Gender Dysphoria / Gender Identity Disorder

[DD214_DOC]

I tend to avoid the news, but I recently ran across what Bruce/Caitlyn Jenner is up to lately. Apparently, s/he isn't going for the surgery, talks about wanting men to be attracted to him as a woman, and has been seen switching back and forth between Bruce and Caitlyn depending on what he's doing.

Anyway, that got me thinking about this stuff again, as it came up during fellowship. I admit, I don't get it -- I can't wrap my head around our current conceptualization of these diagnoses. I feel like we get this one very wrong. How is this any different than those with BDD, perpetually having surgery and changing their looks only to never be satisfied? During a lecture on this topic, I begged the question, "Does going through a complete transformation actually work and resolve the internal conflict? Or, at some point do they realize that -- no matter how much they change their bodies -- they will never actually be the opposite sex. Do they ever confront the reality that they can never change their chromosomes, and that even as an identify of only gender and not biological sex, that society will always label them as, 'trans'"?

I didn't get an answer. Do we end up being complicit in treatment that is ultimately futile? Thoughts?

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[Shikima]

Dude is a walking personality disorder wanting to drive his own business interests.

 

[PikminOC]

Dude is a walking personality disorder wanting to drive his own business interests.

Just like ALL of them. imo.

 

[Shikima]

Not all have an image/business they're attempting to draw interest. Some are genuinely confused.

 

[wolfvgang22]

I tend to avoid the news, but I recently ran across what Bruce/Caitlyn Jenner is up to lately. Apparently, s/he isn't going for the surgery, talks about wanting men to be attracted to him as a woman, and has been seen switching back and forth between Bruce and Caitlyn depending on what he's doing.

Anyway, that got me thinking about this stuff again, as it came up during fellowship. I admit, I don't get it -- I can't wrap my head around our current conceptualization of these diagnoses. I feel like we get this one very wrong. How is this any different than those with BDD, perpetually having surgery and changing their looks only to never be satisfied? During a lecture on this topic, I begged the question, "Does going through a complete transformation actually work and resolve the internal conflict? Or, at some point do they realize that -- no matter how much they change their bodies -- they will never actually be the opposite sex. Do they ever confront the reality that they can never change their chromosomes, and that even as an identify of only gender and not biological sex, that society will always label them as, 'trans'"?

I didn't get an answer. Do we end up being complicit in treatment that is ultimately futile? Thoughts?

Good questions. I'm right there with you. Can't be easy being trans, especially if one isnt wealthy.

 

[deleted343839]

I admit, I don't get it -- I can't wrap my head around our current conceptualization of these diagnoses. I feel like we get this one very wrong. How is this any different than those with BDD, perpetually having surgery and changing their looks only to never be satisfied?

I'm not sure that "never satisfied" is the typical outcome of people who transition. The evidence out there is not of the highest quality, but it does suggest that most people with gender dysphoria become less distressed and less symptomatic after sex reassignment procedures. The few transgender people I've known personally who have transitioned are pretty high functioning, and though they are just individual examples (one FTM, one MTF) their backgrounds are more typical than that of Caitlyn Jenner. I shudder to think of a Kardashian as the public face of any health condition.

Gender dysphoria theory is all over the map right now and it's a PC minefield. I don't think there is one etiology of gender dysphoria, however. If you want some interesting reading go to Google Scholar and search for "autogynephilia." Fascinating stuff, but definitely not PC.

 

[sunlioness]

The treatment actually isn't futile. Most transfolk are pretty well-adjusted and far happier living as their chosen gender. I've seen pretty severe depression and anxiety resolve just through working through the process of transitioning.

I really wouldn't draw any conclusions based on Kaitlyn/Bruce. I think his/her experience isn't typical and some of my trans friends feel that s/he has set their acceptance back by years.

There's a lot of difficult things to navigate though that I don't have answers for. I've helped people transition, but I would never help a patient go blind just because she felt she was supposed to not be able to see. And part of me thinks that if humanity didn't have so many hang ups around gender in general, it wouldn't be such a big deal. People would be themselves, whoever that turned out to be, and not worry so much about if their junk matched up.


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[Shikima]

I'm not sure that "never satisfied" is the typical outcome of people who transition. The evidence out there is not of the highest quality, but it does suggest that most people with gender dysphoria become less distressed and less symptomatic after sex reassignment procedures. The few transgender people I've known personally who have transitioned are pretty high functioning, and though they are just individual examples (one FTM, one MTF) their backgrounds are more typical than that of Caitlyn Jenner. I shudder to think of a Kardashian as the public face of any health condition.

Gender dysphoria theory is all over the map right now and it's a PC minefield. I don't think there is one etiology of gender dysphoria, however. If you want some interesting reading go to Google Scholar and search for "autogynephilia." Fascinating stuff, but definitely not PC.

We need more non-PC discussions to really help people.

 

[SmallBird]

I'm not sure that "never satisfied" is the typical outcome of people who transition. The evidence out there is not of the highest quality, but it does suggest that most people with gender dysphoria become less distressed and less symptomatic after sex reassignment procedures. The few transgender people I've known personally who have transitioned are pretty high functioning, and though they are just individual examples (one FTM, one MTF) their backgrounds are more typical than that of Caitlyn Jenner. I shudder to think of a Kardashian as the public face of any health condition.

Gender dysphoria theory is all over the map right now and it's a PC minefield. I don't think there is one etiology of gender dysphoria, however. If you want some interesting reading go to Google Scholar and search for "autogynephilia." Fascinating stuff, but definitely not PC.

Data from a large sample (n = 325) suggests that gender reassignment (hormones and surgery) are extremely effective at reducing symptoms of gender dysphoria:

Sex reassignment: outcomes and predictors of treatment for adolescent and adult transsexuals. Psychological Medicine, 2005, 35, 89–99.

I would not presume to understand how satisfied or dissatisfied Caitlyn Jenner feels, however I think it is important to acknowledge that many people may have more complex narratives; we may have a role in helping them navigate these complexities should they cause distress.

 

[SmallBird]

We need more non-PC discussions to really help people.

It may initially be effortful, but ultimately, internalizing language that validates a range of experiences is of value.

 

[DD214_DOC]

Sorry, I meant to say that the Jenner stuff just brought me back to my original thoughts, not that I was using him as an example of GD/GID. I'm not yet convinced that's truly what his issue is.

 

[SmallBird]

Sorry, I meant to say that the Jenner stuff just brought me back to my original thoughts, not that I was using him as an example of GD/GID. I'm not yet convinced that's truly what his issue is.

Sure, I mean I appreciated your post. Like previous public figures have done for other issues, Caitlyn Jenner's story has served to normalize gender reassignment for a huge swathe of people in a very brief space of time. But as a non-perfect person with her own idiosyncrasies, there is a risk that some of the less common aspects of her experience might be incorrectly applied to the broader transgender community.

I agree that current diagnostic categories are very problematic - I think a dimensional approach to gender is more consistent with empirical data and theory. There is for example a ridiculous surge in literature suggesting that GD/GID is 10 times more common in individuals with ASD. A dimensional approach would allow for a more measured statement that individuals with ASD may have a different trajectory in terms of identifying with gender owing to a significantly narrowed social frame. And so I think it is important that when individuals with gender related concerns presented to psychiatrists, that we consider the extent to which they may identify with their own gender, another gender, or no gender, and understand this as a developmental process. At the same time, when individuals experience tension insofar as they identify prominently with a gender that does not match their anatomy, I don't feel that we should get in the way with them undergoing either surgery or hormone therapy.

 

[Shikima]

It may initially be effortful, but ultimately, internalizing language that validates a range of experiences is of value.

Clear dialogue is always better than euphemisms when tacking issues of emotional dysregulation. When you speak more clearly and concisely, your patients also respond without a lot of vagarities being tossed around because they've learned to accurately express themselves and there is nothing lost to translation.

 

[Information Underload]

When you look at the still very-high rates of suicide for those who have completed the surgery, I'm more than a bit skeptical about the diagnosis. I also became even more skeptical when I learned how politicized the formation of the DSM-5 was with regards to gender dysphoria, with the decision to leave the diagnosis in the DSM based almost solely on having insurance pay for gender reassignment surgery and to not have it become a cosmetic procedure. That was per one of the committee members on the topic, which really stunk it up to high heaven in my eyes. (Interestingly, this individual was just fine with that.) That's not what I want the DSM based upon. At all.

Almost every individual who I have met with gender identity issues has also been a victim of sexual trauma and has a family psych history a mile long, so my clinical impression of these individuals is perhaps also tainted by my clinical experience.

 

[Shikima]

When you look at the still very-high rates of suicide for those who have completed the surgery, I'm more than a bit skeptical about the diagnosis. I also became even more skeptical when I learned how politicized the formation of the DSM-5 was with regards to gender dysphoria, with the decision to leave the diagnosis in the DSM based almost solely on having insurance pay for gender reassignment surgery and to not have it become a cosmetic procedure. That was per one of the committee members on the topic, which really stunk it up to high heaven in my eyes. (Interestingly, this individual was just fine with that.) That's not what I want the DSM based upon. At all.

Almost every individual who I have met with gender identity issues has also been a victim of sexual trauma and has a family psych history a mile long, so my clinical impression of these individuals is perhaps also tainted by my clinical experience.

You can see the politicizing all the way back to DSM-III.... Just isn't discussed in the open. It's un-PC.

 

[DD214_DOC]

When you look at the still very-high rates of suicide for those who have completed the surgery, I'm more than a bit skeptical about the diagnosis. I also became even more skeptical when I learned how politicized the formation of the DSM-5 was with regards to gender dysphoria, with the decision to leave the diagnosis in the DSM based almost solely on having insurance pay for gender reassignment surgery and to not have it become a cosmetic procedure. That was per one of the committee members on the topic, which really stunk it up to high heaven in my eyes. (Interestingly, this individual was just fine with that.) That's not what I want the DSM based upon. At all.

Almost every individual who I have met with gender identity issues has also been a victim of sexual trauma and has a family psych history a mile long, so my clinical impression of these individuals is perhaps also tainted by my clinical experience.

Yes, this was more or less my exact thought process. I knew the suicide rates were still very high even with the surgery, so what's really being missed? Are they realizing they will never be, "a real man/woman"?

Also, how do they even know that they should be the opposite gender/sex? They have absolutely no frame of reference to have any idea what that experience is even like.

 

[hamstergang]

Also, how do they even know that they should be the opposite gender/sex? They have absolutely no frame of reference to have any idea what that experience is even like.

Gender identify is something you innately feel in your brain, right?

One reason I separate GID from BDD is the delusional quality. In BDD, the person actually sees their body part differently than others. In GID, the person recognizes that their genitals and DNA are what they are, but in their brain they feel differently. I view this more similarly to some depressed patients -- they recognize that everything is great in their lives, but they feel differently in their brains.

 

[PikminOC]

Not all have an image/business they're attempting to draw interest. Some are genuinely confused.

I meant his whole family.

 

[DD214_DOC]

Gender identify is something you innately feel in your brain, right?

One reason I separate GID from BDD is the delusional quality. In BDD, the person actually sees their body part differently than others. In GID, the person recognizes that their genitals and DNA are what they are, but in their brain they feel differently. I view this more similarly to some depressed patients -- they recognize that everything is great in their lives, but they feel differently in their brains.

Yes, I feel male gender in my brain because I'm a male. Or, at least I assume that what I feel is male. See where this starts to get silly? Has anyone really ever asked how GID people, "know" what the other gender feels like?

 

[birchswing]

Yes, I feel male gender in my brain because I'm a male. Or, at least I assume that what I feel is male. See where this starts to get silly? Has anyone really ever asked how GID people, "know" what the other gender feels like?

It's interesting that you assume that what you feel is male. I would guess it's less of an assumption and maybe more of a finding you have similarities to other males in their behaviors and thoughts they express.

I've never felt like other males, but on the other hand I've never felt like I'm female. I can feel contrast between me and other males. But when I see there are things that females do that are stereotypically female to do or feel, it makes me just want to be able to be more free to be whatever I want. I don't have the drive to be female in order to do/feel those things. If I thought I could only do/feel those things if I were female, then maybe I would be more pushed into identifying as female. Like, I've never worn a dress for example. But if I were to wear a dress, I wouldn't consider myself female because of it. Actually the other day I was looking up house coats. I think they look quite practical and nice. They have nice big pockets and look comfy for lounging or when you're cleaning up the house. The equivalent for men is a robe, but it's a bit of a fuss with tying it closed and it coming undone.

 

[Rogue Penguin]

Yes, this was more or less my exact thought process. I knew the suicide rates were still very high even with the surgery, so what's really being missed? Are they realizing they will never be, "a real man/woman"?

Also, how do they even know that they should be the opposite gender/sex? They have absolutely no frame of reference to have any idea what that experience is even like.

Look, I know I'm just a med student and all, but please, for the love of everything decent, don't ever say this stuff to a transgender person. This kind of attitude is a big part the reason transpeople still have a high suicide rate after transition. Some transpeople don't "pass" even after transition and then people reject their identity. Do you have any idea what it must be like to lose your family, friends, and/or job because of something you view as a core component of who are you? And then even after you've lost so much, you still aren't accepted as who you see yourself to be? Some transpeople can't even walk down the street without being harassed. Being a broad-shouldered, hairy, 6'2'' woman who wants to look feminine is not fun. When the people you care about and even strangers reject you, it's hard to feel good about yourself. You're completely ignoring the social factors associated with being trans. If you took all that stuff away from me, I'd be depressed too. And the process of transitioning itself can be very traumatic. It can involve a lot of verbal, emotional, and even physical abuse. Those are things that make many cis-people depressed, anxious, etc. For some, the issue probably is a failure to feel like the gender they identify as in spite of SRS, HRT, etc, but that's not the whole story.

Gender identity is solidified by age 3-ish. Most transpeople have known their entire lives that something is wrong (that they're the opposite sex). Transitioning has been shown to relieve gender dysphoria, as people have said. It doesn't relieve the pain that can come with being rejected and mocked by greater society or your loved ones. There is science behind this stuff. I don't mean to freak out, but it really upsets me when mental health professionals don't understand basic things about being transgender. Transgender people are one of the most vulnerable demographics out there. If even we can't be understanding and supportive, then who can?

Also, whoever said that the DSM shouldn't include things for insurance reasons.... I feel like that's a pretty self-important stance. The "purity" of your diagnostic manual is so important that thousands of people should be left to suffer in hopeless gender dysphoria because they can't pay for surgery/hormones? Give me a break. The life expectancy for an african american transwoman is ~35 due to the risk of suicide, murder, lack of self care due to depression, etc. No one would choose to have such a difficult life. It's not cosmetic. It's necessary and we have to operate according to the reality that we live in, which includes very high cost healthcare. In my opinion, putting another barrier in the way of people who are already hurting is contrary to our goal as physicians.

I can't relate to gender dysphoria on a personal level, but that doesn't make me doubt that it's real. I certainly don't think it's just some kind of cluster B weirdness. Transpeople who are supported and able to transition early do well. I can't say what the mechanism behind the gender identity-genome disconnect is, but I don't think that's what's most important right now.

 

[Ceke2002]

There's more than just 'transgender male/female' when it comes to gender identity though. I do think part of the problem is that we as a society still insist on having everything placed into neat binary categories of 'male' or 'female', and even within the trans community itself there can still be this pressure to conform/transition/whatever to one or the other - if you're a male who identifies as female, then transition and you'll be happy, if you're a female who identifies as male do the same thing and get the same results, instant feelings of peace because you're finally who you're really meant to be. Well what if you don't identify as either gender, what if you identify as both, what if you're bigendered, pangendered, agendered, or genderfluid? I have at least one friend who identifies as genderqueer, he is a gender assigned female who doesn't identify as such, but also doesn't wish to transition to be male either, he slips between genders and gender identities and is perfectly happy doing so. It's great that there's more education and discussion and visibility within society when it comes to gender identity issues, but then we still run into the problem that main stream society will tend to default people back to the gender binary of male or female, which then places pressure on non gender conforming people to conform to a gender expression that may not actually be their own.

 

[Ceke2002]

We need more non-PC discussions to really help people.

I actually agree with this, I do sometimes think being too PC about things tends to shut down discussions rather than encourage them to take place. People should be able to question, debate, discuss, hold a conversation etc etc, in this sort of situation without fear that they'll say the wrong thing and be raked over the coals for it (within reason of course, I mean the discussion itself has to be a genuine discourse between persons, not an excuse for someone to just be flat out disrespectful).

 

[Ceke2002]

I tend to avoid the news, but I recently ran across what Bruce/Caitlyn Jenner is up to lately. Apparently, s/he isn't going for the surgery, talks about wanting men to be attracted to him as a woman, and has been seen switching back and forth between Bruce and Caitlyn depending on what he's doing.

1) Not all trans people feel the need to transition through gender reassignment surgery. Caitlyn's individual decision to keep her male genitalia intact doesn't make her 'not a woman', same as a cisgendered man who loses his genitalia to cancer doesn't suddenly become 'not a man'. Also see my comment above, not all trans people match the binary of male or female, nor do they wish to (not saying this is the case for Caitlyn Jenner in particular).

2) Some articles are wrongly equating gender identity and/or expression with sexual orientation, and are trying to say that Caitlyn's statements that she isn't gay are false because she wants men to be attracted to her as a woman, and therefore if she's lying about her sexual orientation (because a woman who wants men to find her attractive is gay now? That's news to me) she must also be lying about her gender identity. In different interviews Caitlyn has said she isn't gay, and is still attracted to women, she's also said she wants men to find her attractive - by definition that makes her possibly bisexual, pansexual or queer, not gay (there's that damn binary at work again).

3) Some articles are also claiming that she's 'switching back to being Bruce', because she's not maintaining this image of ultra femininity 24/7 and has been known to be a bit 'blokey' in her voice and mannerisms after a few drinks, or has been seen dressing in more masculine looking attire when she's out playing golf. A woman not being the bastion of femininity every waking moment of her life, doesn't make her 'not a woman' and it certainly doesn't mean that as a trans woman that she is suddenly reverting back to a male identity or male gender expression.

 

[NotTheBestUSMLE]

I feel like this is super un-PC, and I don't know if there's any good data on this, but has anyone else noticed the association between transgenderism and various forms of developmental delay (as well as BPAD and BPD)? I think 1/2 - 2/3 of the transgender patients I've met in clinical circumstances had an evident degree of MR. It almost struck me as imitative or provocative behavior over genuine "gender dysphoria."

 

[clausewitz2]

Yes, I feel male gender in my brain because I'm a male. Or, at least I assume that what I feel is male. See where this starts to get silly? Has anyone really ever asked how GID people, "know" what the other gender feels like?

This may be of interest:
https://thingofthings.wordpress.com/2015/01/28/cis-by-default/

 

[DD214_DOC]

Yeah, that actually makes a lot if sense. I have even said I don't feel, "male" or "female". I feel like HooahDOc.

 

[smalltownpsych]

I feel like this is super un-PC, and I don't know if there's any good data on this, but has anyone else noticed the association between transgenderism and various forms of developmental delay (as well as BPAD and BPD)? I think 1/2 - 2/3 of the transgender patients I've met in clinical circumstances had an evident degree of MR. It almost struck me as imitative or provocative behavior over genuine "gender dysphoria."

It is not surprising that with the neurological abnormalities associated with developmental delay that gender identity could be affected, as well. As far as BPD goes, unstable identity is one of the diagnostic criteria so again not too surprising. I don't know about Bipolar Disorder although I have a very complex patient who is both transgender and BPAD on my current caseload.

 

[bd290]

Also, whoever said that the DSM shouldn't include things for insurance reasons.... I feel like that's a pretty self-important stance. The "purity" of your diagnostic manual is so important that thousands of people should be left to suffer in hopeless gender dysphoria because they can't pay for surgery/hormones? Give me a break.

To me this isn't that different from most public/county/etc. mental health programs only accepting certain diagnoses - I've seen this impact the diagnoses patients receive in order for them to be eligible.