A 21-year-old woman comes to the office for a routine health maintenance evaluation. The patient shares that looking in the mirror has been increasingly difficult due to feeling upset about "how my breasts look." The patient frequently imagines what it would be like to not have breasts and wears a chest binder to make them appear flatter. The patient says, "I've always wanted to change how I look but didn't want to upset my parents. I don't want people to see me as a woman anymore because I've never felt like one." The patient recently moved to the area a month ago due to "overbearing parents" and "feeling too confined." Medical history is noncontributory. Vital signs are within normal limits. The patient appears somewhat anxious and is wearing trousers and a loose T-shirt. Which of the following is the most likely explanation for this patient's condition?

Question

A 21-year-old woman comes to the office for a routine health maintenance evaluation.  The patient shares that looking in the mirror has been increasingly difficult due to feeling upset about "how my breasts look."  The patient frequently imagines what it would be like to not have breasts and wears a chest binder to make them appear flatter.  The patient says, "I've always wanted to change how I look but didn't want to upset my parents.  I don't want people to see me as a woman anymore because I've never felt like one."  The patient recently moved to the area a month ago due to "overbearing parents" and "feeling too confined."  Medical history is noncontributory.  Vital signs are within normal limits.  The patient appears somewhat anxious and is wearing trousers and a loose T-shirt.  Which of the following is the most likely explanation for this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d7c9_6685_bc81_ddc33e2075cb_MD0003_00 This patient's discomfort with the incongruence between gender identity and birth-assigned gender is suggestive of gender dysphoria (GD). Patients with GD typically describe not identifying with their assigned gender since childhood or adolescence and are distressed by the development of unwanted secondary sexual characteristics that do not reflect their gender identity. They have a strong and persistent desire to live and be treated according to their experienced gender. Gender dysphoria should be differentiated from gender nonconformity, in which individuals do not conform to stereotypical gender roles but still identify with their assigned gender. Although cultural attitudes to gender diversity are changing, patients may encounter bullying and discrimination. GD in adults is associated with an elevated prevalence of psychiatric comorbidities, especially mood disorders, anxiety disorders, and suicidality. Gender identity-affirming care can include psychosocial support, hormonal therapy, and gender-affirming surgeries. (Choice A) Adjustment disorder is diagnosed when symptoms occur within 3 months of an identifiable stressor. This patient's distress is related to long-standing concerns about gender identity. (Choice B) GD and body dysmorphic disorder are both characterized by a strong desire to change physical features that are distressing. However, this patient's breasts are distressing because they signify assigned gender and are incongruent with experienced gender. Body dysmorphic disorder should not be diagnosed in patients who are preoccupied with changing only their primary and secondary sexual characteristics and who meet other diagnostic criteria for GD. (Choice C) Patients with depersonalization disorder experience recurrent feelings of detachment or estrangement from one's self (eg, sense of being an automaton or an outside observer), typically in response to acute or chronic trauma. (Choice D) Dissociative identity disorder is a severe dissociative disorder characterized by switching among two or more distinct personality states and an extensive inability to recall important personal information. Educational objective: Gender dysphoria is characterized by persistent distress due to the incongruence between gender identity and assigned gender. It is often accompanied by discomfort with the development of unwanted secondary sexual characteristics. References: Gender dysphoria in adults. (http://www.ncbi.nlm.nih.gov/pubmed/26788901) Mental health and gender dysphoria: a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/26835611)

A 21-Year-Old Woman Comes to the Office for a Routine