Gender Dysphoria

Introduction

Definitions

• Sex: biological indicator Indicator Methods for assessing flow through a system by injection of a known quantity of an indicator, such as a dye, radionuclide, or chilled liquid, into the system and monitoring its concentration over time at a specific point in the system. Body Fluid Compartments of one’s male or female reproductive capacity
• Gender: socially constructed characteristics of men/women
• Gender assignment: initial assignment as male or female given at birth
• Gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology: one’s own identification Identification Defense Mechanisms and acceptance as man, woman, or other
• Transgender: one who identifies with a gender that is different from that assigned at birth
  • Sometimes understood as an umbrella term covering other people with nontraditional gender identities, possibly including but not limited to genderqueer and agender people
  • “Trans men” should be described as men and “trans women” as women.
  • “Transgender” should not be used as a noun (as in “a transgender”) because it is considered inaccurate and offensive.
• Cisgender: one whose gender assignment and identity are congruent
• Gender dysphoria: a medical diagnosis that identifies the conflict and discomfort experienced by some individuals from the incongruence between their gender identities and their external sexual anatomy at birth
• Homosexual:
  • A term which is acceptable when a noun is needed for the concept of same-sex attraction, and can be used when writing about scientific research Research Critical and exhaustive investigation or experimentation, having for its aim the discovery of new facts and their correct interpretation, the revision of accepted conclusions, theories, or laws in the light of newly discovered facts, or the practical application of such new or revised conclusions, theories, or laws. Conflict of Interest that uses the terminology to describe sexual activity
  • It should be avoided when referring to people.
• Bisexual:
  • A person attracted to more than one gender, when used as a noun; as an adjective, of or relating to attraction to more than one gender 
  • Does not presume nonmonogamy
• Gay:
  • Usually refers to men who are attracted to other men, but may also refer to women who are attracted to other women. 
  • Should not be used as a singular noun: e.g., “Juan is gay,” not “Juan is a gay.”
• MSM: abbreviation for “men who have sex with men”
  • It is used in a medical or scientific context, as a behavioral and public health category.
  • It does not refer to sexual identity and is not synonymous with gay and bisexual men.

• Transsexuals:
  • Refers to those who want to have the physical traits or the body of the opposite gender 
  • Do not have to have undergone gender reassignment 
• Queer: those whose sexual orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment or gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology do not conform to social norms.
  • The term is extremely offensive when used as an epithet, and still offensive to many LGBTQ people regardless of intent.
  • The term has been reclaimed (from its long history of being a derogatory term) by some gay, lesbian, bisexual, and transgender people as a self-affirming umbrella term.
• Crossdressers: refers to those who maintain their assigned gender but dresses in ways associated with the opposite gender
• Transvestism: sexual arousal from wearing opposite gender clothes.
• LGBT, LGBTQ: acceptable abbreviations for “lesbian, gay, bisexual and transgender” or for “lesbian, gay, bisexual, transgender and queer and/or questioning”

Epidemiology

• Reports suggest that 0.3%–0.6% of the adult population are transgender.
• For every girl referred for clinical evaluation of gender dysphoria, there are 4–5 boys. 
• More common in individuals with particular intersex conditions, including 46,XY individuals with high degrees of somatic hypomasculinization and 46,XX individuals with high degrees of somatic hypermasculinization
• Among adults, the prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of male to female dysphoria is higher than female to male. 
• Many children who show gender nonconforming behavior do not grow up to be transgender. 
• Adults diagnosed with gender dysphoria have higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency of other psychiatric disorders.
• Suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide and completed suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide are dramatically increased in GD GD Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder caused by a deficiency of glucocerebrosidase enzyme activity, resulting in accumulation of glucocerebroside in cells and certain organs. The disease is categorized into 3 types with variable clinical presentation. Gaucher Disease.
• Multiple factors (i.e., biological, psychological, and social) appear to influence the development of gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology.

Etiology

• Genetic causes or physiological changes in those with gender dysphoria are not fully understood. 
• Multiple sex-biasing factors determine sex differences in the phenotype Phenotype The complete genetic complement contained in the DNA of a set of chromosomes in a human. The length of the human genome is about 3 billion base pairs. Basic Terms of Genetics of both body and brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification as well as behaviors; however, no definite biological predetermination of gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology has been identified.
  • The sex-biasing factors are genetic, epigenetic, sex-chromosomal, and hormonal.
  • Sex differences in brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification structure are well documented in humans, but are only weakly linked to behavioral differences.
  • The brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tissues are most sensitive to the organizational effects of sex hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types at the prenatal/perinatal stages of development.
  • Two other discrete sensitive periods are at puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty and, for females, the first pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care.
  • Prenatal androgenization has a strong effect on later behavior, best demonstrated by studies on people with somatic intersex conditions who had varying degrees of functional androgen exposure.
    • GD GD Gaucher disease (GD) is an autosomal recessive lysosomal storage disorder caused by a deficiency of glucocerebrosidase enzyme activity, resulting in accumulation of glucocerebroside in cells and certain organs. The disease is categorized into 3 types with variable clinical presentation. Gaucher Disease is more likely if an individual is assigned as female after having been exposed prenatally to a full complement of masculinizing hormones Hormones Hormones are messenger molecules that are synthesized in one part of the body and move through the bloodstream to exert specific regulatory effects on another part of the body. Hormones play critical roles in coordinating cellular activities throughout the body in response to the constant changes in both the internal and external environments. Hormones: Overview and Types, regardless of genetic constitution or gonadal or genital development at birth.
    • Most 46,XY individuals with complete androgen insensitivity syndrome Complete Androgen Insensitivity Syndrome Androgen Insensitivity Syndrome (therefore no functional androgenization of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification) develop a female gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology, despite having a Y chromosome Y chromosome The male sex chromosome, being the differential sex chromosome carried by half the male gametes and none of the female gametes in humans and in some other male-heterogametic species in which the homologue of the X chromosome has been retained. Basic Terms of Genetics and normally developed and functioning testes Testes Gonadal Hormones.
  • Androgenization of the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification depends not only upon the level of androgen to which a fetus is exposed, but also on how the androgen is metabolized in the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification.
  • No brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification marker of sexual differentiation has been validated to guide the initial gender assignment of infants with intersex conditions.
• Although not determinative, psychological and social factors during childhood have a major influence on behavioral outcome during childhood, including:
  • Verbal labeling (e.g., ‘‘boy’’ and ‘‘girl’’)
  • Nonverbal gender-cuing (e.g., gender-specific clothing, haircuts)
  • Shaping of children’s gendered behavior by positive and negative reinforcement Negative reinforcement Psychotherapy
  • Explicit statements of gender-role expectations
  • Formation of gender stereotypes

Diagnosis

Management

Management involves a multidisciplinary approach (medical and psychological) to determine the best treatment plan for the patient.

Before any medical or surgical interventions, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship must meet eligibility criteria outlined by Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People by the World Professional Association for Transgender Health.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

• Family support, referral for specialist services 
• The goal of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy is to achieve comfort in one’s own gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology to improve chances for social success. 
• Conversion therapy, which tries to change one’s gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology or sexual orientation Orientation Awareness of oneself in relation to time, place and person. Psychiatric Assessment, is against all current practice recommendations. 
• The lifetime rate of suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide among those with gender dysphoria is 40%.

Medication

Medications are used based on the patient’s age group and gender:

• Adolescent patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship:
  • Hormonal treatment using gonadotropin-releasing hormone Gonadotropin-releasing hormone A decapeptide that stimulates the synthesis and secretion of both pituitary gonadotropins, luteinizing hormone and follicle stimulating hormone. Gnrh is produced by neurons in the septum preoptic area of the hypothalamus and released into the pituitary portal blood, leading to stimulation of gonadotrophs in the anterior pituitary gland. Puberty (GNRH) to delay puberty Puberty Puberty is a complex series of physical, psychosocial, and cognitive transitions usually experienced by adolescents (11-19 years of age). Puberty is marked by a growth in stature and the development of secondary sexual characteristics, achievement of fertility, and changes in most body systems. Puberty 
  • While GNRH has been safely used in treating precocious puberty Precocious puberty Precocious puberty (PP) is the appearance of secondary sexual characteristics due to elevated sex hormones before the age of 6-8 in girls and 9 in boys. Excess hormone secretion may occur only at the level of the sex hormone or may involve the whole hypothalamic-pituitary-gonadal axis. Precocious Puberty, use in gender dysphoria among adolescents requires careful clinical evaluation.
• Adult male-to-female transition:
  • The goal is to create a female body contour, increase breast formation, and eliminate facial hair. 
  • Antiandrogen therapy:
    • Spironolactone Spironolactone A potassium sparing diuretic that acts by antagonism of aldosterone in the distal renal tubules. It is used mainly in the treatment of refractory edema in patients with congestive heart failure, nephrotic syndrome, or hepatic cirrhosis. Its effects on the endocrine system are utilized in the treatments of hirsutism and acne but they can lead to adverse effects. Potassium-sparing Diuretics
    • Cyproterone acetate
  • GNRH combined with estrogen therapy Estrogen therapy The use of hormonal agents with estrogen-like activity in postmenopausal or other estrogen-deficient women to alleviate effects of hormone deficiency, such as vasomotor symptoms, dyspareunia, and progressive development of osteoporosis. This may also include the use of progestational agents in combination therapy. Menopause (increased risk of venous thromboembolism Thromboembolism Obstruction of a blood vessel (embolism) by a blood clot (thrombus) in the blood stream. Systemic Lupus Erythematosus ( VTE VTE Obstruction of a vein or veins (embolism) by a blood clot (thrombus) in the bloodstream. Hypercoagulable States))
    • Monitor prolactin Prolactin A lactogenic hormone secreted by the adenohypophysis. It is a polypeptide of approximately 23 kd. Besides its major action on lactation, in some species prolactin exerts effects on reproduction, maternal behavior, fat metabolism, immunomodulation and osmoregulation. Breasts: Anatomy levels, which may rise with estrogen therapy Estrogen therapy The use of hormonal agents with estrogen-like activity in postmenopausal or other estrogen-deficient women to alleviate effects of hormone deficiency, such as vasomotor symptoms, dyspareunia, and progressive development of osteoporosis. This may also include the use of progestational agents in combination therapy. Menopause. 
    • Side effects include increased risk of blood clots as well as decreased libido. 
• Adult female-to-male transition:
  • The goal is to increase muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and body hair.
  • Testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens supplementation
    • Monitor the liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy function test, complete metabolic panel, and lipid panel
    • Side effects include liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver: Anatomy disease, stroke, and dyslipidemia. 
  • Testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens is a teratogen:
    • Discuss family planning
    • Discuss contraception

Surgical sex reassignment

• Offered for patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship more than 18 years old
• Offered only after living 1 year in the desired gender role Gender role Social role encompassing a range of behaviors and attitudes that are considered acceptable based on perceived sex. Sexual Physiology and after 1 year of continuous hormone therapy
• Categorized into:
  • Breast/chest surgery (top surgery)
  • Genital surgery (bottom surgery)
  • Non-genital/breast surgery 
• Adult male to female:
  • Breast augmentation is a popular top surgery. 
  • Orchiectomy is commonly performed for decreasing the body’s production of testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens.
  • Facial feminization surgeries are also performed. 
  • Penile inversion vaginoplasty with a neurovascular neoclitoris:
    • After orchiectomy, the surgeon makes “like become like,” using parts of the original penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy to create a sensate neo-vagina.
    • The skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions from the scrotum Scrotum A cutaneous pouch of skin containing the testicles and spermatic cords. Testicles: Anatomy is used to make the labia.
    • The erectile tissue of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy is used to make the neoclitoris.
    • The urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy is preserved and functional.
• Adult female to male:
  • Top surgery to construct a male-contoured chest 
  • Metoidioplasty:
    • Procedure in which the clitoris Clitoris An erectile structure homologous with the penis, situated beneath the anterior labial commissure, partially hidden between the anterior ends of the labia minora. Vagina, Vulva, and Pelvic Floor: Anatomy is released and tissue is added to increase its girth and length to create male-appearing genital
    • Very expensive and not commonly performed 
  • Facial masculinization surgeries are less common, as testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens therapy can achieve the effect.

Differential Diagnosis

• Psychotic disorders: psychotic disorders such as delusional disorder Delusional disorder In delusional disorder, the patient suffers from 1 or more delusions for a duration of 1 month or more, without any other psychotic symptoms or behavioral changes and no decline in functioning abilities. Delusional Disorder or schizophrenia Schizophrenia Schizophrenia is a chronic mental health disorder characterized by the presence of psychotic symptoms such as delusions or hallucinations. The signs and symptoms of schizophrenia are traditionally separated into 2 groups: positive (delusions, hallucinations, and disorganized speech or behavior) and negative (flat affect, avolition, anhedonia, poor attention, and alogia). Schizophrenia are characterized by delusional thinking and hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia. Belief or insistence that one is of another gender should not be considered a delusion Delusion A false belief regarding the self or persons or objects outside the self that persists despite the facts, and is not considered tenable by one’s associates. Delusional Disorder. For those who may potentially have gender dysphoria and a psychotic disorder—if the transgender identity diminishes as their psychosis is treated, then they do not have gender dysphoria. 
• Body dysmorphic disorder Body dysmorphic disorder Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder ( BDD BDD Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder): a common psychiatric condition that is characterized by preoccupation Preoccupation Body Dysmorphic Disorder with false ideas about one’s own physical appearance. The preoccupation Preoccupation Body Dysmorphic Disorder leads to repetitive compulsive behavior that aims to fix the perceived physical defects. Body dysmorphia is different from gender dysphoria since the belief in body dysmorphia is specific to an incorrect body part without any desire to change an assigned gender.
• Transvestic disorder Transvestic disorder Disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing in a heterosexual male. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational or other areas of functioning. Paraphilic Disorders: part of a larger paraphilic disorder, transvestic disorder Transvestic disorder Disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing in a heterosexual male. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational or other areas of functioning. Paraphilic Disorders is defined as intense sexual pleasure from wearing clothes associated with the other gender. The intensity and recurrence of such fantasies must interact with daily life functioning. Those with transvestic disorder Transvestic disorder Disorder characterized by recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing in a heterosexual male. The fantasies, urges, or behaviors cause clinically significant distress or impairment in social, occupational or other areas of functioning. Paraphilic Disorders have a gender identity Gender identity A person’s concept of self as being male and masculine or female and feminine, or ambivalent, based in part on physical characteristics, parental responses, and psychological and social pressures. It is the internal experience of gender role. Sexual Physiology that remains consistent with their assigned gender.