(071) Outside the Binary: Diagnostic Grey Areas in Gender Dysphoria

‎Background/Significance: As referral rates to psychiatric consultation services for gender dysphoria ‎evaluations are on the rise, current diagnostic formulations of gender dysphoria have become increasingly inadequate ‎for capturing the ever evolving societal and medical conceptualizations of gender. Here we present two cases of ‎patients seeking gender affirming interventions but who do not meet diagnostic criteria for gender dysphoria. We ‎briefly review how psychiatric conceptualizations of transgender and gender diverse populations have evolved to ‎inform our current definitions and discuss considerations for supporting patients that do not fit into those definitions.‎

‎Cases: BH is a 35-year-old non-binary individual (assigned male at birth (AMAB), uses "he/him" pronouns) ‎seeking vaginoplasty and testosterone therapy. The patient was motivated by a disdain for being an insertive partner ‎during intercourse and a hope that testosterone would lead to a more "toned," "perfect" body. He also desired more ‎feminine traits. Significant depressive and anxiety symptoms were identified and treated, with the patient ultimately ‎being referred for hormone replacement therapy and consultation with urology.‎

TR is a 64 -year-old (AMAB, uses "he/him" pronouns), seeking vaginoplasty due to significant erectile dysfunction. He ‎was motivated by a desire to improve his sexual satisfaction and did not wish to present or live as female. He met ‎criteria for alcohol use disorder and had a history of suicidal behavior but had no prior psychiatric care. He was ‎ultimately lost to follow-up after being told that he would not be able to pursue this surgery.‎

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Discussion: Psychiatric definitions of transgender experiences first appeared in the DSM II and have evolved ‎with each subsequent edition (Crouq, 2022). Access to gender affirming care remains largely predicated on patients ‎meeting the diagnostic criteria for gender dysphoria, which requires a "marked incongruence between one's ‎experienced/expressed gender and assigned gender" (APA, 2022). As illustrated by these case examples, individuals ‎can experience clinically significant gender-related distress in the absence of gender dysphoria. Expanding diagnostic ‎criteria to allow for more dimensionality may better account for the heterogeneity of gender variant individuals and ‎improve psychiatric outcomes (Cohen-Kettenis, 2010).‎

‎Conclusion/Implications: Societal and medical conceptualizations of gender-related experiences and ‎identities have evolved over centuries. The current definition of gender dysphoria and its role in the medical model of ‎gender transition may exclude individuals on the gender identity spectrum who experience clinically significant ‎distress. To best care for these individuals, psychiatrists should critically examine current diagnostic criteria for gender ‎dysphoria and consider more expansive and dimensional definitions in the future.‎

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References: ‎
‎1. American Psychiatric Association. (2022). Gender Dysphoria. In Diagnostic and statistical manual of mental ‎disorders (5th ed., text rev.).‎
‎2. Cohen-Kettenis, P. T., & Pfäfflin, F. (2010). The DSM diagnostic criteria for gender identity disorder in adolescents ‎and adults. Archives of sexual behavior, 39(2), 499–513.‎
‎3. Crocq MA. How gender dysphoria and incongruence became medical diagnoses - a historical review. Dialogues Clin ‎Neurosci. 2022 Jun 1;23(1):44-51.‎