Controversies in The Management of Gender Dysphoria

Educational Objectives

The goal of this program is to improve the management of gender dysphoria. After hearing and assimilating this program, the clinicians will be able to:

1. Define various terms used in the care of transgender and gender-nonconforming persons.
2. Identify barriers to care that affect transgender individuals.
3. Destigmatize conversations about transgender issues in clinical and social settings.
4. Recognize trends in the prevalence of adolescents presenting with gender dysphoria to specialty clinics.
5. Advocate for individuals with gender dysphoria who need care.

Summary

Definitions: the word “sex” refers to biology; “gender” refers to how a person expresses themselves; biology and psychosocial factors have some role in the creation of gender; historically, sexual orientation and gender identity were conflated; sexual orientation is the erotic response tendency or sexual attraction; when directed toward someone of the same sex it is referred to as homosexuality; if directed toward a different sex, it is heterosexuality; if directed toward both sexes, it is called bisexuality; when working with transgender populations, this terminology is challenging as sexual orientation before and after transition can differ; androphilic is being attracted to men, and gynephilic is being attracted to women; a person may be androphilic or gynephilic both before and after transition; gender identity is unrelated to sexual orientation; sexual identity is the subjective experience of sexual desires or attractions; a person may have homosexual attraction but reject a gay identity; gender identity refers to whether an individual identifies as male, female, or some other category

In terms of gender: “transgender” — colloquial, not scientific; part of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) umbrella; it was coined in the 1970s to describe persons whose gender identity, expression, and behavior did not conform to what was typically associated to their gender assigned at birth; “genderfluid” and “gender nonconforming” — later developed and are used variably; patients can be asked how they define their own identity as it is subjective; gender expression — increasingly accepted in legal settings; refers to how a person demonstrates their gender to others via dress, behaviors, and appearance; some places have legal protections to prevent discrimination against people who have atypical gender expression; gender assignment — occurs at birth; historically, the terms “biological male” and “biological female” were used; however, the origin of the biology of gender is unknown; it is commonly believed that genitalia at birth are an indication of the gender the person develops; this is true for the majority, but not everyone; when working with these patient populations, they are referred to as birth-assigned male or female; the language is changing; the terms “natal female” and “natal male” have grown out of use

Disorders of sex development: inborn somatic deviations of the reproductive tract from the norm or discrepancies from conventional biological indicators of male and female sex; people with such conditions were historically called “hermaphrodites” and are now referred to as being intersex; some members of the community do not like the term “disorders of sex development” and prefer “differences in sex development”

Gender dysphoria: refers to the distress that accompanies incongruence between experienced and assigned gender, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), and replaced the term “gender identity disorder”; gender incongruence — the term used in the International Classification of Diseases, 11th Revision (ICD-11), to describe the same condition and is used in many countries; replaced the terms “transsexualism” and “gender identity disorder of childhood”, which were previously used

Gender reassignment or confirmation: refers to an official or legal change of gender; may involve social transition, implying no use of medical or surgical interventions and only change in clothing, name, and pronouns; may involve hormone treatment with masculinizing or feminizing hormones; some people may choose gender confirmation surgery (previously called “sex reassignment” surgery) to change existing sexual characteristics to resemble those of the other sex; this may involve top surgery (eg, mastectomy, breast implants) or bottom surgery to alter genital appearance

Gender-affirming treatment: not all transgender patients receive or can afford all treatments; there is a broad range of clinical appearances and patient desires; with the exception of children with intersex conditions, surgery is rarely performed; “transsexual” is a historic medical term for people who receive hormones or surgical treatments; it was divided into partial or complete based on the treatments received; patients who transitioned from their birth-assigned sex were referred to as male-to-female (transwomen) or female-to-male (transmen); in the past, a birth-assigned male attracted to women who wished to transition to female could not disclose their sexual orientation, as they would be considered a lesbian after undergoing gender confirmation surgery, and clinical practice was historically heteronormative; “cisgender” is a term used by the transgender community to describe persons whose gender identities align with their assigned sex at birth and is gradually entering popular language

Transphobia: patterned on the word “homophobia”; includes a wide range of negative attitudes, feelings, or actions toward transgender persons; underlies much of the social stigma against transgender individuals and certain laws, eg, bathroom bills that force birth-assigned males to use men's bathrooms regardless of their physical appearance; also leads to fatal violence, which disproportionately affects transgender women of color

Social issues: misgendering — the lack of recognition of the gender expression of a person; while it can happen accidentally, it is sometimes deliberate; deadnaming — refers to the use of the pretransition name of a transgender person and refusal to recognize their posttransition name; this can also be accidental or deliberate; the best approach to knowing which pronoun to refer to someone by is to ask them directly; patient preference should be recorded in the beginning of the chart and used consistently; even if their pretransition name is on their insurance, this is not an issue; gender policing — defined as the imposition or enforcement of normative gender expression on others; by age 3 or 4 yr, children learn about the world in binary terms; “male and female” is one of the first binaries children learn, and they learn to code people accordingly; therefore, it is common to police gender if a person does not express gender typically; gatekeeping — this term originates from the transgender community; it is a definition of psychiatric evaluation, since, until recently, transition was not possible without the permission of a mental health professional who could testify that the person was a “true” transsexual; this is no longer the standard of care for hormonal treatment, but surgeons still require letters from mental health professionals attesting to a diagnosis that supports them providing transition surgery; gender policing is also seen in the realm of countertransference

Clinical controversies: the DSM-5 was created during the age of the internet and was subject to public scrutiny; the American Psychiatric Association was accused of stigmatizing expressions of gender variance as symptoms of a mental disorder; there was a push for these diagnoses to be excluded or depathologized, as well as to retain them from advocacy groups who represented the interests of transgender people; there were concerns that removing the diagnosis would affect access to care; there were also suggestions to make it a V code, representing a condition that might come to the attention of a mental health professional but is not a mental disorder; however, the V code is not reimbursed and would not solve the issue of access to care; in the United States, if a transwoman is arrested, she is put into a men’s prison and may not be given hormone treatments; advocacy groups for these patients argue that this is a medical condition that requires treatment, and denying it is cruel and unusual punishment, which is unconstitutional; for these reasons, the diagnosis was retained as one overarching diagnosis with separate developmentally appropriate criteria for children, adolescents, and adults; the only recommendation rejected was not to use “other” and “unspecified” categories, which are subthreshold categories for making a diagnosis; the DSM changes with time as clinical thinking and research evolves

ICD-11: published by the World Health Organization; in 2019, the recommendation was made to remove the diagnosis from the chapter on mental disorders; unlike the DSM, which is binary, the ICD has more options; access to care could therefore be maintained by moving the diagnosis to a new chapter called “Conditions Related to Sexual Health”; there are diagnoses for adolescents, adults, and children; the DSM-5 and ICD-11 refer to prepubescent children, as those who develop gender incongruence or dysphoria before puberty are mostly a different patient population than those who develop it after puberty; the ICD-11 has an “unspecified” category as well; some articles protested the retention of a childhood diagnosis due to concerns that they were pathologizing children, but as the ICD-11 contains conditions like menopause, which are not medical illnesses but have codes to ensure access to care, it was not removed; the ICD-11 is used by 80 countries, but it is not yet used in the United States as this would require changes to hospital and insurance databases

Treatment of prepubescent children: most children who develop dysphoria before puberty do not grow up to be transgender, but homosexual and cisgender, and a small number grow to be heterosexual; these children are called “desisters”; children who do not outgrow dysphoria are called “persisters”; many transgender advocates dislike these terms, claiming that they rely on overtly inclusive criteria for gender identity disorder; however, this dislike may also be because they contradict the belief that people are born transgender; research shows that transgender children make up <1% of the population, but the number of children presenting to gender clinics is increasing significantly; most of these children were desisters, and there was no way to predict who would be a desister or a persister; the belief was that dysphoria persisting into adolescence was more likely to persist into adulthood, and that the presentations and needs of prepubertal children were different; the relative contributions of biology and psychosocial environment in development of gender identity and the stress related to it are unknown; there was significant controversy on how to manage gender dysphoria in prepubertal children

Treatment approaches: one clinic in Canada attempted to reduce gender dysphoria by making children more comfortable with the bodies they were born with, so that they would not grow up to be transsexual or transgender; a clinic in Amsterdam used watchful waiting, and worked with the families to help them accept the atypical behavior; however, they did not think children should socially transition until they were older; clinics in the United States have used a gender affirmative approach, ie, they thought the children would benefit from social transition and encouraged everyone to help them transition; if the children changed their minds, they could transition back socially; puberty suppression was used for all children as some did not desist until after puberty; no randomized controlled trials were done to compare these approaches; puberty blockers were approved in 1980 to treat precocious puberty; it is considered the gold standard, and all three approaches allow puberty suppression; children with gender dysphoria who undergo puberty may have severe reactions to the changes or anticipated changes in their bodies and often want to avoid developing secondary sex characteristics of the dysphoric gender; puberty blockers can affect bone metabolism and cause mineralization and osteoporosis, which are remedied with sex steroids; puberty blockers have been well studied; 20 states in the United States have passed laws banning efforts to change the sexual orientation or gender identity of a minor

Prevalence and other concerns: more adolescents are presenting to specialty clinics; around the mid-2010s, the birth-assigned sex ratio of patients with gender dysphoria was equal, but currently, more birth-assigned females are presenting than birth-assigned males; the emotionally charged nature of the topic has resulted in opposition to puberty suppression and allegations that puberty blockers are experimental; however, it is no less evidence-based than most other approaches in medicine or surgery; some people believe children should not be able to make these decisions as they cannot understand the long-term consequences; this is reasonable, and children usually do not make these decisions on their own; most children decide with permission from their parents; other concerns include future fertility and the possibility of regretting the decision to transition; some people do not believe that gender dysphoria exists; several psychotherapists and psychoanalysts feel it is a symptom of another underlying issue, and some of them advocate gender exploratory therapy; others feel that no medical treatment should be provided until the age of 25 to 30 yr as the human brain does not fully develop until then; “detransitioning” refers to stopping or reversing gender-affirming care, eg, hormones and surgical procedures; some people may detransition but continue to identify as transgender or nonbinary, while some may reidentify with their birth-assigned sex

Regret: estimates of regret range from 1% to 13%; a study of 100 people who detransitioned found no single reason for regret; some literature suggests that it may be iatrogenic, but this is rare; in one study, the personal definitions of “male” and “female” changed for some people, and they became comfortable identifying with their birth-assigned sex; nearly half the participants changed because of concerns about medical complications; some people may find the medical challenges of transitioning uncomfortable and choose to detransition; due to the sensationalization of the topic, it is not considered in a way that other concepts in medicine are considered; some people felt that transitioning did not make them feel better and chose to detransition, and others were unhappy with the physical results; some discovered that a trauma or mental health condition was causing their dysphoria; for some people, external pressure and cost of treatment were issues; to better serve these patients, time and money should be invested in research and training

Legal and ethical issues: a lawsuit was filed against a gender clinic in London, claiming concerns about the ability of minors to give informed consent for puberty suppression; the Court of Appeal stated that clinicians can decide on competence, but the clinic was stopped; 2 regional health centers, and relationships between their clinical and academic representatives, were set up instead; rather than stopping treatments, clinicians were asked to evaluate carefully before helping children transition; in the United States, there has been a 2500% increase in anti-transgender legislation, mostly related to this subject; some bills seek to make gender-related medical treatment a felony, while others seek to bar transgender youth from joining school sports teams consistent with their gender identities; 49 states introduced a total of 549 bills in 2023, of which 71 have passed and 62 were signed into law; some children will benefit from treatment while others will not; slowing down the transition process helps children who will not benefit from treatment but may harm children who would benefit from treatment; this is an ethical dilemma that needs to be addressed, and the anxiety of uncertainty should be tolerated so that a better answer can be found; treatment guidelines have been published by the Endocrine Society, and the World Professional Association for Transgender Health has been created

Readings

Bhatt N, Cannella J, Gentile JP. Gender-affirming care for transgender patients. Innov Clin Neurosci. 2022;19(4-6):23-32; Crocq MA. How gender dysphoria and incongruence became medical diagnoses - a historical review. Dialogues Clin Neurosci. 2022;23(1):44-51. Published 2022 Jun 1. doi:10.1080/19585969.2022.2042166; Drescher J. Controversies in gender diagnoses. LGBT Health. 2014;1(1):10-14. doi:10.1089/lgbt.2013.1500; Drescher J, Cohen-Kettenis P, Winter S. Minding the body: situating gender identity diagnoses in the ICD-11. Int Rev Psychiatry. 2012;24(6):568-577. doi:10.3109/09540261.2012.741575; Gaskins LC, McClain CR. Visible name changes promote inequity for transgender researchers. PLoS Biol. 2021;19(3):e3001104. Published 2021 Mar 9. doi:10.1371/journal.pbio.3001104; Graham P. Transgender children and young people: how the evidence can point the way forward. BJPsych Bull. 2023;47(2):98-104. doi:10.1192/bjb.2022.3; Jorgensen SCJ. Transition regret and detransition: Meanings and uncertainties. Arch Sex Behav. 2023;52(5):2173-2184. doi:10.1007/s10508-023-02626-2; Karrington B. Defining desistance: Exploring desistance in transgender and gender expansive youth through systematic literature review. Transgend Health. 2022;7(3):189-212. Published 2022 Jun 13. doi:10.1089/trgh.2020.0129; Moseson H, Zazanis N, Goldberg E, et al. The imperative for transgender and gender nonbinary inclusion: Beyond women's health. Obstet Gynecol. 2020;135(5):1059-1068. doi:10.1097/AOG.0000000000003816; Olson J, Garofalo R. The peripubertal gender-dysphoric child: puberty suppression and treatment paradigms. Pediatr Ann. 2014;43(6):e132-e137. doi:10.3928/00904481-20140522-08; Reed GM, Drescher J, Krueger RB, et al. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations [published correction appears in World Psychiatry. 2017 Jun;16(2):220. doi: 10.1002/wps.20433]. World Psychiatry. 2016;15(3):205-221. doi:10.1002/wps.20354; Roselli CE. Neurobiology of gender identity and sexual orientation. J Neuroendocrinol. 2018;30(7):e12562. doi:10.1111/jne.12562.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Drescher’s lecture contains information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Drescher was recorded at the 2023 Annual Meeting of the American Psychiatric Association, held May 20-24, 2023, in San Francisco, CA, and presented by the American Psychiatric Association. For information about upcoming CME activities from this presenter, please visit Psychiatry.org. Audio Digest thanks Dr. Drescher and the American Psychiatric Association for their cooperation in the production of this program.

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