跨性別及性別不安──從臨床照護到心理壓力觀點

Transgender and Gender Dysphoria: Viewpoints on Clinical Care and Psychological Stress

性別認同議題近年來越來越受到精神醫療與心理健康學界的重視，非傳統性別認同的個體常遭到污名與霸凌，導致精神疾病的風險。跨性別是一群高度異質性的個體，其性別認同與出生時被認定的性別不一致，其中有一些人符合DSM- 5-TR（diagnostic and statistical manual of mental disorders, fifth edition, text revision）中「性別不安」的診斷，當這些女跨男或男跨女的個案在社會性別轉變的歷程中，也可能會尋求荷爾蒙治療或性別確認手術，而被稱為變性者。在台灣若要變更法律上的性別身分，需要兩個條件：一是取得兩位精神科醫師的診斷證明書、二是由合格醫療機構開立摘除原生生殖器官的證明。在DSM-5-TR中，性別不安這個詞彙描述的是當事人所經驗／所展現的性別與指定性別之間有顯著的不一致，因此造成困擾及痛苦。性別不安在各年齡層中有不同的困境，針對不同發展階段也有不同的賀爾蒙治療選項。青春期的性徵發育常常造成性別不安的當事人更加痛苦，因此也有性腺激素釋放素促進劑可以延後青春期，讓當事人有更多思考時間。而性別確認賀爾蒙則能幫助當事人的外觀男性化或女性化，以符合自身性別認同。除了生理上的治療之外，心理介入也相當重要，跨性別者因社會結構問題，常面臨更高的暴力、自殺、性侵風險，也有許多研究指出跨性別與自閉症類群障礙症的發生率相關，這些議題都需要醫療及心理健康從業人員的高度重視。

Gender identity is a topic of growing interest in mental health research. People with non-conforming gender identity are prone to suffer from stigmatization and bullying, and often present with psychiatric issues. Transgender denotes the broad spectrum of individuals who identify differently from their assigned gender. Some transgender people meet the requirements of the“gender dysphoria”(GD) diagnosis in the DSM-5-TR (diagnostic and statistical manual of mental disorders, fifth edition, text revision). When these individuals seek or undergo a social transition from male to female or female to male, which in many, but not all, cases also involves a somatic transition by cross-sex hormone treatment and genital (gender affirming) surgery, they are categorized as“transsexual”. There are two requirements for transgender identity recognition in Taiwan: two psychiatrists’certificates of GD and the surgical removal of external and internal genitalia. In the DSM-5-TR, GD, as a general descriptive term, refers to the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. GD manifests itself differently in different age groups. Several developmental-stage-dependent hormonal treatment options are available for GD. Puberty may exacerbate dysphoria due to the development of unwanted secondary sexual characteristics, which may be suppressed using a gonadotropin-releasing hormone agonist. On the other hand, gender-affirming hormones (aka cross-sex hormonal therapy) allow individuals to actively masculinize or feminize their physical appearance to become more consistent with their gender identity. In addition to biological treatment, psychosocial intervention is another key point for transgender people. These individuals experience higher risks of violence victimization, suicide, and sexual violence than their cisgender peers. Several studies have also indicated the presence of an association between autism spectrum disorder and GD. Mental health professionals should address these issues in practice and seek further understanding from transgender people.