Gender Identity and Gender Identity Disorder

Issues for Clinical Practice

Gender dysphoria (GD) is a term coined for "persistent discomfort with one's biologic sex or assigned gender, replaced the diagnosis of gender identity disorder" in the Diagnostic and Statistical Manual of Mental Disorders in 2013.[¹] The term GD has received tremendous attention, in recent years, because of many cases coming to the fore and the problem also emerging in adolescents in the school setting. There is some reprieve with the term GD as it replaces the earlier terms gender identity disorder (GID) which gave a mental disorder such as connotation to the condition and transgenderism which also was not liked in some quarters. The current article provides an overview of some terms used in GD and related disorders and the clinical dilemmas that may be seen in these conditions.

OVERVIEW OF CLINICAL TERMINOLOGY

• The term GD was first introduced by Fisk to describe "individuals who experience discomfort with their biological sex to form the wish for sex reassignment"[²]
• DSM-IVTR referred to the condition as GID and it was included under the section of sexual disorders[³]
• In the DSM-5, GD is defined as "an individual's affective/cognitive discontent with the assigned gender (usually at birth and referred to as natal gender)" (p. 451)[¹]
• There are many other terms abundant in the literature that has been used to describe these conditions and these include "gender variant," "gender nonconforming," "genderqueer," "bigender," "agender," and "nonbinary," along with the terms "transmale," "transfemale," "transsexual", and "transgender." Sometimes, the word "third gender" is also used.[⁴]

CERTAIN OTHER DEFINITIONS[⁴]

• Gender – denotes "the public (and usually legally recognized) lived role as boy or girl, man or woman." Biological factors combined with social and psychological factors contribute to gender development
• Assigned gender – refers to "a person's initial assignment as male or female at birth." It is based on the child's genitalia and other visible physical sex characteristics
• Gender-atypical – refers to "physical features or behaviors that are not typical of individuals of the same assigned gender in a given society"
• Gender-nonconforming – refers to "behaviors that are not typical of individuals with the same assigned gender in a given society"
• Gender reassignment – denotes "an official (and usually legal) change of gender"
• Sexual identity – A broad term, referring to "an individual's perception of themselves in sexual matters"
• Gender role – it is referred to as "the role or behavior learned by a person as appropriate to their gender, determined by the prevailing cultural norms"
• Sexual orientation – it is referred to "a person's identity in relation to the gender or genders to which they are sexually attracted; the fact of being heterosexual, homosexual, etc."
• Gender identity – is a category of social identity and refers to "an individual's identification as male, female, or occasionally, some category other than male or female." It is one's deeply held core sense of being male, female, some of both or neither, and does not always correspond to biological sex
• GD – as a general descriptive term refers to "an individual's discontent with the assigned gender." It is more specifically defined when used as a diagnosis
• Transgender – refers to "the broad spectrum of individuals who transiently or persistently identify with a gender different from their gender at birth". (Note: The term transgendered is not generally used.)
• Transsexual – refers to "an individual who seeks, or has undergone, a social transition from male to female or female to male." In many, but not all, cases this also involves a physical transition through cross-sex hormone treatment and genital surgery (sex reassignment surgery [SRS])
• Genderqueer – blurring the lines around gender identity and sexual orientation. Genderqueer individuals "typically embrace a fluidity of gender identity and sometimes sexual orientation"
• Gender fluidity – having different gender identities at different times
• Agendered – "without gender," as "individuals identifying as having no gender identity"
• Cisgender – describes "individuals whose gender identity or expression aligns with the sex assigned to them at birth"
• Gender expansiveness – conveys a wider, more flexible range of gender identity, and/or expression than typically associated with the binary gender system
• Gender expression – "the manner in which a person communicates about gender to others through external means such as clothing, appearance, or mannerisms." This communication may be conscious or subconscious and may or may not reflect their gender identity or sexual orientation.

CHANGES IN DSM-5 AS FAR AS GENDER DYSPHORIA IS CONCERNED

• Transsexualism or GID was proposed to be a normal variant of a cisgender identity. Researchers felt that adding it as a disorder in DSM would bring stigma to it and nothing was inherently wrong in a person with gender identity issues. It was debated whether it must be included in DSM-5 or not[⁵]
• It was retained because lack of a legal diagnosis would deny access to health care and insurance reimbursement for SRS would be denied. Some researchers proposed that GID is a medical condition which has a neural and endocrine interface rather than psychiatric connotations but evidence to say that psychopathology never existed was not justifiable and hence it was retained as GD as a separate category than sexual disorders in DSM-5[⁶]
• For inclusion, a reconceptualization was where "identity" was not considered a sign of a mental disorder was considered. The problem was an "incongruence between one's felt gender and assigned sex/gender (usually at birth) leading to distress and/or impairment that was the core feature of the diagnosis."[⁶] Thus, a change in name from GID to GD to better reflect this incongruence was proposed in DSM-5[⁷]
• A 6-month duration criteria were added for clinical reasons to prevent a fast diagnosis and so that no patient with GD gets inappropriately treated and as many times the symptoms of GD may be transitory
• The inclusion of disorders of sexual development (DSD) and intersex conditions under GID has always been a debatable topic. Many patients with DSD may have GD and may want to undergo SRS. The cause of GD is dependent on the type of DSD and the expression of GD by these patients may be similar to other patients with GD but there is a causal mechanism at play here. DSD and GD may be a separate variants of GD and DSD has been included as a specifier in DSM-5[^8,9]
• The specifier of sexual orientation was done away with in DSM-5. While sexual orientation may play an important role in GD, it has been thought that sexual orientation depends on a variety of developmental and environmental factors while GD has distinct causal pathways. Sexual orientation-wise-based GD may be a subtype of GD but rather cannot be specifier as disorder criteria as sexual orientation problems are no longer considered psychiatric problems but are a variant of normal sexual preferences[¹⁰]
• Posttransition as a specifier has been added in DSM-5 as many individuals after gender transition by medical or surgical means may not meet the diagnostic criteria for GD but may need chronic hormonal therapy, further surgeries for gender confirmation, continuous psychotherapy, and medical treatment for any psychopathology that may ensue[¹¹]
• There is a current debate ongoing that GD may be replaced by the term gender incongruence in further editions of DSM as well as ICD-11.

ISSUES AND DILEMMAS FOR CLINICAL PRACTICE

1. Is it prudent that more than one psychiatrist diagnoses GID: This is a vital issue as it often may happen that a single psychiatrist versus a panel of psychiatrist would be better in the diagnosis of GID. The reasons for the same would be that there may be some facets that may be overlooked at times and a panel would be stronger in establishing the diagnosis from a legal and ethical standpoint. How many psychiatrists and whether there must be a psychologist on the same panel is a matter of choice and there is a need for clear guidelines for both government hospital-based clinics and well as private clinics on the same
2. Clinical issues when a 16–17-year-old patient presents with GID: This is important as very often like in the case of personality disorders where we see adolescents between the age of 15–17 years that show all the features of an adult with borderline or antisocial personality but we may not diagnose the same due to the age being below 18 years. It is a very critical clinical issue when we may have 16–17-year-old patients that maybe have all the features of GID and are vehement about gender reassignment surgery. We must realize that no decisions on diagnosis and further gender-related treatments should be taken in a haste and the person must be an adult before such decisions are made
3. Sexual orientation and GID: This is an important issue as in clinical practice sometimes patients that belong to the LGBTQ + community may seek a gender reassignment surgery to be able to be married in a country like India where gay marriages are illegal. This is not actually a case of GID and is actually a sex change sought for a specific purpose. We must be sure that the diagnosis of GID is reserved for actual GID
4. Gender fluidity and GID: The critical factor is sometimes that patients who are gender fluid may feel that they have GID and present with similar symptoms and later develop the insight that they are gender fluid. One must inquire into sexual orientation and outlook as that would be a vital factor in GID. Gender fluidity and GID are different and must be understood separately so that no confusion in diagnosis happens
5. Team approach – sensitivity: The management of GID entails a team approach and it is very important that all team members such as the urologist, andrologist, gynecologist, endocrinologist, and plastic surgeon must be sensitized to the needs of patients with GID and they must equipped to understand the psychological ramifications of the condition and social- and family-based challenges that the patient faces rather than just looking at their roles that they play in the treatment. Constant communication between the team is also vital in these cases
6. GD in school-based settings: Sometimes, in school-based consultation work, we get students studying in the 8^th to 10^th standards that may present with symptoms of GD, and they may express their desire to belong to the opposite gender and this may demand consultations from a GID perspective. It is important that we speak to their parents and orient them about the same and also speak to the student and explain that such feelings may be a normal facet of sexual development as they attain puberty and grow cognitively and sexually. They have to be passing through this with counseling and must wait till they are 18 years before any formal assessment and consult is done
7. GID and body dysmorphic disorder (BDD): Some patients that present with GID may also want a change in gender that is a consequence of impending BDD which may result in them seeking a gender reassignment to help them overcome the repugnance they have for their body and the fact that they are seeking a cure for their problem. This is important as some of these patients may even have delusional disorders and that may cloud their judgment with regard to GID and consent for any examination/procedure
8. History of Child Sexual Abuse: Many patients with GID report child sexual abuse as a trigger point following which their dislike for gender arose. It is prudent that while GID of this nature be treated, one must also treat the child sexual abuse trauma which remains unresolved as the GID may not be true GID but a pseudo-GID and resolution of the child sexual abuse trauma may also result in the resolution of GID symptoms that have been reported
9. Paranoia, schizophrenia, and GID: In one of the studies, it has been reported that patients with GID may report high scores on the paranoia and schizophrenia subscales of the MMPI when psychological evaluated for fitness for gender reassignment surgery. It is important that we understand that the paranoia may often be anxiety-driven and not true paranoia and may be the result of societal stigma and rejection and thus must be evaluated as it may not be psychotic in nature. This is vital when considering the fitness of a patient with GID[¹²]
10. Parental acceptance and societal awareness: Parental acceptance of GID and the acceptance of the patient are one of the greatest social support systems that we can provide the patient with GID. Society and hospitals and medical specialties also need to be aware of the disorder of GID and all that it entails so that these patients are approached with sensitivity and not rejected in treatment settings where there is a lack of awareness of the disorder.