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Gender Incongruency Part 2

Gender Incongruency part 2 is the continuation of the simple straight-forward definition provided previously and now we delve into why Gender Incongruency is the preferred term verses Gender Identity Disorder.

The documentation provided on the different views of Gender Identity Dysphoria sound complex, but really it is not that complicated when you break it down.  I will do my best to provide clear reasoning to explain it.  First of all everyone has Gender Identity, just as they have a sexual orientation.  When this identity is incongruent with the natal sex and established stereotypes a diagnosis of Gender Identity Disorder is given.  Since this is really an issue of incongruency and not necessarily a dysfunction the term disorder is inappropriate.

Think carefully about the term disorder.  Most allopathic treatments use a chemical and/or a surgical approach by prescribing a medicine or surgically altering the body to treat the illness or disorder.  Medicines are intended to be temporary till the body heals itself.  Gender Dysphoria is based on an incongruency from birth.  Some feel it is a birth defect, depending on how it manifests.  Often, if the patient is born completely male or female they do not deal with the issue due to societal and peer pressure until later in life. They have dealt with this condition all their life because they do not know any better.  Since there are many things in this world that do not make sense we all deal with incongruences.  Is it so hard to believe that a person cannot live with these feelings?

“Principle 18 of The Yogyakarta Principles states that “Notwithstanding any classifications to the contrary, a person’s sexual orientation and gender identity are not, in and of themselves, medical conditions and are not to be treated, cured, or suppressed.” According to these Principles, any gender identity of a transsexual or transgendered person is neither “disorder” nor mental illness, thus the diagnosis “gender identity disorder” can be contradictory and irreverent.” (, 2012)

Given this fact and the fact that physicians need a way to treat patients who request it the term Gender Incongruency seems very appropriate, thus the Concerned Professionals proposal.  The other issue is treatment and payment.  In our present system insurance usually picks up the bill but many specifically exclude transgender/transsexual treatments.  This trend is shifting however and it is because they have a diagnosis in the DSM to use along with the ICD-10 that insurance is willing to cover hormone therapy, although most do not cover surgical interventions.  Lobbying by activist groups, LGBT awareness groups, and allies have helped increase awareness of the need a great deal.

Eventually Gender Identity will not be pathologized and people will be free to live outside the gender binary.  This is another trend that is promising at the moment.  However there will still be individuals who feel they need to change their sex and who benefit from hormone treatment, so the health care system needs to be prepared to address these needs.  Insurance needs to cover this simple and relatively inexpensive treatment, esp. when compared to other sophisticated medical treatments.  Gender Incongruency conveys the essence of this condition quite nicely.

🙂 Sequoia Elisabeth

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Gender Incongruency

Gender Incongruency may be unfamiliar to some of our readers so I will take the next two Transitions Blogs to explain it further.  I will first give the simple straight-forward definition of it and then in the next part explain why it is the preferred term now verses Gender Identity Disorder.

Incongruous or Incongruent:

— adj

1. incompatible with (what is suitable); inappropriate

2. containing disparate or discordant elements or parts (

Thus applied to gender it means the individual feels certain parts (gender and/or sex) are incompatible, inappropriate, disparate, or discordant.  The definition of transgender varies a little from transsexual so I will simply say that transgender is an umbrella term that covers all gender non-conforming identities, while transsexual is more specific to a feeling of marked incongruity requiring both hormone therapy and sexual reassignment surgery.  The diagnosis of gender incongruency would apply to all transsexuals, and some but not all transgender individuals.

Treatment is the way I discern the difference between transgender and transsexual.  Many transgender individuals need no treatment at all other than the acknowledgement of their gender expression and role.  Sexual orientation or sexual pleasure type are separate issues and are not discussed here.  The following definitions from the American Psychiatric Association, Concerned Professionals, and The Yogyakarta Principles are offered in regards to Transsexualism mainly, but also pertain to Transgender, esp The Yogyakarta Principles.

First let us consider in the United States, the American Psychiatric Association permits a diagnosis of gender identity disorder if the four diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4thEdition, Text-Revised (DSM-IV-TR) are met. (There is a proposal to change this GID diagnosis term to Gender Incongruence in the new DSM-V, of which I will discuss further in the next blog)

The criteria are:

  • Long-standing and strong identification with another gender
  • Long-standing disquiet about the sex assigned or a sense of incongruity in the gender-assigned role of that sex
  • Significant clinical discomfort or impairment at work, social situations, or other important life areas.
  • The diagnosis is not made if the individual also has physical intersex characteristics.

If the four criteria are met under the DSM-IV-TR, a diagnosis is made under ICD-9 code 302.85.   The International Classification of Diseases (ICD-10) list three diagnostic criteria:

Transsexualism (F64.0) has three criteria:

  1. The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment
  2. The transsexual identity has been present persistently for at least two years
  3. The disorder is not a symptom of another mental disorder or a chromosomal abnormality (Intersex).

Mental health and medical professionals, clinicians, researchers, and scholars are concerned about psychiatric nomenclature and diagnostic criteria for gender-variant, gender-nonconforming, transgender, and transsexual people in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and call themselves Professionals Concerned About Gender Diagnoses in the DSM. Below are their suggestions for the Gender Incongruence (in adults) diagnosis in the DSM V.

A. A distressing sense of incongruence between persistent experienced or expressed gender and current physical sex characteristics or ascribed gender role in adults, as manifested by at least one of the following indicators for duration of at least 3 months. Incongruence, for this purpose, does not mean gender expression that is nonconforming to social stereotypes of ascribed gender role or natal sex.

1. A distress or discomfort with living in the present gender or being perceived by others as the present gender, which is distinct from the experiences of discrimination or the societal expectations associated with that gender.

2. A distress or discomfort caused by deprivation of gender expression congruent with persistent experienced gender. Experienced gender may include alternative gender identities beyond binary stereotypes.

3. A distress or discomfort with one’s current primary or secondary sex characteristics that are incongruent with persistent experienced gender.

4. A distress or discomfort caused by deprivation of primary or secondary sex characteristics that are congruent with persistent experienced gender.

B. Distress or discomfort is clinically significant or causes impairment in social, occupational or other important areas of functioning, and is not due to external prejudice or discrimination. (Professionals Concerned with Gender Diagnoses in the DSM, 2010)

The Yogyakarta Principles on the Application of International Human Rights Law in relation to Sexual Orientation and Gender Identity is a set of principles relating to sexual orientation and gender identity, intended to apply international human rights law standards to address the abuse of the human rights of lesbian, gay, bisexual, and transgender (LGBT) people, and issues of intersexuality.

“The Principle 3 of The Yogyakarta Principles on The Application of International Human Rights Law in Relation to Sexual Orientation and Gender Identity states that “A person of diverse sexual orientation and gender identities shall enjoy legal capacity in all aspects of life. Each person’s self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom” and the Principle 18 of this states that “Notwithstanding any classifications to the contrary, a person’s sexual orientation and gender identity are not, in and of themselves, medical condition and are not to be treated, cured or suppressed.” According to these Principles, any gender identity of a transsexual or transgendered person is neither “disorder” nor mental illness, thus the diagnosis “gender identity disorder” can be contradictory and irreverent. As well, The Activist’s Guide of the Yogyakarta Principles in Action states that “It is important to note that while “sexual orientation” has been declassified as a mental illness in many countries, “gender identity or gender identity disorder” often remains under consideration.” (, 2012)

To read the entire publication “An Activist’s Guide to The Yogyakarta Principles” please click here, although be warned it is quite lengthy.  More on Gender Incongruence in Part 2, pleasant reading till then.

🙂 Sequoia Elisabeth

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SRS/GRS Treatment Planning

Where does SRS/GRS fit into the treatment plan for Gender Incongruity(GI)/Gender Identity Disorder(GID)?  The terms GRS (Genital Reassignment Surgery) and GI (Gender Incongruity) will be used from here on to make this flow easier.  The diagnosis has been made and you are now in therapy, so what next?

The answer to this question is really up to you and your therapist or physician.  There are no rules here so I recommend doing your research and getting to know the options as well as getting to know yourself a little better. Your therapist should be helpful in guiding you in the decision of whether you need GRS and where to place it in your treatment plan.  It is not their decision to make though, it is yours.  Please understand that you are responsible for finding your way to relief.  The professionals are there to help and provide guidance.

The next step is to decide if you have enough funding to get the surgery soon or will it be years before you can afford it?  If you have money or the resources to get it, then you have several options.  Even if you don’t have the money now, you have options.  Here they are.  Get an orchiectomy right at the beginning (if you are FtoM – hysterectomy) so you do not have to take hormone blockers.  For FtoM it just makes the testosterone that much more effective.  Any cosmetic surgeries desired can be done later in the transition as is convenient.  After fully transitioning and living in the chosen gender and knowing you are happy, get the full GRS.  This option makes the most sense to me, however most doctors are uneasy with this choice, probably because they are not the ones with discomfort. (Reproduction desires need to be addressed also, since this option sterilizes)

The next option is to get hormone treatment and electrolysis done and after going full time as your chosen gender, have GRS done and leave cosmetic surgery to last.  The reasoning here is financial and basically goes in order of importance and cost.  This seems to be the most popular option chosen, for obvious reasons.  Start where you are and take a new step each day toward your ideal. 

Those with lots of money sometimes get carried away with the surgeries and do all kinds of physical alteration without fully embracing the changes emotionally.  From my experience this is a difficult path and somewhat backwards.  Gender transition is an emotional process and the surgery is meant to assist in the assimilation into society.  Where the surgery is very important, so is taking the time to learn what it means to be a woman when you were raised as a man, or vice versa.  Jumping in with the surgery can lead to disaster when you have changed your appearance and not your self concept. 

When I first started my journey one of the questions I asked my therapist is where does GRS fit into my treatment? (I already knew I wanted it, and most of us do)  He told me it does not matter if you get it early or later, the important part is to break down the false persona you created to fit into society and allow your natural self to emerge.  The surgery will re-enforce your feelings and make it easier for you, but does not really matter to a person who will never see between your legs!  GRS is for your own satisfaction in knowing your body reflects your self image.   

🙂 Sequoia Elisabeth

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