Gender Identity Disorder

Gender identity disorder occurs when a person feels as if their biological gender doesn’t accord with who they feel themselves to be.

Definition

Gender identity disorder (GID) or transsexualism is defined by strong, persistent feelings of identification with the opposite gender and discomfort with one's own assigned sex. People with GID desire to live as members of the opposite sex and often dress and use mannerisms associated with the other gender. For instance, a person identified as a boy may feel and act like a girl. This is distinct from homosexuality in that homosexuals nearly always identify with their apparent sex or gender.

Identity issues may manifest in a variety of different ways. For example, some people with normal genitals and secondary sex characteristics of one gender privately identify more with the other gender. Some may cross-dress, and some may actually seek sex-change surgery. Others are born with ambiguous genitalia, which can raise identity issues.

Associated Features and Disorders of Gender Identity Disorder

Many individuals with gender identity disorder become socially isolated, whether by choice or through ostracization, which can contribute to low self-esteem and may lead to school aversion or even dropping out. Peer ostracism and teasing are especially common consequences for boys with the disorder.

Boys with gender identity disorder often show marked feminine mannerisms and speech patterns.

The disturbance can be so pervasive that the mental lives of some individuals revolve only around activities that lessen gender distress. They are often preoccupied with appearance, especially early in the transition to living in the opposite sex role. Relationships with parents also may be seriously impaired. Some males with gender identity disorder resort to self-treatment with hormones and may (very rarely) perform their own castration or penectomy. Especially in urban centers, some males with the disorder may engage in prostitution, placing them at a high risk for human immunodeficiency virus (HIV) infection. Suicide attempts and substance-related disorders are common.

Children with gender identity disorder may manifest coexisting separation anxiety disorder, generalized anxiety disorder and symptoms of depression.

Adolescents are particularly at risk for depression and suicidal ideation and suicide attempts.

Adults may display anxiety and depressive symptoms. Some adult males have a history of transvestic fetishism as well as other paraphilias. Associated personality disorders are more common among males than among females being evaluated at adult gender clinics.

Symptoms

Children:

  • Express the desire to be the opposite sex
  • Have disgust with their own genitals
  • Believe that they will grow up to become the opposite sex
  • Are rejected by their peer group and feel isolated
  • Have depression
  • Have anxiety

Adults:

  • Desire to live as a person of the opposite sex
  • Wish to be rid of their own genitals
  • Dress in a way that is typical of the opposite sex
  • Feel isolated
  • Have anxiety

To be clinically diagnosed with GID:

A. Must persistently and strongly identify with the opposite gender (aside from desiring any perceived cultural advantage of being the other gender). In children, the disturbance is manifested by four (or more) of the following:

In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. A persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex. Must have strong discomfort with own gender and may express these qualities:

Boys:

  • Disgust with own genitals
  • Belief that genitals will disappear or that it would be preferable not to have a penis
  • Rejection of male activities such as rough and tumble play, games and toys

Girls:

  • Rejection of urinating in seated position
  • Desire not to develop breasts or menstruate
  • Claims that she will have a penis
  • Strong dislike for typical female clothing

In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (such as request for hormones, surgery or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.

C. The disturbance is not concurrent with physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning.

Causes

People with gender identity disorder act and present themselves as members of the opposite sex. The disorder may affect self-concept, choice of sexual partners and the display of femininity or masculinity through mannerisms, behavior and dress.

The feeling of being in the body of the "wrong" gender must persist for at least two years for this diagnosis to be made. The cause is unknown, but hormonal influences in the womb, genetics and environmental factors (such as parenting) are suspected to be involved. The disorder may occur in children or adults, and is rare.

There are no recent studies to provide data on prevalence of gender identity disorder. Data from some countries in Europe suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery.

Onset of cross-gender interests and activities is usually between ages 2 and 4 years, and some parents report that their child has always had cross-gender interests. Only a very small number of children with gender identity disorder will continue to have symptoms that meet criteria for the disorder in later adolescence or adulthood. Typically, children are referred around the time of school entry because of parental concern that what they regarded as a phase does not appear to be passing.

Adult onset is typically in early to mid-adulthood, usually after or concurrent with transvestic fetishism. There are two different courses for the development of gender identity disorder:

  • The first, typically found in late adolescence or adulthood, is a continuation of GID that had an onset in childhood or early adolescence.
  • In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood usually following, but sometimes concurrent with, transvestic fetishism.

The later-onset group:

  • may be more fluctuating in the degree of cross-gender identification
  • more ambivalent about sex-reassignment surgery
  • more likely to be sexually attracted to women
  • less likely to be satisfied after sex-reassignment surgery.
  • Males with gender identity disorder who are sexually attracted to males tend to present in adolescence or early childhood with a lifelong history of gender dysphoria. In contrast, those who are sexually attracted to females, to both males and females or to neither sex tend to present later and typically have a history of transvestic fetishism. If gender identity disorder is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported.

Treatments

Individual and family counseling is recommended for children, and individual or couples therapy is recommended for adults. Sex reassignment through surgery and hormonal therapy is an option, but severe problems may persist after this form of treatment. A better outcome is associated with the early diagnosis and treatment of this disorder.

Sources

  • Diagnostic and Statistical Manual of Mental Disorders
  • National Institutes of Health - National Library of Medicine
Last reviewed 02/17/2015