Gender Identity Disorders

Some people assert a gender identity that is at odds with their anatomy and genetic traits. The American Psychiatric Association (APA) treats some of those people as suffering from gender identity disorder (GID). GID sometimes is called gender dysphoria, and it occurs in children, adolescents, and adults. According to the APA, people with this disorder are characterized by a "strong and persistent cross-gender indentification" (American Psychiatric Association, 2000, p. 581).

This preoccupation is said to pass into the pathological when there is strong and persistent cross-gender identification and clinically significant distress or impairment in social, occupation, or other important areas of function. The diagnosis is not applied to persons with cross-gender identification who have intersex conditions. To some extent gender identity disorder replaces what previously has been treated as transsexualism, a term that came into use in the 1940s. Although some commentators still use that term, transgenderism and cross-gendered identities have come into common use.

The prevalence of cross-gender identities has been poorly studied. There have been no studies of prevalence in the United States, although there have been some studies in smaller countries. According to those studies, cross-gender identities occur in 1 in 30,000 adult males and 1 in 30,000 adult females (American Psychiatric Association, 2000). There are various theories about why some people come to have cross-gender identities, although no single theory is accepted as conclusive. Researchers have explored prenatal hormonal exposure, birth order, genetics, brain structure, and various psychological and social learning theories (Green and Blanchard; Devor). Whatever the origins of cross-gender identification are, there is a general pattern of development: People have a sense of dissatisfaction with their sex characteristics and assigned gender, conclude that that dissatisfaction would be alleviated by change and therefore pursue varying degrees of reassignment (Devor).

Adults with cross-gender identities differ in regard to expectations from medicine and how far they want to conform their bodies to a particular gender (McCloskey).

Not everyone wants to assume every male or female trait. Transgendered men may elect to have testosterone treatment, excision of the breasts and genitals, reduction in thyroid cartilage to minimize the Adam's apple, and the construction of a vagina. Transgendered women may elect to have estrogen treatment, electrolysis of unwanted hair, and the construction of male genitalia. However, some transgendered people continue to value aspects of their originally assigned sex and want to keep them even as they add other transfomations. Also, not all instances of cross-dressing or atypical gender expression represent cross-gender identities. Some men and women cross-dress for sexual reasons; this phenomenon is known in psychiatry as transvestism. In these instances there is no discordance between one's biological traits and one's desired gender identity. The issue here is gender expression rather than identity.

There are no specific clinical or psychological tests to diagnose cross-gendered identities; the diagnosis is made on the basis of the case presentation. Moreover, there are no pharmaceutical or surgical treatments for this condition. Generally, behavioral or psychosocial treatments are used to orient a person to a gender identity; no hormonal or pharmacological treatments are known. Some studies have shown that cross-gender identification can be reduced in children through a variety of psychological and social interventions (Green). Advocates of treatment with children focus their interventions on helping children become content with their birth sex. They counsel, for example, that "young children should be taught that sex is irreversible" (Green and Blanchard, p. 1658).

Some practitioners justify therapy for children to alleviate the distress associated with cross-gender identities and behaviors and prevent the emergence of a homosexual orientation in adolescence and adulthood (Rosen et al.). Critics have contested both of those goals. In 1996 the Human Rights Commission of the City and County of San Francisco condemned the use of the diagnosis of GID. According to that group, the diagnosis of GID in children is used to screen for homosexuality and stigmatize gender nonconformity. Others have defended the use of the diagnosis and therapy: "Whether or not someone else agrees, parents have the legal right to bring a child for therapy to modify behavior they disapprove of and with the goal of preventing a later behavior of which they disapprove" (Green and Blanchard, p. 1659). Those commentators compare this option to parents' rights with respect to their children's education, religion, and diet.

Parents have a prima facie right to choose on behalf of their children, but that right is tempered by the moral right of children to be protected from undue risk and useless treatments. For reasons of beneficence parents should not use therapies that bring more harm than good to their children. Medical ethics also recognizes that maturing adolescents deserve a degree of choice in regard to birth control practices, psychiatric treatment, and involvement in research even when those choices conflict with parental wishes. Gender therapies for maturing adolescents require much stronger justifications than do those undertaken with much younger children.

Harry Benjamin holds a central place in the scientific study of transsexualism or transgenderism. Benjamin was a German national who immigrated to the United States and published The Transsexual Phenomenon in 1966. In that book he offered the first comprehensive treatment guide for transsexuals. In late 1970s a group of healthcare professionals codified his approach in the Harry Benjamin Standards of Care. Among other things, those rules require that people who seek gender interventions:

1. obtain a diagnosis of gender disorder;

2. begin a relationship with a therapist;

3. receive hormone therapy;

4. live as cross-dressed for a sustained period; and

5. after therapists authorize it, receive desired surgical interventions (Harry Benjamin International Gender Dysphoria Association).

These standards are observed widely in professional relationships with transgendered people. However, some commentators believe that the standards are paternalistic in the sense that they represent a degree of control over medical interventions that is not required elsewhere, for example, in cosmetic surgeries.

Transgender therapy has important implications for a person's social and legal status. The physician and tennis player Renee Richards, formerly Richard, gained the right to play in women's professional tennis as a transgendered woman (Richards). Other transgendered men and women have not been as successful in finding accommodation in society and the law. Individuals who undergo transgender therapy often face legal difficulties insofar as they may violate laws regarding cross-dressing and the use of public washrooms. Those people are sometimes restricted in their right to marry and have children. Prison housing also raises special problems because transgendered persons are especially vulnerable to mistreatment and violence. Some jurisdictions have adopted laws that prohibit discrimination against people having or being perceived as having a self-image or identity not traditionally associated with one's biological sex. Most jurisdictions have no such laws.

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