Tuesday 16 March 2021

Is Gender Dysphoria a Disorder?

In this post, Antonella Mazziotta, MSc student at the Institute for Mental Health at the University of Birmingham, discusses Gender Dysphoria. Gender Dysphoria is a topic not so well understood by scientists and society with this being reflected in the type of treatments and stigma around LGBTQ+ communities. Antonella's research interests include exploring Gender Dysphoria in childhood as well as language comprehension and production in Mental Health conditions.


Antonella Mazziotta


I had the opportunity to observe how dysphoria affects transgender people, especially children, and how society plays a vital role in the psychological outcomes of treatment for young people. This led to my interest in researching the pathological features of Gender Dysphoria. Do we believe that transgender children are aware of their inner identity or simply confused and therefore have a mental disorder?

The DSM-IV called this condition ‘Gender Identity Disorder’ which was changed to ‘Gender Dysphoria’ in its latest edition, the DSM-5, because of its unethical and controversial label. The diagnosis of Gender Dysphoria in adolescents consists of symptoms signaling discomfort of the patient with their biological sex and an incongruence between their assigned gender and the expressed one. Therefore, to better understand Gender Dysphoria, the condition and its possible underlying causes we need to start from the basics. What do we mean by biological sex and gender?

Biologically speaking, sex is defined by chromosomes: XX for female and XY for male. However, there is only one set of genes (called SRY) in the Y chromosome that are important to defining the individuals’ sex. It is proven by research that SRY genes can escape from the Y chromosome and ‘jump’ into the X chromosome. It is very complicated science, and we’ll leave this type of research to geneticists, but this gives us a possible hint on where Gender Dysphoria might arise biologically. This means that we have a genetic sex, a chromosomal sex and hormonally altered male, female or non-binary sex. 

Philosophically speaking though, gender is the inner perception of identity, the one felt by the patient which is not necessarily represented by their physical characteristics. Gender Dysphoria, most of the times, starts in childhood when children begin to understand the basic differences between genders around the age of 3. This phenomenon has been numerously documented in accounts of transgender adults that describe the discomfort with their natal sex from a very young age.

Treatments for Gender Dysphoria are complex, distressing and sometimes also inhumane. There is not a specific treatment for this condition, only a series of hormone therapies which consist of blocking the natural development of the natal sex organs to allow the child to experience the desired gender for at least two years. However, such intervention can lead to a loss of fertility and hence the inability to have biological offspring in the future, in addition to the psychological confusion that such therapy may cause. 

Finally, to complete the transition process, the patient must undertake sex reassignment surgery which is also necessary by law to be finally recognised with the desired gender. This suggests that this whole process of gender reassignment is not seen as a relief for the patient rather as a relief for policy makers. As expected, a requirement of this gravity by the law created rancour in the LGBTQ+ community which considered such process unethical and a human rights violation. Not all transgender people want to permanently change their natal sex with surgery and the problem is definitely not in their genitals for a percentage of transgenders.

Going back to the starting question we can conclude by saying that perhaps societal ideologies are partly responsible for such interventions and requirements. Such treatments can be psychologically distressing during early life. In addition, recent research is unravelling the possibility of a comorbidity between Autistic Spectrum Disorder and Gender Dysphoria which should be furthered investigated to better understand both conditions (9-10).

I urge you to ask yourselves some questions. Do people with Gender Dysphoria need treatment? Is there a lack of understanding of the differences between sex and gender in society? Can we really consider Gender Dysphoria in children a phase where there is confusion about identity? Or are we just trying to accommodate society’s beliefs about what is considered normal and abnormal? Education and early prevention seem to be key, especially in those classrooms from which transgender children are normally excluded. Goal directed groups in each classroom can help both parents and children to accept diversity and practice equality.

6 comments:

  1. I think this statement is incorrect: "Finally, to complete the transition process, the patient must undertake sex reassignment surgery which is also necessary by law to be finally recognised with the desired gender." Please could you check it.

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  2. Dear Dave,
    Thank you for your comment. I must clarify; the UK and Europe in general are very ahead regarding transgender rights and human rights. However, I urge you to read about the Freddy McConnells' very complex case and how things are not as clear as people think even in a country so ahead as the UK.
    In many other countries this requirement is still compulsory (for more info: https://wiadlek.pl/wp-content/uploads/archive/2020/WLek202012233.pdf).

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  3. I don't get this: "This suggests that this whole process of gender reassignment is not seen as a relief for the patient rather as a relief for policy makers."
    Requiring that people go through the whole process of gender reassignment treatments in order to change their legal gender, yeah, that's bad, and mostly about policy makers being uncomfortable with people not fitting neatly into proper gender/sex categories. Trans people are different, not everyone wants to do this, and being pressured into treatments you don't want is terrible.
    But I know people who had serious body dysphoria before their gender reassignment treatment and who did experience enormous relief once this was completed. I'm pretty sure there's also ample research on this. Is the author somehow denying that this is a thing, or did I misunderstand something?

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  4. Also, this part of the text
    " There is not a specific treatment for this condition, only a series of hormone therapies which consist of blocking the natural development of the natal sex organs to allow the child to experience the desired gender for at least two years. However, such intervention can lead to a loss of fertility and hence the inability to have biological offspring in the future, "
    ...seems to be about children, and puberty blockers for children.
    But the link in "loss of fertility" goes to this paper https://www.sciencedirect.com/.../pii/S0003426615011324... , and that paper looks like it's about hormone therapy for adult transsexual people, which is different.
    (In this paper, for instance, https://pubmed.ncbi.nlm.nih.gov/33593872/ , Cameron Beattie writes that puberty blockers have been used for children with "precocious puberty" for a long time, and what we've seen there is that normal reproductive functioning returns. Maybe that's wrong, this is not my expert area, but Beattie specifically warns that people often mix up puberty blockers with cross sex hormone therapy, e.g., what adult transsexual people get. And it looks to me that this is what the author did above.)
    If I'm misunderstanding something here, I'd be happy to have it cleared up.

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    Replies
    1. Puberty blockers allow the child to stop the natural growth of the natural sex to help the child experience the desired gender. However, I believe that such intervention may cause further confusion in the child especially at such delicate age like adolescence where the brain is fully developing and undergoes crucial changes (there are no human studies on the cognitive outcomes of pubertal agonist GnRH but this study can be interesting https://www.sciencedirect.com/science/article/pii/S0306453016305595). I lived for one year with a transgender child and I had witnessed this phase of confusion and psychological distress, that sometimes goes beyond the need of tackling their dysphoria (mental health causation are a myriad). Obviously, this is not the case of every trans child but can be food for thoughts since there is a substantial lack of research on the importance of a personalized and holistic approach before giving chemicals like candies to children.
      Hormone therapy is a completely different approach and risks: there are several physical and mental health benefits (of course!) BUT also risks such as tumors (much more longitudinal studies are needed) but also infertility (this can be an interesting paper to fully read on risks and benefits: https://reader.elsevier.com/reader/sd/pii/S1538544219301245?token=6A7206A72395D1D17F72B40E354FC2958A3BD144A4F362085CB9DA0C7EE7E8C929CA9B120B32292CBD5B135BF546ABE5)
      Unfortunately, fertility preservation is not considered much among trans teens for different reasons (costs, lack of information etc.)(https://www.sciencedirect.com/science/article/pii/S1054139X16309582?casa_token=YwQCRkT-yQMAAAAA:d7SY_BS45VuZ4HtyQV_KLlOWyE6hCpopUqQbia1xCiwJXiddIeRbpvGOPGXTjLUMKzl6m9t23mQc). I believe that clinically, these issues are not really presented to transgender children with dysphoria who really prioritise their transition, but what if one day they change their mind and really want biological children? Only, 3% is willing to delay hormone treatments to preserve their fertility. However, a good percentage said that would have considered FP if it was mentioned before to them (https://www.liebertpub.com/doi/full/10.1089/lgbt.2016.0153 & Persky, R. W., Gruschow, S. M., Sinaii, N., Carlson, C., Ginsberg, J. P., & Dowshen, N. L. (2020). Attitudes Toward Fertility Preservation Among Transgender Youth and Their Parents. Journal of Adolescent Health. & https://link.springer.com/article/10.1007/s11673-012-9378-7 on the importance of counseling before hormone treatments for FP).
      By “inhumane” I obviously refer to requirements of sterilization. These have been recently abolished by most countries in Europe, but in some countries (such as Finland, Ukraine and India) sterilization is still a requirement. The UK is ahead but see the case of Freddy McConnell (you can just type his name and his complex case will come out). I believe that transgender clinical care should be firstly more researched, the lack of studies leads to lack of personalised clinical approaches. Therefore, risks and benefits of such interventions should be considered more longitudinally, holistically and should really meet the needs of the individual person before permanently changing biological aspects and chemical balances. I have a scientific background and clinical views and, unfortunately, I never had the possibility to approach philosophical theories on this area, but I am open to expanding my knowledge.

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  5. Hey, Antonella. This is a very well balanced and interesting piece of writing that asks some very important questions. I worry that young people especially are being driven to decisions about their gender identity by activists and then inadvertent bad policies. You only have to look at places like California, New York, and New Jersey to see this unfolding. You are absolutely right though that more research is required, though I wonder how much activism is driving the agenda rather than critical thinking?

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