Gender identity disorder (gender dysphoria)

• What is gender identity disorder?
• Statistics on gender identity disorder
• Risk factors for gender identity disorder
• Progression of gender identity disorder
• Symptoms of gender identity disorder
• Clinical examination of gender identity disorder
• Prognosis of gender identity disorder
• How is gender identity disorder treated?
• References

What is gender identity disorder?

Gender identity disorder is the existence of persistent feelings that your mind and body are of differing genders. It is a sense of inappropriateness of one’s anatomic sex.
Boys with gender identity disorder see themselves as girls and vice versa. This is distinct from homosexuality – people with gender identity disorder may be attracted to the same or the opposite sex, but they feel that their own biological sex is “wrong” and doesn’t represent their actual gender identity.

Statistics on gender identity disorder

Almost no information is available about the prevalence of gender identity disorders among children, teenagers, and adults. Most estimates of prevalence are based on the number of people seeking sex-reassignment surgery, which exhibits a male preponderance. The sex ratio between boys and girls from various child gender identity clinics varies from 30:1 to 6:1, therefore this is clearly a disorder that affects males more than females. However this may indicate a greater male vulnerability to gender identity disorders or a greater sensitivity to and worry about cross-gender-identified boys than girls.

Risk factors for gender identity disorder

The causative factors relating to the development of this disorder can be divided into various biological and psychosocial factors. Biological factors pertain to the role of androgens in the development of gender identity disorders. Maleness and masculinity depend on foetal and perinatal androgens. Sex steroids influence the expression of sexual behaviour in mature men or women. Testosterone affects neurons in the brain that contribute to the masculinisation of the brain in areas such as the hypothalamus. However whether testosterone contributes to masculine or feminine behavioural patterns in gender identity disorders is controversial.
Psychosocial factors include the formation of gender identity. This is influenced by the interaction of the child’s temperament and parents’ qualities and attitudes. Freud believed that gender identity problems resulted from conflicts experienced by children within the oedipal triangle. Whatever interferes with a child’s loving the opposite sex parent and identifying with the same sex parent interferes with normal gender identity. The quality of the mother-child relationship in the first years of life, and the father’s role in the early years all play a substantial role in the development of the child’s gender identity.

Progression of gender identity disorder

The DSM-IV diagnostic criteria for gender identity disorder include:
A. A strong and peristent 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 pastimes and games 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 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.
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.
Age of onset: boys begin to have the disorder before the age of 4 years. Girls also have an early onset, but most give up masculine behaviour by adolescence.
In both cases, homosexuality is likely to develop in one to two thirds of all cases, however fewer girls than boys have a homosexual orientation. Transsexualism (the desire for sex-reassignment surgery) occurs in less than 10% of cases.
Impaired social and occupational functioning is common, as a result of the person wanting to participate in the desired gender role. Depression is therefore a common associated problem.

Prognosis of gender identity disorder

The prognosis for gender identity disorder depends on the age of onset and the intensity of the symptoms. For a positive outcome to be achieved early diagnosis is required.

How is Ggender identity disorder treated?

Treatment of gender identity disorders is complex and is rarely successful when the goal is to reverse the disorder.
Children
Improve existing role models or, in their absence, provide one from the family or elsewhere. Caregivers are helped to encourage sex-appropriate behaviour and attitudes. Any associated mental disorder should be addressed.
Adolescents
Are difficult to treat due to the coexistence of normal identity crises and gender identity confusion. Acting out is common, and adolescents rarely have a strong motivation to alter their stereotypic cross-gender roles.
Adults
i) Psychotherapy, with the goal of helping patients to become comfortable with the gender identity they desire. Also explores sex-reassignment surgery and the indications and contraindications for such procedures.
ii) Sex-reassignment surgery. This is definitive and irreversible. Patients must go thru a 3 to 12 month trial of cross dressing and receive hormone treatment. 70-80% of patients are dissatisfied with the results. A reported 2% commit suicide.
iii) Hormonal treatments. In this case patients are treated with hormones in lieu of surgery.

Gender Identity Disorder References

[1] Kaplan, H.I. & Sadock, B.J. 2002, Kaplan and Sadock’s Synopsis of Psychiatry, Lippincott Williams & Wilkins, Maryland.