This letter is in response to the case report of the 17-year-old boy from a lower socioeconomic background diagnosed with gender dysphoria (GD) which was published in your journal.
We would want to take this opportunity to highlight that it is important to understand that, sex and gender are not dichotomous categories but fall on a continuum. Hence, it is imperative that we know the difference between biological sex, gender identity, and gender presentation. As in this case, the reader does not get a full picture about the subject's gender identity and gender presentation. If for the sake of argument, we presume that the subject who is biologically a male identifies as a female and was hence diagnosed with GD and then arises the issue of labeling the subject's sexual orientation as homosexual. In our opinion, if the subject identifies as a female and prefers a male sexual partner, then the orientation is heterosexual, because of his female gender presentation.
The treatment modality would depend once we establish the cause of the subject's distress, i.e. if it is associated with not being comfortable with the assigned gender at birth or if it is due to their sexual orientation. There is robust evidence to prove that psychotherapy is the mainstay treatment in such cases. Gender reassignment treatments may be required depending on the client's request.
In line with minority stress theory, psychiatric morbidity in LGBTQ+ community is already high. To diagnose gender incongruence as a mental disorder in a historically disadvantaged community further increases stigma, rather then helping them. To be more inclusive in our practice, it is being advocated to routinely ask about the client's preferred pronouns or use gender neutral pronouns such as singular they/them and respected person. The new transgender persons (Protection of Rights) Act, 2019, pave way to ease the process to self-identify their gender by a transexual, as upheld by a recent judgment by the Bombay Supreme court and has removed the role of physical screening by doctors.
As psychiatrists, we should be considerate about the sociocultural implications of shelving a person in one of the diagnostic categories. We need to be sensitive while applying the Diagnostic and Statistical Manual of Mental Disorders-5 diagnosis of GD to transexual persons, as not all transexual persons suffer from GD. The renaming of “transsexualism” to gender incongruence and re-classification from mental disorders to a separate chapter (chapter 17) called “conditions related to sexual health” in International Classification of Diseases (ICD) 11th Revision is a welcome step. This diagnosis is more appropriate as it uses the terms which have less psychopathological connotations, i.e., dislike or discomfort instead of distress.
Our hope is that in future, WHO takes the same route as homosexuality, demedicalize being transexual by completely removing it from ICD. To ensure medical service utilization and for administrative purposes, it can be added in the “Z” category of ICD.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
1. Nathvani M, Saini VK, Gehlawat P. Sociocultural barriers in management of gender dysphoria: A case report Indian J Psychiatry. 2021;63:106–7
2. Ladenheim A, Wormser GP. A new gender-neutral honorific: 'RP' Am J Med. 2019;132:902–4
3. American Psychological Association. Therapy Supporting and Affirming LGBTQ Youth. 2015Last accessed on 2020 Jun 03 Available from: https://www.apa.org/advocacy/civil-rights/sexual-diversity/lgbtq-therapy
4. Cochran SD, Drescher J, Kismödi E, Giami A, García-Moreno C, Atalla E, et al Proposed declassification of disease categories related to sexual orientation in the International Statistical Classification of Diseases and Related Health Problems (ICD-11) Bull World Health Organ. 2014;92:672–9
5. Bombay HC Asserts TRANSGENDER People's Right to SELF-IDENTIFY their Gender. 2021Last accessed on 2021 Mar 20 Available from: https://thewire.in/lgbtqia/bombay-hc-asserts-transgender-peoples-right-to-selfidentify-their-gender