 |
Paraphilias
Diagnostic Features
There are two components of Gender Identity Disorder, both of which must be
present to make the diagnosis. Thee must be evidence of a strong and persistent
gross-gender identification, which is the desire to be, or the insistence that
one is of the other sex (Criteria A). This cross-gender identification must not
merely be a desire for any perceived cultural advantages of being the other sex.
there must also be evidence of persistent discomfort about one’s assigned sex or
a sense of inappropriateness in the gender role of that sex (Criteria B). The
diagnosis is not made if the individual has a concurrent physical intersex
condition (e.g., androgen insensitivity syndrome or congenital adrenal
hyperplasia) (Criteria C). To make the diagnosis, there must be evidence of
clinically significant distress or impairment in social, occupational, or other
important areas of functioning (Criteria D).
In boys, the cross gender identification is manifested by a marked
preoccupation with traditionally feminine activities. They may have a preference
for dressing in girls’ or women’s clothes or may improvise such items from
available materials when genuine articles are unavailable. Towels, aprons, and
scarves are often used to represent long hair or skirts. There is a strong
attraction for the stereotypical games and pastimes of girls. They particularly
enjoy playing house, drawing pictures of beautiful girls and princesses, and
watching television or videos of their favorite female-type dolls, such as
Barbie, are often their favorite toys, and girls are their preferred playmates.
When playing "house", these boys role-play female figures. Most commonly
"mother
roles", and often are quite preoccupied with female fantasy figures. they avoid
rough-and-tumble play and competitive sports and have little interest in cars
and trucks or other no-aggressive but stereotypical boy’s toys. They may express
a wish to be a girl and assert that they will grow up to be a woman. they may
insist on sitting to urinate and pretend not to have a penis by pushing it in
between their legs. More rarely, boys with Gender Identity Disorder may state
that they find their penis or testes disgusting, that they want to remove them,
or that they have, or wish to have, a vagina.
Girls with Gender Identity Disorder display intense negative reactions to
parental expectations or attempts to have them wear dresses or other feminine
attire. Some may refuse to attend school or social events where such clothes may
be required. They prefer boy’s clothing and short hair, are often misidentified
by strangers as boys, and may ask to be called a boy’s name. their fantasy
heroes are most often powerful male figures, such as Batman or Superman. these
girls prefer boys as playmates, with whom they share interests in contact
sports, rough-and-tumble play and traditional boyhood games. they show little
interest in dolls or any form of feminine dress up or role-play activity. A girl
with this disorder may occasionally refuse to urinate in a sitting position. She
may claim that she has or will grow a penis and may not want to grow breasts or
menstruate. She may assert that she will grow up to be a man. Such girls
typically reveal marked cross-gender identification in role-play, dreams and
fantasies.
Adults with Gender Identity Disorder are preoccupied with their wish to live
as a member of the other sex. This preoccupation may be manifested as an intense
desire to adopt the social role of the other sex or to acquire the physical
appearance of the other sex through hormonal or surgical manipulation. Adults
with this disorder are uncomfortable being regarded by others as, or functioning
in society as, a member of their designated sex. To varying degrees, they adopt
the behavior, dress, and mannerisms of the other sex. In private, these
individuals may spend much time cross-dressed and working on the appearance of
being the other sex. Many attempt to pass in public as the other sex. With
cross-dressing and hormonal treatment (and for males, electrolysis), many
individuals with this disorder may pass convincingly as the other sex. The
sexual activity of these individuals with same-sex partners is generally
constrained by the preference that their partners neither see nor touch their
genitals. For some males who present later in life, (often following marriage),
sexual activity with a woman is accompanied by the fantasy of being lesbian
lovers or that his partner is a man and he is a woman.
In adolescents, the clinical features may resemble either those of children
or those of adults, depending on the individual’s developmental level, and the
criteria should be applied accordingly. In younger adolescents, it may be more
difficult to arrive at an accurate diagnosis because of the adolescent’s
guardedness. This may be increased if the adolescent feels ambivalent about
cross-gender identification or feels that it is unacceptable to the family. The
adolescent may be referred because the parents or teachers are concerned about
social isolation or peer teasing and rejection. In such circumstances, the
diagnosis should be reserved for those adolescents who appear quite cross-gender
identified in their dress and who engage in behaviors that suggest significant
cross-gender identification (e.g., shaving legs in males). Clarifying the
diagnosis in children and adolescents may require monitoring over an extended
period of time.
Distress or disability in individuals with Gender Identity Disorder is
manifested differently across the life cycle. in young children, distress is
manifested by the stated unhappiness about their assigned sex. Preoccupation
with cross-gender wishes often interferes with ordinary activities. In older
children, failure to develop age-appropriate same sex peer relationships and
skills often leads to isolation and distress, and some children may refuse to
attend school because of the teasing or pressure to dress in attire
stereotypical of their assigned sex. in adolescents and adults, preoccupation
with cross-gender wishes often interferes with ordinary activities. Relationship
difficulties are common and functioning at school or at work may be
impaired.
Specifiers
For sexually mature individuals, the following specifiers may be noted based
on the individual’s sexual orientation: Sexually Attracted to Males, Sexually
Attracted to Females, Sexually Attracted to Both, and Sexually Attracted
to Neither. Males with Gender Identity Disorder include substantial
proportions with all four specifiers. Virtually all females with Gender Identity
Disorder will receive the same specifier-Sexually Attracted to Female- although
there are exceptional cases involving females who are sexually Attracted to
Males.
Recording Procedures
The assigned diagnostic code depends on the individual’s current age: if the
disorder occurs in childhood, the code 302.6 is used; for an adolescent or
adult, 302.85 is used.
Associated Features and Disorders
Associated descriptive features and mental disorders.
Many
individuals with Gender Identity Disorder become socially isolated. Isolation
and ostracism contribute to low self esteem and may lead to school aversion or
dropping out of school. Peer ostracism and teasing are especially common
sequelae for boys with the disorder. Boys with Gender Identity Disorder often
show marked feminine mannerisms and speech patterns.
The disturbance can be so pervasive that the mental lives of some individuals
revolve only around those activities that lessen gender distress. they are often
preoccupied with appearance, especially early in the transition to living in the
opposite sex role. Relationships with one or both parents also may be seriously
impaired. Some males with Gender Identity Disorder resort to self-treatment with
hormones and may very rarely perform their own castration or penectomy.
especially in urban centers, some males with the disorder may engage in
prostitution, which places them at a high risk for human immunodeficiency virus
(HIV) infection. Suicide attempts and Substance-Related Disorders are commonly
associated.
Children with Gender Identity Disorder may manifest coexisting Separation
Anxiety Disorder, Generalized Anxiety Disorder, and symptoms of depression.
Adolescents are particularly at risk for depression and suicidal ideation and
suicide attempts. In adults, anxiety and depressive symptoms may be present.
Some adult males have a history of Transvestic Fetishism as well as other
paraphilias. Associated Personality Disorders are more common among males than
among females being evaluated at adult gender clinics.
Associated laboratory findings.
There is no diagnostic test
specific for Gender Identity Disorder. In the presence of a normal physical
examination, karyotyping for sex chromosomes and sex hormone assays are usually
not indicated. Psychological testing may reveal cross-gender identification of
behavior patterns.
Associated physical examination findings and general medical
conditions.
Individuals with Gender Identity Disorder have normal
genitalia (in contrast to the ambiguous genitalia or hypogonadism found in
physical intersex conditions). Adolescents and adult males with Gender Identity
Disorder may show breast enlargement resulting from hormone ingestion, hair
denuding from temporary or permanent epilation, and other physical changes as a
result of procedures such as rhinoplasty or thyroid cartilage shaving (surgical
reduction of the Adam’s Apple). Distorted breasts or breast rashes may be
seen in
females who wear breast binders. Postsurical complications in genetic females
include prominent chest wall scars, and in generic males, vaginal strictures,
rectovaginal fistulas, urethral stenoses, and misdirected urinary streams. Adult
females with Gender Identity Disorder may have a higher than expected likelihood
of polycystic ovarian disease.
Specific Age and Gender Features
Females with Gender Identity Disorders generally experience less ostracism
because of cross-gender interests and may suffer less from peer rejection, at
least until adolescence. In child clinic samples, there are approximately five
boys for each girl referred with this disorder. In adult clinic samples, men
outnumber women by about two or three times. In children, the referral bias
towards males may partly reflect the greater stigma that gross-gender behavior
carries for boys than for girls.
Prevalence
There are no recent epidemiological studies to provide data on prevalence of
Gender Identity Disorder. Data from smaller countries in Europe with access to
total population statistics and referrals suggest that roughly 1 per 30,000
adult males and 1 per 100,000 adult females seek sex-reassignment surgery.
Course
For clinically referred children, onset of cross-gender interests and
activities is usually between ages 2 and 4 years, and some parents report that
their child has always had cross-gender interests. Only a very small number of
children with gender Identity Disorder will continue to have symptoms that meet
criteria for Gender Identity Disorder in later adolescence or adulthood.
Typically, children are referred around the time of school entry because of
parental concern that what they regarded as a phase does not appear to be
passing. Most children with Gender Identity Disorder display less overt
cross-gender behaviors with time, parental intervention, or response from peers.
By late adolescence or adulthood, about three-quarters of boys who had a
childhood history of Gender Identity Disorder report a homosexual or bisexual
orientation, but without concurrent Gender Identity Disorder. Most of the
remainder report a heterosexual orientation, also without concurrent Gender
Identity Disorder. The corresponding percentages for sexual orientation in girls
are not known. some adolescents may develop a clearer cross-gender
identification and request sex-reassignment surgery or may continue in a chronic
course of gender confusion or dysphoria.
In adult males, there are two different
courses for the development of Gender
Identity Disorder. The first is a continuation of Gender Identity Disorder that
had an onset in childhood or early adolescence. These individuals typically
present in late adolescence or adulthood. In the other course, the more overt
signs of cross-gender identification appear later and more gradually, with a
clinical presentation in early to mid-adulthood usually following, but sometimes
concurrent with, Transvestic Fetishism. The later-onset group may be more
fluctuating in the degree of cross-gender identification, more ambivalent about
sex-reassignment surgery, more likely to be sexually attracted to women, and
less likely to be satisfied after sex-reassignment surgery. Males with Gender
Identity disorder who are sexually attracted to males tend to present in
adolescence or early childhood with a lifelong history of gender dysphoria. In
contrast, those who are sexually attracted to females, to both males and
females, or to neither sex tend to present later and typically have a history of
Transvestic Fetishism. If Gender Identity Disorder is present in adulthood, it
tends to have a chronic course, but spontaneous remission has been reported.
Differential Diagnosis
Gender Identity disorder can be distinguished from simple
nonconformity to
stereo-typical sex role behavior by the extent and pervasiveness of the
cross-gender wishes, interests, and activities. This disorder is not meant to
describe a child’s nonconformity to stereotypic sex-role behavior as, for
example, in "tomboyishness" in girls or "sissyish" behavior in boys. Rather, it
represents a profound disturbance of the individual’s sense of identity with
regard to maleness or femaleness. Behavior in children that merely does not fit
the cultural stereotype of masculinity or femininity should not be given the
diagnosis unless the full syndrome is present, including marked distress or
impairment.
Transvestic Fetishism occurs in heterosexual (or bisexual) men for whom
the cross-dressing behavior is for the purpose of sexual excitement. Aside from
cross-dressing, most individuals with Transvestic Fetishism do not have a history
of childhood cross-gender behaviors. Males with presentation that meets full
criteria for Gender Identity Disorder as well as Transvestic Fetishism should be
given both diagnoses. If gender dysphoria is present in an individual with Transvestic
Fetishism but full criteria for Gender Identity Disorder are not met,
the specifier With Gender Dysphoria can be used.
The category Gender Identity Disorder Not Otherwise specified can be
used for individuals who have a gender identity problem with concurrent
congenital intersex condition (e.g., androgen insensitivity syndrome or
congenital adrenal hyperplasia).
In Schizophrenia, there may rarely be delusions of belonging to the other
sex. Insistence by a person with Gender Identity Disorder that he or she is of
the other sex is not considered a delusion, because what is invariably meant is
that the person feels like a member of the other sex rather than truly believes
that he or she is a member of the other sex. In very rare cases, however,
Schizophrenia and severe Gender Identity Disorder may coexist.
Diagnostic Criteria for Gender Identity Disorder
- 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:
- Repeatedly stated desire to be, or insistence that he or she is, the
other sex.
- In boys, preference for cross-dressing or simulating female attire; In
girls, insistence on wearing only stereotypical masculine clothing.
- Strong and persistent preferences for cross-sex roles in make believe
play or persistent fantasies of being the other sex.
- Intense desire to participate in the stereotypical games and pastimes of
the other sex.
- 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 or sense of
inappropriateness in the gender role of that 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 aversion toward
rough-and-tumble play and rejection of male stereotypical toys, games, and
activities.
In girls, 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 breasts or menstruate, or marked aversion toward normative
feminine clothing.
In adolescents and adults, the disturbance is manifested by symptoms such
as preoccupation with getting rid of primary and secondary sex characteristics
(e.g., request for hormones, surgery, or other procedures to physically alter
sexual characteristics to simulate the other sex) or belief that he or she was
born the wrong sex.
- C. The disturbance is not concurrent with physical intersex
condition.
- D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
302.6 Gender Identity Disorder Not Otherwise Specified
This category is included for coding disorders in gender identity that are
not classifiable as a specific Gender Identity Disorder. Examples include:
- Intersex conditions (e.g., androgen insensitivity syndrome or congenital
adrenal hyperplasia) and accompanying gender dysphoria
- Transient, stress-related cross-dressing behavior
- Persistent preoccupation with castration or penectomy without a desire to
acquire the sex characteristics of the other sex
Paraphilias
302.3 Transvestic Fetishism
The paraphiliac focus of Transvestic Fetishism involves cross-dressing.
Usually the male with Transvestic Fetishism keeps a collection of female clothes
that he intermittently uses to cross-dress. While cross dressed, he usually
masturbates, imagining himself to be both the male and the female object of his
sexual fantasy. This disorder has been described only in heterosexual males.
Transvestic Fetishism is to be diagnosed when cross-dressing occurs
exclusively during the course of Gender Identity Disorder.
Transvestic phenomena range from occasional solitary wearing of female
clothes to extensive involvement in a transvestic subculture. Some males wear a
single item of women's apparel (e.g., underwear or hosiery) under their
masculine attire. Other males with Transvestic Fetishism dress entirely as
females and wear makeup. The degree to which the cross-dressed individual
successfully appears to be a female varies, depending on mannerisms, body
habitus, and cross-dressing skill.
When not cross-dressed, the male with Transvestic Fetishism is usually
unremarkably masculine. Although his basic preference is heterosexual, he tends
to have few sexual partners and may have engaged in occasional homosexual acts.
An associated feature may be the presence of Sexual Masochism. The disorder
typically begins with cross-dressing in childhood or early adolescence. In many
cases, the cross-dressing is not done in public until adulthood. The initial
experience may involve partial or total cross-dressing; partial cross-dressing
often progresses to complete cross-dressing.
A favored article of clothing may become erotic in itself and may be used
habitually, first in masturbation and later in intercourse. In some individuals,
the motivation for cross-dressing may change over time, temporarily or
permanently, with sexual arousal in response to the cross-dressing diminishing
or disappearing. In such instances, the cross-dressing becomes an antidote to
anxiety or depression or contributes to a sense of peace and calm.
In other individuals, gender dysphoria may emerge, especially under
situational stress with or without symptoms of depression. For a small number of
individuals, the gender dysphoria becomes a fixed part of the clinical picture
and is accompanied by the desire to dress and live permanently as a female and
to seek hormonal or surgical reassignment. Individuals with Transvestic
Fetishism often seek treatment when gender dysphoria emerges. The subtype with
Gender Dysphoria is provided to allow the clinician to note the presence of
gender dysphoria as part of Tranvestic Fetishism.
Diagnostic Criteria for 302.3 Transvestic Fetishism
- A. Over a period of at least 6 months, in a heterosexual male, recurrent,
intense sexually arousing fantasies, sexual urges, or behaviors involving
cross-dressing.
- B. The fantasies, sexual urges, or behaviors cause clinically
significant distress or impairment in social, occupational, or other important areas of
functioning.
Specify if: With Gender Dysphoria: if the person has persistent
discomfort with gender role or identity.
|