Gender nonconformance (formerly gender identity disorder)
Gender identity disorder (GID) refers to a spectrum of conditions in which the individual has a strong persistent cross-gender identification and feels inappropriate in his or her assigned birth role. The cardinal feature of GID is the feeling of gender dysphoria, the uncomfortable feeling of one’s assigned gender. The diagnosis of GID is typically made using the Diagnostic and Statistical Manual of Mental Disorders (DSM, now currently in revision) by an experienced mental health professional. Following a period of counseling, individuals are referred for hormonal therapies and/or surgical therapies to initiate their transition into the appropriate gender.
Transsexuals are individuals who seek both hormonal and surgical therapies to match their external appearance to match their gender identification. Transgender refers to the individuals who make seek a combination or hormones and/or surgery to relieve their sense of gender dysphoria. The exact prevalence of GID in the United States and most countries is not known. It is estimated that 1 out of 30,000 to 100,000 individuals have GID; however, these are likely under estimates since many individuals do not seek therapy due to the social stigma of GID that remains even in the present day.
Typically, individuals will manifest cross-gender identification symptoms early in childhood. These include role playing in the opposite gender, insisting that one is a member of the opposite gender, dressing in the clothes of the opposite gender and feeling uncomfortable or rejecting one’s genitalia. Some individuals may present in adulthood where depression may also be a co-presenting condition.
The causes of GID are not known and are likely to be multi-factorial. Several proposed contributing factors include pre-natal hormone exposure, biological differences in the brain including the hypothalamus, genetic and environmental factors. However, no single factor provides the sole explanation for the gender dysphoria experienced by individuals with GID.
The diagnosis of GID requires the evaluation by a mental health therapist with experience in gender identity disorders. Guidelines for the diagnosis of GID in adolescents and adults are found in the DSM (most current version DSM-IV-TR). Once the diagnosis is made, the Standards of Care (SOC) by the World Professional Association for Transgender Health provide guidelines for the eligibility and readiness for hormones or surgery.
The treatment of GID involves a multi-disciplinary approach. Most individuals should have ongoing support by their mental health therapist for issues that may arise during the transition into the opposite gender. Detailed hormone regimens are outlined in the Endocrine Society Guidelines for Treatment of Transsexuals published in 2009. Male to female transgender patients receive estrogen and anti-estrogen treatment. Female to male transgender patients receive testosterone therapy. Careful attention must be made to avoid supra- physiologic levels of sex hormones to avoid adverse reactions. Monitoring of hormone levels and potential side effects of therapy is important in the initial years of starting hormonal therapy. Potential side effects in male to female transsexuals includes: thromboembolic disease, liver dysfunction, lipid abnormalities and pituitary enlargement. Potential side effects in female to male transsexuals includes: polycythemia, liver dysfunction, endometrial hyperplasia, and lipid abnormalities. The long term impact on cardiovascular disease and cancer risk is not known but does not appear to be adversely affected by cross-hormone therapy.
Surgical options for male to female individuals include gonadectomy, penectomy, vaginoplasty, facial feminization surgery and breast augmentation. Surgical options for female to male individuals include phalloplasty, total hysterectomy, and mastectomy with chest reconstruction.