1. Gender Dysphoria
Sexual Taboo
By,
Dr. Muhammad Wajahat, MBBS.
House Officer,
Psychiatry Department, Civil
Hospital Karachi.

2. General Consideration
•Salient Features
•Comorbidity
•Differential Diagnosis
•Management
•Case
Overview

3. General
Consideration

4. Definitions
•Sex
It refers to a person’s biological
status & is typically categorized as
male, female, or intersex (i.e.,
atypical combinations of features
that usually distinguish male from
female). There are a number of
indicators of biological sex, including
sex chromosomes, gonads, internal
reproductive organs, and external

5. Definitions
•Gender Stereotypes or Gender
Role:
A gender stereotype is a fixed,
conventional idea about how man
and woman are supposed to behave.
Cultural beliefs about men and
women involve clusters of
stereotypes called gender roles.

6. Definitions
•Gender
It refers to the attitudes, feelings, and
behaviors that a given culture
associates with a person’s biological
sex. Behavior that is compatible with
cultural expectations is referred to as
gender-normative; behaviors that are
viewed as incompatible with these
expectations constitute gender non-
conformity.

7. Definitions
•Gender Identity
Gender identity is a category of
social identity and refers to an
individual's identification as male,
female, or, occasionally, some
category other than male or female

8. Definitions
•Gender Expression
It refers to the way in which a
person acts to communicate gender
within a given culture; for example, in
terms of clothing, communication
patterns and interests.
A person’s gender expression may or
may not be consistent with socially
stereotyped gender roles, and may
or may not reflect his or her gender

9. Definitions
•Gender Assignment
It refers to the initial assignment as
male or female. This occurs usually
at birth and, thereby, yields the "natal
gender.”

10. Definitions
•Gender Reassignment
It refers to the change of one’s
gender.

11. Definitions
•Sexual Orientation
It refers to the sex of those to whom
one is sexually and romantically
attracted.

12. Definitions
•Gender Dysphoria
Gender dysphoria as a general
descriptive term refers to an
individual's affective/ cognitive
discontent with the assigned gender
which may accompany the
incongruence between one's
experienced or expressed gender
and one's assigned gender.

13. Definitions
•Transgender:
Transgender refers to the broad
spectrum of individuals who
transiently or persistently identify
with a gender different from their
natal or assigned gender.

14. Definitions
•Transexual:
Transsexual denotes an individual
who seeks, or has undergone, a
social transition from male to female
or female to male, which in many, but
not all, cases also involves a somatic
transition by cross-sex hormone
treatment and genital surgery (sex
reassignment surgery).

15. • For natal adult males, prevalence
ranges from 0.005% to 0.014%.
• For natal adult females, prevalence
ranges from 0.002% to 0.003%.
• 01 in 30’000 adult male and 01 in
100’000 adult female is gender
dysphoric.
Epidemiology

16.  A Gender dysphoric is a male or female who has
a lifelong feeling of being trapped in the wrong
body. (Docter,1988)
 There are four dimensions of gender dysphoria in
natal male identified as:
1. aversion of being a man
2. desire to be a woman
3. feeling not to be a man
4. feeling to be a woman.
The former is associated with well being and
suicide.(Coleman,1992)

17.  It is not bound to a stable or unstable personality
 It can occur at every age, with a peak between 20
and 30 years.
 It is not culturally defined(it appears in every
sociaty and it is spread over every lawyer of the
population)
 It is not bound to certain Intelligence.
(Winter,2002)

18. Salient
Features

19. A. A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months’ duration, as
manifested by at least six of the following (one of which must be
Criterion A1):
• A strong desire to be of the other gender or an insistence that one
is the other gender (or some alternative gender different from
one’s assigned gender).
• In boys (assigned gender), a strong preference for cross-dressing
or simulating female attire: or in girls (assigned gender), a strong
preference for wearing only typical masculine clothing and a
strong resistance to the wearing of typical feminine clothing.
Diagnostic Features in
Children

20. • A strong preference for cross-gender roles in make-believe play
or fantasy play.
• A strong preference for the toys, games, or activities
stereotypically used or engaged in by the other gender.
• A strong preference for playmates of the other gender.
• In boys (assigned gender), a strong rejection of typically
masculine toys, games, and activities and a strong avoidance of
rough-and-tumble play; or in girls (assigned gender), a strong
rejection of typically feminine toys, games, and activities.
Diagnostic Features in
Children

21. • A strong dislike of one’s sexual anatomy.
• A strong desire for the primary and/or secondary sex
characteristics that match one’s experienced gender.
B. The condition is associated with clinically significant distress or
impairment in social, school, or other important areas of
functioning.
Specify if:
With a disorder of sex development
Diagnostic Features in
Children

22. A. A marked incongruence between one’s experienced/expressed
gender and assigned gender, of at least 6 months’ duration, as
manifested by at least two 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).
• 2. 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
Diagnostic Features in
Adolescents and adults

23. •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)
Diagnostic Features in
Adolescents and adults

24. B. The condition is associated with clinically significant
distress or impairment in social, occupational or other
important areas of functioning.
Specify if:
With a disorder of sex development
Specify if:
Post Transition
Diagnostic Features in
Adolescents and adults

25. •When visible signs of puberty develop, natal boys may shave their legs at
the first signs of hair growth.
•They sometimes bind their genitals to make erections less visible.
•Girls may bind their breasts, walk with a stoop, or use loose sweaters to
make breasts less visible
•Non clinically referred adolescents request, or may obtain without medical
prescription and supervision, hormonal suppressors.
• Clinically referred adolescents often want hormone treatment and many
also wish for gender reassignment surgery.
• Adolescents living in an accepting environment may openly express the
desire to be and be treated as the experienced gender and dress partly or
completely as the experienced gender
Associated Features

26. • For clinic-referred children, ONSET of cross-
gender behaviors is usually between ages 2 and
4 years. This corresponds to the developmental
time period in which most typically developing
children begin expressing gendered behaviors
and interests.
Development and
Course

27. • Rates of PERSISTENCE of gender dysphoria
from childhood into adolescence or adulthood
vary.
1. In natal males, persistence has ranged from 2.2%
to 30%.
2. In natal females, persistence has ranged from
12% to 50%.
• For both natal male and female children showing
Development and
Course

28. •For natal male children without persistence, 63% to
100% self-identify themselves as homosexual.
•For natal female children without persistence, 32%
to 50% self-identify themselves as homosexual.
Development and
Course

29. In both adolescent and adult natal males, there
are two broad trajectories for development of
gender dysphoria:
1. Early Onset Gender Dysphoria
2. Late Onset Gender Dysphoria
Development and
Course

30. Early Onset Gender Dysphoria:
•It starts in childhood and continues into adolescence
and adulthood or there is an intermittent period in
which the gender dysphoria desists and these
individuals self-identify as gay or homosexual, followed
by recurrence of gender dysphoria.
•They almost always self identity themselves as
homosexual.
•They seek out clinical care for hormone treatment or
Development and
Course

31. Late Onset Gender Dysphoria:
• Late-onset gender dysphoria occurs around puberty or much
later in life
• Adolescents and adults with late-onset gender dysphoria
frequently engage in transvestic behavior with sexual
excitement.
•The majority of these individuals are gynephilic or sexually
attracted to other posttransition natal males.
• A substantial percentage of adult males with late-onset gender
dysphoria cohabit with or are married to natal females. After
gender transition, many self-identify as lesbian.
•They seem to be less likely satisfied after gender reassignment
Development and
Course

32. • Interference with daily activities.
•Failure to develop same-sex peer relationship and
skills
•Social Isolation and Distress
•Stigmatization, discrimination and victimization
•School drop out
•Economic marginalization
•Low self esteem, self doubts
•Increasing Psychiatric co-morbidities
Functional
Consequences

33. •Anxiety Disorders
•Disruptive & Impulse control Disorders
•Depression Disorder
•Personality Disorders esp. cluster B.
•Substance related Disorder
•Psychotic Disorder & Eating Disorder
•Increased Risk of Suicide
Comorbidity

34. •Nonconformity to Gender roles
•Transvestic Fetishism
•Body Dysmorphic Disorder
•Schizophrenia and Other Psychotic
Disorders
Differential Diagnosis

35. Management
Standards of care are
determined by the World
Professional Association
for Transgender Health
(WPATH).

36. I. Psychotherapy
Psychotherapy is often given before SRS but is not required.
Your role in treating patients with GID goes beyond making an accurate
diagnosis, identifying comorbid psychopathology, and instituting a
treatment plan.
Other tasks include:
•counseling the patient about the range of treatment options and their
implications
•engaging in psychotherapy
•ascertaining eligibility and readiness for hormones and surgical therapy
•making formal recommendations to medical and surgical colleagues
•documenting the patient’s relevant history in a letter of

37. Triadic therapy for appropriately screened adults
with severe Gender Dysphoria include:
• 3-phase approach centered around reallife
experience in the desired role
•Hormones of the desired gender
•Surgery to change the genitalia and secondary
sex characteristics.
I. Psychotherapy

38. Eligibility Criteria Set by WPATH
1. Patient is at least age 18.
2. Patient understands what hormones medically can and cannot do
and their social benefits and risks
3. Patients has had either:
• Documented real-life experience of 3 months before the
administration of hormones; or
• b. Psychotherapy after initial evaluation of a duration specified by
the mental health professional (usually 3 months
II. Hormone Replacement
Therapy

39. Readiness Criteria set by WPATH
1. Patient has had further consolidation of gender
identity during the real-life experience or
psychotherapy
2. Patient has made some progress mastering other
identified problems leading to improving or
continuing stable mental health (this implies
satisfactory control of problems such as sociopathy,
substance abuse, psychosis, and suicidality.
II. Hormone Replacement
Therapy

40. •Male to female transexuals use estrogen
(conjugated, oral or transdermal) ,progesterone and
spironolactone.
•Female to male transexuals use testesterone(IM or
transdermal)
II. Hormone Replacement
Therapy

41. •USA after Thailand is the heart of SRS.
•WPATH recommends SRS as an
effective treatment for severe gender
dysphoria.
III. Sex Reassignment Surgery