Gender identity disorder
Encyclopedia
Gender identity disorder (GID) is the formal diagnosis used by psychologist
s and physician
s to describe persons who experience significant gender dysphoria
(discontent with their biological sex
and/or the gender
they were assigned at birth). It describes the symptoms related to transsexualism
, as well as less severe manifestations of gender dysphoria. GID is classified as a medical disorder by the ICD-10 CM and by the DSM-IV TR
It is likely that the new version of the DSM will replace this category with "Gender Dysphoria." Some authorities do not classify gender dysphoria as a mental illness
, including the NHS
which describes it as "a condition for which medical treatment is appropriate in some cases."
Gender identity disorder in children
is usually reported as "having always been there" since childhood, and is considered clinically distinct from GID that appears in adolescence
or adulthood, which has been reported by some as intensifying over time. As gender identity develops in children, so do sex-role stereotypes. Sex-role stereotypes are the beliefs, characteristics and behaviors of individual cultures that are deemed normal and appropriate for boys and girls to possess. 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. In many cases, transgendered individuals report discomfort stemming from the feeling that their bodies are "wrong" or meant to be different.
Many transgendered people and researchers support the declassification of GID as a mental disorder for several reasons. Recent medical research on the brain structures of transgendered individuals have shown that some transgendered individuals have the physical brain structures that resemble their desired sex even before hormone treatment. In addition, recent studies are indicating more possible causes for gender dysphoria, stemming from genetic reasons and prenatal exposure to hormones, as well as other psychological and behavioral reasons. (See Causes of transsexualism).
One contemporary treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.
permits a diagnosis of gender identity disorder if the four diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4thEdition, Text-Revised (DSM-IV-TR) are met. The criteria are:
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:
Transsexualism (F64.0) has three criteria:
Uncertainty about gender identity which causes anxiety or stress is diagnosed as sexual maturation disorder
.
Psychologist
Psychologist is a professional or academic title used by individuals who are either:* Clinical professionals who work with patients in a variety of therapeutic contexts .* Scientists conducting psychological research or teaching psychology in a college...
s and physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
s to describe persons who experience significant gender dysphoria
Dysphoria
Dysphoria is medically recognized as a mental and emotional condition in which a person experiences intense feelings of depression, discontent and indifference to the world around them.Mood disorders can induce dysphoria, often with a heightened risk of suicide, especially in...
(discontent with their biological sex
Sex
In biology, sex is a process of combining and mixing genetic traits, often resulting in the specialization of organisms into a male or female variety . Sexual reproduction involves combining specialized cells to form offspring that inherit traits from both parents...
and/or the gender
Gender
Gender is a range of characteristics used to distinguish between males and females, particularly in the cases of men and women and the masculine and feminine attributes assigned to them. Depending on the context, the discriminating characteristics vary from sex to social role to gender identity...
they were assigned at birth). It describes the symptoms related to transsexualism
Transsexualism
Transsexualism is an individual's identification with a gender inconsistent or not culturally associated with their biological sex. Simply put, it defines a person whose biological birth sex conflicts with their psychological gender...
, as well as less severe manifestations of gender dysphoria. GID is classified as a medical disorder by the ICD-10 CM and by the DSM-IV TR
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
It is likely that the new version of the DSM will replace this category with "Gender Dysphoria." Some authorities do not classify gender dysphoria as a mental illness
Mental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
, including the NHS
National Health Service (England)
The National Health Service or NHS is the publicly funded healthcare system in England. It is both the largest and oldest single-payer healthcare system in the world. It is able to function in the way that it does because it is primarily funded through the general taxation system, similar to how...
which describes it as "a condition for which medical treatment is appropriate in some cases."
Gender identity disorder in children
Gender identity disorder in children
Gender identity disorder in children is the formal diagnosis used by psychologists and physicians to describe children who experience significant gender dysphoria ....
is usually reported as "having always been there" since childhood, and is considered clinically distinct from GID that appears in adolescence
Adolescence
Adolescence is a transitional stage of physical and mental human development generally occurring between puberty and legal adulthood , but largely characterized as beginning and ending with the teenage stage...
or adulthood, which has been reported by some as intensifying over time. As gender identity develops in children, so do sex-role stereotypes. Sex-role stereotypes are the beliefs, characteristics and behaviors of individual cultures that are deemed normal and appropriate for boys and girls to possess. 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. In many cases, transgendered individuals report discomfort stemming from the feeling that their bodies are "wrong" or meant to be different.
Many transgendered people and researchers support the declassification of GID as a mental disorder for several reasons. Recent medical research on the brain structures of transgendered individuals have shown that some transgendered individuals have the physical brain structures that resemble their desired sex even before hormone treatment. In addition, recent studies are indicating more possible causes for gender dysphoria, stemming from genetic reasons and prenatal exposure to hormones, as well as other psychological and behavioral reasons. (See Causes of transsexualism).
One contemporary treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.
Diagnostic criteria
In the United States, the American Psychiatric AssociationAmerican Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
permits a diagnosis of gender identity disorder if the four diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, 4thEdition, Text-Revised (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
- The diagnosis is not made if the individual also has physical intersexIntersexIntersex, in humans and other animals, is the presence of intermediate or atypical combinations of physical features that usually distinguish female from male...
characteristics.
- Significant clinical discomfort or impairment at work, social situations, or other important life areas.
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:
Transsexualism (F64.0) has three criteria:
- The desire 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 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
Sexual maturation disorder
Sexual maturation disorder is a disorder of anxiety or depression related to an uncertainty about one's gender identity or sexual orientation...
.
Treatment
The World Professional Association for Transgender Health (WPATH, formerly HBIGDA) Standards of CareStandards of care for gender identity disorders
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are non-binding protocols outlining the usual treatment for individuals who wish to undergo hormonal or surgical transition to the other sex...
(Version 6 from 2001) are considered by some as definitive treatment guidelines for providers. Other Standards exist (see those discussed in Standards of care for gender identity disorders
Standards of care for gender identity disorders
The Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People are non-binding protocols outlining the usual treatment for individuals who wish to undergo hormonal or surgical transition to the other sex...
, including the guidelines outlined in Gianna Israel and Donald Tarver's classic 1997 book "Transgender Care". Several health clinics in the United States (e.g. Tom Waddell in San Francisco, Callen Lorde in New York City, Mazzoni in Philadelphia) have developed “protocols
Guideline (medical)
A medical guideline is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare...
” for transgender hormone therapy following a “harm reduction
Harm reduction
Harm reduction refers to a range of public health policies designed to reduce the harmful consequences associated with recreational drug use and other high risk activities...
” model which increasing numbers of providers have adopted. Nick Gorton et al. suggest a flexible approach based on harm reduction, “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.”
Formal gender clinics for individuals seeking medical sex reassignment began operating in the 1960s and 1970s, leading to long-term follow-up studies that began appearing in the research literature in the 1980s and 1990s. These studies have examined transsexuals who received clinical approval to undergo reassignment and proceeded to do so. The great majority of patients who met clinics' screening criteria reported being satisfied in the long-term with the results.
Prepubescent children
The question of whether to counsel young children to be happy with their biological 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 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. It should be noted, however, that such blocking of growth hormones may cause significant detrimental musculo-skeletal problems if done for a prolonged period of time .Controversy
People diagnosed with gender identity disorder (GID) may not regard their own cross-gender feelings and behaviors as a disorderMental illness
A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...
, and may question what constitutes a normal gender identity
Gender identity
A gender identity is the way in which an individual self-identifies with a gender category, for example, as being either a man or a woman, or in some cases being neither, which can be distinct from biological sex. Basic gender identity is usually formed by age three and is extremely difficult to...
or gender role
Gender role
Gender roles refer to the set of social and behavioral norms that are considered to be socially appropriate for individuals of a specific sex in the context of a specific culture, which differ widely between cultures and over time...
. One argument is that 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
Homosexuality
Homosexuality is romantic or sexual attraction or behavior between members of the same sex or gender. As a sexual orientation, homosexuality refers to "an enduring pattern of or disposition to experience sexual, affectional, or romantic attractions" primarily or exclusively to people of the same...
or transgenderism as normal behavior. Individuals diagnosed with GID may also view "transgendering" as a means for deconstructing
Deconstruction
Deconstruction is a term introduced by French philosopher Jacques Derrida in his 1967 book Of Grammatology. Although he carefully avoided defining the term directly, he sought to apply Martin Heidegger's concept of Destruktion or Abbau, to textual reading...
gender; however, not all transgender people wish to deconstruct gender or feel that they are doing so.
Those in the community who disagree with the diagnosis of GID also state that the treatment for this disorder consists primarily of physical modifications to bring the body into harmony with one's perception of mental (psychological, emotional) gender identity, rather than vice versa.
Some critics of the classification of GID as a mental disorder argue that transsexualism instead should be listed as a "birth defect" or "rare disease," citing in evidence research suggesting a physiological cause. This argument is supported by evidence that includes overall more feminine white matter and neuron patterns observed in male-to-female transsexual participants 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.
The question of continued inclusion of gender identity disorder with mental illnesses has expanded in recent years. One opponent, 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. Hill insists “There is little evidence of pathology” in GID and compares the treatment prescribed to "reparative therapies" for changing sexual orientation. Others, including Dr. Robert Spitzer and Dr. Paul J. Fink, disagree with Hill's assertions, contending that the behaviors and experiences seen in transsexualism are abnormal and constitute a dysfunction. A middle ground also exists: Dr. Katherine Wilson suggests that the diagnosis be made of gender dysphoria without emphasis on gender nonconformity.
Members of the HBIGDA are split on the issue, but are concerned that those who experience distress have proper access to medical treatment, including psychological, endocrinological, and surgical services, and insurance coverage for those services.
The DSM-V Task Force proposes that the classification of the disorder be maintained with emphasis on gender variant behavior and thoughts as well as distress, evaluated separately, but the classification will be under a different name due to "criticisms that the term was stigmatizing." The revisions include expanding criteria, separating child and adult dysphoria, removing a specifier for sexual orientation, and allowing the inclusion of other disorders such as somatic disorder of sex development. In response to criticism that the new criteria would include all gender-variant people, the distinction would not include all gender-variant people, as the disorder must be "associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning, or with a significantly increased risk of suffering, such as distress or disability."
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.
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
Gender identity
A gender identity is the way in which an individual self-identifies with a gender category, for example, as being either a man or a woman, or in some cases being neither, which can be distinct from biological sex. Basic gender identity is usually formed by age three and is extremely difficult to...
of a transsexual or transgender
Transgender
Transgender is a general term applied to a variety of individuals, behaviors, and groups involving tendencies to vary from culturally conventional gender roles....
ed person is neither "disorder" nor mental illness, thus the diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
"gender identity disorder" can be contradictory and irreverent. As well, The Activist's Guide of the Yogyakarta Principles in Action
Yogyakarta Principles in Action
Yogyakarta Principles in Action is a movement for activists and human rights defenders to promote human rights, especially those of LGBTI around the Yogyakarta Principles, supported by ARC International, Hivos and Dreilinden Gesellschaft für gemeinnütziges Privatkapitel, Germany.They published the...
states that "It is important to note that while "sexual orientation" has been declassified as a mental illness in many countries, "gender identity
Gender identity
A gender identity is the way in which an individual self-identifies with a gender category, for example, as being either a man or a woman, or in some cases being neither, which can be distinct from biological sex. Basic gender identity is usually formed by age three and is extremely difficult to...
" or gender identity disorder" often remains under consideration."
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 the opposite 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
Kenneth Zucker
Kenneth J. Zucker is a Jewish American-Canadian psychologist and sexologist, and head of the child and adolescent gender identity clinic at Toronto's Centre for Addiction and Mental Health. Based on his collaboration with Susan Bradley, Zucker is considered an international authority in the field...
and Robert Spitzer
Robert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
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".
The GID controversy figured prominently at the 2009 meeting of the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
in San Francisco, both in presentations in the meeting and in protests outside the meeting; protesters focused on the attitude of the psychiatric community and tried to make the point that GID is not a mental disorder, as well focusing on the role of Kenneth Zucker in leading the DSM-V Task Force on Sexual and Gender Identity Disorders.
In 31 August 2010, Thomas Hammarberg
Thomas Hammarberg
Thomas Hammarberg is a Swedish diplomat and human rights defender.He is currently the Commissioner for Human Rights at the Council of Europe in Strasbourg...
, Commissioner for Human Rights
Commissioner for Human Rights
The Commissioner for Human Rights is an independent institution within the Strasbourg-based Council of Europe, mandated to promote the awareness of and respect for human rights in member states...
within the Strasbourg-based Council of Europe, an independent institution, opposed the mental disorder classification and the sterilisation of transgendered persons as a requirement for legal sex change.
See also
- Gender identity disorder in childrenGender identity disorder in childrenGender identity disorder in children is the formal diagnosis used by psychologists and physicians to describe children who experience significant gender dysphoria ....
- List of transgender-related topics
- Anti-psychiatryAnti-psychiatryAnti-psychiatry is a configuration of groups and theoretical constructs that emerged in the 1960s, and questioned the fundamental assumptions and practices of psychiatry, such as its claim that it achieves universal, scientific objectivity. Its igniting influences were Michel Foucault, R.D. Laing,...
- Yogyakarta Principles in ActionYogyakarta Principles in ActionYogyakarta Principles in Action is a movement for activists and human rights defenders to promote human rights, especially those of LGBTI around the Yogyakarta Principles, supported by ARC International, Hivos and Dreilinden Gesellschaft für gemeinnütziges Privatkapitel, Germany.They published the...
External links
- Standards of Care for Gender Identity Disorders – published by the Harry Benjamin International Gender Dysphoria Association, includes a description of ICD-10 criteria.
- Health Law Standards of Care for Transsexualism An alternative to the Benjamin Standards of Care proposed by the International Conference on Transgender Law and Employment Policy.
- THE LORD CHANCELLOR'S DEPARTMENT Government Policy concerning Transsexual People
- Gender Identity Disorder & Transsexualism – Synopsis of Etiology in Adults provides an alternative to the current classifications of psychiatric disorder and mental illness.
- Conway, Lynn: "Successful Transwomen" and " Successful Transmen" -Lynn Conway's "Success Pages".