Evaluation of Gender Dysphoria — MCQs
Body dysmorphic disorder can be associated with all except
A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?
A 40-year-old female has visited multiple plastic surgeons requesting correction of a perceived facial deformity. She was referred to a psychiatrist because she repeatedly checks her face, insists that it is deformed and needs surgery despite no evidence on examination. She persists with her demand despite reassurances by family members and doctors. What is the most appropriate management?
Congenital adrenal hyperplasia most commonly presents as
Which of the following symptoms is NOT included in the diagnostic criteria for DSM-IV-TR somatization disorder?
What term describes the practice of wearing clothes of the opposite sex?
What is the definition of sex ratio?
A child can ride a tricycle, copies a circle, knows name and gender. The developmental age of this child is
According to PCPNDT Act, 1994, what is the punishment for a doctor found guilty of sex determination for the first offense?
A multidisciplinary team is developing protocols for adolescent gender-affirming care. When evaluating the appropriateness of GnRH analog therapy versus immediate cross-sex hormones in a 16-year-old with persistent gender dysphoria (Tanner stage 5), which factor most strongly supports proceeding directly to cross-sex hormones?
Evaluation of Gender Dysphoria Indian Medical PG Practice Questions and MCQs
Question 1: Body dysmorphic disorder can be associated with all except
- A. Bulimia nervosa
- B. OCD
- C. Anxiety
- D. Mania (Correct Answer)
Explanation: ***Mania*** - **Mania** is a state of elevated, expansive, or irritable mood that is distinct from the persistent preoccupation with perceived bodily defects seen in **body dysmorphic disorder (BDD)**. - While agitation can occur in BDD, the core symptom profile of **mania**, including decreased need for sleep, grandiosity, and racing thoughts, is not a typical associated feature. *Bulimia nervosa* - **Bulimia nervosa** can co-occur with BDD, particularly when the perceived defects relate to body weight, shape, or specific body parts. - Both disorders involve intense preoccupation with body image and often lead to harmful behaviors to attempt to "correct" perceived flaws. *OCD* - **Obsessive-compulsive disorder (OCD)** shares strong phenomenological similarities with BDD, including intrusive thoughts (obsessions) and repetitive behaviors (compulsions). - BDD is often conceptualized as part of the **OCD spectrum**, with both disorders involving obsessive thoughts and repetitive behaviors related to specific concerns. *Anxiety* - **Anxiety disorders** are highly comorbid with BDD, as individuals often experience significant distress, fear of judgment, and social avoidance due to their perceived flaws. - The constant preoccupation and efforts to conceal or fix perceived defects can lead to chronic anxiety and panic attacks.
Question 2: A 20-year-old girl complains of headache while studying. Her vision is found to be normal. In the initial medical evaluation of her headache, which of the following would be the LEAST essential to assess?
- A. Family history of headache
- B. Menstrual history
- C. Fundoscopy examination
- D. Her interest in studies (Correct Answer)
Explanation: ***Her interest in studies*** - While **stress** and **academic pressure** can contribute to headaches, this represents a **psychosocial assessment** rather than a standard medical evaluation. - Among the listed options, this would be the **least essential** in the initial medical workup compared to the other clinical assessments. *Family history of headache* - Essential evaluation as many headache disorders, particularly **migraine** and **tension-type headache**, have strong **genetic predisposition**. - Family history helps establish diagnosis and guides appropriate management strategies for the patient's headaches. *Menstrual history* - Crucial in young women as **hormonal fluctuations** during the menstrual cycle are major triggers for headaches, especially **menstrual migraine**. - Understanding menstrual patterns can identify cyclical headache triggers and inform treatment approaches. *Fundoscopy examination* - Important to rule out **papilledema** (optic disc swelling) and signs of **increased intracranial pressure**, even with normal visual acuity. - Normal vision does not exclude underlying pathology that could be detected through **ophthalmoscopic examination** of the retina and optic nerve.
Question 3: A 40-year-old female has visited multiple plastic surgeons requesting correction of a perceived facial deformity. She was referred to a psychiatrist because she repeatedly checks her face, insists that it is deformed and needs surgery despite no evidence on examination. She persists with her demand despite reassurances by family members and doctors. What is the most appropriate management?
- A. Behavior therapy (Correct Answer)
- B. SSRI
- C. Atypical antipsychotics
- D. Allow her to have surgery
Explanation: ***Behavior therapy*** - This patient presents with **body dysmorphic disorder (BDD)**, characterized by preoccupation with a perceived defect in appearance that is not observable to others, leading to significant distress and impairment. - **Cognitive behavioral therapy (CBT)**, specifically **CBT-BDD with exposure and response prevention (ERP)**, is the **first-line treatment** with the strongest evidence base for BDD. - CBT-BDD addresses the core cognitive distortions, reduces checking behaviors, and provides sustained long-term improvement without medication side effects. - **Most appropriate management** involves CBT as primary treatment, often combined with pharmacotherapy for optimal outcomes. *SSRI* - **Selective serotonin reuptake inhibitors (SSRIs)** are the first-line **pharmacotherapy** for BDD, often requiring higher doses than those used for major depressive disorder. - SSRIs are highly effective and can be used as monotherapy or preferably in combination with CBT. - While SSRIs are appropriate, CBT has superior evidence as the primary intervention for BDD. *Atypical antipsychotics* - **Atypical antipsychotics** may be considered as an augmentation strategy for BDD in cases that do not respond to SSRI monotherapy, especially with significant delusional features or severe functional impairment. - They are not first-line pharmacological treatment. *Allow her to have surgery* - Allowing plastic surgery is **contraindicated** in patients with BDD because it rarely alleviates distress and often leads to dissatisfaction with surgical outcomes, potentially worsening symptoms or causing further unnecessary procedures. - The core problem is distorted perception of self, not an actual physical defect that can be remedied surgically.
Question 4: Congenital adrenal hyperplasia most commonly presents as
- A. 46,XY DSD
- B. Ovotesticular DSD
- C. 46,XX DSD with virilization (Correct Answer)
- D. 46,XY DSD with undervirilization
Explanation: ***46,XX DSD with virilization*** (formerly female pseudohermaphroditism) - This is the **most common presentation** of congenital adrenal hyperplasia (CAH), particularly due to **21-hydroxylase deficiency**, which accounts for >90% of CAH cases. - Affects genetically female (46,XX) individuals with excess **androgens** produced by hyperplastic adrenal glands leading to **virilization** of external genitalia. - Clinical features include **clitoromegaly, labioscrotal fusion**, and varying degrees of masculinization, while **internal female organs (uterus, ovaries, fallopian tubes) remain normal**. - This is the classic presentation that brings CAH to clinical attention in newborn screening programs. *46,XY DSD* (formerly 46,XY intersex) - This terminology refers to conditions where genetically male individuals (46,XY) have atypical genital development. - Common causes include **androgen insensitivity syndrome** or disorders of testosterone synthesis (5α-reductase deficiency, 17β-hydroxysteroid dehydrogenase deficiency). - CAH in 46,XY individuals typically presents with **isosexual precocious pseudopuberty** (early virilization) in simple virilizing forms or **salt-wasting adrenal crisis** in severe forms, not undervirilization. *Ovotesticular DSD* (formerly true hermaphroditism) - Very rare condition where an individual has **both ovarian and testicular tissue**, either as separate gonads or combined as ovotestes. - Often involves complex chromosomal patterns including **46,XX/46,XY mosaicism** or 46,XX with SRY translocation. - Not related to CAH pathophysiology, which involves enzymatic defects in steroidogenesis. *46,XY DSD with undervirilization* (formerly male pseudohermaphroditism) - Occurs when 46,XY individuals have **undervirilized or ambiguous external genitalia** due to impaired androgen synthesis or action. - Causes include disorders of testicular development, androgen biosynthesis defects, or **androgen insensitivity**. - While CAH can affect males, it causes **excess androgens** leading to precocious puberty, not undervirilization.
Question 5: Which of the following symptoms is NOT included in the diagnostic criteria for DSM-IV-TR somatization disorder?
- A. Sexual symptom
- B. Pain symptom
- C. GI symptom
- D. Visual symptoms (Correct Answer)
Explanation: ***Visual symptoms*** - **Visual symptoms** is NOT a separate diagnostic category in DSM-IV-TR somatization disorder criteria. - While visual symptoms (such as **double vision** or **blindness**) ARE part of the diagnostic criteria, they fall under the **pseudoneurological symptom** category, not as a distinct standalone category. - The DSM-IV-TR required **one pseudoneurological symptom** (which could include visual, motor, sensory symptoms, or seizures), but did not list "visual symptoms" as one of the four main symptom categories. *Sexual symptom* - The DSM-IV-TR diagnostic criteria for somatization disorder explicitly included **sexual symptoms** as one of the four main categories. - At least **one sexual symptom** was required (such as sexual indifference, erectile dysfunction, irregular menses, or painful intercourse). *Pain symptom* - The DSM-IV-TR criteria included **pain symptoms** as one of the four main categories. - The criteria required **four pain symptoms** occurring in at least four different sites or functions (e.g., head, abdomen, back, joints, chest). *GI symptom* - The DSM-IV-TR criteria included **gastrointestinal symptoms** as one of the four main categories. - At least **two gastrointestinal symptoms** were required (such as nausea, bloating, vomiting other than during pregnancy, or diarrhea). **Key Point:** The four DSM-IV-TR symptom categories for somatization disorder were: (1) Pain, (2) Gastrointestinal, (3) Sexual, and (4) Pseudoneurological—NOT "visual symptoms" as a separate category.
Question 6: What term describes the practice of wearing clothes of the opposite sex?
- A. Masochism
- B. Sadism
- C. Transvestism (Correct Answer)
- D. Fetishism
Explanation: ***Transvestism*** - **Transvestism** (also known as transvestic fetishism in DSM-IV-TR/ICD-10) is the term that describes the practice of dressing in clothes typically associated with the opposite sex. - This involves **cross-dressing** for personal pleasure, comfort, or sexual arousal, without necessarily implying a desire to permanently change one's sex. - **Note:** Modern classifications (DSM-5-TR/ICD-11) now use "transvestic disorder" only when the behavior causes marked distress or impairment, distinguishing pathological behavior from non-clinical cross-dressing. *Masochism* - **Masochism** refers to deriving sexual gratification from experiencing pain, humiliation, or submission. - This is a distinct paraphilic pattern and does not involve wearing clothes of the opposite sex. *Sadism* - **Sadism** involves deriving sexual gratification from inflicting pain, humiliation, or suffering on others. - This is unrelated to cross-dressing behavior. *Fetishism* - **Fetishism** involves sexual arousal from inanimate objects or non-genital body parts (e.g., shoes, feet, leather items). - While it can involve clothing items, it does not specifically refer to wearing clothes of the opposite sex as a complete ensemble, which defines transvestism.
Question 7: What is the definition of sex ratio?
- A. Number of live births per year
- B. Number of females per 1000 males
- C. Number of males per 1000 females (Correct Answer)
- D. Crude birth rate
Explanation: **Number of males per 1000 females** ✓ - The **sex ratio** is a demographic measure that expresses the number of males relative to the number of females in a population, typically presented as the number of males per 1000 females. - This ratio provides insight into the **gender distribution** within a population and can vary significantly due to factors like birth rates, mortality rates, and migration. - This is the **standard definition** used in Census data, WHO reports, and epidemiological studies. *Number of live births per year* - This definition refers to the **absolute number of births** occurring within a specific time frame, typically a year. - It is a component of the **birth rate** but not the definition of sex ratio, which specifically compares the numbers of each sex. *Number of females per 1000 males* - While this is a **ratio of sexes**, it is the inverse of the commonly accepted definition of the sex ratio. - The standard convention is to express the number of males per 1000 females, making this an **unconventional expression** of the sex ratio. *Crude birth rate* - The **crude birth rate** is defined as the number of live births per 1,000 people (of both sexes) in a population per year. - This measure reflects the **overall fertility** of a population and does not distinguish between male and female numbers, unlike the sex ratio.
Question 8: A child can ride a tricycle, copies a circle, knows name and gender. The developmental age of this child is
- A. 4 years
- B. 5 years
- C. 2 years
- D. 3 years (Correct Answer)
Explanation: ***3 years*** - A child who can **ride a tricycle**, **copy a circle**, and knows their **name and gender** has achieved developmental milestones typically seen around **3 years of age**. - **Riding a tricycle** demonstrates advanced gross motor skills, while **copying a circle** indicates fine motor skill development. **Knowing name and gender** points to cognitive and social-emotional understanding. *4 years* - By 4 years, a child can typically **hop on one foot**, **draw a square**, and **tell stories**. - While they might refine skills acquired at 3, the listed milestones are primary for the 3-year mark. *5 years* - A 5-year-old usually can **skip**, **draw a triangle**, and **count 10 or more objects**. - These milestones represent further advancements beyond those described in the question. *2 years* - At 2 years, a child typically starts to **kick a ball**, **draw a straight line**, and can say **two-to-four-word sentences**. - The skills described (tricycle, circle) are generally too advanced for a 2-year-old.
Question 9: According to PCPNDT Act, 1994, what is the punishment for a doctor found guilty of sex determination for the first offense?
- A. 5 years
- B. 3 years (Correct Answer)
- C. 2 years
- D. 1 year
Explanation: ***3 years*** - The **PCPNDT Act, 1994** (Pre-Conception and Pre-Natal Diagnostic Techniques Act) specifies imprisonment of up to **3 years** for a first-time offense of sex determination. - This is paired with a fine of up to **₹10,000**, and the registration of the medical practitioner is also suspended for a period of **five years** for the first offense. - The Act aims to prevent female feticide and maintain the **sex ratio**. *5 years* - An imprisonment term of **5 years** applies for **subsequent offenses** after conviction for the first offense. - The registration can be permanently cancelled for repeat offenders. *2 years* - This duration is **not specified** in the PCPNDT Act as a punishment for sex determination. - Neither imprisonment nor suspension of registration for 2 years is mentioned in the Act for this offense. *1 year* - A 1-year imprisonment is not specified under the PCPNDT Act for sex determination. - The Act intends to impose stringent penalties (up to 3 years for first offense, up to 5 years for subsequent offense) to deter such practices.
Question 10: A multidisciplinary team is developing protocols for adolescent gender-affirming care. When evaluating the appropriateness of GnRH analog therapy versus immediate cross-sex hormones in a 16-year-old with persistent gender dysphoria (Tanner stage 5), which factor most strongly supports proceeding directly to cross-sex hormones?
- A. Parental consent is available
- B. Mental health evaluation shows no contraindications
- C. Completion of pubertal development makes GnRH analogs ineffective (Correct Answer)
- D. Patient expresses strong desire for rapid physical changes
Explanation: ***Completion of pubertal development makes GnRH analogs ineffective*** - **GnRH analogs** are primarily used to suppress the progression of endogenous puberty; once a patient has reached **Tanner stage 5**, biological puberty is complete, rendering suppression redundant. - At this physiological stage, initiating **cross-sex hormones** (gender-affirming hormone therapy) is the appropriate clinical step to align physical characteristics with gender identity. *Parental consent is available* - While **parental consent** is a legal and ethical requirement for treating minors, it does not dictate the physiological choice between suppression and hormone therapy. - Consent is necessary for either **GnRH analogs** or **cross-sex hormones**, but the patient's **Tanner stage** is the medical deciding factor here. *Mental health evaluation shows no contraindications* - A thorough **mental health evaluation** is a prerequisite for all gender-affirming medical interventions to ensure the diagnosis of **gender dysphoria**. - While it confirms readiness for treatment, it does not differentiate which specific endocrine intervention is biologically appropriate for a **Tanner 5** adolescent. *Patient expresses strong desire for rapid physical changes* - **Patient autonomy** and goals are vital, but clinical protocols prioritize developmental staging over the desired speed of changes to ensure safety. - Although **cross-sex hormones** do produce rapid changes compared to analogs, the medical rationale for skipping analogs is the **completion of puberty**, not patient preference.
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