The DSM-IV classification in
its definition and description of the gender identity disorder omits a
number of diagnostically significant features.
Although the critical analysis
of the DSM-IV classification of the gender identity disorder has been shown to be adequate, it nevertheless has shortcomings which may impede
exact diagnosis.
DSM IV
Gender
Identity Disorder
Paraphilias
Diagnostic Features
There are two components of Gender Identity
Disorder, both of which must be present to make the diagnosis. Thee 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).
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.
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.
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.
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 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, 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 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. Postsurical 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
"tomboyishness" 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:
- Repeatedly stated desire to be, or
insistence that he or she is, the other sex.
- In boys, preference for
cross-dressing or simulating female attire; In girls, insistence on
wearing only stereotypical masculine clothing.
- Strong and persistent preferences
for cross-sex roles in make believe play or persistent fantasies of
being the other sex.
- Intense desire to participate in the
stereotypical games and pastimes of the other sex.
- 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 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-and-tumble 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 is 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 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):
- Sexually Attracted to Males
- Sexually Attracted to Females
- Sexually Attracted to Both
- Sexually Attracted to Neither
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:
- Intersex conditions (e.g., androgen
insensitivity syndrome or congenital adrenal hyperplasia) and
accompanying gender dysphoria
- Transient, stress-related cross-dressing
behavior
- Persistent preoccupation with castration
or penectomy without a desire to acquire the sex characteristics of the
other sex
Paraphilias
302.3 Transvestic Fetishism
The paraphiliac focus of Transvestic
Fetishism involves cross-dressing. Usually the male with Transvestic
Fetishism keeps a collection of female clothes that he intermittently uses
to cross-dress. While cross dressed, he usually masturbates, imagining
himself to be both the male and the female object of his sexual fantasy.
This disorder has been described only in heterosexual males. Transvestic
Fetishism is to be diagnosed when cross-dressing occurs exclusively during
the course of Gender Identity Disorder.
Transvestic phenomena range from occasional
solitary wearing of female clothes to extensive involvement in a transvestic
subculture. Some males wear a single item of women's apparel (e.g.,
underwear or hosiery) under their masculine attire. Other males with
Transvestic Fetishism dress entirely as females and wear makeup. The degree
to which the cross-dressed individual successfully appears to be a female
varies, depending on mannerisms, body habitus, and cross-dressing skill.
When not cross-dressed, the male with
Transvestic Fetishism is usually unremarkably masculine. Although his basic
preference is heterosexual, he tends to have few sexual partners and may
have engaged in occasional homosexual acts. An associated feature may be the
presence of Sexual Masochism. The disorder typically begins with
cross-dressing in childhood or early adolescence. In many cases, the
cross-dressing is not done in public until adulthood. The initial experience
may involve partial or total cross-dressing; partial cross-dressing often
progresses to complete cross-dressing.
A favored article of clothing may become
erotic in itself and may be used habitually, first in masturbation and later
in intercourse. In some individuals, the motivation for cross-dressing may
change over time, temporarily or permanently, with sexual arousal in
response to the cross-dressing diminishing or disappearing. In such
instances, the cross-dressing becomes an antidote to anxiety or depression
or contributes to a sense of peace and calm.
In other individuals, gender dysphoria may
emerge, especially under situational stress with or without symptoms of
depression. For a small number of individuals, the gender dysphoria becomes
a fixed part of the clinical picture and is accompanied by the desire to
dress and live permanently as a female and to seek hormonal or surgical
reassignment. Individuals with Transvestic Fetishism often seek treatment
when gender dysphoria emerges. The subtype with Gender Dysphoria is provided
to allow the clinician to note the presence of gender dysphoria as part of
Tranvestic Fetishism.
Diagnostic Criteria for 302.3 Transvestic
Fetishism
- A. Over a period of at least 6 months,
in a heterosexual male, recurrent, intense sexually arousing fantasies,
sexual urges, or behaviors involving cross-dressing.
- B. The fantasies, sexual urges, or
behaviors cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning.
Specify if: With Gender
Dysphoria: if the person has persistent discomfort with gender role or
identity.
Citation: The
American Psychiatric Association.
