Gender Dysphoria in Adults

Gender dysphoria refers to a marked incongruence between one’s gender identity and assigned sex at birth with the dissatisfaction occurring for at least six consecutive months.  Gender dysphoria is manifested in various ways including strong and persistent desires to become the desired gender (e.g., adopting mannerism or dressing in clothing of the opposite gender), or to eliminate primary and secondary sex characteristics of one’s assigned sex at birth (e.g., wishing to remove genitalia). While transgender refers to individuals who are gender non-conforming (e.g., genderqueer, cross-dresser), individuals who experience gender dysphoria are referred to as transsexual; they wish to live and to fully embrace, the gender role of their desired gender. A helpful resource is the DSM-5 Gender Dysphoria Fact Sheet: http://www.dsm5.org/Documents/Gender%20Dysphoria%20Fact%20Sheet.pdf

Prevalence
In adults, prevalence of gender dysphoria ranges from 0.005% to 0.014% for biological men and from 0.002% to 0.003% for biological women (American Psychiatric Association, 2013). It is important to note that it is difficult to achieve an accurate estimation of prevalence as not all individuals who experience gender dysphoria seek treatment.

Identification/Assessment Strategies

Clinical Interview
The purpose of the clinical interview is to develop a thorough and well-rounded history of the client’s transgender identity development. The majority of individuals with gender dysphoria first experience gender incongruence in early childhood. Although less common, some individuals demonstrate a later onset of gender dysphoria in adulthood.  Detailed information (e.g., clinical onset, presentation, persistence, severity) regarding the development of transgender identity is critical to achieve accurate diagnosis.

Clinicians may use a list of interview questions (e.g., Potential Areas of Inquiry in Gender Evaluation-Transgender Person; Bockting, Knudson, & Goldberg, 2006) to gather detailed information regarding one’s transgender identity development. Questions concerning gender identity, gender expression, perceptions of others, sexuality, and support resources may be helpful to consider. A valuable resource for exploring potential areas of inquiry in gender evaluation for transgender persons can be found at: http://transhealth.phsa.ca/for-service-providers-2/standards-of-care.

Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults (GIDYQ-AA; Deogracias, Johnson, Meyer-Bahlburg, Kessler, Schober, & Zucker, 2007)
The GIDYQ-AA (Deogracias et al., 2007) is a 27 item self-report scale which measures gender identity and dysphoria related to subjective, social, somatic, and sociolegal experiences which have occurred over the past 12 months.  The GIDYQ-AA offers both female and male versions and is presented at a reading level that is appropriate for most adolescents and adults. For both versions, participants respond to items on a scale ranging from 1 (always) to 5 (never). Questions for the female version include, “In the past 12 months, have you felt that you were not a real woman?” or “In the past 12 months, at work or at school, have you presented yourself as a man?” Questions for the male version include “In the past 12 months, have you had the wish or desire to be a woman?” or “In the past 12 months, have you felt uncertain about yourself, at times feeling more like a woman and at times feeling more like a man?” Evidence suggests that the GIDYQ-AA has strong discriminant validity and can be used to evaluate one’s feelings associated with gender identity confusion or dysphoria (Singh et al., 2010).

Clinicians may administer the GIDYQ-AA as an initial screening tool to assess a client’s level of experienced gender dysphoria. Clinicians may integrate the client’s responses and results from the GIDYQ-AA with other presenting factors (e.g., gender incongruent behaviors) to enhance case conceptualization and treatment planning.

Resource: Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F., Kessler, S. J., Schober, J. M., & Zucker, K. J. (2007). The gender identity/gender dysphoria questionnaire for adolescents and adults. Journal of Sex Research, 44, 370-379. doi: 10.1080/00224490701586730 

Intervention Strategies

Effective treatments for gender dysphoria involve altering one’s physical appearance to match with gender identity (i.e., hormone therapy, surgical procedures). Little research has focused on counseling as a sole treatment of gender dysphoria. This is because gender dysphoria is a complex condition that affects one’s biological, psychological, emotional, and social well-being. Treatment of gender dysphoria is usually integrative and requires a multidisciplinary effort among health (e.g., endocrinologists, plastic surgeons) and mental health care (e.g., counselors, psychologists, psychiatrists) professionals (Coleman et al., 2011). Counseling is considered an adjunctive service or a supportive intervention when treating gender dysphoria.

Individualized Treatment Approach
Although it is no longer a requirement for hormone therapy and genital reconstructive surgery, counseling plays an important role in the gender transition process. Each person presenting with gender dysphoria is uniquely different and requires treatment tailored to distinctive needs. The clinician’s role is to help clients clarify the client’s gender identity and role, address related mental health concerns, and facilitate gender transition. Decisions to pursue specific types of treatment (e.g., social transition, hormone therapy) should be rooted in clients’ intentions; counselors are responsible for providing a variety of treatment options and facilitating the client’s informed decision making process.

Resource: Bockting, W. O. (2008). Psychotherapy and the real life experience: From gender dichotomy to gender diversity. Sexologies, 17, 211-224. doi: 10.1016/j.sexol.2008.08.001

Addressing Related Mental Health Concerns
Gender non-conforming behavior has historically been viewed as deviant or abnormal.  Historically, gender dysphoria was defined as Gender Identity Disorder and was included in the sexual disorders section of the DSM- IV.  In an attempt to reduce the stigma associated with this condition, gender dysphoria now has its own diagnostic category that is separate from sexual disorders in DSM-5. However, it is important to note that individuals with gender dysphoria continue to face various life challenges including mental health concerns. Although some of the distress presented by individuals with gender dysphoria is caused by the condition itself (e.g., gender incongruence and discomfort), much distress is caused by transprejudice and transphobia (i.e., discrimination based on gender identity, violence and crime toward transgender people; Bockting, Miner, Swinburne Romine, Hamilton, & Coleman, 2013). Individuals with gender dysphoria may experience mental health concerns including anxiety disorders, depressive disorders, non-suicidal self-injurious behavior, suicidal ideation and behaviors, personality disorders (Bockting et al., 2006), and eating disorders (Murray, Boon, & Touyz, 2013). Because coexisting mental health concerns can impact a client’s psychological adjustment during gender transition, it is important that counselors address symptoms of mental health concerns related to gender dysphoria such as anxiety, depressive, and substance use disorders prior to, or concurrently with, treatment for gender dysphoria. A helpful resource for that can be used in considering mental health issues with this population can be located at http://transhealth.ucsf. edu/trans?page=protocol-mental-health

Counseling/Psychotherapy Approaches
Because the mental health issues of individuals with gender dysphoria are complex, research has focused on understanding types and impacts of mental illness that these individuals experience rather than on suggesting effective counseling interventions and/or modalities (e.g., Bockting et al., 2013; Bradford, Reisner, Honnold, & Xavier, 2013; Clements-Nolle, Marx, & Katz, 2006; Testa et al., 2012). Despite a paucity of quality research that identifies effective counseling strategies, scholars (e.g., Carroll, Gilroy, & Ryan, 2002; Hendricks & Testa, 2012; Sangganjanavanich, 2014; Wester, McDonough, White, Vogel, & Taylor, 2010) have suggested essential components in counseling/psychotherapy with individuals who experience gender dysphoria. It is important to note that, to date, none of the studies regarding transgender issues in counseling/psychotherapy has used randomized controlled trials or a large sample size to evaluate the effectiveness of counseling interventions and/or modalities in treating gender dysphoria.

Transaffirmative therapy.
There are a number of sources which highlight the importance of a non- judgmental and accepting therapeutic environment when working with clients experiencing gender dysphoria. Distress caused by social pressure to conform to traditional gender roles may cause individuals to experience minority stress (Bockting et al., 2013). Individuals with gender dysphoria typically report that the most important aspect of a therapeutic relationship is support and empathy from their counselor (Bess & Stabb, 2009). A person-centered approach can be optimal in ensuring counseling focuses on assisting individuals in exploring and reflecting upon their gender identity and sexuality rather than changing the client (Bockting et al., 2006; Livingstone, 2008).

Resource: Person-Centered Therapy Livingstone, T. (2008). The relevance of a person-centered approach to therapy with transgendered or transsexual clients. Person-Centered and Experiential Psychotherapies, 7, 135-144.

Group therapy.
Busari (2013) suggested the use of a “bolstering self-esteem group” to decrease the distress associated with gender dysphoria (e.g., anxiety, depression) in adolescents. The bolstering self-esteem group is an 8-week psychoeducational group aimed at improving self-esteem and reducing negative self-perceptions of participants who experienced gender dysphoria. Busari’s initial findings suggested the “bolster self-esteem group” was effective in reducing the symptoms associated with gender dysphoria in adolescents.

Resource: Bolstering self-esteem group
Busari, A. O. (2013). Bolstering self-esteem as intervention technique in the management of symptoms of gender identity disorder among adolescents. Gender & Behaviour, 11, 5535-5545.