Gender Identity Disorders



Gender Identity Disorders





Gender identity refers to the sense one has of being male or being female, which corresponds, normally, to the person’s anatomical sex. The text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines gender identity disorders as a group whose common feature is a strong, persistent preference for living as a person of the other sex. The affective component of gender identity disorders is gender dysphoria—discontent with one’s designated birth sex and a desire to have the body of the other sex and to be regarded socially as a person of the other sex. Gender identity disorder in adults was referred to in early versions of the DSM as transsexualism.

In DSM-IV-TR, no distinction is made for the overriding diagnostic term gender identity disorder as a function of age. In children, it can manifest as statements of wanting to be the other sex and as a broad range of sex-typed behaviors conventionally shown by children of the other sex. Gender identity crystallizes in most persons by age 2 or 3 years.


EPIDEMIOLOGY


Children

Most children with gender identity disorder are referred for clinical evaluation in early grade school years. Parents, however, typically report that the cross-gender behaviors were apparent before 3 years of age. Among a sample of boys younger than age 12 years referred for a range of clinical problems, the reported desire to be the opposite sex was 10 percent. For clinically referred girls younger than age 12 years, the reported desire to be the opposite sex was 5 percent.

The sex ratio of referred children is four to five boys for each girl.


Adults

The best estimate of gender identity disorder or transsexualism in adults comes from Europe, with a prevalence of 1 in 30,000 men and 1 in 100,000 women. Most clinical centers report a sex ratio of three to five male patients for each female patient. Many adults with gender identity disorder may well have qualified for gender identity disorder in childhood. Most adults with gender identity disorder report having felt different from other children of their same sex, although, in retrospect, many could not identify the source of that difference. Many report feeling extensively cross-gender identified from the earliest years, with the cross-gender identification becoming more profound in adolescence and young adulthood.


ETIOLOGY


Biological Factors

For mammals, the resting state of tissue is initially female; as the fetus develops, a male is produced only if androgen (coded for by a region of the Y chromosome, which is responsible for testicular development) is introduced. Without testes and androgen, female external genitalia develop. Thus, maleness and masculinity depend on fetal and perinatal androgens. The sexual behavior of animals lower on the evolutionary tree is governed by sex steroids, but this effect diminishes as one ascends the evolutionary tree. Sex steroids influence the expression of sexual behavior in mature men and women; that is, testosterone can increase libido and aggressiveness in women, and estrogen can decrease libido and aggressiveness in men. However, masculinity, femininity, and gender identity result more from postnatal life events than from prenatal hormonal organization.

The same principle of masculinization or feminization has been applied to the brain. Testosterone affects brain neurons that contribute to the masculinization of the brain in such areas as the hypothalamus. Whether testosterone contributes to so-called masculine or feminine behavioral patterns in gender identity disorders remains a controversial issue.


Psychosocial Factors

Children usually develop a gender identity consonant with their sex of rearing (also known as assigned sex). The formation of gender identity is influenced by the interaction of children’s temperament and parents’ qualities and attitudes. Culturally acceptable gender roles exist: Boys are not expected to be effeminate, and girls are not expected to be masculine. There are boys’ games (e.g., cops and robbers) and girls’ toys (e.g., dolls and dollhouses). These roles are learned, although some investigators believe that some boys are temperamentally delicate and sensitive and that some girls are aggressive and energized—traits that are stereotypically known in today’s culture as feminine and masculine, respectively. However, greater tolerance for mild cross-gender activity in children has developed in the past few decades.

The quality of the mother-child relationship in the first years of life is paramount in establishing gender identity. During this period, mothers normally facilitate their children’s awareness of, and pride in, their gender: Children are valued as little boys and girls, but devaluing, hostile mothering can result in gender problems. At the same time, the separation-individuation process is unfolding. When gender problems become associated with separation-individuation problems, the result can be the use of
sexuality to remain in relationships characterized by shifts between a desperate infantile closeness and a hostile, devaluing distance.

Some children are given the message that they would be more valued if they adopted the gender identity of the opposite sex. Rejected or abused children may act on such a belief. Gender identity problems can also be triggered by a mother’s death, extended absence, or depression, to which a young boy may react by totally identifying with her—that is, by becoming a mother to replace her.

The father’s role is also important in the early years, and his presence normally helps the separation-individuation process. Without a father, mother and child may remain overly close. For a girl, the father is normally the prototype of future love objects; for a boy, the father is a model for male identification.


DIAGNOSIS AND CLINICAL FEATURES

Current diagnostic criteria for children and adults are organized under two main groupings: cross-gender identification and discomfort with assigned gender role. For children, this includes the intense desire to participate in the games and pastimes of the other sex and may include rejection of gender-conventional toys and games. The essential features, for all ages, are a persistent and intense distress about his or her assigned sex and a desire to be of the other sex. Table 18-1 lists the DSM-IV-TR criteria for the disorder.


Children

At the extreme of gender identity disorder in children are boys who, by the standards of their cultures, are as feminine as the most feminine of girls and girls who are as masculine as the most masculine of boys. No sharp line can be drawn on the continuum of gender identity disorder between children who should receive a formal diagnosis and those who should not. Girls with the disorder regularly have male companions and an avid interest in sports and rough-and-tumble play; they show no interest in dolls or playing house (unless they play the father or another male role). They may refuse to urinate in a sitting position, claim that they have or will grow a penis and do not want to grow breasts or to menstruate, and assert that they will grow up to become a man (not merely to play a man’s role).

Boys with the disorder are usually preoccupied with stereotypically female activities. They may have a preference for dressing in girls’ or women’s clothes or may improvise such items from available material when the genuine articles are not available. (The cross-dressing typically does not cause sexual excitement, as in transvestic fetishism.) They often have a compelling desire to participate in the games and pastimes of girls. Female dolls are often their favorite toys, and girls are regularly their preferred playmates. When playing house, they take a girl’s role. Their gestures and actions are often judged to be feminine, and they are usually subjected to male peer group teasing and rejection, a phenomenon that rarely occurs with boyish girls until adolescence. Boys with the disorder may assert that they will grow up to become a woman (not merely in role). They may claim that their penis or testes are disgusting or will disappear or that it would be better not to have a penis or testes. Some children refuse to attend school because of teasing or the pressure to dress in attire stereotypical of their assigned sex. Most children deny being disturbed by the disorder, except that it brings them into conflict with the expectations of their families or peers.








Table 18-1 DSM-IV-TR Diagnostic Criteria for Gender Identity Disorder








































































A.

A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four (or more) of the following:

(1)

repeatedly stated desire to be, or insistence that he or she is, the other sex

(2)

in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3)

strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4)

intense desire to participate in the stereotypical games and pastimes of the other sex

(5)

strong preference for playmates of the other sex


In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.


B.

Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.

In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.


C.

The disturbance is not concurrent with a physical intersex condition.


D.

The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Code based on current age:

Gender identity disorder in children

Gender identity disorder in adolescents or adults


Specify if (for sexually mature individuals):

Sexually attracted to males

Sexually attracted to females

Sexually attracted to both

Sexually attracted to neither


From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text rev. Washington, DC: American Psychiatric Association; copyright 2000, with permission.




The parents of a 7-year-old boy came for consultation because the boy had told his parents on several occasions that he would like to be a girl. From 2 to 3 years of age, he

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Jun 8, 2016 | Posted by in PSYCHIATRY | Comments Off on Gender Identity Disorders

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