Gender identity disorder

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 with gender identity problems and is manifested in adolescence or adulthood by a person dressing in clothing appropriate for the desired gender, as opposed to one's birth gender. In extreme cases, persons with gender identity 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.

Gender identity and gender-appropriate behaviors are generally learned. This learning first occurs at home and later outside the home. 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's gender is normal and usually constitute learning experiences in the acquisition of normal sex role socialization.

In pathological cases, however, children deviate from the normal 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.

Such males 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. 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 request sex-change or sex reassignment surgery.

Persons with gender identity disorder frequently complain 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 try to hide their secondary sex characteristics. For instance, males may try to shave off or pluck their body hair. Many elect to take female hormones in an effort to enlarge their breasts. Females may try to hide their breasts by binding them.

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, in addition to a X chromosome, while females have two X chromosomes. The Y chromosome contains a gene known as the testes determining factor. This gene causes cells in an embryo to differentiate and develop male genitals. Embryos without the testes determining factor continue to develop undifferentiated as females.

The newly formed male testes release significant quantities of male hormones during the third month of pregnancy, further enhancing male differentiation. This sudden surge of hormones occurs again in males sometime between the second and twelfth week after birth. It is important to note that there is no corresponding feminizing hormonal surge sequence observed in females at this age.

These facts provide the biological basis for gender identity disorder. Male hormonal surges must occur not only in sufficient amounts, but also during a short window of time to cause masculinization of the developing infant. If there is insufficient androgen, the hormone primarily responsible for masculinization, or the surge comes too early or too late, the developing infant may be incompletely masculinized.

Disruptions of hormonal surges may come from a variety of sources. A partial list includes a disorder in the mother's endocrine system, common maternal stress , or maternal medications or some other toxic substances yet to be identified.

Recent post-mortem studies conducted on male-to-female transsexuals, non-transsexual men, and non-transsexual women show a significant difference in the volume of a portion of the hypothalamus that is essential for sexual behavior. While further investigations are needed, these initial studies seem to confirm that one's sense of gender resides in the brain and that it may be chemically determined.

In addition to biological factors, environmental conditions, such as socialization, seem 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.

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 gender identity disorder may engage in stereo-typical, 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 get married and have children without telling their spouse about their disorder. Typically, it is kept secret because they have the mistaken conviction that participation in marriage and parenting will eliminate or cure their gender identity problems. The fear of being discovered further raises their anxiety. With some justification, people with gender 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 change 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. Accurate 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 psychological disorder. 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. More specific descriptions and examples of the first two criteria follow the list.

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, such as hermaphroditism in which a person is born with the genitalia of both male and female.
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 (request for hormones, surgery, or other procedures to alter sexual characteristics to simulate the other sex, for example) 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 earlier the intervention, the greater likelihood of success. Early intervention can lead to reduced levels of transsexual behavior later in life. The initial aim of treatment is to help individuals function in their biologic sex roles to the greatest degree possible.

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 approximately a year before surgery is performed.

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.

Prevention

Providing gender-appropriate clothing and toys in infancy and early childhood is helpful in preventing or mitigating gender identity disorder. Avoiding derogatory comments about a child's toy, clothing, or activity preference reduces the potential for inadvertent psychic harm.

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. Fourth edition, text revised. 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, no. 5 (2000): 499-507.

Marks, I., R. Green, and D. Mataix-Cols. "Adult gender identity disorder can remit." Comprehensive Psychiatry 41, no. 4 (2000): 273-275.

Zucker, K. J., N. Beaulieu, S. J. Bradley, G. M. Grimshaw, and A. Wilcox. "Handedness in boys with gender identity disorder." Journal of Child Psychology and Psychiatry 42, no. 6 (2001): 767-776.

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> .

L. Fleming Fallon, Jr., M.D., Dr.P.H.