Running head: GENDER IDENTITY DISORDER

Gender Identity Disorder Lauren A. Shapiro FOR 6600 - Psychopathology May 5, 2012 Dr. N. Damavandi

GENDER IDENTITY DISORDER Abstract

According to the Diagnostic and Statistical Manual of Mental Disorders, Gender Identity Disorders "are characterized by strong and persistent crossgender identification accompanied by persistent discomfort with one's assigned sex". While the etiology of the disorder remains unknown, therapeutic interventions are being heavily researched in order to provide those afflicted with optimal care. Researchers are hoping to identify whether nature, nurture or an interaction between the two are at the root of the disorder. At the forefront of Gender Identity Disorder debates is the question of whether children can be diagnosed with the disorder. Secondary consideration is given to whether sex-reassignment surgery is necessary or advisable.

GENDER IDENTITY DISORDER Gender Identity Disorder

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), Gender Identity Disorders "are characterized by strong and persistent cross-gender identification accompanied by persistent discomfort with one's assigned sex" (American Psychiatric Association, 2000). This class of disorders can be diagnosed in childhood, adolescence or adulthood (Barlow, Reynolds, & Agras, 1973). These individuals were formerly referred to as transsexuals; although the term continues to persist and remains politically correct. Gender identity is rare, with an estimated prevalence among men of 1 in 30,000; among women 1 in 100,000 (Rekers, 1995). Gender, gender identity, gender roles, transgender, biological sex, and sexuality are all important aspects that are often in conflict in individuals with Gender Identity Disorders (GIDs). Individuals who seek to resolve their persistent cross-gender identification and discomfort with their assigned sex undergo a process of change to live as their desired sex which is referred to as a transition. Individuals who choose to undergo this transition are often referred to as trans people (or transsexual people) or, more specifically, as trans men (female-tomale transitions) and trans women (male-to-female transitions) (Rekers & Kilgus, 1995). According to Jacobs, Thomas and Lang (1997), gender refers to "cultural rules, ideologies, and expected behaviors for individuals". In contrast, biological sex, which is often misconstrued as gender, relates to "one's

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anatomical and reproductive structures... it follows a binary model assigned at birth based on the presence of external genitalia" (Dragowski, Scharron-del Rio, & Sandigorsky, 2011). Therefore, an individual's gender identity relates to the subjective awareness of congruence between one's gender and biological sex (Dragowski et al., 2011). It is important to note that gender is a social construct, "a public display of gender identity", intended to be an archetype of society's expectations of male and female behavioral patterns (Dragowski et al., 2011). Historically, society dictated that there were two discrete biological sexes that corresponded with two distinct genders which inherently gave rise to heterosexuality, opposite-sex attraction. However, these notions have been dispelled by individuals who claim homosexual and bisexual orientations as well as those who allege to have cross-gender identities and those who do not adhere to typical gender roles. As such, recent research endeavors have sought to explain these anomalous gender disconformities by exploring any underlying biopsychosocial mechanisms (Dragowski et al., 2011). Diagnosis "The DSM has consistently approached gender problems from the position that a divergence between the assigned sex "the" physical sex and the "the" psychological sex per se signals a psychiatric disorder" (Cohen-Kettenis & Pfafflin, 2009). Furthermore, the DSM has made it clear that distinctions exists between Gender Identity Disorder in childhood, adolescence and adulthood. The core feature of a gender identity diagnosis is whether the

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individual reports feelings of distress about one's assigned sex; however, other features should be present in making a formal diagnosis. As outlined in the DSM-IV-TR (APA, 2000), a formal diagnosis of Gender Identity Disorder requires: A. A strong and 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: (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 games and pastimes 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 a stated desire to be the other sex, frequent passing as the other sex, desire to live or be

GENDER IDENTITY DISORDER 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. In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-andtumble play and rejection of male stereotypical toys, games and activities; in girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing. In adolescents and adults, the disturbance in 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. C. The disturbance is not concurrent with a physical intersex condition.

GENDER IDENTITY DISORDER D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (APA, 2000) Etiology According to Diamond (2006), the vast majority of gender identity theories conform to a continuum in which nature (biology) is at one extreme and nurture (environment) is at the other; however, "a recent idea gaining

prominence is that both innate and acquired aspects of the human experience are inextricably involved in the development of gender identity."

Nature According to biologically-oriented theorists, nonconforming gender identity can be attributed to "abnormal brain sex differentiation with subsequent gender development occurring along predetermined lines and in conflict with the assigned gender role" (Newman, 2002). In 2006, the Gender Identity Research and Education Society (GIRES) conducted research in hopes of differentiating atypical from typical gender identity development. GIRES was able to identify three separate pathways of atypical gender identity formation. The first is the notion that there is an altered prenatal sex hormone. According to Green and Young (2006), "prenatal diethylstilbestrol (DES) exposure" is associated with a higher prevalence of transsexualism as is the number of successive male pregnancies a woman experiences (Green & Young, 2001). A second pathway, developmental instability, is associated with a

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nonconformist gender identity. It has been posited that a range of stressors found in a child's environment have been linked to Gender Identity Disorder; however, it is believed that a predisposition caused by genetic influences and heritability must be triggered (GIRES, 2006). This perspective is often referred to as the biased interaction theory in which "infants are born with a certain evolutionary heritage, family genetics, and uterine environment influences that bring out a propensity for certain sexual gender patterns' expression that depends upon upbringing and societal values" (Diamond, 2006). The third and final pathway is anatomical brain differences. The GIRES study determined that there are discrepancies between individuals who are comfortable with their assigned-sex and those who identify as cross-gender (GIRES, 2006). Nurture Those who believe that environmental causes are responsible for eliciting Gender Identity Disorder typically align themselves with a psychological perspective. For example, the psychoanalytic perspective stresses the importance of early childhood experiences and identification with parents (Schechner, 2010). Learning theories, on the other hand, underscore the role of imitation, modeling, punishment and reinforcement in gender development. This is to say that a child who is praised for their cross-gender behaviors are more likely to further engage in those type of behaviors. It is important to note that all children are treated differently and that children who are engaged in sextyped play behaviors are encouraged while those who do not conform to expectations are often belittled, ridiculed or punished (Dragowski et al., 2011).

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Others subscribe to the social constructivist perspective which emphasize the "social construction of gender against the backdrop of time, place and social experience of people" (Dragowski et al., 2011). Cognitive theories focus on children's knowledge about gender and behavior expectations and assume that children act in accordance with what they know and understand about gender and gender-behaviors. It is important to note that, while each of these perspectives is strong in their own right, an integrative perspective exists. The integrative perspective assumes that Gender Identity Disorder is a product of complex biological and psychological processes in which each person is unique and therefore "involves a variety of genetic, hormonal and environmental factors, acting separately or in combination with each other" (GIRES, 2006) Treatment Based on research and ethical considerations, the best therapeutic intervention for Gender Identity Disorder is to alleviate the overwhelming amount of suffering that is often associated with the condition through early detection and early intervention with effective, specially-developed childbehavior therapy in conjunction with family counseling" (Maxmen, Ward, & Kilgus, 2009). At present, there are several direct and indirect interventions available to those who suffer from Gender Identity Disorder. These include, biological therapies, talk therapy and/or surgical interventions. In some cases, individuals with Gender Identity Disorder will undergo a combination of therapies in order to alleviate the associated suffering.

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Many individuals, who identify as transsexuals, resort to taking drugs in order to transition to their desired sex; however, medication in conjunction with talk therapy, does not alter their cross-gender identification. Instead, transsexuals who have definitely decided to transition must also commit to a very costly sex reassignment surgery in order to fully complete the process. Adults with Gender Identity Disorder typically try to 'pass' as members of the opposite sex. They are often successful at hiding their true sex from coworkers and friends but find themselves unable to engage in intimacy. Therefore, a majority of transsexuals don't marry. It is important to note; however, that they "prefer normal heterosexual partners of the same biological sex, but they do not view themselves as "homosexual" because of their crossgender identity" (Byrd & Nicolosi, 2002). Standards of Care The World Professional Association for Transgender Health has established the Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. These standards are protocols outlining typical treatment for individuals who wish to undergo hormonal or surgical sex transitions. Now in its 7th revision, the protocol is gaining worldwide acceptance in the treatment of individuals with Gender Identity Disorder. The sixth revision suggested that all mental health professionals document a patient's relevant sexual, psychological and developmental history in a letter, which should be required by all medical professionals prior to any physical intervention such as surgery or hormone therapy. It has since been

GENDER IDENTITY DISORDER established that one letter is required for hormone replacement therapy or augmentation mammoplasty for Male-to-Female transitions and male chest reconstruction for Female-to-Male transitions. Two additional letters are needed for genital surgeries which are essentially irreversible and extremely costly (The World Professional Association for Transgender Health, 2011). Hormonal Therapies Often referred to as hormone replacement therapy (HRT), individuals with Gender Identity Disorder resort to hormones in order to develop the secondary sex characteristics of their desired sex. HRT can induce breast growth for male-to-female transsexuals and increase facial hair growth for female-to-male transsexuals. HRT typically reverses some characteristics,

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especially the distribution of fat and muscle in the body. It is also effective in stopping menstruation in female-to-male transsexuals. However, once these hormones are stopped, these traits are typically reversed to the original, undesired sex unless chemical or surgical castration has occurred (Rekers, 1995). Hormones are typically administered through pills, shots or patches. For female-to-male transsexuals, androgens like testosterone typically help develop body and facial hair, increase the individual's muscle tone and deepen the voice tone. Meanwhile, male-to-female transsexuals take feminizing hormones like estrogen in order to develop breast and reduce the amount of hair on the body (Rekers & Kilgus, 1995). Psychosocial Therapies

GENDER IDENTITY DISORDER While the hormonal and surgical interventions complete the physical

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process of the sex-reassignment surgery, psychosocial interventions, especially talk therapy, seek to reduce the cognitive dissonance elicited by the individual's cross-gender identification. Typically individuals with Gender Identity Disorder who complete the three-fold treatment (replacement hormone therapy, sexreassignment surgery and therapy) indicate a high degree of satisfaction with their transition. 87% of male-to-female transitions and 97% of female-to-male transitions report a high degree of satisfaction with their treatment and surgery decisions (Lev, 2004). In her discussion, Lev (2004) points out that outcomes seemingly depend on the individual's personal strengths in conjunction with their level of social and professional support before, during and after their sex transition process. It is important that therapists validate their client's cognitive dissonance and the difficulties that they encounter before, during and after their transition. In other words, the idea is not to remove the condition but to mitigate and soften the impact of the stress that it seemingly causes (Israel, Tarver, & Shaffer, 1998). It is believed that there are 13 single-case reports of Gender Identity Disorder that have been treated using behavioral interventions. Each one of these cases focuses on the environmental factors of gender development such as sextyped play behaviors. Behavioral interventions; however, have been clinically ineffective and are often disregarded as an valuable treatment (Zucker & Cohen-Kettenis, 2008). Instead, clinicians have aligned themselves with researchers who have established a clear connection between psychosocial

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interventions and life satisfaction in individuals suffering from Gender Identity Disorder. While various individual and group psychosocial interventions for children, adolescents and adults have been tried and tested, therapies that converge on acceptance, support and self-esteem enhancement have met the most success. Furthermore, therapeutic interventions that focus on the importance of psychoeducation for the individual afflicted and their friends and families have resulted in even higher levels of post-treatment satisfaction (Israel et al., 1998). Treatment goals often include reducing the preoccupation with dissonant thoughts regarding cross-gender identification, social ostracism and isolation, body dysphoria and any psychological comorbidities that might be present, such as depression, anxiety and eating disorders. It is also important that therapeutic interventions seek to manage negative thoughts and emotions that are associated with the possibility of having a future asexual, homosexual or lesbian orientation. Typically, these goals are set early in the intervention process or at the onset of psychosocial interventions (Lev, 2004). Surgical Interventions According to the latest statistics, two to eight times more men than women seek surgical sex reassignment, in the United States. Qualification is far from simple and often requires sex-reassignment-seekers to live as the opposite sex for a minimum of two years, during which time they need to be able to demonstrate to their over-seeing therapist that they can maintain adequate social and occupational functioning, sustain long-term friendships

GENDER IDENTITY DISORDER and stay free of any major psychopathology (Maxmen et al., 2009). This rigorous process was implemented in hopes of deterring individuals from making impulsive and light decisions regarding their desired sex; however,

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many individuals continue to undergo the three-fold process which culminates with a very costly and sometimes painful surgery. Male-to-female surgery requires the removal of the penis, otherwise referred to as penectomy. Within this procedure, the male genitalia are dismembered, folded back and inverted to create female genitalia. This procedure allows male-to-female transsexuals to feel the sensations of arousal and sexual stimulations. Meanwhile, female-to-male surgery requires a mastectomy to remove the breasts and, through plastic surgery, recreation of the area to resemble a masculine chest. This procedure is commonly known as "top surgery" in the trans-community. It is also usually considered the first step in the physical transition. In addition to a mastectomy, female-to-male transsexuals require plastic surgery to transform female genitalia into male genitalia. The labia and surrounding region are used as a base for the penis; however, sexual sensations and arousal are not easily generated in this area. In many cases, female-to-male transsexuals will require additional surgeries to perfect the phallic genitalia as well as implanted devices commonly used in the treatment of erectile dysfunction to achieve full functionality (Israel et al., 1998). Post-surgery typically requires patients to take estrogen or testosterone in order to produce the intended secondary sex characteristics. It should be

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noted, however, that several sex reassignment surgery studies have failed to determine a significant difference between those who have undergone surgery and those who continue to struggle with Gender Identity Disorder in terms of "psychological, relational and vocational adjustment" (Maxmen et al., 2009). However, a preponderance of studies have found the opposite, concluding that individuals who have completed the three-fold therapeutic intervention and sex reassignment lead happier and more balanced lives. Furthermore, these individuals claim that they have made the right decision and that they would not hesitate to recommend the same course of treatment to others in the same position (Bieschke, Perez, & DeBord, 2006). Conclusion Gender Identity Disorder is a complex disorder that is compounded by a astonishing lack of education and understanding by society. Its exact causes remain unknown despite decades of research and highly informative studies. Individuals suffering from cross-gender identification and discomfort with their assigned sex often feel alone and are confused by their cognitive dissonance. Their true affliction is often masked by comorbid diagnoses like body dysmorphia, depression or anxiety. Future studies will hopefully shed light on the etiology of Gender Identity Disorder and perhaps settle the nature vs. nurture debate that has stumped clinicians, researchers and parents alike. Diagnoses and treatments of Gender Identity Disorder remain highly controversial and many currently debate the effects of pathologizing children with sexual disorders. Many argue that children are not sexual beings and

GENDER IDENTITY DISORDER simply do not have the cognitive ability to experience dissonance regarding their assigned sex. Furthermore, proponents of this view argue that

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pathologizing children ensures unhealthy development and that all attempts should be made to dissuade children that their biological sex and gender do not match (Byrd & Nicolosi, 2002). Another significant debate that remains controversial is whether Gender Identity Disorder is, in fact, a mental disorder or rather a biological or physiological disorder or genetic defect that should be addressed by the medical community as opposed to the psychiatric community. At present, both sides have agreed to take an integrative stance on the issue in hopes of raising awareness and garnering support and finances to continue research until a conclusion has been formulated (Schechner, 2010). Further research and studies will provide additional information that can potentially lead to the establishment of a standard method of care for all sufferers of Gender Identity Disorder. In the meantime, an eclectic approach to therapy is most advisable and currently embraced by community members. On the same token, it is essential that we educate society and seek to address any and all misconceptions of Gender Identity Disorder which is often confused with other paraphilias and myths about gender and sex. Discussion I am hesitant to argue that Gender Identity Disorder should be classified as a mental disorder; however, the psychosocial impairment experienced by transsexuals appears to necessitate the diagnosis. Still, I would prefer to air

GENDER IDENTITY DISORDER on the side of caution and classify Gender Identity Disorder as a

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physiological/biological disorder that might require those who are afflicted to seek therapy much like self-help groups for individuals diagnosed with cancer. I fear that we live in a society that overpathologizes deviant behavior and behaviors that differ from the imposed norm, and classifying Gender Identity Disorder as a mental disorder would further perpetuate this trend. At this time, I believe it is in the best interest of the medical and psychiatric communities, as well as the public, to classify Gender Identity Disorder as a biological/physiological disorder until further studies have confirmed its etiology and established an optimal and effective course of treatment. In my opinion, an eclectic approach to therapy is the most effect treatment strategy. I truly believe that since people are so inherently unique that no single treatment is guaranteed to be effective for every single person. First and foremost, I believe that psychoeducation should be the primary goal of therapy for sufferers and their families alike. I think it is imperative that those afflicted be given information regarding each and every option available to them; be it, talk therapy, group therapy, hormone therapy or a full-sex reassignment surgery. Additionally, I think it is exceptionally helpful for individuals who choose to undergo a sex-transition to undergo either individual or group-therapy so that they have the necessary support and care throughout their transition. From all these debates, misconceptions and differing perspectives, it is clear that Gender Identity Disorder is by no means a simple diagnosis or label

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with a concrete treatment plan and predictable outcome. It is a complex issue that absolutely needs to be addressed with further research in hopes of standardizing care for those who are afflicted.

GENDER IDENTITY DISORDER References

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American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision ed.). Washington, DC: American Psychiatric Association. Barlow, D. H., Reynolds, E. J., & Agras, W. S. (1973). Gender identity change in a transsexual. Archives of General Psychiatry , 569-576. Bieschke, K. J., Perez, R. M., & DeBord, K. A. (2006). Handbook of counseling and psychotherapy with lesbian, gay, bisexual and transgender clients. New York, NY: American Psychological Association. Byrd, A. D., & Nicolosi, J. (2002). A meta-analytic review of treatment of homosexuality. Psychological Reports , 139-152. Cohen-Kettenis, P. T., & Pfafflin, F. (2009). The DSM diagnostic creiteria for Gender Identity Disorder in adolescents and adults. Archives of Sexual Behavior , 499513. Diamond, M. (2006). Biased-interaction theory of psychosexual development: "How does one know if one is male or female?". Sex Roles , 589-600. Dragowski, E. A., Scharron-del Rio, M. R., & Sandigorsky, A. L. (2011). Childhood gender identity... Disorder?: Developmental, cultural and diagnostic concerns. Journal of Counseling & Development , 360-366. Gender Identity Research and Education Society. (2006). Atypical gender development: A review. International Journal of Transgenderism , 22-44. Green, R., & Young, R. (2001). Hand preference, sexual preference, and transsexualism. Archives of Sexual Behavior , 565-574.

GENDER IDENTITY DISORDER Israel, G. E., Tarver, D. E., & Shaffer, D. (1998). Transgender care: Recommended guidelines, practical information, and personal accounts. Temple University Press: Philadelphia, PA. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Birmingham, UK: Routledge.

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Maxmen, J. S., Ward, N. G., & Kilgus, M. D. (2009). Essential Psychopathology and Its Treatment. New York, NY: W.W. Norton & Company. Newman, L. K. (2002). Sex, gender and culture: Issues in the definition, assessment and treatment of gender identity disorder. Clinical Child Psychology and Psychiatry , 352-359. Rekers, G. A. (1995). Assessment and treatment methods for gender identity disorder and transvestism. In G. A. Rekers, Handbook of child and adolescent sexual problems (pp. 272-289). New York, NY: Lexington Books. Rekers, G. A. (1995). Early detection and treatment of sexual problems. In G. A. Rekers, Handbook of child and adolescent sexual problems (pp. 3-13). New York, NY: Lexington Books. Rekers, G. A., & Kilgus, M. D. (1995). Differential diagnosis and rationale for treatment of gender identity disorders and transvestism. In G. A. Rekers, Handbook of child and adolescent sexual problems (pp. 255-271). New York, NY: Lexington Books. Schechner, T. (2010). Gender identity disorder: A literature review from a developmental perspective. Israel Journal of Psychiatry and Related Science .

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The World Professional Association for Transgender Health. (2011). Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People. Minneapolis, MN: The World Professional Association for Transgender Health. Zucker, K. J., & Cohen-Kettenis, P. T. (2008). Gender identity disorder in children and adolescents. In D. L. Rowland, & L. Incrocci, Handbook of sexual and gender identity disorders (pp. 376-422). Hoboken, NJ: Wiley.