1.
UNDER GUIDENCE OF DR SURENDRA PALIWAL
PRESENTER:- DR.K. K.SHARMA

2.
 Introduction
 Prevalence & sex ratio
 ETIOLOGY- biological ,psychosocial , and
Psychological aspect
 Diagnostic Criteria
 Course and prognosis
 Differential Diagnosis
 Treatment

3.
 The term gender dysphoria appears as a
diagnosis for the first time DSM-5to refer to
“those persons with a marked incongruence
between their experienced or expressed
gender and the one they were assigned at
birth.”
It was known as gender identity disorder in the
previous edition of DSM.

4.
 Gender identity: the sense one has of being male or
being female which corresponds, normally, to the
person's anatomical sex.
 The affective component of GID is gender dysphoria,
discontent with one's designated birth sex and a desire
to have the body of the other sex, and to be regarded
socially as a person of the other sex.

5.
 Transgender is a general term used to refer to
those who identify with a gender different from
the one they were born with(sometimes referred
to as their assigned gender).
 Genderqueer those who feel they are between
genders, of both genders, or of neither gender.
 Crossdressers who wear clothing traditionally
associated with another gender, but who
maintain a gender identity that is the same as
their birth assigned gender known as cross
dressers.

6.
 GID(transexualism in older version of DSM)
 Gender identity becomes fixed in most
persons by age 2 or 3 years.
 The sex ratio of referred children is 4 to 5
boys for each girl.

7.
 Male -0.005 to 0.014,
Female-0.002 to 0.003%
Sex ratio-child -2:1 to 4.5:1
adol.-1:1
adult-1:1 to 6.1:1
( Japan 1: 2.2 Poland 1 : 3.4)
In Europe male 1:30000 female 1:100,000

8.
 Resting state of tissue in mammals is initially
female & as fetus develops, a male is produced
only if androgen is introduced by Y chromosome.
 maleness and masculinity depend on fetal and
perinatal androgens.
 Testosterone can increase libido and aggressiveness
in women, and estrogen can decrease libido and
aggressiveness in men.
 Masculinity, femininity, and gender identity result
more from postnatal life events.

9.
 Children usually develop a gender identity
consonant with their sex of rearing (also known
as assigned sex).
 The formation of gender identity is influenced by
the interaction of children's temperament and
parents' qualities and attitudes.
 Sex-role stereotypes are the beliefs,
characteristics and behaviors of individual
cultures that are deemed normal and appropriate
for boys and girls to possess.

10.
 Mother and child relationship - relationship in the first
years of life is paramount in establishing gender identity. During this period,
mothers normally facilitate their children’s awareness of, and pride in,
their gender: Children are valued as little boys and girls.
 Separation individualization process- the separation–
individuation process is unfolding. When gender problems become
associated with separation–individuation problems, the result can be
the use of sexuality to remain in relationships characterized by shifts
between a desperate infantile closeness and a hostile, devaluing
distance.

11.
 Role of mother- devaluing, hostile mothering can result in gender
problems, can also be triggered by a mother’s death, extended absence,
or depression, to which a young boy may react by totally identifying with
her—that is, by becoming a mother to replace her.
 Abused child- Some children are given the message that they would
be more valued if they adopted the gender identity of the opposite sex.
Rejected or abused children may act on such a belief.
 father’s Role - The father’s role is also important in the early years,
and his presence normally helps the separation–individuation 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.

12.
 Sigmund Freud believed that gender identity
problems resulted from conflicts experienced
by children within the Oedipal triangle.
 In his view, these conflicts are fueled by both
real family events and children’s fantasies.
 Whatever interferes with a child’s loving the
opposite-sex parent and identifying with the
same-sex parent, interferes with normal
gender identity development.

13.
 These "norms" are influenced by
family and friends, the mass-
media, community and other
socializing agents.
 Since many cultures strongly
disapprove of cross-gender
behavior, it often results in
significant problems for affected
persons and those in close
relationships with them.

14.
A. strong and persistent cross-gender identification (not merely a
desire for any perceived cultural advantages of being the other
sex).
In children, the disturbance is manifested by four (or more) of
the following:
 repeatedly stated desire to be, or insistence that he or she is, the other
sex
 in boys, preference for cross-dressing or simulating female attire; in girls,
insistence on wearing only stereotypical masculine clothing
 strong and persistent preferences for cross-sex roles in make-believe play
or persistent fantasies of being the other sex
 intense desire to participate in the stereotypical games and pastimes of
the other sex
 strong preference for playmates of the other sex

15.
In adolescents and adults, the
disturbance is manifested by symptoms
such as a stated
desire to be the other sex, frequent
passing as the other sex,
desire to live or be treated as the other
sex, or the conviction that he or she has
the typical feelings and reactions of the
other sex.

16.
B.Persistent discomfort with his or her sex or
sense of inappropriateness in the gender role
of that sex.
In children, the disturbance is manifested by any
of the following:
in boys, assertion that his penis or testes are
disgusting or will disappear or aversion toward
rough-and-tumble play and rejection of male
games, and activities;
in girls, rejection of urinating in a sitting
position, she has or will grow a penis, or assertion
that she does not want to grow breasts or
menstruate, or marked aversion toward normative
feminine clothing.

17.
In adolescents and adults, the disturbance is
manifested by symptoms such as preoccupation
with getting rid of primary and secondary sex
characteristics (e.g., request for hormones,
surgery, or other procedures to physically alter
sexual characteristics to simulate the other sex)
or belief that he or she was born the wrong sex.

18.
C.The disturbance is not concurrent with a
physical intersex condition.
D. The disturbance causes clinically
significant distress or impairment in
social, occupational, or other important
areas of functioning.

19.
 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:
 Persistent and strong desire to be of the other sex or insistence that they belong to
the other sex
 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
 Fantasizing about playing opposite gender roles in make-belief play or activities
 Preference for toys, games, or activities typical of the opposite sex.
 Preference for playmates of the other sex
 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
 Dislike for sexual anatomy. Boys may hate their penis and testes and girls dislike
urinating sitting.
 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.

20.
A definite mismatch between the assigned gender and
experienced/expressed gender for at least 6 months
duration as characterized by at least two or more of the
following features –
 Mismatch between experienced or expressed gender and gender
manifested by primary and/or secondary sex characteristics at puberty
 Persistent desire to rid oneself of the primary or secondary sexual
characteristics of the biological sex at puberty.
 Strong desire to possess the primary and/or secondary sex
characteristics of the other gender
 Desire to belong to the other gender
 Desire to be treated as the other gender
 Strong feeling or conviction that he or she is reacting or feeling in
accordance with the identified gender.
 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.

21.
F64.0 Transsexualism
A. Desire to live and be accepted as a member of the opposite sex,
usually accompanied by the wish to make
one's body as congruent as possible with one's preferred sex through
surgery and hormonal treatment.
B. Presence of the transsexual identity for at least two years persistently.
C. Not a symptom of another mental disorder, such as schizophrenia, or
associated with chromosome
abnormality.
F64.1 Dual-role transvestism
A. Wearing clothes of the opposite sex in order to experience temporarily
membership of the opposite sex.
B. Absence of any sexual motivation for the cross-dressing.(f 65)
C. Absence of any desire to change permanently into the opposite sex.

22.
F64.2 Gender identity disorder of childhood
For females:
A. Persistent and intense distress about being a girl, and a stated desire to
be a boy (not merely a desire for any perceived cultural advantages from
being a boy), or insistence that she is a boy.
B. Either (1) or (2):
(1)Persistent marked aversion to normative feminine clothing and
insistence on wearing stereotypical masculine clothing, e.g. boys'
underwear and other accessories.
(2) Persistent repudiation of female anatomic structures, as evidenced by
at least one of the following:
(a) an assertion that she has, or will grow, a penis
(b) rejection of urinating in a sitting position
(c) assertion that she does not want to grow breasts or
menstruate
C. The girl has not yet reached puberty.
D. The disorder must have been present for at least six months.

23.
For males:
A. Persistent and intense distress about being a boy and an intense desire to
be a girl or, more rarely, insistence that he is a girl.
B. Either (1) or (2):
(1) Preoccupation with female stereotypical activities, as shown by a
preference for either cross-dressing or simulating female attire, or by an
intense desire to participate in the games and pastimes of girls and
rejection of male stereotypic toys, games and activities.
(2) Persistent repudiation of male anatomic structures, as indicated by at
least one of the following repeated assertions:
(a) that he will grow up to become a woman (not merely in role)
(b) that his penis or testes are disgusting or will disappear
(c) that it would be better not to have a penis or testes.
C. The boy has not yet reached puberty.
D. The disorder must have been present for at least six months.

24.
 Child
Persistence in male 2.2to 30 %
female12to 50%
(severe symptoms,low socioeconomic status)
Male child 63 to 100 % androphilc
Female child 32 to 50 % gynephilic
 Adult
a.Early onset –in childhood GID –desists –adult GID; androphilic
b. Late onset –around puberty, transvestic or gynephilic ,more
ambivalent

25.
 Gender-atypical children.
For girls, tomboys without GID prefer functional and gender-
neutral clothing. By contrast, girls with GID adamantly refuse to
wear girls' clothes and reject gender-neutral clothes.
For boys, the differential diagnosis must distinguish those who
do not conform to traditional masculine sex-typed expectations, but
do not show extensive cross-gender identification and are not
discontent with being male.
 Hermaphrodism Because the diagnosis of gender GID
excludes children with anatomical intersex, a medical history needs
to be taken with the focus on any suggestion of hermaphrodism in
the child. With doubt, referral to a pediatric endocrinologist is
indicated.

26.
 BODY DYSMORPHIC DISORDER
 TRANSVESTIC DISORDER
 PSYCHOTIC DISORDER

27.
Tomboy
hermaphrodite

28.
 At present, no convincing evidence indicates that
psychiatric or psychological intervention for children
with GID affects the direction of subsequent sexual
orientation.
 The treatment of GID in children is directed largely
at developing social skills and comfort in the sex role
expected by birth anatomy. To the extent that
treatment is successful, transsexual development
may be interrupted.
 No hormonal or psychopharmacological treatments
for GID in childhood have been identified.

29.
 Adolescents whose GID has persisted beyond
puberty present unique treatment problems.
 Treatment management is to slowing down or
stopping pubertal changes expected by anatomical
birth sex and then implementing cross-sex body
changes with cross-sex hormones.
 Parents must also be informed of the non-
pathological nature of same-sex orientation. The
goal of family intervention is to keep the family
stable and to provide a supportive environment for
the teenager.

30.
 Adult patients coming to a gender identity
clinic usually present with straight forward
requests for hormonal and surgical sex
reassignment.
 No drug treatment has been shown to be
effective in reducing cross-gender desires per
se.
 When patient gender dysphoria is severe and
intractable, sex reassignment may be the best
solution.

31.
 Sex reassignment surgery for a person born
anatomically male consists principally of
removal of the penis, scrotum, and testes,
construction of labia, and vaginoplasty. Some
clinicians attempt to construct a neoclitoris
from the former frenulum of the penis. The
neoclitoris may have erotic sensation.
 Postoperative complications include urethral
strictures, rectovaginal fistulas, vaginal
stenosis, and inadequate width or depth.
 Female-to-male patients typically may undergo
bilateral mastectomy and construct a
neophallus. Because of increased technical
skills in phalloplasty, more female-to-male
patients are now electing these procedures.

32.
 Persons born male are typically treated with daily doses of oral
estrogen- conjugated equine estrogens or ethinylestradiol
which produce breast enlargement, testicular atrophy,
decreased libido, and diminished erectile capacity.. Facial hair
removal is required by laser treatment or electrolysis.
 Biological women are treated with monthly or three weekly
injections of testosterone. The pitch of the voice drops
permanently into the male range as the vocal cords thicken.
The clitoris enlarges to two or three times its pretreatment
length and is often accompanied by increased libido. Hair
growth changes to the male pattern, and a full complement of
facial hair may grow.
 Cross-sex steroid hormones affect general body fat and muscle
distribution as well as promote breast development in patients
born male.

33.
 This category is included for coding disorders in
gender identity that are not classifiable as a
specific GID. Examples include
1. Intersex conditions (e.g., partial androgen
insensitivity syndrome or congenital adrenal
hyperplasia) and accompanying gender dysphoria
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration or
penectomy without a desire to acquire the sex
characteristics of the other sex

34.
 Intersexuality: person’s biological sex cannot
be classified as clearly male or female.
 It refers to intermediate or atypical
combinations of physical features that usually
distinguish female from male and is usually
congenital involving chromosomal, morphologic
and genital anomalies.

35.
Intersex
condition
Description
Congenital
virilizing
adrenal
hyperplasia
Sex karyotype: XX. Most common cause of sexual ambiguity, overproduction of adrenal
androgens and virilization of the female fetus, androgenization can range from mild clitoral
enlargement to external genitals that look like a normal scrotal sac, testes, and a penis, but
hidden behind these external genitals are a vagina and a uterus.
Androgen
insensitivity
syndrome
Sex karyotype: XY. Normal female look at birth and so raised as girl. Cryptorchid testes,
clitoromegaly, micropenis co-exist in some. Testosterone do not respond to tissue. Minimal or
absent internal sexual organs (uterus, ovary, cervix).
Turner’s
syndrome
Sex karyotype: XO. Children have female genitalia, are short, anomalies like shield-shaped
chest and a webbed neck. Tx: exogenous estrogen to develop female secondary sex
characteristics.
Klinfelter’s
syndrome
Sex karyotype: XXY. normal male at birth. Excessive gynecomastia may occur in adolescence.
Small testes without sperm production. They are tall with reduced fertility.
Higher rate of GID.
5-α-
Reductase
Deficiency
Sex karyotype: XY. unable to convert testosterone to dihydrotestosterone (DHT). ambiguous
genitalia at birth with some sexual anomaly. Affected person appears to be female. Children
are sometimes misdiagnosed as having AIS.
Pseudoherm
aphroditism
Infants born with ambiguous genitals, True hermaphroditism: presence of both testes and
ovaries.
Male pseudohermaphroditism: incomplete differentiation of the external genitalia even
though a Y chromosome is present; testes are present but rudimentary.
Female pseudohermaphroditism: presence of virilized genitals in person who is XX

36.
 Management of intersex can be categorized into one of the following
two:
1. Treatments: Restore functionality (or potential functionality) –
generally undertaken before age 3
2. Enhancements: Give the ability to identify with “mainstream” –
breast enlargement surgery
 It is easier to assign a child to be female than to assign one to be
male, because male-to-female genital surgical procedures are far
more advanced than female-to-male procedures.
 The exact procedure of the surgery depends on what is the cause of a
less common body phenotype in the first place. There is often
concern as to whether surgery should be performed at all.
 The goal of treatment is to have genitals concordant with
chromosomal, biological, physiological, and other genetic
antecedents, thus allowing the development of a person with healthy
gender identity.

37.
 If the disorder is not stress related, persons who cross-dress are
classified as having transvestic fetishism, which is described as a
paraphilia in DSM-IV-TR. An essential feature of transvestic fetishism
is that it produces sexual excitement. The DSM-IV-TR lists cross-
dressing- dressing in clothes of the opposite sex- as a gender
identity disorder if it is transient and related to stress.
 A cross-dresser is a person who has an apparent gender
identification with one sex, and who has and certainly has been
birth-designated as belonging to one sex, but who wears the
clothing of the opposite sex. Cross-dressers may not identify with
opposite gender & do not adopt behaviors of the opposite gender,
and generally do not want to change their bodies medically.
 Cross-dressing can coexist with paraphilias, such as sexual sadism,
sexual masochism, and pedophilia.
 The disorder is most common among female impersonators.

38.
 A combined approach, using psychotherapy and
pharmacotherapy, is often useful in the treatment of
cross-dressing.
 Antianxiety and antidepressant agents, is used to treat
the symptoms as cross-dressing can occur impulsively,
medications that reinforce impulse control may be
helpful, such as fluoxetine (Prozac).

39.
 The category of preoccupation with castration
is reserved for men and women who have a
persistent preoccupation with castration or
penectomy without a desire to acquire the sex
characteristics of the opposite sex.
 They are clearly uncomfortable with their
assigned sex and their lives are driven by the
fantasy of what it would be like to be a
different gender.
 They may be asexual and lack sexual interest
in either men or women.