10.4: Treatments Related to Gender Dysphoria
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- 221753
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\(\newcommand{\avec}{\mathbf a}\) \(\newcommand{\bvec}{\mathbf b}\) \(\newcommand{\cvec}{\mathbf c}\) \(\newcommand{\dvec}{\mathbf d}\) \(\newcommand{\dtil}{\widetilde{\mathbf d}}\) \(\newcommand{\evec}{\mathbf e}\) \(\newcommand{\fvec}{\mathbf f}\) \(\newcommand{\nvec}{\mathbf n}\) \(\newcommand{\pvec}{\mathbf p}\) \(\newcommand{\qvec}{\mathbf q}\) \(\newcommand{\svec}{\mathbf s}\) \(\newcommand{\tvec}{\mathbf t}\) \(\newcommand{\uvec}{\mathbf u}\) \(\newcommand{\vvec}{\mathbf v}\) \(\newcommand{\wvec}{\mathbf w}\) \(\newcommand{\xvec}{\mathbf x}\) \(\newcommand{\yvec}{\mathbf y}\) \(\newcommand{\zvec}{\mathbf z}\) \(\newcommand{\rvec}{\mathbf r}\) \(\newcommand{\mvec}{\mathbf m}\) \(\newcommand{\zerovec}{\mathbf 0}\) \(\newcommand{\onevec}{\mathbf 1}\) \(\newcommand{\real}{\mathbb R}\) \(\newcommand{\twovec}[2]{\left[\begin{array}{r}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\ctwovec}[2]{\left[\begin{array}{c}#1 \\ #2 \end{array}\right]}\) \(\newcommand{\threevec}[3]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\cthreevec}[3]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \end{array}\right]}\) \(\newcommand{\fourvec}[4]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\cfourvec}[4]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \end{array}\right]}\) \(\newcommand{\fivevec}[5]{\left[\begin{array}{r}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\cfivevec}[5]{\left[\begin{array}{c}#1 \\ #2 \\ #3 \\ #4 \\ #5 \\ \end{array}\right]}\) \(\newcommand{\mattwo}[4]{\left[\begin{array}{rr}#1 \amp #2 \\ #3 \amp #4 \\ \end{array}\right]}\) \(\newcommand{\laspan}[1]{\text{Span}\{#1\}}\) \(\newcommand{\bcal}{\cal B}\) \(\newcommand{\ccal}{\cal C}\) \(\newcommand{\scal}{\cal S}\) \(\newcommand{\wcal}{\cal W}\) \(\newcommand{\ecal}{\cal E}\) \(\newcommand{\coords}[2]{\left\{#1\right\}_{#2}}\) \(\newcommand{\gray}[1]{\color{gray}{#1}}\) \(\newcommand{\lgray}[1]{\color{lightgray}{#1}}\) \(\newcommand{\rank}{\operatorname{rank}}\) \(\newcommand{\row}{\text{Row}}\) \(\newcommand{\col}{\text{Col}}\) \(\renewcommand{\row}{\text{Row}}\) \(\newcommand{\nul}{\text{Nul}}\) \(\newcommand{\var}{\text{Var}}\) \(\newcommand{\corr}{\text{corr}}\) \(\newcommand{\len}[1]{\left|#1\right|}\) \(\newcommand{\bbar}{\overline{\bvec}}\) \(\newcommand{\bhat}{\widehat{\bvec}}\) \(\newcommand{\bperp}{\bvec^\perp}\) \(\newcommand{\xhat}{\widehat{\xvec}}\) \(\newcommand{\vhat}{\widehat{\vvec}}\) \(\newcommand{\uhat}{\widehat{\uvec}}\) \(\newcommand{\what}{\widehat{\wvec}}\) \(\newcommand{\Sighat}{\widehat{\Sigma}}\) \(\newcommand{\lt}{<}\) \(\newcommand{\gt}{>}\) \(\newcommand{\amp}{&}\) \(\definecolor{fillinmathshade}{gray}{0.9}\)- Examine historical and current perspectives on gender dysphoria
- Describe and evaluate treatments for gender dysphoria
Modern Perspectives on Gender and Gender Identity
Gender dysphoria (GD) exists when a person suffers discontent due to gender identity, causing them emotional distress. Researchers disagree about the nature of distress and impairment in people with gender dysphoria. Some authors have suggested that people with gender dysphoria suffer because they are stigmatized and victimized by society; if the society was more accepting of transgender identities and non-binary expressions of gender, they would suffer less and/or may not experience dysphoria at all. Other research into genetic variation, hormones, and differences in brain functioning and brain structures suggest evidence for the biological etiology of the symptoms associated with gender dysphoria; however, much of this research is preliminary and still controversial.
As you have read, in the past, gender identity development was mostly viewed through cognitive and behaviorist lens—arguing that struggles with gender identity developed from the environment or cognitive schemas. More recent research has been done to understand biological and influences on gender variances and how early social experiences may create lasting epigenetic changes related to sex differences. Research suggests that, for example, early social experiences may act as such epigenetic influence that they ultimately shape lasting sex differences in brain and behavior, but a lot more research is needed in this field to obtain solid knowledge relevant for understanding GD.
For example, early postmortem studies of transsexual neurological differentiation was focused on the hypothalamic and amygdala regions of the brain. Using magnetic resonance imaging (MRI), some transgender women were found to have female-typical putamina that were larger in size than those of cisgender males.[1] Some trans women have also shown a female-typical central part of the bed nucleus of the stria terminalis (BSTc) and interstitial nucleus of the anterior hypothalamus number 3 (INAH-3), looking at the number of neurons found within each.[2]
Changing the Stigma
Today, most medical professionals who provide transgender transition services to adults now reject conversion therapies (the pseudoscientific practice of trying to change an individual’s sexual orientation from homosexual or bisexual to heterosexual using psychological, physical, or spiritual interventions) as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else.
The APA’s guidelines for psychotherapy with lesbian, gay, and bisexual clients (American Psychological Association, 2000, 2012) serve as a main reference for clinicians and highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision.
Treatment for Gender Dysphoria
Today, sex reassignment surgery is performed on people who choose to have this change so that their anatomical sex will match their gender identity. Transgender individuals sometimes wish to undergo this type of surgery to refashion their primary sexual characteristics, secondary characteristics, or both, because they feel they will be more comfortable with different genitalia. This may involve removal of penis, testicles or breasts, or the fashioning of a penis, vagina, or breasts. In the past, sex assignment surgery has been performed on infants who are born with ambiguous genitalia. However, current medical opinion is strongly against this procedure on infants since many adults have regretted that these decisions were made for them at birth.
Gender confirmation surgery (or sexual reassignment surgery) refers to any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity. Surgical procedures are usually preceded by hormone replacement therapy.
Some forms of gender confirmation surgery include
- bottom surgery, or surgery to alter the genitalia.
- top surgery, or surgery to alter the chest and breast tissue.
- facial reconstruction surgery, to alter the appearance of the face.
Those who plan to have surgery but not yet done so are often referred to as pre-op while those who have already had surgery are referred to as post-op. Those who do not wish to include surgery in their transition are referred to as non-op.
Sex reassignment surgery performed on nonconsenting minors (babies and children) may result in catastrophic outcomes (including PTSD and suicide—such as in the David Reimer case following a botched circumcision) when the individual’s sexual identity (determined by neuroanatomical brain wiring) is discrepant with the surgical reassignment previously imposed. Milton Diamond at the John A. Burns School of Medicine of the University of Hawaii recommended that physicians do not perform surgery on children until they are old enough to give informed consent and to assign such infants in the gender to which they will probably best adjust. Diamond believed introducing children to others with differences of sex development could help remove shame and stigma. Diamond considered the intersex condition as a difference of sex development, not as a disorder.
Psychological Treatments
Treatment for a person diagnosed with GD may include psychotherapy or to support the individual’s preferred gender through hormone therapy, gender expression and role, or surgery. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. This may include psychological counseling, resulting in lifestyle changes or physical changes resulting from medical interventions such as hormonal treatment, genital surgery, electrolysis or laser hair removal, chest/breast surgery, or other reconstructive surgeries. Psychotherapeutic treatment of GD involves helping the patient to adapt. The goal of treatment may simply be to reduce problems resulting from the person’s transgender status, for example, counseling the patient in order to reduce guilt associated with cross-dressing or counseling a spouse to help them adjust to the patient’s situation.
Until the 1970s, psychotherapy was the primary treatment for gender dysphoria and generally was directed to helping the person adjust to the gender of the physical characteristics present at birth. Though some clinicians still use only psychotherapy to treat gender dysphoria, it may now be used in addition to biological interventions. Attempts to alleviate GD by changing the patient’s gender identity to reflect birth characteristics have been ineffective.
Biological Treatments
Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual’s physical body and gender identity. Biological treatments for GD without any form of psychotherapy is quite uncommon. Researchers have found that if individuals bypass psychotherapy in their GD treatment, they often feel lost and confused when their biological treatments are complete.[3]
Prepubescent Children
The question of whether to counsel young children to be happy with their biological sex or to encourage them to continue to exhibit behaviors that do not match their biological sex—or to explore a transgender transition—is controversial. The follow-up studies of children with gender dysphoria consistently show that the majority cease to feel transgender during puberty and identify instead as gay or lesbian.[4][5] Other clinicians also report that a significant proportion of young children diagnosed with gender dysphoria later do not exhibit any dysphoria.[6]
Professionals who treat gender dysphoria in children have begun to refer and prescribe hormones, known as puberty blockers, to delay the onset of puberty until a child is believed to be old enough to make an informed decision on whether hormonal gender reassignment leading to surgical gender reassignment will be in that person’s best interest.
Psychological and Social Consequences
Overall, psychotherapy, hormone replacement therapy, and sex reassignment surgery together can be effective treating GD when the WPATH standards of care are followed. The overall level of patient satisfaction with both psychological and biological treatments is very high.
After sex reassignment surgery, transsexual individuals (people who underwent cross-sex hormone therapy and sex reassignment surgery) tend to be less gender dysphoric. They also normally function well both socially and psychologically. Anxiety, depression, and hostility levels were lower after sex reassignment surgery. They also tend to score well for self-perceived mental health, which is independent from sexual satisfaction. Many studies have been carried out to investigate satisfaction levels of patients after sex reassignment surgery. In these studies, most of the patients have reported being very happy with the results and very few of the patients have expressed regret for undergoing sex reassignment surgery.
Although studies have suggested that the positive consequences of sex reassignment surgery outweigh the negative consequences, it has been suggested that most studies investigating the outcomes of sex reassignment surgery are flawed as they have only included a small percentage of sex reassignment surgery patients in their studies. These methodological limitations such as lack of double-blind randomized controls, small number of participants due to the rarity of transsexualism, high drop-out rates, and low follow-up rates, which would indicate need for continued study.
Persistent regret can occur after sex reassignment surgery. Regret may be due to unresolved gender dysphoria, or a weak and fluctuating sense of identity, and may even lead to suicide. Risk categories for post-operative regret include being older, having characterized personality disorders with personal and social instability, lacking family support, lacking sexual activity, and expressing dissatisfaction with the results of surgery. During the process of sex reassignment surgery, transsexuals may become victims of different social obstacles such as discrimination, prejudice, and stigmatizing behaviors. The rejection faced by transsexuals is much more severe than what is experienced by LGB individuals. The hostile environment may trigger or worsen internalized transphobia, depression, anxiety, and post-traumatic stress.
Many patients perceive the outcome of the surgery as not only medically but also psychologically important. Social support can help them to relate to their minority identity, ascertain their trans identity, and reduce minority stress. Therefore, it is suggested that psychological support is crucial for patients after sex reassignment surgery, which helps them feel accepted and to have confidence in the outcome of the surgery; also, psychological support will become increasingly important for patients with lengthier sex reassignment surgery process.
This video tells the first-person account of Jamie’s experience during his hormonal treatment and transition.
You can view the transcript for “My Gender Transition From Female To Male • Dear BuzzFeed” here (opens in new window).
bottom surgery: surgery to alter the genitalia
conversion therapies: the pseudoscientific practice of trying to change an individual’s sexual orientation from homosexual or bisexual to heterosexual using psychological, physical, or spiritual interventions
gender confirmation surgery: sexual reassignment surgery or any form of surgical procedure performed on a transgender person in order to change their sex characteristics to better reflect their gender identity
identity: the way one understands, describes and expresses oneself and the reflection of those entities to others
non-op: those who do not wish to include surgery in their transition
post-op: those who have already had surgery
pre-op: those who plan to have surgery but not yet done so
top surgery: surgery to alter the chest and breast tissue
transsexual: a person who has undergone cross-sex hormone therapy and sex reassignment surgery
- Saleem F, Rizvi SW (December 2017). "Transgender Associations and Possible Etiology: A Literature Review". Cureus. 9 (12): e1984. doi:10.7759/cureus.1984 ↵
- Guillamon A, Junque C, Gómez-Gil E (October 2016). "A Review of the Status of Brain Structure Research in Transsexualism". Archives of Sexual Behavior. 45 (7): 1615–48. doi:10.1007/s10508-016-0768-5 ↵
- Hakeem, Az (2008). "Changing Sex or Changing Minds: Specialist Psychotherapy and Transsexuality". Group Analysis. 41 (2): 182–196. doi:10.1177/0533316408089883. S2CID 143359476. ↵
- Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 47, 1413–1423. ↵
- Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors associated with desistence and persistence of childhood gender dysphoria: A quantitative follow-up study. Journal of the American Academy of Child and Adolescent Psychiatry, 52, 582–590. ↵
- Spiegel, Alix (May 8, 2008). "Q&A: Therapists on Gender Identity Issues in Kids". NPR. Retrieved September 16, 2008. ↵
- Modification, adaptation, and original content. Authored by: Sonja Ann Miller for Lumen Learning. Provided by: Lumen Learning. License: CC BY-SA: Attribution-ShareAlike
- Gender Dysphoria. Provided by: Wikipedia. Located at: https://en.Wikipedia.org/wiki/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.. License: CC BY-SA: Attribution-ShareAlike
- Sex reassignment surgery. Provided by: Wikipedia. Located at: https://en.Wikipedia.org/wiki/Sex_reassignment_surgery. License: CC BY-SA: Attribution-ShareAlike
- Gender confirmation surgery. Provided by: Wikipedia. Located at: https://gender.wikia.org/wiki/Gender_Confirmation_Surgery. License: CC BY-SA: Attribution-ShareAlike
- Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Provided by: Wikipedia. Located at: https://en.Wikipedia.org/wiki/Standards_of_Care_for_the_Health_of_Transsexual,_Transgender,_and_Gender_Nonconforming_People. License: CC BY-SA: Attribution-ShareAlike
- Judith Butler. Authored by: Dontworry, modified by Emma7stern. Located at: https://commons.wikimedia.org/wiki/File:Judith-butler-frankfurt-2012.jpg. License: CC BY-SA: Attribution-ShareAlike
- Exam room. Authored by: Zackary Drucker. Located at: https://genderphotos.vice.com/. Project: The Gender Spectrum Collection. License: CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives
- Gender Dsyphoria. Provided by: Boundless. Located at: https://courses.lumenlearning.com/boundless-psychology/chapter/gender-dysphoria/. License: CC BY: Attribution
- Conversion Therapy. Provided by: Wikipedia. Located at: https://en.Wikipedia.org/wiki/Conversion_therapy. License: CC BY-SA: Attribution-ShareAlike
- Gender Dysphoria. Provided by: Wikipedia. Located at: https://www.susans.org/wiki/Gender_dysphoria#Treatment%20. License: CC BY-SA: Attribution-ShareAlike
- Sexual orientation and gender identity: review of concepts, controversies and their relation to psychopathology classification systems. Authored by: Carla Moleiro and Nuno Pinto. Provided by: Instituto Universitu00e1rio de Lisboa ISCTE-IUL, CIS, Lisboa, Portugal. Located at: https://www.frontiersin.org/articles/10.3389/fpsyg.2015.01511/full. Project: Frontiers in Psychology. License: CC BY: Attribution
- My Gender Transition From Female To Male. Provided by: BuzzFeedVideo. Located at: https://www.youtube.com/watch?v=RYuipbRGu5s&feature=emb_logo. License: Other. License Terms: Standard YouTube License