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A powerpoint presentation on Gender Identity Disorder for a graduate level psychopathology class.

A powerpoint presentation on Gender Identity Disorder for a graduate level psychopathology class.

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Gender identity disorder Gender identity disorder Presentation Transcript

  • GENDER IDENTITY DISORDER
  • Symptoms - Children
    • Strong desire to be the opposite sex
    • Believes self to be the opposite sex
    • Cross dressing as the opposite/desired sex
    • Engaging in stereotypical games/role play of the opposite sex
    • Preference to have friends or play with others of the opposite/desired sex
    • Refusal to wear stereotypical clothing of biological sex
    • Refusal to engage in stereotypical activities of biological sex
    • Disgust with own genitalia
    • Assertion that genitalia will disappear or change to genitalia of the opposite sex
  • Symptoms – Adolescents & Adults
    • Strong desire to be the opposite sex
    • Believes self to be the opposite sex
    • Passing as the opposite sex
    • Desire to live and be accepted as the opposite sex
    • Belief of being born the wrong sex
    • Intense desire to change primary & secondary sex characteristics
  • DSM-IV Criteria
    • Strong and persistent cross-gender identification (not for cultural gain)
    • Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex
    • Disturbance not concurrent with a physical intersex condition
    • Disturbance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning
    • Specify: sexually attracted to males, sexually attracted to females, sexually attracted to both, sexually attracted to neither
  • Differential Diagnoses
    • Transvestic Fetishism
      • Heterosexual/bisexual biological men
      • Dress in women’s clothes for sexual excitement
      • Do not desire to be the opposite sex
    • Nonconformity to Stereotypical sex-role Behavior
      • “ Tomboys” or feminine boys
    • Schizophrenia
      • Delusions of belong to the other sex
  • Etiology – Familial Factors
    • Overall weak and insufficient evidence
    • Psychodynamic
      • Stoller (1974) Blissful Symbiosis – over identification of boys with mother
      • Father’s absence
      • Maternal wish for a daughter
    • Other Factors
      • Psychopathology in parents
      • Parents who are rejecting & lack of emotional warmth
  • Etiology - Biological
    • Brain Structure Differences : BST – Bed nucleus of the stria terminalis
    • MFs have similar size BST as biological females. Sex hormones had no effect. (Zhou, Hofman, Gooren, Swaab, 1997)
    • BST differs in the number of somatostatin neurons. Men have significantly more somatostatin neurons than women. MFs have similar # of somatostatin neurons as biological females; # somatostatin neurons in FMs similar to biological males (Frank et al., 2000)
    • BST differences in size only became significant in adulthood suggesting that sex differences are not fully developed until adulthood (Chung, De Vries, & Swaab, 2002)
    • In utero exposure to progestagens and estrogenic drugs not linked to transsexualism
  • Children - Prevalence
    • No accurate number of how many suffer from GID
    • More prevalent in boys than in girls
    • Most cases of childhood GID will resolve even without therapeutic interventions although many will consider themselves homosexual as adults
      • 12% of gender dysphoric female children were still considered gender dysphoric in adulthood
      • 32% considered themselves homosexual as adults
      • 12-20% of GID boys still considered gender dysphoric in adulthood
      • 52% of feminine boys considered themselves homosexual or bisexual in adulthood
      • (Drummond, Bradley, Peterson-Bedali, Zucker, 2008)
  • Adolescents & Adults - Prevalence
    • 1 in 11,900 males; 1 in 30,400 females
    • FMs- primarily homosexual type, early onset
    • MFs – homosexual type vs heterosexual type
    • Early onset MFs: pervasive pattern in life of cross-sex identification, high desire for SRS, more satisfaction with SRS
    • Late onset heterosexual MFs: more fluctuation in cross-sex identification, ambivalent about SRS, less satisfaction with SRS
      • Increasing in North America, 25% of transsexuals in 1982, 59% in 1992 (Blanchard & Sheridan, 1992 as cited by Lawrence, 2003)
  • Treatment
    • The Harry Benjamin International Gender Dysphoria Association’s Standards of Care For Gender Identity Disorders, Sixth Version (2001)
    • Goal of Treatment: “Lasting personal comfort with the gendered self in order to maximize overall psychological well being and self fulfillment”
    • Multidisciplinary Team
      • Mental Health Professional, Physician, Surgeon
  • Goal of the MHP
    • Accurately diagnose the individual’s Gender Disorder
    • Diagnose commorbid psychiatric conditions
    • Counsel individuals about their treatment options & their implications
    • Engage in psychotherapy
    • Determine eligibility and readiness for hormones and surgical therapies
    • Make formal recommendations to medical & surgical colleagues
    • Document patient’s relevant history in a letter of recommendation
    • Be a colleague on a team of professionals with an interest in GID
    • Educate family members, employers, and institutions about GID
    • Be available for follow-up with patients
  • Treatment - Children
    • Psychological and Social Interventions
    • Acknowledge and accept the GID in the child; remove secrecy from child
    • Explore the function and characteristics of child’s gender identity
    • Resolve any commorbid problems
    • Provide support for the child and family in making decisions
      • Attire, activities, names
  • Treatment - Children
    • Physiological Interventions
    • Refrain from any physical treatments
      • Ever changing gender identity/sexuality of child/adolescent
    • In extreme cases of significant distress (onset of puberty)
      • Child has maintained persistent cross-sex gender identity
      • Family agrees and participates in treatment
    • Fully Reversible Interventions – puberty delaying hormones
    • Partially Reversible Interventions – masculinizing/feminizing hormone therapy (age 16+)
      • Pt must have been working w/therapist for 6 months +
    • Irreversible Interventions (Surgical)
      • Not performed until adulthood and/or patient has experienced at least 2 years in the new gender role
  • Treatment – Adults
    • Psychological Interventions
    • Basic Observation
    • Psychotherapy
      • Educate patient of options, create realistic life goals, define and alleviate patient’s conflicts
    • Gender Adaptation Options (no hormonal/major surgical management)
      • Biological Males- cross dressing, body hair removal, minor body surgical procedures, vocal expression skills
      • Biological Females-cross dressing, breast binding, weight lifting, fake facial hair, padding underpants
  • The Real Life Experience
    • Living in the desired gender role
    • Maintain full/part time employment, function as a student or community volunteer or some combination of these
    • Acquire legal gender identity appropriate first name
    • Provide documentation that other people know that the patient functions in the desired gender role
    • Real Life Test vs Real Life Experience
  • Treatment – Adults: Hormones
    • Androgens for biological females
    • Estrogen, progesterone, testosterone blocking agents for biological males
    • Full effects take 2 years and are mostly reversible
    • Eligibility Criteria
    • Age 18
    • Demonstrate knowledge of the consequences of taking hormones and what they can accomplish and not accomplish
    • Documented 3 month real life experience -OR- 3 months of psychotherapy
    • Readiness Criteria
    • Pt has further consolidation of gender identity through real life experience or psychotherapy
    • Made Progress in stable mental health
    • Pt will use hormones responsibly
  • Treatment – Adults : Surgical
    • Sexual Reassignment Surgery: 1931 first detailed description of SRS
    • Eligibility Criteria
    • Legal age
    • 12 months continuous hormonal therapy
    • 12 months continuous real life experience
    • Possible psychotherapy
    • Demonstrate knowledge of cost, complications and rehabilitation required
    • Have awareness of different competent surgeons
    • Readiness Criteria
    • Continued progress with consolidation of gender identity
    • Continued progress with a stable mental health and life
  • Predictors of Satisfaction of SRS
  • Surgical Satisfaction
    • Vaginoplasty, Clitoroplasty
      • 75% satisfaction with vaginal volume
      • 80-87% experience clitoral orgasms
      • 22% need some form of secondary surgery
    • Phalloplasty and Scrotal Reconstruction
      • 80% overall satisfaction
      • 70% ability to have vaginal intercourse
      • 72% ability to have orgasm with neopenis stimulation
      • 90% able to void in standing position
    • Resolution of Gender Dysphoria
  • References
    • Adams, H.E., & Sutker, P.B. (Eds). (2004). Comprehensive handbook of psychopathology (3 rd ed). NewYork: Springer Science+Business Media, LLC.
    • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000.
    • Chung, W.C.J., De Vries, G.J., Swaab, D.F. (2002). Sexual Differentiation of the Bed Nucleus of the Stria Terminalis in Humans May Extend into Adulthood. The Journal of Neuroscience, 22 (3), 1027-1033.
    • Cohen-Kettenis, P.T., & Gooren, L.J.G. (1999). Transsexualism: A Review of Etiology, Diagnosis and Treatment. Journal of Psychosomatic Research, 46 (4), 315-333.
    • Drummond, K. D., Bradley, S.J., Peterson-Badali, M., Zucker, K.J. (2008). A Follow-Up Study of Girls With Gender Identity Disorder. Developmental Psychology, 44 (1), 34-45.
    • Kruijver, F.P.M., Zhou, J., Pool, C.W., Hofman, M.A., Gooren, L.J.G., Swaab, D.F. (2000). Male-to-Female Transsexuals Have Female Neuron Numbers in a Limbic Nucleus. The Journal of Clinical Endocrinology and Metabolism, 85 (5), 234-241.
  • References continued
    • Lawrence, A. A. (2003). Factors Associated With Satisfaction or Regret Following Male-to-Female Sex Reassignment Surgery. Archives of Sexual Behavior, 32 (4), 299-315.
    • Meyer, W., III, Bockting, W. O., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor, H., et al. (2001). The standards of care for gender identity disorders, (6 th version). Düsseldorf: Symposion.
    • Sohn, M., & Bosinski, H.A.G. (2007). Gender Identity Disorders: Diagnostic and Surgical Aspects. The Journal of Sexual Medicine, 4 , 1193-120.
    • Stoller, R. (1974). Symbiosis anxiety and the development of masculinity. Archives of General Psychiatry, 30 (2), 164-172.
    • Zhou, J.N., Hofman, M.A., Gooren, L.J., Swaab, D.F. (1997). A Sex Difference in the Human Brain and its Relation to Transsexuality. The International Journal of Transgererism 1 (1), Retrieved November 1 st , 2008 from: http://www.symposion.com/ijt/ijtc0106.htm .