Psychiatry , social work, LGBT, transgender, anxiety ect.

1. Gender Identity
disorders/ gender
dysphoria
Deblina Roy
M.Sc. Psychiatric nursing 2nd Year

2. Introduction
Transgender

3. Definition:
• Gender dysphoria or gender identity disorder (GID) is the
dysphoria (distress) a person experiences as a result of
the sex and gender they were assigned at birth.
• According to the DSM V: gender dysphoria refers to those
persons who have marked incongruence between their
experienced of the expressed gender and the one they were
assigned at birth.
• ICD 10: F64 A disorder characterized by a strong and
persistent cross-gender identification (such as stating a desire
to be the other sex or frequently passing as the other sex)
coupled with persistent discomfort with his or her sex
(manifested in adults, for example, as a preoccupation with
altering primary and secondary sex characteristics through
hormonal manipulation or surgery).

4. Epidemiology
• Children :
less than 3 years start showing the gender confirmatory
behaviors. 10 % of the boys aged 12 years who were
referred for clinical problems showed desires to be of other
gender, and in girls the ratio was found to be 5%.
• Adults :
• The estimates in Europe from the Hormonal / surgical
clinics are 1 -11000 male assigned, for female assigned
people it is about 1- 30,000.

5. Cont.
• DSM 5 reports the prevalence rate ranging from the
0.005 to 0.014 for the male assigned and 0.002-0.003
in female assigned gender .
• Overall the prevalence of the male to female dysphoria is
greater as there is social acceptance of the females to
be dressed as males (tomboys) than there is birth
assigned males acting as females (so called sissies).
Some researchers speculate that one in 500 adults may
fall somewhere in the transgender spectrum based on
the population data.

6. ETIOLOGY

7. Biological factors
• The resting state of the tissue is initially female.
• The male is produced because there is androgen and
the presence of the Y chromosome
• Basically the gender dysphoria occurs due to more of the
postnatal factors .
• Brain organization theory.
• Genetic causes are still under study
• Incidental finding suggests that the transgender persons
are left handed

8. Psychosocial factors
• Children usually develop a gender identity consonant
with their assigned sex.
• Unresolved oedipal and Electra complex in the formative
years of childhod.

10. Diagnosis and clinical
features
• Children
• Differential diagnosis in children
• Trans gender as adults
• Intersex

11. • Adolescents and adults
• they show incongruence with their own assigned gender
• Gender-queer
• DIFFERNTIAL DIAGNOSIS:
• Delusional thinking, schizophrenia.
• Body dysmorphic disorder
• Trnasvestic disorders
• Paraphilic disorders

12. Course and the prognosis of
the disorder

13. Children
• Gender identity is typically established by the age f
three years
• Anxiety regarding the gender assigned and the strong
will to change the gender.
• Various research studies have shown that the children
diagnosed with the gender identity disorders in childhood
later identify with the birth assigned gender when they
reach adult hood. (Wallein MSC, Cohen KP ,
2008)

14. Co- morbidities in the
children
• Higher rates of anxiety (Adelson Sl.2011)
• Higher rates of depression
• Some researches also find that the children tend to fall
into the Autism spectrum.(Spack NP Edward LL, 2012 ).

15. Adults
• They recall the continuous identity of the development
of the transgender identities .
• In the meantime they turn into stereotypical activities and
job roles of the assigned gender.
• Many people identify themselves as Gay , Lesbian, or
Bisexual before coming out as a transgender .

16. Co morbidities in the
Adults
• Increased rates of anxiety and depression, also have self
harming activities , suicidality and substance abuse .
• Life time rate of suicidal thoughts in the transgender
people is about 40 %.
• DSM5 reports that persons wit late onset gender
dysphoria may have greater fluctuations in the extent of
their distress and more ambivalence and less
satisfaction after the sex reassignment surgery.

17. TREATMENT

18. CHILDEREN
• TYPICALLY consists of the various therapies
• Individual
• Family
• Group therapy .
• Reparative or conversion therapy

19. ADOLESCENTS
• As gender non confirming children approach puberty,
some show intense fear and preoccupation related to the
physical changes experienced by them.
• Pharmacologically : in such cases GnRH Agonists are
used.( they delay the pubertal symptoms

20. Adults
• Psychotherapy ( to explore the gender issues)
• Hormonal treatment
• Surgical treatment
These modalities may decrease depression and may
improve the quality of life.

21. Mental health treatment
• lack of support from the mental health professional has
led to reduction in the health seeking behaviors of the
trans identified people.
• The world professional Association for the transgender
health (WAPTH) Standards of care (SOC) has become
more open to the informed consent models.
• Some mental health professionals are specializing in the
transgender populations that is increasing

22. Hormones
• Transgender men it is: testosterone(
weekly )
• Side effects :
• Increased acne
• Muscle mass
• Increased libido.
• Cessation of menses
• Deepening of the voice
• Increased body hair
• Enlargement of the clitoris
Monitoring of the other parameters : (LFT, Lipid profile )
• Fertility counseling

23. • Transgender woman: they mainly take
Estrogen , testosterone blockers , or progesterone or in
combination.
• These hormones can cause the softening of the skin and
the redistribution of the fat. As well as breast growth and
breast development.
• Sex drive may decrease and there might be erections
and ejaculations.
• Body hair may decrease but not as desired.
• Voice coaching may be done for training.
Monitoring of the parameters : (LFT, Blood pressure
cholesterol, prolactin level)
They may develop prolactinomas .
• Reproductive counseling is very important as there
may be permanent sterility.

24. Surgery
• Many fewer people go for the gender related surgeries ,
many don’t want them, most cant afford them, and few
are not satisfied with the results presently available.
• Most common surgery is top surgery.( chest , breast).
• Then is bottom surgeries that is for the woman Sex
reassignment surgeries (vagino plasty) and for men
clitoris is freed from the ligament attached to it.
• Then more mass is added and penis is formed then
scrotoplasty and testicular implants .

25. Transgender-woman-shares-graphic-account-really-feels-like-undergo-gender-
reassignment-surgery.html#v-2593855332742379662

26. Male to female gender
reassignment surgery

27. Female to male gender
reassignment surgery

28. Intersex dsoreders
• According to the DSM IV TR intersex disorders are
diagnosed when gender dysphoria is present, as gender
identity disorders not other wise specified .

29. Congenital virilizing
adrenal hyperplasia
• This disorder was formerly called as adrenogenital syndrome.
• Its an enzymatic defect in the production of cortisol in the
prenatal period, leads to the over production of adrenal
androgens and virilization of the female foetus.
• With the early diagnosis children develop gender identity
consistent with the chromosomal or the gonadal sex .
• But girls tend to be tomboyish.
• Higher rates of bisexual and homosexual behaviors have
been reported.
• Treatment : hormonal therapies and surgical feminization ,
enzymatic replacement

30. Androgen insensitivity
syndrome
• It was formerly called testicular feminization.
• In these persons with XY karyotype , the tissue cells are
unable to use testosterone.
• Therefore the person is born as a girl and raised as a girl
they have reported to be satisfied with their feminity.
• Persons with partial androgen insensitivity has been
associated with the gender change from female to male

31. Turner syndrome
• In turner syndrome 1 sex chromosome is missing so the
karyotype is X. they may have shield shaped chests and
webbed neck.
• Due to dysfunctional ovaries they need hormonal
support in the development of the female sexual
characteristics.
• They identify themselves as female
• they are infertile .

32. Kleinefelter Syndrome
• An extra X chromosome is present so the karyotype is
XXY.
• At birth the people are born as the normal males, there
may be excessive gyneacomastia in the adolescence
usually they are tall. Testes are small without sperm
production. They are tall and bodily habitus is eunuchoid
. Reportedly having gender identity disorder.

33. 5-alpha reductase
deficiency
• Deficiency of the enzyme 5 alpha reductase for the
conversion of the testosterone to dihydroxy-testosterone
. So the person is normally born with a female
characteristics and then at puberty there is virilization of
the genitalia
• The person identifies himself as a male gender.

34. Early life surgeries for the
intersex children.
• Controversy has developed over surgery of the genitalia
for anatomically inter-sexed children.
• Many people whose sex change surgeries had been
done in childhood now complain regarding the mutilation
of the and limited full erotic arousal.
• currently there had been a professional movement in
the delay in implementing the surgeries

35. patients with gender identity
disorders
• Assessment :
anxiety level,
• Depression level
• Stress related to the dysphoric identity of biological and
identified gender
• Stress level of he family members related to the
dysphoric gender identity.
• Coping strategies of the patient and the family and the
available services in mental health

36. Nursing diagnosis
• Anxiety related to incongruence between the identified
gender and the biological gender as evidenced by
verbalization of the patient.
• Persistent stress related to the thoughts of changing own
biological gender as evidenced by visits to hormone and
surgical clinics
• Maladaptive coping related to the inability to cope with
the desire to change the gender as evidenced by abuse
of substances.
• Low self confidence related to humiliation at the school /
office / home as evidenced by shy and avoidant
behavior.

37. Interventions to reduce
anxiety
• Assess the level f anxiety.
• Teach the client various techniques to reduce anxiety.
• Tell the patient that it is not completely his/ her fault that
they have this problem
• Mutually explore the various methods of reducing anxiety
through the meditation, and group activity.
• Give small tasks to the client according to the gender
preferences so that the patient has reduced anxiety.
• Short acting benzodiazepines and newer anxiolytics can
be given to the patient.

38. Interventions for coping
• Assess the coping strategies commonly used by the
patient .
• Accept the patient as he/she is.
• Inform the patients regarding the various coping
mechanisms.
• Involve the patients in group therapy so that patient can
discuss the methods of coping wit the similar people.
• mutually explore the various coping strategies and
collaborate and coordinate with the psychologist and the
therapists for the improvement in the coping strategies

39. Measures to improve self
confidence
• Assess the patients level of self confidence
• Provide various activities to improve self esteem
• give supportive psychotherapy to help understand the
conditions
• Family therapy should be given
• Referral to the appropriate support groups
• Avoidance of risky behavior .

40. Research article related to
gender identity

41. Kosenko, Kami PhD*; Rintamaki, Lance PhD†; Raney, Stephanie BA*; Maness, Kathleen BA
• Objectives: Transgender individuals, or those who cross or transcend
sex categories, commonly experience stigma and discrimination.
Anecdotal evidence indicates that this transphobia manifests in health
care settings, but few studies address the forms of mistreatment
experienced in this context. This study was designed to explore
transgender patients’ experiences with health care. This brief report
focuses on their negative experiences.
• Methods: A total of 152 transgender adults were recruited to complete
an online questionnaire about their health care. Participants were asked
if and how they had been mistreated, and responses were analyzed by
qualitative content analysis.
• Results: Participants’ descriptions of mistreatment coalesced around 6
themes: gender insensitivity, displays of discomfort, denied services,
substandard care, verbal abuse, and forced care.
• Conclusions: These findings provide insight into transgender patients’
perceptions of and sensitivity to mistreatment in health care contexts.
This information might be used to increase providers’ cultural

42. summary

43. Discussion

44. N Engl J Med 1979; 300:1233-1237May 31, 1979DOI:
10.1056/NEJM197905313002201
• Abstract:
• To determine the contribution of androgens to the formation of male-gender
identity, we studied male pseudohermaphrodites who had decreased
dihydrotestosterone production due to 5α-reductase deficiency. These subjects
were born with female-appearing external genitalia and were raised as girls.
They have plasma testosterone levels in the high normal range, show an
excellent response to testosterone and are unique models for evaluating the
effect of testosterone, as compared with a female upbringing, in determining
gender identity. Eighteen of 38 affected subjects were unambiguously raised as
girls, yet during or after puberty, 17 of 18 changed to a male-gender identity and
16 of 18 to a male-gender role. Thus, exposure of the brain to normal levels of
testosterone in utero, neonatally and at puberty appears to contribute
substantially to the formation of male-gender identity. These subjects
demonstrate that in the absence of sociocultural factors that could interrupt the
natural sequence of events, the effect of testosterone predominates, over-riding
the effect of rearing as girls. (N Engl J Med 300:1233–1237, 1979)

45. Bibliography
• SaddockBJ. SaddockVA . Synopsis of psychiatry, 11th ed,
walterkluers publicaion, Philladelphia PA USA ;2015. pp-
600-618
• Saddock BJ, SaddockVA,Ruiz P. Kaplan and saddocks
comprehensie text book of psychiatry 9th ed.
Wolterkluer,Philladelphia PA USA; 2012.pp-2099-2111.
• Kosenko K, Rintamaki L, Raney S,Maness K.
Transgender Patient Perceptions of Stigma in Health
Care Contexts. Medical care ; Sep 2013 vol-29 :19[819-
822] BAhttp://journals.lww.com/lww-
medicalcare/Abstract/2013/09000/Transgender_Patient_
Perceptions_of_Stigma_in.10.aspx