Gender Dysphoria: Prevalence and Psychopathology

Prevalence

• Approximately 0.5% of the population identifies as transgender.
• In Sweden, the ratio for legal name change applications is 1:7,750 for adult males and 1:13,000 for females.
• In Ireland, 1:10,000 adult males and 1:28,000 females are referred for hormonal treatment.
• A meta-analysis indicates a transsexualism prevalence of 1:15,000 in males and 1:38,000 in females.

Associated Psychopathology

• Adults with gender dysphoria have higher comorbidity rates of mood and anxiety disorders compared to the general population.
• A study of 300 individuals post-sex reassignment surgery revealed 19% of males-to-females and 17% of females-to-males were hospitalized for psychiatric reasons other than gender dysphoria before the surgery.
• Post-surgery, the risk of psychiatric hospitalization remained over double compared to controls.
• Individuals with gender dysphoria are 4.9 times more likely to attempt suicide and 19 times more likely to die by suicide.
• In a European study, 38% of individuals had a current Axis I disorder and 69% had a lifetime Axis I disorder, primarily mood and anxiety disorders.

Aetiology

• Gender dysphoria’s causes include a combination of genetic, hormonal, brain structure, and psychosocial factors.
• Genetic Factors: Family and twin studies suggest a genetic component; 39% of monozygotic twins showed concordance for gender dysphoria, while none of the dizygotic twins did.
• Prenatal Hormones: Atypical sexual differentiation of the brain due to prenatal hormone exposure may lead to gender incongruence.
• Brain Structure: Studies indicate homosexual male-to-females demonstrate dissimilarities in brain grey matter volume, cortical thickness, and white matter microstructure compared to their natal sex. Non-homosexual male-to-females show less clear results.
• Psychosocial Factors: Gender identity can exhibit fluidity; clinical populations may show reduced cross-gender behavior over time, especially without social transition prior to puberty.

Treatment

• Treatment protocols for adults with gender dysphoria have been standardized in high-income countries, influenced by clinical guidelines such as the Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People.
• Multidisciplinary management includes endocrine, surgical, and psychological support, with an emphasis on alleviating emotional distress rather than enforcing alignment with assigned gender.
• Individuals with gender dysphoria generally undertake a "real life experience" for a year in their new gender role before surgery, though this requirement faces criticism regarding its psychosocial risks.

Hormonal Therapy

• Hormone therapy is an effective treatment option, with significant quality of life improvements linked to concomitant sex reassignment surgery.
• Males-to-females undergo testosterone suppression while females-to-males receive androgen therapy, leading to various physical changes, including deeper voice and increased facial hair in males-to-females.

Gender-Confirming Surgery

• Surgical options include mammoplasty and orchidectomy for male-to-female procedures, and mastectomy and phalloplasty for female-to-male procedures.
• Follow-up studies post-surgery generally report favorable outcomes, but a meta-analysis reveals 86% of females-to-males and 71% of males-to-females report quality of life improvement, albeit with notable minority dissatisfaction.

Gender Identity Disorders in Children

• Children with gender dysphoria often demonstrate behaviors aligning with the opposite sex, with both early-onset (typically from ages 2-4) and later-onset forms.
• Early-onset forms are associated with later homosexual orientations, whereas late-onset forms tend to be non-homosexual.
• Referral rates for gender dysphoria are higher in boys compared to girls.