Gender dysphoria is a condition that isn’t well understood by the public and carries a stigma that, like many other conditions described in the DSM-V, burdens those experiencing it with others’ moral judgements and often, social exclusion. In this paper, we will explore the etiology, developmental course, diagnosis criteria and educational considerations of students who experience gender dysphoria.
First, it needs to be noted that the majority of sources included in this paper aren’t based in the US so any conclusions they draw are tentative in their application to US populations, especially studies in countries with significant differences in social attitudes towards gender expression like the Netherlands.
Etiology
The following factors have been found to be connected with an individual developing gender dysphoria: one’s hormonal chemistry both in utero and throughout a person’s development, genetic influences, and differences in the phenotype of neuroanatomy from cisgendered non-dysphoric individuals (Ettner, 2020). It should be noted that the studies within the current literature have largely been conducted on adults; many manifestations of these factors do not become apparent until adulthood and therefore, should not be considered reliable criteria for diagnosing children and adolescents.
For some factors such as structural differences between the brains of cisgender and transgender individuals, the direction of the relationship between the presence of structural differences and GD symptomology is unclear because the transgender adults who participated in the studies had already undergone hormone therapy so researchers weren’t able to determine whether these physiological differences caused gender dysphoria or whether these differences are due to having undergone hormone therapy. As there is currently very little practical application to be obtained from studying the etiology of GD as school psychologists, we will move on to discuss current diagnosis models.
Diagnostic Criteria
The DSM-V currently has the following diagnostic criteria for GD:
- A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by at least two or more of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated 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 (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
- A strong desire for the primary and/or secondary sex characteristics of the other gender.
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender).
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender).
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).
- The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, 2013).
The diagnostic criteria of GD according to the DSM-V requires the individual to have a strong desire to change their appearance or their perceived gender identity from the one they were assigned at birth and that the individual experiences significant personal distress or impairment in their daily functioning as a result of it.
Behavioral criteria include cross-dressing; adopting cross-gender roles in fantasy play; a strong preference for toys, games and activities of the other gender; a preference for playmates of the other gender; and a strong aversion or rejection of typically gender-congruent roles, interests, preferences and behaviours.
Prevalence and Incidence
As a heavily stigmatized identity in the US, it’s difficult to collect information on the incidence and prevalence of individuals. Due to this, broad, general population-level data on the prevalence and incidence of GD in the US aren’t available. Some estimates have been made from 0.17%-1.3% for adolescents in the US (Connolly et al., 2016) but as more and more gender non-conforming kids come out each year, this number is expected to increase. The majority of what we know about the prevalence/incidence rates of GD still come from medical or crisis settings where these individuals are forced to interact with institutions.
In their sample sizes of just over a million individuals, the Kids’ Inpatient Database (KID), which collects information on young patients (6-20 years old) who have been hospitalized each year in the US, found a GD prevalence rate of 161 per 100,000 hospitalizations in 2016 and 475 per 100,000 hospital admission in 2019. They defined GD according to ICD-10 codes (an international medical classification list) which have similar diagnostic criteria as the DSM-V. In addition, they found that individuals who are White, have private insurance and/or live in higher median-income ZIP codes are overrepresented as having GD which may be due to a higher prevalence of GD within these populations but is more likely to be due to better access to healthcare systems. This study also examined rates of suicidality and found that patients who are GD-coded have much higher rates of suicidal ideation/attempts (36%) than those who are not (5%) (Mitchell et al., 2022).
Outside of the United States, research about gender dysphoria in children and adolescents is more robust. A study conducted with Canadian and Dutch youth report that 2.6% of kids who are assigned male at birth (AMAB) and 5% of kids who are assigned female at birth (AFAB) were reported by their parents as “behaving like the opposite sex” and 1.4% kids who are AMAB and 2% of kids who are AFAB were reported to “wish to be of the opposite sex”. While these measures do not constitute a diagnosis of GD, they do point to the possibility of some GD symptomology in these children. The study also collected data from gender identity clinics and reported that referrals to these clinics are much more common for kids who are AMAB than kids who are AFAB (Ristori & Steensma, 2016). These two findings, one that suggests AFAB girls show more gender non-conforming traits and the other where more AMAB boys are referred to gender identity clinics, could mean that variability in gender expression is more acceptable in AFAB individuals than AMAB individuals which could affect the severity of dysphoria in AMAB individuals who are more policed socially in their gender expression. In addition, Ristori and Steensma note that in both Denmark and Canada, rates of referrals decrease between their pre-2000 data and post-2000 data which may indicate an improvement in social attitudes towards a wider range of gender expression/identity.
Developmental Course
Desistance rates of children with GD is a contentious topic as gender expression in children has become the object of moral panics and political attention. Research on desistance rates has produced a wide range of results.
One Australian paper published by Elkadi et al. in 2018 detailed a number of pathways their minor patients(n=79) took after referral to their clinic for gender dysphoric feelings. They found that out of their patients who met the DSM-V criteria for diagnosis, 60 out of 66 or 90.9% persisted on a GD pathway in the follow-up study 4-9 years after initial referral where they continue to make a transition into their preferred gender identity. The majority of this group would start puberty blockers and later, take cross-sex hormones to start transitioning while a small number (3 individuals) would adopt a nonbinary gender identity (which includes gender-neutral identities). In addition, there were a couple of individuals who terminated their medical transition process and persisted in their transgender identity. This in conjunction with alternative identifications other than cisgender and binary transgender identities shows that there are other available pathways to be considered other than whether or not to transition for individuals with GD. They also noted that the majority of patients (88%) had a comorbid mental health diagnosis, the most common being depression and anxiety, a relationship between mental health and GD which we will explore in greater detail later in the paper.
Another study found much of the same results: after 5 years, 94% (n=317, 208 AFAB, 109 AMAB) of kids who had socially transitioned (came out to their community and are living socially as a gender other than the one assigned at birth) persisted while 3.5% transitioned to a nonbinary identity and 2.5% desisted to a cisgender identity (Olson et al., 2022). The study also states that they found detransition to a cisgender identity to be more common in children who socially transitioned before 6 years of age. Both of these studies support the conclusion that feeling regret and subsequent detransitioning amongst minors with GD who chose to transition is uncommon.
This starkly contrasts with findings from earlier studies described in Ristroni and Steensma’s (2016) literature review where they found that, from the 10 persistence studies they included, desistance rates average around 80%. They suggested a number of reasons why their desistance rate is so high—from societal stigma to inconsistent diagnostic criteria (a few of the studies took place in the 70s and 80s) to the lack of information on the severity of GD symptoms for participants (which correlates with persistence rates) to the lack of long-term follow-up studies (especially since the onset of puberty not only have physiological implications but also cognitive and social ones).
This disparity of findings as well as factors around the causes of persistence or desistance is an area in need of more research, especially as kids with GD and those who are trans become increasingly visible and their treatment increasingly politicized.
Treatment
Treatment is also controversial with many ethical questions still hotly debated. Some practitioners think that, despite regret and desire to detransition being uncommon, individuals experiencing GD and especially minors should not readily have access to gender-affirming hormonal treatments due to potentially permanent effects and uncertainty whether the patient is fully informed about the effects of such treatment (Clayton, 2021). Although caution is appropriate, there is a popular misconception that the process one has to go through to get gender-affirming treatment is easy. Puberty blockers, hormone replacement therapy (HRT) and various types of surgical interventions (mastectomy, vaginoplasty, etc.) are hard to access as is, requiring a great deal of money and privilege to access, and are being made more inaccessible through legislation criminalizing gender-affirming care like Georgia’s Senate Bill 140.
Medical providers in the United States often have inadequate training in and knowledge of gender-affirming care which makes seeking care a long, laborious process. In addition, seeking care often exposes individuals to additional discriminatory treatment and traumatic experiences (from condescension and doubt about the patient’s lived experience to misgendering and deadnaming patients) (Brooker & Loshak, 2020). This coupled with astronomically high medical costs in the United States makes accessing gender-affirming treatment a herculean task. As mentioned earlier, GD is often comorbid with other mental health disorders. Research has shown that gender-affirming care like puberty blockers results in significantly reduced risk of suicidality, and improved affect, psychological functioning and social relationships (Rew et al., 2020). In these cases, gender-affirming care is potentially life-saving.
However, it is also important to keep in mind that not every person with GD wants to physically transition; Elkadi et al’s (2023) analysis of GD pathways also described individuals who socially transitioned but didn’t medically transition or individuals who inhabited an identity between or outside of the binary. In those cases, counseling and psychoeducation as described in Ristori and Steensma’s (2016) article would be the primary interventions to provide a safe place and guidance to both patient and family when attempting to socially transition.
Conclusion
As the US’s culture slowly shifts to be more gender-inclusive, individuals with GD will continue to become more visible. Yet, despite increasing cultural acceptance, many structural barriers remain in place for such individuals to access care. From research, we understand that the presence of GD has some correlation with biological processes, that distress related to an incongruent gender expression is persistent, and that this distress is often comorbid with negative mental health outcomes. Accessing care requires deliberate, effortful and persistent intention, and those seeking it often experience significant pushback; inequitable access to healthcare, as well as social stigma and politicized erasure of diverse gender identities, continue to make GD hard to study, further complicating attempts to not only understand GD but also explore treatment options. All in all, gender-diverse individuals remain a highly marginalized group and there’s much work to be done to bring awareness of and attention to increasing their acceptance in society.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Brooker, A.-S., & Loshak, H. (2020). Gender affirming therapy for gender dysphoria: A rapid qualitative review [internet]. National Center for Biotechnology Information. Retrieved April 19, 2023, from https://pubmed.ncbi.nlm.nih.gov/33231964/
Clayton, A. (2021). The gender affirmative treatment model for youth with gender dysphoria: A medical advance or dangerous medicine? Archives of Sexual Behavior, 51(2), 691–698. https://doi.org/10.1007/s10508-021-02232-0
Elkadi, J., Chudleigh, C., Maguire, A. M., Ambler, G. R., Scher, S., & Kozlowska, K. (2023). Developmental pathway choices of young people presenting to a gender service with gender distress: A prospective follow-up study. Children, 10(2), 314. https://doi.org/10.3390/children10020314
Ettner, R. (2020). Etiology of gender dysphoria. Gender Confirmation Surgery, 21–28. https://doi.org/10.1007/978-3-030-29093-1_2
Meyer, G., Boczek, U., & Bojunga, J. (2020). Hormonal gender reassignment treatment for gender dysphoria. Deutsches Ärzteblatt International. https://doi.org/10.3238/arztebl.2020.0725
Mitchell, H. K., Keim, G., Apple, D. E., Lett, E., Zisk, A., Dowshen, N. L., & Yehya, N. (2022). Prevalence of gender dysphoria and suicidality and self-harm in a national database of paediatric inpatients in the USA: A population-based, serial cross-sectional study. The Lancet Child & Adolescent Health, 6(12), 876–884. https://doi.org/10.1016/s2352-4642(22)00280-2
Olson, K. R., Durwood, L., Horton, R., Gallagher, N. M., & Devor, A. (2022). Gender identity 5 years after Social Transition. Pediatrics, 150(2). https://doi.org/10.1542/peds.2021-056082
Rew, L., Young, C. C., Monge, M., & Bogucka, R. (2020). Review: Puberty blockers for transgender and gender diverse youth—a critical review of the literature. Child and Adolescent Mental Health, 26(1), 3–14. https://doi.org/10.1111/camh.12437
Ristori, J., & Steensma, T. D. (2016). Gender dysphoria in childhood. International Review of Psychiatry, 28(1), 13–20. https://doi.org/10.3109/09540261.2015.1115754
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