Monday 15 July 2013

GENDER IDENTITY DISORDER


INTRODUCTION
Gender identity is the sense of knowing to which gender one belongs—that is, the awareness of one’s masculinity or femininity. Gender identity disorders occur when there is incongruity between anatomic sex and gender identity. An individual with gender identity disorder has an intense desire to be, or insists that he or she is, of the other gender.1
Definition
DSM-IV-TR defines gender identity disorders as a group whose common feature is a strong, persistent preference for living as a person of the other sex.1
 The affective component of gender identity disorders is gender dysphoria, discontent with one's designated birth sex and a desire to have the body of the other sex, and to be regarded socially as a person of the other sex. Gender identity disorder in adults was referred to in early versions of the DSM as transsexualism.
Gender identity disorders are characterized by strong and persistent cross-gender identification accompanied by persistent discomfort with one’s assigned sex (APA, 2000).2
Epidemiology
Children
Most children with gender identity disorder are referred for clinical evaluation in early grade school years. Parents, however, typically report that the cross-gender behaviors were apparent before 3 years of age. Among a sample of boys under age 12 referred for a range of clinical problems, the reported desire to be the opposite sex was 10 percent. For clinically referred girls under age 12, the reported desire to be the opposite sex was 5 percent.
The sex ratio of referred children is 4 to 5 boys for each girl.1
Adults
The best estimate of gender identity disorder or transsexualism in adults emanates from Europe with a prevalence of 1 in 30,000 men and 1 in 100,000 women. Most clinical centers report a sex ratio of three to five male patients for each female patient. Most adults with gender identity disorder report having felt different from other children of their same sex, although, in retrospect, many could not identify the source of that difference. Many report feeling extensively cross-gender identified from the earliest years, with the cross-gender identification becoming more profound in adolescence and young adulthood. Many adults with gender identity disorder may well have qualified for gender identity disorder in childhood.1
Etiology
Biological Factors
Sex steroids influence the expression of sexual behavior in mature men or women; that is, testosterone can increase libido and aggressiveness in women, and estrogen can decrease libido and aggressiveness in men. But masculinity, femininity, and gender identity result more from postnatal life events than from prenatal hormonal organization.
The same principle of masculinization or feminization has been applied to the brain. Testosterone affects brain neurons that contribute to the masculinization of the brain in such areas as the hypothalamus. Whether testosterone contributes to so-called masculine or feminine behavioral patterns in gender identity disorders remains a controversial issue.1
Psychosocial Factors
Children usually develop a gender identity consonant with their sex of rearing (also known as assigned sex). The formation of gender identity is influenced by the interaction of children's temperament and parents' qualities and attitudes. Culturally acceptable gender roles exist: Boys are not expected to be effeminate, and girls are not expected to be masculine. There are boys' games (e.g., cops and robbers) and girls' toys (e.g., dolls and dollhouses). These roles are learned, although some investigators believe that some boys are temperamentally delicate and sensitive and that some girls are aggressive and energized and traits that are stereotypically known in today's culture as feminine and masculine, respectively. However, greater tolerance for mild cross-gender activity in children has developed in the past few decades.
        Sigmund Freud believed that gender identity problems resulted from conflicts experienced by children within the oedipal triangle. These conflicts are fueled by both real family events and children's fantasies. Whatever interferes with a child's loving the opposite-sex parent and identifying with the same-sex parent interferes with normal gender identity.
The quality of the mother and child relationship in the first years of life is paramount in establishing gender identity. During this period, mothers normally facilitate their children's awareness of, and pride in, their gender: Children are valued as little boys and girls, but devaluing, hostile mothering can result in gender problems. At the same time, the separation-individuation process is unfolding. When gender problems become associated with separation-individuation problems, the result can be the use of sexuality to remain in relationships characterized by shifts between a desperate infantile closeness and a hostile, devaluing distance.
Some children are given the message that they would be more valued if they adopted the gender identity of the opposite sex. Rejected or abused children may act on such a belief. Gender identity problems can also be triggered by a mother's death, extended absence, or depression, to which a young boy may react by totally identifying with her and that is, by becoming a mother to replace her. The father's role is also important in the early years, and his presence normally helps the separation-individuation process. Without a father, mother and child may remain overly close. For a girl, the father is normally the prototype of future love objects; for a boy, the father is a model for male identification.
Classification
F64 Gender identity disorders
F64.0 Transsexualism
F64.1 Dual-role transvestism
F64.2 Gender identity disorder of childhood
F64.8 Other gender identity disorders
F64.9 Gender identity disorder, unspecified3
Clinical features
In children or adolescents:
1. Repeatedly stating intense desire to be of the opposite gender.
2. Insistence that one is of the opposite gender.
3. Preference in males for cross-dressing or simulating female attire.
4. Insistence by females on wearing only stereotypical masculine clothing.
5. Fantasies of being of the opposite gender.
6. Strong desire to participate only in the stereotypical games and pastimes of the opposite gender.
7. Strong preference for playmates (peers) of the opposite gender.
In adults:
1. A stated desire to be of the opposite gender.
2. Frequently passing as the opposite gender.
3. Desire to live or be treated as the opposite gender.
4. Stated conviction that one has the typical feelings and reactions of the opposite gender.
5. Persistent discomfort with or sense of inappropriateness in the assigned gender role.
6. Request for opposite gender hormones or surgery to alter sexual characteristics.2

ICD-10 Diagnostic Criteria for Gender Identity Disorders
Transsexualism
  1. The individual desires to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make his or her body as congruent as possible with the preferred sex through surgery and hormonal treatment.
  2. The transsexual identity has been present persistently for at least 2 years.
  3. The disorder is not a symptom of another mental disorder, such as schizophrenia, nor is it associated with chromosome abnormality.
Dual-role transvestism
  1. The individual wears clothes of the opposite sex in order to experience temporarily membership of the opposite sex.
  2. There is no sexual motivation for the cross-dressing.
  3. The individual has no desire for a permanent change to the opposite sex.
Gender identity disorder of childhood
For girls:
  1. The individual shows persistent and intense distress about being a girl, and has a stated desire to be a boy (not merely a desire for any perceived cultural advantages to being a boy), or insists that she is a boy.
  2. Either of the following must be present:
    1. persistent marked aversion to normative feminine clothing and insistence on wearing stereotypical masculine clothing, e.g., boy's underwear and other accessories;
    2. persistent repudiation of female anatomical structures, as evidenced by at least one of the following:
      1. an assertion that she has, or will grow, a penis;
      2. rejection of urinating in a sitting position;
      3. assertion that she does not want to grow breasts or menstruate.
    3. The girl has not yet reached puberty.
    4. The disorder must have been present for at least 6 months.
For boys:
  1. The individual shows persistent and intense distress about being a boy, and has an intense desire to be a girl or, more rarely, insists that he is a girl.
  2. Either of the following must be present:
    1. preoccupation with stereotypical female activities, as shown by a preference for either cross-dressing or simulating female attire, or by an intense desire to participate in the games and pastimes of girls and rejection of stereotypical male toys, games, and activities;
    2. persistent repudiation of male anatomical structures, as indicated by at least one of the following repeated assertions:
      1. that he will grow up to become a woman (not merely in role);
      2. that his penis or testes are disgusting or will disappear;
      3. that it would be better not to have a penis or testes;
  3. The boy has not yet reached puberty.
  4. The disorder must have been present for at least 6 months.1
Treatment
Children
At present, no convincing evidence indicates that psychiatric or psychological intervention for children with gender identity disorder affects the direction of subsequent sexual orientation. The treatment of gender identity disorder in children is directed largely at developing social skills and comfort in the sex role expected by birth anatomy. To the extent that treatment is successful, transsexual development may be interrupted. The low prevalence of transsexualism in the general population, however, even in the special population of cross-gender children, thwarts the testing of this assumption.1 Inclusion of GID for children in the list of disorders is also seen by some critics as perpetuating sex stereotyping in society, and demanding that children conform to traditional masculine/feminine behaviours. A response to this is that the diagnosis is not made merely for gender non-conformity but only when the child is unhappy being male or female, and where the child's behaviours are so atypical that there is substantial adverse reaction from the peer group.4
No hormonal or psychopharmacological treatments for gender identity disorder in childhood have been identified.1
Adolescents
Adolescents whose gender identity disorder has persisted beyond puberty present unique treatment problems. One is how to manage the rapid emergence of unwanted secondary sex characteristics. Thus, a new area of treatment management has evolved with respect to slowing down or stopping pubertal changes expected by anatomical birth sex and then implementing cross-sex body changes with cross-sex hormones.
Young persons whose previous gender identity disorder has remitted may experience new conflicts should homosexual feelings emerge. This may be a source of anxiety in the adolescent and may cause conflict within the family. Teenagers should be reassured about the prevalence and non pathological aspects of a same-sex partner preference. Parents must also be informed of the non pathological nature of same-sex orientation. The goal of family intervention is to keep the family stable and to provide a supportive environment for the teenager.
Adults
Adult patients coming to a gender identity clinic usually present with straightforward requests for hormonal and surgical sex reassignment. No drug treatment has been shown to be effective in reducing cross-gender desires per se. When patient gender dysphoria is severe and intractable, sex reassignment may be the best solution.
Sex-Reassignment Surgery
Sex reassignment surgery for a person born anatomically male consists principally of removal of the penis, scrotum, and testes, construction of labia, and vaginoplasty. Some clinicians attempt to construct a neoclitoris from the former frenulum of the penis. The neoclitoris may have erotic sensation. Postoperative complications include urethral strictures, rectovaginal fistulas, vaginal stenosis, and inadequate width or depth.
Some male patients who do not have adequate breast development from years of hormone treatment may elect augmentation mammaplasty. Some also have thyroid cartilage shaved to reduce the male-appearing thyroid cartilage. Patients need to undergo vocal retraining, and those who do not have a fully effective response may undergo a cricothyroid approximation procedure, which can raise vocal pitch. The results of these operations are variable.
Female-to-male patients typically may undergo bilateral mastectomy and construct a neophallus. Because of increased technical skills in phalloplasty, more female-to-male patients are now electing these procedures.
Uncertainty and controversy exist with respect to the capacity for sexual arousal by the patient postsurgery. Some patients maintain that they are orgasmic. They describe the sensation of orgasm as more gradual and attenuated than their orgasms preoperatively. On the other hand, some patients report little sexual responsivity postsurgery. To date, no adequate assessments have been made of the physiological functioning of postoperative male-to-female transsexuals with respect to the human sexual response cycle. Many patients, however, report satisfaction with being able to have vaginal intercourse with a male partner.1
Hormonal Treatment
Persons born male are typically treated with daily doses of oral estrogen. This may be conjugated equine estrogens or ethinylestradiol or estrogen patches. These hormones produce breast enlargement, the amount being largely determined by genetic predisposition, which continues for approximately 2 years. Other major effects of estrogen treatment are testicular atrophy, decreased libido, and diminished erectile capacity. Also, a decrease occurs in the density of body hair and, perhaps, an arrest of male pattern baldness. Side effects of endocrine treatment can be elevated levels of prolactin, blood lipids, fasting blood sugar, and hepatic enzymes. Patients should be monitored with appropriate blood tests. Smoking is a contraindication of endocrine treatment, because it increases the risk of deep vein thrombosis and pulmonary embolism. There is no effect on voice. Facial hair removal is required by laser treatment or electrolysis.
Biological women are treated with monthly or three weekly injections of testosterone. Because the effects of exogenous testosterone are more profound than those of estrogen, clinicians should be more cautious about commencing female patients on hormone treatment. The pitch of the voice drops permanently into the male range as the vocal cords thicken. The clitoris enlarges to two or three times its pretreatment length and is often accompanied by increased libido. Hair growth changes to the male pattern, and a full complement of facial hair may grow. Menses cease. Male pattern baldness may develop, and acne may be a complication.
Ethinylestradiol in male-to-female transsexuals increases regional fat depots and thigh muscle mass. Conversely, female-to-male transsexuals receiving testosterone may have increased thigh muscle and reduced subcutaneous fat deposition. Thus, cross-sex steroid hormones affect general body fat and muscle distribution, as well as promote breast development in patients born male.1

Nursing management
·         Inability to distinguish between self and nonself related to parenting patterns that encourage culturally unacceptable behaviors for assigned gender or unresolved Oedipal/Electra conflict.

Short-Term Goals
1. Client will verbalize knowledge of behaviors that are appropriate and culturally acceptable for assigned gender.
2. Client will verbalize desire for congruence between personal feelings and behavior assigned gender.
Long-Term Goals       
1. Client will demonstrate behaviors that are appropriate and culturally acceptable for assigned gender.
2. Client will express personal satisfaction and feelings of being comfortable in assigned gender.
Interventions
1. Spend time with client and show positive regard.
2. Be aware of own feelings and attitudes toward this client and his or her behavior.
3. Allow client to describe his or her perception of the problem.
4. Discuss with the client the types of behaviors that are more culturally acceptable. Practice these behaviors through role-playing or with play therapy strategies (e.g., male and female dolls). Positive reinforcement or social attention may be given for use of appropriate behaviors. No response is given for stereotypical opposite-gender behaviors.
Outcome Criteria
1. Client demonstrates behaviors that are culturally appropriate for assigned gender.
2. Client verbalizes and demonstrates self-satisfaction with assigned gender role.
3. Client demonstrates development of a close relationship with the parent of the same gender.2
● Impaired social interaction related to socially and culturally unacceptable behavior ,negative role modeling and low self-esteem.
short-Term Goal
Client will verbalize possible reasons for ineffective interactions with others.
Long-Term Goal
Client will interact with others using culturally acceptable behaviors.
Interventions
1. Once client feels comfortable with the new behaviors in role playing or one-to-one nurse–client interactions, the new behaviors may be tried in group situations. If possible, remain with the client during initial interactions with others.
2. Observe client behaviors and the responses he or she elicits from others. Give social attention (e.g., smile, nod) to desired behaviors. Follow up these “practice” sessions with one-to-one processing of
the interaction. Give positive reinforcement for efforts.
3. Offer support if client is feeling hurt from peer ridicule. Matter of factly discuss the behaviors that elicited the ridicule. Offer no personal reaction to the behavior.
Outcome Criteria
1. Client interacts appropriately with others demonstrating culturally acceptable behaviors.
2. Client verbalizes and demonstrates comfort in assigned gender role in interactions with others.2
● Low self-esteem  related to rejection by peers , lack of positive feedback and lack of personal satisfaction with assigned gender.
Short-Term Goal
Client will verbalize positive statements about self, including past accomplishments and future prospects.
Long-Term Goal
Client will verbalize and demonstrate behaviors that indicate self-satisfaction with assigned gender, ability to interact with others, and a sense of self as a worthwhile person.
Interventions
1. To enhance the child’s self-esteem:
a. Encourage the child to engage in activities in which he or she is likely to achieve success.
b. Help the child to focus on aspects of his or her life for which positive feelings exist. Discourage rumination about situations that are perceived as failures or over which the client has no control. Give positive feedback for these behaviors.
2. Help the client identify behaviors or aspects of life he or she would like to change. If realistic, assist the child in problem-solving ways to bring about the change.
3. Offer to be available for support to the child when he or she is feeling rejected by peers.
Outcome Criteria
1. Client verbalizes positive perception of self.
2. Client verbalizes self-satisfaction about accomplishments and demonstrates behaviors that reflect self-worth.2
Conclusion
Gender identity is the sense of knowing to which gender one belongs—that is, the awareness of one’s masculinity or femininity. Gender identity disorders occur when there is incongruity between anatomic sex and gender identity. An individual with gender identity disorder has an intense desire to be, or insists that he or she is, of the other gender. Intervention with adolescents and adults with gender identity disorder is difficult. Adolescents commonly act out and rarely have the motivation required to alter their cross-gender roles. Adults generally seek therapy to learn how to cope with their altered sexual identity, not to correct it. Treatment of children with the disorder is aimed at helping them to become more comfortable with their assigned sex and to avoid the possible development of gender dissatisfaction in adulthood.2
Discussion
What are the ethical issues to be considered while considering a client for sex reassignment surgery?
What are the psychosocial issues faced by a client after sex reassignment surgery?







References
1 Sadock, Benjamin James; Sadock, Virginia Alcott, Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 2007, 10th Edition ,Lippincott Williams & Wilkins,718-722,726
2 Townsend MC Nursing Diagnosis in Psychiatric Nursing ,Care Plans and Psychotropic Medications,2008,7th edn, FA Davis,187,196-202
3 The ICD-10 Classification of Mental and Behavioural Disorders, Diagnostic criteria for research ,World Health Organization ,Geneva
4   Michael G. Gelder, Juan J. López-Ibor, Jr. and Nancy Andreasen ,New Oxford Textbook of Psychiatry ,2000, Oxford University Press,

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