority are gynephilic (attracted to women) or sexually attracted to other post-transition natal males with late onset gender dysphoria
–> substantial % of this pop cohabit with or are married to natal females ; after transition, many ID as lesbian
in both adolescence and adult natal females, what is the most common form of gender dysphoria
early onset (late onset much less common in natal females than natal males)
how does sexual orientation vary in natal females with early vs late onset gender dysphoria
early onset–> almost always gynephilic
late onset–> almost always androphilic (and go on to ID as gay men)
–> natal females with late onset gender dysphoria do NOT have no occurring transvestic behaviour with sexual excitement
why are physicians often more willing to perform cross-sex hormone treatments and genital surgery before adulthood in those people who have gender dysphoria in association with a disorder of sex devleopment
as infertility is common in this population
is gender dysphoria common in those who also have a disorder of sex development?
gender dysphoria does not occur in majority of cases of those iwth disorders of sex development
as they become aware of med hx and condition, many experience UNCERTAINTY about their gender as opposed to firm conviction that they are another gender
most do NOT progress to gender transition
gender dysphoria + gender transition may vary substantially as a function of a disorder of sex development, its severity and assigned gender
is there a genetic component to gender dysphoria
maybe–> seems to be some degree of heritability
weak familiality of transsexualism amongst nonsibling twins + monozygotic vs dizogotic same sex twins
is there evidence to label gender dysphoria without disorder of sex development as a form of intersexuality limited to the CNS?
current evidence INSUFFICIENT for this
is the prenatal androgen milieu more closely related to gendered behavior or identity
behaviour (though there is some correlation with identity… just not robust enough to be used as diagnostic marker)
many people with disorders of sex development and markedly gender atypical behaviour do NOT develop gender dysphoria
this, gender atypical behaviour BY ITSELF should not be interpreted as an indicator of current or future gender dysphoria
ddx gender dysphoria
nonconformity to gender roles
transvestic disorder
BDD
schizophrenia and other psychotic disorders
other clinical presentation (i.e males seeking castration for aesthetic reasons etc)
what is transvestic disorder
occurs in heterosexual (or bisexual) adolescent and adult males (rarely in females) for whom cross dressing behaviour generates SEXUAL EXCITEMENT and causes distress/impairment WITHOUT drawing primary gender into question
(occasionally accompanied by gender dysphoria)
what are the most common comorbid psych disorders in clinically referred children with gender dysphoria
anxiety
depressive
disruptive and impulse control disorders
what neurodevelopmental disorder is more prevalence in clinically referred children + teens with gender dysphoria than in the general population
autism
what endocrinological difference has been found in natal females with gender dysphoria
increased androgen levels (but still below those of natal males)
how do you approach treatment/what is the treatment for children with gender dysphoria
individual, family and group therapy that guides in exploring their gendered interests and identities
what agent can be used to temporarily block release of hormones that lead to secondary sex characteristics
GnRH agonists
what is the treatment for adults with gender dysphoria
psychotherapy to explore gender issues
hormonal treatment
surgical treatment
are regrets common for those undergoing gender reassignment surgery
WPATH: “regrets were extremely rare”
can gender dysphoria be alleviated without hormone or surgical treatments in adults and teens
WPATH: “hormone therapy and surgery have been found to be MEDICALLY NECESSARY to alleviate gender dysphoria in many people” (some only need one or the other, some need both, and some are able to integrate their gender identity with their assigned gender without intervention–tx is more individualzied now)
is treatment aimed at changing a persons gender identity and expression to become more congruent with assigned sex considered ethical
no, not anymore
what are fully reversible interventions for gender dysphoria for teens
GnRH analogues to suppress sex hormone production and delay changes assoc. with puiberty
also can use progestins or other medications like spironolactone that decrease the effects of androgens secreted by testicles of those not on a GnRH analogue
continuous OCP can be used to suppress menses
are physical interventions ever used in children with gender dysphoria
no–> psychotherapy and support only
can socially transition
list partially reversible interventions for gender dysphoria in teens
hormone therapy to masculinize or feminize body
some hormone induced changes may need reconstructive surgery to reverse the effect i.e gynecomastia caused by estrogens
other changes are not reversible–> deepening of voice cause by testosterone
what are irreversible intervention for gender dysphoria
surgical procedures
what are the 4 criteria for puberty suppressing hormones for gender dysphoria in teens? (WPATH 7, the old one)
- teen has demonstrated a long lasting and intense pattern of gender nonconformity or gender dysphoria (whether suppressed or expressed)
- gender dysphoria emerged or worsened with onset of puberty
- any coexisting psychological, medical or social problems that could interfere with treatment (i.e that may compromise treatment adherence) have been addressed such that the adolescents situation and functioning are stable enough to start treatment
- teen has given informed consent and, particularly when ten has not reached age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the teen throughout the treatment process
what negative side effects do you worry about with using GnRH analogues to treat gender dysphoria
negative impact on height and bone development
what criteria need to be met for a person to undergo genital surgery for gender dysphoria
- patient is legal age of majority to give consent for medical procedures
- patients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity
how many referrals from a qualified mental health professional are needed for breast/chest surgery in gender dysphoria
one
how many referrals from a qualified mental health professional are needed for genital surgery for gender dysphoria
two–> who have independently assessed the patient
is psychotherapy an absolute requirement for hormone therapy and surgery for gender dysphoria
no (but a mental health assessment is needed, but not necessarily ongoing therapy)
what physical changes can be expected to occur due to hormone therapy in a FtM patient
deepened voice
clitoral enlargement
growth in facial hair and body hair
cessation of menses
atrophy of breast tissue
decreased percentage of body fat compared to muscle mass
what physical changes can be expected to occur due to hormone therapy in a MtF patient
breast growth
decreased erectile function
decreased testicular size
increased percentage of body fat to muscle mass
over what period of time do the physical changes assoc. with hormone therapy for gender dysphoria generally occur
over about two years
exact timelines vary
feminizing hormones are LIKELY to increase risk of what possible side effects
VTE
gallstones
hypertriglyceridemia
weight gain
elevated liver enzymes
masculinizing hormones are LIKELY to increase risk of what possible side effects
polycythemia
weight gain
acne
androgenic alopecia/balding
sleep apnea
*also possible increased risk for destabilizing other psych disorders
is there increased risk of breast cancer with feminizing hormones
no
