Gender identity disorder
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2]
Synonyms and keywords: Gender dysphoria
Overview
Gender identity disorder, as identified by psychologists and physicians, is a condition in which a person has been born one gender, usually on the basis of their sex at birth (compare intersex disorders), but identifies as belonging to another gender, and feels significant discomfort or the inability to deal with this condition. It is a psychiatric classification and describes the problems related to trans sexuality, transgender identity and more rarely transvestism. It is the diagnostic classification most commonly applied to transsexuals. The core symptom of gender identity disorders is gender dysphoria, literally being uncomfortable with one's assigned gender. This feeling is usually reported as "having always been there" since childhood, although in some cases, it appears in adolescence or adulthood, and has been reported by some as intensifying over time. Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them. In many cases, discomfort is also reported as stemming from the feeling that one's body is "wrong" or meant to be different.
Historical Perspective
- The concept of gender dysphoria is not recent but has been the center of objection in many cultures. Since ancient times as mentioned in the mythology, people have existed who wish to lead a life of the opposite gender.[1]
- A Greek tale mentions about a woman raised as a man, who fell in love with another woman and before the wedding, she was metamorphosed into a male. They both lived together thereafter. [2]
- Another evidence of gender diversity in history is from Hatshepsut, the Egyptian female pharaoh (1478-1458 BCE) who was portrayed as a bearded emperor. [3]
- A Roman king Elagabalus (218- 222 CE) was well-known for his beauty, his feminine dressing manner and extensive use of cosmetics. As he wanted the people to remember him as a woman and wished to have female genitalia, he had approached a surgeon who could transform him. [4]
- The first sex reassignment surgery was by Harry Benjamin, who published a case of a 'woman trapped in the body of a man'. It was later known as transsexualism. [5]
- Gender Identity Disorder and several other conditions like fetishism, homosexuality etc had no clear-cut classification margins and were overlapping till 1950s.
- In 1957, John William Money proposed the concept of gender and focused on the conditions associated with sex development.[6]
Classification
- There are multiple classification systems for Gender Identity Disorder.
- In 1980, the notion of this disorder was first mentioned in DSM-III. [7]
- DSM-III-R divided it into 3 broad types- 'non-transsexualism', 'transsexualism' and 'not otherwise specified'. [8]
- DSM- IV combined the former two into Gender Identity Disorder.[9]
- ICD-10 categorized Gender Identity Disorder into four main groups.[10]
- DSM-5 has changed the terminology of Gender Identity Disorder to Gender Dysphoria.[11]
Pathophysiology
- The exact pathogenesis of Gender Identity Disorder is not fully understood.
- Gender identity disorder is hypothesized to be due to a combination of biological and cultural factors, the former having a predominant role.
- Multiple studies have demonstrated an admixture of hormonal, neuroanatomical, and genetic factors in the development of this disorder. However, a single candidate gene has not been isolated in relation with this condition.[12]
- It has been found that prenatal and postnatal neurohormonal factors also have a role in this condition.
- Brain derived neurotrophic factor (BDNF) levels have been found to be significantly decreased in patients with Gender Identity Disorder.[13]
Differential Diagnosis
- Body dysmorphic disorder
- Non conformity to gender roles
- Other clinical presentations
- Other psychotic disorders
- Schizophrenia
- Transvestic disorder[14]
Epidemiology and Demographics
Prevalence
The prevalence of gender dysphoria is:
- 5-14 per 100,000 (0.005%-0.014%) among natal adult males
- 2-3 per 100,000 (0.002%-0.003%) among natal females[14]
Age
- Patients of all age groups may develop Gender identity Disorder.
- It has been observed that most children with Gender Dysphoria do not continue to have the condition after puberty.[15]
- Homosexual men have been found to have later than expected birth order.[16]
- Feminine homosexual men tend to have more than expected number of brothers.[16]
Gender
- In adults, the prevalence of male-to-female transsexualism is observed to be higher than female-to-male transsexualism.[17]
- The relationships of children with gender dysphoria have been observed to be better with children of opposite-sex as compared to that of same-sex at the level of elementary school.[18]
Race
- Gender Dysphoria is a multifactorial condition and the studies performed for determining the racial predominance have presented variable results.
- Race and ethnicity play an important role in the management of Gender Dysphoria and the cross-cultural training of mental health professionals can result in better treatment outcomes. [19]
Risk Factors
- High degree of atypicality
- Habitual fetishistic transvestism[14]
- High birth weight[20]
- Genetic factors [21]
- Cigarette Smoking [22]
- Autism Spectrum disorder(ASD)[20]
Diagnostic criteria
DSM-5 Diagnostic Criteria:
- According to DSM-5, Gender Dysphoria has been divided into-
- Gender Dysphoria in children
- Gender Dysphoria in adolescents and adults
- Other specified Gender Dysphoria
- Unspecified Gender Dysphoria
Gender Dysphoria in Children[14]
“ |
AND
Specify if; With a disorder of sex development (like congenital adrenal hyperplasia or androgen insensitivity syndrome). |
” |
Gender Dysphoria in Adolescents and Adults[14]
“ |
AND
Specify if:
|
” |
Other Specified Gender Dysphoria
- Symptoms of gender dysphoria cause clinically significant distress in social, occupational, and/or other domains of functioning but do not meet the full criteria for gender dysphoria.
Unspecified Gender Dysphoria
- This category is used in the circumstances where the clinician chooses not to specify the reason that the full criteria for gender dysphoria are not met or have insufficient information to formulate a more specific diagnosis.
ICD-10 Diagnostic Criteria
Gender Identity Disorder | ||
"Transsexualism" | ||
ICD-10 | F64 | |
---|---|---|
ICD-9 | 302.5 | |
OMIM | 600952 | |
eMedicine | med/3439 | |
MeSH | F03.800.800.800 |
International Statistical Classification of Diseases and Related Health Problems has five different diagnoses for gender identity disorder: transsexualism, Dual-role Transvestism, Gender Identity Disorder of Childhood, Other Gender Identity Disorders, and Gender Identity Disorder, Unspecified.[23]
Transsexualism has the following criteria:
- The desire to be accepted as or live as a member of the opposite sex, usually accompanied by the wish to make his/her body as congruent as possible with the preferred sex by the process of surgery and hormone treatment.
- The transsexual identity has been present continuously for a minimum period of two years.
- The disorder is not secondary to a mental condition or a chromosomal abnormality.
Dual-role transvestism is characterized by:
- The individual wearing clothes of the opposite sex in order to experience temporary membership in the other sex.
- No sexual motivation has been found for the cross-dressing.
- No desire for permanent sex transformation.
Gender Identity Disorder of Childhood has four criteria, which may be summed as:
- The individual is persistently and severely distressed about being a girl/boy, and desires (or claims) to be the member of the opposite gender.
- The individual is preoccupied with the clothing, roles, and/or anatomy of the opposite gender, or rejects the clothing, roles, or anatomy of his/her birth gender.
- Puberty has not been attained yet.
- The disorder must have been present for a minimum of 6 months.
The remaining two classifications have no specific criteria.
Many people assume that the classifications "transsexual" and "transvestite" can apply only to adults and therefore, the F64 section of the ICD-10 is often criticized, for example, the wish for sexual reassignment surgery (SRS) is perceived as a requirement for the diagnosis of "transsexualism".
Treatment
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Some medical and psychological professional have tried to 'dissuade individuals from their transgender behaviour/feelings at least since the mid-19th century. Only occasionally have such cures been reported, and almost all such reports lack substantiation.[citation needed] (Overlapping reports suggest some in fact were cured several times, implying that these individuals were not cured at all.[citation needed]) While in 1973 the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM)[24], and many believed sexual identities were finally freed of medicalized stigma, today many LGB and "gender non-conforming" youth and adults remain vulnerable to diagnosis of psychosexual disorder under the GID diagnosis which replaced homosexuality in the DSM version III in 1980. Thus many LGB and gender variant youth and adults, including transgender individuals, are still directed to conversion therapies.[citation needed]
Today, most medical professionals who provide transgender transition services now reject conversion therapies as abusive and dangerous, believing instead what many transgender people have been convinced of: that when able to live out their daily lives with both a physical embodiment and a social expression that most closely matches their internal sense of self, transgender and transsexual individuals live successful, productive lives virtually indistinguishable from anyone else (e.g. Lynn Conway’s “Success Pages” in External Links below).[citation needed] “Transgender transition services”, the various medical treatments and procedures that alter an individual's primary and/or secondary sexual characteristics, are thus now considered highly successful, medically necessary interventions for many transgender persons, including but not limited to transsexuals, especially those who experience the deep distress of body dysphoria. (See discussion of body dysphoria for how this concept relates to the misnomer "gender dysphoria". Similarly, see Transgender transition for a critical discussion of the concept of “reassignment” as in sex reassignment therapy and for a discussion of related medical services and procedures.)
The World Professional Association for Transgender Health (WPATH, formerly HBIGDA) Standards of Care (Version 6 from 2001) are considered by some as definitive treatment guidelines for providers. Other Standards exist (see those discussed in Standards of care for gender identity disorders, including the guidelines outlines in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care". Several health clinics in the United States (e.g. Tom Waddell in San Francisco, Callen Lorde in New York City, Mazzoni in Philadelphia) have developed “protocols” for transgender hormone therapy following a “harm reduction” model which is coming to be embraced by increasing numbers of providers. In their 2005 book Medical Therapy and Hormone Maintenance for Transgender Men, Dr. Nick Gorton et al suggest a flexible approach based in harm reduction, “Willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful.” (See External Links below.)
Medical body interventions and procedures are often necessary to enable living socially in a gender role that more closely matches one's gender identity, and many assume that being accurately perceived by others is a primary goal of body transformations. However, for those transgender individuals who experience the deep internal distress of body dysphoria, the effects wrought by physical changes - hormones, surgeries, or other procedures - go much deeper than surface appearances and are far from cosmetic.[citation needed] The primary effects of hormonal and/or surgical interventions are experienced directly by self, internally, increasing a sense of internal harmony and well-being at the deepest psychological and emotional levels, as well as through the physical senses especially proprioception - the body's own knowledge of itself. Many medical professionals have come to consider "post-transition" transsexuals (see “transgender transition”) to be fully cured of their dysphoria or any other disorder.[citation needed]
Therefore, many feel the diagnosis of gender identity disorder is at best only temporarily applicable, if ever.[citation needed] Indeed, through transition many transsexuals are able to bring their body and their lived/expressed gender into alignment with the internal sense of self. Thus, many post-transition transsexuals cease to regard themselves as "trans" in any sense: many transwomen (male-to-female) self-describe as "women" and, similarly, many transmen feel themselves to be unequivocally "men." While some of these individuals may require continued hormone replacement therapy (estrogen or testosterone, respectively) throughout their adult life, such HRT is not substantially different from the HRT often prescribed for cisgender females or males (not only are dosage levels similar, so are the effects of lack of treatment). Thus, many medical providers in the United States now routinely prescribe such HRT under the same medical codes used for other women and men.[citation needed]
Achieving basic human rights for all transgender persons undoubtedly requires increased social acceptance of each individual's own expression of their identity, regardless of their birth gender or social role expectations. However, for those transgender individuals who experience the internal distress of body dysphoria, social acceptance of variation, while vastly important, will not be sufficient. For this segment of the transgender community, some medical services and procedures will also be required in order for these individuals to feel aligned with their bodies and for the distress of body dysphoria to be fully alleviated.
Gorton et al. underscore the importance of medical interventions for some transgender individuals, warning that “Providers must however consider not only the adverse effects of providing hormones but the adverse consequences of denying access to medically supervised hormonal therapy. […] Non-treatment of transgender patients can result in significantly worse psychological outcomes.” Failure to treat and/or delayed access to transition may have tragic, indeed catastrophic, results for some transgender individuals. It is well-known that the rate of teen suicides is highest for LGBT youth.[citation needed] Recent studies now suggest that suicide rates are highest for transgender youth and adults, especially those unable to live their gender identity and those unable to access transgender transition services. Gorton et al. suggest rates as high as 20% for untreated transsexuals. (See also “transgender health priorities”). However, even when transition services are available, suicide rates are still higher than for the general population.
References
- ↑ Dorlands Medical Dictionary
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Poteat, Tonia; Rachlin, Katherine; Lare, Sean; Janssen, Aron; Devor, Aaron (2019). "History and Prevalence of Gender Dysphoria": 1–24. doi:10.1007/978-3-030-05683-4_1. ISSN 2523-3785.
- ↑ Poteat, Tonia; Rachlin, Katherine; Lare, Sean; Janssen, Aron; Devor, Aaron (2019). "History and Prevalence of Gender Dysphoria": 1–24. doi:10.1007/978-3-030-05683-4_1. ISSN 2523-3785.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Koh J (2012). "[The history of the concept of gender identity disorder]". Seishin Shinkeigaku Zasshi. 114 (6): 673–80. PMID 22844818.
- ↑ Fisher, Alessandra D.; Ristori, Jiska; Morelli, Girolamo; Maggi, Mario (2018). "The molecular mechanisms of sexual orientation and gender identity". Molecular and Cellular Endocrinology. 467: 3–13. doi:10.1016/j.mce.2017.08.008. ISSN 0303-7207.
- ↑ Fontanari, Anna-Martha V.; Andreazza, Tahiana; Costa, Ângelo B.; Salvador, Jaqueline; Koff, Walter J.; Aguiar, Bianca; Ferrari, Pamela; Massuda, Raffael; Pedrini, Mariana; Silveira, Esalba; Belmonte-de-Abreu, Paulo S.; Gama, Clarissa S.; Kauer-Sant'Anna, Marcia; Kapczinski, Flavio; Lobato, Maria Ines R. (2013). "Serum concentrations of brain-derived neurotrophic factor in patients with gender identity disorder". Journal of Psychiatric Research. 47 (10): 1546–1548. doi:10.1016/j.jpsychires.2013.04.012. ISSN 0022-3956.
- ↑ 14.0 14.1 14.2 14.3 14.4 Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D.C: American Psychiatric Association. 2013. ISBN 0890425558.
- ↑ Wallien, Madeleine S.C.; Cohen-Kettenis, Peggy T. (2008). "Psychosexual Outcome of Gender-Dysphoric Children". Journal of the American Academy of Child & Adolescent Psychiatry. 47 (12): 1413–1423. doi:10.1097/CHI.0b013e31818956b9. ISSN 0890-8567.
- ↑ 16.0 16.1 Blanchard, Ray; Zucker, Kenneth J.; Cohen-Kettenis, Petty T.; Gooren, Louis J. G.; Bailey, J. Michael (1996). "Birth order and sibling sex ratio in two samples of Dutch gender-dysphoric homosexual males". Archives of Sexual Behavior. 25 (5): 495–514. doi:10.1007/BF02437544. ISSN 0004-0002.
- ↑ Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. (2016). "Gender Dysphoria in Adults". Annual Review of Clinical Psychology. 12 (1): 217–247. doi:10.1146/annurev-clinpsy-021815-093034. ISSN 1548-5943.
- ↑ Wallien, Madeleine S. C.; Veenstra, René; Kreukels, Baudewijntje P. C.; Cohen-Kettenis, Peggy T. (2009). "Peer Group Status of Gender Dysphoric Children: A Sociometric Study". Archives of Sexual Behavior. 39 (2): 553–560. doi:10.1007/s10508-009-9517-3. ISSN 0004-0002.
- ↑ Stanford, E. Percil; Bois, Barbara C. Du (1992). "Gender and Ethnicity Patterns": 99–117. doi:10.1016/B978-0-12-101277-9.50008-5.
- ↑ 20.0 20.1 VanderLaan, Doug P.; Leef, Jonathan H.; Wood, Hayley; Hughes, S. Kathleen; Zucker, Kenneth J. (2014). "Autism Spectrum Disorder Risk Factors and Autistic Traits in Gender Dysphoric Children". Journal of Autism and Developmental Disorders. 45 (6): 1742–1750. doi:10.1007/s10803-014-2331-3. ISSN 0162-3257.
- ↑ Heylens, Gunter; De Cuypere, Griet; Zucker, Kenneth J.; Schelfaut, Cleo; Elaut, Els; Vanden Bossche, Heidi; De Baere, Elfride; T'Sjoen, Guy (2012). "Gender Identity Disorder in Twins: A Review of the Case Report Literature". The Journal of Sexual Medicine. 9 (3): 751–757. doi:10.1111/j.1743-6109.2011.02567.x. ISSN 1743-6095.
- ↑ Hoffman, Leah; Delahanty, Janine; Johnson, Sarah E.; Zhao, Xiaoquan (2018). "Sexual and gender minority cigarette smoking disparities: An analysis of 2016 Behavioral Risk Factor Surveillance System data". Preventive Medicine. 113: 109–115. doi:10.1016/j.ypmed.2018.05.014. ISSN 0091-7435.
- ↑ HBIGDA Standards Of Care For Gender Identity Disorders, Sixth Version
- ↑ Zucker KJ, Spitzer RL, 2005, "Was the gender identity disorder of childhood diagnosis introduced into DSM-III as a backdoor maneuver to replace homosexuality? A historical note."Journal of Sex and Marital Therapy 2005 Jan-Feb;31(1):31-42
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