16th November 2023

Gender Identity and Gender Dysphoria

Again, this is a category that has changed dramatically between ICD-10, DSM-5 and ICD-11. But first, let us look at what gender identity is. Gender identity relates to the perception of one’s own sex, whereas gender dysphoria describes distress due to a divergence from one’s biological sex. Because there is incongruence to biological sex, this does not mean gender dysphoria is present; this can be described as gender nonconformity. It is also important to separate dual role transvestism (ICD-10) – which is wearing the clothes of the opposite sex to temporarily belong to that gender without wishing for a permanent change – and fetishistic transvestism where cross-dressing results in sexual arousal. In ICD-10, transsexualism is associated with experiencing discomfort, distress or impaired functioning due to their assigned gender.

Assessment and investigations

Thorough medical, psychiatric and physical examination need to be undertaken. These can help to rule out differentials such as body dysmorphic disorder, intersex conditions, schizophrenia and other psychoses. Past medical and family history are also essential to identify potential risks of treatments such as cardiovascular risk factors and VTE. Investigations will also help to identify the same risks alongside any endocrine abnormalities, prostate, cervical or sexual health diagnoses.

Diagnosis

In ICD-11, gender incongruence sits in ‘conditions related to sexual health’ rather than ‘mental behavioural and neurodevelopmental disorders’. It covers gender incongruence in adolescence or adulthood (HA60) and in childhood (HA61). For adults and adolescents, there must be a strong wish to be able to transition to the sex they identify with and for children; there may be a desire to have the primary and/or secondary sexual characteristics of their preferred gender depending on developmental stage. These desires must be present for about two years.

Treatment

Treatment should be based on the individual’s unique needs and goals.

Non-medical / psychological treatment – There is a role for voice modulation, temporary or permanent methods of hair removal (particularly facial hair) and counselling for support.

Medical/endocrine treatment – Possible aims of therapy are the suppression of puberty or endogenous sex hormones and replacement with the sex hormones of the alternative gender at a physiological level. For biologically male patients, this would be suppression of androgens and giving synthetic oestrogen. For biologically female patients, this would be the administration of testosterone. Fertility preservation treatments should be offered. Patients must be counselled on potential side effects and red flags.

Surgical treatment – In the UK, there is a higher threshold for assessment and consent for reconstruction interventions. Chest or ‘top surgery’ is offered more readily than genital reconstruction or ‘bottom surgery’.

Social – In the time leading up to transition, it is important to consider the social surroundings and stigma a patient may face. It might not always be possible for a social transition to take place before medical or surgical interventions are undertaken. However, testing this out is no longer required before non-surgical treatments. Patients can be signposted to support groups. Legal support may be required in the process of changing names and gender on official documentation.

References

• Semple D; Smyth R. (2019). Oxford Handbook of Psychiatry, fourth edition.
• International Statistical Classification of Diseases, tenth revision (ICD-10), Version:2016, https://icd.who.int/browse10/2016/en#/F60-F69
• International Statistical Classification of Diseases, eleventh revision (ICD-11), Version 01/2023, https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/411470068