HOUSTON — Most adolescents with gender identity issues initially are treated for comorbid conditions such as depression, Flynn O'Malley, Ph.D., said at the annual meeting of the American Society for Adolescent Psychiatry.
Managing adolescents with gender issues includes treating the comorbid conditions (if any) first, and then educating the patient about the realities of a sex change.
The clinician can help the adolescent develop a plan for life as a person of the opposite gender after his/her sex change treatment, and can assess family support and encourage discussion of the family's discomfort with the adolescent's transgendered feelings. A patient who expresses a desire for a sex change must be thoroughly assessed to determine whether he or she meets the DSM-IV criteria for gender identity disorder (GID) and shows commitment to the sex change process.
The problems faced by an adolescent with a gender issue include a personal struggle with his or her identity; fear of rejection, attack, or humiliation; a desire to keep gender preference a secret; concern about parental reaction; problems in school and community settings; and the wide range of professional attitudes about treatment, said Dr. O'Malley of Baylor College of Medicine, Houston. Dr. O'Malley, also of the Menninger Clinic, an inpatient facility in Houston for adolescents with unremitting psychiatric problems, reported no conflicts of interest related to his talk.
Many patients with gender issues also have mood disorders, substance abuse disorders, serious family problems, and a history of multiple suicide attempts, Dr. O'Malley said. In addition, many patients have a history of failure to improve or to regress after some improvement.
Suicidality, self-harm, and thought disorders may all occur in the context of gender dysphoria, Dr. O'Malley noted. Some patients reveal the gender dysphoria as part of their psychiatric treatment course; many report a history of sexual abuse. It is tempting to link gender dysphoria to sexual abuse, but the etiology of gender dysphoria is extremely complex.
“If gender dysphoria started early, whatever sexual experiences teenagers have had have been awkward and confusing for them,” Dr. O'Malley said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas.
Adolescents come to the Menninger Clinic in varying stages of intervention. Some have not identified their gender issues; others are already taking hormones. “There is enormous controversy when we admit someone with these difficulties,” he added.
Some adolescents with gender dysphoria are confused about their gender problems, while others are adamant that they are transsexuals and insist on treatment that would facilitate a sex change.
A controversy persists between professionals who support psychodynamic therapy and those who back sex reassignment. Careful diagnosis is important. Intersex conditions such as chromosomal abnormalities, pseudohermaphroditism, and enzyme deficiencies should not be confused with gender identity disorders. Intersex conditions, which arise from developmental problems with sexual differentiation, have clear physiologic and biologic aspects. People with those conditions may or may not suffer from psychiatric problems. In contrast, transgender patients do not have ambiguous genitalia or physical inconsistencies related to sex at birth.
Criteria for a GID diagnosis include a persistent, strong identification with the opposite gender, persistent discomfort with one's sex, and feelings of inappropriateness in the gender role for one's sex. To meet the GID diagnosis, these characteristics must not be concurrent with an intersex condition and must cause significant distress and impairment in important areas of everyday life.
Subcriteria for a GID diagnosis in children include repudiation of the genitals among young boys and preference for a penis among young girls. GID is categorized in the DSM-IV under Sexual and Gender Identity Disorders, not Psychosexual Disorders, which suggests something about the etiology of the disorders, Dr. O'Malley noted.
Transvestitism differs from gender dysphoria because it involves a feeling of sexual arousal created by putting on the clothes of the opposite sex. In dual-role transvestitism, the person dresses in the clothes of the opposite sex to feel like a person of the opposite sex for a while—with no desire for a permanent change.
Some relationship appears to exist between childhood gender identity disorder and adolescent transsexuality. However, many children who cross-dress and exhibit gender issues at an early age do not become adolescent gender dysphoric patients or undergo sex change procedures, Dr. O'Malley said. Most children who meet the diagnosis for GID become transsexuals, and early cross-gender behavior often leads to homosexuality.
Transgender Terminology
Although no consensus exists for these definitions, they can be useful when talking to adolescents with gender issues.
▸ Sex: biologic maleness or femaleness.