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Chapter 14 Gender Dysphoria Psychiatrists study, categorize, and treat all manners of mental illness. Although there is a fringe perspective that all mental illness is “myth,” almost no one within psychiatry doubts the distress and dysfunction that accompany such mental illnesses as schizophrenia, psychotic depression, and bipolar mania. There is more debate, however, about symptom clusters that blend subtly into variations on normal. When is shyness an anxiety disorder? When does quirkiness become high-functioning autism spectrum disorder? At what point do disagreeable behaviors become a personality disorder? When do “senior moments” become minor neurocognitive disorder? These debates are inevitable and are akin to similar debates about such nonpsychiatric medical diagnoses as diabetes and hypertension. Definitions of normalcy directly affect psychiatric research funding and clinical insurance coverage, and they affect how society views atypical feelings, behaviors, and thoughts. To deal with this issue, DSM-5 focuses heavily on distress and dysfunction and, throughout the text, advises clinicians to make diagnoses only when symptoms are both enduring and significant. This mandate seems clinically and ethically satisfying: if no one is suffering or being negatively affected, there is no disorder. A heated debate remains, however, in regard to clusters of behaviors, cognitions, and feelings that are not intrinsically pathological but are problematic because they exist within a certain social structure. Perhaps nowhere is this debate more heated than in the discussion of sexual behavior. Historically, for example, homosexuality was classified as a psychiatric disorder. At least partly in response to political pressure, the diagnosis of homosexuality was changed in DSM-III to a diagnosis of unhappiness over being homosexual (ego-dystonic homosexuality). DSM-IV included persistent and marked distress about sexual orientation as a “sexual disorder not otherwise specified.” DSM-5 has moved further away from pathologizing homosexuality by eliminating all specific references to sexual orientation as a cause of psychiatric disturbance. Obviously, people who engage in or fantasize about sex with people of the same gender can have any of the DSM-5 diagnoses—and they can also be unhappy about their sexuality—but their sexual orientation is not viewed as a contributor privileged over any other characteristic. Historically, gender identity referred to an individual’s identification as a male or female. Typically, gender identity was viewed as binary and consistent with biological markers such as chromosomes and external genitalia. Some well-known clinics provided evaluations and treatment to assist people with discordant gender identity in their efforts to develop a body that matched their internal conception; however, for most psychiatrists, gender identity was rarely much of an issue. Societal shifts have muddied these waters, and there are increasing numbers of people who do not see themselves as falling into traditional dichotomies (male/female; heterosexual/homosexual) and who connect with lesbian, gay, bisexual, and transgender organizations for a variety of reasons, including the shared sense of being societal outsiders. DSM-III and DSM-IV entered these complex and largely uncharted waters with diagnoses (transsexualism and gender identity disorder, respectively) that indicated that the clinical problem was the discordant gender identity. DSM-5 moves further in the direction of depathologizing discordant gender identity by developing a new diagnosis, gender dysphoria, which emphasizes clinically significant distress or dysfunction along with the discordance. The diagnosis of gender dysphoria may reflect a compromise between conflicting, pragmatic goals. For example, having a diagnosis that specifically references gender identity issues might be important for people who seek insurance coverage for gender reassignment surgery and hormonal therapy, as well as for transgender people who seek legal protection when they have experienced discrimination based on gender identity. On the other hand, it might be possible for a diagnosis related to gender identity to be used in legal settings as an indicator of some sort of pathology. DSM-5 is not, however, most concerned with the financial and legal ramifications of its nomenclature. It also seems unlikely that DSM-5 intends the term gender dysphoria to refer primarily to psychological reactions to societal prejudice; discrimination comes in many forms, and no other triggers for discrimination are privileged with their own diagnosis. DSM-5 also clarifies that the diagnosis does not refer simply to gender nonconformity or transvestism. Instead, the DSM-5 diagnosis of gender dysphoria reflects a clinical reality: a subset of patients present with unhappiness that seems bound up with the discordance between their bodies and their sense of self as well as the reality that surgical and hormonal interventions are far from perfected. While perhaps an imperfect label, gender dysphoria is intended to improve the likelihood that these patients’ specific issues will be the subject of clinical attention. Case 14.1 Gender Reassignment Jody Rohmer, a 52-year-old salesperson, presented to a psychiatrist as part of a court proceeding that was intended to legally reassign her gender to female. Jody had been born with male genitals and raised as a boy. In contrast to a more gender-typical older brother, Jody had been seen as a “sissy” since early childhood, generally preferring the company of girls to boys. She had considered herself a bisexual male through her teen years. Around age 19, during a romantic relationship with a man, she had become aware of a strong desire to be a woman. The relationship ended, but the desire to be a woman evolved into a strong sense that she had been born into the wrong gender. She had tried to figure out whether this sense had existed earlier, but all she could recall was occasionally wishing she were a girl to fit in more comfortably with her friends. She definitely recalled, however, that by age 19 or 20, she was very unhappy with being seen as a man and viewed her genitalia as “repugnant” and a “mistake of nature.” Between ages 22 and 24, Ms. Rohmer lived as a female, including changing her name and exclusively wearing women’s clothes. She also dated. Gay and straight men were generally uninterested, so she primarily dated lesbians or people at various stages of cross-sex treatment. At age 24, Ms. Rohmer was evaluated by two experienced court-assigned psychiatrists, who agreed with her perspective. In the same year, she had sex reassignment surgery, followed by a legal sex change from male to female. The results of her sex reassignment surgery were not very satisfactory. She lived as a woman for over 15 years, but the experience did not live up to her expectations. A tall, muscular person, she was frequently identified as a transsexual rather than a woman like any other woman. She found this constant public scrutiny to be “exhausting.” Although she dated regularly during this period, she was routinely disappointed in relationships with both male and female sexual partners. At age 42, Ms. Rohmer consulted a plastic surgeon and asked him to remove her breast implants. She hoped that her life would be “easier and more relaxed” in the male role. She was also curious and excited about the prospect of integrating “male personality traits,” which she saw as increased assertiveness and dominance. After the breast surgery, she began to take male hormones, which did make her more active and aggressive. The shift did not, however, help her feel better. She missed her male genitals and was aware that they could never be satisfactorily reconstructed. The male hormones stimulated her sexual appetite, but she was left without the possibility of achieving a normal male orgasm. Instead of being relaxed after a sexual encounter, she felt tense and dissatisfied. Furthermore, dating became more complicated. She was still bisexual but primarily attracted to men. Most gay men were uninterested in a relationship (and/or sex) with someone with female genitalia, whereas most straight men were uninterested in a relationship (and/or sex) with someone who appeared male even if the person had female genitalia. She gravitated to lesbian circles but was unable to find a girlfriend. She also found that the male hormones made her edgier and more aggressive at work, which led to a job loss and welfare, which was an embarrassing decline from her previously successful professional career. Ms. Rohmer stopped taking male hormones at age 51 and found that her female identity was still very strong and even stronger than she herself had anticipated. She calmed down, found a new job, and came to the conclusion that her femininity was now irreversible. At age 52 she got new breast implants and applied to the court to again assign her legally as a woman. Ms. Rohmer said she had been “depressed” in her early 20s and found psychotherapy to be helpful. She said she was an anxious person, generally worried that people were judging her negatively. She added that she also thought her perspective was accurate, that most people would immediately identify her as a man in a woman’s body and think about her critically. She described a period of time during her 30s when she drank alcohol every evening to put herself to sleep, but denied negative consequences. She denied suicide attempts, arrests, and self-injuries such as cutting. She said she had “almost” given up on having a successful relationship but was “somehow” still optimistic that something would work out. She denied that her relationships had been particularly stormy or difficult; typically, she said, the other person would be initially intrigued but then become uninterested.