Diagnosis of Gender Dysphoria

Oct 21, 2018

Gender dysphoria is a condition where then person identifies himself or herself with the opposite of their original biological sex. This is not a mental disorder. However, some people may need therapy.

Diagnosis of gender dysphoria is thus important to rule out other concurrent or underlying mental disorders like anxiety, depression etc. (1)

A multidisciplinary team is required for diagnosis

Assessment of persons with gender dysphoria and diagnosis of the condition is a multidisciplinary action.

A detailed psychiatric history, psychosexual development and behavior history, neuropsychological testing and behavioral analysis may be needed.

The team may comprise of:

Psychiatrists
Psychologists
Neurologists
Endocrinologists (who specialize in hormonal functions)
Urologists (who specialize in the urinary tract and its abnormalities)
Behavioral and occupation therapists
Counsellors etc.

Gender dysphoria must be separated from homosexuality. Not all persons with gender dysphoria are homosexual. (1, 2)

Two phase diagnosis

Diagnosis may be a challenge since results of psychological testing may not be conclusive.

The International Harry Benjamin Gender Dysphoria Association lays down guidelines for a two phase diagnosis. (1)

Phase I – Diagnosis is based on the Diagnostic and Statistical Manual for Mental Disorders IV (Text Revision) or DSM – IV TR.
Phase II – Here the patient is assessed if he or she can live in the desired sex role permanently. This involves family information and counselling and name change. Hormonal therapy, gender re-assignation surgery and psychotherapy is administered as needed.

Ruling out other diagnosis

Differential diagnosis or other diagnosis that need to be ruled out during assessment of a suspected person with gender dysphoria include (1):–

Nonconformity to stereotypical sex role behaviors
Transvestic fetishism – The person may have a sexual fetish with cross dressing
Concurrent congenital intersex condition – The person may have ambiguous genitalia
Schizophrenia

Criteria for gender dysphoria diagnosis according to DSM V guidelines

The criteria for diagnosis according to the latest DSM V proposed guidelines is broken down into in children and in adolescents and adults. (3, 4):

DSM V diagnosis in children

In children –

A definite difference between experienced/expressed gender and the one assigned at birth of at least 6 months duration. At least six of the following must be present:
1. Persistent and strong desire to be of the other sex or insistence that they belong to the other sex
2. In males a strong preference for cross-dressing and in female children a strong preference for wearing typical masculine clothing and dislike or refusal to wear typical feminine clothing
3. Fantasising about playing opposite gender roles in make-belief play or activities
4. Preference for toys, games, or activities typical of the opposite sex.
5. Rejection of toys, games and activities conforming to one’s own sex. In boys avoidance of rough-and-tumble play and in girls rejection of typically feminine toys and activities
6. Preference for playmates of the other sex
7. Dislike for sexual anatomy. Boys may hate their penis and testes and girls dislike urinating sitting.
8. Desire to acquire the primary and/or secondary sex characteristics of the opposite sex.
The gender dysphoria leads to clinically significant distress and/or social, occupational and other functioning impairment. There may be an increased risk of suffering distress or disability.
The subtypes may be ones with or without defects or defects in sexual development.

DSM V diagnosis in adults and adolescents

In adults and adolescents –