{"id":815,"date":"2020-08-10T20:29:34","date_gmt":"2020-08-10T20:29:34","guid":{"rendered":"https:\/\/courses.lumenlearning.com\/abnormalpsych\/?post_type=chapter&#038;p=815"},"modified":"2022-07-26T20:06:23","modified_gmt":"2022-07-26T20:06:23","slug":"gender-dysphoria","status":"publish","type":"chapter","link":"https:\/\/courses.lumenlearning.com\/wm-abnormalpsych\/chapter\/gender-dysphoria\/","title":{"raw":"Gender Dysphoria","rendered":"Gender Dysphoria"},"content":{"raw":"<div class=\"textbox learning-objectives\">\r\n<h3>Learning Objectives<\/h3>\r\n<ul>\r\n \t<li style=\"font-weight: 400;\">Describe symptoms and factors associated with gender dysphoria<\/li>\r\n<\/ul>\r\n<\/div>\r\n<h2>DSM-5 Diagnostic Criteria<\/h2>\r\nIn 2013, the diagnosis for gender dysphoria (GD) was renamed from <em>gender identity disorder<\/em>\u00a0(GID) after criticisms that the latter term was stigmatizing. The DSM-5 also moved this diagnosis out of the sexual disorders category and into a category of its own. In order to be diagnosed with gender dysphoria (GD), a person must experience, for at least six months, a noticeable difference between how they experience\/express their own gender and their sex assigned at birth. Symptoms related to this difference may include the expressed desire for others to treat or perceive them as another gender; discomfort with genitals or sex characteristics; wishing these genitals or sex characteristics were different or aligned with another gender; and\/or a strong sense of being another gender despite how others perceive them. This discrepancy must cause significant impairment in social, occupational, school, or daily life functioning.\r\n<h3>Symptoms<\/h3>\r\n[caption id=\"attachment_3709\" align=\"alignright\" width=\"201\"]<img class=\"wp-image-3709 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/25231731\/A_boy_playing_nursing_his_doll-201x300.jpg\" alt=\"A young boy nursing a baby doll. \" width=\"201\" height=\"300\" \/> <strong>Figure 1.\u00a0<\/strong>A preference for opposite-sex typical toys may be a symptom of gender dysphoria.[\/caption]\r\n\r\nThe cardinal symptom of gender dysphoria (GD) is distress stemming from an incongruence between a person's experienced gender and assigned sex\/gender. Symptoms of GD in children include preferences for opposite-sex typical toys, games, or activities; great dislike of their own genitalia; and a strong preference for playmates of the opposite sex. Some children may also experience social isolation from their peers, anxiety, loneliness, and depression. According to the American Psychological Association, transgender children are more likely to experience harassment and violence in school, foster care, residential treatment centers, homeless centers, and juvenile justice programs than other children.[footnote]American Psychological Association (2008). \"Resolution on transgender, gender identity, and gender expression non-discrimination\"[\/footnote]\u00a0The diagnosis for children has been separated from that for adults. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing or to express it in the event that they have insight. In order for children to be assigned this diagnostic category, they must verbalize their desire to become the other gender.\r\n\r\nIn adolescents and adults, symptoms include the desire to be and to be treated as the other gender. Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide. Studies indicate that transgender people have an extremely high rate of suicide attempts; one study of 6,450 transgender people in the United States found 41% had attempted suicide, compared to a national average of 1.6%. It was also found that suicide attempts were less common among transgender people who said their family ties had remained strong after they came out, but even transgender people at comparatively low risk were still much more likely to have attempted suicide than the general population.[footnote]Grant; Jaime, M.; Mottet, Lisa; Tanis, Justin; Harrison, Jack; Herman, Jody; Keisling, Mara (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (PDF). Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. Archived from the original (PDF) on November 4, 2015. Retrieved May 10, 2015.[\/footnote] Transgender people are also at heightened risk for eating disorders and substance abuse.\r\n<h3>Gender Dysphoria and Transgender Individuals<\/h3>\r\nMany people who are diagnosed with gender dysphoria identify as transgender, <strong>genderfluid <\/strong>(a gender that varies over time), or otherwise <strong>gender non-conforming <\/strong>(anyone whose\u00a0appearance and behavior\u00a0does not reflect the\u00a0gender roles\u00a0expected of them) in some way; however, not everyone who identifies as transgender or gender non-conforming experiences gender dysphoria.\r\n\r\n<em>Transgender<\/em>\u00a0or <em>transsexual<\/em>\u00a0is an umbrella term for people whose\u00a0internal experience of gender\u00a0does not match their sex assigned at birth (normally based on first and secondary\u00a0sex\u00a0characteristics). Transgender people may experience\u00a0discomfort or distress\u00a0due to their gender not aligning with their sex, and therefore wish to\u00a0transition\u00a0to being the gender they identify with.\r\n\r\n[caption id=\"attachment_3716\" align=\"alignright\" width=\"300\"]<img class=\"wp-image-3716 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/25233420\/A-non-binary-femme-in-a-gender-neutral-bathroom-300x200.jpg\" alt=\"A non-binary femme in a gender neutral bathroom.\" width=\"300\" height=\"200\" \/> <strong>Figure 2.<\/strong>\u00a0Recognizing spaces as gender-neutral is important in helping transgender and non-binary individuals feel included.[\/caption]\r\n\r\nSome transgender people feel this way from a very young age, while others go through a period of\u00a0questioning\u00a0before realizing they are transgender. Transgender people can be\u00a0men,\u00a0women, or\u00a0<strong>non-binary<\/strong> (a spectrum of\u00a0gender identities\u00a0that are not exclusively\u00a0masculine\u00a0or\u00a0feminine\u200d). They can have any sexual orientation,\u00a0express their gender\u00a0through their appearance in any way, and may or may not fit into\u00a0society's views of gender.\u00a0Every transgender person has different desires for what they want (or do not want) to include in their transition, including surgery and other medical procedures. Transgender people who do not plan to have surgery are sometimes referred to as\u00a0non-op;\u00a0<strong>transsexual<\/strong>\u00a0is sometimes used to refer to only those who do. It is important not to make assumptions about what is, was, or will be involved in any individual person's transition. <strong>Transition<\/strong>\u00a0is any action a transgender person takes in order for the external world to better recognize and reflect their experienced gender. This can range from asking people to use different\u00a0names\u00a0and\u00a0pronouns, to a change in\u00a0dress or appearance, to\u00a0extensive gender-affirming surgery. The three main forms of transition are\u00a0social,\u00a0legal, and\u00a0medical, although all of these are broad categories that can reflect dozens of different possible actions.\r\n\r\nA post-transition specifier was also added for transgender individuals who have transitioned to their experienced gender (i.e., undergone gender affirming hormonal or surgical procedures to alter their body in a way that matches their experienced gender identity). This specifier helps to ensure post-transition individuals can continue to receive ongoing hormonal or other treatment as needed.\r\n<div class=\"textbox exercises\">\r\n<h3>Controversy Surrounding the Diagnosis of Gender Dysphoria<\/h3>\r\nThe previous diagnosis of gender identity disorder (GID) caused a great deal of controversy. Many transgender people and researchers supported the declassification of gender identity disorder (GID), arguing that the diagnosis pathologizes a natural form of gender variance, reinforces the binary model of gender (i.e., the idea that there are only two genders and that everyone must fit neatly into one of these two genders), and can result in stigmatization of transgender individuals. The official reclassification of gender dysphoria as a disorder in the DSM-5 may help resolve some of these issues, because the term <em>gender dysphoria<\/em>\u00a0applies only to the discontent experienced by some persons resulting from gender identity issues, rather than suggesting that their identity is disordered.\r\n\r\nAdvantages and disadvantages exist to classifying gender dysphoria as a disorder, however. Many people argue that the distress associated with gender dysphoria is not caused by any disorder within the individual, but by difficulties encountered from social disapproval of transgender identities and alternative genders. As such, they argue that any form of diagnosis is still stigmatizing and places the \"problem\u201d unnecessarily on the individual, rather than on society. However, because gender dysphoria is classified as a disorder in the DSM-5, many insurance companies are willing to cover some of the expenses related to gender-affirming surgery. Without the classification of gender dysphoria as a medical disorder, gender-affirming surgery may be viewed as cosmetic treatment\u2014rather than medically necessary treatment for many transgender individuals\u2014and thus may not be covered.\r\n\r\n<\/div>\r\n<h3>Early and Late-Onset Gender Dysphoria<\/h3>\r\nGender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset. <strong>Early-onset gender dysphoria<\/strong> is behaviorally visible in childhood. Sometimes gender dysphoria will desist in this group and they will identify as gay or homosexual for a period of time, followed by recurrence of gender dysphoria. In adulthood, this group is usually sexually attracted to members of the sex they were assigned at birth.\r\n\r\n<strong>Late-onset gender dysphoria<\/strong> does not include visible signs in early childhood, but some report having had wishes to be the opposite sex in childhood that they did not report to others. Trans women who experience late-onset gender dysphoria will usually be sexually attracted to women and may identify as lesbians. It is common for people assigned male at birth who have late-onset gender dysphoria to engage in cross-dressing with sexual excitement. In those individuals who are assigned female at birth, early-onset gender dysphoria is the most common course. This group is usually sexually attracted to women. Trans men who experience late-onset gender dysphoria will usually be sexually attracted to men and may identify as gay.[footnote]Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). \"A Review of the Status of Brain Structure Research in Transsexualism\". Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5. PMC 4987404. PMID 27255307.[\/footnote]\r\n<h2>Epidemiology<\/h2>\r\nGender dysphoria occurs in one in 30,000 individuals assigned male at birth and one in 100,000 individuals assigned female at birth.[footnote]Gender identity disorders. (2018). In H. Marcovitch (Ed.), Black's Medical Dictionary, 43rd edition (43rd ed.). London, UK: A&amp;C Black.[\/footnote] It is estimated that about 0.005% to 0.014% of individuals assigned male at birth and 0.002% to 0.003% of individuals assigned female at birth would be diagnosed with gender dysphoria, based on 2013 diagnostic criteria, though this is considered a modest underestimate.[footnote]Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 454. ISBN 978-0-89042-555-8.[\/footnote] Research indicates people who transition in adulthood are up to three times more likely to be assigned male at birth, but that among people transitioning in childhood the sex ratio is close to 1:1.[footnote]Land\u00e9n M, W\u00e5linder J, Lundstr\u00f6m B (April 1996). \"Prevalence, incidence and sex ratio of transsexualism\". Acta Psychiatrica Scandinavica. 93 (4): 221\u20133. doi:10.1111\/j.1600-0447.1996.tb10638.x. PMID 8712018[\/footnote]\r\n\r\nAccording to an analysis of national probability samples in 2016, there were 390 per 100,000 adults who were transgender. However, it also suggested that future surveys will probably observe a higher prevalence.[footnote]Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 Feb;107(2):e1-e8.[\/footnote]\r\n\r\nAccording to a recent national survey, 1.4 million individuals (0.6%) in the United States identify as transgender. It is also believed that\u00a0these numbers are underrepresented due to the social stigma. Also, a part of this population might not want to engage in studies;\u00a0hence, the true prevalence remains higher than what is reported. Nevertheless, an increasing shift is observed\u00a0in this population seeking health care over the last decade.[footnote]Polderman TJC, Kreukels BPC, Irwig MS, Beach L, Chan YM, Derks EM, Esteva I, Ehrenfeld J, Heijer MD, Posthuma D, Raynor L, Tishelman A, Davis LK., International Gender Diversity Genomics Consortium. The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table. Behav. Genet. 2018 Mar;48(2):95-108.[\/footnote]\r\n\r\nSubstance use disorders are commonly found in individuals with GD, with some studies showing 28% having reported problems with substance use. In a recent study, about 48.3% of a\u00a0study population had suicidal ideation, and 23.8% had attempted suicide at least once in their lifetime. Although, they were not able to appreciate any clinically significant difference between male-to-female (MTF) or female-to-male (FTM) groups. Anxiety, depression, and personality disorders are also common comorbidities. One study by Madeddu in 2009 found that personality disorder was comorbid in 52% of cases and the most common was Cluster B personality disorders.[footnote]Garg G, Elshimy G, Marwaha R. Gender Dysphoria (Sexual Identity Disorders) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532313\/[\/footnote]\r\n<h2 id=\"_article-28950_s2_\" class=\"ui-helper-clearfix\">Etiology<\/h2>\r\nThe etiology of GD remains unclear, but it is thought to originate from a complex biopsychosocial link.\u00a0Individuals born with congenital\u00a0adrenal hyperplasia (a condition that involves excessive or deficient production of sex steroids and can alter the development of\u00a0primary\u00a0or\u00a0secondary sex characteristics\u00a0in some affected infants, children, or adults) or androgen insensitivity syndrome (an intersex condition) are usually brought up and socialized as girls, even though they often cross-dress and have an innate sense of belonging to the opposite sex. These changes are more evident around and during puberty. This is one of the well-established biological links.\r\n\r\nAssociations have also been found with in-utero exposure to phthalates in plastics and polychlorinated biphenyls. They are known to\u00a0disrupt the regular endocrinology of sex determination before birth. Phthalates can lead to an increase in total fetal testosterone levels, which in turn\u00a0increases the risk of autism\u00a0spectrum disorder as well as GD.\r\n\r\nGD\u00a0has been found to have a higher prevalence in people with psychiatric illnesses such as schizophrenia and autism\u00a0spectrum disorder. The link seems to be neuroanatomical and needs more research. There was growing evidence those on the autism spectrum have a higher prevalence of GD; however, certain studies seek to disprove this hypothesis.\r\n\r\nThere is also growing evidence that childhood abuse, neglect, maltreatment, and physical or sexual abuse may be associated with GD. Individuals reporting higher body dissatisfaction and GD have a worse prognosis in terms of mental health. And as mentioned above in epidemiology, individuals with GD are found to have higher rates of depression, suicidal ideations, and substance use. Neuroanatomical links in those with GD have been found in certain studies, including a faulty neuronal development and differentiation in the hypothalamic links. Functional neuroimaging has shown variations in hemispheric ratios and amygdala connectivity according to gender. A few case reports have reported some\u00a0association of GD to maternal toxoplasma infection, although additional data is needed for further evidence.\r\n\r\nA genetic\u00a0association is also identified as one of the causes of GD. Heritability and familiarity of GD\u00a0have been identified: for instance, higher prevalence in monozygotic twins than dizygotic twins. Some alleles\u00a0(CYP17 and CYP17 T-34C)\u00a0have also been found to have an\u00a0association, although it is difficult to say if it is merely association or causation.\r\n<div class=\"textbox examples\">\r\n<h3>Watch It<\/h3>\r\nWatch this video to review the\u00a0definition, diagnosis, treatment, and challenges of gender dysphoria.\r\n\r\n[embed]https:\/\/youtu.be\/W669-8aQzTk[\/embed]\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/GenderDysphoriaDefinitionDiagnosis_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"Gender dysphoria: definition, diagnosis, treatment and challenges\" here (opens in new window)<\/a>.\r\n\r\nThis video takes a look at the story of transgender advocate and spokesperson, Jazz Jennings.\r\n\r\n<iframe src=\"\/\/plugin.3playmedia.com\/show?mf=5576160&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=bJw3s85EcxM&amp;video_target=tpm-plugin-xvcmwx72-bJw3s85EcxM\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe>\r\n\r\nYou can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/TransgenderAt11ListeningToJazzJennings_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for \"Transgender at 11: Listening to Jazz Jennings | 20\/20 | ABC News\" here (opens in new window)<\/a>.\r\n\r\n<\/div>\r\n<div class=\"textbox key-takeaways\">\r\n<h3>Key Takeaways: Gender Dysphoria<\/h3>\r\n<iframe title=\"43. Gender Dysphoria\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291235576908245968\/embed\" width=\"1088\" height=\"519\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script>\r\n\r\n<\/div>\r\n<div class=\"textbox tryit\">\r\n<h3>Try It<\/h3>\r\nhttps:\/\/assess.lumenlearning.com\/practice\/36d7d88c-dd14-4d7d-bfbc-880a6925276d\r\n\r\n<\/div>\r\n<div class=\"textbox learning-objectives\">\r\n<h3>Glossary<\/h3>\r\n<strong>early-onset gender dysphoria: <\/strong>gender dysphoria\u00a0behaviorally visible in childhood\r\n\r\n<b>genderfluid:\u00a0<\/b>a\u00a0gender identity that varies over time\r\n\r\n<b>gender non-conforming:\u00a0<\/b>describes anyone whose\u00a0appearance and behavior\u00a0does not reflect the\u00a0gender roles\u00a0expected of them\r\n\r\n<strong>late-onset gender dysphoria: <\/strong>gender dysphoria that does not include visible signs in early childhood\r\n\r\n<strong>non-binary:\u00a0<\/strong>a spectrum of\u00a0gender identities\u00a0that are not exclusively\u00a0masculine\u00a0or\u00a0feminine\u200d\r\n\r\n<b>transsexual<\/b><strong style=\"color: #800000;\"><span style=\"color: #333333;\">:<\/span> <\/strong>a\u00a0term sometimes used to refer to individuals with gender dysphoria who choose to undergo gender-affirming surgery\r\n\r\n<span style=\"color: #333333;\"><strong style=\"font-size: 1rem; text-align: initial;\">transition:<\/strong><\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0any action a transgender person takes in order for the external world to better recognize and reflect their experienced gender<\/span>\r\n\r\n<\/div>","rendered":"<div class=\"textbox learning-objectives\">\n<h3>Learning Objectives<\/h3>\n<ul>\n<li style=\"font-weight: 400;\">Describe symptoms and factors associated with gender dysphoria<\/li>\n<\/ul>\n<\/div>\n<h2>DSM-5 Diagnostic Criteria<\/h2>\n<p>In 2013, the diagnosis for gender dysphoria (GD) was renamed from <em>gender identity disorder<\/em>\u00a0(GID) after criticisms that the latter term was stigmatizing. The DSM-5 also moved this diagnosis out of the sexual disorders category and into a category of its own. In order to be diagnosed with gender dysphoria (GD), a person must experience, for at least six months, a noticeable difference between how they experience\/express their own gender and their sex assigned at birth. Symptoms related to this difference may include the expressed desire for others to treat or perceive them as another gender; discomfort with genitals or sex characteristics; wishing these genitals or sex characteristics were different or aligned with another gender; and\/or a strong sense of being another gender despite how others perceive them. This discrepancy must cause significant impairment in social, occupational, school, or daily life functioning.<\/p>\n<h3>Symptoms<\/h3>\n<div id=\"attachment_3709\" style=\"width: 211px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3709\" class=\"wp-image-3709 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/25231731\/A_boy_playing_nursing_his_doll-201x300.jpg\" alt=\"A young boy nursing a baby doll.\" width=\"201\" height=\"300\" \/><\/p>\n<p id=\"caption-attachment-3709\" class=\"wp-caption-text\"><strong>Figure 1.\u00a0<\/strong>A preference for opposite-sex typical toys may be a symptom of gender dysphoria.<\/p>\n<\/div>\n<p>The cardinal symptom of gender dysphoria (GD) is distress stemming from an incongruence between a person&#8217;s experienced gender and assigned sex\/gender. Symptoms of GD in children include preferences for opposite-sex typical toys, games, or activities; great dislike of their own genitalia; and a strong preference for playmates of the opposite sex. Some children may also experience social isolation from their peers, anxiety, loneliness, and depression. According to the American Psychological Association, transgender children are more likely to experience harassment and violence in school, foster care, residential treatment centers, homeless centers, and juvenile justice programs than other children.<a class=\"footnote\" title=\"American Psychological Association (2008). &quot;Resolution on transgender, gender identity, and gender expression non-discrimination&quot;\" id=\"return-footnote-815-1\" href=\"#footnote-815-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a>\u00a0The diagnosis for children has been separated from that for adults. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing or to express it in the event that they have insight. In order for children to be assigned this diagnostic category, they must verbalize their desire to become the other gender.<\/p>\n<p>In adolescents and adults, symptoms include the desire to be and to be treated as the other gender. Adults with GD are at increased risk for stress, isolation, anxiety, depression, poor self-esteem, and suicide. Studies indicate that transgender people have an extremely high rate of suicide attempts; one study of 6,450 transgender people in the United States found 41% had attempted suicide, compared to a national average of 1.6%. It was also found that suicide attempts were less common among transgender people who said their family ties had remained strong after they came out, but even transgender people at comparatively low risk were still much more likely to have attempted suicide than the general population.<a class=\"footnote\" title=\"Grant; Jaime, M.; Mottet, Lisa; Tanis, Justin; Harrison, Jack; Herman, Jody; Keisling, Mara (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (PDF). Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. Archived from the original (PDF) on November 4, 2015. Retrieved May 10, 2015.\" id=\"return-footnote-815-2\" href=\"#footnote-815-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a> Transgender people are also at heightened risk for eating disorders and substance abuse.<\/p>\n<h3>Gender Dysphoria and Transgender Individuals<\/h3>\n<p>Many people who are diagnosed with gender dysphoria identify as transgender, <strong>genderfluid <\/strong>(a gender that varies over time), or otherwise <strong>gender non-conforming <\/strong>(anyone whose\u00a0appearance and behavior\u00a0does not reflect the\u00a0gender roles\u00a0expected of them) in some way; however, not everyone who identifies as transgender or gender non-conforming experiences gender dysphoria.<\/p>\n<p><em>Transgender<\/em>\u00a0or <em>transsexual<\/em>\u00a0is an umbrella term for people whose\u00a0internal experience of gender\u00a0does not match their sex assigned at birth (normally based on first and secondary\u00a0sex\u00a0characteristics). Transgender people may experience\u00a0discomfort or distress\u00a0due to their gender not aligning with their sex, and therefore wish to\u00a0transition\u00a0to being the gender they identify with.<\/p>\n<div id=\"attachment_3716\" style=\"width: 310px\" class=\"wp-caption alignright\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-3716\" class=\"wp-image-3716 size-medium\" src=\"https:\/\/s3-us-west-2.amazonaws.com\/courses-images\/wp-content\/uploads\/sites\/5351\/2020\/08\/25233420\/A-non-binary-femme-in-a-gender-neutral-bathroom-300x200.jpg\" alt=\"A non-binary femme in a gender neutral bathroom.\" width=\"300\" height=\"200\" \/><\/p>\n<p id=\"caption-attachment-3716\" class=\"wp-caption-text\"><strong>Figure 2.<\/strong>\u00a0Recognizing spaces as gender-neutral is important in helping transgender and non-binary individuals feel included.<\/p>\n<\/div>\n<p>Some transgender people feel this way from a very young age, while others go through a period of\u00a0questioning\u00a0before realizing they are transgender. Transgender people can be\u00a0men,\u00a0women, or\u00a0<strong>non-binary<\/strong> (a spectrum of\u00a0gender identities\u00a0that are not exclusively\u00a0masculine\u00a0or\u00a0feminine\u200d). They can have any sexual orientation,\u00a0express their gender\u00a0through their appearance in any way, and may or may not fit into\u00a0society&#8217;s views of gender.\u00a0Every transgender person has different desires for what they want (or do not want) to include in their transition, including surgery and other medical procedures. Transgender people who do not plan to have surgery are sometimes referred to as\u00a0non-op;\u00a0<strong>transsexual<\/strong>\u00a0is sometimes used to refer to only those who do. It is important not to make assumptions about what is, was, or will be involved in any individual person&#8217;s transition. <strong>Transition<\/strong>\u00a0is any action a transgender person takes in order for the external world to better recognize and reflect their experienced gender. This can range from asking people to use different\u00a0names\u00a0and\u00a0pronouns, to a change in\u00a0dress or appearance, to\u00a0extensive gender-affirming surgery. The three main forms of transition are\u00a0social,\u00a0legal, and\u00a0medical, although all of these are broad categories that can reflect dozens of different possible actions.<\/p>\n<p>A post-transition specifier was also added for transgender individuals who have transitioned to their experienced gender (i.e., undergone gender affirming hormonal or surgical procedures to alter their body in a way that matches their experienced gender identity). This specifier helps to ensure post-transition individuals can continue to receive ongoing hormonal or other treatment as needed.<\/p>\n<div class=\"textbox exercises\">\n<h3>Controversy Surrounding the Diagnosis of Gender Dysphoria<\/h3>\n<p>The previous diagnosis of gender identity disorder (GID) caused a great deal of controversy. Many transgender people and researchers supported the declassification of gender identity disorder (GID), arguing that the diagnosis pathologizes a natural form of gender variance, reinforces the binary model of gender (i.e., the idea that there are only two genders and that everyone must fit neatly into one of these two genders), and can result in stigmatization of transgender individuals. The official reclassification of gender dysphoria as a disorder in the DSM-5 may help resolve some of these issues, because the term <em>gender dysphoria<\/em>\u00a0applies only to the discontent experienced by some persons resulting from gender identity issues, rather than suggesting that their identity is disordered.<\/p>\n<p>Advantages and disadvantages exist to classifying gender dysphoria as a disorder, however. Many people argue that the distress associated with gender dysphoria is not caused by any disorder within the individual, but by difficulties encountered from social disapproval of transgender identities and alternative genders. As such, they argue that any form of diagnosis is still stigmatizing and places the &#8220;problem\u201d unnecessarily on the individual, rather than on society. However, because gender dysphoria is classified as a disorder in the DSM-5, many insurance companies are willing to cover some of the expenses related to gender-affirming surgery. Without the classification of gender dysphoria as a medical disorder, gender-affirming surgery may be viewed as cosmetic treatment\u2014rather than medically necessary treatment for many transgender individuals\u2014and thus may not be covered.<\/p>\n<\/div>\n<h3>Early and Late-Onset Gender Dysphoria<\/h3>\n<p>Gender dysphoria in those assigned male at birth tends to follow one of two broad trajectories: early-onset or late-onset. <strong>Early-onset gender dysphoria<\/strong> is behaviorally visible in childhood. Sometimes gender dysphoria will desist in this group and they will identify as gay or homosexual for a period of time, followed by recurrence of gender dysphoria. In adulthood, this group is usually sexually attracted to members of the sex they were assigned at birth.<\/p>\n<p><strong>Late-onset gender dysphoria<\/strong> does not include visible signs in early childhood, but some report having had wishes to be the opposite sex in childhood that they did not report to others. Trans women who experience late-onset gender dysphoria will usually be sexually attracted to women and may identify as lesbians. It is common for people assigned male at birth who have late-onset gender dysphoria to engage in cross-dressing with sexual excitement. In those individuals who are assigned female at birth, early-onset gender dysphoria is the most common course. This group is usually sexually attracted to women. Trans men who experience late-onset gender dysphoria will usually be sexually attracted to men and may identify as gay.<a class=\"footnote\" title=\"Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). &quot;A Review of the Status of Brain Structure Research in Transsexualism&quot;. Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5. PMC 4987404. PMID 27255307.\" id=\"return-footnote-815-3\" href=\"#footnote-815-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/p>\n<h2>Epidemiology<\/h2>\n<p>Gender dysphoria occurs in one in 30,000 individuals assigned male at birth and one in 100,000 individuals assigned female at birth.<a class=\"footnote\" title=\"Gender identity disorders. (2018). In H. Marcovitch (Ed.), Black's Medical Dictionary, 43rd edition (43rd ed.). London, UK: A&amp;C Black.\" id=\"return-footnote-815-4\" href=\"#footnote-815-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a> It is estimated that about 0.005% to 0.014% of individuals assigned male at birth and 0.002% to 0.003% of individuals assigned female at birth would be diagnosed with gender dysphoria, based on 2013 diagnostic criteria, though this is considered a modest underestimate.<a class=\"footnote\" title=\"Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 454. ISBN 978-0-89042-555-8.\" id=\"return-footnote-815-5\" href=\"#footnote-815-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a> Research indicates people who transition in adulthood are up to three times more likely to be assigned male at birth, but that among people transitioning in childhood the sex ratio is close to 1:1.<a class=\"footnote\" title=\"Land\u00e9n M, W\u00e5linder J, Lundstr\u00f6m B (April 1996). &quot;Prevalence, incidence and sex ratio of transsexualism&quot;. Acta Psychiatrica Scandinavica. 93 (4): 221\u20133. doi:10.1111\/j.1600-0447.1996.tb10638.x. PMID 8712018\" id=\"return-footnote-815-6\" href=\"#footnote-815-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/p>\n<p>According to an analysis of national probability samples in 2016, there were 390 per 100,000 adults who were transgender. However, it also suggested that future surveys will probably observe a higher prevalence.<a class=\"footnote\" title=\"Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 Feb;107(2):e1-e8.\" id=\"return-footnote-815-7\" href=\"#footnote-815-7\" aria-label=\"Footnote 7\"><sup class=\"footnote\">[7]<\/sup><\/a><\/p>\n<p>According to a recent national survey, 1.4 million individuals (0.6%) in the United States identify as transgender. It is also believed that\u00a0these numbers are underrepresented due to the social stigma. Also, a part of this population might not want to engage in studies;\u00a0hence, the true prevalence remains higher than what is reported. Nevertheless, an increasing shift is observed\u00a0in this population seeking health care over the last decade.<a class=\"footnote\" title=\"Polderman TJC, Kreukels BPC, Irwig MS, Beach L, Chan YM, Derks EM, Esteva I, Ehrenfeld J, Heijer MD, Posthuma D, Raynor L, Tishelman A, Davis LK., International Gender Diversity Genomics Consortium. The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table. Behav. Genet. 2018 Mar;48(2):95-108.\" id=\"return-footnote-815-8\" href=\"#footnote-815-8\" aria-label=\"Footnote 8\"><sup class=\"footnote\">[8]<\/sup><\/a><\/p>\n<p>Substance use disorders are commonly found in individuals with GD, with some studies showing 28% having reported problems with substance use. In a recent study, about 48.3% of a\u00a0study population had suicidal ideation, and 23.8% had attempted suicide at least once in their lifetime. Although, they were not able to appreciate any clinically significant difference between male-to-female (MTF) or female-to-male (FTM) groups. Anxiety, depression, and personality disorders are also common comorbidities. One study by Madeddu in 2009 found that personality disorder was comorbid in 52% of cases and the most common was Cluster B personality disorders.<a class=\"footnote\" title=\"Garg G, Elshimy G, Marwaha R. Gender Dysphoria (Sexual Identity Disorders) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532313\/\" id=\"return-footnote-815-9\" href=\"#footnote-815-9\" aria-label=\"Footnote 9\"><sup class=\"footnote\">[9]<\/sup><\/a><\/p>\n<h2 id=\"_article-28950_s2_\" class=\"ui-helper-clearfix\">Etiology<\/h2>\n<p>The etiology of GD remains unclear, but it is thought to originate from a complex biopsychosocial link.\u00a0Individuals born with congenital\u00a0adrenal hyperplasia (a condition that involves excessive or deficient production of sex steroids and can alter the development of\u00a0primary\u00a0or\u00a0secondary sex characteristics\u00a0in some affected infants, children, or adults) or androgen insensitivity syndrome (an intersex condition) are usually brought up and socialized as girls, even though they often cross-dress and have an innate sense of belonging to the opposite sex. These changes are more evident around and during puberty. This is one of the well-established biological links.<\/p>\n<p>Associations have also been found with in-utero exposure to phthalates in plastics and polychlorinated biphenyls. They are known to\u00a0disrupt the regular endocrinology of sex determination before birth. Phthalates can lead to an increase in total fetal testosterone levels, which in turn\u00a0increases the risk of autism\u00a0spectrum disorder as well as GD.<\/p>\n<p>GD\u00a0has been found to have a higher prevalence in people with psychiatric illnesses such as schizophrenia and autism\u00a0spectrum disorder. The link seems to be neuroanatomical and needs more research. There was growing evidence those on the autism spectrum have a higher prevalence of GD; however, certain studies seek to disprove this hypothesis.<\/p>\n<p>There is also growing evidence that childhood abuse, neglect, maltreatment, and physical or sexual abuse may be associated with GD. Individuals reporting higher body dissatisfaction and GD have a worse prognosis in terms of mental health. And as mentioned above in epidemiology, individuals with GD are found to have higher rates of depression, suicidal ideations, and substance use. Neuroanatomical links in those with GD have been found in certain studies, including a faulty neuronal development and differentiation in the hypothalamic links. Functional neuroimaging has shown variations in hemispheric ratios and amygdala connectivity according to gender. A few case reports have reported some\u00a0association of GD to maternal toxoplasma infection, although additional data is needed for further evidence.<\/p>\n<p>A genetic\u00a0association is also identified as one of the causes of GD. Heritability and familiarity of GD\u00a0have been identified: for instance, higher prevalence in monozygotic twins than dizygotic twins. Some alleles\u00a0(CYP17 and CYP17 T-34C)\u00a0have also been found to have an\u00a0association, although it is difficult to say if it is merely association or causation.<\/p>\n<div class=\"textbox examples\">\n<h3>Watch It<\/h3>\n<p>Watch this video to review the\u00a0definition, diagnosis, treatment, and challenges of gender dysphoria.<\/p>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Gender dysphoria: definition, diagnosis, treatment and challenges\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/W669-8aQzTk?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/GenderDysphoriaDefinitionDiagnosis_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;Gender dysphoria: definition, diagnosis, treatment and challenges&#8221; here (opens in new window)<\/a>.<\/p>\n<p>This video takes a look at the story of transgender advocate and spokesperson, Jazz Jennings.<\/p>\n<p><iframe loading=\"lazy\" src=\"\/\/plugin.3playmedia.com\/show?mf=5576160&amp;p3sdk_version=1.10.1&amp;p=20361&amp;pt=375&amp;video_id=bJw3s85EcxM&amp;video_target=tpm-plugin-xvcmwx72-bJw3s85EcxM\" width=\"800px\" height=\"450px\" frameborder=\"0\" marginwidth=\"0px\" marginheight=\"0px\"><\/iframe><\/p>\n<p>You can view the <a href=\"https:\/\/course-building.s3-us-west-2.amazonaws.com\/Abnormal+Psychology\/transcripts\/TransgenderAt11ListeningToJazzJennings_transcript.txt\" target=\"_blank\" rel=\"noopener\">transcript for &#8220;Transgender at 11: Listening to Jazz Jennings | 20\/20 | ABC News&#8221; here (opens in new window)<\/a>.<\/p>\n<\/div>\n<div class=\"textbox key-takeaways\">\n<h3>Key Takeaways: Gender Dysphoria<\/h3>\n<p><iframe loading=\"lazy\" title=\"43. Gender Dysphoria\" src=\"https:\/\/lumenlearning.h5p.com\/content\/1291235576908245968\/embed\" width=\"1088\" height=\"519\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><script src=\"https:\/\/lumenlearning.h5p.com\/js\/h5p-resizer.js\" charset=\"UTF-8\"><\/script><\/p>\n<\/div>\n<div class=\"textbox tryit\">\n<h3>Try It<\/h3>\n<p>\t<iframe id=\"assessment_practice_36d7d88c-dd14-4d7d-bfbc-880a6925276d\" class=\"resizable\" src=\"https:\/\/assess.lumenlearning.com\/practice\/36d7d88c-dd14-4d7d-bfbc-880a6925276d?iframe_resize_id=assessment_practice_id_36d7d88c-dd14-4d7d-bfbc-880a6925276d\" frameborder=\"0\" style=\"border:none;width:100%;height:100%;min-height:300px;\"><br \/>\n\t<\/iframe><\/p>\n<\/div>\n<div class=\"textbox learning-objectives\">\n<h3>Glossary<\/h3>\n<p><strong>early-onset gender dysphoria: <\/strong>gender dysphoria\u00a0behaviorally visible in childhood<\/p>\n<p><b>genderfluid:\u00a0<\/b>a\u00a0gender identity that varies over time<\/p>\n<p><b>gender non-conforming:\u00a0<\/b>describes anyone whose\u00a0appearance and behavior\u00a0does not reflect the\u00a0gender roles\u00a0expected of them<\/p>\n<p><strong>late-onset gender dysphoria: <\/strong>gender dysphoria that does not include visible signs in early childhood<\/p>\n<p><strong>non-binary:\u00a0<\/strong>a spectrum of\u00a0gender identities\u00a0that are not exclusively\u00a0masculine\u00a0or\u00a0feminine\u200d<\/p>\n<p><b>transsexual<\/b><strong style=\"color: #800000;\"><span style=\"color: #333333;\">:<\/span> <\/strong>a\u00a0term sometimes used to refer to individuals with gender dysphoria who choose to undergo gender-affirming surgery<\/p>\n<p><span style=\"color: #333333;\"><strong style=\"font-size: 1rem; text-align: initial;\">transition:<\/strong><\/span><span style=\"font-size: 1rem; text-align: initial;\">\u00a0any action a transgender person takes in order for the external world to better recognize and reflect their experienced gender<\/span><\/p>\n<\/div>\n\n\t\t\t <section class=\"citations-section\" role=\"contentinfo\">\n\t\t\t <h3>Candela Citations<\/h3>\n\t\t\t\t\t <div>\n\t\t\t\t\t\t <div id=\"citation-list-815\">\n\t\t\t\t\t\t\t <div class=\"licensing\"><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Original<\/div><ul class=\"citation-list\"><li>Modification, adaptation, and original content. <strong>Authored by<\/strong>: Sonja Ann Miller for Lumen Learning. <strong>Provided by<\/strong>: Lumen Learning. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">CC licensed content, Shared previously<\/div><ul class=\"citation-list\"><li>Gender Dysphoria. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.\">https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender Dysphoria. <strong>Provided by<\/strong>: Boundless. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/courses.lumenlearning.com\/boundless-psychology\/chapter\/gender-dysphoria\/\">https:\/\/courses.lumenlearning.com\/boundless-psychology\/chapter\/gender-dysphoria\/<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><li>Gender Fluid. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/gender.wikia.org\/wiki\/Gender_Fluid\">https:\/\/gender.wikia.org\/wiki\/Gender_Fluid<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender non-conforming. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/gender.wikia.org\/wiki\/Gender_Non-Conforming\">https:\/\/gender.wikia.org\/wiki\/Gender_Non-Conforming<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Transgender. <strong>Provided by<\/strong>: Wikipedia. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/gender.wikia.org\/wiki\/Transgender\">https:\/\/gender.wikia.org\/wiki\/Transgender<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender Dysphoria (Sexual Identity Disorders). <strong>Authored by<\/strong>: Garima Garg, Ghada Elshimy, Raman Marwaha. <strong>Provided by<\/strong>: StatPearls. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532313\/#article-28950.s2\">https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532313\/#article-28950.s2<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by\/4.0\/\">CC BY: Attribution<\/a><\/em><\/li><li>Boy nursing his doll. <strong>Authored by<\/strong>: Ms. Melissa. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/commons.wikimedia.org\/wiki\/File:A_boy_playing,_nursing_his_doll.jpg\">https:\/\/commons.wikimedia.org\/wiki\/File:A_boy_playing,_nursing_his_doll.jpg<\/a>. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-sa\/4.0\/\">CC BY-SA: Attribution-ShareAlike<\/a><\/em><\/li><li>Gender neutral bathroom. <strong>Authored by<\/strong>: Zackary Drucker. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/genderphotos.vice.com\/\">https:\/\/genderphotos.vice.com\/<\/a>. <strong>Project<\/strong>: The Gender Spectrum Collection. <strong>License<\/strong>: <em><a target=\"_blank\" rel=\"license\" href=\"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/\">CC BY-NC-ND: Attribution-NonCommercial-NoDerivatives <\/a><\/em><\/li><\/ul><div class=\"license-attribution-dropdown-subheading\">All rights reserved content<\/div><ul class=\"citation-list\"><li>Gender dysphoria: definition, diagnosis, treatment and challenges. <strong>Provided by<\/strong>: Demystifying Medicine. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?time_continue=158&#038;v=W669-8aQzTk&#038;feature=emb_logo\">https:\/\/www.youtube.com\/watch?time_continue=158&#038;v=W669-8aQzTk&#038;feature=emb_logo<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><li>Transgender at 11: Listening to Jazz Jennings. <strong>Provided by<\/strong>: ABC News. <strong>Located at<\/strong>: <a target=\"_blank\" href=\"https:\/\/www.youtube.com\/watch?time_continue=71&#038;v=bJw3s85EcxM&#038;feature=emb_logo\">https:\/\/www.youtube.com\/watch?time_continue=71&#038;v=bJw3s85EcxM&#038;feature=emb_logo<\/a>. <strong>License<\/strong>: <em>Other<\/em>. <strong>License Terms<\/strong>: Standard YouTube License<\/li><\/ul><\/div>\n\t\t\t\t\t\t <\/div>\n\t\t\t\t\t <\/div>\n\t\t\t <\/section><hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-815-1\">American Psychological Association (2008). \"Resolution on transgender, gender identity, and gender expression non-discrimination\" <a href=\"#return-footnote-815-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-815-2\">Grant; Jaime, M.; Mottet, Lisa; Tanis, Justin; Harrison, Jack; Herman, Jody; Keisling, Mara (2011). Injustice at Every Turn: A Report of the National Transgender Discrimination Survey (PDF). Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force. Archived from the original (PDF) on November 4, 2015. Retrieved May 10, 2015. <a href=\"#return-footnote-815-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-815-3\">Guillamon A, Junque C, G\u00f3mez-Gil E (October 2016). \"A Review of the Status of Brain Structure Research in Transsexualism\". Archives of Sexual Behavior. 45 (7): 1615\u201348. doi:10.1007\/s10508-016-0768-5. PMC 4987404. PMID 27255307. <a href=\"#return-footnote-815-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-815-4\">Gender identity disorders. (2018). In H. Marcovitch (Ed.), Black's Medical Dictionary, 43rd edition (43rd ed.). London, UK: A&amp;C Black. <a href=\"#return-footnote-815-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-815-5\">Diagnostic and Statistical Manual of Mental Disorders 5. American Psychiatric Association. 2013. p. 454. ISBN 978-0-89042-555-8. <a href=\"#return-footnote-815-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-815-6\">Land\u00e9n M, W\u00e5linder J, Lundstr\u00f6m B (April 1996). \"Prevalence, incidence and sex ratio of transsexualism\". Acta Psychiatrica Scandinavica. 93 (4): 221\u20133. doi:10.1111\/j.1600-0447.1996.tb10638.x. PMID 8712018 <a href=\"#return-footnote-815-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><li id=\"footnote-815-7\">Meerwijk EL, Sevelius JM. Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples. Am J Public Health. 2017 Feb;107(2):e1-e8. <a href=\"#return-footnote-815-7\" class=\"return-footnote\" aria-label=\"Return to footnote 7\">&crarr;<\/a><\/li><li id=\"footnote-815-8\">Polderman TJC, Kreukels BPC, Irwig MS, Beach L, Chan YM, Derks EM, Esteva I, Ehrenfeld J, Heijer MD, Posthuma D, Raynor L, Tishelman A, Davis LK., International Gender Diversity Genomics Consortium. The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table. Behav. Genet. 2018 Mar;48(2):95-108. <a href=\"#return-footnote-815-8\" class=\"return-footnote\" aria-label=\"Return to footnote 8\">&crarr;<\/a><\/li><li id=\"footnote-815-9\">Garg G, Elshimy G, Marwaha R. Gender Dysphoria (Sexual Identity Disorders) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK532313\/ <a href=\"#return-footnote-815-9\" class=\"return-footnote\" aria-label=\"Return to footnote 9\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":29,"menu_order":5,"template":"","meta":{"_candela_citation":"[{\"type\":\"cc\",\"description\":\"Gender Dysphoria\",\"author\":\"\",\"organization\":\"Wikipedia\",\"url\":\"https:\/\/en.wikipedia.org\/wiki\/Gender_dysphoria#:~:text=Gender%20dysphoria%20(GD)%20is%20the,gender%20dysphoria%20are%20typically%20transgender.\",\"project\":\"\",\"license\":\"cc-by-sa\",\"license_terms\":\"\"},{\"type\":\"cc\",\"description\":\"Gender Dysphoria\",\"author\":\"\",\"organization\":\"Boundless\",\"url\":\"https:\/\/courses.lumenlearning.com\/boundless-psychology\/chapter\/gender-dysphoria\/\",\"project\":\"\",\"license\":\"cc-by\",\"license_terms\":\"\"},{\"type\":\"original\",\"description\":\"Modification, adaptation, and original content\",\"author\":\"Sonja Ann Miller for 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