DSM-5: Gender Dysphoria. Myths and Realities. Ideology and Science

Transsexuality is a victim of gender ideology, to the added misfortune of those who suffer from it.

Joaquín Díaz Atienza

INTRODUCTION

CIt is necessary that we clarify the meanings of sexual orientation y of sexual identity before going into a more exhaustive discussion on the sexual identity. It is understood by sexual orientation The attraction an individual may feel for the same sex or the opposite sex. When a man feels sexual attraction for another man, we call it homosexuality, When this happens to a woman, it is called lesbianism. When the attraction is indifferent, it is called bisexualityWe would say that this classification is the usual one and the one that, nowadays, is considered non-pathological or normal by most people. However, many others may exist.: bestiality – when one feels sexual attraction to animals- ; fetishism – The most frequent instance is when there is attraction to underwear, other articles of clothing, or a particular body part – pedophilia – when one feels sexual attraction to children, etc.  

Sexual identity – gender dysphoria

We are born with a biological sex: male (XY) or female (XX). However, there are individuals who identify with the opposite sex to the one they would be biologically assigned: men who identify as women and women who identify as men. It is common for the development of sexual identity (something quite different is sexual orientation: homosexuality, lesbianism and bisexuality) corresponds to biological sex. It is called gender dysphoria This refers to a person identifying with the sex opposite to their biological sex. It is more popularly known as transsexuality.

DSM-5 diagnostic criteria for gender dysphoria

Version 5 of the Diagnostic and Clinical Manual of Mental Disorders (DSM-5)  of the American Psychiatric Association (APA), subdivides gender dysphoria into: children (302.6 – F64.2) and into adolescents and adults (302.85 – F84.1).

1. Gender dysphoria in children For at least six months, the individual exhibits a marked incongruence between their biologically assigned sex and their lived or felt sex. At least six of the following criteria must be met. These may manifest as: A very intense desire to be of the other sex, insistence on being of the other sex (This item is mandatory). Boys show a strong tendency to imitate feminine attire or cross-dress. Girls show resistance to wearing feminine clothing and a preference for wearing masculine clothing. Marked and lasting preferences for the role of the other sex or fantasies about belonging to the other sex. Marked preference for toys, games, or activities normally performed or used by the other sex. A marked preference for playmates of the opposite sex. In boys, a strong aversion to typically masculine toys, games, and activities, as well as a marked avoidance of rough play. In girls, a strong aversion to typically feminine toys, games, and activities. A marked disgust with one's own sexual anatomy. A strong desire to possess both primary and secondary sexual characteristics, corresponding to the sex one feels. The problem is associated with clinically significant distress or impairment in social, academic, or other important areas of functioning. It should be specified whether or not it is accompanied by a disorder of sexual development (e.g., congenital adrenogenital disorder, congenital adrenal hyperplasia, or androgen insensitivity syndrome). Gender dysphoria in adolescents and adults. A marked incongruence between one's felt or expressed sex and biological sex, lasting at least six months. At least two of the following characteristics must be present: A marked incongruity between the sex one feels or expresses and their primary or secondary sexual characteristics. A strong desire to get rid of one's own primary or secondary sexual characteristics, due to a marked incongruity with the sex one feels or expresses. A strong desire to possess the primary and secondary sexual characteristics of the opposite sex. A strong desire to be of the opposite sex. A strong desire to be treated as the opposite sex. A strong conviction that one has the feelings and reactions typical of the other sex. The problem is associated with severe clinically significant distress or impairment in social, occupational, or other important areas of functioning. As with childhood dysphoria, it is necessary to specify whether the individual has a disorder of sexual development. Likewise, the post-transition status must be specified: whether they fully live as the desired gender, and whether they have undergone or are awaiting medical treatment or surgical intervention (penectomy, vaginoplasty, mastectomy, or phalloplasty).

For some researchers, this classification would be incomplete as it does not include cases of gender dysphoria. Male – Female (M/F) (homophilic or non-homophilic) and cases of Female – Male (M/F) (gynephilic or non-gynephilic). This would be important for functional brain research in gender dysphoria. However, for Gooren (2006), this subclassification would be meaningless. He considers it normal for a biological trans man to feel attraction to another man since he lives as a woman.

Prevalence of Gender Dysphoria

It is acknowledged that the prevalence of assisted reproductive technology has increased in recent decades (1996–2004). In California, the rates were 1:21.031 among men and 1:48.096 among women. Cited by Gómez Gil et al. (2006).

This increase has been especially significant in recent years, as reflected in prevalence studies in the general population. Kuyper and Wijsen (2014), in a Dutch sample of 80,074 people (aged 15-70), found that 1,1% of males and 0,8% of females self-identified as transgender (gender dysphoria). In another study conducted on a sample of 1,832 people in Flanders (Van Caeneguem et al., 2015), they found rates of 0,6% among women and 0,7% among men.

The reasons given to explain this increase in the prevalence/incidence of gender dysphoria are usually varied and interrelated: The increased visibility of transsexuals in the media, the awareness in society about this reality with the consequent less stigmatization, greater accessibility to information, greater social tolerance and the offer of medical treatments, such as hormonal treatment and surgical sex reassignment.

Comorbidity in gender dysphoria

• There is a greater prevalence of depressive symptoms, anxiety, self-harm, suicidal ideation, attempts, and completed suicides. These symptoms appear to be primarily related to psychosocial factors, and most research indicates that they tend to improve with appropriate support.
• A study conducted in Lebanon by Ibrahim et al. (2016) corroborates these symptoms and links them to ostracism, social and/or familial rejection. They propose the implementation of non-transphobic mental health teams to prevent psychiatric complications.
• A higher prevalence of Autism Spectrum Disorders (ASD) has been detected in individuals with gender dysphoria than in the general population, leading to the creation of working groups to develop specific guidelines for diagnosis and treatment (Strang et al., 2016). As high as 7,9% of individuals with gender dysphoria have been found to have ASD.
• The prevalence of eating disorders is usually higher in gender dysphoria and homosexual orientation problems (Witcomb GL et al., 2015), although more research is still needed in this field.

Etiopathogenesis

Gender dysphoria has been linked to a wide variety of neurobiological and psychosocial situations.

• Genetics:
  • Investigations with negative results: Gooren (2006) (opinion article); Lombardi et al (2013) (genetic research); Fernández et al (2014): No association between transsexualism and the ERβ, AR, and CYP19A1 genes related to hormone production.
  • Research yields positive results: Fernández et al. (2015): Association between the ERβ gene and F/M transsexualism; Fernández et al. (2015): Association with a CYP17 MspA1 polymorphism greater in M/F than in F/M; Shabir et al. (2015): Enzymatic alteration in subtypes of gender dysphoria; Cortés-Cortés et al. (2017) find an association between the XbaI-rs9340799 gene and female/male transsexuality

Therefore, although some positive findings are emerging, they are not yet conclusive in the sense that we can categorically affirm or deny the genetic implication in the etiopathogenesis of transsexuality. The same occurs with other child and adolescent psychiatric disorders where, if a genetic cause exists, it is usually multigenic and where we still do not fully understand how some genes are affected in their inhibitory or facilitative function when others present some type of anomaly.

• Neuroimaging and gender dysphoria

New functional neuroimaging techniques are providing us with valuable information that was previously inaccessible. Being able to observe the changes produced in specific brain structures in response to administered stimuli gives us the opportunity to study how each individual responds differently, both in situations of neurological pathology and in other processes of an emotional or sensory nature. In our case, we are interested in seeing if there are structural and/or functional differences in subjects with gender dysphoria, and if these differences exist in male-to-female and female-to-male cases.

In 2010, Hideyuki et al. conducted a study in patients with male/female gender dysphoria, measuring regional cerebral blood flow. Eleven transgender subjects were compared to controls. The patients showed a significant reduction in blood flow in the left anterior cingulate cortex and an increase in the right insula compared to controls.

Seok-Kiun et al. (2012) investigated brain activation patterns in male-to-female transsexuals and controls in response to the presentation of erotic visual stimuli (images of naked men and women). The research was conducted on transsexuals who had undergone surgical sex reassignment. When images of naked men were presented, the cerebellum, hippocampus, putamen, anterior angular gyrus, head and body of the caudate nucleus, amygdala, midbrain, thalamus, and insula were activated. However, the most activated structures when images of naked women were presented were the hypothalamus and the septal area. The authors concluded that the sexual orientation of male-to-female transsexuals is toward the male sex (homophilic).

Lajos et al. (2013) hypothesized that a different neuroanatomical pattern exists in gender dysphoria. To confirm or refute their hypothesis, they designed a study comparing male-to-female (M/F) and female-to-male (M/F) transgender individuals to men and women whose sexual orientation was congruent with their biological sex. The structural brain differences found in transgender individuals compared to controls were located in the regional gray matter, the cerebellum, the left angular gyrus, and the left inferior parietal lobe. They also found differences depending on whether the controls were male or female, or male-to-female (M/F) or male-to-male (M/F) transgender individuals.

In 2013, Hsiao-Lun et al. observed that increased functional connectivity in the ventral tegmental area was significantly correlated with the representation of dysphoric genitalia. These researchers suggested that brain connectivity patterns and their functionality were the signature of psychosocial distress due to gender incongruence.

Kranz et al. (2014) used diffusion tensor imaging (fMRI) to study potential variations in white matter in transgender subjects compared to controls. Fractional, axial, and radial anisotropy, as well as mean diffusibility, were calculated. The results showed a significant difference between the groups in terms of diffusibility. Testosterone levels correlated strongly with mean, axial, and radial diffusibility. They concluded that these results support the hypothesis that the development of brain tract fibers is largely influenced by the hormonal environment during late pregnancy and early postnatal periods..

Neural networks

But what is providing scientifically very valuable information is diffusion MRI and the possibility of studying in depth the processing of psychosensory information through brain networks (Zuo et al., 2012). Brain information is regulated by neural networks who meet in nodes. and these on portalsThe network that processes body image and its representation, giving rise to subjectivity regarding our identity and awareness of it, is known. The functional importance of this network is defined as Degree of CentralityThe greater the centrality, the more relevant it is in the function it performs.

In this line of research, Chia-Shu et al. (2014) hypothesize that the incongruence between perception and biological sex in individuals with gender dysphoria is due to changes in the resting state of the functional connectivity network. They measure the regional brain changes produced in the degree of centrality (as mentioned, the degree of centrality is an index of the functional importance of a node in the neural network). They found that transgender individuals exhibit a higher degree of centrality in the upper parietal lobe and in the primary somatosensory cortex. Furthermore, centrality between the right insula and the bilateral primary somatosensory cortex correlates negatively with self-assessment of their desired sex. This would explain the dissociation between the emotional perception of their body and their actual body image.

Similarly, particularities have been found in voice processing depending on sex, Junger et al. (2014). These researchers found the involvement of structures such as the medial prefrontal gyrus, the island y the precuneus gyrus.

CONCLUSIONS

• Transsexuality or gender dysphoria is a medical condition that we must continue to investigate for the benefit of those who suffer from it.
• Research development must be accompanied by non-discrimination policies that eliminate any social stigmatization.
• We believe it is a serious mistake on the part of the WHO to change the terminology due to ideological pressure. This could harm the healthcare rights of transgender people. Public healthcare systems do not offer treatments for non-diseases or non-disorders. Furthermore, it greatly damages the reputation of the WHO itself, which, despite being aware of all the scientific evidence, allows itself to be manipulated by ideological lobbies.
  

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