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.
• 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.
• Another evidence of gender diversity in history is from Hatshepsut, the Egyptian female pharaoh (1478-1458 BCE) who was portrayed as a bearded emperor.
• 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.
• 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.
• 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.

Classification

• In 1980, the notion of gender identity disorder was first mentioned in DSM-III.
• DSM-III-R divided it into 3 broad types- 'non-transsexualism', 'transsexualism' and 'not otherwise specified'.
• DSM- IV combined the former two into Gender Identity Disorder.
• ICD-10 categorized Gender Identity Disorder into four main groups.
• DSM-5 has changed the terminology of Gender Identity Disorder to Gender Dysphoria.

Differential Diagnosis

• Body dysmorphic disorder
• Non conformity to gender roles
• Other clinical presentations

• Castration
• Penectomy

• Other psychotic disorders
• Schizophrenia
• Transvestic disorder

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

Risk Factors

• High degree of atypicality
• Habitual fetishistic transvestism
• Genetic predisposition

Diagnostic criteria

DSM-V Diagnostic Criteria for Gender Dysphoria in Children

“

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months' duration, as manifested by at least six of the following (one of which must be Criterion A1): 1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender). 2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire: or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing. 3. A strong preference for cross-gender roles in make-believe play or fantasy play. 4. A strong preference for the toys, games, or activities stereo typically used or engaged in by the other gender. 5. A strong preference for playmates of the other gender. 6. In boys (assigned gender), a strong rejection of typically masculine toys, games,and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities. 7. A strong dislike of one’s sexual anatomy. 8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender. AND B. The condition is associated with clinically significant distress or impairment in social,school, or other important areas of functioning. Specify if; With a disorder of sex development (e.g., a congenital adreno genital disorder such as congenital adrenal hyperplasia or androgen insensitivity syndrome).

”

DSM-V Diagnostic Criteria for Gender Dysphoria in Adolescents and Adults

“

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration, as manifested by at least two of the following: 1. A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics). 2. A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics). 3. A strong desire for the primary and/or secondary sex characteristics of the other gender. 4. A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender). 5. A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender). 6. A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender). AND B. The condition is associated with clinically significant distress or impairment in social,occupational or other important areas of functioning. Specify if: With a disorder of sex development (e.g., a congenital adrenogenital disorder such congenital adrenal hyperplasia or androgen insensitivity syndrome). Specify if: Post transition: The individual has transitioned to full-time living in the desired gender (with or without legalization of gender change) and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen—namely, regular cross-sex hormone treatment or gender reassignment surgery confirming the desired gender (e.g., penectomy, vaginoplasty in a natal male; mastectomy or phalloplasty in a natal female).

”

ICD-10

Gender Identity Disorder
"Transsexualism"
ICD-10	F64
ICD-9	302.5
OMIM	600952
eMedicine	med/3439
MeSH	F03.800.800.800

The current edition of the 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.

Transsexualism has the following criteria:

• The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment.
• The transsexual identity has been present persistently for at least two years.
• The disorder is not a symptom of another mental disorder or a chromosomal abnormality.

Dual-role transvestism has the following criteria:

• The individual wears clothes of the opposite sex in order to experience temporary membership in the opposite sex.
• There is no sexual motivation for the cross-dressing.
• The individual has no desire for a permanent change to the opposite sex.

Gender Identity Disorder of Childhood has essentially four criteria, which may be summarised as:

• The individual is persistently and intensely distressed about being a girl/boy, and desires (or claims) to be of the opposite gender.
• The individual is preoccupied with the clothing, roles or anatomy of the opposite sex/gender, or rejects the clothing, roles, or anatomy of his/her birth sex/gender.
• The individual has not yet reached puberty.
• The disorder must have been present for at least 6 months.

The remaining two classifications have no specific criteria and may be used as "catch-all" classifications in a similar way to GIDNOS.

Since, very often, many people (including doctors, judges etc.) assume that the classifications "transsexual" and "transvestite" can apply only to adults, the F64 section of the ICD-10 is often criticised, especially since the "usually" in "usually accompanied by the wish to make his or her body as congruent as possible " is often ignored as well, and wish for sexual reassignment surgery (SRS) is seen as a requirement for the diagnosis of "transsexualism". However, an increasing number of physicians and therapists are treating transsexual people who have no desire for surgery, sometimes known as "non-op" transsexuals.

Many transgender people, however, do not fit into either of these two categories; for example, transgender people who wish to change their social gender completely, but who do not bother with SRS. This can lead to significant problems with things such as procuring medical treatment and legal change of name and/or gender; in some cases, it may make them completely impossible.

Controversy

Many transgender people do not regard their cross-gender feelings and behaviours as a disorder. People within the transgender community often question what a "normal" gender identity or "normal" gender role is supposed to be. One argument is that gender characteristics are socially constructed and therefore naturally unrelated to biological sex. This perspective often notes that other cultures, particularly historical ones, valued gender roles that would presently suggest homosexuality or transsexuality as normal behavior. Some people see "transgendering" as a means for deconstructing gender. However, not all transgender people wish to deconstruct gender or feel that they are doing so.

Other transgender people object to the classification of GID as a mental disorder on the grounds that there may be a physical cause, as suggested by recent studies about the brains of transsexual people. Many of them also point out that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.

Although evidence suggests that transgender behaviour has a neurological basis, there is no scientific consensus on whether the etiology of transgenderism is mental or physical. Psychiatric diagnoses will continue to carry authority, and remain useful for medical billing purposes and potentially for the classification of research results, unless those diagnoses are changed. However, little research into transgenderism or transsexualism is actually being conducted. The mental illness diagnoses are also enshrined in the WPATH-SOCs; they persist because no other medical diagnoses are available.

In a landmark publication in December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states "What transsexualism is not...It is not a mental illness." Nonetheless, existing psychiatric diagnoses of gender identity disorder or the now obsolete categories of homosexual disorder, gender dysphoria syndrome, true transsexual, etc., continue to be accepted as formal evidence of transsexuality.

The official politics in many countries interpret transgenderism as an undesirable behavior that must be prohibited, or as a psychiatric disorder, which should be cured. See Heteronormativity.

Additionally, some youth have been diagnosed with GID on the basis of their sexual orientation (because they are viewed as "gender non-conforming" due to their sexual attractions and/or dress/manner) and treated against their will in religious residential treatment centers. One of the more well known cases was that of Lyn Duff, a 15-year-old girl from Los Angeles who was forcibly transported to Rivendell Psychiatric Center in West Jordan, Utah, and subjected to aversion therapy in an attempt to change her sexual orientation.

Many people feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the GID diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of the opposite sex/gender). People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. As Kelley Winters PhD (pen-name Katharine Wilson), an advocate for GID reform put it, "Behaviors that would be ordinary or even exemplary for gender-conforming boys and girls are presented as symptomatic of mental disorder for gender nonconforming children." However, Zucker and Spitzer argue that GID was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion".

Treatment

Main articles: Hormone replacement therapy (male-to-female) and Hormone replacement therapy (female-to-male)

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. (Overlapping reports suggest some in fact were cured several times, implying that these individuals were not cured at all.) While in 1973 the American Psychiatric Association (APA) removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), 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.

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). “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. 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.

Therefore, many feel the diagnosis of gender identity disorder is at best only temporarily applicable, if ever. 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.

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. 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.