What is gender?

Gender Dysphoria is complex, it is hard to define. It is more a social or cultural idea as opposed to a biologically defined one. Gender goes beyond being male or female, there are people whose gender doesn’t neatly fit into these two groups. 

What is Gender Dysphoria?

Is a term used to describe the distress caused by a discrepancy between one’s experienced or expressed gender with one’s assigned gender and or primary and secondary sexual characteristics? It is discomfort with how their body is perceived and allocated a gender by others. 

 Assigned gender is the gender attributed to an individual at birth, it’s what is written on a birth certificate for example. 

Psychiatry and Gender Dysphoria - Background

The historical practice of psychiatry is stepped in pathologizing and highly stigmatizing view and approaches to transgender people. Non-binary or transgender individuals, even young people are likely to be aware of this history and likely cautious speaking to mental health professionals as a result. 

Health care training offers little in the way of exposure to transitioning services for student health care workers. This has left psychiatrists and other health care workers on the back foot to meet the demands.

The understanding of gender dysphoria has changed significantly in the last 50 years. Previously classified as a mental disorder, there are attempts to move the term under the sexual health conditions umbrella.  

How common is Gender Dysphoria?

In a single word, very. Gender Dysphoria as a state can be transitionary. It is thought that about 1 in every 100 people experience gender dysphoria at some point in their lives. The number of people that go on to get formal help for it is much lower. 

It is important to remember that changing views about one’s gender doesn’t mean gender dysphoria. A key part of the label of gender dysphoria is the distress due to a gender mismatch between experienced and assigned gender. 

Drivers of Gender Dysphoria and Gender Variance

People express their gender in different ways. They may be assigned female at birth but later grow up to identify as male. They could also as they get older view themselves again to be female or another different sense of their gender identity. 

Changes in how a person views their gender can change over time. Often different aspects of their lives are contributing. Sometimes hormonal changes, greater self-awareness or a change of environment might be the trigger. 

Below we have listed some of the factors thought to contribute to gender dysphoria. 

Biological

There appears to be a number of biological factors that contribute to gender. These include sex chromosomes, hormones, genetic and epigenetic factors. Epigenetics refers to how our environment impacts the expression of our genes. 

The foveal and infant brains appear to be particularly sensitive to sex hormones. Sexual maturation trajectories can differ, especially as there are so many variables. 

Psychosocial 

Social, family-based and psychological factors can all play a role in how a young person experiences gender. Here are some examples of how these psychosocial factors can play a part.

  • Gender-specific clothing, colours of the child’s items, toys and haircut all go some way towards influencing gender. A child whose hair is cut short and given boys clothing will be reinforced that their gender is male. 
  • Verbal labelling such as son or daughter, boy or girl can go a long way towards reiterating assigned genders.
  • Being sent to gender-specific schools, having gender-specific experiences can influence how someone sees themselves. For instance, been sent to football practice twice weekly with a group of other boys will easily impact how a child views themselves with regards to their gender. 
  • Cultural, familial factors are likely to play a role. There are varying degrees of openness and as a result suppression of gender variance, depending on where one lives. 
  • Educational, awareness and maturity level. Until recently, with the help of the internet, there is increased communication and learning about gender variance. This has likely led to more people understanding their distress and seeking help. 

An interplay of psychosocial and biological factors are complex. This probably explains the diversity of gender presentations. Also, treatments or ways to help people experiencing gender-related distress has also increased.

Impacts of gender related stigma

Gender variant children and adults experience high levels of stigma and abuse. It is not uncommon for these people to experience discrimination, employment and homelessness. Fortunately, there are increasing supports available and awareness drives in place.  

How can mental health professionals help?

There has been a significant change in the consensus view on the role of mental health professionals in gender dysphoria. In this article, we will cover various roles mental health professionals can play in helping adults with gender dysphoria.

  • Assist to clarify and understand the person’s commitment to changes in gender. 
  • As part of the consent to the treatment process, it is important that there is an awareness of the treatment options and alternatives that have been considered. Therapists will explore these with you and want to understand your choice. 
  • Psychologists can help with coming out to co-workers, friends and family members. This can be done by helping to better understand the interpersonal dynamics and the use of role-plays as practice. 
  • Family therapists can help with couples counselling, help with family dynamics. Sometimes when adult parents transition it can impact their children, it’s important that the child’s needs are considered and addressed.
  • Sometimes psychiatrists are involved in determining eligibility for certain hormones or surgical procedures. Usually, this depends on the local laws and regulations. 
  • Ensuring preparedness for changes, both psychological and social, from gender reassignment therapies. 
  • Complete a thorough assessment of overall mental health and wellbeing. Gender variance is associated with higher rates of mood and anxiety concerns. 

What to expect during an assessment

It really depends on the individual and in particular where they are in their journey with regards to gender. Someone at the beginning, starting to explore options will have different concerns to someone who has transitioned many years ago. 

Given the high rates of stigma and co-occurring mental health concerns, often a broad-ranging assessment is needed. It shouldn’t be surprising that questions about suicidality are asked. This is especially true during periods of high risk such as in the immediate aftermath of trauma or prior to coming out to loved ones. 

During a gender assessment, clinicians often inquire when a person first noticed differences between them and what was expected of their assigned gender. Questions about distress during the emergence of unwanted secondary sexual characteristics. 

Discussions around practicalities such as pronouns, name and clothing changes all form part of an assessment. Therapists will inquire about wishes to transition and more broadly on how best to support the person. 

A mental health assessment can take a couple of sessions. It’s important that everyone feels comfortable, informed and expectations are openly communicated. The pace of the assessment, what is covered and what isn’t is up to the person being assessed. 

Most people who are transitioning seek mental health inputs at various points along the journey. Therapists often want to know what helped, and what didn’t in the past. 

Diagnostic checklist for Gender Dysphoria

Often for people who have experienced long-standing distress, the diagnosis of gender dysphoria is quite straightforward. It gets more complicated when a person is ambivalent or uncertain about their sexual identity. This is not uncommon. Other complicating factors could be co-occurring mental illnesses or presentations, for instance, psychosis, autism spectrum disorders or low intellect. 

To help with diagnosis clinicians use the American Psychiatric Association’s DSM-5 diagnostic criteria. In that diagnostic manual the following criteria are looked for:

  • A strong wish to change one’s primary or secondary characteristics due to a mismatch with one’s own experience of one sexual characteristic
  • A wish to be of a different gender to the one assigned at birth. 
  • A desire to be treated differently to one’s assigned gender.
  • A strong view that one has the typical emotions, thought processes and reactions to that of a gender different to the assigned gender. 

More ways mental health professionals can help

Sometimes there is ambivalence or ambiguity around gender. A therapist can provide an environment that is open yet containing for a person to explore options 

Some people who are struggling with gender variance and identity concerns can benefit from support groups. Mental health clinicians can direct people toward and also facilitate peer-led groups. Gender dysphoria can be an isolating experience, being involved in groups can help.

As mentioned above, gender dysphoria is associated with higher rates of mental illness. Oftentimes positive psychology techniques and other attempts to improve resilience can help. 

Adjustment in hormone levels for those transitioning can lead to changes in mental state. For instance, excessive use of male hormones like testosterone is linked to manic and or psychotic episodes. 

Gender dysphoria is a common condition that can cause significant psychological distress. Stigma, both discriminatory and self-stigmatization can lead to mental anguish. At Epsychiatry appointments can be organized for you to speak to a psychologist or psychiatrist regarding gender. Contact our friendly support team to learn more. 

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