Post Traumatic Stress Disorder and the Transsexual Experience

One of the most frequent features of the vast majority of transsexuals I have worked with in my experience is the extremely high rate of Post Traumatic Stress Disorder symptoms that are common to the vast majority of us. It is also probably the most often overlooked and underdiagnosed problem that is not a focus of treatment. This is an often important aspect of gender dysphoria that has been mostly overlooked. It is not well represented in the literature, nor does it seem to be a frequent consideration for treatment.

Consider the diagnostic criteria of PTSD in DSM V

Criterion A: stressor

The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (1 required)

1. Direct exposure.
2. Witnessing, in person.
3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental.
4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: intrusion symptoms

The traumatic event is persistently re-experienced in the following way(s): (1 required)

1. Recurrent, involuntary, and intrusive memories. Note: Children older than 6 may express this symptom in repetitive play.
2. Traumatic nightmares. Note: Children may have frightening dreams without content related to the trauma(s).
3. Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. Note: Children may reenact the event in play.
4. Intense or prolonged distress after exposure to traumatic reminders.
5. Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: avoidance

Persistent effortful avoidance of distressing trauma-related stimuli after the event: (1 required)

1. Trauma-related thoughts or feelings.
2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

Criterion D: negative alterations in cognitions and mood

Negative alterations in cognitions and mood that began or worsened after the traumatic event: (2 required)

1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol or drugs).
2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous.").
3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.
4. Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt or shame).
5. Markedly diminished interest in (pre-traumatic) significant activities.
6. Feeling alienated from others (e.g., detachment or estrangement).
7. Constricted affect: persistent inability to experience positive emotions.

Criterion E: alterations in arousal and reactivity

Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (2 required)

1. Irritable or aggressive behavior.
2. Self-destructive or reckless behavior.
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems in concentration.
6. Sleep disturbance.

Criterion F: duration

Persistence of symptoms (in Criteria B, C, D and E) for more than one month.

Criterion G: functional significance

Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: attribution

Disturbance is not due to medication, substance use, or other illness.

Specify if: With dissociative symptoms.

In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli:

1. Depersonalization: experience of being an outside observer of or detached from oneself (e.g., feeling as if "this is not happening to me" or one were in a dream).
2. Derealization: experience of unreality, distance, or distortion (e.g., "things are not real").

Specify if: With delayed expression.

Full diagnosis is not met until at least 6 months after the trauma(s), although onset of symptoms may occur immediately.

Of the over 400 gender dysphoria patients I have seen personally, the majority of them exhibit enough symptoms to justify a diagnosis of PTSD. It is empirical from my practice experience that from the time one realizes one's body's sex does not match their gender identity, this is going to become a severely traumatizing event and the effects of this trauma can have the potential to be profound as a result of not being addressed early in life when the realization of this incongruence manifests itself. The mediating factor in the severity of PTSD appears to be the resiliency of the individual; some people appear to be extremely debilitated by their trauma symptoms and some individuals appear to cope better and minimize to some degree the impact of the trauma of gender dysphoria on their overall quality of life.

DSM V is a major improvement in the conceptualization of what is the focus of treatment in the transsexual individual. The DSM IV- TR diagnosis of Gender Identity Disorder wrongfully conceptualized having a cross gender identityas being a psychological pathology. In fact, it isn't the identity that is pathological at all: its the intense distress at having a cross gender identity. To improve conceptualizing the problem and to this end, DSM V now has the Diagnosis of Gender Dysphoria and I have listed the new criteria here.

Here are the proposed criteria for adults and teenagers for the upcoming DSM-V.

Gender Dysphoria
A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by 2 or more of the following indicators:

1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics) [13, 16]
2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics) [17]
3. A strong desire for the primary and/or secondary sex characteristics of the other gender
4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning,  or with a significantly increased risk of suffering, such as distress or disability**
Subtypes

• With a disorder of sex development [14]
• Without a disorder of sex development

Specifier
Post-transition, i.e., the individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is undergoing) at least one cross-sex medical procedure or treatment regimen, namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male, mastectomy, phalloplasty in a natal female).

Over the years, I, as a mental health professional, and as someone who is a transsexual have struggled with the proper place of transsexualism and gender dysphoria in the pantheon of mental health disorders. To my way of thinking, anything that creates as much distress as the incongruence of one's gender identity being in conflict with one's physical sex rightfully has some place in the DSM and is worthy of being addressed in a manner to relieve that distress. I am also of the mind that it is not one's gender identity that is disordered and that is why I like the move to change the diagnostic nomenclature to Gender Dysphoria. It implies that it is environmental factors, not an innate etiology, that is responsible for our distress, much like the diagnostic category Adjustment Disorder.

This seems straightforward enough and also provides a mechanism to get the services we need to successfully transition. I know that there are many who don't like that descriptor either, but I think it is a step in the right direction and for a condition as obscure as ours, it will take many more years before this is correctly sorted out.

I have come to believe that perhaps many if not all of the symptoms we experience from having a gender identity that does not match our physical body habitus can be better accounted for with the diagnosis of PTSD and that the criteria should be expanded to include symptoms of gender dysphoria. As is true of the degree of gender dysphoria we experience, ranging from mild to severe, so the relative degree of PTSD affects a person differently due to a number of biopsychosocial factors.

I think that one's earliest recognition that their gender identity does not match their physical sex is extremely traumatic and that the experiences we have along the way in attempting to reconcile this most often contribute to life long traumas being experienced for much, if not all of one's life until they are able to facilitate a successful transition. Some people experience this in profound ways which is why there is such a high rate of attempted suicide and addiction as well as other negative outcomes in the members of our population. Even in successful post transitioners, PTSD symptoms can remain debilitating and are a potential point of intervention.

Including symptoms of gender dysphoria under the diagnosis of PTSD will resolve the problems we face trying to get insurance coverage for the services we need to improve our quality of life as PTSD is an accepted diagnosis by the health insurance industry.

Critics may argue that no reference to any gender disorder should be included in the DSM and that it is stigmatizing to individuals. I disagree based on my clinical experience. I have not met anyone who was not distressed by their conflict between their identity and their physical body and have not been helped by facilitating a process in which they can decide and obtain what is necessary to have a quality of life each and every one of us should have.

Some people do not experience any dysphoria over their gender identity and they should not be diagnosed as having a problem that does not exist for them. They are best served by being offered case management to inform them of options available to them for gender transition and to plan for, link to and serve as a coordinator to help the person who is ready to complete their transition or by simply identifying resources to explore on their own.

Whether transgender individuals in emotional distress would be better served with a stand alone diagnosis or whether gender dysphoria should be subsumed under Post Traumatic Stress Disorder is a debate worth having.

What do you think?