Diagnosis Critical in Adolescent Gender Dysphoria

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.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley

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.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley

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.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley