Gender identity disorder

The psychological diagnosis gender identity disorder (GID) is used to describe a male or female who feels a strong identification with the opposite sex and experiences considerable distress because of his or her actual sex.

Gender identity disorder can affect children, adolescents and adults. Individuals with gender identity disorder have strong cross-gender identification. They believe that they are, or should be, the opposite sex. They are uncomfortable with their sexual role and organs and may express a desire to alter their bodies.

While not all persons with GID are labeled as transsexuals, some are determined to undergo sex change procedures or to pass socially as the opposite sex.Transsexuals alter their physical appearance cosmetically and hormonally, andmay eventually undergo a sex-change operation.

Children with gender identity disorder refuse to dress and act in sex-stereotypical ways. It is important to remember that many emotionally healthy children experience fantasies about being a member of the opposite sex. The distinction between these children and gender identity disordered children is that the latter experience significant interference in functioning because of theircross-gender identification. They may become severely depressed, anxious, orsocially withdrawn. Psychologists who work with children and teens on genderidentity note that cross-gender behaviors generally become less overt with time and by late adolescence, GID is usually no longer present.

Long-term studies of children referred to a specialty clinic for GID show that cross-gender behavior is tolerated in girls to a far greater degree than itis in boys. Thus, parents are quicker to bring boys in for evaluation. The clinicians who conducted the study theorized that girls may be underreferred for GID because there is more social tolerance of "tomboys" than there is of "sissies." While much more research is needed, scientists theorize that thereare other social factors in play as well. It is much more common for males towish to cross to the female gender, but there are exceptions. In Poland, theratio of women who wish to change gender is five times the rate of men who wish to change. Researchers theorize that Polish women face unfavorable livingconditions and gender-related economic and occupational hardships to a degree that they seek relief by changing gender.

The biological causes of gender identity disorder are not known. According toone theory, a prenatal hormonal imbalance may predispose individuals to thedisorder. Problems in the individual's family interactions or family dynamicsmay play a part.

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the standard diagnostic reference for United States mental health professionals, describes the criteria for gender identity disorderas strong and lasting cross-gender identification and persistent discomfort with one's biological gender role. For classification as a clinical disorder,this discomfort must cause a significant amount of distress or impairment inthe functioning of the individual.

The DSM-IV guidelines specify that children must display at least fourof the following symptoms of cross-gender identification for a diagnosis ofgender identity disorder:

  • A repeatedly stated desire to be, or insistence that he or she is, the opposite sex.
  • A preference for cross-dressing.
  • A strong and lasting preference to play make-believe and role-playing games as a member of the opposite sex or persistent fantasies that heor she is the opposite sex.
  • A strong desire to participate in the stereotypical games of the opposite sex.
  • A strong preference for friends and playmates of the opposite sex.

Gender identity disorder is typically diagnosed by a psychiatrist or psychologist who conducts an interview with the patient and takes a detailed social history. Family members may also be interviewed during the assessment process.This evaluation usually takes place in an outpatient setting.

Treatment for children with gender identity disorder focuses on treating secondary problems such as depression and anxiety, and improving self-esteem. Treatment may also work on instilling positive identifications with the child'sbiological gender. Children typically undergo psychosocial therapy sessions;their parents may also be referred for family or individual therapy.

Children and adolescents with GID have never been systematically counted, butgender identity disorder is generally regarded as a rare phenomenon. In Europe, there are treatment centers in London, England; Utrecht, the Netherlands;and in Frankfurt, Germany. In North America, patients may seek treatment atspecial centers for gender identity disorder in Toronto; in New York City; atthe University of California, Los Angeles; at Johns Hopkins University in Baltimore; and at Case Western University in Cleveland. The larger number of GID patients in North America may be related to a less permissive attitude toward gender nonconformity. Traditionally, Europe is more tolerant of gender nonconformity and parents are less likely to see their children's GID symptoms as requiring treatment.

With adolescents, there are many variations in gender role behavior and experienced gender identity specialists avoid making premature decisions, particularly when sex reassignment surgery is under consideration. One study described in a review in the American Journal of Psychotherapy showed that a large number of children with GID grow up to be homosexual or bisexual. The concept of treatment for GID children and adolescents has become highly politicized, since some groups fear that treatment of GID is actually a thinly veiled attempt to curb or even prevent homosexuality.

Transsexual adults often request hormone and surgical treatments to suppresstheir biological sex characteristics and acquire those of the opposite sex. Ateam of health professionals, including the treating psychologist or psychiatrist, medical doctors, and several surgical specialists, oversee this transitioning process. Because of the irreversible nature of the surgery, candidates for sex-change surgery are evaluated extensively and are often required tospend a period of time integrating themselves into the cross-gender role before the procedure begins. Usually sex reassignment surgery is not offered to anyone under 18. Before surgery can be considered, candidates undergo at leasta year of psychotherapy. A "real life" test of living for at least a year asa member of the desired gender is recommended.

A male who has been cleared for surgery will have a vaginoplasty, the surgical technique for creating a neovagina. The penis and testes are removed. Surgeons permanently remove male hair growth and perform corrective plastic surgery on the larynx. For the patient to successfully pass as a woman, the growthof facial and body hair must be suppressed, and this can be accomplished witha drug such as cyproterone acetate. The surgery for changing a man into a woman is simpler than the surgery for changing a woman into a man, and many more men than women undergo sex change operations. A woman who has been clearedfor surgery will undergo surgical removal of the breasts, uterus and ovaries.In some cases, a phalloplasty will be performed, creating a neophallus. Premenopausal women who receive sex change operations are given a drug such as lynestrenol to suppress menstruation. Long-term follow-up studies have shown positive results for many transsexuals who have undergone sex-change surgery. However, significant social, personal, and occupational issues may result fromsurgical sex changes, and the patient may require psychotherapy or counseling.

In the ongoing debate on gender stereotypes, new areas of inquiry have openedup. Scholars and activists have sought new responses to the questions of gender dysphoria (dissatisfaction or discomfort with one's biological gender). In the literature on issues of transgender, some scholars point out that gender is a performance that everyone learns from birth. Under this theory, by thetime people are old enough to recognize that their gender identity is a kindof performance, it is so ingrained that people do not think of their genderidentity as a separate entity.

There are many political points of view in the literature of transgender, butthe generally agreed definition of transgender covers everything that does not fall into society's narrow terms of "man" and "woman." Some of the peoplewho consider themselves as transgendered would include transsexuals (who mayor may not have had sex reassignment surgery), transvestites (who wear clothing and adopt behavior of the opposite sex), people with ambiguous genitalia,and people who have chosen to perform either an ambiguous gender role or no gender role at all.

There are four main categories in the study of transgender:

  • Essentialist or naturalist. This group believes there is no difference between sex andgender, that there are only two genders, and these cannot be changed.
  • Social constructivist. This group believes sex and gender can only be considered as part of a social interaction. In other words, sex and gender are a "construction" assigned by society.
  • Performance. Gender performance theorists believe gender is best understood through performance studies and theylook at what is revealed from clues such as body position, gesture, facial expression, proximity, voice modulation, speech pattern, social space, clothing, adornment and cosmetics.
  • Memory and language generation. This group looks at the body as the expression of the symbols of words, gestures anda larger cultural language. On a gut level, the body has deeper knowledge that may not be registered by the mind.

While transgender theorists do not always agree on definitions and underlyingphilosophies, this is an emerging field with many avenues for scholarly andpolitical dialog. As the study of transgender develops, it will influence many other disciplines such as anthropology, psychology, psychiatry, sociology,women's studies, men's studies, and gender studies.

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