Is Gender Dysphoria a Mental Disorder?

What is a mental illness? The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the manual that aids many psychologists in diagnosis, states that part of the qualification of a mental disorder is for it to cause a “clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior” (DSM-5). If there is distress, noted as particularly important for the diagnosis, is a person who identifies with a gender other than the one they were assigned at birth experiencing a mental disorder? Does your opinion change knowing that the DSM-5 carries on to mention that a mental disorder may involve “a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (DSM-5)? Individuals with gender dysphoria may experience not only a loss of freedom, but also an increased risk of death due to a greater likelihood of committing suicide (see hyperlink above).

Now, to further complicate the issue, how does this effect our thinking about individuals who are born with female-looking genitalia and are assigned with a female gender identity at birth, but are genetically male? This is the case for individuals with with 5α-reductase-2 deficiency. The condition occurs when 5α-reductase-2 does not convert testosterone into dihydrotesosterone, which is involved in the development of male genitalia. The diagram below illustrates typical mammalian sex determination and development of male and female adult phenotypes:

Fifty-six to sixty-three percent of individuals with 5α-reductase-2 deficiency undergo gender role changes (Cohen-Kettenis, 2005). Are these individuals suffering from a mental disorder? My first instinct, because of the negative connotation of the word disorder, was to say no. To answer this question considering the existing research, let us look at the DSM-5 definition of Gender Dysphoria, the diagnosis most relevant to this issue. For adolescents and adults, this definition begins with “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration” (DSM-5). The DSM-5 carries on to state that the individual must express 2 out of 6 certain characteristics, such as “a strong conviction that one has the typical feelings and reactions of the other gender”. Notably, the manual proceeds: “Specify if: with a disorder of sex development (e.g., a congenital adrenogenital disorder…)” (DSM-5). Should this include those with 5α-reductase-2 deficiency?

If all of these individuals did undergo a gender identity switch we could postulate that the female gender assignment was a mistake and thus none of them have any sort of mental disorder. However, how can we make sense of the estimation that 36-44% of these individuals do not switch their gender identities from female to male? Are about half of these individuals experiencing Gender Dysphoria, and if so, which half? In addition, is it fair to say that someone has a mental disorder if the biological procedure of gender reassignment can essentially “fix” it? Perhaps the individuals who do not switch their gender identities from female to male do not have a disorder because they are at peace with their condition; individuals who do switch may be at peace as well, as they finally are able to live in the bodies they always wanted.

            I want to be very clear that I am not trying to make a radical statement that individuals with Gender Dysphoria may have a disorder, but simply to ask if this is what the DSM-5 is suggesting. Is the inclusion of Gender Dysphoria in the DSM-5 helpful, or does it fuel avoidable controversy?

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Cohen- Kettenis, P.T. (2005). Gender change in 46,XY persons with 5α-reductase-2 deficiency and 17β-hydroxysteroid dehydrogenase-3 deficiency. Arch Sex Behav, 34, 399-410.

Pappas, S. (2012). Mental health problems plague transgender kids. Retrevied from http://www.livescience.com/16110-transgender-teen-mental-health.html.

Pappas, S. (2011). Top 10 controversial psychiatric disorders. Retrieved from http://www.livescience.com/12908-top-10-controversial-psychiatric-disorders.html.

Sex determination in mammals is a process [image]. Retrieved 8 October, 2014, from: http://kcampbell.bio.umb.edu/MamTox/Presentations/Session13/Session13.html

Alzheimer’s Disease, Music Therapy and Sex Hormones: An Unexpected Solution

Alzheimer’s disease (AD) is all around us, with over 5 million individuals diagnosed across the United States. Interestingly, of these 5 million Americans, over 3.5 million of them are women, suggesting women are significantly more likely to suffer from AD than men.^1,2 While AD is best known for its impairment of memory, both short-term and long-term depending on the extent of the illness, a variety of other symptoms may accompany memory loss such as disorientation, confusion about time and place, changes in mood and behavior, and difficulties with speech, eating, and walking. These symptoms, collectively, lead to a significant loss in communication and personal identity.

Low levels of sex hormones plays a significant role in the onset of AD, and have led many scientists and doctors to propose Hormone Replacement Therapy (HRT) as a potential treatment for this disease.^4,5 While levels of sex hormones decrease with age, Alzheimer’s patients routinely possess especially low levels of both testosterone and estrogen. Women see an especially rapid, significant drop in sex hormone levels with menopause, which subsequently leads to their significantly increased risk for developing AD. Both estrogen and testosterone have been linked to cell proliferation and nerve protection, and estrogen has been shown to increase cholinergic activity.^4,5 Additionally, these hormones have been shown to suppress the effects of beta-amyloid, a series of peptides which are involved in plaque formation and the development of AD. Specifically, estrogen and testosterone prevent beta-amyloid accumulation by increasing the activity of beta-amyloid-degrading enzymes, and also protect against its neurotoxicity. Collectively, testosterone and estrogen improve cognitive function and delay the progression and effects of AD.⁴ Despite the clear importance of these two hormones, HRT has not been accepted as a treatment of AD due to inconsistent results and a series of serious side-effects, such as heart-attack, stroke, and an increased risk for breast cancer and prostatic cancer.⁴

Recently, an article was published in the International Journal of Alzheimer's Disease which links sex hormones with music therapy, and thus proposes music therapy as an alternative to hormone replacement therapy.⁴ Stimulatory therapies, such as music therapy, have been extremely useful in the management of AD for many individuals. I have personally witnessed the benefits music can have on the mood and cognition of someone diagnosed with AD, and it is widely accepted as an effective treatment both in neuroscientific blogs (BrainBlogger), and the AD support community (Alz.org Blog). While music therapy can have a wide variety of effects, scientific studies have shown that music therapy moderates problematic behavior, improves social involvement, promotes better cognition and awareness, increases brain plasticity, and reduces levels of stress, anxiety and depression.⁶

Figures taken from Fukui et al. 2012 (see reference 4).

Although the behavioral effects of music therapy are well-supported, our understanding of why and how this treatment works biologically has been extremely limited. Fukui et al. have investigated these biological causes by measuring levels of testosterone and estradiol in 6 female AD patients in a nursing home, before and after three different therapy conditions: therapist only, music only, and music + therapist. Note that estradiol is one of three hormones which are collectively known as estrogens. Music therapy proved to be the only treatment which resulted in a significant increase in both estrogen and testosterone, while music alone solely increased estrogen levels (Figures 1 & 2). ⁴ Additionally, caregivers noted that problematic behavior decreased for 24 hours after music therapy, supporting previous behavioral observations associated with AD and music therapy. These results suggest that music therapy could be used as a natural alternative to hormone replacement therapy, increasing hormone levels by engaging in an activity, as opposed to direct injection.

Of course, it should be noted that this study’s methodology is far from full-proof. With only six participants it can hardly be considered an all-inclusive study, and Fukui et al. make no mention of how much music therapy is needed before results are seen. Perhaps most importantly, the authors fail to include how severe each patient’s AD was, leading to questions about how effective this treatment will be at various stages of the disease. However, despite these experimental flaws, I hope that this study encourages other researchers to investigate music therapy as a natural alternative to hormone replacement therapy for Alzheimer’s disease. While these studies are difficult, research on larger populations with AD of varying severity as well as differences in exposure to music therapy are necessary for the implementation of this treatment on a larger scale. Music therapy would be a fantastic treatment in that it is low-cost, non-invasive, and perhaps even enjoyable for these patients who so badly deserve relief from their symptoms.

References:

1. Alzheimer's Association. (2014). 2014 Alzheimer's Disease Facts and Figures. Retrieved from: http://www.alz.org/downloads/facts_figures_2014.pdf
2. Bao A., Swaab D.F. (2011). Sexual differentiation of the human brain: relation to gender identity, sexual orientation and neuropsychiatric disorders. Front Neuroendocrinol, 32, 214-226.
3. Alzheimer's Association. (2014). What is Alzheimer’s? Retrieved from: http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp
4. Fukui H., Arai, A., Toyoshima, K. (2012). Efficacy of Music Therapy in Treatment for the Patients with Alzheimer’s Disease. Int J Alzheimers Dis, vol 2012.
5. Barron A.M., Pike, C.J. (2013) Sex hormones, aging, and Alzheimer’s disease. Front Biosci (Elite Ed), 4, 976-997.
6. Wollen, K. A. (2010). Alzheimer’s disease: the pros and cons of pharmaceutical, nutritional, botanical, and stimulatory therapies, with a discussion of treatment strategies from the perspective of patients and practitioners. Altern Med Rev, 15(3), 223-44; Sakamoto, M., Ando, H., & Tsutou, A. (2013). Comparing the effects of different individualized music interventions for elderly individuals with severe dementia. International Psychogeriatrics, 25(5), 775-784; Koger, S. M., Chapin, K., & Brotons, M. (1999). Is music therapy an effective intervention for dementia? A meta-analytic review of literature. Journal of Music Therapy, 36, 2-15.