Gender identity disorder

Gender identity disorder (GID), also known as gender dysphoria, is the formal diagnosis used by psychologists and physicians to describe persons who experience significant dysphoria (discontent) with the sex they were assigned at birth and/or the gender roles associated with that sex. It describes the symptoms related to transsexualism, as well as less extreme manifestations. Affected individuals are commonly referred to as transgender. Though no recent research has been conducted, the prevalence of gender dysphoria is estimated to be at least 1 in 500. Similarly, little research has been done regarding sex ratios of gender dysphoria, but previous research indicates that people assigned male at birth are three times more likely than those assigned female at birth to be transsexual.

Gender identity disorder in children is considered clinically distinct from gender dysphoria that appears in adolescence or adulthood. As gender identity develops in children, so do gender role stereotypes. Gender role stereotypes are the beliefs, characteristics and behaviors of individual cultures that are deemed normal and appropriate for males and females to possess. These "norms" are influenced by family and friends, the mass-media, community and other socializing agents. Since many cultures strongly disapprove of gender-atypical behavior, it often results in significant distress for affected persons and those close to them. In many cases, transgender individuals report discomfort stemming from feeling "trapped in the wrong body".

Gender identity disorder is classified as a medical disorder by the ICD-10 CM and was also in the DSM-IV TR. The current DSM-5, however, removed the diagnosis and replaced it with an updated diagnosis called gender dysphoria. Controversy exists as to whether GID should be classified as a mental disorder. Many transgender people and researchers support the declassification of GID as a mental disorder for several reasons. The classification of GID as a mental disorder pathologizes gender variance, and reinforces the binary model of gender. Diagnosis of a mental disorder can also result in harmful stigmatization of transgender individuals. In addition, there is growing evidence that transsexualism has biological causes, such as brain differences, genetic abnormality, and prenatal exposure to hormones, in addition to psychological and behavioral causes.

Treatment for gender dysphoria is also controversial, as changes made are typically irreversible. The current approach to treatment for people diagnosed with gender dysphoria is physically to modify their bodies so that they match their gender identities.

Causes
Though the exact etiology of gender dysphoria is unknown, there is evidence of biological and sociocultural influences in its development.

Biological causes
Genetic variation, hormones, and differences in brain functioning and brain structures provide evidence for the biological etiology of the symptoms associated with GID. Twin studies indicate that GID is 62% heritable, evidencing the genetic influence in the development of the disorder. In male-to-female transsexuals, GID is associated with variations in an individual's genes that make the individual less sensitive to androgens. Zhou et al. (1995) found that in one area of the brain, male-to-female transsexuals have a typically female structure, and female-to-male transsexuals have a typically male structure. In addition, some aspects of trans women's hypothalamus functioning resembles that typical of cisgender women.

Sociocultural causes
The sociocultural influences on the development of GID are traumatic rearing and sexual orientation. Traumatic child-rearing that developed into gender dysphoria is evidenced by the experience of David Reimer, a natal male whose penis was accidentally amputated as an infant, so his parents raised him as female. David was never comfortable with his assigned femaleness, and he transitioned back to a male later in life. He committed suicide at age of 39. In terms of sexual orientation as a cause for GID, Ray Blanchard proposes that male-to-female "homosexual transsexuals" transition because they are attracted to men, and male-to-female "non-homosexual transsexuals" become transsexual because they are autogynephillic, attracted to the idea of themselves as a female.

Diagnostic criteria
In the United States, the American Psychiatric Association permits a diagnosis of gender identity disorder if the four diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text-Revised, or DSM-IV-TR are met. The criteria are:
 * Long-standing and strong identification with another gender


 * Long-standing disquiet about the sex assigned or a sense of incongruity in the gender-assigned role of that sex


 * No physical intersex characteristics


 * Significant distress or impairment in occupational functioning, social functioning and other areas of life

If the four criteria are met under the DSM-IV-TR, a diagnosis is made under ICD-9 code. See the classification and external resources sidebar at right for other diagnostic codes for gender identity disorder.

The International Classification of Diseases (ICD-10) list three diagnostic criteria for "transsexualism" (F64.0):


 * The desire to live and be accepted as a member of another sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment


 * The transsexual identity has been present persistently for at least two years


 * The disorder is not a symptom of another mental disorder or a chromosomal abnormality

Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder, according to the ICD-10.

General
Treatment for GID is generally divided into psychological treatments and biological. Treatment for GID is somewhat controversial, and guidelines have been put in place to aid clinicians in their treatment of transgender individuals. The World Professional Association for Transgender Health (WPATH) Standards of Care, are used as treatment guidelines for GID by some clinicians. Others utilize guidelines outlined in Gianna Israel and Donald Tarver's "Transgender Care". Guidelines for treatment generally follow a "harm reduction" model. Nick Gorton et al. suggest a flexible approach to treatment based on harm reduction, and "willingness to provide hormonal therapy based on assessment of individual patients needs, history and situation with an overriding goal of achieving the best outcome for patients rather than rigidly adhering to arbitrary rules has been successful".

Prepubescent children
The question of whether to counsel young children to be happy with their assigned sex, or to encourage them to continue to exhibit behaviors that do not conform to gender stereotypes—or to explore a transsexual transition—is controversial. Some clinicians report a significant proportion of young children with gender identity disorder no longer have such symptoms later in life. There is an active and growing movement among professionals who treat gender dysphoria in children to refer and prescribe hormones, known as a puberty blocker, to delay the onset of puberty until a child is old enough to make an informed decision on whether hormonal gender reassignment leading to surgical gender reassignment will be in that person's best interest.

Psychological treatments
Until the 1970s, psychotherapy was the primary treatment for GID. Psychotherapy is any therapeutic interaction that aims to treat a psychological problem. Though some clinicians still use only psychotherapy to treat GID, it is now typically used in addition to biological interventions as treatment for GID. Psychotherapy alone used to 'cure' individuals of GID is highly controversial and largely ineffective.

Biological treatments
Biological treatments physically alter primary and secondary sex characteristics to reduce the discrepancy between an individual's physical body and gender identity. Treatments to alter one's sex characteristics are included in the umbrella term of "sex reassignment therapy" and include hormone replacement therapy, cosmetic procedures (e.g. hair removal), and sex reassignment surgery. Biological treatments for GID without any form of psychotherapy is quite uncommon, but researchers found that when individuals bypass psychotherapy in their GID treatment, they often feel lost and confused when their biological treatments are complete.

The most effective form of treatment for GID is a combination of psychotherapy, hormone replacement therapy, and sex reassignment surgery. The overall level of satisfaction with both psychological and biological treatments is very high.

Controversy
Individuals with GID may or may not regard their own cross-gender feelings and behaviors as a disorder. Advantages and disadvantages exist to classifying GID as a disorder.

Gender as a social construction
Gender characteristics are socially constructed and therefore naturally unrelated to biological sex. This perspective often notes that other cultures, particularly historical ones, valued gender roles that would presently suggest homosexuality or transgenderism as normal behavior. Some cultures have three defined genders: male, female, and effeminate male. In Samoa, the fa'afafine, a group of feminine males, are entirely socially accepted. The fa'afafine do not experience any of the stigma or distress typically associated with deviating from a male/female gender role, indicating that the distress that is so frequently associated with GID in a Western context is not caused by the disorder, rather it is a secondary result of social disapproval. Individuals diagnosed with GID may also view "transgendering" as a means for deconstructing gender and reject gender binaries; however, not all transgender people wish to deconstruct gender or feel that they are doing so.

GID as a birth defect
Some critics argue that instead of being classified as a mental disorder, GID should be listed as a "birth defect" or "rare disease," citing evidence suggesting a physiological cause. This argument is supported by physiological evidence, such as the presence of typically-female patterns of white matter and neuron patterns observed in the brains of male-to-female transsexuals and overall longer instances of the androgen receptor gene. (Also see Causes of transsexualism.) One rebuttal to this view is that these markers do not identify every individual who undergoes transition, and that using them to define transsexualism could falsely exclude some people from treatment.

Distress as a consequence of stigma
The DSM-IV-TR diagnostic component of distress is not inherent in the cross-gender identity, rather it is a result of social rejection and discrimination. Dr. Darryl Hill, insists that GID is not a mental disorder, but rather that the diagnostic criteria reflect psychological distress in children that occurs when parents have trouble relating to their child's gender variance.

Replacement for homosexuality in the DSM
Some people feel that the deletion of homosexuality as a mental disorder from the DSM-III and the ensuing creation of the GID diagnosis was merely sleight of hand by psychiatrists, who changed the focus of the diagnosis from the deviant desire (of the same sex) to the subversive identity (or the belief/desire for membership of another sex/gender). People who believe this tend to point out that the same idea is found in both diagnoses, that the patient is not a "normal" male or female. As Kelley Winters (pen-name Katharine Wilson), an advocate for GID reform put it, "Behaviors that would be ordinary or even exemplary for gender-conforming boys and girls are presented as symptomatic of mental disorder for gender nonconforming children." However, Kenneth Zucker and Robert Spitzer argue that GID was included in the DSM-III (7 years after homosexuality was removed from the DSM-II) because it "met the generally accepted criteria used by the framers of DSM-III for inclusion".

International classification
In December 2002, the British Lord Chancellor's office published a Government Policy Concerning Transsexual People document that categorically states "What transsexualism is not...It is not a mental illness." In May 2009, the government of France has also declared that a transsexual gender identity will no longer be classified as a psychiatric condition in France.

In August 31, 2010, Thomas Hammarberg, Commissioner for Human Rights within the Strasbourg-based Council of Europe, an independent institution, opposed the mental disorder classification and the sterilization of transgender persons as a requirement for legal sex change.

The Principle 3 of The Yogyakarta Principles on The Application of International Human Rights Law In Relation to Sexual Orientation and Gender Identity states that "Person of diverse sexual orientation and gender identities shall enjoy legal capacity in all aspects of life. Each person's self-defined sexual orientation and gender identity is integral to their personality and is one of the most basic aspects of self-determination, dignity and freedom" and the Principle 18 of this states that "Notwithstanding any classifications to the contrary, a person's sexual orientation and gender identity are not, in and of themselves, medical condition and are not to be treated, cured or suppressed." According to these Principles, any gender identity of a transsexual or transgender person is neither "disorder" nor mental illness, thus the diagnosis "gender identity disorder" can be contradictory and irrelevant. As well, The Activist's Guide of the Yogyakarta Principles in Action states that "It is important to note that while "sexual orientation" has been declassified as a mental illness in many countries, "gender identity" or gender identity disorder" often remains under consideration."

GID as dysfunctional
Some researchers, including Dr. Robert Spitzer and Dr. Paul J. Fink, contend that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction.

Insurance coverage
Because GID is considered a disorder in the DSM-IV-TR, many insurance companies are willing to cover some of the expenses of sex reassignment therapy. Without the classification of GID as a medical disorder, sex reassignment therapy may be viewed as cosmetic treatment, rather than medically necessary treatment, and may not be funded.

Proposed revisions in the DSM-5
The DSM-5 Task Force proposed revisions to the classification of gender identity disorder in the DSM-5. In the DSM-5, GID is now called "gender dysphoria", because of "criticisms that the [previous] term was stigmatizing." Cohen-Kettenis and Pfafflin (2009) propose that to reduce the current stringency of a certain number of GID indicators being required for a diagnosis, gender dysphoria could follow a dimensional approach, and the degree to which an individual experiences gender dysphoria could be based on the number of criteria the individual meets. The proposed revisions to GID were:

A. Discomfort with one's assigned sex or gender role for a period of at least 6 months, as manifested by at least two of the following indicators:
 * Feeling of incongruence between one's felt gender identity and one's primary and secondary sex characteristics
 * Desire to be rid of one's primary and secondary sex characteristics
 * Desire for the sex characteristics of the other sex
 * Desire to be the other sex
 * Desire to be treated as the other sex
 * Belief that one has the feelings and reactions typical of the other sex

B. The individual does not have an intersex or sexual development condition

C. The condition causes clinically significant distress or impairment in social, occupational, or other areas of functioning

Subtypes: "Gender identity disorder not otherwise specified" is proposed to include individuals who cannot be diagnosed as having a specific gender identity disorder, but experience distress and impairment in functioning as a result of their gender identity.
 * Sexually attracted to males
 * Sexually attracted to females
 * Sexually attracted to both
 * Sexually attracted to neither

Revisions in the DSM-5
The fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released in May 2013. This edition officially eliminated the term "gender identity disorder", which was considered stigmatizing, instead referring to "gender dysphoria," which focuses attention only on those who feel distressed by their gender identity. Subtypes of gender identity disorder based on sexual orientation were also deleted. Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one’s gender) were combined. The edition also saw the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The creation of a specific diagnosis for children reflects the supposedly lesser ability of children to have insight into what they are experiencing, or ability to express it in the event that they have insight. The grouping has also been moved out of the sexual disorders category and into its own.