Investigating Gender Identity Disorder & Transsexualism
March 8, 2009
This paper will focus on the diagnosis known as “Gender Identity Disorder” (GID), coded as 302.85 (in adolescents and adults), in the DSM-IV-TR. Gender identity disorder is defined as a strong and persistent feeling or desire to be the opposite gender from one’s birth gender, combined with a persistent discomfort associated with one’s genitals (DSM, 2000). Those diagnosed with gender identity disorder sometimes are also called “transsexual,” or “transgendered.” A diagnosis of GID is required for those wishing to make permanent surgical or medical transitions to the opposite gender (Istar Lev, 2004). To be diagnosed with this disorder, one must demonstrate the above two criterion, as well as clinically significant distress or impairment associated with one’s condition, as well as evidence that one’s gender dysphoria is not related to a physical intersex condition (in which genitalia of both genders or ambiguous genitals are present) (DSM, 2000).
Diagnostic Criteria for Gender Identity Disorder
The DSM-IV-TR (2000) describes four criteria that must be met for a diagnosis of Gender Identity Disorder. These include the following:
· “A strong and persistent cross-gender identification” (p. 581)
· Persistent discomfort with one’s sex-at-birth
· An intersex condition is not present
· Clinically significant distress or impairment is present in social, occupational, or other important areas of functioning
Historical & Political Examination
Throughout contemporary history, those people who exhibit traits or behavior outside society’s current norms have been considered not just different, but abnormal, and thus pathologizable. The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been the prevailing standard for determining mental health conditions and although supposedly based on scientific and statistical analysis, it has often been used as a political tool for social control (Istar Lev, 2004). Tarver (2002) supported this assertion when he said, “the persistence of classifying transgender identity or cross-dressing behavior as an aberrant mental disorder may be a result of negative social views rather than empirical justification” (p. 97). Gender identity disorder was introduced as a new pathological diagnosis in the third revision of the DSM, the same year that homosexuality was removed from the manual. In 2002, when Tarver wrote a chapter on transgender mental health, he stated that “psychiatric perceptions of transgender persons by American psychiatrists are remarkably parallel to those for gay men and lesbians before the declassification of homosexuality as a mental disorder in 1973” (Tarver, 2002, p. 106).
Because transgenderism is still classed as a gender identity disorder in the professional literature, many clinicians assume pathology in anyone presenting as transgendered. There is often an assumption that when a transgendered person seeks counseling, the cause or root of all their problems is related to their transgendered status. Sometimes, because of the DSM’s description of gender identity disorder, TGs may be misdiagnosed or wrongly pathologized. Hale (2008), in reviewing a book by Viviane Namaste, a Canadian transsexual activist, shared Namaste’s assertion that sometimes the focus on gender identity “obscures other critical issues” (p. 204). TGs may seek counseling for issues directly related to their transition or new identity, but sometimes they seek help for other aspects of their lives, and it is a mistake to assume that their transgenderism is at fault for all their difficulties.
It has also been shown that the oft-presented symptoms of dysphoria, depression, and suicidality may have less to do with an individual’s gender variance, per se, but instead may be related to the stress of living in a culture that either doesn’t recognize they exist, or when it does, stigmatizes, discriminates against, and victimizes them because of their gender variance. Many TGs have suffered further mental distress as a result of ignorant or non-compassionate clinicians who refuse to treat them or who insist on diagnosing them with gender identity disorder and then treating them from that assessment, as opposed to treating them for the concerns they present (Istar Lev, 2004). Wilson (1997, as cited in Istar Lev, 2004) said, “The psychiatric interpretations of inherent transgender pathology serves to attribute the consequences of prejudice to its victims, neglecting the true cause of distress” (p. 7).
Ethical and Multicultural Issues Associated with a Diagnosis of GID
The American Counselors Association Code of Ethics (2005) states in its introduction that “the primary responsibility of counselors is to respect the dignity and to promote the welfare of clients” (p. 10). Therefore, it seems to undermine a transgender client’s dignity and welfare to ignore their presenting concerns of depression, anxiety, or whatever, in favor of focusing on their transgender status as an explanation for their troubles. Counselors are also obligated to avoid doing harm (§A.4.a) and imposing their values on their clients (§A.4.b). Respecting diversity includes the diversity in gender expression and identity, and in fact the Code (ACA, 2005) covers this explicitly under the section on Nondiscrimination: “Counselors do not condone or engage in discrimination based on age, culture, disability, ethnicity, race, religion/spirituality, gender, gender identity, sexual orientation, marital status/partnership, language preference, socioeconomic status, or any basis proscribed by law” (§C.5, p. 20).
While there is some argument in favor of removing the diagnosis of gender identity disorder from the DSM altogether, there are some ethical and practical issues that need to be worked out first. For instance, although every person may have a right to determine their own gender expression, not everyone has the same decision-making capacity to determine the appropriateness of gender expression or sex reassignment surgery (Istar Lev, 2004). Young children, those with mental retardation, and those with a history of schizophrenia or traumatic abuse may not be able to give informed consent for sex reassignment surgery. Additionally, other people with various mental illnesses may not be good candidates for the invasive, life-changing experience of gender reassignment (Istar Lev, 2004). Further, gender dysphoria is sometimes one of the symptoms of another mental health disorder, and not associated with one’s being transgendered at all. Clinicians need to be able to recognize the difference and they need to be able to accurately diagnose when gender dysphoria is actually a problem.
The DSM does not indicate any multicultural issues to be aware of associated with this diagnosis. However, people who are transgendered as well as having an additional minority status pertaining to their race, ethnicity, age, or some other factor have additional mental health and discrimination challenges. “Many ethnic lesbians and gay men report that adjusting to being a double minority is much more difficult than being either an ethnic minority or a sexual minority” (Kimmel, 2002). Unfortunately, there is very little empirical research regarding multiple minority challenges for sexual minorities, and almost none for those who identify as transgender. Hernandez (2008) pointed out that there has been little attention paid to how transgendered people of color experience their transition, and how the issues of racism impacts their experience. “Trans people of color are finding that they have an extremely different relationship to gender transition than white people” (Hernandez, 2008, ¶ 11). Interestingly, many of the transmen of color that Hernandez interviewed found the gender transition a relatively smooth process because they were prepared for the various problems and challenges associated with transitioning, but they did not anticipate the problems they would encounter as black men.
Istar Lev (2004) also pointed out that the trauma experienced by gender-variant people is often increased when compounded by some other stigmatizing feature, such as race, class, or ethnic oppression. “Gender-variant people are commonly the victims of sexual and bias-related violence” (p. 198).
The Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders (2001) states that those who exhibit gender variance in other cultures are likely to behave differently, depending on the cultural context, and so clinicians must be alert to the cultural differences in their transgendered clients. The Standards go on to point out that, “While in most countries, crossing gender boundaries usually generates moral censure rather than compassion, there are striking examples in certain cultures of cross-gendered behaviors (e.g., in spiritual leaders) that are not stigmatized” (p. 3).
Case Study: Roxanna/Robert*
Client Demographic & Descriptive Data
Roxanna/Robert is a 24 year old Black college graduate, with a degree in computer information technology, who works for a small start-up company, where s/he is the sole Information Technology specialist. Roxanna/Robert is unmarried, but has been in relationship with another woman for three years, and neither have any children. Roxanna/Robert is quite involved in hir local LGBT (lesbian, gay, bisexual, transgendered) community, and participates in activism activities. S/he also participates in “Drag King” shows, which are performances by male-impersonators (women who can “pass” as male and perform convincingly in that masculine persona). S/he has an extensive network of friends within this community, but few outside it. S/he is estranged from hir family, except for hir brother, and most of hir childhood friends, although s/he does have one childhood friend s/he considers very close.
Family & Social History
Roxanna/Robert is the youngest of three siblings. Hir older sister lives in another state, and rarely speaks with hir, but hir older brother (who is only a year and a half older than Roxanna/Robert) lives in the same town and regularly spends social time with hir. Roxanna/Robert reports him as the only supportive member of hir family, and remembers spending quite a bit of time tagging along behind hir brother and his friends while growing up. Roxanna/Robert’s parents have refused to speak to hir since s/he came out as lesbian to them four years prior.
Growing up, hir family was considered middle-class, and they lived in a predominantly White neighborhood. Roxanna/Robert reports that s/he felt alienated amongst female classmates and disliked many of the things the rest of the girls were interested in. At 14, s/he joined a local girls’ softball team, where s/he was able to make friends with other girls who rejected “girl-ish” things. S/he refused to wear dresses most of hir childhood and adolescence, cut hir hair very short and resisted attempts to get hir to wear make-up. Because hir older sister and mother were “quintessential ladies,” in hir words, they couldn’t understand Roxanna/Robert’s rejection of pretty things. S/he preferred to play rough and tumble games with hir brother and his friends and excelled in the more “male” subjects in school, like math, science, shop, and Phys Ed.
Complete Presenting Problem & Symptoms
Roxanna/Robert has come to therapy because s/he has “finally figured out what’s wrong with me.” In the course of hir activism work within the LGBT community, Roxanna/Robert has been exposed to a number of transgendered individuals, and s/he has come to believe that s/he, too, is actually transgendered. S/he wishes to be evaluated for GID, so that s/he may qualify for “top surgery” to reduce or remove hir breasts, and for hormone therapy, so that s/he may begin developing secondary male characteristics.
When asked why s/he feels that s/he is transgendered, Roxanna/Robert describes how s/he has never felt comfortable in hir female body. S/he cites hir dress preferences, hir aversion to long hair and make-up, hir desired playmates and style of play as a child. S/he also describes how s/he used to try to bind hir breasts when they first started manifesting. S/he detests hir menstrual period and swears s/he never wants to become pregnant; in fact, s/he has considered a full hysterectomy to ensure s/he never gets pregnant, and to cease menstruating altogether. S/he has often fantasized about what it would be like to be male and to have male genitalia. Roxanna/Robert also relates the reason s/he is in the field and particular job s/he’s in is due to the fact that “IT geeks are more accepting of people who are different” and being the only person in hir department means s/he doesn’t have to try to fit in with work peers.
Complete 5 Axis Diagnosis, Client Map, & Treatment Plan for Roxanna/Robert
Axis I: 302.85 Gender Identity Disorder in Adolescents or Adults, Sexually Attracted to Females
Roxanna/Robert meets the criteria for GID: strong and persistent cross-gender identification since childhood; persistent discomfort with current sex; disturbance is not concurrent with intersex condition; clinically significant distress present in social and occupational areas of functioning.
Axis II: V71.09 None present
Axis III: None – however, physical examination reveals normal genitalia (no intersex condition present)
Axis IV: Problems with primary support group (family estranged); Occupational problems (feels s/he needs to be in isolated office, due to fears of rejection by work peers)
Axis V: GAF = 58 (current)
Roxanna/Robert does have several friends and a long-term partner, but s/he has difficulty making friends outside of the LGBT community and s/he is estranged from most members of hir family. S/he has also constrained/restricted hirself in hir work environments due to fear of social rejection.
Objectives of Treatment
According to the Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders (2001), “The general goal of psychotherapeutic, endocrine, or surgical therapy for persons with gender identity disorders is lasting personal comfort with the gendered self in order to maximize overall psychological well-being and self-fulfillment” (p. 1). According to Istar Lev (2004), “The goal of therapy is to assist the client in greater self-knowledge so he or s/he can make informed decisions about his or her gender expression, self-identity, body configuration, and ultimate direction of his or her life” (p. 171). Seligman (2005) said that “promoting adjustment or helping people make decisions about biological treatment are usually more viable goals than eliminating the symptoms of GID” (p. 293).
Since Roxanna/Robert is not presenting with depression, or other comorbid disorders, the primary objective will be assisting hir in deciding whether the permanent, irreversible step of sex reassignment surgery and hormone therapy is right for hir. Additionally, it may be necessary to assist Roxanna/Robert in coping with hir fears and anxieties regarding interacting with people outside of the LGBT community. Finally, the process of transition is quite stressful, and Roxanna/Robert will need support before, during, and after his transition.
Roxanna/Robert is between the second and fourth stages of transgender emergence (which is equivalent to the homosexual coming out process), as defined by Istar Lev (2004), the second of which includes the two primary goals of seeking information and reaching out to others. The therapeutic goals of this stage include providing education about gender-variance and options for dealing with it, and helping the client connect with others who are gender-variant. Stage three involves disclosure to significant others, and the therapist must emotionally support both the client and the client’s partner and family, without taking sides. Stage four is associated with exploring identity and transition, and the therapist’s goal here is to assist the client in this exploration of their identity and then help the client integrate their transgendered identity into their overall sense of self. The therapist may also be called on to be an advocate for the client during this time, as employment, school, and relationship issues often become quite challenging.
There are no psychological tests available that can differentiate between gender-variant people and those who are not gender-variant (Istar Lev, 2004). The process of determining if someone qualifies for this diagnosis is through assessment interviews and comparing to the DSM’s diagnostic criteria, or through self-report, with supporting evidence.
It is advisable to administer a suicide assessment to anyone self-reporting as transgendered, as the stress of daily living with this stigma is significant, and up to 2% of those who self-identify as transgendered attempt suicide (Istar Lev, 2004).
It is sometimes complicated to differentiate between symptoms and sequelae of mental illness in gender-variant people. Istar Lev (2004) reminds us that “it is important when working with people with active mental illnesses to examine how gender issues and mental illnesses have become entwined in the etiology, treatment, or self-understanding of mental illness” (p. 195). In Roxanna/Robert’s case, no comorbid mental illness seems to be present.
Clinicians desiring to work with transgendered clients must have a thorough understanding of the identity development process experienced by transgendered people, as well as familiarity with the types and effects of discrimination faced by this population. The clinician must have already dealt with any transphobia and other negative personal views and values pertaining to transgenderism. A safe, supportive, compassionate atmosphere is required. Transgendered clients “need a therapist who is able to offer compassion, education, and resources as the clients explore the gender needs and future options, as well as assess for other mental health difficulties” (Istar Lev, 2004, p. 207).
It will be sufficient to conduct therapy in an outpatient setting, in the clinician’s office.
Narrative therapy to help client discover words and ways of describing himself in ways that are congruent with his self-concept (Istar Lev, 2004).
Education regarding effects of hormones and surgery on life and relationships.
Assist client through transition process, including real-life experience (living entire life as new gender), employment challenges, family and partner issues
Possibly cognitive restructuring, to challenge any internalized transphobia
Anxiety management and social skills training
Emphasis of Treatment
Supportive, non-directive, educational, co-collaborative
Individual therapy, couples therapy (to help the client’s partner understand and support the transition process), group therapy
One hour per week
Refer for hormonal therapy, after decision is reached with client that this is appropriate
Support groups online and in person
Very little research exists on the efficacy of treatment of Gender Identity Disorder. In general, studies have focused on the outcome of clients who have undergone sex reassignment surgery, and most of these have found that a majority of people who have the surgery are satisfied with the results (Seligman, 2005). Those who have comorbid mental health disorders are less likely to have positive or satisfying outcomes, but in the case of Roxanna/Robert, this is not a concern, as s/he has not exhibited additional disorders. Those who go through a gender transition will continue to have challenges and may often suffer from the ignorance and stigmatization of the society in which they live, possibly requiring long-term care and support. However, as Istar Lev (2004) said,
a knowledgeable and compassionate gender therapist can assist in an active depathologizing of the emotional vortex of gender variance, gender exploration, and gender transition, and can, through the process of dialogue and empowerment, support the person in authentic reauthoring of his or her life experiences (p. 228).
American Counseling Association. (2005). Code of ethics. In Codes of Ethics for the Helping Professional (3rd ed.). Belmont, CA: Thomson Brooks/Cole.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Arlington, VA: APA.
Hale, C. J. (2008). [Review of the book Sex change, social change: Reflections on identity, institutions, and imperialism]. Hypatia, 23(1). 204-207.
Harry Benjamin International Gender Dysphoria Association. (2001). Standards of care for gender identity disorders, sixth version. Retrieved March 5, 2009, from http://www.wpath.org/Documents2/socv6.pdf
Hernandez, D. (2008). Becoming a black man. AlterNet. Retrieved November 22, 2008, from http://www.alternet.org/module/printversion76384
Istar Lev, A. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Philadelphia, PA: Haworth Press.
Kimmel, D.C. (2002). Aging and sexual orientation. In Jones, B.E., & Hill, M. (2002). Mental health issues in lesbian, gay, bisexual, and transgender communities (pp. 17-35). Arlington, VA: American Psychiatric Publishing.
Seligman, L. (2005). Principles of psychopathology diagnosis and treatment. Hoboken, NJ: John Wiley & Sons, Inc.Tarver, D. E. (2002). Transgender mental health: The intersection of race, sexual orientation, and gender identity. In Jones, B.E., & Hill, M. (2002). Mental health issues in lesbian, gay, bisexual, and transgender communities (pp. 93-108). Arlington, VA: American Psychiatric Publishing.
* Note regarding name and pronoun usage: It is appropriate to refer to a transgender person using the name and gendered pronoun consistent with their gender presentation. Roxanna/Robert’s appearance is androgynous in nature, and out of respect for the reality that s/he is in the process of determining hir preferred gender presentation, this paper will refer to hir with the combined name (hir given name and the name s/he is considering adopting to reflect her male gender expression), and with the more gender neutral pronouns of “s/he” and “hir”.