Gender Identity Disorder | Description | Prevention | Causes and symptoms | Treatment
Definition
Gender identity disorder is a condition characterized by a persistent feeling of discomfort or inappropriateness concerning one’s anatomic sex. The disorder typically begins in childhood withgender identity disconnects and is manifested in adolescence or adulthood by a person dressing in clothing associated with the desired gender, as opposed to one’s birth gender and exhibiting other behaviors associated with the self-perceived sex identity. In extreme cases, persons with genderidentity disorder may seek gender reassignment surgery, also known as a sex-change operation.
Description
Gender identity disorder is distressing to those who have it. It is especially difficult to cope with because it remains unresolved until gender reassignment surgery has been performed. Most people with this disorder grow up feeling rejected and out of place. Suicide attempts and substance abuse are common. Most adolescents and adults with the disorder eventually attempt to pass or live as members of the opposite sex.
Gender identity disorder may be as old as humanity. Cultural anthropologists and other scientists have observed a number of cross-gender behaviors in classical and Hindu mythology, Western and Asian classical history, and in many late nineteenth- and early twentieth-century pre-literate cultures. This consistent record across cultures and time lends support to the notion that the disorder may be, at least in part, biological in origin. Not all behavioral scientists share this conclusion, however.
Behavioral experimentation, particularly when a child is young, is considered normal. As they grow, children will often experiment with a variety of gender role behaviors as they learn to make the fine distinctions between masculine and feminine role expectations of the society in which they live. Some young boys occasionally exhibit behaviors that Western culture has traditionally labeled “feminine.” Examples of these behaviors include wearing a dress, using cosmetics, or playing with dolls.
In a similar manner, some young girls will occasionally assume masculine roles during play. An example of this behavior includes pretending to be the father when playing house. Some girls temporarily adopt a cluster of masculine behaviors. These youngsters are often designated as tomboys. Most experts agree that such temporary or episodic adopting of behaviors opposite to one’sgender is normal and usually constitute learning experiences in the acquisition of normal sex role socialization.
In cases that are considered pathological, however, children deviate from the typical model of exploring masculine and feminine behaviors. Such children develop inflexible, compulsive, persistent, and rigidly stereotyped patterns. On one extreme are boys who become excessively masculine. The opposite extreme is seen in effeminate boys who reject their masculinity and rigidly insist that they are really girls or that they want to become mothers and bear children.
Boys with these traits frequently avoid playing with other boys, dress in girls’ clothing, play predominantly with girls, try out cosmetics and wigs, and display stereotypically feminine gait, arm movements, and body gestures. Although much less common, some girls may similarly reject traditionally feminine roles and mannerisms in favor of masculine characteristics, including a refusal to urinate sitting down. Professional intervention is required for both extremes of gender behavior.
This disorder is different from transvestitism or transvestic fetishism , in which cross-dressing occurs for sexual pleasure. Furthermore, the transvestite does not identify with the other sex.
Adults with gender identity disorder sometimes live their lives as members of the opposite sex. They often cross-dress and prefer to be seen in public as a member of the other sex. Some people with the disorder seek sex reassignment surgery.
Persons with gender identity disorder frequently state that they were born the wrong sex. They may describe their sexual organs as being ugly and may refrain from touching their genitalia. People with gender identity disorder may also try to hide their secondary sex characteristics. For instance, males may try to shave off or pluck their body hair. Many men elect to take estrogens in an effort to enlarge their breasts. Females may try to hide their breasts by binding them. There is a growing movement among people who consider themselves transgendered to demand that the condition not be viewed or classified as a disorder but as part of a spectrum of sexual development.
Causes and symptoms
Causes
There is no clearly understood or universally agreed-upon cause for gender identity disorder. However, most experts agree that there may be a strong biological basis for the disorder.
The sex of a human baby is determined by chromosomes. Males have a Y chromosome and one X chromosome, while females have two X chromosomes. The Y chromosome carries a gene known as the testis-determining factor. This gene sets off a developmental pathway that is typically “male,” resulting in testes development and development of secondary sexual structures that are male, including a penis and scrotum and differentiation in the fetal brain . Embryos lacking testis-determining factor usually develop as females. The newly formed testes are responsible for releasing the hormones that continue the fetus on a male developmental pathway.
These prenatal events provide the biological basis for gender identity disorder. Hormone levels must be appropriate for male development during the appropriate developmental windows for typical male development to occur. In addition, the cellular pathways that recognize the signals the hormones send must also be in place. Changes in hormone levels from the norm or exposure to environmental compounds that behave like hormones in the fetus can alter male development, resulting in a feminized fetus if this alteration ends in inhibition of typical male development.
Disruptions of hormone signaling may arise from a variety of sources, including a disorder in the mother’s endocrine system, maternal stress , maternal medications, and some environmental, endocrine-active substances.
Post-mortem studies conducted on male-to-female transsexuals, non-transsexual men, and non-transsexual women show a significant difference in sex-specific brain structures. Studies have shown that in male-to-female transsexuals, for example, brain structures look like those of nontransgendered women. These studies indicate that one’s sense of gender resides in the brain and that it may be biochemically determined. A hypothesis underlying the link between gonadal sex and the sex of the brain is the organization-activation hypothesis. According to this hypothesis, the hormones that organize the body as masculine, e.g, result in the formation of a penis rather than a clitoris, also organize the brain as masculine. At puberty, hormones activate the brain for gender-specific sex behavior. In some cases, there may be a disconnect between gonadal development and brain sexual development.
In addition to biological factors, environmental conditions, such as socialization, are thought by some to contribute to gender identity disorder. Social learning theory, for example, proposes that a combination of observational learning and different levels and forms of reinforcement by parents, family, and friends determine a child’s sense of gender, which, in turn, leads to what society considers sex-appropriate or inappropriate behavior. Recent research, however, suggests that even when people who are transgendered or born with ambiguous genitalia are reared based on their “assigned” sex, they still retain their perceived sexual identity.
Symptoms
The onset of puberty increases the difficulties for people with gender identity disorder. The subsequent development of unwanted secondary sex characteristics, especially in males, increases a person’s anxiety and frustrations. In an effort to cope with their feelings, some men with genderidentity disorder may engage in stereotypical, or even super-masculine, activities. For example, a man struggling with the disorder may engage in such “macho” sports as wrestling and football in order to feel more “male.” Unfortunately, the result is usually an increase in anxiety.
This anxious state is characterized by feelings of confusion, shame, guilt, and fear. These individuals are confused over their inability to handle their problem. They feel shame over their inability to control what society considers “perverse” activities. Even though cross-dressing and cross-gender fantasies provide relief, the respite is temporary. These activities often leave individuals with a profound shame over their thoughts and activities.
Closely associated with shame is guilt, particularly about being dishonest with family and friends. Sometimes people with gender identity disorder marry and have children without telling their spouse about their disorder. Typically, their self-identity is kept secret because they have the mistaken conviction that participation in marriage and parenting will eliminate their problems or “cure” them. The fear of being discovered further raises their anxiety. With some justification, people withgender identity disorder fear being labeled “sick” and being rejected and abandoned by people they love.
If an individual’s gender identity disorder is profound, a lifestyle adaptation such as occasional cross-dressing may be insufficient. In such a case, gender expression may move from a lifestyle problem to a life-threatening imperative. The result can be extreme depression that requires medical treatment. If sufficiently severe, the imperative may result in gender reassignment surgery. If an individual lacks the psychological commitment to undertake surgery, the result may be suicide.
Demographics
Gender identity disorder is more prevalent in males than in females. Reliable estimates of prevalence for either males or females are not available.
Diagnosis
A mental health professional makes a diagnosis of gender identity disorder by taking a careful personal history. He or she obtains the age of the patient and determines whether the patient’s sexual attraction is to males, females, both, or neither. Laboratory tests are neither available nor required to make a diagnosis of gender identity disorder. However, it is very important not to overlook a physical illness such as a tumor that might mimic or contribute to a psychologicaldisorder. If there is any question that a physical problem might be the underlying cause of an apparent gender identity disorder, a mental health professional should recommend a complete physical examination by a medical doctor. Laboratory tests might be necessary as components of the physical evaluation.
According to the clinician’s handbook for diagnosing mental disorders, the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revised (DSM-IV-TR), the following criteria must be met to establish a diagnosis of gender identity disorder.
· a strong and persistent cross-gender identification
· persistent discomfort with his or her sex or having a sense of inappropriateness in the gender role of one’s birth sex
· the disturbance is not concurrent with a physical intersex condition, in which a person is born, for example, with the genitalia that exhibit male and female characteristics
· the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
A strong and persistent cross-gender identification
In children, the disturbance is manifested by four (or more) of the following:
· repeatedly stating a desire to be, or insistence that he or she is, a member of the other sex
· strong preference for wearing clothes of the opposite gender. In boys, displaying a preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
· displaying strong and persistent preferences for cross-sex roles in make-believe play or experiencing persistent fantasies of being a member of the other sex
· having an intense desire to participate in the games and pastimes that are stereotypical of the other sex
· exhibiting a strong preference for playmates of the other sex
Among adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to become a member of the other sex, frequent passing as a person of the other sex, a 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. These characteristics cannot be merely from a desire for any perceived cultural advantages of being the other sex.
Persistent discomfort with his or her sex or having a sense of inappropriateness in the gender role of one’s birth sex
Among children, the disturbance is manifested by any of the following:
· among boys, asserting that his penis or testes are disgusting or will disappear, asserting that it would be better not to have a penis, or having an aversion toward rough-and-tumble play and rejecting male stereotypical toys, games, and activities
· among girls, rejecting the gender-typical practice of urinating in a sitting position, asserting that she has or will grow a penis, or stating that she does not want to grow breasts or menstruate, or having a marked aversion toward normative feminine clothing
Among 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 alter sexual characteristics to simulate the other sex) or a belief that he or she was born the wrong sex.
Treatments
One common form of treatment for gender identity disorder is psychotherapy. The initial aim of treatment is to help individuals function in their biologic sex roles to the greatest degree possible. The World Professional Association for Transgender Health, which has formulated and published its ownStandards of Care manual for working with transgendered people, does not support psychotherapy designed to “convert” a transgendered person from their own personal perception of their sex.
Adults who have had severe gender identity disorder for many years sometimes request reassignment of their sex, or sex-change surgery. Before undertaking such surgery, they usually undergo hormone therapy to suppress same-sex characteristics and to accentuate other-sex characteristics. For instance, the female hormone estrogen is given to males to make breasts grow, reduce facial hair, and widen hips. The male hormone testosterone is administered to females to suppress menstruation, deepen the voice, and increase body hair. Following the hormone treatments, pre-operative candidates are usually required to live in the cross-gender role for at least a year before surgery is performed.
KEY TERMS
Cross-dressing —Wearing clothing and other attire typically associated with the opposite sex.
Paraphilia —A disorder that is characterized by recurrent intense sexual urges and sexually arousing fantasies generally involving non-human objects, the suffering or humiliation of oneself or one’s partner (not merely simulated), or children or other non-consenting persons.
Transsexual —A person whose gender identity is opposite his or her biologic sex.
Transvestite —A person who derives sexual pleasure or gratification from dressing in clothing of the opposite sex.
Prognosis
If gender identity disorder persists into adolescence, it tends to be chronic in nature. There may be periods of remission. However, adoption of characteristics and activities typical for one’s birth sex is unlikely to occur.
Most individuals with gender identity disorder require and appreciate support from several sources. Families, as well as the person with the disorder, need and appreciate both information and support. Local and national support groups and informational services exist, and health care providers and mental health professionals can provide referrals.
Resources
BOOKS
American Psychiatric Association. Diagnostic and Statistical Manual. 4th ed., text rev. Washington, D.C.: American Psychiatric Association, 2000.
Gelder, Michael, Richard Mayou, and Philip Cowen. Shorter Oxford Textbook of Psychiatry. 4th ed. New York: Oxford University Press, 2001.
Wilson, Josephine F. Biological Foundations of Human Behavior. New York: Harcourt, 2002.
PERIODICALS
Green, R. “Family concurrence of ‘gender dysphoria’: Ten sibling or parent-child pairs.” Archives of Sexual Behavior 29.5 (2000): 499–507.
Marks, I., R. Green, and D. Mataix-Cols. “Adult Gender Identity Disorder can Remit.”Comprehensive Psychiatry 41.4 (2000): 273-5.
Reiner, William G. “Gender Identity and Sex-of-rearing in Children With Disorders of Sexual Differentiation.” Journal of Pediatric Endocrinology and Metabolism 18 (2005): 549–53.
Wylie, Kevan. “ABC of Sexual Health: Gender Related Disorders.” British Medical Journal 329 (2004): 615–19.
Zucker, K. J., N. Beaulieu, S. J. Bradley, G. M. Grimshaw, and A. Wilcox. “Handedness in boys withgender identity disorder.” Journal of Child Psychology and Psychiatry 42.6 (2001): 767–76.
ORGANIZATIONS
American Academy of Family Physicians. 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672. Telephone: (913) 906-6000. Web site: <http://www.aafp.org>.
American Academy of Pediatrics. 141 Northwest Point Boulevard, Elk Grove Village, IL 60007-1098. Telephone: (847) 434-4000. FAX: (847) 434-8000. Web site: <http://www.aap.org/default.htm>.
American Medical Association. 515 N. State Street, Chicago, IL 60610. Telephone: (312) 464-5000. Web site: <http://www.ama-assn.org>.
American Psychiatric Association. 1400 K Street NW, Washington, DC 20005. Telephone: (888) 357-7924. Fax: (202) 682-6850.
American Psychological Association. 750 First Street NW, Washington, DC 20002-4242. Phone: (800) 374-2721 or (202) 336-5500. Web site: <http://www.apa.org>.
World Professional Association for Transgender Health. 1300 South Second Street, Suite 180 Minneapolis, MN 55454. Telephone: (612) 624-9397. Fax: (612) 624-9541. <http://www.wpath.org/IJT.htm>.
L. Fleming Fallon, Jr., MD, Dr.PH
Emily Jane Willingham
