Outward

Gender Dysphoria Is Killing Transgender Teens. Why Aren’t We Talking About It?

Recognizing patients’ pain is a basic part of the physician’s job.

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A 2011 survey of 6,500 transgender people published by the National Center for Transgender Equality revealed that 41 percent of transgender individuals have attempted suicide at least once. Fifty percent of transgender youth will attempt suicide before their 20th birthday.

In an attempt to make sense of these staggering statistics, I spoke to Michael Mancilla, a licensed clinical social worker at Children’s National Hospital in Washington, D.C. He told me the story of a 15-year-old patient he had seen the previous day. The patient, a transgender male, was admitted following an aspirin overdose—his third suicide attempt. After speaking to him, Mancilla learned that the attempts were temporally linked to the patient’s menstrual periods. The hormonal changes and the physical and emotional dissonance caused by menstruation were severe enough to lead to suicide attempts.

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There is a term for the severe distress experienced by individuals due to the incongruence between assigned and experienced gender: gender dysphoria. This complex condition often first becomes evident in adolescents and young adults. Because adolescents represent a vulnerable population facing unique social and legal barriers to care, the recent emergence of health care initiatives aimed at providing access to care for LGBTQ adolescents is particularly important. One of the most progressive such initiatives is the Youth Pride Clinic at Children’s National Hospital, where Mancilla works. This LGBTQ health clinic serves patients ages 12–22 and offers a variety of resources from individual and family counseling to hormonal therapy.

These interventions are necessary because even though there are an estimated 700,000 transgender individuals currently living in the United States, many physicians report a lack of awareness of the resources available to patients who are transitioning or dealing with symptoms of gender dysphoria.

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One issue is a lack of education in both medical schools and in the workplace. Therefore, Mancilla believes that it is vital to focus on instruction. In addition to working in the Youth Pride Clinic, Mancilla, who is a co-recipient of a grant aimed at delivering LGBTQ education to health care providers, spends his time raising awareness of gender dysphoria and LGBTQ health.

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With research demonstrating the success of curricular reforms, projects like Mancilla’s may hold a lot of promise. For example, a 2015 study examined the efficacy of incorporating a lecture on transgender medicine into the standard internal medicine residency curriculum. The addition of one lecture increased the percentage of trainees who felt comfortable in assisting with hormone therapy during transitioning from 5 percent to 71 percent, while a significant change was observed in the number of trainees who understood that gender orientation had a biological component and was not simply a psychological anomaly. Similar results were shown when a single lecture on transgender medicine was incorporated into medical school education.

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For physicians, the lack of familiarity with gender dysphoria may also be traced back to the relatively recent introduction of the term into the medical lexicon. The American Psychiatric Association made earlier attempts to medically categorize gender identification: The concept of transsexuality first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders in 1980 under the heading of “gender identity disorder”—an umbrella term encompassing a cluster of disorders that included transsexualism, gender identity disorder of childhood, and transvestic fetishism.* However, in 2013, a major revision occurred with the 5th edition update. In it, the DSM–5 replaced gender identity disorders with the term gender dysphoria, broadly defining it as “an individual’s affective/cognitive discontent with the assigned gender.” With this revision, the APA shifted the emphasis away from gender nonconformity and toward the experienced distress.

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It’s important to note that there are linguistic issues with the word dysphoria, which may fail to capture the variation and potential severity seen with the condition. However, as Mancilla points out, the presentation of gender dysphoria should be seen as a spectrum. He described two other patients he’d recently seen, an eighth-grader who was so paralyzed by gender dysphoria that he stopped attending school or venturing outside altogether, leading to a severe Vitamin D deficiency; and a 17-year-old Syrian Muslim patient who required a feeding tube to combat a life-threatening eating disorder he resorted to in order to combat the curves that began appearing with the surge of female sex hormones in puberty. “And we’ve lost patients to gender dysphoria, too,” Mancilla adds.

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The profound cases of distress such as those described by Mancilla make the APA’s incorporation of gender dysphoria into the DSM an important development. However, the addition of the term can be seen as a double-edged sword. There are clear issues with pathologizing questions of identity or with reinforcing the binary view of gender. But giving gender dysphoria an identifiable diagnosis may also assist health care professionals in advocating for increased resources and improved coverage, as insurance coverage is intrinsically tied to known diagnoses. In this way, the inclusion of gender dysphoria in the DSM–5 may assist in making resources such as counseling, hormone therapy, or surgical interventions more available and affordable to patients. (Specific guidelines for the treatment of gender dysphoria can be found in the Standards of Care released by the World Professional Association for Transgender Health.)

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At the same time, the DSM’s emphasis on gender dysphoria may itself raise awareness and serve as a much-needed impetus for increasing health care providers’ understanding of the severity of the psychological impact that a mismatch between mind and body can have on an individual.

Though the trends do appear promising, a lot of work still needs to be done to reform health care education and to improve access to care. That’s why projects like the Youth Pride Clinic, education initiatives, and health care advocacy will play a vital role in helping thousands of individuals receive the help they need. More important, they will save lives.

*Correction, May 20, 2016: This piece originally misstated the name of the organization that publishes the Diagnostic and Statistical Manual of Mental Disorders.

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