The theory of gender identity disorders

Detransition Narratives Trouble the Simple Attribution of Madness in Transantagonistic Contexts: A Qualitative Analysis of 16 Canadians' Experiences

Emerging evidence suggests that transgender individuals are more likely than cisgender peers to receive a diagnosis with a primary mental disorder. Attributions of madness, though, may serve the social function of dismissing and discrediting transgender individual's self-perceptions. The narratives of individuals who stop or reverse an initial gender transition who also identify as living with mental health conditions can sometimes amplify these socio-political discourses about transgender people. Through a critical mental health lens, this article presents a qualitative analysis of 16 individuals who stopped or reversed a gender transition and who also reported a primary mental health condition. Semi-structured, virtual interviews were conducted with people living in Canada. Applying constructivist grounded theory methodology, and following an iterative, inductive approach to analysis, we used the constant comparative method to analyse these 16 in-depth interviews. Results show rich complexity such that participants narrated madness in nuanced and complex ways while disrupting biased attitudes that madness discredited their thoughts and feelings, including prior gender dysphoria. Instead, participants incorporated madness into expanding self-awareness and narrated their thoughts and feelings as valid and worthy. Future research must consider provider's perspectives, though, in treating mad individuals who detransitioned, since alternate gender-affirming care models may better support the identification and wellness of care-seeking individuals who may be identified (in the past, present, or future) as mad.

Distinguishing and Addressing Gender Minority Stress and Borderline Personality Symptoms

As transgender and gender-diverse people are gaining increased visibility in clinical settings, clinicians are requesting better guidance on providing affirming care to improve the mental health and well-being of these patients. In particular, more direction is needed on whether, when, and how to diagnose and treat borderline personality disorder among gender minorities, partially in response to beliefs among some mental health clinicians that a gender minority identity may be a manifestation of identity diffusion. In this Perspectives article, we argue that gender minority identity, even when fluid, is rarely a sign of identity diffusion. By taking a careful history of a patient's gender identity development, the clinician can clarify and gain more conviction regarding the presence of a patient's gender minority identity. Moreover, multiple stigma-related stressors experienced by gender minorities may produce symptoms and behaviors that can mimic or be consistent with certain diagnostic criteria for borderline personality disorder. We therefore conclude with recommendations for adopting a gender-affirming framework to treat borderline personality symptoms when present among gender minority patients, with implications for future research and practice.

Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria

The increasing incidence of requests for medical services to support gender transition for children, adolescents, and adults has consequences for society, governmental institutions, schools, families, health-care professionals, and, of course, patients. The sociological momentum to recognize and accommodate to trans phenomena has posed ethical dilemmas for endocrinologists, mental health professionals, and sexual specialists as they experience within themselves the clash between respect for patient autonomy, beneficence, nonmaleficence, and informed consent. The larger ethical clashes are cultural and therefore political. There is a distinct difference between pronouncements that represent human rights ideals and the reality of clinical observations. Some interpret this clash as a moral issue. This article delves into these tensions and reminds apologists from both passionate camps that clinical science has a rich tradition of resolving controversy through careful follow-up, which is not yet well developed in this arena.

Gender dysphoria - prevalence and co-morbidities in an irish adult population

INTRODUCTION

Gender dysphoria (GD) is a condition in which there is a marked incongruence between an individual's psychological perception of his/her sex and their biological phenotype. Gender identity disorder was officially renamed "gender dysphoria" in the DSM-V in 2013. The prevalence and demographics of GD vary according to geographical location and has not been well-documented in Ireland.

METHODS

We retrospectively reviewed medical records of 218 patients with suspected or confirmed GD referred to our endocrine service for consideration of hormonal therapy (HT) between 2005 and early 2014. We documented their demographics, clinical characteristics, and treatment during the study period.

RESULTS

The prevalence of GD in the Irish population was 1:10,154 male-to-female (MTF) and 1:27,668 female-to-male (FTM), similar to reported figures in Western Europe. 159 of the patients were MTF and 59 were FTM, accounting for 72.9% and 27.1% of the cohort, respectively. The rate of referral has increased year-on-year, with 55 patients referred in 2013 versus 6 in 2005. Mean ages were 32.6 years (MTF) and 32.2 years (FTM). 22 of the patients were married and 41 had children, with 2 others having pregnant partners. 37.6% were referred by a psychologist, with the remainder evenly divided between GPs and psychiatric services. There were low rates of coexistent medical illness although psychiatric conditions were more prevalent, depression being a factor in 34.4% of patients. 5.9% of patients did not attend a mental health professional. 74.3% are currently on HT, and 9.17% have had gender reassignment surgery (GRS). Regret following hormonal or surgical treatment was in line with other Western European countries (1.83%).

CONCLUSION

The incidence of diagnosis and referral of GD in Ireland is increasing. This brings with it multiple social, health, and financial implications. Clear and accessible treatment pathways supported by mental health professionals is essential.

Correlates of gender dysphoria in Taiwanese university students

There have been no published reports regarding the epidemiological and psychiatric features of gender dysphoria in non-clinical young adults. The current study aimed to investigate the demographics, co-occurring psychiatric symptoms, and perceived parenting style and family support in Taiwanese young adults with gender dysphoria. The sample consisted of 5010 university freshmen (male, 51.6%) with a mean age of 19.6 years (SD = 2.7) from a national university in Taiwan. The questionnaires used for this university-based survey included the Adult Self Report Inventory-4 for psychopathology (including gender dysphoria), the Parental Bonding Instrument for parenting style, and the Family APGAR for perceived family support. Results showed that gender dysphoria was more prevalent in females (7.3%) than males (1.9%). Young adults with gender dysphoria were more likely to meet a wide but specific range of co-occurring psychiatric symptoms. The most significantly associated symptoms for males were agoraphobia, hypochondriasis, manic episode, and pathological gambling, and for females dissociative disorder, hypochondriasis, and body dysmorphic disorder. Both males and females with gender dysphoria perceived significantly less support from their families and less affection/care from both parents. Findings suggest that gender dysphoria, associated with a specific range of psychopathology and family/parenting dissatisfaction (with both similar and dissimilar patterns between sexes), is not uncommon in Taiwanese university students, particularly in females. This implies the importance of attention and specific measures to offset psychiatric conditions and to promote mental well-being of this population.

Gender identity disorders in childhood and adolescence: currently debated concepts and treatment strategies

INTRODUCTION

Gender identity disorders (GID) can appear even in early infancy with a variable degree of severity. Their prevalence in childhood and adolescence is below 1%. GID are often associated with emotional and behavioral problems as well as a high rate of psychiatric comorbidity. Their clinical course is highly variable. There is controversy at present over theoretical explanations of the causes of GID and over treatment approaches, particularly with respect to early hormonal intervention strategies.

METHODS

This review is based on a selective Medline literature search, existing national and international guidelines, and the results of a discussion among experts from multiple relevant disciplines.

RESULTS

As there have been no large studies to date on the course of GID, and, in particular, no studies focusing on causal factors for GID, the evidence level for the various etiological models that have been proposed is generally low. Most models of these disorders assume that they result from a complex biopsychosocial interaction. Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism. The current state of research on this subject does not allow any valid diagnostic parameters to be identified with which one could reliably predict whether the manifestations of GID will persist, i.e., whether transsexualism will develop with certainty or, at least, a high degree of probability.

CONCLUSIONS

The types of modulating influences that are known from the fields of developmental psychology and family dynamics have therapeutic implications for GID. As children with GID only rarely go on to have permanent transsexualism, irreversible physical interventions are clearly not indicated until after the individual's psychosexual development ist complete. The identity-creating experiences of this phase of development should not be restricted by the use of LHRH analogues that prevent puberty.

Utility of the MMPI-2 in assessing gender dysphoric patients

We compared MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles of 2 groups of adult biological men requesting sex reassignment surgery; 1 group was diagnosed with Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev. [DSM-III-R]; American Psychiatric Association, 1987) transsexualism and the other with gender identity disorder of adolescence and adulthood, nontranssexual type (GIDAANT). Although the mean profiles for the transsexual group did not demonstrate any psychopathology, the GIDAANT group showed moderate psychopathology. A cluster analysis indicated that 85% of the transsexual group showed low psychopathology and 47% of the GIDAANT group showed severe psychopathology. Neither the MMPI-2 results nor the DSM-III-R clinical evaluation support the conclusion of many authors that transsexualism is associated with severe personality disorder; rather, the data indicate that transsexualism and other gender identity disorders without persistent wish for sex reassignment differ significantly in degree of psychopathology.

Transsexualism: a review of etiology, diagnosis and treatment

Transsexualism is considered to be the extreme end of the spectrum of gender identity disorders characterized by, among other things, a pursuit of sex reassignment surgery (SRS). The origins of transsexualism are still largely unclear. A first indication of anatomic brain differences between transsexuals and nontranssexuals has been found. Also, certain parental (rearing) factors seem to be associated with transsexualism. Some contradictory findings regarding etiology, psychopathology and success of SRS seem to be related to the fact that certain subtypes of transsexuals follow different developmental routes. The observations that psychotherapy is not helpful in altering a crystallized cross-gender identity and that certain transsexuals do not show severe psychopathology has led clinicians to adopt sex reassignment as a treatment option. In many countries, transsexuals are now treated according to the Standards of Care of the Harry Benjamin International Gender Dysphoria Association, a professional organization in the field of transsexualism. Research on postoperative functioning of transsexuals does not allow for unequivocal conclusions, but there is little doubt that sex reassignment substantially alleviates the suffering of transsexuals. However, SRS is no panacea. Psychotherapy may be needed to help transsexuals in adapting to the new situation or in dealing with issues that could not be addressed before treatment.

Self-image and personality traits in gender identity disorders: an empirical study

Self-image and personality traits, measured by SASB and SCID screen respectively, were compared between transsexuals, patients diagnosed as Gender Identity Disorders of Adolescence and Adulthood, Non-transsexual Type (GIDAANT), and normal controls. Transsexual and GIDAANT patients differed significantly in both their self-image and personality traits. While both the transsexuals' and controls' self-images were positive with self-love, the GIDAANT patients had a negative self-image. On the SCID screen, the GIDAANT group fulfilled 39.8% of all axis II criteria; transsexuals fulfilled 28.6% versus 17.1% for the control group. Mean GAF scores (axis V) were 62, 70, and 83, respectively. For all patients a more negative self-image was significantly related to lower social functioning according to GAF and to more personality pathology according to SCID screen. The prevalence of additional clinical axis I and II disorders was about twice as high among GIDAANT patients as among transsexuals. Although the two conditions are closely related, we found more differences than similarities in the studied aspects and a clear tendency that the GIDAANT patients had more psychopathology overall. Although the transsexuals also differed significantly in some aspects from the controls, they showed less personality pathology and they had a normal self-image. Negative self-image, high degree of fulfilled axis II criteria, and low GAF scores seem to be corresponding factors and in this study clearly differentiate transsexuals from GIDAANT patients.

Partial versus complete autogynephilia and gender dysphoria

Autogynephilia (sexual arousal in men produced by the thought or image of themselves as women) is often associated with gender dysphoria (the desire to belong to the opposite sex). Previous research has shown that autogynephiles who are principally aroused by images of themselves as nude women are more gender dysphoric than those principally aroused by images of themselves as partially or fully dressed women. This study tested the hypothesis that the feature of the nude self-image most responsible for its correlation with gender dysphoria is the imagined vulva. The subjects were 220 nonhomosexual male outpatients who reported sexual arousal while imagining themselves with one or more features of the female anatomy. Autogynephilia and gender dysphoria were assessed with questionnaires. The findings confirmed that men who are sexually aroused at the thought of having a vulva are more likely to want to be women.

Some theoretical and technical aspects of gender and social reality in clinical psychoanalysis

Since the social order embodies and authorizes ideals of femininity and masculinity, a psychoanalysis of gender entails decisions as to how social reality figures in the clinical situation. This paper approaches social reality as part of a general problem of neurosis, in which all versions of normality are analyzed as aspects of resistance. What such an approach emphasizes about social ideals is their role in a psychopathology of conformity, which constitutes a stage in the development of neurosis.

The classification and labeling of nonhomosexual gender dysphorias

This report suggests systematic strategies for the descriptive classification of nonhomosexual gender identity disorders, based on clinical observations and research findings. The classification of biological males is considered first. A review of cross-gender taxonomies shows that previous observers have identified and labeled a homosexual type far more consistently than any other category of male gender dysphoric. It is suggested that the apparent difficulty in differentiating reliably among the nonhomosexual types results from the sharing of many overlapping characteristics by the various groups. This is supported by a review of informal, mostly clinical, observations and by the findings of three studies designed to test the hypothesis that the nonhomosexual gender dysphorias, together with transvestism, constitute a family of related disorders in men. It is concluded that the main varieties of nonhomosexual gender dysphoria are more similar to each other than any of them is to the homosexual type. Two recommendations, based on the foregoing review, are offered for the classification of male gender dysphorics in research studies. When the number of subjects is small, they may be classified simply as homosexual or nonhomosexual. When the number is larger, the nonhomosexual cases may be classified as heterosexual, bisexual, or analloerotic (unattracted to male or female partners, but not necessarily devoid of sexual drive or activities).

Transsexualism: syndrome or symptom?

The desire to identify with and assume the role of the opposite gender has been present with us since antiquity. Unfortunately, the syndrome of transsexualism as defined by the DSM-III encompasses many individuals who are seeking a gender change perhaps allowing reassignment to take place when not indicated. This paper reviews the major classifications applied to the condition of transsexualism and a new model of classification for individuals with Gender Dysphoria is outlined. It will be shown that by subdividing the condition into those with the hypothesized syndrome (primary (true) transsexualism, or the symptom, secondary transsexualism) a better understanding of gender dysphoria is achieved. By applying this new model of classification, a management/treatment protocol is outlined which is helpful in dealing with the gender dysphoric patient.

Borderline manifestations in the Rorschachs of male transsexuals

It was hypothesized that male transsexuals manifest a character structure consistent with Kernberg's criteria for borderline personality organization. Exploring this hypothesis, Kernberg's criteria for borderline personality organization were operationalized using Rorschach measures. The following variables were examined: aggression (Holt System Aggressive Content Section), object relations (Urist's Mutuality of Autonomy Scale), reality testing (Exner System X + %), and self/object differentiation (Exner System Special Scorings). A group of male college students, a group of male borderlines, and a group of male transsexuals were compared on the above variables. Compared to the normals, the transsexuals and borderlines displayed significantly more intense levels of aggression, a lower level of object relations, poorer reality testing, and impaired boundary differentiation. The transsexuals and borderlines did not differ significantly. The results were taken as suggesting that male gender dysphorics may be a sub-group of the wider borderline diagnostic category.