Gender Identity Disorder (GID)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is undergoing substantial revisions. [1] Currently in its fourth edition, the DSM-IV will be replaced by the DSM-V. [2] In late 2012, the American Psychiatric Association announced that the upcoming DSM-V will no longer recognize gender identity disorder as a medical condition. The DSM-V revision will instead use the term “gender dysphoria” to apply to individuals who experience dysphoria associated with their gender identity. [3]
There have been long-standing debates on the use of the term “gender identity disorder” because the disorder is characterized by feelings of distress over one’s gender identity. [4] The DSM-V revision seeks to de-classify the connection between transsexualism and gender identity disorder because not all transsexuals are distressed over their gender identity. This is particularly important for individuals who have transitioned and suffer from no residual mental distress over their gender identity.
Gender Identity Disorder is the most commonly diagnosed mental health condition that applies to transsexuals. It does not apply to crossdressers, Drag Kings/Queens, Intersex individuals, androgynous individuals, or transvestites, the reason being is that only transsexuals are the ones who are uncomfortable in their pre-transition gender or who feel uncomfortable or unfit in that gender. Gender Identity Disorder is not co-synonymous with transsexualism. Not all transsexuals experience gender identity disorder.

Diagnosis

Gender Identity Disorder, aka GID, is defined by persistent cross-gender identification without an intersex condition present. The person with GID must be distressed or show considerable impairment in functioning to have GID, otherwise their transgenderism is not classified as a psychological disorder. The intersex condition is present even if all physical signs of it have been altered. Gender Identity Disorder cannot be diagnosed if the cross-gender identification is only evident because of a wish for a different social standing. Gender Identity Disorder can be diagnosed in children, because children, just as adults, may have a different gender identification than their actual physical sex.
The American Psychiatric Association has pinpointed the exact diagnoses and criteria for GID. This criteria is what all psychiatrists and most therapists use to diagnose the condition.

Diagnostic Features

There are two components of Gender Identity Disorder, both of which must be present to make the diagnosis. These must be evidence of a strong and persistent gross-gender identification, which is the desire to be, or the insistence that one is of the other sex (Criteria A). This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one’s assigned sex or a sense of inappropriateness in the gender role of that sex (Criteria B). The diagnosis is not made if the individual has a concurrent physical intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) (Criteria C). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criteria D).

Gender Identity Disorder (GID) in Children: Boys

In boys, the cross gender identification is manifested by a marked preoccupation with traditionally feminine activities. They may have a preference for dressing in girls’ or women’s clothes or may improvise such items from available materials when genuine articles are unavailable. Towels, aprons, and scarves are often used to represent long hair or skirts. There is a strong attraction for the stereotypical games and pastimes of girls. They particularly enjoy playing house, drawing pictures of beautiful girls and princesses, and watching television or videos of their favorite female-type dolls, such as Barbie, are often their favorite toys, and girls are their preferred playmates. When playing “house”, these boys role-play female figures. Most commonly “mother roles”, and often are quite preoccupied with female fantasy figures. they avoid rough-and-tumble play and competitive sports and have little interest in cars and trucks or other no-aggressive but stereotypical boy’s toys. They may express a wish to be a girl and assert that they will grow up to be a woman. they may insist on sitting to urinate and pretend not to have a penis by pushing it in between their legs. More rarely, boys with Gender Identity Disorder may state that they find their penis or testes disgusting, that they want to remove them, or that they have, or wish to have, a vagina.

Gender Identity Disorder (GID) in Children: Girls

Girls with Gender Identity Disorder display intense negative reactions to parental expectations or attempts to have them wear dresses or other feminine attire. Some may refuse to attend school or social events where such clothes may be required. They prefer boy’s clothing and short hair, are often misidentified by strangers as boys, and may ask to be called a boy’s name. Their fantasy heroes are most often powerful male figures, such as Batman or Superman. These girls prefer boys as playmates, with whom they share interests in contact sports, rough-and-tumble play and traditional boyhood games. They show little interest in dolls or any form of feminine dress up or role-play activity. A girl with this disorder may occasionally refuse to urinate in a sitting position. She may claim that she has or will grow a penis and may not want to grow breasts or menstruate. She may assert that she will grow up to be a man. Such girls typically reveal marked cross-gender identification in role-play, dreams and fantasies.

Gender Identity Disorder (GID) in Adults

Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex. This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Adults with this disorder are uncomfortable being regarded by others as, or functioning in society as, a member of their designated sex. To varying degrees, they adopt the behavior, dress, and mannerisms of the other sex. In private, these individuals may spend much time cross-dressed and working on the appearance of being the other sex. Many attempt to pass in public as the other sex. With cross-dressing and hormonal treatment (and for males, electrolysis), many individuals with this disorder may pass convincingly as the other sex. The sexual activity of these individuals with same-sex partners is generally constrained by the preference that their partners neither see nor touch their genitals. For some males who present later in life, (often following marriage), sexual activity with a woman is accompanied by the fantasy of being lesbian lovers or that his partner is a man and he is a woman.

Gender Identity Disorder (GID) in Adolescents

In adolescents, the clinical features may resemble either those of children or those of adults, depending on the individual’s developmental level, and the criteria should be applied accordingly. In younger adolescents, it may be more difficult to arrive at an accurate diagnosis because of the adolescent’s guardedness. This may be increased if the adolescent feels ambivalent about cross-gender identification or feels that it is unacceptable to the family. The adolescent may be referred because the parents or teachers are concerned about social isolation or peer teasing and rejection. In such circumstances, the diagnosis should be reserved for those adolescents who appear quite cross-gender identified in their dress and who engage in behaviors that suggest significant cross-gender identification (e.g., shaving legs in males). Clarifying the diagnosis in children and adolescents may require monitoring over an extended period of time.

Distress or Disability arising from Gender Identity Disorder (GID)

Distress or disability in individuals with Gender Identity Disorder is manifested differently across the life cycle. in young children, distress is manifested by the stated unhappiness about their assigned sex. Preoccupation with cross-gender wishes often interferes with ordinary activities. In older children, failure to develop age-appropriate same sex peer relationships and skills often leads to isolation and distress, and some children may refuse to attend school because of the teasing or pressure to dress in attire stereotypical of their assigned sex. in adolescents and adults, preoccupation with cross-gender wishes often interferes with ordinary activities. Relationship difficulties are common and functioning at school or at work may be impaired.

Specifiers for sexually mature individuals

For sexually mature individuals, the following specifiers may be noted based on the individual’s sexual orientation: Sexually Attracted to Males, Sexually Attracted to Females, Sexually Attracted to Both, and Sexually Attracted to Neither. Males with Gender Identity Disorder include substantial proportions with all four specifiers. Virtually all females with Gender Identity Disorder will receive the same specifier-Sexually Attracted to Female- although there are exceptional cases involving females who are sexually Attracted to Males.

Recording Procedures

The assigned diagnostic code depends on the individual’s current age: if the disorder occurs in childhood, the code 302.6 is used; for an adolescent or adult, 302.85 is used.

Associated features and mental disorders

Associated descriptive features and mental disorders. Many individuals with Gender Identity Disorder become socially isolated. Isolation and ostracism contribute to low self esteem and may lead to school aversion or dropping out of school. Peer ostracism and teasing are especially common sequelae for boys with the disorder. Boys with Gender Identity Disorder often show marked feminine mannerisms and speech patterns. The disturbance can be so pervasive that the mental lives of some individuals revolve only around those activities that lessen gender distress. they are often preoccupied with appearance, especially early in the transition to living in the opposite sex role. Relationships with one or both parents also may be seriously impaired. Some males with Gender Identity Disorder resort to self-treatment with hormones and may very rarely perform their own castration or penectomy. especially in urban centers, some males with the disorder may engage in prostitution, which places them at a high risk for human immunodeficiency virus (HIV) infection. Suicide attempts and Substance-Related Disorders are commonly associated. Children with Gender Identity Disorder may manifest coexisting Separation Anxiety Disorder, Generalized Anxiety Disorder, and symptoms of depression. Adolescents are particularly at risk for depression and suicidal ideation and suicide attempts. In adults, anxiety and depressive symptoms may be present. Some adult males have a history of Transvestic Fetishism as well as other paraphilias. Associated Personality Disorders are more common among males than among females being evaluated at adult gender clinics. Associated laboratory findings. There is no diagnostic test specific for Gender Identity Disorder. In the presence of a normal physical examination, karyotyping for sex chromosomes and sex hormone assays are usually not indicated. Psychological testing may reveal cross-gender identification of behavior patterns.

Associated physical examination findings and general medical conditions

Individuals with Gender Identity Disorder have normal genitalia (in contrast to the ambiguous genitalia or hypogonadism found in physical intersex conditions). Adolescents and adult males with Gender Identity Disorder may show breast enlargement resulting from hormone ingestion, hair denuding from temporary or permanent epilation, and other physical changes as a result of procedures such as rhinoplasty or thyroid cartilage shaving (surgical reduction of the Adam’s Apple). Distorted breasts or breast rashes may be seen in females who wear breast binders. Postsurgical complications in genetic females include prominent chest wall scars, and in generic males, vaginal strictures, rectovaginal fistulas, urethral stenoses, and misdirected urinary streams. Adult females with Gender Identity Disorder may have a higher than expected likelihood of polycystic ovarian disease. Specific Age and Gender Features Females with Gender Identity Disorders generally experience less ostracism because of cross-gender interests and may suffer less from peer rejection, at least until adolescence. In child clinic samples, there are approximately five boys for each girl referred with this disorder. In adult clinic samples, men outnumber women by about two or three times. In children, the referral bias towards males may partly reflect the greater stigma that gross-gender behavior carries for boys than for girls.

Prevalence

There are no recent epidemiological studies to provide data on prevalence of Gender Identity Disorder. Data from smaller countries in Europe with access to total population statistics and referrals suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery.

Course

For clinically referred children, onset of cross-gender interests and activities is usually between ages 2 and 4 years, and some parents report that their child has always had cross-gender interests. Only a very small number of children with gender Identity Disorder will continue to have symptoms that meet criteria for Gender Identity Disorder in later adolescence or adulthood. Typically, children are referred around the time of school entry because of parental concern that what they regarded as a phase does not appear to be passing. Most children with Gender Identity Disorder display less overt cross-gender behaviors with time, parental intervention, or response from peers. By late adolescence or adulthood, about three-quarters of boys who had a childhood history of Gender Identity Disorder report a homosexual or bisexual orientation, but without concurrent Gender Identity Disorder. Most of the remainder report a heterosexual orientation, also without concurrent Gender Identity Disorder. The corresponding percentages for sexual orientation in girls are not known. some adolescents may develop a clearer cross-gender identification and request sex-reassignment surgery or may continue in a chronic course of gender confusion or dysphoria.
In adult males, there are two different courses for the development of Gender Identity Disorder. The first is a continuation of Gender Identity Disorder that had an onset in childhood or early adolescence. These individuals typically present in late adolescence or adulthood. In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood usually following, but sometimes concurrent with, Transvestic Fetishism. The later-onset group may be more fluctuating in the degree of cross-gender identification, more ambivalent about sex-reassignment surgery, more likely to be sexually attracted to women, and less likely to be satisfied after sex-reassignment surgery. Males with Gender Identity disorder who are sexually attracted to males tend to present in adolescence or early childhood with a lifelong history of gender dysphoria. In contrast, those who are sexually attracted to females, to both males and females, or to neither sex tend to present later and typically have a history of Transvestic Fetishism. If Gender Identity Disorder is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported.

Differential Diagnosis

Gender Identity disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities. This disorder is not meant to describe a child’s nonconformity to stereotypic sex-role behavior as, for example, in “tom-boyishness” in girls or “sissyish” behavior in boys. Rather, it represents a profound disturbance of the individual’s sense of identity with regard to maleness or femaleness. Behavior in children that merely does not fit the cultural stereotype of masculinity or femininity should not be given the diagnosis unless the full syndrome is present, including marked distress or impairment.
Transvestic Fetishism occurs in heterosexual (or bisexual) men for whom the cross-dressing behavior is for the purpose of sexual excitement. Aside from cross-dressing, most individuals with Transvestic Fetishism do not have a history of childhood cross-gender behaviors. Males with presentation that meets full criteria for Gender Identity Disorder as well as Transvestic Fetishism should be given both diagnoses. If gender dysphoria is present in an individual with Transvestic Fetishism but full criteria for Gender Identity Disorder are not met, the specifier With Gender Dysphoria can be used.
The category Gender Identity Disorder Not Otherwise specified can be used for individuals who have a gender identity problem with concurrent congenital intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia).
In Schizophrenia, there may rarely be delusions of belonging to the other sex. Insistence by a person with Gender Identity Disorder that he or she is of the other sex is not considered a delusion, because what is invariably meant is that the person feels like a member of the other sex rather than truly believes that he or she is a member of the other sex. In very rare cases, however, Schizophrenia and severe Gender Identity Disorder may coexist.

Diagnostic Criteria for Gender Identity Disorder

A. A strong 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:

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:

C. The disturbance is not concurrent with 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

302.6 Gender Identity Disorder in Children
302.85 Gender Identity Disorder in Adolescents or Adults Specify if (for sexually mature individuals):

302.6 Gender Identity Disorder Not Otherwise Specified. This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder. Examples include:

References

[1] DSM-IV-TR: Diagnostic and Statistical Manuel of Mental Disorders. Text Revision. American Psychiatric Association. (2000).
[2] Details of DSM-V revisions. American Psychiatric Association. http://www.dsm5.org
[3] Transgender no longer a medical disorder. http://www.salon.com/2012/12/27/transgender_no_longer_a_medical_disorder/ (12/27/2012)
[4] Debates surrounding the DSM-IV diagnostic criteria of gender identity disorder. Wikipedia. http://en.wikipedia.org/wiki/Gender_identity_disorder