Persistent and intense distress about assigned gender or insistence that individual belongs to a different gender
Marked incongruence between one's experienced/expressed gender and primary and/or secondary sex characteristics
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Gender Identity Disorder/ Gender Dysphoria
1. GENDER IDENTITY
DISORDER
Total slides –77
1
Gender Dysphoria / Gender Incongruence
Presenter
Dr Rachit Sharma
Junior Resident (Psychiatry)
Armed Forces Medical College,
Pune
Moderator
Dr Harpreet Singh
Sr Adv (Psychiatry) & HoD
Dept of Psychiatry
Command Hospital (SC), Pune
2. Outline
• Introduction
• Important terms
• Mythology and History
• Comparative Nosology
• Epidemiology
• Acquisition of gender
identity
• Differential diagnosis
• Treatment
• Course and Prognosis
• Role of psychiatrist
• Indian scenario
• Armed Forces
perspective
• Take home points
2
4. Important terminology
• SEX
– Status of biological variables that can be
described as either male typical or female typical
in normatively developed individual
• GENDER
– Attributes of people, which are associated with
biological sex
– Refers to social categories of Males (boys, Men)
and females (girls, women)
4
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
5. Important terminology
• GENDER IDENTITY (EXPERIENCED GENDER)
– One’s persistent inner sense of belonging to either
male or female gender category
• GENDER ROLE (EXPRESSED GENDER)
– Outward expression of inner sense of gender identity
– Those things that a person say or does to disclose
himself or herself as having the status of a boy or
man, girl or women
5
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
6. Important terminology
• TRANSGENDER
– Indl whose gender identity (or gender expression) and
natal gender are discordant or not conforming to
social norms
• The Transgender Persons Bill 2016 defines
Transgender as
“Neither wholly female nor wholly male; a
combination of female or male; neither female nor
male”, and “whose sense of gender does not match
with the gender assigned to the person at the time of
birth”
6
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
7. Important terminology
• TRANSSEXUAL
– Indl who has , or plans to employ hormonal or
surgical means to modify the body so as it
conforms to one’s experienced gender
– MTF or transwomen
– FTM or transman
• GENDER REASSIGNMENT SURGERY/ GENDER
CONFIRMATION SURGERY
7
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
8. Important terminology
• HOMOSEXUAL/ HETEROSEXUAL/BISEXUAL
(ANDROPHILIC/GYNAEPHILIC/ANALOPHILIC)
• GENDER DYSPHORIA
– Unhappiness or a sense of inappropriateness with
one’s natal sex or the gender role associated with
that sex
• FETISHISTIC TRANSVESTITISM
• DUAL ROLE TRANSVESTITISM
8
F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/ gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
10. Mythology
• INDIAN MYTHOLOGY
– DWAPAR YUG –
• SHIKANDINI – SHIKANDI legend
• ARJUNA- Cross gender and cross dressing as
VIRHANALLA
• ARAVAN – MOHINI
10
Somasundaram O. Transgenderism: Facts and fictions. Indian Journal of Psychiatry 2009 Jan-Mar; 51(1)
11. Mythology
• GREEK MYTHOLOGY
– TIRESIAS, a man whose body was changed into
female body by Goddess Hera
11
Somasundaram O. Transgenderism: Facts and fictions. Indian Journal of Psychiatry 2009 Jan-Mar; 51(1)
12. History
• 19TH & 20TH CENTURY
KARL ULRICH (1825 – 1895)
– Urnings – Men born with a female
spirit trapped inside their body
RICHARD VON KRAFFT-EBING (1840-1902)
• PSYCHOPATHIA SEXUALIS
• METAMORPHOSIS SEXUALIS PARANOIA
12
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
13. History
MAGNUS HIRSCHFELD (1868 – 1935)
• Established Scientific humanitarian society
• Differentiated between desires of
Homosexuality to have partner of same
sex) and transsexualism
(to live as other sex)
13
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
14. History
• 20TH CENTURY
– George Jorgensen Christine Jorgensen
– Dr Christian Hamburger performed this surgery
and published his report in JAMA
– Awareness about the concept of gender identity
14
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
15. History
JOHN MONEY (1921 – 2006)
• Research on children born with DSD
• Gender identity is acquired
• Parental attitude and Family rearing practices
HARRY BENJAMIN (1885-1986)
• Coined the term transsexual
• Transsexualism – Biological in nature
• HBIGDA WPATH
15
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
16. History
– ROBERT STOLLER (1924-1991)
• Introduced and described the concept of gender identity
• Emphasized the role of childhood family dynamics in
gender identity
• Influenced by Separation – Individualization theory of
Margret Mahler
– RICHARD GREEN (1936 - )
• Studied cross gender behaviour in prepubescent children
• The “Sissy Boy Syndrome” and the Development of
Homosexuality
16
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
22. Comparative Nosology
22
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.
23. Comparative Nosology
23
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.
25. Comparative Nosology
25
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S,
Briken P. Disorders related to sexuality and gender identity in the ICD‐11: revising the ICD‐10 classification based on current
scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. 2016 Oct;15(3):205-21.
28. Transsexualism (F 64.0 )
A. Desire to live and be accepted as a member of the
opposite sex, usually accompanied by the wish to
make one's body as congruent as possible with
one's preferred sex through surgery and hormonal
treatment
B. Presence of the transsexual identity for at least two
years persistently.
C. Not a symptom of another mental disorder, such as
schizophrenia, or associated with chromosome
abnormality
28
29. Dual-role transvestism (F 64.1)
A. Wearing clothes of the opposite sex in order to
experience temporarily membership of the opposite
sex
B. Absence of any sexual motivation for the cross-
dressing
C. Absence of any desire to change permanently into
the opposite sex
29
30. Gender identity disorder of childhood
(F 64.2)
A. Persistent and intense distress about assigned gender or
insistence that indl belongs to different gender
B. Persistent marked aversion to assigned gender’s clothing
and insistence on wearing clothing and accessories of other
gender, intense desire to participate in the games and
pastimes of other gender
C. Persistent repudiation of anatomic structures of his/her
gender
D. Has not yet reached puberty
E. The disorder must have been present for at least six months
30
32. Gender Dysphoria in Children
1. A strong desire or an insistence that one is the other gender
2. A strong preference for cross-dressing
3. A strong preference for cross-gender roles in make-believe
play or fantasy play
4. A strong preference for the toys, games, or activities
stereotypically used or engaged in by the other gender
5. A strong preference for playmates of the other gender
6. A strong rejection of gender typical toys, games, and
activities
7. A strong dislike of one's sexual anatomy
8. A strong desire for the primary and/or secondary sex
characteristics that match one's experienced gender.
32
33. Gender Dysphoria in
adolescents and adults
1. A marked incongruence between one's experienced/ expressed
gender and primary and/or secondary sex characteristics (or in
young adolescents, the anticipated secondary sex
characteristics)
2. A strong desire to be rid of one's primary and/or secondary sex
characteristics because of a marked incongruence with one's
experienced/expressed gender (or in young adolescents, a
desire to prevent the development of the anticipated secondary
sex characteristics)
3. A strong desire for the primary and/or secondary sex
characteristics of the other gender
4. A strong desire to be or to be treated as other gender
5. A strong conviction that one has the typical feelings and
reactions of the other gender 33
35. Gender incongruence of childhood
1. A strong desire to be a different gender or insistence that he
or she is a gender different from one’s assigned gender
2. A strong dislike for his or her sexual anatomy or anticipated
secondary sex characteristics and/or a strong desire for the
primary and/or anticipated secondary sex characteristics
that match the experienced gender
3. A strong preference for the toys, games, plays or activities
stereotypically used or engaged in by the other gender
35
36. Gender incongruence of
adolescence and adulthood
1. A strong dislike or discomfort with one’s primary
and/or secondary sex characteristics (in adolescents,
anticipated secondary sex characteristics)
2. A strong desire to be rid of some of all of one’s
primary and/or secondary sex characteristics (in
adolescents, anticipated secondary sex
characteristics)
3. A strong desire to have the primary or secondary sex
characteristics of the experienced gender
4. A desire to be treated (to live and be accepted) as a
person of the experienced gender
36
38. Epidemiology
• Prevalence (In specialized gender clinics)
– Natal adult males – 0.005 – 0.014 %
– Natal adult females – 0.002 – 0.003 %
• Age wise sex differences in rates of referrals to
speciality clinics (natal male to natal female)
– Children– 2:1 to 4.5:1
– Adolescents – 1:1
– Adults – 1:1 to 6:1
38
Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolescent
health, medicine and therapeutics. 2018;9:31.
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
40. Milestones
AGE MILESTONES
9 months Able to associate male and female faces with male
and female voices
15 to 24
months
Able to associate gender labels such as lady or man
with male and female voices
Can label adults as male or female
30 months Can label peer and self appropriately by gender
3 years Awareness about their genitals
6-7 years Gender constancy and Gender stability
40
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
41. Role of Biological factors
Models for potential role of biological and
psychosocial factors for development of gender
identity
1. Model of Direct biological effect
2. Model of Indirect biological effect
3. Model of Permissive biological effects
41
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
42. Model of
Permissive biological effects
Biological factors
Neural machinery
Restricted period
Gender identity
Formative
experiences
42
43. Role of Psychosocial factors
1. Verbal labelling and nonverbal gender-cuing
of children by parents and others in their
social environment
2. Shaping of gendered behaviour by
– Positive and negative reinforcement
– Explicit statements of gender-role expectations
3. Parent–child attachment
43
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
45. DD: GD in childhood
1. Non conformity to gender role/ Simple
atypical gender behaviour
2. Epiphenomena of coexisting disorders,
including psychotic disorders
3. Perceived social advantage of being that
gender
4. To escape a perceived disadvantage of the
assigned gender (e.g. sexual trauma)
45
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.
46. DD: GD in Adolescents and Adults
1. Fetishistic transvestism (F65.1) (Transvestic
disorder )
2. Body dysmorphic disorder
3. Schizophrenia and other psychotic disorders
46
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.
48. STAGED TRANSITION
Fully reversible steps 1. Presenting as the desired
gender
2. Pubertal suspension
Partially reversible procedures Administration of gonadal
hormones to bring about the
desired secondary sex
characteristics
Irreversible procedures Bottom surgeries -
Gonadectomy, Vaginoplasty in
natal males
Top surgeries –
Mastectomy and surgical
construction of male-typical
chest
48
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
49. Treatment: Prepubertal children
• Only psychotherapeutic approaches are used
1. First approach – Inducing desistence
• Working with the child and caregivers to lessen
gender dysphoria
• To decrease cross-gender behaviours and
identification
2. Dutch approach – Wait and watch
3. To educate and guide them through the process
of transitioning
49
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
50. Treatment: Adolescents
1. Rule out any psychopathlogy
– Recent psychological trauma
– Psychotic or other disorders
2. Pubertal suspension
3. Gender reassignment surgery
– After ample time of living in the desired gender
role
– After 1 year of hormonal treatment
– Legal age of majority to consent
50
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
51. Treatment: Adults
• Gender reassignment surgery
– Gender reassignment surgery (TOP/BOTTOM)
• For MTF - Breast augmentation and surgical
construction of a vulva, clitoris, and vagina
• For FTM - Bilateral mastectomy, surgical construction of
penis and scrotum
– Additional surgical procedures
• For MTF - Voice training, vocal cord modification, and
Botox injections
• For FTM - Procedures to feminize facial appearance
51
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An
Overview and Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-A3.
52. Treatment
• Counselling regarding practical legal matters
– To maintain the option of being a parent of one’s
biological child – Sperm banking
– How to change a gender descriptor on a birth
certificate, a driver’s license, or a passport
– How to be responsive to the concerns of
family, school, job and place of worship
– Increased libido with androgen use, Safe sexual
practices
52
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry 10th ed. 2017 Wolters Kluwer
Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An
Overview and Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-A3.
54. Course and Prognosis
• Onset – Between 2 – 4 yrs
• Gender incongruence among prepubescent
children - Feelings are unstable and are likely to
change
• Gender incongruence extending beyond puberty -
Leads to its persistence into adulthood
• Rates of persistence (childhood to adolescence)
– Natal males – 2.2 - 30 %
– Natal females – 12 - 50 %
54
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.
55. Course and Prognosis
• Non-persistence of gender dysphoria
(childhood to adolescence)
– Natal males – 63 -100 % - androphilic
– Natal Females – 32 -50 % - gynaephilic
55
American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub;
2013 May 22.
57. Role of Psychiatrist
1. Assess and diagnose gender concerns and to
ensure that they are addressed
2. Assess and diagnose any coexisting
psychopathology and see that it is addressed
3. Assess eligibility for hormonal and/or surgical
treatments, or refer to professionals capable
of making such assessments
57
58. Role of Psychiatrist
4. Assess capacity to give informed consent for
hormonal and surgical treatments
5. To make them aware of the full range of
treatment options and their physical,
psychological, and social implications,
including risks, benefits, and impact on
sexual functioning and reproductive
potential
58
59. Role of Psychiatrist
6. Ensure adequate psychological and social
preparation for transition treatments
7. Refer patients for hormonal or surgical
treatments, collaborating with providers as
needed
8. Ensure continuity of mental healthcare as
indicated throughout transition and beyond
59
61. Transgender community
• The Transgender Persons Bill 2016 defines
Transgender as
• “Neither wholly female nor wholly male; a combination
of female or male; neither female nor male”, and “whose
sense of gender does not match with the gender assigned
to the person at the time of birth”
• Hijras , Aravanis, Kothis, Jogtas/Jogappas , Shiv-
Shakthis , Khwaja saras
61
A Right to Exist: Eunuchs and the State in Nineteenth-Century India Laurence W. Preston Modern Asian Studies, Vol.21,No.2 (1987), pp.371-387)
Singh Y, Aher A, Shaikh S, Mehta S, Robertson J, Chakrapani V. Gender transition services for Hijras and other male-to-
female transgender people in India: availability and barriers to access and use. International Journal of Transgenderism.
2014 Jan 2;15(1):1-5.
62. NALSA v/s UoI
• The Hon’ble Supreme Court directed Centre and
State Governments to grant
– Legal recognition of gender identity whether it be
male, female or third-gender
– The SC said they will be given educational and
employment reservations as OBCs
– If a person surgically changes his/her sex, then he or
she is entitled to her changed sex and can not be
discriminated
62
National Legal Services Authority v. Union of India 15 april 2014
63. Sec 377 of IPC
• 06 September 2018 - Navtej Singh Johar &
Ors. v. Union of India & Ors
• Judgement by Hon’ble Supreme court
• “Only constitutional morality and not social
morality can be allowed to permeate rule of law.
Sexual orientation is one of the many natural
phenomena, any discrimination on basis of sexual
orientation amounts to violation of fundamental
rights”
63
Navtej Singh Johar vs. UOI; Akkai Padmashali vs. UOI; Keshav Suri vs. UOI; Arif Jafar vs. UOI; Ashok Row Kavi
vs. UOI; Anwesh Pokkuluri vs. UOI
65. • The sailor underwent the gender
reassignment in 2017 as she felt that she was
"a woman trapped in a man's body"
65
66. • "sad and worrying that a 'man' the Indian Navy
deemed fit for the job of being a sailor has suddenly
been declared unfit because of an organ change,“
• Sabi, who was diagnosed with Gender Identity
Disorder, said that she had tried to seek help from the
naval doctors, but they had turned her away, consulted
civil doctors in Visakhapatnam
• She also alleged that she was "mentally harassed and
kept in a psychiatric ward for six months. They tried
to prove me mentally unfit but they failed"
66
76. Take home points
• There can be incongruity between assigned
gender and experienced gender
• This incongruity is no longer considered as a
disorder, with picture becoming more clear
with recent judgements
• Greater responsibility lies with mental health
professionals to help these indl in treatment,
social awareness and their integration into the
society
76
77. References
1. Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of
Psychiatry 10th ed. 2017 Wolters Kluwer
2. Berlin FS. A conceptual overview and commentary on gender
dysphoria. Journal of the American Academy of Psychiatry and the
Law Online. 2016 Jun 1;44(2):246-52.
3. Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB,
Cohen‐Kettenis PT, Arango‐de Montis I, Parish SJ, Cottler S, Briken
P. Disorders related to sexuality and gender identity in the ICD‐11:
revising the ICD‐10 classification based on current scientific
evidence, best clinical practices, and human rights considerations.
World Psychiatry. 2016 Oct;15(3):205-21.
4. Lee PA, Houk CP. Evaluation and management of children and
adolescents with gender identification and transgender disorders.
Current opinion in pediatrics. 2013 Aug 1;25(4):521-7.
77
78. References
5. American Psychiatric Association. Diagnostic and statistical manual
of mental disorders (DSM-5®). American Psychiatric Pub; 2013 May
22.
6. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender
dysphoria in adolescence: current perspectives. Adolescent health,
medicine and therapeutics. 2018;9:31.
7. Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg
HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and
Primer for Psychiatrists. Transgender health. 2018 May 1;3(1):57-
A3.
8. Singh Y, Aher A, Shaikh S, Mehta S, Robertson J, Chakrapani V.
Gender transition services for Hijras and other male-to-female
transgender people in India: availability and barriers to access and
use. International Journal of Transgenderism. 2014 Jan 2;15(1):1-5.
78
79. References
9. F. Beek T, Cohen-Kettenis PT, Kreukels BP. Gender incongruence/
gender dysphoria and its classification history. International
Review of Psychiatry. 2016 Jan 2;28(1):5-12.
10. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender
dysphoria in adolescence: current perspectives. Adolescent health,
medicine and therapeutics. 2018;9:31.
11. Section 377 IPC Navtej Singh Johar vs. UOI; Akkai Padmashali vs.
UOI; Keshav Suri vs. UOI; Arif Jafar vs. UOI; Ashok Row Kavi vs. UOI;
Anwesh Pokkuluri vs. UOI
12. NALSA vs UoI 2014
13. Somasundaram O. Transgenderism: Facts and fictions. Indian
Journal of Psychiatry 2009 Jan-Mar; 51(1)
14. WHO. The ICD -10 Classification of Mental and Behavioural
Disorders;1992
79
SEX- Status of biological variables that can be described as either male typical of female typical in normatively developed individuals (gene, chromosome, gonads, internal and external genital structures) , but not necessarily determined by it
GENDER- and factors related to living in the social role of man or women
DSD - (DSD) lead to somatic intersex conditions in which one or more of the biological variables is discordant with the others or in a form that cannot be classified as either male or female typical
GENDER - refer to the social categories of males (i.e., boys, men) and females (girls, women) as well as to factors related to living in the social role of a man or a woman. The gender initially assigned to individuals with somatic intersex conditions has been referred to as natal gender (often called natal sex), a term which has more recently been used to refer to the gender initially assigned to all individuals (particularly in the case of transgender individuals)
GENDER IDENTITY - one’s persistent inner sense of belonging to either the male or female gender category – BOY OR GIRL/ MAN OR WOMEN GENDER ROLE - those things that a person says or does to disclose him- or herself as having the status of boy or man, girl or woman, respectively (e.g., general mannerisms, mode of dress, interests, pastimes, deportment, and demeanor; spontaneous topics of talk in unprompted conversation and casual comment). GENDER ROLE - the outward expression of the inner sense of gender identity
TRANSGENDER - having an experienced gender that is different from one’s natal gender and is often associated with a desire to transition to a gender different from the natal gender (i.e., male, female, or other gender category such as genderqueer or eunuch)
Transgender has become an umbrella term and usually refers to someone whose gender identity (or gender expression) and natal gender are discordant or not conforming to social norms
TRANSSEXUAL – Transgender indl transsexual refers to a transgender individual who has, or plans to, employ hormonal or surgical means to modify the body so that it conforms to one’s experienced gender. MTF (TRANSWOMEN), FTM(TRANSMAN)
Gender role – eg general mannerisms, mode of dress, interests, pastime, deportment and demeanor, spontaneous topics of talk in unprompted conversations and casual comment
Transgender (UMBRELLA TERM) - It may be associated with a desire to transition to or live as a gender different from the natal gender (which could be male, female, or some other gender category such as genderqueer or eunuch)
CISGENDER - Indl whose gender identity and birth assigned sex are in alignment
GENDER DYSPHORIA- unhappiness or a sense of inappropriateness with one’s biological sex, must cause clinically significant distress or impairment in order to satisfy the DSM FETISHISTIC TRANSVESTITISM - refers to sexual urges and fantasies involving crossdressing
DUAL ROLE TRANSVESTITISM - heterosexual men who cross-dress in private
Arjuna spent the one year of his exile as Brihannala at King Virata’s Matsya Kingdom. He taught song and dance to the princess Uttara
Aravan becomes the patron saint of transsexuals of Tamilnadu. He is worshipped in the Koovagam temple in Villupuram district. Transsexuals all over the country assemble here on the Chitrapournami Day. The Mahabharata scene is enacted and the transsexuals adopt the widowhood in the temple
a blind prophet of Apollo in Thebes, famous for clairvoyance and for being transformed into a woman for seven years. On Mount Cyllene in the Peloponnese,[4] as Tiresias came upon a pair of copulating snakes, he hit the pair with his stick. Hera was displeased, and she punished Tiresias by transforming him into a woman. As a woman, Tiresias became a priestess of Hera, married and had children, including Manto, who also possessed the gift of prophecy. After seven years as a woman, Tiresias again found mating snakes; depending on the myth, either she made sure to leave the snakes alone this time, or, according to Hyginus, trampled on them.[5] As a result, Tiresias was released from his sentence and permitted to regain his masculinity. This ancient story was recorded in lost lines of Hesiod
German lawyer and activist, Karl Ulrichs, hypothesized that some men were born with a woman’s spirit trapped in their bodies. He believed these men constituted a third sex and named them urnings. While historians of homosexuality unremarkably and routinely seem to regard Ulrichs’ urnings as homosexual men, a female spirit in a male body closely resembles the narratives of 20th century theories of transsexualism
He was recognized as an authority on deviant sexual behavior and its medicolegal aspects. He was recognized as an authority on deviant sexual behavior and its medicolegal aspects. In a chapter entitled “General Pathology,” he presented what today would be thought of as transgender representations as cases of what he called Metamorphosis Sexualis Paranoia. The twelfth and final edition of Psychopathia Sexualis presented four categories of what Krafft-Ebing called "cerebral neuroses"
German physician and sexologist educated primarily in Germany; he based his practice in Berlin-Charlottenburg. An outspoken advocate for sexual minoritiesIt was the first LGBT rights organization in history.
American George Jorgensen went to Denmark as a natal man and returned to the United States in 1952 as transwoman Christine Jorgensen
Christian Hamburger and the other Danish physician who performed her surgery published a report of their treatment of her “transvestitism” in the Journal of the American Medical Association. The publicity surrounding Jorgensen’s transition eventually led to greater popular, medical, and psychiatric awareness of a then little known concept that would eventually come to be known as gender identityturned to the United States in 1952 as transwoman Christine Jorgensen
John money -
HARRY BENJAMIN - He pioneered the treatment of gender dysphoric individuals using sex hormones. Notably, he accomplished this in a private practice setting without either university or academic support. In acknowledgment of his early advocacy for the medical treatment of transsexualism, in 1979 the newly formed Harry Benjamin International Gender Dysphoria Association (HBIGDA) was named in his honor
opined that gender dysphoria in prepubescent boys was a developmental arrest due to an excessively close and gratifying mother–infant symbiosis that prevented the child from adequately separating himself from his mother’s female body and feminine behavior ROBERT STOLLER - arrest due to an excessively close and gratifying mother–infant symbiosis that prevented the child from adequately separating himself from his mother’s female body and feminine behavior.
RICHARD GREEN – The “Sissy Boy Syndrome” and the Development of Homosexuality, was a prospective study that tracked into adulthood the development of 66 gender-atypical boys who stated a wish to be a girl. Seventy-five percent of the children Green studied grew up to be gay men
(not merely a desire for any perceived cultural advantages from other gender)
Persistent repudiation of anatomic structures - In females
(a) an assertion that she has, or will grow, a penis
(b) rejection of urinating in a sitting position
(c) assertion that she does not want to grow breasts or menstruate
In males- (a) that he will grow up to become a woman (not merely in role)
(b) that his penis or testes are disgusting or will disappear
(c) that it would be better not to have a penis or testes.
a. Marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration
b. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning
a. Marked incongruence between one's experienced/expressed gender and assigned gender, of at least 6 months duration
b. The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning
GID of Childhood renamed Gender Incongruence (GI) of Children
Transsexualism renamed Gender Incongruence of Adolescents and Adults
Both diagnoses removed from the Mental and Behavioral Disorders section of ICD and will be part of a new section entitled Conditions Related to Sexual Health
A marked incongruence between the child’s experienced/expressed gender and the child’s assigned sex must be manifested by the following three indicators:
b. Incongruence must have persisted for about 2 years so the diagnosis cannot be made before approximately age 5.
c. The diagnosis can only be assigned to children before puberty.
1. at least two of the following four criteria
2. The diagnosis cannot be assigned prior to the onset of puberty
3. The gender incongruence must have been continuously present for at least several months.
Random phone survey in U.S. 0.5 % -were identified as transgender
Dutch population – 1.0 % Natal males 0.8 % Natal females – transgender
In at least two countries, however, the sex ratio appears to favor natal females (Japan: 2.2:1; Poland: 3.4:1)
9 months - looking longer at a female than a male face, when a female voice was presented and vice versa
Gender constancy - an understanding that external changes in appearance or activity do not change one’s gender identity
Gender stability - the understanding that for most individuals, gender remains constant throughout life
1. genes or hormones (androgens)would directly influence the organization or activity of brain circuits that mediate gender identity
2. biological factors influence gender identity only indirectly as the more direct or immediate action of biological factors is upon temperament or other personality traits. From birth, these personality or temperamental traits influence how an individual experiences, interacts with, and modifies the environment. This would include how an individual participates in shaping the relationships and experiences thought by some to influence the development of a gender identity
In this model biology plays a permissive role by providing the neural machinery through which gender identity is inscribed by formative experience. A permissive role could also include delimiting the developmental stage during which the relevant formative experiences must occur.
Some songbirds must learn their species’ song by hearing it during a restricted period of early development. While the song is clearly acquired through experience, biology determines the sensitive period during which that experience must occur
Verbal labelling - as a boy or girl
Nonverbal gender-cuing (e.g., mannerisms, clothing, hair length and style)
1. Tomboyishness in girls or girly behaviour in boys, Occassional crossdressing in men. The majority of such children are comfortable with their bodies and assigned genders and remain so in adolescence or adulthood
1. paraphilia in which individuals are sexually aroused by cross-dressing
2. Involving a wish to alter or remove a specific body part perceived to be unattractive or abnormally formed
3. (in which delusions of being another gender may present).
WPATH Standards of Care (7th SOC)
Improving social integration, including positive relationships, with same-sex peers which are expected to come with decreased gender atypicality without hurting child’s self esteem
2. Dutch approach - To allow the developmental trajectory of gender identity to unfold naturally without pursuing or encouraging a specific outcome
To remain neutral with respect to gender identity outcome and to not target gender identity and gender atypical behaviors for change
3. With the option of age-appropriate endocrinological and surgical interventions if GD persists primary caregivers and clinicians may opt to support early social transition
Pubertal suspension can be done for a period of up to several years during which time the patient, with the clinicians, can decide whether it is preferable for the adolescent to revert to living in the birth sex or to continue gender transition with cross-sex hormone therapy
Requirements for puberty suppressing hormones - are that the adolescent has demonstrated a longstanding and intense pattern of gender nonconformity or GD; that GD has emerged or worsened with the onset of puberty, informed consent
Only one medical-college–attached public hospital in Chennai has a free SRS program (limited to removal of male genitalia and creation of vagina) for MtF transgender people following an order from the state government of Tamil Nadu in 2009. One public hospital in Mumbai and a semiautonomous government hospital in Delhi provide SRS on an ad hoc basis and in both these hospitals the costs for SRS need to be partly borne by the patients
Natal males - And often self identify as gay or homosexuals
Natal Females – and often self identify as lesbians
Hijras: They are biological males who reject their masculinity identity in due course of time to identify either as women, or ‘not men’. Hijras in Tamil Nadu identify as ‘Aravani’.
Kothi: AravanisKothis are heterogeneous group. Kothis can be described as biological males who show varying degrees of ‘feminity’.
Jogtas/Jogappas: They are those who are dedicated to serve as servant of Goddess Renukha Devi whose temples are present in Maharashtra and Karnataka. Sometimes, Jogti Hijras are used to denote such male-to-female transgender persons who are devotees of Goddess Renukha and are also from the Hijra community.
Shiv-Shakthis: They are considered as males who are possessed by or particularly close to a goddess and who have feminine gender expression). The way they behave and acts differs from the normative gender role of a men and women
National Legal Services Authority v. Union of India 15 april 2014
377. Unnatural offences: Whoever voluntarily has carnal intercourse against the order of nature with any man, woman or animal shall be punished with imprisonment for life, or with imprisonment of either description for a term which may extend to ten years, and shall also be liable to fine
On 6 September 2018, the Supreme Court of India ruled that the application of Section 377 to consensual homosexual sex between adults was unconstitutional, "irrational, indefensible and manifestly arbitrary",[1] but that Section 377 remains in force relating to sex with minors, non-consensual sexual acts, and bestiality
19 countries allow transgender military personnel to serve openly: Australia, Austria, Belgium, Bolivia, Canada, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Ireland, Israel, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom.[3] Cuba and Thailand reportedly allowed transgender service in a limited capacity
The eponymous hero is born as a male nobleman in England during the reign of Elizabeth I. He undergoes a mysterious change of sex at the age of about 30 and lives on for more than 300 years into modern times without ageing perceptibly.
The Hot Chick is a 2002 American teen comedy film about a teenage girl whose body is magically swapped with that of a 30-year-old criminal
