GENDER DYSPHORIA

DEFINITION OF TERMS
SEX/SEXUAL refers to the biological indicators of male and female, (understood in the context
of reproductive capacity) such as in sex chromosome, gonads, sex hormones and non ambiguous
internal and external genitalia.
TRANSSEXUAL denotes an individual who seeks or has undergone, a social transition from
male to female or female to male. Involves somatic transition by cross-sex hormone and sex
reassignment surgery.
GENDER used to denote the public (usually legally recognized) lived role as boy or girl, man or
woman and some other category
GENDER NON-CONFORMING refers to people who do not conform to society’s expectations
for their gender roles or gender expressions
GENDER IDENTITY is a category of social identity and refers to an individual identification as
male, female or occasionally, some category other than male or female
TRANSGENDER refers to an individual who transiently or persistently identify with a gender
different from their natal gender

“THE MORE I TRIED TO BE A GIRL, IT JUST WASN’T RIGHT.”

GENDER DYSPHORIA
Definition: Gender dysphoria refers to the distress that may accompany the incongruence
between one’s experienced or expressed gender and one’s assigned gender. In other words,
people who experience this phenomenon asserts that he/she has been born in the wrong body.
DIFFERENTIAL DIAGNOSIS
1. Nonconformity to gender roles.
 When making a differential diagnosis, the clinician should rule out gender
nonconformity, variant gender expression, or dissatisfaction with society’s gender
roles that reflect a separate issue from the distressing disconnect between one’s
sex and gender (American Psychiatric Association, 2013).
2. Transvetic Disorder.
 Gender dysphoria must be distinguished from transvestic fetishism, a paraphilic
disorder (discussed earlier) in which individuals, usually males, are sexually
aroused by wearing articles of clothing associated with the opposite sex. the aim
of cross-dressing in gender dysphoria is to appear to be the opposite gender in
order to feel consistent with one’s sense of self, rather than for sexual arousal.
Transvestic is for sexual gratification while GD is the desire to openly live life in
a manner consistent with the other gender. Though, a transvestic disorder ay
pwede ding significant when it comes to GD, in many cases late-onset GD in
gynephilic natal male transvestic disorder with sexual excitement is a precursor.
3. Body dysmorphic disorder.
  Disgust with one’s genitals could also be a symptom of body dysmorphic disorder
(BDD). BDDis nagfofocus siya sa pagbabago or removal ng isang parte ng
katawan because he or she feel na yung part na yon sa katawan niya is abnormaly
formed not because it represents a repudiated assigned gender. While sa GD is
nakikita niya yong genitals as an unwanted reminder of one’s natal sex. For
example, a healthy person can amputate his leg because it makes him look and
feel complete and do not wish to change gender but rather the desire to live as an
amputeebor as a disabled person. But if a person meets the criteria of the same
disorder pwede silang madiagnose as both.
4. Schizophrenia and other psychotic disorder.
 A standard clinical assessment may include items pertaining to psychotic and
delusional symptoms, and an individual may experience both gender dysphoria
and psychotic symptoms as well (American Psychiatric Association, 2013).
However, gender dysphoria must not be deemed a fleeting psychotic symptom for
a diagnosis to be made. By the same token, the insistence that one was born in the
wrong body in terms of one’s sex is a symptom of gender dysphoria, rather than a
delusion (American Psychiatric Association, 2013).

PSYCHOPATHOLOGY
BIOLOGICAL FACTORS
 Scientists have studied girls aged 5 to 12 with an intersex condition known as
congenital adrenal hyperplasia (CAH). In CAH, the brains of these chromosomal
females are flooded with male hormones (androgens), which, among other results,
produce mostly masculine external genitalia, although internal organs (ovaries
and so on) remain female. Meyer-Bahlburg and colleagues (2004) studied 15 girls
with CAH who had been correctly identified as female at birth and raised as girls
and looked at their development. Compared with groups of girls and boys without
CAH, the CAH girls were masculine in their behavior, but there were no
differences in gender identity. us, scientists have yet to establish a link between
prenatal hormonal influence and later gender identity, although it is still possible
that one exists. Structural differences in the area of the brain that controls male
sex hormones have also been observed in individuals with male-to-female gender
dysphoria (Zhou, Hofman,
 Gender dysphoria can also occur among individuals with disorders of sex
development (DSD), formerly known as intersexuality or hermaphroditism who
are born with ambiguous genitalia associated with documented hormonal or other
physical abnormalities. Depending on their particular mix of characteristics,
individuals with DSDs are usually “assigned” to a specic sex at birth, sometimes
undergoing surgery, as well as hormonal treatments, to alter their sexual anatomy.
If gender dysphoria occurs in the context of a DSD, this should be specied when
making a diagnosis. But most individuals with gender dysphoria have no
demonstrated physical abnormalities.
 Early research suggested that, as with sexual orientation, slightly higher levels of
testosterone or estrogen at certain critical periods of development might
 masculinize a female fetus or feminize a male fetus (see, for example, Keefe,
2002). Variations in hormonal levels could occur naturally or because of
medication that a pregnant mother is taking. Another study reported on possible
effects of testosterone on brain differentiation (Zhou, Horman, Gooren, & Swaab,
1995). The researchers found that the red nucleus of the stria terminalis (a region
of the hypothalamus) in male-to-female transsexuals corresponded to that of
typical females, rather than that of typical males. This was the case whether the
individual was heterosexual or homosexual, and was not accounted for by
hormone therapy
 Genetic research has emphasized twin studies; more specifically, monozygotic
(identical) twins have much higher rates of concordance for gender dysphoria
than dizygotic (fraternal) twins of the same or different genders, although the
majority of identical twins are also discordant for gender dysphoria (Heylens et
al., 2012). Parents’ ratings of their twins’ gender dysphoric symptoms also
showed substantial concordance (Coolidge, Thede, & Young, 2002). Twin studies
can be difficult to interpret, however, since twins’ family and social environments
may be similar, and in that twins may choose similar environments and evoke
similar responses from others based on their shared appearance and personality
factors.

PSYCHOSOCIAL
 The psychoanalytic theory suggests that gender identity problems begin during the
struggle of the Oedipal/Electra conflict. Problems may reflect both real family events and
those created in the child’s imagination. These conflicts, whether real or imagined,
interfere with the child’s loving of the opposite gender parent and identifying with the
same-gender parent, and ultimately with normal gender identity.
 It appears that family dynamics may play an influential role in the etiology of gender
dysphoria. Sadock and Sadock (2007) state, “Children usually develop a gender identity
consonant with their sex of rearing (also known as assigned sex)” (p. 718). Gender roles
are culturally determined, and parents encourage masculine or feminine behaviors in their
children. Although “temperament” may play a role with certain behavioral characteristics
being present at birth, mothers usually foster a child’s pride in their gender. Sadock and
Sadock (2007) state: The father’s role is also important in the early years, and his
presence normally helps the separationindividuation process. Without a father, mother
and child may remain overly close. For a girl, the father is normally the prototype of
future love objects; for a boy, the father is a model for male identification.” (p. 719) In a
2003 study, Zucker and associates found a high rate of psychopathology and family
dysfunction in children with gender dysphoria. Maternal depression and bipolar disorder
were frequently demonstrated, whereas fathers often exhibited depression and substance
use disorders. The authors recommended that parental conflicts and psychopathology
must be given careful consideration as an aspect in childhood gender dysphoria.

GENDER DYSPHORIA IN CHILDREN

Signs and Symptoms
 The insistence of being the opposite gender
 Disgust with one’s own genitals
 Belief that one will grow up to become the opposite gender
 Refusal to wear clothing of the assigned gender
 Desirous of having genitals of the opposite gender
 Refusal to participate in the games and activities culturally associated with assigned
gender

GENDER DYSPHORIA IN ADULTS

Signs and Symptoms
 Despite having the anatomical characteristics of a given gender, has the self-perception of
being the opposite gender
 Do not feel comfortable wearing clothes of their assigned gender
 Engaged in cross-dressing
 Find their own genitals repugnant
 Repeatedly submit for hormonal and surgical gender reassignment

TRAJECTORIES FOR DEVELOPMENT OF GD

1. Early-onset gender dysphoria starts in childhood and continues into adolescence and
adulthood
 • there is an intermittent period in which the gender dysphoria desists and these
individuals self-identify as gay or homosexual, followed by recurrence of gender
dysphoria
• are almost always sexually attracted to men (androphilic)
• Among adult natal males with gender dysphoria, the early-onset group seeks out
clinical care for hormone treatment and reassignment surgery at an earlier age
than does the late-onset group.
• the most common course
• Adolescent and adult natal females with early-onset gender dysphoria are almost
always gynephilic.
2. Late-onset gender dysphoria occurs around puberty or much later in life
• these individuals report having had a desire to be of the other gender in childhood
that was not expressed verbally to others
• parents often report surprise because they did not see signs of gender dysphoria
during childhood
• Adolescents and adults with late-onset gender dysphoria frequently engage in
transvestic behavior with sexual excitement. The majority of these individuals are
gynephilic or sexually attracted to other posttransition natal males with late-onset
gender dysphoria. A substantial percentage of adult males with late-onset gender
dysphoria cohabit with or are married to natal females.
• The late-onset group may have more fluctuations in the degree of gender
dysphoria and be more ambivalent about and less likely satisfied after gender
reassignment surgery
• Parents of natal adolescent females with the late-onset form also report surprise,
as no signs of childhood gender dysphoria were evident.
• Adolescents and adults with the late-onset form of gender dysphoria are usually
androphilic and after gender transition self-identify as gay men. Natal females
with the late-onset form do not have co-occurring transvestic behavior with sexual
excitement.
NURSING DIAGNOSES

• DISTURBED PERSONAL IDENTITY

• IMPAIRED SOCIAL INTERACTION
• LOW SELF-ESTEEM
TREATMENTS

Unlike treatments for most disorders, which involve helping individuals to change their thoughts,
feelings, and behaviors, successful treatment for gender dysphoria may involve helping
individuals explore and change their gender and/or sex, if indicated (Byne et al., 2012; Coleman
et al., 2011). This transition may include a variety of treatments, including medications, such as
hormone treatments, voice and communication therapy, hair transplants, electrolysis for men to
remove unwanted facial and body hair, and varying degrees of surgery to masculinize or
feminize the face, neck, chest, genitals, and other areas as needed. It is important for
clients/patients to be advised of all of the treatment possibilities and their potential consequences
and degree of permanence to the body, including fertility issues and potential health risks (Byne
et al., 2012; Coleman et al., 2011).

PSYCHOSOCIAL INTERVENTION (in children)

Becker and Johnson (2008) stated: Treatment [of gender dysphoria in the child] has three goals:
increasing peer support and acceptance, treating co-occurring mental health concerns, and
reducing the likelihood of [gender dysphoria] in adulthood. (p. 737) Treatment of children with
gender dysphoria may be initiated when the behaviors cause significant distress and when the
client desires it. One type of treatment suggests that they should be encouraged to become
satisfied with their assigned gender.
 Behavior Modification Therapy serves to help the child embrace the games and activities
of their assigned gender and promotes development of friendship and peers. The goal is
acceptance of culturally appropriate self-image without mental health concerns from
discomfort associated with the assigned gender.
 Group, and family therapy for a helpful and supportive environment. Another treatment
model suggests that children who have problems with gender identity are dysphoric only
because of their image within the culture. In this view, children should be accepted as
they see themselves—different from their assigned gender—and supported in their efforts
to live as the gender in which they feel most comfortable
 True gender self child therapy. This approach emphasizes supportive, attentive listening
and encouragement of creativity in order for the child to safely explore and express his or
her self-harmonious gender identity, called the true gender self, while liberating the child
from the stifling gender expectations imposed by others that involve playing a role,
termed the false gender self.

BIOLOGICAL/PHARMACOLOGIC/SURGICAL INTERVENTION
Some professionals are recommending pubertal delay for adolescents aged 12 to 16 years who
have suffered with extreme lifelong gender dysphoria, and who have supportive parents that
encourage the child to pursue a desired change in gender (Gibson & Catlin, 2010).
  Hormone Therapy
• Gonadotropin-releasing hormone agonist suppresses pubertal changes
• Spiro lactone

When the medication is withdrawn, external sexual development proceeds, and the individual
has avoided permanent surgical intervention. If he or she decides as an adult to advance to the
surgical intervention, the proponents of the hormonal treatment suggest that initiating pubertal
delay at an early age will “most certainly result in high percentages of individuals who will more
easily pass into the opposite gender role than when treatment commenced well after the
development of secondary sexual characteristics” (Delemarre-van de Waal & Cohen-Kettenis,
2006).
The type of treatment one chooses for gender dysphoria (if any) is very individual and a matter
of personal choice. However, issues associated with mental health concerns, such as depression,
anxiety, social isolation, anger, self-esteem, and parental conflict, must be addressed, even if the
client elects not to proceed with the behavior modification approach. Cohen-Kettenis and Pfäfflin
(2003) reported that, in their clinic population, when the functional mental health problems
within the family were resolved, the gender dysphoria often dissipated.
PSYCHOSOCIAL INTERVENTION (in adult)
 Some adults seek therapy to learn how to cope with their altered sexual identity, helping
to build resilience, working within existing family structures
 when addressing adult patients with gender dysphoria more specifically, begin with the
least intrusive step of full psychological evaluation and education
Minority Stress Theory. The concept of minority stress applied to this population entails the
stress of living in a world that stigmatizes transgender individuals, along with the internalization
of this deprecating view of oneself (Hendricks & Testa, 2012). Further, there is an added burden
of trying to present oneself in a manner that seems acceptable, while anticipating and preparing
oneself for negative encounters with others (Hendricks & Testa, 2012). Coping strategies may
therefore become the focus of treatment.

For clients who do decide to change their gender, the primary focus of psychotherapy may be
preparing them for changes in their relationships with others and with the broader society
through the “coming-out” process (Byne et al., 2012). It is not uncommon for gender dysphoric
individuals to also struggle with psychiatric symptoms (particularly during adolescence and prior
to their transition), such as depression, social anxiety, other types of anxiety, substance use, and
suicidal thoughts and actions, which also should be addressed in therapy (Gomez-Gil et al.,
2012; Hepp, Kraemer, Schnyder, Miller, & Delsignore, 2005; Hoshiai et al., 2010; Nuttbrock et
al., 2010; Spack et al., 2012). These symptoms are not surprising, given that gender is such a
salient part of social identity, and given the increased risk for suffering caused by a number of
possible stressors, such as social and familial rejection, a history of being bullied and victimized,
and experiences of prejudice and discrimination (Carroll et al., 2002; Nuttbrock et al., 2010;
Spack et al., 2012).

BIOLOGICAL/PHARMACOLOGIC/SURGICAL INTERVENTION
  Surgical Treatment
• Sex reassignment surgery includes but not limited to the ffg:
• Vaginoplasty
• Breast Augmentation
• Thyroid chondroplasty surgery
• Pitch-raising vocal fold surgery
• Chest reconstruction surgery
• Phalloplasty
• Penectomy
 Hormone Therapy
• Male receive estrogen which results to a more feminine changes in their body
• Women receives testosterone which also causes of body image of a man.

NURSING MANAGEMENT
Disturbed Personal Identity
Disturbed personal identity is defined as the “inability to maintain an integrated and complete
perception of self” (NANDA-I, 2012, p. 282).
Client Goals: Outcome criteria include short- and long-term goals. Timelines are individually
determined.
Short-Term Goals
■ Client will verbalize knowledge of behaviors that are appropriate and culturally acceptable for
assigned gender.
■ Client will verbalize desire for congruence between personal feelings and behavior and
assigned gender.
Long-Term Goals
■ Client will demonstrate behaviors that are appropriate and culturally acceptable for assigned
gender.
■ Client will express personal satisfaction and feelings of being comfortable in assigned gender.

Interventions
■ Spend time with the client and show positive regard. Trust and unconditional acceptance are
essential to the establishment of a therapeutic nurse-client relationship.
■ Be aware of personal feelings and attitudes toward this client and his or her behavior. Attitudes
influence behavior. The nurse must not allow negative attitudes to interfere with the effectiveness
of interventions.
■ Allow the client to describe his or her perception of the problem. It is important to know how
the client perceives the problem before attempting to correct misperceptions.
■ Discuss with the client the types of behaviors that are more culturally acceptable. Practice
these behaviors through role-playing or with play therapy strategies (e.g., male and female dolls).
Positive reinforcement or social attention may be given for use of appropriate behaviors. No
response is given for stereotypical opposite gender behaviors. Behavioral change is attempted
with the child’ best interests in mind. That is, to help him or her with cultural and societal
integration, while maintaining individuality. To preserve self-esteem and enhance self-worth, the
child must know that he or she is accepted unconditionally as a unique and worthwhile
individual.

Impaired Social Interaction

Impaired social interaction is defined as “insufficient or excessive quantity or ineffective quality
of social exchange” (NANDA-I, 2012, p. 320).
Client Goals: Outcome criteria include short- and long-term goals. Timelines are individually
determined.
Short-Term Goal
■ Client will verbalize possible reasons for ineffective interactions with others.
Long-Term Goal
■ Client will interact with others using culturally acceptable behaviors.

Interventions
■ Once the client feels comfortable with the new behaviors in role playing or one-to-one nurse-
client interactions, the new behaviors may be tried in group situations. If possible, remain with
the client during initial interactions with others. The presence of a trusted individual provides
security for the client in a new situation, and also provides the potential for feedback to the client
about his or her behavior.
■ Observe client behaviors and the responses he or she elicits from others. Give social attention
(smile, nod) to desired behaviors. Follow up these “practice” sessions with one-to-one processing
of the interaction. Give positive reinforcement for efforts. Positive reinforcement encourages
repetition of desirable behaviors. One-to-one processing pro- vides time for discussing the
appropriateness of specific behaviors and why they should or should not be repeated.
■ Offer support if client is feeling hurt from peer ridicule. Matter-of-factly discuss the behaviors
that elicited the ridicule. Offer no personal reaction to the behavior. Personal reaction from the
nurse would be considered judgmental. Validation of client’s feelings is important, yet it is also
important that client understand why his or her behavior was the subject of ridicule and how to
avoid it in the future.
■ The goal is to create a trusting, nonthreatening atmosphere for the client in an attempt to
change behavior and improve social interactions. Long-term studies have not yet revealed the
significance of therapy with these children for psychosexual relationship development in
adolescence or adulthood. One variable that must be considered is the evidence of
psychopathology within the families of many of these children.

Low Self-Esteem
Low self-esteem is defined as “negative self-evaluating/feelings about self or self-capabilities”
(NANDA-I, 2012, pp. 285-287).
Client Goals: Outcome criteria include short- and long-term goals. Timelines are individually
determined.
Short-Term Goal
■ Client will verbalize positive statements about self, including past accomplishments and future
prospects.
Long-Term Goal
■ Client will verbalize and demonstrate behaviors that indicate self-satisfaction with assigned
gender, ability to interact with others, and a sense of self as a worthwhile person.

Interventions
■ In an effort to enhance the child’s self-esteem, encourage him or her to engage in activities in
which he or she is likely to achieve success.
■ Help the child to focus on aspects of his or her life for which positive feelings exist.
Discourage rumination about situations that are perceived as failures or over which the client has
no control. Give positive feedback for these behaviors.
■ Help the client identify behaviors or aspects of life he or she would like to change. If realistic,
assist the child in problem-solving ways to bring about the change. Having some control over his
or her life may decrease feelings of powerlessness and increase feelings of self-worth and self
satisfaction.
■ Offer to be available for support to the child when he or she is feeling rejected by peers.
Having an available support person who does not judge the child’s behavior and who provides
unconditional acceptance assists the child to progress toward acceptance of self as a worthwhile
person.
Evaluation
■ Does the client perceive that a problem existed that requires a change in behavior for
resolution?
■ Does the client demonstrate use of behaviors that are culturally accepted for his or her assigned
gender?
■ Can the client use these culturally accepted behaviors in interactions with others?
■ Is the client accepted by peers when same-gender behaviors are used?
■ If the client is refusing to change behaviors, what is the peer reaction?
■ What is the client’s response to negative peer reaction?
■ Can the client verbalize positive statements about self?
■ Can the client discuss past accomplishments with- out dwelling on the perceived failures?
■ Has the client shown progress toward accepting self as a worthwhile person regardless of
others’ responses to his or her behavior?