Gender Identity Disorders - Wales Counseling Center,PLLC

By Yulonda Williams, LMSW
1. A tormented and abused teen
2 . A 3 year old boy who identified more with
activities associated with girls
3. A child (9 yrs of age) diagnosed with Gender
Identify Disorder
4. Close family member who struggled with
sexual orientation and gender identify issues as
a child
Many studies have found that LGB youth attempt
suicide more frequently than straight peers. Garafalo
et al. (1999) found that LGB high school students
and students unsure of their sexual orientation were
3.4 times more likely to have attempted suicide in the
last year than their straight peers.
Eisneberg and Resnick (2006) found that LGB high
school students were more likely as their straight peer
to have attempted suicide.
The American Public Health Association (2001)
conducted a study that examined sexual orientation and
suicidality, using data that included critical youth and
suicide risk factors.
Methods: Data from the National Longitudinal Study
of Adolescent Health were examined. Survey of
logistic regression was used to control for sample
design effects.
The findings showed that there is a strong link between
adolescent sexual orientation and suicidal thoughts and
The strong effect of sexual orientation and suicidal
thoughts is mediated by critical youth suicide risk
factors, which include:
 Hopelessness
 Alcohol abuse
 Recent suicide attempts by a peer or family
 Experiences of victimization
The findings also provided strong evidence that
sexual minority youths are more likely than their
peers to think about and attempt suicide.
Boykins addresses colored boys who have
contemplated suicide “When the Rainbow is still Not
Enough.” Boykins addresses longstanding issues of
sexual abuse, suicide, HIV/AIDS, racism, and
homophobia in the African American, Latino, and
Asian communities, and more especially among gay
men of color.
Emotional distress among 9th -12th grade students in
Boston Massachusetts was evaluated.
This study examined whether the association between
being lesbian, gay, bisexual, and/or transgendered
(LGBT), and emotional distress was mediated by
perceptions of having been treated badly or
discriminated against because others thought they were
10% were LGBT and 58% were female and ages
ranged from 13 to 19 years.
About 45% were Black and 31% were Hispanic, and
14 % were White.
LGBT youth scored significantly higher on the scale
of depressive symtomatology
LGBT youth were more likely than heterosexual nontransgendered youth to report suicidal ideation (30%
vs. 6%,p < 0.0001) and self-harm(21% vs. 6%, p <
Mediation analysis showed that perceived
discrimination accounted for increased depressive
symtomatology among LGBT youth males and
females, and accounted for an elevated risk of selfharm and suicidal ideation among LGBT males.
The mediation analysis showed that perceived
discrimination accounted for an increased
depressive symptomatology among LGBT
males and females, and accounted for an
elevated risk of self-harm and suicidal ideation
among LGBT males.
According the American Psychological Association
(APA)“Sexual orientation refers to an enduring
pattern of emotional, romantic, and/or sexual
attractions to men, women, or both sexes.”
Sexual orientation also refers to a person’s sense
of identity based on those attractions, related
behaviors, and membership in a community of
others who share those attractions.
Research over the years has demonstrated that sexual
orientation ranges along a continuum, from exclusive
attraction to the other sex to exclusive attraction to the
same sex.
Sexual orientation also refers to a person’s sense of
identity based on those attractions, related behaviors,
and membership in a community of others who share
those attractions.
However, sexual orientation is usually discussed in three
categories. Those three categories are: heterosexual,
gay/lesbian and bisexual.
Heterosexual (having emotional, romantic, or sexual
attractions to members of the other sex)
Gay/lesbian ( having emotional, romantic, or sexual
attractions to members of one’s own sex)
Bisexual (men or women attracted to both sexes).
According to current scientific and professional
understanding, the core attractions that form the
basis for adult sexual orientation typically
emerge between middle childhood and early
 These patterns of emotional, romantic and sexual
attraction may arise without any prior sexual
Different lesbian, gay, and bisexual people have
very different experiences regarding their sexual
Some people know that they are gay, or bisexual for a
long time before they actually pursue relationships with
other people
Sex refers to attributes that collectively and usually
harmoniously, characterize biological maleness and
In humans, the most well-known attributes that
constitute biological sex include the sex-determining
genes, the sex chromosomes, the H-Y antigen, the
gonads, sex hormones, the internal reproductive, and
the external genitalia (Migeon & Wisniewski, 1999).
Over the past couple of decades, there has been great
interest in the possibility that the human brain has
certain sex-dimorphic neuroanatomic structures that
perhaps emerge during the process of prenatal
physical sex differentiation.
For resent developments see Arnold, 2003; Grumbach, Hughes & Conte,
2003;Haqq & Donahoe, 1998; Vilain, 2000; and chaper 11, this volume).
Gender is used to refer to psychological or behavioral
characteristics associated with males and females (Ruble,
Martin, & Berenbaum, 2006). From a historical perspective
gender is a technical term much younger than the technical
term sex (Haig, 2004).
Fifty years ago, for example, the term gender was not even
part of the professional literature that purported to study
psychological similarities and differences between male and
In fact, the first terminology introduced literature gender
role not gender (Money, 1955).
There has been a tendency to conflate the usage of the
term sex and gender. In addition, it is not always clear
if one is referring to the biological or the psychological
characteristics that distinguish males from females
(Gentile, 1993).
The usage of the above terms sex and gender sot that it
is not always clear if one is referring to the biological
or the psychological characteristics that distinguish
males from females (Gentiles, 1993).
The use of these assumptions have also been related to
assumptions about causality in that the former is used
to refer exclusively to biological processes and latter is
used to refer exclusively to psychological or
sociological processes (see Maccoby, 1988; Money,
As a result, some researchers who study humans
employ such terms as sex-typical, sex-dimorphic, and
sex-typed to characterize sex differences in behavior, as
terms of this kind are descriptively more neutral with
regard to reputed etiology.
Gender Identity is one’s own perception to one’s sex
(Martin Martin, Ruble, & Szkrybalo, 2002).
Gender Identity was introduced into the professional
glossary by Hooker and Stoller almost simultaneously
in the early 1960s (see Money, (1985).
Stoller for example, used a slightly different term
called core gender identity to describe a young child’s
developing which is a “fundamental sense of
belonging to one sex” p. (453).
Core gender identity was later adopted by cognitivedevelopmental psychologists such as Kohlberg (1966),
who defined gender identity as the child’s ability to
accurately discriminate males from females and then to
identify his or her own gender status correctly- a task
considered by some to be the first “stage” in gender
constancy development, the end state of which is the
knowledge of gender invariance (Martin, Ruble, &
Szkrybalo, 2002).
Gender role has been used extensively by developmental
psychologist to refer to behaviors, attitudes, and personality
traits that a society, in a given culture and historical period,
designates as masculine or feminine, that is, more
“appropriate” to or typical of the male and female role
(Ruble et al.,2006).
From a descriptive point of view, the measurement of
gender role behavior in young children includes several
easily observable phenomena, including affiliative
preference for the same-sex versus opposite-sex peers, roles
in fantasy play, toy interest, dress-up play, and interest in
rough and tumble play.
Gender Role Cont’d
 In older children or adolescents, gender role has also
been measured using personality attributes with
stereotypic masculine or feminine connotations or with
regard to recreation and occupational interests and
aspirations (Ruble et al.,2006; Zuker, 2005).
Sexual Identity
 It is important to separate the construct of sexual
orientation from the construct of sexual identity.
 For example, a person may be predominately aroused
by homoerotic stimuli, yet not regard himself or herself
to be gay or lesbian.
 According to the Nursing Outcomes Classification
(NOC) sexual identity is defined as the
acknowledgment and acceptance of one's own sexual
Transvestic Fetishism The wearing of cloths of the
opposite sex (cross-dressing) principally to obtain
sexual excitement and to create the appearance of a
person of the opposite sex (referred to as
Fetisistic transvestism is distinguished from transsexual
transvestism by it’s clear association to with sexual
arousal and strong desire to remove the clothing once
orgasm occurs. After sexual orgasm occurs, sexual
arousal declines.
Transgender is an umbrella term fro people whose
gender identity, expression or behavior is different from
those typically associated with their assigned sex at
birth, including but not limited to transsexuals, cross
dressers, and androgynous people, genderqueers, and
gender non-confirming people. Transgender is a broad
term and is good for non-transgender people to use.
Trans is shorthand for “transgender” (National Center
for Transgender Equality, 2008).
Transsexualism a desire to live and be accepted as a
member of the opposite sex, usual accompanied by a
sense of discomfort with, or inappropriateness of, one’s
anatomic sex, and a wish to have surgery and hormonal
treatment to one’s body as congruent as possible with
one’s preferred sex
Transsexual a person who has undergone medical and
surgical procedures to alter external sexual
characteristics to those of the opposite sex
Exclusively attracted to men
Overly feminine during
Rated as more feminine by
Not sexual aroused by cross
Usually transition in 20s
My be attracted to women,
women and men, or neither sex
Not overtly feminine during
Rated as less feminine by
Sexually aroused by crossdressing currently or in the past
Usually transition in 30s or later
Almost exclusively attracted
to women
Overly masculine during
Sexual attitudes are more
Greater desire for
Less comorbid
Usually transition in 20s
May be primarily attracted
to men or women and men
Usually less overtly
masculine during childhood
Sexual attitudes are less
male typical
Less desire for phalloplasty
More comorbid
Usually transition in 20s
A. A strong persistent cross-gender identification (not
merely a desire for any perceived cultural advantages
of being the other sex).
 In children, the disturbance is manifested by four or
more of the following:
1. Repeatedly stated desire to be, or insistence that he or
she is, the other sex
2. In boys, preference for cross-dressing or simulating
female attire; in girls, insistence on wearing only
stereotypical masculine clothing
(3) Strong and persistent preferences for cross-sex
roles in make-believe play or persistent fantasies of
being the other sex
(4) Intense desire to participate in the stereotypical
games and pastimes of the other sex
(5) Strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested
by symptoms such as a stated desire to be the other sex,
frequent passing as the other sex, desire to live or be
treated as the other sex, or the conviction that he or she
has the typical feelings and reactions of the other sex
B. Persistent discomfort with his or her sex sense of
inappropriateness in he gender role of the sex.
In children, the disturbance is manifested by any of the following:
in boys, assertion that his penis or testes are disgusting
or will disappear or assertion that it would be better not to have a
penis or testes are disgusting or
or aversion toward rough-and-tumble play and rejection of the male
stereotypical toys, games, and actives
In girls, the rejection of urinating in a sitting position, assertion that
she has or will grow a penis, or assertion that she does not want to
grow breast or menstruate, or marked aversion toward normative
feminine clothing.
In adolescents and adults, the disturbance is manifested by
symptoms such as pre-occupation with getting rid of primary
and secondary sex characteristics (e.g., request for hormones,
surgery or procedures to physically alter sexual characteristics
to stimulate the other sex) or belief that he or she was born the
wrong sex.
C. The disturbance is not concurrent with a physical
intersex condition.
D. The disturbance causes clinically significant
distress or impairment in social, occupational, or
other important areas of functioning
Code Based on current age:
302.6 Gender Identity Disorder in Children
Gender Identity Disorder in Adolescents or Adults
Specify if (for sexually mature individuals):
Sexually attracted to males
Sexually attracted to females
Sexually attracted to both
Sexually attracted to neither
The onset of most behaviors occurs during the
preschool years (2-4 years), if not earlier. Clinical
referrals often occur when parents begin to feel that the
pattern of behavior is no longer a “phase,” a common
initial parental appraisal, threat their child will “grow
out of (Stoller, 1997; Zuker, 2000).
From a developmental perspective, the onset occurs
during the same period that more sex-dimorphic
behaviors can be observed in young children
Among children between the ages of 3 to 12, boys are
referred clinically more often than girls for concerns
regarding gender identity (Cohen-Kettenis, Wwen,
Kaijser, Bradley, and Zucker (2003).
An office in Toronto Canada, reported a sex ratio of
5.75:1 of boys to girls based on consecutive referrals
from 1975 to 2000.
Comparative data were available on children evaluated
at a clinic in the Netherlands. Although the sex ratio
was significantly smaller (2.93:1), boys referral rates
were still higher as oppose to girls (Zuker, 2005).
One possibility is that prevalence data from the general
population are lacking and this remains a matter of
speculation (Zucker & Bradly, 1995).
Social factors- for example it is well established that
parents, teachers, and peers are less tolerant of cross-gender
behavior in boys than in girls, which might result in the sexdifferential in clinical referrals (Zucker & Bradly, 1995).
Another factor could affect the sex referral rates relates to
the salience of cross-gender behavior in boys verses girls.
For example, It has been long observed that the sexes
differ in the extent to which they display sex-typical
behavior; when there is significant between-sex
variation, it is almost always the case that girls are
more likely to engage in masculine behaviors than boys
are to engage in feminine behaviors (Zuckers, 2005).
The DSM not only determines how mental disorders are
defined and diagnosed, it also impacts how people see
themselves and how we see each other. While diagnostic
terms facilitate clinical care and access to insurance
coverage that supports mental health, these terms can
also have a stigmatizing affect.
Source: Gender Dysphoria. American Pyschiatric Association, 2013.
Gender Identity Disorder/ Gender Dysphoria
 Respecting and ensuring care
 DSM-V aims to avoid the stigma and ensure clinical care for
individuals who see and feel themselves to be a different gender
than their assigned gender.
It replace the diagnostic name “gender identity disorder with
gender dysphoria,” as well as makes other important
clarifications in the criteria.
It is important to note hat gender nonconformity is not in itself a
mental disorder. The critical element of gender dysphoria is the
presence of clinically significant distress associated with the
Characteristics of the Condition
For a person diagnosed with gender dysphoria, there
a clear or marked difference between the individual’s
expressed/experienced gender and the gender others
would assign him or her, and it must continue for at least
six months. In children, the desire to be of the other
gender must be present and verbalized. This condition
causes clinically significant distress or impairment in
social, occupational, or other important areas of
Gender dysphoria is manifested in a variety of ways,
including strong desires to be treated as the other
gender or to be rid of one’s sex characteristics, or a
strong conviction that one has feelings and reactions
of the other gender.
The DSM-5 diagnosis adds a post-transition specifier
for people who are living full-time as the desired
gender (with or without legal sanction of the gender
change). This ensures treatment access for individual
who continue to undergo hormone therapy, related
surgery, or psychotherapy or counseling to support their
gender transition.
Gender dysphoria will have its own chapter in DSM-5
and will be separated for Sexual dysfunctions and
Paraphilic Disorders.
Persons experiencing gender dysphoria need a diagnostic term
that protects their access to care and won’t be used against them
in social occupational, or legal areas.
When it comes to access to care, many of the treatment options
for this condition include counseling, cross-sex hormones,
gender reassignment surgery, and social and legal transition to
the desired gender.
To get insurance coverage for the medical treatments, individuals
need a diagnosis. The Sexual and Gender Identity Disorder
Swork Group was concerned that removing the condidtion as a
psychiatric diagnossis—as some suggested—would jeoporadize
acess to care.
Part of removing sitgma is about choosing the right
words. (Replacing “disorder” with “dysphoria”) in the
diagnostic label is not only more appropriate and
consistent with familial clinical sexology terminology,
it also removes the connotation the patient is
Suicide and self-harm
Van Kestern, Asscheman, Megens, and Gooren (1997)
found that in the Netherlands 13 (1.6 %) of 816 MtF
transsexuals receiving hormone therapy had died of
suicide—a percentage more than nine times that of the
general population-while none of 293 FtM transsexual
had died of suicide.
Some persons with gender identity disorders engage in
self-mutilation of their genitals and breasts: Dixen et al
(1984) found that 9.4 of MtF applicants for sex
reassignment and 2.4 of FtM applicants had done so.
Comorbid personality disorders are common
among persons with gender identity disorders.
Howening and Keanna (1974) observed pesonality
diosroder in 18% of their MtF and FtM transexual
patients. Haraldsen and Dahl (2000) reported a similar
figure, 20%.
Some MtF transgender persons in the United States, many of whom would
probably fit the diagnostic criteria for a gender identity disorder, have a
disproportionately high prevalence of HIV infection.
Reported HIV seropositivity figures, based on studies conducted with
convenience samples of MtF transgender persons include: 25% in New
York City, 19% in Philadelphia ,35% 16% and 48% in San Francisco; 32%
in Washington, DC and 22% in Los Angeles (Simon, Reback, &Bemis ,
HIV infection is especially prevalent among MtF transgender persons who
engage in sex work and in MtF person of color, particular African
Americans. Ft M transgender are much lower(Kenagy, 2002; MaGowan,
 Behavior
 Psychotherapy
 Treatment of Parents
 Limit Setting
 Supportive Treatments
Consider the following clinical scenario:
A mother of a 4 year old boy calls a well-known clinic
that specializes in gender identity problems. She
describes behaviors consistent with the DSM diagnosis
of GID. She says that she should like her child treated
so he does not grow up to be gay. She also worries that
her childe will be ostracized within the peer group
because of this pervasive cross-gender behavior? What
should the clinician do?
Consider the following Scenario:
The parents of 6 year old boy (somatically male)
conclude that their son is really a girl, so they seek the
help of an attorney to institute a legal name change
(from Zachary to Aurora) and inform the school and
the principal that their son ill attend school as a girl.
The local child protection agency is notified and the
childe is removed from the parents’ cae (Cloud, 2000).
If a clinical was asked to evaluate the situation, what
would be in the best interest of the child and family?

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