Gender Identity Disorder in Adolescents or Adults (302.85)

DSM-IV-TR criteria

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the opposite sex, frequent dressing as the opposite sex, desire to live or be treated as the opposite sex, or the conviction that he or she has the typical feelings and reactions of the opposite sex.
Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of their sex. 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.
The disturbance is not concurrent with a physical intersex condition.
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if (for sexually mature individuals): Sexually attracted to males, Sexually attracted to females, Sexually attracted to both, Sexually attracted to neither

Associated features

Differentiation of sex vs. gender – The terms sex and gender are commonly, mistakenly, considered interchangeable. Stoller (1968) defines sex as the sum of overt anatomical and physiological differences between male and female. Gender, separate from sex, refers to the sum of behavioral or psychological differences between the sexes.
General descriptive features – Individuals with GID experience strong, persistent desires to live as the opposite sex. These desires lead to pervasive distress over their assigned sex. Adults, often independent of immediate familial pressures, may seek hormonal treatment or gender reassignment surgery in order to pass as the opposite sex. This appearance is further enhanced by cross-dressing. Tension may exist between individuals with GID and their families; tension is typically greater when the subject is male, though generally neither males nor females are supported by their families in matters relating to their dissatisfaction with their assigned sex. In extreme cases, individuals with GID may resort to mutilation of, or self-removal of, their genitalia.
Physical examination findings – individuals with GID generally have normal, rather than ambiguous, genitalia, which debunks the notion that GID onset may be related to ambiguous genitalia. Hormonal treatments may result in noticeable increases in breast size in males. Individuals with GID may also resort to plastic surgery or surgical reduction of the Adam’s apple in order to complete their desired appearances.

Adolescent vs adult presentation

Adolescent presentation – Adolescents with GID are at a greater risk for depression, thoughts relating to suicide, and suicide attempts. In adolescents, GID presentation may resemble child or adult presentation depending on the level of development. Criteria are applied accordingly, but assessment of developmental levels may take considerable time in order to assure the valid application of said criteria. Younger adolescents may be difficult to diagnose because lack of cooperation from the child to discuss their feelings, particularly if they are concerned with how their families may react. Subjects may be referred to a clinic for issues concerning poor social integration with peers.
Adult presentation – Adults with GID commonly experience anxiety and depressive symptoms. Adult individuals with GID experience frustrations with their biological sex and frequently cross-dress in the privacy of their homes. Through hormonal treatment and skillful cross-dressing techniques, many adults can convincingly pass for members of the opposite sex. Unless gender reassignment surgery has been performed, sexual activity is typically limited by individuals’ insistence that partners abstain from touching or seeing their genitalia.

Gender and cultural differences in presentation

Gender – Typically, females with GID are more accepted than males with GID, this is because men are often ostracized (with considerable severity). Females generally experience less peer rejection and ridicule. In clinical settings, males outnumber females at a ratio as high as 3:1, and males are at a higher risk for associated Personality Disorders.
Culture – GID seems to be more present in males than females across cultures, but cultural acceptance is highly varied. In Western culture, GID is pathologized and individuals with the disorder, particularly males, are heavily stigmatized. In Native American cultures, such individuals are received differently; individuals who assume the roles of the opposite sex are known as the Two-Spirit. As the name suggests, the two-spirited are those who have both male and female spirits. Two-Spirits perform the work of the opposite sex and don garments appropriate for their new roles. This concept appears to be consistent across contemporary Native American cultures.

Epidemiology

Prevalence – Due to the stigma associated with GID, epidemiologists have encountered great difficulties in determining its prevalence; it is considered relatively rare even when accounting for underreporting due to the fear of stigmatization. The Meyer-Bahlburg (1985) study suggests a 1 in 30,000 occurrence in men and a 1 in 100,000 occurrence in women. Another study (Bakker, van Kesteren, Gooren, & Bezemer, 1993) suggests higher rates based on the prevalence of hormonal treatments for persons suffering from gender-identity-related problems in the Netherlands.
Course – Typically, gender dysphoria in childhood subsides before adulthood is reached, but some studies suggest that its previous presence may influence sexual orientation. Individuals with gender dysphoria in childhood sometimes reconcile their issues by identifying themselves as homosexual during adolescence. GID can follow two courses in adulthood. The first course is a continuation of GID that has persisted through childhood. The second course is characterized by a gradual onset beginning in early to mid-adulthood that follows, or is comorbid with, Transvestic Fetishism. Both forms of GID present in adulthood are persistent, but spontaneous remissions have been noted.

Etiology

Biological factors – A great deal of research has been dedicated to assessing the effects of biological factors in determining risk for GID. Current research is inconsistent and exiguous, and much of it concerns the sensitive topic of homosexuality rather than GID directly. Some studies attempt to link GID with prenatal hormone environments; it has been posited that DES (diethylstilbesterol), a drug thought to prevent miscarriages that has the side effect of exposing the fetus to abnormally high levels of testosterone, results in masculine behavioral patterns in females. This hypothesis is not well supported, due to there being few differences between subjects exposed to this drug and control subjects. Other studies suggest physical attractiveness as a factor in GID. Typically, males with GID are rated as more physically attractive, while females with GID are rated as less physically attractive. It has been hypothesized that parental behavior may influence notions of gender identity in children. For example, a boy with a feminine appearance may be dressed in non-masculine accoutrement; the imaged imposed upon him by his parents may influence his notions of appropriate masculine behavior in later life. Limited research studying GID and twins has shown that if one twin has GID, the other is more likely to have it as well. This would provide good support for biological theories, but very small sample sizes have made it difficult to examine this hypothesis thoroughly.
Psychosocial factors – Sex assignment at birth has been hypothesized as a determining factor of GID. Infants born with ambiguous genitalia who are assigned sex roles typically develop gender identities consistent with their assigned roles; however, supporters of said hypothesis maintain that if these roles are not decisively reinforced, subjects may develop GID. Social reinforcement is also considered a deciding factor in the development of GID. A lack of corrective measures taken when observing play patterns inconsistent with that of an individual’s sex has been associated with the development of GID. The quality of parenting as a factor has been examined; Zucker & Bradley (1995) suggested that mothers diagnosed with mental illnesses may be less capable in their parenting, which may increase the likelihood of GID onset. Similarly, Coates (1985) and Green (1987) suggested that distant or absent fathering may be linked to GID onset.

Empirically supported treatments

Psychotherapy – Psychotherapy has proven useful in interventions, though its effectiveness is dependent upon how early it is administered. The purpose of this treatment is to help individuals cope with their biologically determined sex and reinforce the behavioral patterns associated with those roles. This method may reduce transsexual behavior in later life.
Hormonal treatment and surgery – Adults with GID may request surgical reassignment of sex. Individuals who desire this treatment have typically experienced hormonal therapy to reduce undesired secondary sex characteristics and to develop those present in the opposite sex. Hormonal treatment causes breast growth and reductions of facial hair in males and cessation of menstruation, increases in body hair, and voice deepening effects in females. Subjects are typically required to live as the opposite sex with hormonal treatment for a year or more before surgery is considered an option.
Past treatments have included various behavioral therapies targeted toward changing the individual’s social and sexual behaviors to be more stereotypically masculine or feminine, including behavioral modification of vocal characteristics, sexual fantasies, patterns of sexual arousal, even movements and posture.
In contrast, current treatment, as outlined by the Standards of Care, includes three principal elements comprising a ” triadic therapy.” These elements include living as the desired gender, hormone therapy, and sex reassignment surgery- although not all individuals will desire, or complete, all three steps.

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 appropriate for one’s birth sex is unlikely to occur.