Week 5: Learning Goals
Lecture 9: Gender Dysphoria
1. To identify the characteristics of Gender Dysphoria (GD), including:
Gender Dysphoria in Children
Diagnostic Criteria A marked incongruence between one’s experienced/expressed gender and assigned gender,
of at least 6 months duration, as manifested by SIX of the following (one of which must be
criterion A)
A strong desire to be of the other gender – or an insistence that one is the other gender
(or some alternative gender different from the assigned one)
In boys (assigned gender) – a strong preference for cross-dressing or simulating female
attire
In girls (assigned gender) – a strong preference for only wearing typical masculine
clothing and a strong resistance to wearing typical feminine clothing
A strong preference for cross-gender roles in 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 – a strong rejection of masculine toys, games, and activities and a strong
avoidance of rough-and-tumble play
In girls – a strong rejection of typically feminine toys, games, activities
A strong dislike of one’s sexual anatomy
A strong desire for the primary/secondary sex characteristics that match one’s
experienced gender
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 – e.g., congenital adrenogenital disorder
Development and Course
Expression of Criteria for children are defined in a more concrete, behavioral manner than those for
Gender Dysphoria adults/adolescents
Many of the core criteria draw on well-documented behavioral gender differences b/m
typically developing boys and girls
Young children are less likely than older children, adolescents, and adults – to express
extreme and persistent anatomic dysphoria
Distress and A very young child may show signs of distress – e.g., intense crying – only when
Impairment parents tell the child it is “really” not a member of the other gender but only “desires” to
be
Distress may not manifest in social environments that are supportive of the child’s
desire to live in the role of the other gender
Distress may emerge only if the desire is interfered with
Gender Dysphoria For clinic-referred children – the onset of cross-gender behaviors is usually b/n 2-4
Without a Disorder years old
of Sex Development This corresponds to the developmental time period in which most typically developing
children begin expressing gendered behaviors and interests
For some preschool-age children – both (1) pervasive cross-gender behaviors and (2)
the expressed desire to be of the other gender – may present
More rarely – labeling oneself as member of the other gender may occur
The expressed desire to be the other gender appears later in some cases – usually at
entry into elementary school
Small minority of children express discomfort with their sexual anatomy – or will state
desire to have sexual anatomy corresponding to experienced gender – i.e., anatomic
dysphoria
Such expressions become more common as children with GD approach and anticipate
puberty
Persistence of GD is modestly correlated with dimensional features of severity –
ascertained at the time of a childhood baseline assessment
Lower SES is modestly correlated with persistence
Gender Dysphoria in Most individuals with a disorder of sex development who develop GD – have already
,Association with a come to medical attention at an early age
Disorder of Sex For many, starting at birth, issues of gender assignment were raised by physicians and
Development parents
As infertility is quire common for this group – physicians are more willing to perform
(1) cross-sex hormone treatments and (2) genital surgery before adulthood
Risk and Prognostic Factors
Temperamental For individuals with GD without a disorder of sex development – atypical gender
behavior among early-onset dysphoria develops in early preschool age
Environmental Among those with GD without a disorder of sex development – males with GD both in
(1) childhood and (2) adolescence more commonly have older brothers than do males
without GD
Genetic and GD without Disorder of Sex Development:
Physiological Some genetic contribution suggested by evidence for weak familiality of
transsexualism among non-twin siblings
Some degree of heritability of GD also suggested
No endogenous systemic abnormalities in sex-hormone levels have been found
There appear to be increased androgen levels in natal females
Current evidence is insufficient to label GD without disorder of sex development as a
form of intersexuality limited to the CNS
GD with Disorder of Sex Development:
The likelihood of later GD is increased if prenatal production and utilization of
androgens are grossly atypical
The likelihood of GD is further increased by additional, prolonged, highly gender-
atypical postnatal androgen exposure – may occur in female-raised and non-castrated
natal males
The prenatal androgen milieu is more closely related to gendered behavior than to
gender identity
Most individuals with gender-atypical behavior do not develop GD
Gender-atypical behavior itself should not be interpreted as an indicator of current or
future GD
There appears to be a higher rate of (1) GD and (2) patient-initiated gender change
from assigned female to male than from assigned male to female
, Functional Consequences of Gender Dysphoria
Preoccupation with cross-gender wishes may develop at all ages after the first 2-3 years
of childhood – and often interfere with daily activities
In older children – failure to develop age-typical same-sex peer relationships and skills
may lead to (1) isolation from peer groups and (2) distress
Some children may refuse to attend school due to (1) teasing and harassment – or (1)
pressure to dress in attire associated with assigned sex
Gender Dysphoria in Adolescents and Adults
Diagnostic Criteria A marked incongruence between one’s experienced/expressed gender and assigned gender,
of at least 6 months duration, as manifested by TWO of the following:
A marked incongruence b/n experienced/expressed gender and primary and/or
secondary sex characteristics (in young adolescents – the anticipated secondary sex
characteristics)
A strong desire to be rid of one’s primary and/or secondary sex characteristics – due to
marked incongruence with experienced/expressed gender (in young adolescents – a
desire to prevent development of the anticipated secondary sex characteristics)
A strong desire for the primary/secondary sex characteristics of the other gender
A strong desire to be of the other gender – or some alternative other than the assigned
gender
A strong desire to be treated as the other gender
A strong conviction that one has the typical feelings and reactions of the other gender
The condition is associated with clinically sig distress or impairment in social,
occupational, or other important areas of functioning
Specify if:
With a disorder of sex development
Specify if:
Post-transition – one has transitioned to full-time living in the desired gender (with or
without legalization of gender change) and has undergone – or preparing to have – at
least one cross-sex medical procedure or treatment regimen (e.g., cross-sex hormone
Lecture 9: Gender Dysphoria
1. To identify the characteristics of Gender Dysphoria (GD), including:
Gender Dysphoria in Children
Diagnostic Criteria A marked incongruence between one’s experienced/expressed gender and assigned gender,
of at least 6 months duration, as manifested by SIX of the following (one of which must be
criterion A)
A strong desire to be of the other gender – or an insistence that one is the other gender
(or some alternative gender different from the assigned one)
In boys (assigned gender) – a strong preference for cross-dressing or simulating female
attire
In girls (assigned gender) – a strong preference for only wearing typical masculine
clothing and a strong resistance to wearing typical feminine clothing
A strong preference for cross-gender roles in 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 – a strong rejection of masculine toys, games, and activities and a strong
avoidance of rough-and-tumble play
In girls – a strong rejection of typically feminine toys, games, activities
A strong dislike of one’s sexual anatomy
A strong desire for the primary/secondary sex characteristics that match one’s
experienced gender
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 – e.g., congenital adrenogenital disorder
Development and Course
Expression of Criteria for children are defined in a more concrete, behavioral manner than those for
Gender Dysphoria adults/adolescents
Many of the core criteria draw on well-documented behavioral gender differences b/m
typically developing boys and girls
Young children are less likely than older children, adolescents, and adults – to express
extreme and persistent anatomic dysphoria
Distress and A very young child may show signs of distress – e.g., intense crying – only when
Impairment parents tell the child it is “really” not a member of the other gender but only “desires” to
be
Distress may not manifest in social environments that are supportive of the child’s
desire to live in the role of the other gender
Distress may emerge only if the desire is interfered with
Gender Dysphoria For clinic-referred children – the onset of cross-gender behaviors is usually b/n 2-4
Without a Disorder years old
of Sex Development This corresponds to the developmental time period in which most typically developing
children begin expressing gendered behaviors and interests
For some preschool-age children – both (1) pervasive cross-gender behaviors and (2)
the expressed desire to be of the other gender – may present
More rarely – labeling oneself as member of the other gender may occur
The expressed desire to be the other gender appears later in some cases – usually at
entry into elementary school
Small minority of children express discomfort with their sexual anatomy – or will state
desire to have sexual anatomy corresponding to experienced gender – i.e., anatomic
dysphoria
Such expressions become more common as children with GD approach and anticipate
puberty
Persistence of GD is modestly correlated with dimensional features of severity –
ascertained at the time of a childhood baseline assessment
Lower SES is modestly correlated with persistence
Gender Dysphoria in Most individuals with a disorder of sex development who develop GD – have already
,Association with a come to medical attention at an early age
Disorder of Sex For many, starting at birth, issues of gender assignment were raised by physicians and
Development parents
As infertility is quire common for this group – physicians are more willing to perform
(1) cross-sex hormone treatments and (2) genital surgery before adulthood
Risk and Prognostic Factors
Temperamental For individuals with GD without a disorder of sex development – atypical gender
behavior among early-onset dysphoria develops in early preschool age
Environmental Among those with GD without a disorder of sex development – males with GD both in
(1) childhood and (2) adolescence more commonly have older brothers than do males
without GD
Genetic and GD without Disorder of Sex Development:
Physiological Some genetic contribution suggested by evidence for weak familiality of
transsexualism among non-twin siblings
Some degree of heritability of GD also suggested
No endogenous systemic abnormalities in sex-hormone levels have been found
There appear to be increased androgen levels in natal females
Current evidence is insufficient to label GD without disorder of sex development as a
form of intersexuality limited to the CNS
GD with Disorder of Sex Development:
The likelihood of later GD is increased if prenatal production and utilization of
androgens are grossly atypical
The likelihood of GD is further increased by additional, prolonged, highly gender-
atypical postnatal androgen exposure – may occur in female-raised and non-castrated
natal males
The prenatal androgen milieu is more closely related to gendered behavior than to
gender identity
Most individuals with gender-atypical behavior do not develop GD
Gender-atypical behavior itself should not be interpreted as an indicator of current or
future GD
There appears to be a higher rate of (1) GD and (2) patient-initiated gender change
from assigned female to male than from assigned male to female
, Functional Consequences of Gender Dysphoria
Preoccupation with cross-gender wishes may develop at all ages after the first 2-3 years
of childhood – and often interfere with daily activities
In older children – failure to develop age-typical same-sex peer relationships and skills
may lead to (1) isolation from peer groups and (2) distress
Some children may refuse to attend school due to (1) teasing and harassment – or (1)
pressure to dress in attire associated with assigned sex
Gender Dysphoria in Adolescents and Adults
Diagnostic Criteria A marked incongruence between one’s experienced/expressed gender and assigned gender,
of at least 6 months duration, as manifested by TWO of the following:
A marked incongruence b/n experienced/expressed gender and primary and/or
secondary sex characteristics (in young adolescents – the anticipated secondary sex
characteristics)
A strong desire to be rid of one’s primary and/or secondary sex characteristics – due to
marked incongruence with experienced/expressed gender (in young adolescents – a
desire to prevent development of the anticipated secondary sex characteristics)
A strong desire for the primary/secondary sex characteristics of the other gender
A strong desire to be of the other gender – or some alternative other than the assigned
gender
A strong desire to be treated as the other gender
A strong conviction that one has the typical feelings and reactions of the other gender
The condition is associated with clinically sig distress or impairment in social,
occupational, or other important areas of functioning
Specify if:
With a disorder of sex development
Specify if:
Post-transition – one has transitioned to full-time living in the desired gender (with or
without legalization of gender change) and has undergone – or preparing to have – at
least one cross-sex medical procedure or treatment regimen (e.g., cross-sex hormone
