Gender identity disorder


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

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Gender identity disorder

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