Kaplan and Sadock's Comprehensive Textbook of Psychiatry

1. GENDER IDENTITY
DISORDERS

2. • Gender identity: the sense one has of being male or being female
which corresponds, normally, to the person's anatomical sex.
• The affective component of GID is gender dysphoria, discontent
with one's 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

3. • 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.

4. • 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

5. • 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 children's 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

6. • 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.

7. • Current diagnostic criteria for children and adults are
organized under two main groupings:
1. cross-gender identification
2. discomfort with assigned gender role.

8. 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 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.
DSM-IV-TR Diagnostic Criteria for GID

9. 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 his
penis or testes are disgusting or will disappear or assertion that it would be better not to have
a 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 she
has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or
marked aversion toward normative feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation
with 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 other
sex) 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.

10. • 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 sister's clothing. Initially, both
parents thought that their son's interest in his sister's and, occasionally, his
mother's 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
children's stories. Most of his playmates were girls. He played often with his
sister's 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:

11. • 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

12. hermaphrodite
Tomboy
Gay

13. • 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

14. • 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.

15. • 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

16. • 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

17. • 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

18. • 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

19. • 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

20. • This category is included for coding disorders in gender
identity that are not classifiable as a specific GID.
Examples include
1. Intersex conditions (e.g., partial androgen insensitivity
syndrome or congenital adrenal hyperplasia) and
accompanying gender dysphoria
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration or penectomy
without a desire to acquire the sex characteristics of the
other sex
Gender Identity Disorder not Otherwise Specified

21. • 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

22. Intersex Discription
condition
Congenital Sex karyotype: XX. Most common cause of sexual ambiguity, overproduction of adrenal androgens and
virilizing virilization of the female fetus, androgenization can range from mild clitoral enlargement to external
adrenal genitals that look like a normal scrotal sac, testes, and a penis, but hidden behind these external genitals
are a vagina and a uterus.
hyperplasia
Androgen 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 sexual
syndrome organs (uterus, ovary, cervix).
Turner’s Sex karyotype: XO. Children have female genitalia, are short, anomalies like shield-shaped chest and a
syndrome 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. Small
syndrome 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 at
Reductase birth with some sexual anomaly. Affected person appears to be female. Children are sometimes
Deficiency 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

23. Adrenogenital syndrome & Turner’s syndrome

24. • Management of intersex can be categorized into one of the following two:
1. Treatments: Restore functionality (or potential functionality) – generally
undertaken before age 3
2. 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

25. • 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

26. • 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

27. • 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

28. • Transsexualism
1. 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 transvestism
1. 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

29. • Gender identity disorder of childhood
For 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., boy's 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.

30. • 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.