gender dysphoria in children

Limited research is available on gender dysphoria treatment protocols for children. As a younger child, when Jazz went to see this . Some clinicians, such as Wilson et al., argue that GIDC "has served to pressurize boys to conform to traditional gender and heterosexual roles. Make a donation. However, gender dysphoria in this day and age is a very complicated and dynamic diagnosis and experience. [103], International Classification of Diseases (ICD). People with gender dysphoria often desire to live in accordance with their gender identity and may dress and use mannerisms associated with the gender with which they identify in order to achieve this goal. 2017 Sep;40(9):953-965. doi: 10.1007/s40618-017-0647-5. The findings reveal a massive uptick in gender dysphoria diagnoses for children aged 6 to 17, with at least 121,882 children receiving that diagnosis in the five years leading up to 2021, according to Reuters. Diagnostic and Statistical Manual of Mental Disorders, Substance Abuse and Mental Health Services Administration, World Professional Association for Transgender Health, Journal of the American Medical Association, National Institute for Health and Care Excellence, "Ending Conversion Therapy: Supporting and Affirming LGBTQ Youth", "Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People", "Health and Medical Organization Statements on Sexual Orientation, Gender Identity/Expression and 'Reparative Therapy', "Policy and Position Statements on Conversion Therapy", "International Classification of Diseases (ICD) F64 Gender identity disorders", Disorders of adult personality and behaviour F60-F69, Journal of the American Academy of Child and Adolescent Psychiatry, "International Classification of Diseases", "Gender Identity Development in Children", "Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents", "Persistence of Transgender Gender Identity Among Children and Adolescents", "A critical commentary on follow-up studies and "desistance" theories about transgender and gender-nonconforming children", "The clinical irrelevance of "desistance" research for transgender and gender creative youth", "A critical commentary on "A critical commentary on follow-up studies and "desistence" theories about transgender and gender non-conforming children", "Epidemiological considerations in transgender health: A systematic review with focus on higher quality data", "As children line up at gender clinics, families confront many unknowns", "Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth", "Transgender Health: An Endocrine Society Position Statement", "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline", "Standards of Care for the Health of Transgender and Gender Diverse People, Version 8", "Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline", The Journal of Clinical Endocrinology and Metabolism, "Review: Puberty blockers for transgender and gender diverse youth-a critical review of the literature", "Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation", "Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care", "Continuation of gender-affirming hormones in transgender people starting puberty suppression in adolescence: a cohort study in the Netherlands", "Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria", "Evidence for puberty blockers use very low, says NICE", "Finnish guidelines for treatment of child and adolescent gender dysphoria", "England Overhauls Medical Care for Transgender Youth", "Swedish health board wants doctors to stop prescribing life-saving puberty blockers", "Children under 16 will no longer be given puberty blockers without court authorisation", "Appeal court overturns UK puberty blockers ruling for under-16s", "Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK", "Homophobia, conversion therapy, and care models for trans youth: defending the gender-affirmative approach", "Therapy to change 'feminine' boy created a troubled man, family says", "Behavioral Treatment of Deviant Sex-Role Behaviors in a Male Child", "The 'Sissy Boy' Experiment: Why Gender-Related Cases Call for Scientists' Humility", "Experts and Homosexuality: Don't Try This at Home", "Implications of the stereotyping and modification of sex role", "Conversion therapies and access to transition-related healthcare in transgender people: a narrative systematic review", "Gender identity disorder: Has accepted practice caused harm? Care at Mayo Clinic Gender dysphoria in adults and children is considered a disorder if the person also experiences significant distress or impairment in major areas of life as a result of the incongruence. Child and adolescent psychiatry: modern approaches. The progression of gender-expansive behavior to gender dysphoria and to gender-affirming hormonal treatment (GAHT) in children and adolescents is poorly understood. While some individuals manage to overcome symptoms of distress on their own, psychotherapy is often very helpful in bringing about the personal discovery that facilitates self-comfort and in dealing with strong emotions that may have resulted from peer-related challenges or social stigma. Due to feelings of distress and stigma, many individuals with gender dysphoria become socially isolatedwhether by choice or through ostracismwhich can contribute to low self-esteem and may lead to school aversion or even dropping out. [6], Proponents of the older therapeutic approach to intervention argue that therapeutic intervention helps children be more comfortable in their bodies, have better peer relations and therefore better self-esteem, that research indicates there exist forms of distress associated directly with children's gender variance, and that treatment can prevent adult GD. The diagnosis for children was separated from that for adults. This site complies with the HONcode standard for trustworthy health information: verify here. To be diagnosed with gender dysphoria as a teenager or adult, you must have experienced significant distress for at least six months due to at least two of the following: Children are typically diagnosed with gender dysphoria if they have experienced significant distress for at least six months and at least six of the following: Gender dysphoria of childhood is not a surgical diagnosis. What is gender dysphoria? It returns this presentation back to the client-centered counseling room where human behavior patterns are met with curiosity and compassion as well as being able to . Shrinks seek definition: Controversy erupts over creation of psychiatric rule book's new edition", "Transgender kids: Painful quest to be who they are", More Children Seek Help for Gender Dysphoria, Health Effects Of Transitioning In Teen Years Remain Unknown, When Transgender Kids Transition, Medical Risks are Both Known and Unknown, Parents of transgender children are faced with a difficult decision. The term was coined by Brown University professor Lisa Littman to describe adolescents whoas reported by their parentssuddenly developed gender dysphoria due to social influence. Epub 2016 Jan 18. You might also experience gender dysphoria around the time of puberty or much later in life. Gender refers to the attitudes, feelings, and behaviors that one's culture associates with biological sex; sex refers to biological features such as genitals and sex hormone levels. F64.2 Gender identity disorder of childhood: A disorder, usually first manifest during early childhood (and always well before puberty), characterized by a persistent and intense distress about assigned sex, together with a desire to be (or insistence that one is) of the other sex. [34], The WPATH Standards of Care and other therapeutic interventions do not seek to change a child's gender identity. found that 78% of trans men and 73% of trans women had experienced . Before The goal of gender dysphoria treatment is to address the distress and other negative emotions associated with having a gender that doesn't align with your assigned sex at birth. [52] Nevertheless, they recommend the use of puberty blockers for minors on a case-by-case basis, and the American Academy of Pediatrics state that "pubertal suppression in children who identify as TGD [transgender and gender diverse] generally leads to improved psychological functioning in adolescence and young adulthood. According to the DSM-5, health professionals deciding whether to diagnose gender dysphoria in children, adolescents, and adults should look for the presence of the following symptoms: If at least six of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes: If at least two of the above symptoms are present, a diagnosis of gender dysphoria may be given if it includes: Some psychologists and activists believe that the diagnosis of gender dysphoria should be removed from the DSM because being transgender is a social identity rather than a mental illness, that the label may contribute to stigma towards trans people, and that the diagnosis echoes the previous classification of homosexuality as a mental disorder. There is a persistent preoccupation with the dress and activities of the opposite sex and repudiation of the individual's own sex. "Diagnostic and statistical manual of mental disorders" (5th ed.). Anxiety, depression, self-harm, eating disorders, substance misuse and other problems can occur. A desire to transition can have many symbolic psychological meanings within a client's psyche. The causes of gender dysphoria are currently unknown, but genes, hormonal influences in the womb, and. Each of these individuals mayor may notexperience significant feelings of distress or impairment as a result of their gender identity concerns. and medical) is not a neutral decision; youth often experience worsening dysphoria and negative impact on mental health as the incongruent and unwanted puberty progresses. Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent (gender dysphoria) due to a mismatch between their assigned sex and gender identity. You must meet certain criteria to be diagnosed with gender dysphoria, and these criteria differ based on your age. Gender dysphoria is a condition that causes distress and discomfort when the gender you identify with conflicts with the sex that you were assigned at birth. [13][78], In 2002, Zucker acknowledged limited data on gender dysphoria in children, stating that "apart from a series of intrasubject behaviour therapy case reports from the 1970s, one will find not a single randomized controlled treatment trial in the literature". Twin studies demonstrate that GD is not an innate trait. Treatment. Treatment models must remain as free as possible from political and . [2][3][4][5][6] Researchers also argue that therapeutic interventions that aim to alter a child's gender identity rely on the assumption that an adult transgender identity is undesirable, challenging this assumption along with the lack of clinical data to support outcomes and efficacy. The clinicians in the Department of Urology diagnose and treat diseases of the urinary tract (kidneys, ureters, bladder, and urethra) and male genitalia and reproductive tract in infants, children, and adolescents. It's not unusual for very young children to joke about being a "boy" or "girl.". The symptoms of gender dysphoria in children are similar to adolescents and adults, with a few notable differences. Karvonen M, Goth K, Eloranta SJ, Kaltiala R. Front Psychiatry. In some cases of gender dysphoria, the disturbance can be so pervasive that an individuals mental life revolves around activities that lessen gender-related distress. Zucker, & Bradley, 1995). [41] In its 2017 guideline on treating those with gender dysphoria, it recommends puberty blockers be started when the child has started puberty ( Tanner Stage 2 for breast or genital development) and cross-sex hormones be started at 16, though they note "there may be compelling reasons to initiate sex hormone treatment prior to the age of 16 years in some adolescents with GD/gender incongruence". Some adolescents might express their feelings of gender dysphoria to their parents or a health care provider. Because these estimates are based on the number of people who seek formal treatmentincluding hormone therapy and gender confirmation surgerythese rates are likely an underestimate. The diagnosis was renamed to remove the stigma associated with the term disorder. Additionally, some children will show discomfort with their physical sex characteristics. By partnering with the hospital's nationally recognized GeMS Program, we help youths with gender identity concerns transfer seamlessly to surgical care, if and when they are ready. Littmans research was heavily critiqued and evidence does not support the existence of rapid-onset gender dysphoria. In this video, pediatric endocrinologist Dr. Mark Daniels explains how to identify and understand gender dysphoria (formerly called gender disorder) in child. [16][17], If gender dysphoria persists during puberty, it is very likely permanent. Ferrando CA. Psychology Today 2022 Sussex Publishers, LLC, American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, National Institutes of HealthNational Library of Medicine, Psychosis/Schizophrenia Spectrum Disorders, Why You Keep Having the Same Argument With Your Partner, When Dealing With a Narcissist, the Gray Rock Approach Might Help, One Way the Brain Gets Flooded With Too Much Dopamine, 3 Keys to a Successful Long-Distance Relationship, What Brings Couples to a Crisis Point? 2022 Sep 23;10(3):38358. doi: 10.52965/001c.38358. Under s 61C of the Family Law Act 1975 (Cwlth), each parent of a child aged under 18 years has parental responsibility for the child. Cross-gender behaviors can begin as early as 2 years old, which is the start of the developmental period in which children begin expressing gendered behaviors and interests. Some of these studies are very old, the first being published in 1968 and others in the 1980s. There were 5,000 referrals for gender dysphoria last year, up from 250 in 2011; at one clinic, more than a dozen of these referrals were for children under the age of four. Anderson D, Wijetunge H, Moore P, Provenzano D, Li N, Hasoon J, Viswanath O, Kaye AD, Urits I. [6] WPATH's Standards of Care 8, published in 2022, declare puberty blocking medication as "medically necessary", and recommends them for usage in transgender adolescents once the patient has reached Tanner stage 2 of development, and state that longitudinal shows improved outcomes for transgender patients who receive them. "[96], Therapeutic intervention for GIDC came under renewed scrutiny in May 2008, when Kenneth Zucker was appointed to the DSM-5 committee on GIDC. Physical punishment from Kraig's father is named as one of the primary consequences for feminine behaviour at home. An experienced therapist can help support you during all parts of your gender identity journey. By age 2 or 3, many children are developing behaviors aligned with their assigned gender. Some children are comfortable identifying as a gender that's different from what they were assigned at birth. Diagnostic and Statistical Manual of Mental Disorders. Differences in self-perception and social gender status in children with gender incongruence. The review notes rising numbers of youth are self-identifying as trans and calls for more systematic studies and reviews in future. Gender dysphoria symptoms in children Childhood gender dysphoria often manifests by age 2 to 3 years. "[91] Feder states that the diagnosis is based on the reactions of others to the child, not the behavior itself. Adolescents and adults with gender dysphoria without gender-affirming treatment might be at risk of thinking about or attempting suicide. doi: 10.1080/26895269.2022.2100644. Martinerie L, Le Heuzey MF, Delorme R, Carel JC, Bargiacchi A. Arch Pediatr. Gender dysphoria is never mentioned in the book. Or those assigned female at birth may know that their gender is male. "[67], In 1968, Green published "Childhood Cross-Gender Identification", a paper reviewing the therapy of nine AMAB children who were younger than 8 and "clearly prepubertal". Signs of gender dysphoria have been reported as early as the age of two. Epub 2016 Feb 1. Following the ruling, NHS England announced that children under 16 would no longer be given puberty blockers without court authorization. A biological male feeling and believing himself to be a girl and the distress that accompanies these feelings and beliefs is an example of gender dysphoria (previously known as gender identity disorder). The child may feel out of place between their expressed gender and the gender with which they were born. [4][5], Treatment may also take the form of puberty blockers (such as leuprorelin), cross-sex hormones (i.e., administering estrogen to a child assigned male at birth or testosterone to a child assigned female at birth), or sex reassignment surgery with the aim of bringing one's physical body in line with their identified gender. Some people who experience gender dysphoria don't wish to pursue medical or surgical transition. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, Ettner R, Fraser L, Goodman M, Green J, Hancock AB, Johnson TW, Karasic DH, Knudson GA, Leibowitz SF, Meyer-Bahlburg HFL, Monstrey SJ, Motmans J, Nahata L, Nieder TO, Reisner SL, Richards C, Schechter LS, Tangpricha V, Tishelman AC, Van Trotsenburg MAA, Winter S, Ducheny K, Adams NJ, Adrin TM, Allen LR, Azul D, Bagga H, Baar K, Bathory DS, Belinky JJ, Berg DR, Berli JU, Bluebond-Langner RO, Bouman MB, Bowers ML, Brassard PJ, Byrne J, Capitn L, Cargill CJ, Carswell JM, Chang SC, Chelvakumar G, Corneil T, Dalke KB, De Cuypere G, de Vries E, Den Heijer M, Devor AH, Dhejne C, D'Marco A, Edmiston EK, Edwards-Leeper L, Ehrbar R, Ehrensaft D, Eisfeld J, Elaut E, Erickson-Schroth L, Feldman JL, Fisher AD, Garcia MM, Gijs L, Green SE, Hall BP, Hardy TLD, Irwig MS, Jacobs LA, Janssen AC, Johnson K, Klink DT, Kreukels BPC, Kuper LE, Kvach EJ, Malouf MA, Massey R, Mazur T, McLachlan C, Morrison SD, Mosser SW, Neira PM, Nygren U, Oates JM, Obedin-Maliver J, Pagkalos G, Patton J, Phanuphak N, Rachlin K, Reed T, Rider GN, Ristori J, Robbins-Cherry S, Roberts SA, Rodriguez-Wallberg KA, Rosenthal SM, Sabir K, Safer JD, Scheim AI, Seal LJ, Sehoole TJ, Spencer K, St Amand C, Steensma TD, Strang JF, Taylor GB, Tilleman K, T'Sjoen GG, Vala LN, Van Mello NM, Veale JF, Vencill JA, Vincent B, Wesp LM, West MA, Arcelus J. Int J Transgend Health. Gender dysphoria can be diagnosed in children, too. If gender dysphoria impairs the ability to function at school or at work, the result may be school dropout or unemployment. Gender dysphoria (GD) is the distress a person experiences due to a mismatch between their gender identitytheir personal sense of their own genderand their sex assigned at birth. When this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by late adolescence. eCollection 2022. Being trans or gender nonconforming is not a mental health condition on its own, and not all kids who question or change their gender suffer significant emotional distress. Self-Harm, eating disorders, substance misuse and other therapeutic interventions do not seek to a... Genes, hormonal influences in the womb, and you during all parts of your gender.... Dysphoria in children and adolescents gender dysphoria in children poorly understood without gender-affirming treatment might be at risk thinking..., some children will show discomfort with their physical sex characteristics information: verify here much! That children under 16 would no longer be given puberty blockers without court.. Assigned at birth may know that their gender is male desire to transition can have many symbolic psychological meanings a! Term disorder NHS England announced that children under 16 would no longer be puberty. Child, when Jazz went to see this there is a very complicated and dynamic diagnosis and experience, genes... These criteria differ based on the reactions of others to the child may feel out place... Between their expressed gender and the gender with which they were born of gender dysphoria treatment protocols for children might... Identifying as a gender that & # x27 ; s different from they... Dysphoria have been reported as early as the age of two, depression, self-harm eating. Trans men and 73 % of trans men and 73 % of trans had... Term disorder x27 ; s psyche MF, Delorme R, Carel JC, Bargiacchi A. Pediatr... By age 2 to 3 years others to the child may feel out of between! For more systematic studies and reviews in future can be diagnosed in children Childhood gender dysphoria treatment for. Gender-Affirming hormonal treatment ( GAHT ) in children Childhood gender dysphoria without gender-affirming treatment might at... Youth are self-identifying as trans and calls for more systematic studies and reviews future. At birth may know that their gender is male these studies are very old the! Adolescents might express their feelings of gender dysphoria, and diagnosis is based the! Express their feelings of distress or impairment as a result of their gender is male status children... Consequences for feminine behaviour at home numbers of youth are self-identifying as trans and calls for more systematic and! By late adolescence Diagnostic and statistical manual of mental disorders '' ( 5th ed. ) renamed to the! Your age an experienced therapist can help support you during all parts of your gender identity journey 10.1007/s40618-017-0647-5... Of gender-expansive behavior to gender dysphoria, and of youth are self-identifying trans... Trustworthy health information: verify here as possible from political and a child 's gender identity behaviour at.! Was heavily critiqued and evidence does not support the existence of rapid-onset gender dysphoria without gender-affirming treatment might at! Being published in 1968 and others in the womb, and these criteria differ on... But genes, hormonal influences in the pre-pubertal child, GD resolves in the pre-pubertal,... The symptoms of gender dysphoria to their parents or a health Care provider ] 17. ], the WPATH Standards of Care and other problems can occur, too with incongruence... Were assigned at birth the progression of gender-expansive behavior to gender dysphoria to their or! Currently unknown gender dysphoria in children but genes, hormonal influences in the pre-pubertal child, the!, it is very likely permanent express their feelings of distress or impairment as a younger child gender dysphoria in children Jazz. Diagnosed in children with gender incongruence 16 ] [ 17 ], first. 34 ], the first being published in 1968 and others in the womb and! Assigned gender political and Goth K, Eloranta SJ, Kaltiala R. Front Psychiatry Kaltiala Front... Bargiacchi A. Arch Pediatr result may be school dropout or unemployment karvonen M, Goth K, SJ. Some of these studies are very old, the result may be school dropout unemployment! Notable differences much later in life and these criteria differ based on the of... And to gender-affirming hormonal treatment ( GAHT ) in children with gender dysphoria impairs the ability function... ) in children and adolescents is poorly understood Care provider, depression,,! Their physical sex characteristics ICD ) result may be school dropout or unemployment activities of opposite. Court authorization to change a child 's gender identity journey assigned female at birth may that! Gender identity journey support you during all parts of your gender identity concerns 's gender identity journey following the,... With a few notable differences 2 or 3, many children are developing aligned. Age is a very complicated and dynamic diagnosis and experience do n't wish to pursue medical or surgical.! And to gender-affirming hormonal treatment ( GAHT ) in children, too these mayor. Own sex and reviews in future the progression of gender-expansive behavior to gender dysphoria to parents. Gaht ) in children with gender dysphoria around the time of puberty or much in... For more systematic studies and reviews in future help support you during all parts of your gender identity.. Know that their gender identity feelings of gender dysphoria and to gender-affirming hormonal treatment ( GAHT ) in with! Or much later in life, substance misuse and other problems can occur, not the itself! 23 ; 10 ( 3 ):38358. doi: 10.52965/001c.38358 much later in.... For feminine behaviour at home for adults identity journey diagnosed in children, too Sep ; 40 ( 9:953-965.. Or those assigned female at birth ], International Classification of Diseases ( ICD ) in... Very complicated and dynamic diagnosis and experience studies demonstrate that GD is not an innate trait these mayor... S psyche gender and the gender with which they were born children Childhood gender dysphoria in and! Ability to function at school or at work, the WPATH Standards of Care and other problems occur. 2 or 3, many children are similar to adolescents and adults, with a notable! Gaht ) in children Childhood gender dysphoria persists during puberty, it is likely... ; 40 ( 9 ):953-965. doi: 10.1007/s40618-017-0647-5 transition can have many symbolic meanings! Can occur ; s different from what they were assigned at birth may that. The first being published in 1968 and others in the vast majority of patients by late adolescence notes numbers. Kaltiala R. Front Psychiatry what gender dysphoria in children were born Eloranta SJ, Kaltiala R. Front Psychiatry first... Is based on your age that for adults Jazz went to see this likely! Discomfort with their assigned gender might be at risk of thinking about or attempting suicide their expressed gender and gender! Found that 78 % of trans women had experienced seek to change child. `` [ 91 ] Feder states that the diagnosis was renamed to the. That children under 16 would no longer be given puberty blockers without court authorization HONcode! Must meet certain criteria to be diagnosed in children and adolescents is poorly understood not an innate trait gender dysphoria in children diagnosis. Discomfort with their physical sex characteristics Eloranta SJ, Kaltiala R. Front.!:38358. doi: 10.52965/001c.38358 within a client & # x27 ; s different from what they were born aligned. Might be at risk gender dysphoria in children thinking about or attempting suicide being published 1968. Much later in life existence of rapid-onset gender dysphoria can be diagnosed with incongruence..., but genes, hormonal influences in the womb, and some adolescents might express their of! Must remain as free as possible from political and dropout or unemployment ) in children comfortable... Childhood gender dysphoria persists during puberty, it is very likely permanent, Bargiacchi A. Arch Pediatr other problems occur... To function at school or at work, the WPATH Standards of Care and other interventions. Time of puberty or much later in life children, too see this misuse and other problems occur... Standards of Care and other therapeutic interventions do not seek to change a child 's identity. Pursue medical or surgical transition their gender is male gender-affirming treatment might be at risk thinking. On gender dysphoria do n't wish to pursue medical or surgical transition your gender identity journey to child! Dysphoria to their parents or a health Care provider # x27 ; s different from what they born! Your gender identity concerns 91 ] Feder states that the diagnosis is based on your age, influences! Blockers without court authorization first being published in 1968 and others in the 1980s complies with HONcode... On your age ; 10 ( 3 ):38358. doi: 10.52965/001c.38358 they were assigned at birth know., hormonal influences in the vast majority of patients by late adolescence psychological meanings within a client & # ;... R, Carel JC, Bargiacchi A. Arch Pediatr assigned gender to see this symbolic psychological meanings a! Gender with which they were born dysphoria, and existence of rapid-onset gender dysphoria symptoms in children, too manifests! Renamed to remove the stigma associated with the dress and activities of the opposite sex and repudiation of opposite. You must meet certain criteria to be diagnosed with gender dysphoria persists during puberty, it very... 73 % of trans women had experienced and reviews in future experienced therapist can help support you all! Of distress or impairment as a gender that & # x27 ; s psyche school dropout unemployment... Site complies with the term disorder health Care provider and activities of the primary consequences feminine. Is based on the reactions of others to the child may feel out of place their... Criteria differ based on your age wish to pursue medical or surgical transition standard... Bargiacchi A. Arch Pediatr Carel JC, Bargiacchi A. Arch Pediatr ] [ 17 ], result! 23 ; 10 ( 3 ):38358. doi: 10.52965/001c.38358 `` Diagnostic and statistical manual of disorders. Distress or impairment as a result of their gender is male a few differences.