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Bose S, Das K, George B, Raman V, Shubha AM, Mahadevappa K, Kumar P, Bantwal G, Ayyar V, Deb M. 46 XY disorder of sex development (DSD) due to 5 alpha (SRD5A2) deficiency - Experience from a multidisciplinary Pediatric Gender Clinic. J Pediatr Urol 2022; 18:492.e1-492.e8. [PMID: 35668006 DOI: 10.1016/j.jpurol.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 04/21/2022] [Accepted: 05/12/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND SRD5A2 deficiency leads to incomplete masculinization of individuals with a 46 XY karyotype. A definitive diagnosis in early infancy facilitates decisions concerning choice of sex of rearing and management. AIM To review the clinical presentation, diagnosis, treatment and outcome of children with 46 XY DSD due to SRD5A2 deficiency at a Paediatric Gender Clinic. STUDY DESIGN AND METHODS Retrospective review of cases of SRD5A2 deficiency (2000-15) managed with a standard protocol at a multidisciplinary clinic. Demographic data, clinical presentation, physical findings, investigations (hormonal profile, imaging, genitoscopy), psychological evaluation (child, family), medical and surgical management, outcome and follow up were collated and analyzed. RESULTS There were 12 cases aged 3 days-14 years at presentation, 3 had parental consanguinity. Eight were reared as males and 4 as females. Specialist referral was sought for hypospadias (5), atypical genitalia (5) or incongruent pubertal masculinization (2). All had chordee, symmetrical inguinoscrotal gonads, rugose labioscrotum and proximal hypospadias (perineoscrotal -9, perineal -3). Both pubertal cases had significant masculinization and no gynecomastia. The median testosterone/dihydrotestosterone ratio was 22.1(IQR-8.6-55.7). Despite a classical phenotype, four (2 prepubertal, 2 pubertal) had a ratio <10. Genitoscopy showed urogenital sinus remnant (4) and hypoplastic verumontanum (5). Sex reassignment was done in 4. Surgical management was staged and completed by 4 years in those with infantile presentation. Besides correction of chordee and urethroplasty in 11, other procedures included orchidopexy (5), excision of a urogenital sinus remnant (4) and correction of penoscrotal transposition (4). The urethroplasty was single staged in 3. All operated cases were followed up (mean age at last follow up - 10.63 years, mean follow up period - 7.25 years). The overall cosmetic result was satisfactory, but the phallic structure remained relatively small across prepubertal period. Uroflowmetry curves were normal in 9. All showed penile tumescence/erection and two peripubertal cases had typical secondary sexual characters. All cases, including those with sex reassignment, have a well-adjusted male psyche. DISCUSSION AND CONCLUSION The diagnosis, management and longitudinal follow up of cases of SRD5A2 deficiency at a multidisciplinary gender clinic is presented. Diagnostic dilemmas with low T/DHT ratios remained in a third of cases. Most were diagnosed in infancy and assigned a male sex of rearing, all underwent staged masculinizing genitoplasty. Those with sex reassignment also fared well with comprehensive management after family counseling.
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Affiliation(s)
- Sumona Bose
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Kanishka Das
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Belinda George
- Department of Endocrinology, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Vijaya Raman
- Department of Psychiatry, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - A M Shubha
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Kiran Mahadevappa
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Prasanna Kumar
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Ganapathi Bantwal
- Department of Endocrinology, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Vageesh Ayyar
- Department of Endocrinology, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
| | - Mainak Deb
- Department of Paediatric Surgery, Paediatric Gender Clinic, St. John's Medical College, Bangalore, 560034, India.
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2
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Bloom TM, Nguyen TP, Lami F, Pace CC, Poulakis Z, Telfer M, Taylor A, Pang KC, Tollit MA. Measurement tools for gender identity, gender expression, and gender dysphoria in transgender and gender-diverse children and adolescents: a systematic review. THE LANCET CHILD & ADOLESCENT HEALTH 2021; 5:582-588. [PMID: 34111389 DOI: 10.1016/s2352-4642(21)00098-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 12/01/2022]
Abstract
Increasing numbers of children and adolescents are being referred to gender services for gender-related concerns. Various instruments are used with these patients in clinical care, but their clinical validity, strengths, and limitations have not been systematically reviewed. In this systematic review, we searched MEDLINE, PubMed, and PsycINFO databases for available tools that assess gender identity, gender expression, or gender dysphoria in transgender and gender-diverse (TGD) children and adolescents. We included studies published before Jan 20, 2020, that used tools to assess gender identity, expression, or dysphoria in TGD individuals younger than 18 years. Data were extracted from eligible studies using a standardised form. We found 39 studies that met the inclusion criteria, from which we identified 24 tools. The nature of tools varied considerably and included direct observation, child and adolescent self-report, and parent-report tools. Many methods have only been used with small samples, include outdated content, and lack evaluation of psychometric properties. In summary, a paucity of studies in this area, along with sparse reporting of psychometric properties, made it difficult to compare the relative use of tools, and current tools have substantial limitations. Future research is required to validate existing measures and create more relevant, culturally appropriate tools.
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Affiliation(s)
- Thea M Bloom
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia
| | - Thomas P Nguyen
- Mental Health, School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Francesca Lami
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Carmen C Pace
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Zeffie Poulakis
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Michelle Telfer
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Amelia Taylor
- Tavistock and Portman NHS Foundation Trust, Gender Identity Development Service, London, UK
| | - Kenneth C Pang
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
| | - Michelle A Tollit
- Department of Adolescent Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.
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3
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Fausto-Sterling A. A Dynamic Systems Framework for Gender/Sex Development: From Sensory Input in Infancy to Subjective Certainty in Toddlerhood. Front Hum Neurosci 2021; 15:613789. [PMID: 33897391 PMCID: PMC8062721 DOI: 10.3389/fnhum.2021.613789] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
From birth to 15 months infants and caregivers form a fundamentally intersubjective, dyadic unit within which the infant's ability to recognize gender/sex in the world develops. Between about 18 and 36 months the infant accumulates an increasingly clear and subjective sense of self as female or male. We know little about how the precursors to gender/sex identity form during the intersubjective period, nor how they transform into an independent sense of self by 3 years of age. In this Theory and Hypothesis article I offer a general framework for thinking about this problem. I propose that through repetition and patterning, the dyadic interactions in which infants and caregivers engage imbue the infant with an embodied, i.e., sensori-motor understanding of gender/sex. During this developmental period (which I label Phase 1) gender/sex is primarily an intersubjective project. From 15 to 18 months (which I label Phase 2) there are few reports of newly appearing gender/sex behavioral differences, and I hypothesize that this absence reflects a period of developmental instability during which there is a transition from gender/sex as primarily inter-subjective to gender/sex as primarily subjective. Beginning at 18 months (i.e., the start of Phase 3), a toddler's subjective sense of self as having a gender/sex emerges, and it solidifies by 3 years of age. I propose a dynamic systems perspective to track how infants first assimilate gender/sex information during the intersubjective period (birth to 15 months); then explore what changes might occur during a hypothesized phase transition (15 to 18 months), and finally, review the emergence and initial stabilization of individual subjectivity-the period from 18 to 36 months. The critical questions explored focus on how to model and translate data from very different experimental disciplines, especially neuroscience, physiology, developmental psychology and cognitive development. I close by proposing the formation of a research consortium on gender/sex development during the first 3 years after birth.
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Affiliation(s)
- Anne Fausto-Sterling
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI, United States
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Singh D, Bradley SJ, Zucker KJ. A Follow-Up Study of Boys With Gender Identity Disorder. Front Psychiatry 2021; 12:632784. [PMID: 33854450 PMCID: PMC8039393 DOI: 10.3389/fpsyt.2021.632784] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/18/2021] [Indexed: 11/13/2022] Open
Abstract
This study reports follow-up data on the largest sample to date of boys clinic-referred for gender dysphoria (n = 139) with regard to gender identity and sexual orientation. In childhood, the boys were assessed at a mean age of 7.49 years (range, 3.33-12.99) at a mean year of 1989 and followed-up at a mean age of 20.58 years (range, 13.07-39.15) at a mean year of 2002. In childhood, 88 (63.3%) of the boys met the DSM-III, III-R, or IV criteria for gender identity disorder; the remaining 51 (36.7%) boys were subthreshold for the criteria. At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies. For sexual orientation in behavior, data were available for 108 participants: 51 (47.2%) were classified as biphilic/androphilic, 29 (26.9%) were classified as gynephilic, and 28 (25.9%) reported no sexual behaviors. Multinomial logistic regression examined predictors of outcome for the biphilic/androphilic persisters and the gynephilic desisters, with the biphilic/androphilic desisters as the reference group. Compared to the reference group, the biphilic/androphilic persisters tended to be older at the time of the assessment in childhood, were from a lower social class background, and, on a dimensional composite of sex-typed behavior in childhood were more gender-variant. The biphilic/androphilic desisters were more gender-variant compared to the gynephilic desisters. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation. The implications of the data for current models of care for the treatment of gender dysphoria in children are discussed.
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Affiliation(s)
- Devita Singh
- Department of Human Development and Applied Psychology, Ontario Institute for Studies in Education, University of Toronto, Toronto, ON, Canada
| | - Susan J. Bradley
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Kenneth J. Zucker
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HFL, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2020; 18:336-350. [PMID: 33343244 DOI: 10.1176/appi.focus.18304] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
(Copyright © William Byne et al. 2018; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.).
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6
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Daae E, Feragen KB, Waehre A, Nermoen I, Falhammar H. Sexual Orientation in Individuals With Congenital Adrenal Hyperplasia: A Systematic Review. Front Behav Neurosci 2020; 14:38. [PMID: 32231525 PMCID: PMC7082355 DOI: 10.3389/fnbeh.2020.00038] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/21/2020] [Indexed: 12/12/2022] Open
Abstract
Congenital adrenal hyperplasia (CAH) is a genetic condition of the steroidogenic enzymes in the adrenal cortex normally leading to variable degrees of cortisol and aldosterone deficiency as well as androgen excess. Exposure to androgens prenatally might lead to ambiguous genitalia. The fetal brain develops in traditional male direction through a direct action of androgens on the developing nerve cells, or in the traditional female direction in the absence of androgens. This may indicate that sexual development, including sexual orientation, are programmed into our brain structures prenatally. The objective of this study was to perform a systematic review of the literature, investigating sexual orientation in individuals with CAH. The study also aimed at identifying which measures are used to define sexual orientation across studies. The review is based on articles identified through a comprehensive search of the OVIDMedline, PsycINFO, CINAHL, and Web of Science databases published up to May 2019. All peer-reviewed articles investigating sexual orientation in people with CAH were included. Quantitative, qualitative, and mixed methods were considered, as well as self-, parent-, and third-party reports, and no age or language restrictions were enforced on publications. The present review included 30 studies investigating sexual orientation in patients with CAH assigned female at birth (46, XX) (n = 927) or assigned male at birth (46, XY and 46, XX) (n = 274). Results indicate that assigned females at birth (46, XX) with CAH had a greater likelihood to not have an exclusively heterosexual orientation than females from the general population, whereas no assigned males at birth (46, XY or 46, XX) with CAH identified themselves as non-heterosexual. There was a wide diversity in measures used and a preference for unvalidated and self-constructed interviews. Hence, the results need to be interpreted with caution. Methodological weaknesses might have led to non-heterosexual orientation being overestimated or underestimated. The methodological challenges identified by this review should be further investigated in future studies.
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Affiliation(s)
| | | | | | - Ingrid Nermoen
- Oslo University, Oslo, Norway
- Akershus University Hospital, Lillestrøm, Norway
| | - Henrik Falhammar
- Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
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Meyer-Bahlburg HFL. "Diagnosing" Gender? Categorizing Gender-Identity Variants in the Anthropocene. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:2027-2035. [PMID: 30607711 DOI: 10.1007/s10508-018-1349-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 05/26/2023]
Abstract
In recent decades, two interrelated major controversies have been unfolding in the area of sex/gender research. (1) Are gender-identity variants to be understood as psychopathology or natural variation? (2) Is gender (and perhaps even sex) better conceptualized as binary or non-binary? The answer depends on the conceptual context and related considerations of utility. In the context of evolutionary biology, marked variants of sex and gender decrease reproductive success and are, thereby, deemed pathologic. In the present era of the anthropocene, however, the material conditions underlying the traditional division of labor between the sexes and the role of reproductive success have dramatically changed. These changes decrease the psychosocial importance of the binary gender distinction, provide more freedom for non-binary gender expression and identity formation, and render the distinction of pathologic and non-pathologic less useful, unless gender dysphoria develops secondary to a psychiatric condition. Although most people state their gender identity in the form of a nominal category, most self-report or interview-based ratings and multi-item scales of gender expression and/or identity show continuous distributions, either unimodal-asymmetric or bimodal, depending on whether they are designed for one or both of the traditional genders. Similarly, the rating scales of androgen-influenced variants of the genitalia-usually designed for one of the traditional sexes-typically represent a unipolar-asymmetric continuum. However, the binary gender system remains the primary framework against which individuals evaluate themselves. For those who develop gender dysphoria, assistance by mental-health service providers continues to be important.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- Department of Psychiatry, NYS Psychiatric Institute, Vagelos College of Physicians and Surgeons of Columbia University, 1051 Riverside Drive, Unit 15, New York, NY, 10032, USA.
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8
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Abstract
Gonadal sex steroids play a pivotal role in bone health. Medical and surgical therapies for gender dysphoria in both adolescents and adults can lead to skeletal changes. This review evaluates the literature on transgender bone health, and how the data can be translated into clinical practice.
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9
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Caldarera AM, Marengo D, Gerino E, Brustia P, Rollè L, Cohen-Kettenis PT. A Parent-Report Gender Identity Questionnaire for Children: Psychometric Properties of an Italian Version. ARCHIVES OF SEXUAL BEHAVIOR 2019; 48:1603-1615. [PMID: 30810957 PMCID: PMC6594981 DOI: 10.1007/s10508-018-1372-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 11/07/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
This article presents an Italian version of the Gender Identity Questionnaire for Children (GIQC) (Cohen-Kettenis et al., 2006; Johnson et al., 2004), a parent-report questionnaire covering a range of gender characteristics of children. We developed the GIQC-Italian version with the translation/back translation method and administered it, with a sociodemographic data sheet, to the parents of 1148 children aged 3-12 years (non-clinical sample). After obtaining descriptive data for each item, in line with Johnson et al. (2004), we examined dimensionality through exploratory factor analysis (EFA). Considering the results and that our sample was entirely non-clinical, we developed a new scoring procedure. The EFA on the new scores generated three scales: (1) a Female-Typical Behavior Scale, (2) a Male-Typical Behavior Scale, and (3) a Cross-Gender Scale. Additional EFA and confirmatory factor analyses (WLSMV estimator by using a 80/20 random-split-sample analytical approach) confirmed the three-factor solution as the best fitting dimensional structure for the revised GIQC. The Cronbach's α of the scales showed a satisfactory internal consistency. The frequency distribution of the scales scores showed it is possible to find atypical gender behavior and preferences in non-clinical samples. Independent samples t test confirmed a significant difference between boys' and girls' scores. Older children reported scores indicating less gender non-conforming characteristics than younger, except for the Female-Typical Behavior Scale in the girls' subsample. Results are discussed in the light of the existing literature about gender development. Our findings suggest that the GIQC-Italian version could be a useful tool for studying gender development in the Italian context.
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Affiliation(s)
- Angela M Caldarera
- Department of Psychology, University of Torino, Via Po, 14, 10123, Turin, TO, Italy.
| | - Davide Marengo
- Department of Psychology, University of Torino, Via Po, 14, 10123, Turin, TO, Italy
| | - Eva Gerino
- Department of Psychology, University of Torino, Via Po, 14, 10123, Turin, TO, Italy
| | - Piera Brustia
- Department of Psychology, University of Torino, Via Po, 14, 10123, Turin, TO, Italy
| | - Luca Rollè
- Department of Psychology, University of Torino, Via Po, 14, 10123, Turin, TO, Italy
| | - Peggy T Cohen-Kettenis
- Department of Medical Psychology, Center of Expertise on Gender Dysphoria, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
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Coome LA, Skorska MN, van der Miesen AI, Peragine DE, VanderLaan DP. An examination of the biodevelopment of gender expression in children ages 6- to 12-years. CANADIAN JOURNAL OF HUMAN SEXUALITY 2018. [DOI: 10.3138/cjhs.2018-0013] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Lindsay A. Coome
- Department of Psychology, University of Toronto, Mississauga, ON
| | | | - Anna I.R. van der Miesen
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | | | - Doug P. VanderLaan
- Department of Psychology, University of Toronto, Mississauga, ON
- Child and Youth Psychiatry, Centre for Addiction and Mental Health, Toronto, ON
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Byne W, Karasic DH, Coleman E, Eyler AE, Kidd JD, Meyer-Bahlburg HF, Pleak RR, Pula J. Gender Dysphoria in Adults: An Overview and Primer for Psychiatrists. Transgend Health 2018; 3:57-70. [PMID: 29756044 PMCID: PMC5944396 DOI: 10.1089/trgh.2017.0053] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Regardless of their area of specialization, adult psychiatrists are likely to encounter gender-variant patients; however, medical school curricula and psychiatric residency training programs devote little attention to their care. This article aims to assist adult psychiatrists who are not gender specialists in the delivery of respectful, clinically competent, and culturally attuned care to gender-variant patients, including those who identify as transgender or transsexual or meet criteria for the diagnosis of Gender Dysphoria (GD) as defined by The Diagnostic and Statistical Manual of Mental Disorders (5th edition). The article will also be helpful for other mental health professionals. The following areas are addressed: evolution of diagnostic nosology, epidemiology, gender development, and mental health assessment, differential diagnosis, treatment, and referral for gender-affirming somatic treatments of adults with GD.
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Affiliation(s)
- William Byne
- Mental Illness Research Education and Clinical Center, James J Peters VA Medical Center, Bronx, New York
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai and Center for Transgender Medicine and Surgery at Mount Sinai, New York, New York
| | - Dan H. Karasic
- Department of Psychiatry, University of California, San Francisco, San Francisco, California
| | - Eli Coleman
- Program in Human Sexuality, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota
| | - A. Evan Eyler
- Departments of Psychiatry and Family Medicine, University of Vermont College of Medicine, Burlington, Vermont
| | - Jeremy D. Kidd
- Department of Psychiatry, Division on Substance Use Disorders, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Heino F.L. Meyer-Bahlburg
- Division of Gender, Sexuality, and Health, New York State Psychiatric Institute/Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York
| | - Richard R. Pleak
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, Hofstra North Shore-LIJ School of Medicine, Albert Einstein College of Medicine, Zucker Hillside Hospital, Ambulatory Care Pavilion, Glen Oaks, New York
| | - Jack Pula
- Department of Psychiatry, Division of Gender, Sexuality and Health, College of Physicians and Surgeons of Columbia University, New York, New York
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12
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Shulman GP, Holt NR, Hope DA, Mocarski R, Eyer J, Woodruff N. A Review of Contemporary Assessment Tools for Use with Transgender and Gender Nonconforming Adults. PSYCHOLOGY OF SEXUAL ORIENTATION AND GENDER DIVERSITY 2017; 4:304-313. [PMID: 29201935 DOI: 10.1037/sgd0000233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
There is increasing recognition of the need for culturally sensitive services for individuals who identify as transgender or gender non-conforming (TGNC), and only recently have empirical studies appeared in the literature that inform best practices for TGNC people. Competent, culturally appropriate clinical services and research depend upon methodologically sound assessment of key constructs, but it is unclear whether appropriate self-report or clinician-rated assessment tools for adults exist. This paper reviewed existing published measures to identify areas of strength as well as existing gaps in the available research. The search strategy for this systematic review identified any published paper describing a self-report or clinician-rated scale for assessing transgender-related concerns. Each measure was reviewed for information on its scope, reliability, validity, strengths, limitations, and source. The majority of these questionnaires were developed with the TGNC communities and targeted important factors that affect quality of life for TGNC people. Limitations included limited evidence for validity, reliability, and sensitivity to change. Overall, the field is moving in the direction of TGNC-affirming assessment, and promising measures have been created to monitor important aspects of quality of life for TGNC people. Future research should continue to validate these measures for use in assessing clinical outcomes and the monitoring of treatment progress.
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Bailey JM, Vasey PL, Diamond LM, Breedlove SM, Vilain E, Epprecht M. Sexual Orientation, Controversy, and Science. Psychol Sci Public Interest 2016; 17:45-101. [DOI: 10.1177/1529100616637616] [Citation(s) in RCA: 316] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Summary Ongoing political controversies around the world exemplify a long-standing and widespread preoccupation with the acceptability of homosexuality. Nonheterosexual people have seen dramatic surges both in their rights and in positive public opinion in many Western countries. In contrast, in much of Africa, the Middle East, the Caribbean, Oceania, and parts of Asia, homosexual behavior remains illegal and severely punishable, with some countries retaining the death penalty for it. Political controversies about sexual orientation have often overlapped with scientific controversies. That is, participants on both sides of the sociopolitical debates have tended to believe that scientific findings—and scientific truths—about sexual orientation matter a great deal in making political decisions. The most contentious scientific issues have concerned the causes of sexual orientation—that is, why are some people heterosexual, others bisexual, and others homosexual? The actual relevance of these issues to social, political, and ethical decisions is often poorly justified, however.
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Affiliation(s)
| | | | | | | | - Eric Vilain
- Department of Human Genetics, University of California, Los Angeles
- Department of Pediatrics, University of California, Los Angeles
- Department of Urology, University of California, Los Angeles
- Joint International Unit on Epigenetics, Data, and Politics, Centre National de la Recherche Scientifique, Paris, France
| | - Marc Epprecht
- Department of History, Queen’s University
- Department of Global Development Studies, Queen’s University
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Abstract
PURPOSE OF REVIEW We provide an update of bone health in trans persons on cross-sex hormonal therapy. This drastic hormonal reversal will have direct but also indirect effects on bone, through body composition changes. RECENT FINDINGS Recent evidence suggests that trans women, even before the start of any hormonal intervention, already have a lower bone mass, a higher frequency of osteoporosis, and a smaller bone size vs. natal men. During cross-sex hormonal treatment, bone mass was maintained or gained in trans women. In trans men, bone metabolism seemed to increase during short-term testosterone therapy, but no major changes have been found in bone density. On long-term testosterone therapy, larger cortical bone size was observed in trans men vs. natal women. SUMMARY Follow-up of bone health and osteoporosis prevention in trans persons is important. We advise active assessment of osteoporosis risk factors including the (previous) use of hormonal therapy. Based on this risk profile and the intended therapy, bone densitometry may be indicated. Long-term use of antiandrogens or gonadotropin-releasing hormone agonists alone should be monitored as trans women may have low bone mass, even prior to treatment. Therapy compliance with the cross-sex hormones is of major concern, especially after gonadectomy. Large-scaled, multicenter, and long-term research is needed to determine a well tolerated dosage of cross-sex hormonal treatment, also in elderly trans persons.
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Affiliation(s)
- Eva Van Caenegem
- aDepartment of Endocrinology bCenter for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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Bos H, Sandfort T. Gender Nonconformity, Sexual Orientation, and Dutch Adolescents' Relationship with Peers. ARCHIVES OF SEXUAL BEHAVIOR 2015; 44:1269-79. [PMID: 25548066 PMCID: PMC5545790 DOI: 10.1007/s10508-014-0461-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 08/25/2014] [Accepted: 10/04/2014] [Indexed: 05/29/2023]
Abstract
Same-sex attraction and gender nonconformity have both been shown to negatively affect the relationships of adolescents with their peers. It is not clear, though, whether same-sex attracted adolescents are more likely to have negative peer relationships because they are same-sex attracted or because they are more likely to be gender nonconforming. It is also possible that both stressors affect peer relationships independently or amplify each other in their impact. We explored these questions in a sample of 486 Dutch adolescents (M age = 14.02 years). We found that same-sex attraction and gender nonconformity both had an independent effect and that gender nonconformity moderated, but not mediated, the associations between same-sex attraction and peer relationships at school. Same-sex attraction was more strongly associated with poorer relationships with peers in adolescents who were more gender nonconforming. These findings indicate the importance of including gender nonconformity in the understanding of same-sex attracted adolescents' relationships and suggest that in order to improve same-sex attracted adolescents' social position at school, acceptance of gender diversity should be promoted as well.
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Affiliation(s)
- Henny Bos
- Research Institute of Child Development and Education, Faculty of Social and Behavioral Sciences, University of Amsterdam, POB 94208, 1090 GE, Amsterdam, The Netherlands,
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Abstract
Young people with gender dysphoria are increasingly seen by pediatric endocrinologists. Mental health child specialists assess the adolescent and give advice about psychological or medical treatment. Provided they fulfill eligibility and readiness criteria, adolescents may receive pubertal suspension, consisting of using gonadotrophin-releasing hormone analogs, later followed by cross-sex hormones (sex steroids of the experienced gender). If they fulfill additional criteria, they may have various types of gender affirming surgery. Current issues involve safety aspects. Although generally considered safe in the short-term, the long-term effects regarding bone health and cardiovascular risks are still unknown. Therefore, vigilance is warranted during and long after completion of the last gender affirming surgeries. The timing of the various treatment steps is also under debate: instead of fixed age limits, the cognitive and emotional maturation, along with the physical development, are now often considered as more relevant.
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Affiliation(s)
- Peggy T Cohen-Kettenis
- Department of Medical Psychology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Daniel Klink
- Department of Pediatrics, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands
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Affiliation(s)
- Den Trumbull
- President of the American College of Pediatricians
| | | | - Miriam Grossman
- Psychiatric consultant to the American College of Pediatricians
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Khadilkar VV, Phanse-Gupte S. Issues in the diagnosis and management of disorders of sexual development. Indian J Pediatr 2014; 81:66-75. [PMID: 24052180 DOI: 10.1007/s12098-013-1168-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 06/24/2013] [Indexed: 10/26/2022]
Abstract
Disorders of sexual development (DSD) are a complex group of disorders to manage, not only because the diagnosis is difficult, but also because it involves many factors related to the psychosexual well being, the social stigma associated with the disorder, confusion and reluctance on the part of medical professionals in dealing with this issue, catastrophic experience of parents of these children and difficult interpersonal relationships between parents and children born with this disorder. This brief review attempts to throw light on the recent advances in understanding and management of these disorders to help improve immediate and long term care of these patients and their families.
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Affiliation(s)
- Vaman V Khadilkar
- Department of Pediatric Endocrinology, Jehangir Hospital, 32 Sassoon Road, Pune, 411001, India,
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A Noncategorical Approach to the Psychosocial Care of Persons with DSD and Their Families. GENDER DYSPHORIA AND DISORDERS OF SEX DEVELOPMENT 2014. [DOI: 10.1007/978-1-4614-7441-8_5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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20
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Joel D, Tarrasch R, Berman Z, Mukamel M, Ziv E. Queering gender: studying gender identity in ‘normative’ individuals. PSYCHOLOGY & SEXUALITY 2013. [DOI: 10.1080/19419899.2013.830640] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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21
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Rijn ABV, Steensma TD, Kreukels BPC, Cohen-Kettenis PT. Self-perception in a clinical sample of gender variant children. Clin Child Psychol Psychiatry 2013; 18:464-74. [PMID: 23028200 DOI: 10.1177/1359104512460621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gender variance (GV) in childhood has a negative impact on the self-concept of children in the general population and can lead to mental health problems and even suicidal ideation in adulthood. This study explored the self-concept of clinically referred gender variant children and examined potential risk factors. METHOD The Self-Perception Profile for Children was administered to 147 children, who were referred to a gender identity clinic. Their parents completed the Child Behaviour Checklist and the Gender Identity Questionnaire to assess the degree of GV. RESULTS The referred children were at risk of developing a negative self-concept; more specifically gender variant girls had low scores on 'global self-worth', 'physical appearance' and 'behavioural conduct' compared to Dutch norms for girls. Gender variant boys had low scores on 'global self-worth', 'scholastic competence', 'athletic competence' and 'physical appearance' compared to Dutch norms for boys. Within the group of referred children, sex differences, but no age effects, were found. The referred girls felt more competent than the referred boys on 'athletic competence' and 'scholastic functioning'. For both boys and girls poor peer relations had a significant negative relationship with self-concept and more GV was related to a lower global self-worth. CONCLUSIONS Clinically referred gender variant children seemed vulnerable to developing a negative self-concept. Poor peer relations and extreme GV might be mediating variables. Interventions might focus on enhancing acceptance of the environment and improving social skills of gender variant children.
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Affiliation(s)
- Anouk Balleur-van Rijn
- Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands.
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22
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Van Caenegem E, Taes Y, Wierckx K, Vandewalle S, Toye K, Kaufman JM, Schreiner T, Haraldsen I, T'Sjoen G. Low bone mass is prevalent in male-to-female transsexual persons before the start of cross-sex hormonal therapy and gonadectomy. Bone 2013; 54:92-7. [PMID: 23369987 DOI: 10.1016/j.bone.2013.01.039] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Revised: 01/22/2013] [Accepted: 01/23/2013] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Cross-sex hormonal therapy and sex reassignment surgery (including gonadectomy) in transsexual persons has an impact on body composition and bone mass and size. However, it is not clear whether baseline differences in bone and body composition between transsexual persons and controls before cross-sex hormonal therapy play a role. DESIGN A cross-sectional study with 25 male-to-female transsexual persons (transsexual women) before cross-gender sex steroid exposure (median age 30 years) in comparison with 25 age-matched control men and a male reference population of 941 men. MAIN OUTCOME MEASURES Areal and volumetric bone parameters using respectively dual energy X-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), body composition (DXA), grip strength (hand dynamometer), Baecke physical activity questionnaire, serum testosterone and 25-OH vitamin D. RESULTS Transsexual women before cross-sex hormonal therapy presented with less muscle mass (p≤0.001) and strength (p≤0.05) and a higher prevalence of osteoporosis (16%) with a lower aBMD at the hip, femoral neck, total body (all p<0.001) and lumbar spine (p=0.064) compared with control men. A thinner radial cortex (p≤0.01) and lower cortical area at the radius and tibia (both p<0.05) was found in transsexual women vs. control men. Serum testosterone was comparable in all 3 groups, but 25-OH vitamin D was lower in transsexual women (p≤0.001). CONCLUSIONS Transsexual women before the start of hormonal therapy appear to have lower muscle mass and strength and lower bone mass compared with control men. These baseline differences in bone mass might be related to a less active lifestyle.
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Affiliation(s)
- E Van Caenegem
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium.
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Ercan O, Kutlug S, Uysal O, Alikasifoglu M, Inceoglu D. Gender Identity and Gender Role in DSD Patients Raised as Females: A Preliminary Outcome Study. Front Endocrinol (Lausanne) 2013; 4:86. [PMID: 23874323 PMCID: PMC3711069 DOI: 10.3389/fendo.2013.00086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 06/29/2013] [Indexed: 12/31/2022] Open
Abstract
Gender identity and gender role are expected to be consistent with gender assignment for optimal DSD management outcome. To our knowledge, our study is the first to attempt evaluation of gender related outcomes in Turkish DSD patients. After receiving institutional ethical board approval and subject (or parent) informed consent, subjects with DSD raised as girls (22 patients 46 XX DSD, 11 patients 46 XY DSD) answered 566 questions of the Minnesota Multiphasic Personality Inventory (MMPI) questionnaire including 60-item Masculinity-Femininity (MF) subscale which was the focus in this study. Controls (n: 50) were females similar to the probands in age, level of education, relationship status, and having a job or not also answered all questions. The answers were evaluated by a trained psychologist (Derya Inceoglu) on MMPI. For statistical purposes, seven findings were obtained from the data related to the MF subscale from the patients and controls. Of these seven findings (S1-S7), two were associated with masculinity (S3-S4) and another two were associated with femininity (S5-S6). In DSD patients, the percentages of masculinity findings were significantly higher when compared to controls (p < 0.001 and p < 0.001 for S3 and S4, respectively). In controls, the percentages of femininity findings were significantly higher when compared to DSD females (p < 0.001 and p < 0.001 for S5 and S6 respectively). There was no significant difference between 46 XX DSD patients and 46 XY DSD patients with respect to the percentage of any of the seven findings. Two patients requested gender change to male; only these two patients had the finding stating that sexual impulses could come to existence as actions (S7). In conclusion efforts to identify modifiable factors with negative impact and thus modifying them, and professional guidance may be important in minimizing the encountered gender related problems in DSD patients.
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Affiliation(s)
- Oya Ercan
- Pediatric Endocrinology and Adolescent Divisions, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
- *Correspondence: Oya Ercan, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Fatih 34303, Istanbul, Turkey e-mail:
| | - Seyhan Kutlug
- Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Omer Uysal
- Department of Biostatistics and Medical Informatics, School of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Mujgan Alikasifoglu
- Adolescent Division, Pediatrics Department, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Derya Inceoglu
- Academic Success Monitoring and Counseling Program, Center for Individual and Academic Development-CIAD, Sabanci University, Istanbul, Turkey
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Del Giudice M. The twentieth century reversal of pink-blue gender coding: a scientific urban legend? ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:1321-1323. [PMID: 22821170 DOI: 10.1007/s10508-012-0002-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
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Sandberg DE, Gardner M, Cohen-Kettenis PT. Psychological aspects of the treatment of patients with disorders of sex development. Semin Reprod Med 2012; 30:443-52. [PMID: 23044882 PMCID: PMC3687360 DOI: 10.1055/s-0032-1324729] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Research on the psychological development of persons with Disorders of Sex Development (DSD) has focused on understanding the influence of atypical sex hormone exposure during steroid-sensitive periods of prenatal brain development on the process of psychosexual differentiation (i.e., gender identity, gender role, and sexual orientation). In contrast, analysis of clinical management strategies has focused on gender assignment and the desirability and timing of genital surgery. This review focuses on the psychological issues that confront clinicians managing the care of persons born with DSD and their families. Particular attention is paid to processes and factors that potentially mediate or moderate psychosocial and psychosexual outcomes within and across developmental stages.
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Affiliation(s)
- David E Sandberg
- Division of Child Behavioral Health, Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, Michigan 48109-5318, USA.
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Bley AM, Turato ER, Rivorêdo CRSFD, Silva RBDPE, Maciel-Guerra AT, Marques-de-Faria AP, Guerra-Junior G, Baptista MTM. Sexual difference, identification and object choice in individuals with sex differentiation disorders. REVISTA LATINOAMERICANA DE PSICOPATOLOGIA FUNDAMENTAL 2012. [DOI: 10.1590/s1415-47142012000300002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE: To investigate how sexual identity is structured and also to investigate the relationship between sexual identity, choice of sex object and sexual difference. METHOD: Semi-structured interviews were held with seven adult patients who were born with sex differentiation disorders: Two had 5-alpha-reductase type-2 deficiency and five had congenital adrenal hyperplasia. CONCLUSIONS: Sex is trauma. Neither male nor female nor any other gender identification implies the choice of sex object, genders of partners or sexual practices.
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Martin CL, DiDonato MD, Clary L, Fabes RA, Kreiger T, Palermo F, Hanish L. Preschool children with gender normative and gender non-normative peer preferences: psychosocial and environmental correlates. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:831-47. [PMID: 22528037 PMCID: PMC3761797 DOI: 10.1007/s10508-012-9950-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2010] [Revised: 02/20/2012] [Accepted: 02/25/2012] [Indexed: 05/12/2023]
Abstract
We addressed several issues concerning children who show gender non-normative (GNN) patterns of peer play. First, do young children with GNN peer preferences differ from children with gender normative (GN) peer preferences in problem behaviors? Second, do GNN and GN children differ in sociability and isolation and do they have differential socialization opportunities with externalizing, internalizing, and socially competent peers? We employed a Bayesian approach for classifying children as GNN based on their peer preferences as compared to their peers using a sample of Head Start preschool children from a large Southwestern city (N = 257; 53 % boys; M age = 51 months; 66 % Mexican American). To calculate socialization opportunities, we assessed affiliation to each child in the class and weighted that by each peer's characteristics to determine the exposure that each child had to different kinds of peers. GN children of both sexes interacted more with same-sex peers, which may limit learning of different styles of interaction. As compared to GN children, GNN children exhibited more engagement in other-sex activities and with other-sex play partners and GNN children experienced somewhat fewer peer interactions, but did not differ on problem behaviors or social competence. Boys with GNN peer preferences had increased exposure to peers with problem behaviors. GNN girls experienced little exposure to peers with problem behaviors, but they also had little exposure to socially competent peers, which may reduce learning social skills from peers. Implications of these findings for future socialization and development will be discussed.
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Affiliation(s)
- Carol Lynn Martin
- School of Social and Family Dynamics, Arizona State University, Tempe, AZ 85287-3701, USA.
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Byne W, Bradley SJ, Coleman E, Eyler AE, Green R, Menvielle EJ, Meyer-Bahlburg HFL, Pleak RR, Tompkins DA. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:759-96. [PMID: 22736225 DOI: 10.1007/s10508-012-9975-x] [Citation(s) in RCA: 116] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
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Affiliation(s)
- William Byne
- Department of Psychiatry, JJ Peters VA Medical Center, Bronx, NY, USA.
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Maisto SA, Palfai T, Vanable PA, Heath J, Woolf-King SE. The effects of alcohol and sexual arousal on determinants of sexual risk in men who have sex with men. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:971-86. [PMID: 22009480 PMCID: PMC3745008 DOI: 10.1007/s10508-011-9846-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2010] [Revised: 07/18/2011] [Accepted: 07/31/2011] [Indexed: 05/10/2023]
Abstract
Primary prevention efforts aimed at sexual risk behaviors are critical. This experiment was designed to investigate the effects of alcohol intoxication and sexual arousal, as well as person variables of alcohol sex expectancies and attitudes toward condom use, on hypothesized determinants of sexual risk behaviors among men who have sex with men (MSM). The participants were 117 MSM aged 21-50 years who were randomly assigned to one of six separate experimental conditions created by the combination of beverage administration (water control, placebo or alcohol designed to raise blood alcohol level to .07%) and sexual arousal (low or high, manipulated by participants' viewing non-erotic or mildly erotic film clips). Participants attended two experimental sessions. The first session included completing questionnaires about beliefs about alcohol's effects on sex and attitudes toward condoms' effect on sexual pleasure. The second session involved the beverage condition and arousal manipulations. Following these, participants viewed and responded to two interactive videos depicting high sexual risk scenarios. Participants also completed the CARE, a measure of risk perceptions. The dependent variables were behavioral skills, intentions to have unsafe sex, and "risk exposure," derived from responses to the videos. The results of both planned and exploratory analyses showed general support for the hypothesized enhancement of alcohol's effects on sexual risk by both sexual arousal and expectancies. Also as predicted, condom attitudes showed direct relationships to risk exposure and intentions. Implications of the findings for models of alcohol's effects on sexual risk and for the development of HIV prevention interventions were discussed.
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Affiliation(s)
- Stephen A Maisto
- Department of Psychology, Syracuse University, Syracuse, NY 13244, USA.
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Rieger G, Savin-Williams RC. Gender nonconformity, sexual orientation, and psychological well-being. ARCHIVES OF SEXUAL BEHAVIOR 2012; 41:611-21. [PMID: 21350914 DOI: 10.1007/s10508-011-9738-0] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2010] [Revised: 11/27/2010] [Accepted: 12/07/2010] [Indexed: 05/12/2023]
Abstract
Both a same-sex sexual orientation and gender nonconformity have been linked with poorer well-being; however, sexual orientation and gender nonconformity are also correlated. It is, therefore, critical to investigate their independent contributions to well-being. Based on survey responses of 230 female and 245 male high school seniors, the present study is one of the first to provide empirical data on this topic. Both childhood and adolescent gender nonconformity were negatively related to well-being. In the same analyses, neither sexual orientation nor biological sex was a significant predictor of well-being. These results suggest that gender-atypical traits may be more relevant for psychological health than a same-sex sexual orientation. Both environmental and biological influences may account for these findings.
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Affiliation(s)
- Gerulf Rieger
- Department of Human Development, Cornell University, B42 Martha Van Rensselaer Hall, Ithaca, NY 14853, USA.
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Cools M, Hoebeke P, Wolffenbuttel KP, Stoop H, Hersmus R, Barbaro M, Wedell A, Brüggenwirth H, Looijenga LHJ, Drop SLS. Pubertal androgenization and gonadal histology in two 46,XY adolescents with NR5A1 mutations and predominantly female phenotype at birth. Eur J Endocrinol 2012; 166:341-9. [PMID: 22080441 DOI: 10.1530/eje-11-0392] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Most patients with NR5A1 (SF-1) mutations and poor virilization at birth are sex-assigned female and receive early gonadectomy. Although studies in pituitary-specific Sf-1 knockout mice suggest hypogonadotropic hypogonadism, little is known about endocrine function at puberty and on germ cell tumor risk in patients with SF-1 mutations. This study reports on the natural course during puberty and on gonadal histology in two adolescents with SF-1 mutations and predominantly female phenotype at birth. DESIGN AND METHODS Clinical and hormonal data and histopathological studies are reported in one male and one female adolescent with, respectively, a nonsense mutation (c.9T>A, p.Tyr3X) and a deletion of the first two coding exons (NCBI36/hg18 Chr9:g.(126306276-126307705)_(126303229-126302828)del) of NR5A1, both predicted to fully disrupt gene function. RESULTS LH and testosterone concentrations were in the normal male range, virilization was disproportionate to the neonatal phenotype. In the girl, gonadectomy at 13 years revealed incomplete spermatogenesis and bilateral precursor lesions of testicular carcinoma in situ. In the boy, at the age of 12, numerous germ cells without signs of malignancy were present in bilateral testicular biopsy specimen. CONCLUSIONS In SF-1 mutations, the neonatal phenotype poorly predicts virilization at puberty. Even in poorly virilized cases at birth, male gender assignment may allow spontaneous puberty without signs of hypogonadotropic hypogonadism, and possibly fertility. Patients with SF-1 mutations are at increased risk for malignant germ cell tumors. In case of preserved gonads, early orchidopexy and germ cell tumor screening is warranted. The finding of premalignant and/or malignant changes should prompt gonadectomy or possibly irradiation.
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Affiliation(s)
- M Cools
- Division of Pediatric Endocrinology, Department of Pediatrics, University Hospital Ghent, Ghent University, Building 3K12D, De Pintelaan 185, 9000 Ghent, Belgium.
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Zucker KJ, Bradley SJ, Owen-Anderson A, Kibblewhite SJ, Wood H, Singh D, Choi K. Demographics, behavior problems, and psychosexual characteristics of adolescents with gender identity disorder or transvestic fetishism. JOURNAL OF SEX & MARITAL THERAPY 2012; 38:151-89. [PMID: 22390530 DOI: 10.1080/0092623x.2011.611219] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
This study provided a descriptive and quantitative comparative analysis of data from an assessment protocol for adolescents referred clinically for gender identity disorder (n = 192; 105 boys, 87 girls) or transvestic fetishism (n = 137, all boys). The protocol included information on demographics, behavior problems, and psychosexual measures. Gender identity disorder and transvestic fetishism youth had high rates of general behavior problems and poor peer relations. On the psychosexual measures, gender identity disorder patients had considerably greater cross-gender behavior and gender dysphoria than did transvestic fetishism youth and other control youth. Male gender identity disorder patients classified as having a nonhomosexual sexual orientation (in relation to birth sex) reported more indicators of transvestic fetishism than did male gender identity disorder patients classified as having a homosexual sexual orientation (in relation to birth sex). The percentage of transvestic fetishism youth and male gender identity disorder patients with a nonhomosexual sexual orientation self-reported similar degrees of behaviors pertaining to transvestic fetishism. Last, male and female gender identity disorder patients with a homosexual sexual orientation had more recalled cross-gender behavior during childhood and more concurrent cross-gender behavior and gender dysphoria than did patients with a nonhomosexual sexual orientation. The authors discuss the clinical utility of their assessment protocol.
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Affiliation(s)
- Kenneth J Zucker
- Gender Identity Service, Child, Youth, and Family Program, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
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Abstract
This article focuses on the assessment of children who display gender-atypical behavior and, perhaps, identity. The aim is to provide an overview of assessment techniques that can be used clinically with children who show this behavioral pattern and that complement the routine use of DSM-IV criteria for the diagnosis of gender identity disorder in clinical practice. It will also provide an overview of some common approaches to the assessment of other types of behavioral and socioemotional issues that may require clinical attention in these youngsters.
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Affiliation(s)
- Kenneth J Zucker
- Gender Identity Service, Child, Youth, and Family Program, Centre for Addiction and Mental Health, 250 College Street, Toronto, Ontario, Canada.
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Cohen-Kettenis PT, Steensma TD, de Vries ALC. Treatment of adolescents with gender dysphoria in the Netherlands. Child Adolesc Psychiatr Clin N Am 2011; 20:689-700. [PMID: 22051006 DOI: 10.1016/j.chc.2011.08.001] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In the Netherlands, gender dysphoric adolescents may be eligible for puberty suppression at age 12, subsequent cross-sex hormone treatment at age 16, and gender reassignment surgery at age 18. Initially, a thorough assessment is made of the gender dysphoria and vulnerabilities in functioning or circumstances. Psychological interventions and/or gender reassignment may be offered. Psychological interventions are offered if the adolescent needs to explore gender identity and treatment wishes, suffers from coexisting problems, or needs support and counseling during gender reassignment. Although more studies are necessary, this approach seems to contribute significantly to the well-being of gender dysphoric adolescents.
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Affiliation(s)
- Peggy T Cohen-Kettenis
- Department of Medical Psychology and Medical Social Work, VU University Medical Center, Amsterdam, the Netherlands.
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35
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Meyer-Bahlburg HFL. Gender monitoring and gender reassignment of children and adolescents with a somatic disorder of sex development. Child Adolesc Psychiatr Clin N Am 2011; 20:639-49. [PMID: 22051002 DOI: 10.1016/j.chc.2011.07.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Individuals born with a somatic disorder of sex development (DSD) have high rates of gender-atypical behavior, gender uncertainty, gender dysphoria, and patient-initiated gender change in childhood, adolescence,and adulthood. This article addresses the issues a mental health services provider has to consider in evaluating and assisting such patients and provides examples of assessment-method batteries. To date, the World Professional Association for Transgender Health's Standards of Care, 6th version, for non-DSD patients with gender dysphoria, may be cautiously used for guidance, taking into account the considerable differences in presentation and medical context between gender dysphoric patients with and without a DSD.
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Affiliation(s)
- Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Department of Psychiatry, Columbia University, 1051 Riverside Drive, New York, NY 10032, USA.
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36
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Hines M. Prenatal endocrine influences on sexual orientation and on sexually differentiated childhood behavior. Front Neuroendocrinol 2011; 32:170-82. [PMID: 21333673 PMCID: PMC3296090 DOI: 10.1016/j.yfrne.2011.02.006] [Citation(s) in RCA: 158] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 02/04/2011] [Accepted: 02/14/2011] [Indexed: 11/27/2022]
Abstract
Both sexual orientation and sex-typical childhood behaviors, such as toy, playmate and activity preferences, show substantial sex differences, as well as substantial variability within each sex. In other species, behaviors that show sex differences are typically influenced by exposure to gonadal steroids, particularly testosterone and its metabolites, during early development (prenatally or neonatally). This article reviews the evidence regarding prenatal influences of gonadal steroids on human sexual orientation, as well as sex-typed childhood behaviors that predict subsequent sexual orientation. The evidence supports a role for prenatal testosterone exposure in the development of sex-typed interests in childhood, as well as in sexual orientation in later life, at least for some individuals. It appears, however, that other factors, in addition to hormones, play an important role in determining sexual orientation. These factors have not been well-characterized, but possibilities include direct genetic effects, and effects of maternal factors during pregnancy. Although a role for hormones during early development has been established, it also appears that there may be multiple pathways to a given sexual orientation outcome and some of these pathways may not involve hormones.
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Affiliation(s)
- Melissa Hines
- Department of Social and Developmental Psychology, University of Cambridge, UK.
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Hines M. Sex-related variation in human behavior and the brain. Trends Cogn Sci 2010; 14:448-56. [PMID: 20724210 PMCID: PMC2951011 DOI: 10.1016/j.tics.2010.07.005] [Citation(s) in RCA: 261] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 07/16/2010] [Accepted: 07/16/2010] [Indexed: 01/18/2023]
Abstract
Male and female fetuses differ in testosterone concentrations beginning as early as week 8 of gestation. This early hormone difference exerts permanent influences on brain development and behavior. Contemporary research shows that hormones are particularly important for the development of sex-typical childhood behavior, including toy choices, which until recently were thought to result solely from sociocultural influences. Prenatal testosterone exposure also appears to influence sexual orientation and gender identity, as well as some, but not all, sex-related cognitive, motor and personality characteristics. Neural mechanisms responsible for these hormone-induced behavioral outcomes are beginning to be identified, and current evidence suggests involvement of the hypothalamus and amygdala, as well as interhemispheric connectivity, and cortical areas involved in visual processing.
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Affiliation(s)
- Melissa Hines
- Department of Social and Developmental Psychology, University of Cambridge, Free School Lane, Cambridge CB23RQ, UK.
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Yu L, Winter S, Xie D. The child play behavior and activity questionnaire: a parent-report measure of childhood gender-related behavior in China. ARCHIVES OF SEXUAL BEHAVIOR 2010; 39:807-815. [PMID: 18719986 PMCID: PMC2946550 DOI: 10.1007/s10508-008-9403-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Revised: 03/26/2008] [Accepted: 05/01/2008] [Indexed: 05/26/2023]
Abstract
Boys and girls establish relatively stable gender stereotyped behavior patterns by middle childhood. Parent-report questionnaires measuring children's gender-related behavior enable researchers to conduct large-scale screenings of community samples of children. For school-aged children, two parent-report instruments, the Child Game Participation Questionnaire (CGPQ) and the Child Behavior and Attitude Questionnaire (CBAQ), have long been used for measuring children's sex-dimorphic behaviors in Western societies, but few studies have been conducted using these measures for Chinese populations. The current study aimed to empirically examine and modify the two instruments for their applications to Chinese society. Parents of 486 Chinese boys and 417 Chinese girls (6-12 years old) completed a questionnaire comprising items from the CGPQ and CBAQ, and an additional 14 items specifically related to Chinese gender-specific games. Items revealing gender differences in a Chinese sample were identified and used to construct a Child Play Behavior and Activity Questionnaire (CPBAQ). Four new scales were generated through factor analysis: a Gender Scale, a Girl Typicality Scale, a Boy Typicality Scale, and a Cross-Gender Scale (CGS). These scales had satisfactory internal reliabilities and large effect sizes for gender. The CPBAQ is believed to be a promising instrument for measuring children's gender-related behavior in China.
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Affiliation(s)
- Lu Yu
- Department of Education, Faculty of Education, The University of Hong Kong, Room 109, Hui Oi Chow Science Building, Pokfulam, Hong Kong, China.
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Zucker KJ. The DSM diagnostic criteria for gender identity disorder in children. ARCHIVES OF SEXUAL BEHAVIOR 2010; 39:477-498. [PMID: 19842027 DOI: 10.1007/s10508-009-9540-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In this article, I review the diagnostic criteria for Gender Identity Disorder (GID) in children as they were formulated in the DSM-III, DSM-III-R, and DSM-IV. The article focuses on the cumulative evidence for diagnostic reliability and validity. It does not address the broader conceptual discussion regarding GID as "disorder," as this issue is addressed in a companion article by Meyer-Bahlburg (2009). This article addresses criticisms of the GID criteria for children which, in my view, can be addressed by extant empirical data. Based in part on reanalysis of data, I conclude that the persistent desire to be of the other gender should, in contrast to DSM-IV, be a necessary symptom for the diagnosis. If anything, this would result in a tightening of the diagnostic criteria and may result in a better separation of children with GID from children who display marked gender variance, but without the desire to be of the other gender.
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Affiliation(s)
- Kenneth J Zucker
- Gender Identity Service, Child, Youth, and Family Program, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON M5T 1R8, Canada.
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Abstract
Psychosocial aspects of the treatment of disorders of sex development (DSDs) concern gender assignment, information management and communication, timing of medical interventions, consequences of surgery, and sexuality. Although outcome is often satisfactory, a variety of medical and psychosocial factors may jeopardise the psychological development of children with DSDs. This sometimes results in the desire to change gender later in life. The clinical management of gender dysphoria in individuals with DSD may profit from methods and insights that have been developed for gender dysphoric individuals without DSD. In DSD care, clinical decisions are often made with long-lasting effects on quality of life and should be based on empirical evidence. Yet, such evidence (e.g., regarding gender assignment, information management and timing of surgery) is largely non-existent. DSD-specific protocols and educational materials need to be developed to standardise and evaluate interventions in order to facilitate decision making of professionals and individuals with DSD and enhance psychosocial care in this area.
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Affiliation(s)
- P T Cohen-Kettenis
- Department of Medical Psychology, VU University, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Meyer-Bahlburg HF. Variants of Gender Differentiation in Somatic Disorders of Sex Development: Recommendations for Version 7 of the World Professional Association for Transgender Health'sStandards of Care. Int J Transgend 2009. [DOI: 10.1080/15532730903439476] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Wallien MSC, Quilty LC, Steensma TD, Singh D, Lambert SL, Leroux A, Owen-Anderson A, Kibblewhite SJ, Bradley SJ, Cohen-Kettenis PT, Zucker KJ. Cross-National Replication of the Gender Identity Interview for Children. J Pers Assess 2009; 91:545-52. [DOI: 10.1080/00223890903228463] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Lippa RA. Sex differences in sex drive, sociosexuality, and height across 53 nations: testing evolutionary and social structural theories. ARCHIVES OF SEXUAL BEHAVIOR 2009; 38:631-651. [PMID: 17975724 DOI: 10.1007/s10508-007-9242-8] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2006] [Revised: 06/14/2007] [Accepted: 06/14/2007] [Indexed: 05/25/2023]
Abstract
By analyzing cross-cultural patterns in five parameters--sex differences, male and female trait means, male and female trait standard deviations--researchers can better test evolutionary and social structural models of sex differences. Five models of biological and social structural influence are presented that illustrate this proposal. Using data from 53 nations and from over 200,000 participants surveyed in a recent BBC Internet survey, I examined cross-cultural patterns in these five parameters for two sexual traits--sex drive and sociosexuality--and for height, a physical trait with a biologically based sex difference. Sex drive, sociosexuality, and height all showed consistent sex differences across nations (mean ds = .62, .74, and 1.63). Women were consistently more variable than men in sex drive (mean female to male variance ratio = 1.64). Gender equality and economic development tended to predict, across nations, sex differences in sociosexuality, but not sex differences in sex drive or height. Parameters for sociosexuality tended to vary across nations more than parameters for sex drive and height did. The results for sociosexuality were most consistent with a hybrid model--that both biological and social structural influences contribute to sex differences, whereas the results for sex drive and height were most consistent with a biological model--that evolved biological factors are the primary cause of sex differences. The model testing proposed here encourages evolutionary and social structural theorists to make more precise and nuanced predictions about the patterning of sex differences across cultures.
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Affiliation(s)
- Richard A Lippa
- Department of Psychology, California State University, Fullerton, Fullerton, CA 92834, USA.
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de Vries ALC, Cohen-Kettenis PT. Review of World Professional Association for Transgender Health's Standards of Care for Children and Adolescents with Gender Identity Disorder: A Need for Change? Int J Transgend 2009. [DOI: 10.1080/15532730903008040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Bockting W. Are Gender Identity Disorders Mental Disorders? Recommendations for Revision of the World Professional Association for Transgender Health'sStandards of Care. Int J Transgend 2009. [DOI: 10.1080/15532730902799987] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Karniol R. Israeli kindergarten children's gender constancy for others' counter-stereotypic toy play and appearance: the role of sibling gender and relative age. INFANT AND CHILD DEVELOPMENT 2009. [DOI: 10.1002/icd.592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Meyer-Bahlburg H. Lignes de conduite pour le traitement des enfants ayant des troubles du développement du sexe. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.neurenf.2008.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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50
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Late diagnosed 46,XX child with congenital adrenal hyperplasia (CAH): deciding the gender of rearing. J Natl Med Assoc 2008; 100:759-60. [PMID: 18595583 DOI: 10.1016/s0027-9684(15)31357-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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