In Birdy's Eyes:

Gender Identity Disorder

Date: 1980 forward

Psychopathology

Gender identity disorder is the diagnosis for individuals who are highly uncomfortable with the sex of their bodies and who wish to behave, think, and be members of the opposite sex. This diagnosis is the subject of considerable controversy among psychiatrists. The causes for this disorder remain speculative, and treatment typically aims to diminish associated symptoms of anxiety, depression, or other social interactional difficulties. In severe cases, psychiatrists may recommend sex changes.

Introduction To The Issue:

Gender identity disorder is an artifact of psychiatric politics in the 1970’s and 1980’s. To understand this diagnosis and contemporary debates, some awareness of the past is essential. The American Psychiatric Association (APA), one of the major professional organizations for medical practitioners and therapists dealing with mental health, was the obvious organizational choice when there was a need to create a list of mental illnesses to provide some unity of medical diagnoses across the United States. The early Diagnostic and Statistical Manual of Mental Disorders (1952, DSM) and the second edition, published in 1968, provided brief definitions of psychiatric ailments, although they typically lacked clear diagnostic criteria, posing dilemmas for practitioners.

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During the 1950’s and 1960’s, American psychiatrists were strongly influenced by the Austrian psychologist Sigmund Freud, who popularized psychoanalysis. Freud’s work encouraged the view that adult mental maladies often were the result of stunted or misdirected sexual desires in childhood. This emphasis on the importance of sexuality meant that psychiatrists paid a tremendous amount of attention to activities in the nation’s bedrooms, although little research data supported many contentions about sexual practices.

One of the early outcomes of this history was that the first edition of the manual listed homosexuality as a sociopathic personality disturbance and the second edition moved it into the category of non-psychotic mental ailments, including a variety of other supposedly unhealthy sexual practices. Some psychiatrists argue that this inclusion of homosexuality paved the way for the later conceptualized gender identity disorder, while others would dispute this contention. Certainly, many of the same objections to the earlier inclusion of homosexuality as a mental illness also plague later supporters of gender identity disorder. For this reason, it is important to revisit some of this early history.

During the 1950’s and 1960’s, research evidence provided some challenges to the view that homosexuality was a mental illness. Sexual researcher Alfred Kinsey of Indiana University demonstrated that homosexual behavior was more common in the general population than typically recognized. Evelyn Hooker, who conducted research in the psychology department at the University of California, Los Angeles, and worked with homosexual individuals from outside therapeutic groups, showed that they displayed the same range of mental health issues as members of the general non-homosexual population. In addition, cross-cultural anthropologists wrote about other societies with very different understandings of mental illness and sexuality, casting doubt on the universality and applicability of American beliefs and norms about mental well-being and sexual behaviors. These findings suggested that homosexuality might not be a mental illness, in direct opposition to the information published by the APA. Increasingly, organization members were challenged on this issue, and several association annual conferences in the early 1970’s were disrupted by protests, fueled by the growth of civil rights and gay rights activism. By this time, the Association of Gay and Lesbian.

Psychiatrists (AGLP), informally founded in the late 1960’s, was also active within the ranks of the APA, contributing to the impetus for change. Eventually after considerable internal dispute and political maneuvering, in 1973, the Board of Trustees of the APA (followed by the full membership in 1974) agreed to remove homosexuality from the list of mental illnesses in the next edition of the DSM. This history assists in understanding contemporary disputes about gender identity disorder.

Causes and Diagnostic Criteria

The term “gender identity disorder” was first included in the DSM-III (1980) and appeared in the fourth edition in 1994 and the fourth revised edition in 2000, with its operational definition. An individual suffering from gender identity disorder was a person who felt strongly that he or she was living in an incorrectly sexed body. For example, boys or men would feel their gender, behavior, and feelings were feminine, and their physique should be female to reflect this identity, while girls or women would feel the opposite.

Despite the fact that gender identity disorder has been considered to be a problem for both adults and children for several decades, there are limited data about causation. It has been suggested that biology may play a role, with possible proposals including intrauterine development of the fetus and hormonal influences. Other hypotheses uphold cultural influences, with parental behavior, socialization by peers, or the presence of other social norms providing a causal link. Most likely, the answer lies in some combination of these or other factors.

Although the causes of gender identity disorder remain unclear, distinct diagnostic criteria are presented in the fourth revised edition of the manual. The diagnosis requires the presence of a minimum of four behaviors or beliefs, all of which must be strongly expressed on a variety of occasions over some time period. The criteria include identification with a different sex, cross-dressing, occupying cross-sex roles while playing or daydreaming, stating the strongly expressed goal to perform as the other sex, and expressing the desire to play or interact with members of the different sex, or live as a member of the opposite sex. In addition, individuals are distressed by the presence of their female or male external genitalia and secondary sexual characteristics, such as breasts. Generally, they do not want to behave according to the norms of their socially ascribed gender, and their reactions are not simply based on awareness of gender inequities in society, but on strong feelings of revulsion for the sex of their bodies. These individuals are not physically inter sexed, and their sense of distress is so strong that they function poorly in their daily lives.

Problems with the Diagnosis and Treatment Options

Several different concerns have been expressed about applying a diagnosis of gender identity disorder. One issue is that gender identity disorder is not diagnosed in the same manner internationally, and if it is assumed that all human minds operate in a similar manner, this is problematic. In addition, the history of the APA and the battles over homosexuality foreshadow many of the current debates over gender identity disorder. Certainly, the pathologization of cross-dressing, transgender, and transsexual community members is in striking opposition to greater knowledge about gender and sexual diversity around the world, the relaxing of sexual norms in the United States, and an increasingly activist and rights-conscious society. For these reasons, the diagnosis of gender identity disorder and its inclusion in the APA’s manual is not accepted by all of the association’s members, mental health workers, or members of the general public.

Additional questions surround the practice of applying the diagnosis of gender identity disorder to children. One issue is that some individuals may be diagnosed as gender identity disordered when in fact they are merely expressing their dissatisfaction with contemporary gender inequities, and desiring to behave and be treated in the manner accorded to the more dominant sex. This issue would most likely pertain more to girls. Another development is that girls seem to be diagnosed with gender identity disorder at lower rates than boys, and the underlying reason is unclear. It may relate to hormonal or other factors of the ailment, or it may relate to social comfort with girls cross-dressing and demonstrating “tough boy” behavior. This gender difference in the disorder has been used by some social scientists to argue that gender identity disorder is more a function of American culture rather than a real mental illness.

People who are comfortable with their experiences cross-dressing or "transgendering," and who live in locations where others are comfortable with their identities are unlikely to seek help from psychiatrists. It is those adults who are uncomfortable with their cross-gender identities and their inability to fit social expectations who often feel depression or anxiety, and consequently may seek treatment at clinical outpatient facilities. Gender identity disorder can feel overwhelmingly difficult for people. In these cases, initially, the accompanying anxiety or depression may be treated, possibly by pharmaceutical interventions in combination with talk therapies. The type of treatment will vary depending on the patient’s symptoms. A similar treatment trajectory is often experienced by children or adolescents, although in their cases, parental intervention may play a greater role in moving them into treatment.

Once some of the accompanying issues are under control, individuals may then become more comfortable with their sex and gender disjunction. If this does not occur, people may request psychiatric and medical assistance in changing their bodies and becoming transsexuals. This is a slow process, with individuals first living as the opposite sex for a period of time, often with hormonal prescriptions helping them look more like their desired sex. Ultimately, with medical approval, they may be offered sex change surgeries of various kinds, which allow them to live permanently as the opposite sex.

Sources for Further Study

Bartlett, Nancy H., et al. “Is Gender Identity Disorder in Children a Mental Disorder?” Sex Roles 43, nos. 11/12 (December, 2000): 753-785. Consideration of gender identity disorder and its diagnosis in children.

Bayer, Ronald. Homosexuality and American Psychiatry: The Politics of Diagnosis. Princeton, N.J.: Princeton University Press, 1987. Discussion of the 1970’s disputes among members of the American Psychiatric Association, which can be argued to underlie the creation of the diagnosis of gender identity disorder in DSM-III.

Besnier, Niko. “Polynesian Gender Liminality Through Time and Space.” In Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History, edited by Gilbert Herdt. New York: Zone Books, 1993. Provides cross-cultural data on gender and sexuality that suggests that the diagnosis of gender identity disorder may be a product of specific cultural, geographic, and temporal conditions, rather than a psychiatric illness identifiable in all social groups. Other chapters in the volume contribute to this theme.

Giordano, Simona. “Gender Atypical Organization in Children and Adolescents: Ethico-Legal Issues and a Proposal for New Guidelines.” International Journal of Children’s Rights 15, nos. 3/4 (July, 2007): 365-390. Consideration of gender identity disorder in youth, ethics, legal rights, and a comparison of the situation in the United Kingdom with the United States.

McHugh, Paul R., et al. The Perspectives of Psychiatry. 2d ed. Baltimore: Johns Hopkins University Press, 1998. History of psychiatry, with information about how disorders are conceptualized and researched.

Wilson, Mitchell. “DSM-III and the Transformation of American Psychiatry: A History.” American Journal of Psychiatry 150, no. 3 (March, 1993): 399-410. History of the DSM and the conceptualizations underlying new editions.

Zucker, Kenneth J. “Commentary on Langer and Martin’s 2004 ’How Dresses Can Make You Mentally Ill: Examining Gender Identity Disorder in Children.’” Child and Adolescent Social Work Journal 23, nos. 5/6 (December, 2006): 533-555. Detailed discussion about gender differences in the diagnosis of gender identity disorder, including the history of the disorder.

-Birdy

[With so many different projects going on, I am finding it increasing difficult to write on this Blog, thus my other projects will also be posted here, though in a jumbled mess, as my thought process is becoming...  Enjoy the reading, and until next time...]