Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, Canada. )

According to George Stewart¹ of the organization \\\'Mind\\\' 1 in 30,000 adult males and 1 in 100,000 adult females suffer from Gender Dysphoria. Genetic males outnumber females to a greater extent. Another report states that 1 in 11,000 men and 1 in 30,000 women seek treatment for gender dysphoria.² Though Gender Identity Disorder and Gender Dysphoria are used synonymously at times, gender dysphoria relates to anxiety and confusion about individuals\\\' gender identity. In the Western world, it is accepted that only two genders exist but some countries and cultures accept a third one. The sense of gender identity develops at a very young age of around 2 year. The distress in gender dysphoria is evidenced in disturbed social, occupational or other functioning area of life. Some physical features of opposite sex are evidenced in Androgen insensitivity syndrome or Congenital Adrenal Hyperplasia. Further information from the same reference explains the causes of gender identity disorder including changes in the brain prior to birth that would cause the brain to develop in a pattern opposite to that of physical gender. It mentions that low levels of HY antigen that would mediate the masculinizing effect of the Y chromosome in the males.¹ The working group on Gender Identity Disorder will be addressing some of the following concerns with existing diagnostic category that have been raised before making final recommendations for the categories in the forthcoming DSM V classification. These are: focus on pathology on nonconformity to assigned birth sex in disregard to the definition of mental disorder, issue of clarity on gender dysphoria, issues related to gender-conversion therapies, the misleading title of \\\'gender identity disorder,\\\' maligning terminologies, false positive diagnosis of those who are no longer gender dysphoric, its placement in the class of sexual disorders etc.³ Proposed categories so far are: Gender Dysphoria in Children, Gender Dysphoria in Adolescents or Adults and Unspecified Gender Dysphoria.⁴ Coming back to the issue, it has been suggested that Gender Dysphoria appears to be a consequence of sex atypical cerebral differentiation. Special interest was paid to gray matter and white matter fraction, hemispheric asymmetry and volumes of the hippocampus, thalamus, caudate and putamen.⁵ A report mentions the use of gonadotropin-releasing analogs (GnRHa) to suppress puberty in adolescents with gender dysphoria as a new intervention in the field of gender identity disorders in order to give adolescents time to make balanced decisions on any further treatment steps.⁶ A study suggests that most children with gender dysphoria will not remain gender dysphoric after puberty. It further states that the most likely outcome of childhood GID is homosexuality or bisexuality.⁷
It is important to consider psychiatric connotations in this cohort of population. A Dutch study⁸ indicated that 39% of 584 reported cases, gender identity disorder was regarded as the primary diagnosis, 61% cross-gender confusion occurred along with other psychiatric disorders. In the same study, psychiatric co-morbidity was in the range of mood disorder (26%), dissociative disorders (26%) and psychotic disorder (24%). With regards to prevalence of gender dysphoria, in Scotland-8 per 100,000 people over 15 years of age suffer from this problem. The number of people referred to the specialist NHS and private providers of medical care for gender variance in UK is 1200 per annum.⁹ A further update in the report¹⁰ indicated that gender variant people present for treatment at any age, the median age is 42. Social pressures prevent younger people from seeking help and that the number commencing transition may be around 0.003%. Few studies were done in Pakistan, though none of these present the national picture for a number of methodological reasons. One such study indicated that majority of gender dysphorics in the study group were between ages twenty-six and thirty-five years while 7.7% were between forty-six and fifty-five years.¹¹
Anecdotal reports indicate referrals to specialist-clinics that give a glimpse into the magnitude of this problem. More males present with the issue of gender dysphoria and at times demand surgical intervention. Psychiatrists do come across such cases as a result of secondary referrals for opinion, psychiatric assessment and necessary psychotherapeutic intervention. However, a large systematic study has not been conducted on this issue and we do not have national figures.
This is an area for further research as the problem is very much there. Identification of problem, mobilization of specialist resources and appropriate therapeutic intervention can be challenging for medical professionals in the face of already compromised healthcare situation of the country. Should we face the challenge?

1.Stewart G. Gender Dysphoria. MIND, UK: 1999; pp 1-12. (Online) (Cited 2011 August 10). Available from URL: http://www.transgenderzone.com/library/fg/pdf.
2.Cohen JN, Alderson KG, Canadian Psychological Association. Gender Dysphoria in Adolescents and Adults. (Online) (Cited 2011 August 9). Available from URL: http://www.cpa.ca/psychologyfactsheets/genderdysphoria/.
3.Working Group. Gender Identity Reform. GID Reform Advocates. Issues for DSM V. (Online) (Cited 2011 August 9). Available from URL: http://www.gidreform.org/dsm5.html.
4.American Psychiatric Association-DSM-5. Gender Dysphoria. (Online) (Cited 2011 August 9). Available from URL: http://www.dsm5.org/proposedrevision/pages/genderdysphoria.aspx.
5.Savic I, Arver S. Sex Dimorphism of the Brain in Male-to-Female Transsexuals. Cereb Cortex 2011 Apr 5 (Epub ahead of print).
6. Kreukeis BP, Cohen-Kettenis PT. Puberty suppression in gender identity disorder: the Amsterdam experience. Nat Rev Endocrinol 2011; 7: 466-72.
7.Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry 2008; 47: 1413-23.
8.Campo JC, Nijman H, Merckelbach H, Evers C. Psychiatric Comorbidity of Gender Identity Disorders: A Survey Among Dutch Psychiatrists. AM J Psychiatry 2003; 160: 1332-6.
9.GIRES. Gender Dysphoria, Transsexualism and Transgenderism: Incidence, Prevalence and Growth in the UK and the Implications for the Commissioners and Providers of Healthcare 2008; (Online) (Cited 2011 August 22). Available from URL: http://www.gires.org.uk.
10.GIRES. The Number of Gender Variant People in the UK-Update 2011. (Online) (Cited 2011 August 22). Available from URL: http://www.gires.org.uk/prevalence.php.
11.Haider SKF. Gender Dysphorics in Pakistan. JRSP 2008; 45: 135-47.