genital ambiguity: incomplete development of fetal genitalia as a result of excessive androgen action on a female fetus or inadequate amounts of androgen in a male fetus
• Gender identity: the sense one has of being male or being female which corresponds, normally, to the persons anatomical sex.• The affective component of GID is gender dysphoria, discontent with ones designated birth sex and a desire to have the body of the other sex, and to be regarded socially as a person of the other sex. GENDER IDENTITY DISORDER
• GID in children is usually reported as "wanting to be the other sex “.• In many cases, transgendered individuals report discomfort stemming from the feeling that their bodies are "wrong" or meant to be different.• Gender identity becomes fixed in most persons by age 2 or 3 years.• The sex ratio of referred children is 4 to 5 boys for each girl.
• Resting state of tissue in memmals is initially female & as fetus develops, a male is produced only if androgen is introduced by Y chromosome.• maleness and masculinity depend on fetal and perinatal androgens.• Testosterone can increase libido and aggressiveness in women, and estrogen can decrease libido and aggressiveness in men.• Masculinity, femininity, and gender identity result more from postnatal life events.ETIOLOGY- BIOLOGICAL FACTORS
• Children usually develop a gender identity consonant with their sex of rearing (also known as assigned sex).• The formation of gender identity is influenced by the interaction of childrens temperament and parents qualities and attitudes.• Sex-role stereotypes are the beliefs, characteristics and behaviors of individual cultures that are deemed normal and appropriate for boys and girls to possess. PSYCHOSOCIAL FACTORS
• These "norms" are influenced by family and friends, the mass-media, community and other socializing agents.• Since many cultures strongly disapprove of cross-gender behavior, it often results in significant problems for affected persons and those in close relationships with them.
• Current diagnostic criteria for children and adults are organized under two main groupings:1. cross-gender identification2. discomfort with assigned gender role.
1. A strong and 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 suchas a stated desire to be the other sex, frequent passing as the other sex, desire to live or betreated as the other sex, or the conviction that he or she has the typical feelings andreactions of the other sex. DSM-IV-TR Diagnostic Criteria for GID
2. 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 hispenis or testes are disgusting or will disappear or assertion that it would be better not to havea 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 shehas or will grow a penis, or assertion that she does not want to grow breasts or menstruate, ormarked aversion toward normative feminine clothing.In adolescents and adults, the disturbance is manifested by symptoms such as preoccupationwith 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 othersex) or belief that he or she was born the wrong sex.3. The disturbance is not concurrent with a physical intersex condition.4. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The parents of a 7-year-old boy came for consultation because the boy had told his parents on several occasions that he would like to be a girl. From 2 to 3 years of age, he showed interest in dressing in his older sisters clothing. Initially, both parents thought that their sons interest in his sisters and, occasionally, his mothers clothes was cute. They were reassured of its transient nature by their family doctor. Preschool teachers told them that many boys dress up and that it was normal. When his parents kept the clothes from him, he would improvise with a towel for long hair and a large t-shirt for a dress. When playing mother- father games, he would be mother, and he imitated female characters from childrens stories. Most of his playmates were girls. He played often with his sisters discarded dolls and did not like sports. At school, he was teased by age- mates, notably boys, for cross-gender activities. At consultation, the father was concerned that his son would grow up to be gay. Mother was less concerned with this potential but was more worried that he was becoming a loner and unhappy at school in consequence of peer stigma. (Adapted from case of Richard Green, M.D.) CASE:
• Children with a GID must be distinguished from other gender- atypical children.• For girls, tomboys without GID prefer functional and gender- neutral clothing. By contrast, girls with GID adamantly refuse to wear girls clothes and reject gender-neutral clothes.• For boys, the differential diagnosis must distinguish those who do not conform to traditional masculine sex-typed expectations, but do not show extensive cross-gender identification and are not discontent with being male.• Because the diagnosis of gender GID excludes children with anatomical intersex, a medical history needs to be taken with the focus on any suggestion of hermaphrodism in the child. With doubt, referral to a pediatric endocrinologist is indicated.Differential Diagnosis in Children
• Adolescents and adults with the disorder manifest…… • a stated desire to be the other sex; • frequently try to pass as a member of the other sex and • desire to live or to be treated as the other sex. • desire to acquire the sex characteristics of the opposite sex.• They may believe that they were born the wrong sex.• frequently request medical or surgical procedures to alter their physical appearance. Differential Dx - ADOLESCENTS & ADULTS
• Men take estrogen to create breasts and other feminine contours, have electrolysis to remove their male hair, and have surgery to remove the testes and the penis and to create an artificial vagina.• Women bind their breasts or have a double mastectomy, a hysterectomy, and an oophorectomy; they take testosterone to build up muscle mass and deepen the voice and have surgery in which an artificial phallus is created.
• At present, no convincing evidence indicates that psychiatric or psychological intervention for children with GID affects the direction of subsequent sexual orientation.• Transsexualism, however, can be affected. Transsexuals or adults with GID are unable to cope socially as persons of their anatomical birth sex.• The treatment of GID in children is directed largely at developing social skills and comfort in the sex role expected by birth anatomy. To the extent that treatment is successful, transsexual development may be interrupted.• No hormonal or psychopharmacological treatments for GID in childhood have been identified.TREATMENT- CHILDREN
• Adolescents whose GID has persisted beyond puberty present unique treatment problems.• Treatment management is to slowing down or stopping pubertal changes expected by anatomical birth sex and then implementing cross-sex body changes with cross-sex hormones.• Parents must also be informed of the nonpathological nature of same-sex orientation. The goal of family intervention is to keep the family stable and to provide a supportive environment for the teenager.Tx- ADOLESCENTS
• Adult patients coming to a gender identity clinic usually present with straightforward requests for hormonal and surgical sex reassignment.• No drug treatment has been shown to be effective in reducing cross-gender desires per se.• When patient gender dysphoria is severe and intractable, sex reassignment may be the best solution.Tx- ADULTS
• Sex reassignment surgery for a person born anatomically male consists principally of removal of the penis, scrotum, and testes, construction of labia, and vaginoplasty. Some clinicians attempt to construct a neoclitoris from the former frenulum of the penis. The neoclitoris may have erotic sensation. • Postoperative complications include urethral strictures, rectovaginal fistulas, vaginal stenosis, and inadequate width or depth. • Female-to-male patients typically may undergo bilateral mastectomy and construct a neophallus. Because of increased technical skills in phalloplasty, more female- to-male patients are now electing these procedures.Sex-Reassignment Surgery
• Persons born male are typically treated with daily doses of oral estrogen- conjugated equine estrogens or ethinylestradiol which produce breast enlargement, testicular atrophy, decreased libido, and diminished erectile capacity.. Facial hair removal is required by laser treatment or electrolysis.• Biological women are treated with monthly or three weekly injections of testosterone. The pitch of the voice drops permanently into the male range as the vocal cords thicken. The clitoris enlarges to two or three times its pretreatment length and is often accompanied by increased libido. Hair growth changes to the male pattern, and a full complement of facial hair may grow.• Cross-sex steroid hormones affect general body fat and muscle distribution as well as promote breast development in patients born male. Hormonal Treatment
• This category is included for coding disorders in gender identity that are not classifiable as a specific GID. Examples include1. Intersex conditions (e.g., partial androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria2. Transient, stress-related cross-dressing behavior3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sexGender Identity Disorder not Otherwise Specified
• Intersexuality: person’s biological sex cannot be classified as clearly male or female.• It refers to intermediate or atypical combinations of physical features that usually distinguish female from male and is usually congenital involving chromosomal, morphologic and genital anomalies.Intersex conditions
Intersex DiscriptionconditionCongenital Sex karyotype: XX. Most common cause of sexual ambiguity, overproduction of adrenal androgens andvirilizing virilization of the female fetus, androgenization can range from mild clitoral enlargement to externaladrenal genitals that look like a normal scrotal sac, testes, and a penis, but hidden behind these external genitals are a vagina and a uterus.hyperplasiaAndrogen Sex karyotype: XY. Normal female look at birth and so raised as girl. Cryptorchid testes, clitoromegaly,insensitivity micropenis co-exist in some. Testosterone do not respond to tissue. Minimal or absent internal sexualsyndrome organs (uterus, ovary, cervix).Turner’s Sex karyotype: XO. Children have female genitalia, are short, anomalies like shield-shaped chest and asyndrome webbed neck. Tx: exogenous estrogen to develop female secondary sex characteristics.Klinfelter’s Sex karyotype: XXY. normal male at birth. Excessive gynecomastia may occur in adolescence. Smallsyndrome testes without sperm production. They are tall with reduced fertility. Higher rate of GID.5-α- Sex karyotype: XY. unable to convert testosterone to dihydrotestosterone (DHT). ambiguous genitalia atReductase birth with some sexual anomaly. Affected person appears to be female. Children are sometimesDeficiency misdiagnosed as having AIS.Pseudoherma Infants born with ambiguous genitals, True hermaphroditism: presence of both testes and ovaries.phroditism Male pseudohermaphroditism: incomplete differentiation of the external genitalia even though a Y chromosome is present; testes are present but rudimentary. Female pseudohermaphroditism: presence of virilized genitals in person who is XX
• Management of intersex can be categorized into one of the following two:1. Treatments: Restore functionality (or potential functionality) – generally undertaken before age 32. Enhancements: Give the ability to identify with “mainstream” – breast enlargement surgery• It is easier to assign a child to be female than to assign one to be male, because male-to-female genital surgical procedures are far more advanced than female- to-male procedures.• The exact procedure of the surgery depends on what is the cause of a less common body phenotype in the first place. There is often concern as to whether surgery should be performed at all.• The goal of treatment is to have genitals concordant with chromosomal, biological, physiological, and other genetic antecedents, thus allowing the development of a person with healthy gender identity. TREATMENT- INTERSEX
• If the disorder is not stress related, persons who cross-dress are classified as having transvestic fetishism, which is described as a paraphilia in DSM-IV-TR. An essential feature of transvestic fetishism is that it produces sexual excitement. The DSM-IV-TR lists cross-dressing- dressing in clothes of the opposite sex- as a gender identity disorder if it is transient and related to stress.• A cross-dresser is a person who has an apparent gender identification with one sex, and who has and certainly has been birth-designated as belonging to one sex, but who wears the clothing of the opposite sex. Cross-dressers may not identify with opposite gender & do not adopt behaviors of the opposite gender, and generally do not want to change their bodies medically.• Cross-dressing can coexist with paraphilias, such as sexual sadism, sexual masochism, and pedophilia.• The disorder is most common among female impersonators. Cross-Dressing
• A combined approach, using psychotherapy and pharmacotherapy, is often useful in the treatment of cross-dressing.• Antianxiety and antidepressant agents, is used to treat the symptoms as cross-dressing can occur impulsively, medications that reinforce impulse control may be helpful, such as fluoxetine (Prozac).Cross-Dressing TREATMENT
• The category of preoccupation with castration is reserved for men and women who have a persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the opposite sex.• They are clearly uncomfortable with their assigned sex and their lives are driven by the fantasy of what it would be like to be a different gender.• They may be asexual and lack sexual interest in either men or women.Preoccupation with Castration
• Transsexualism1. The individual desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormonal treatment.2. The transsexual identity has been present persistently for at least 2 years.3. The disorder is not a symptom of another mental disorder, such as schizophrenia, nor is it associated with chromosome abnormality.• Dual-role transvestism1. The individual wears clothes of the opposite sex in order to experience temporarily membership of the opposite sex.2. There is no sexual motivation for the cross-dressing.3. The individual has no desire for a permanent change to the opposite sex. ICD-10 Diagnostic Criteria for GID
• Gender identity disorder of childhoodFor girls:1. The individual shows persistent and intense distress about being a girl, and has a stated desire to be a boy (not merely a desire for any perceived cultural advantages to being a boy), or insists that she is a boy.2. Either of the following must be present: A. persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g., boys underwear and other accessories; B. persistent repudiation of female anatomical structures, as evidenced by at least one of the following: • an assertion that she has, or will grow, a penis; • rejection of urinating in a sitting position; • assertion that she does not want to grow breasts or menstruate.3. The girl has not yet reached puberty.4. The disorder must have been present for at least 6 months.
• For boys:1. The individual shows persistent and intense distress about being a boy, and has an intense desire to be a girl or, more rarely, insists that he is a girl.2. Either of the following must be present: A. preoccupation with stereotypical female activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games, and activities; B. persistent repudiation of male anatomical structures, as indicated by at least one of the following repeated assertions: • that he will grow up to become a woman (not merely in role); • that his penis or testes are disgusting or will disappear; • that it would be better not to have a penis or testes;3. The boy has not yet reached puberty.4. The disorder must have been present for at least 6 months.