STANDARDS OF CARE.

The hormonal and surgical sex reassignment of gender dysphoric persons

Original draft prepared by: The founding committee of the Harry Benjamin International Gender Dysphoria Association, Inc.

Paul A. Walker, Ph.D. (Chairperson)
Jack C. Berger, MD.
Richard Green, MD.
Donald R. Laub, M.D.
Charles L. Reynolds, Jr., M.D.
Leo Wollman, M.D.

Original draft approved by: The attendees of the Sixth International Gender Dysphoria Symposium, San Diego CA February, 1979

Revised draft (1/80) approved by: The majority of the membership of the Harry Benjamin International Gender Dysphoria Association, Inc. (1/80)

Revised draft (3/81) approved by: The majority of the membership of the Harry Benjamin International Gender Dysphoria Association, Inc. (3/81)

Revised draft (1/90) approved by: The majority of the membership of the Harry Benjamin International Gender Dysphoria Association, Inc (1/90)

Distributed by The Harry Benjamin International Gender Dysphoria Association, Inc.

Standards of Care: The Hormonal and surgical sex reassignment of gender dysphoric persons

l. Introduction

As of the beginning of 1979, an undocumentable estimate of the number of adult Americans hormonally and surgically sex-reassigned ranged from 3,000 to 6000. Also undocumentable is the estimate that between 30,000 and 60,000 U.S.A. citizens consider themselves to be valid candidates for sex reassignment. World estimates are not available. As of mid-1978, approximately 40 centers in the Western hemisphere offered surgical sex reassignment to persons having a multiplicity of behavior diagnoses applied under a multiplicity of criteria.

In recent decades, the demand for sex reassignment has increased as have the number and variety of possible psychologic, hormonal and surgical treatments. The rationale upon which such treatments are offered have become more and more complex. Varied philosophies of appropriate care have been suggested by various professionals identified as experts on the topic of gender identity. However, until the present, no statement of the standard of care to be offered to gender dysphoric patients (sex reassignment applicants) has received official sanction by any identifiable professional group. The present document is designed to fill that void.

2. Statement of Purpose

Harry Benjamin International Gender Dysphoria Association, Inc., presents the following as its explicit statement on the appropriate standards of care to be offered to applicants for hormonal and surgical sex reassignment.

3. Definitions

3.1 Standard of care.

The standards of care, as listed below, are minimal requirements and are not to be construed as optimal standards of care. It is recommended that professionals involved in the management of sex reassignment cases use the following as minimal criteria for evaluation of their work. It should be noted that some experts on gender identity recommended that the reasons for any exceptions to these standards, in the management of any individual case, be very carefully documented. Professional opinions differ regarding the permissibility of, and the circumstances warranting, any such exception.

3.2 Hormonal sex reassignment.

Hormonal sex reassignment refers to the administration of androgens to genotypic and phenotypic females, and the administration of estrogens and/or progesterones to genotypic and phenotypic males, for the purpose of effecting somatic changes in order for the patient to more closely approximate the physical appearance of the genotypically other sex. Hormonal sex reassignment does not refer to the administration of hormones for the purpose of medical care and/or research conducted for the treatment or study of non-gender dysphoric medical conditions (e.g., aplastic anemia, impotence, cancer, etc.).

3.3 Surgical sex reassignment.

Genital surgical sex reassignment refers to surgery of the genitalia and/or breasts performed for the purpose of altering the morphology in order to approximate the physical appearance of the genetically-other sex in persons diagnosed as gender dysphoric. Such surgical procedures as mastectomy, reduction mammoplasty, hysterectomy, salpingectomy, vaginectomy, oophorectomy and phalloplasty in the absence of any diagnosable birth defect or other medically defined pathology except gender dysphoria, are included in this category labeled surgical sex reassignment.

Non-genital surgical sex reassignment refers to any and all other surgical procedures of non-genital, or non-breast sites (nose, throat, chin, cheek hips, etc.) conducted for the purpose of effecting a more masculine appearance in a genetic female or for the purpose of effecting a more feminine appearance in a genetic male, in the absence of identifiable pathology which would warrant such surgery regardless of the patient's genetic sex (facial injuries, hermaphroditism, etc.).

3.4 Gender Dysphoria.

Gender Dysphoria herein refers to the psychological state whereby a person demonstrates dissatisfaction with their sex of birth and the sex role, as socially defined, which applies to that sex, and who requests hormonal and surgical sex reassignment or reannouncement. Gender dysphoria, herein, does not refer to cases of infant sex reassignment or reannouncement. Gender dysphoria, therefore, is the primary working diagnosis applied to any and all persons requesting surgical and hormonal sex reassignment.

3.5 Clinical behavioral scientist.*

Possession of an academic degree in a behavioral science does not necessarily attest to the possession of sufficient training or competence to conduct psychotherapy, psychologic counseling, nor diagnosis of gender identity problems. Persons recommending sex reassignment surgery or hormone therapy should have documented training and experience in the diagnosis of a broad range of psychologic conditions. Licensure or certification as a psychological therapist or counselor does not necessarily attest to competence in sex therapy. Persons recommending sex reassignment surgery or hormone therapy should have the documented training and experience to diagnose and treat a broad range of sexual conditions. Certification in sex therapy or counseling does not necessarily attest to competence in the diagnosis and treatment of gender identity conditions or disorders. Persons recommending sex reassignment surgery or hormone therapy should have proven competence in general psychotherapy, sex therapy, and gender counseling/therapy.

Any and all recommendations for sex reassignment surgery and hormone therapy should be made only by clinical behavioral scientists possessing the following minimal documentable credentials and expertise:

3.5.1

A minimum of a Masters Degree in a clinical behavioral science, granted by an institution of education accredited by a national or regional accrediting board.

3.5.2

One recommendation, of the two required for sex reassignment surgery, must be made by a person possessing a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.) in a clinical behavioral science, granted by an institution of education accredited by a national or regional accrediting board.

3.5.3

Demonstrated competence in psychotherapy, as indicated by a license to practice medicine, psychology, clinical social work, marriage and family counseling, or social psychotherapy, etc., granted by the state of residence. In states where no such appropriate license board exists, persons recommending sex reassignment surgery or hormone therapy should have been certified by a nationally known and reputable association, based on education and experience criteria, and, preferably, some form of testing (and not simply on membership received for dues paid) as an accredited or certified therapist/counselor (e.g. American Board of Professional Psychologists, Certified Clinical Social Workers, American Marriage and Family Therapist, American Professional Guidance Association, etc.).

3.5.4

Demonstrated specialized competence in sex therapy and theory as indicated by documentable training and supervised clinical experience in sex therapy (in some states professional licensure requires training in human sexuality; also, persons should have approximately the training and experience as required for certification as a Sex Therapist or Sex Counselor by the American Association of Sex Educators, Counselors and Therapists, or as required for membership in the Society for Sex Therapy and Research). Continuing education in human sexuality and sex therapy should also be demonstrable.

3.5.5

Demonstrated and specialized competence in therapy, counseling and diagnosis of gender identity disorders as documentable by training and supervised clinical experience, along with continuing education.

The behavioral scientists recommending sex reassignment surgery and hormone therapy and the physician and surgeon(s) who accept those recommendations share responsibility for certifying that the recommendations are made based on competency indicators describe above.

4. Principles and Standards

Introduction

4.1.1 Principle 1.

Hormonal and surgical sex reassignment is extensive in its effects, is invasive to the integrity of the human body, has effects and consequences which are not, or are not readily reversible, and may be requested by persons experiencing short-termed delusions or beliefs which may later be changed and reversed.

4.1.2 Principle 2.

Hormonal and surgical sex reassignment are procedures requiring justification and are not of such minor consequence as to be performed on an elective basis.

4.1.3 Principle 3.

Published and unpublished case histories are known in which the decision to undergo hormonal and surgical sex reassignment was, after the fact, regretted and the final result of such procedures proved to be psychologically dehabilitating to the patients.

4.1.4 Standard 1.

Hormonal and/or surgical** sex reassignment on demand (i.e., justified simply because the patient has requested such procedures) is contraindicated. It is herein declared to be professionally improper to conduct, offer, administer or perform hormonal sex reassignment and/or surgical sex reassignment without careful evaluation of the patient's reasons for requesting such services and evaluation of the beliefs and attitudes upon which such reasons based.

4.2.1 Principle 4.

The analysis or evaluation of reasons, motives, attitudes, purposes, etc., requires skills not usually associated with the professional training of persons other than clinical behavioral scientists.

4.2.2 Principle 5.

Hormonal and/or surgical sex reassignment is performed for the purpose of improving the quality of life and subsequent experiences and such experiences are most properly studied and evaluated by the clinical behavioral scientist.

4.2.3 Principle 6.

Hormonal and surgical sex reassignment are usually offered to persons, in part, because a psychiatric/psychologic diagnosis of transsexualism (see DSM-III, section 302.5X), or some related diagnosis, has been made. Such diagnoses are properly made only by clinical behavioral scientists.

4.2.4 Principle 7.

Clinical behavioral scientist, in deciding to make the recommendation in favor of hormonal and/or surgical sex reassignment share the moral responsibility for that decision with the physician and/or surgeon who accepts that recommendation.

4.2.5 Standard 2.

Hormonal and surgical (genital and breast) sex reassignment must be preceded by a firm written recommendation for such procedures made by a clinical behavioral scientist who can justify making such a recommendation by appeal to training or professional experience in dealing with sexual disorders, especially the disorders of gender identity and role.

4.3.1 Principle 8.

The clinical behavioral scientist's recommendation for hormonal and/or surgical sex reassignment should, in part, be based upon an evaluation of how well the patient fits the diagnostic criteria for transsexualism as listed in the DSM-III-R (1) category 302.50 to wit:
bullet A. Persistent discomfort and sense of inappropriateness about one's assigned sex.
bullet B. Persistent preoccupation for at least two years with getting rid of one's primary and secondary sex characteristics and acquiring the sex characteristics of the other sex.
bullet C. The person has reached puberty.
This definition of transsexualism is herein interpreted not to exclude persons who meet the above criteria but who otherwise may, on the basis of their past behavioral histories, be conceptualized and classified as transvestites and/or effeminate male homosexuals or masculine female homosexuals.

4.3.2 Principle 9.

The intersexed patient (with a documented hormonal or genetic abnormality) should first be treated by procedures commonly accepted as appropriate for such medical conditions.

4.3.3 Principle 10.

The patient having a psychiatric diagnosis (i.e., schizophrenia) in addition to a diagnosis of transsexualism should first be treated by procedures commonly accepted as appropriate for such non-transsexual psychiatric diagnoses.

4.3.4 Standard 3.

Hormonal and surgical sex reassignment may be made available to intersexed patients and to patients having non-transsexual psychiatric/psychologic diagnoses if the patient and therapist have fulfilled the requirements of the herein listed standards; if the patient can be reasonably expected to be habilitated or rehabilitated, in part, by such hormonal and surgical sex reassignment procedures; and if all other commonly accepted therapeutic approaches to such intersexed or non-transsexual psychiatrically/psychologically diagnosed patients have been either attempted, or considered for use prior to the decision not to use such alternative therapies. The diagnosis of schizophrenia, therefore, does not necessarily preclude surgical and hormonal sex reassignment.

Hormonal Sex Reassignment

4.4.1 Principle 11.

Hormonal sex reassignment is both therapeutic and diagnostic in that the patient requesting such therapy either reports satisfaction or dissatisfaction regarding the results of such therapy.

4.4.2 Principle 12.

Hormonal sex reassignment may have some irreversible effects (infertility, hair growth, voice deepening and clitoral enlargement in the female-to-male patient and infertility and breast growth in the male-to-female patient) and, therefore, such therapy must be offered only under the guidelines proposed in the present standards.

4.4.3 Principle 13.

Hormonal sex reassignment should precede surgical sex reassignment as its effects (Patient satisfaction or dissatisfaction) may indicate or contraindicate later surgical sex reassignment.

4.4.4 Standard 4***

The initiation of hormonal sex reassignment shall be preceded by recommendation for such hormonal therapy, made by a clinical behavioral scientist.

4.5.1 Principle 14.

The administration of androgens to females and of estrogens and/progesterones to males may lead to mild or serious health threatening complications.

4.5.2 Principle 15.

Persons who are in poor physical health, or who have identifiable abnormalities in blood chemistry, may be at above average risk to develop complications should they receive hormonal medication.

4.5.3 Standard 5.

The physician prescribing medication to a person for the purpose of effecting hormonal sex reassignment must warn the patient of possible negative complications which may arise and that physician should also make available to the patient (or refer the patient to a facility offering) monitoring of relevant blood chemistries and routine physical examinations including, but not limited to, the measurement of SGPT in persons receiving testosterone and the measurement of SGPT, bilirubin, triglycerides and fasting glucose in persons receiving estrogens.

4.6.1 Principle 16.

The diagnostic evidence for transsexualism (see 4.3.1. above) requires that the clinical behavioral scientist have knowledge, independent of the patient's verbal claim, that the dysphoria, discomfort, sense of inappropriateness and wish to be rid of one's own genitals, have existed for at least two years. This evidence may be obtained by interview of the patient's appointed informant (friend or relative) or it may best be obtained by the fact that the clinical behavioral scientist has professionally known the patient for an extended period of time.

4.6.2 Standard 6.

The clinical behavioral scientist making the recommendation in favor of hormonal sex reassignment shall have known the patient in a psychotherapeutic relationship for at least 3 months prior to making said recommendation.

Surgical (Genital and/or Breast) Sex Reassignment

4.7.1 Principle 17.

Peer review is a commonly accepted procedure in most branches of science and is used primarily to ensure maximal efficiency and correctness of scientific decisions and procedures.

4.7.2 Principle 18.

Clinical behavioral scientists must often rely on possibly unreliable or invalid sources of information (patients' verbal reports of the patients' families and friends) in making clinical decisions and in judging whether or not a patient has fulfilled the requirements of the herein listed standards.

4.7.3. Principle 19.

Clinical behavioral scientists given the burden of deciding who to recommend for hormonal and surgical sex reassignment and for whom to refuse such recommendations are subject to extreme social pressure and possible manipulation as to create an atmosphere in which charges of laxity, favoritism, sexism, financial gain, etc., may be made.

4.7.4 Principle 20.

A plethora of theories exist regarding the etiology of gender dysphoria and the purposes or goals of hormonal and/or surgical sex reassignment such that the clinical behavioral scientist making the decision to recommend such reassignment for a patient does not enjoy the comfort or security of knowing that his or her decision would be supported by the majority of his or her peers.

4.7.5 Standard 7.

The clinical behavioral scientist recommending that a patient applicant receive surgical (genital and breast) sex reassignment must obtain peer review, in the format of a clinical behavioral scientist peer who will personally examine the patient applicant, on at least one occasion, and who will, in writing state that he or she concurs with the decision of the original clinical behavioral scientist. Peer review (a second opinion) is not required for hormonal sex reassignment. Non-genital/breast surgical sex reassignment does not require the recommendation of a behavioral scientist. At least one of the two behavioral scientists making the favorable recommendation for surgical (genital and breast) sex reassignment must be a doctoral level clinical behavioral scientist.****

4.8.1 Standard 8.

The clinical behavioral scientist making the primary recommendation in favor of genital (surgical) sex reassignment shall have known the patient in a psychotherapeutic relationship for at least 6 months prior to making said recommendation. That clinical behavioral scientist should have access to the results of psychometric testing (including IQ testing of the patient) when such testing is clinically indicated.

4.9.1 Standard 9.

Genital sex reassignment shall be preceded by a period of at least 12 months during which time the patient lives full-time in the social role of the genetically other sex.

4.10.1 Principle 21.

Genital surgical sex reassignment includes the invasion of, and the alteration of, the genitourinary tract. Undiagnosed pre-existing genitourinary disorders may complicate later genital surgical sex reassignment.

4.10.2 Standard 10*****

Prior to genital surgical sex reassignment a urological examination should be conducted for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract.

4.11.1 Standard 11.

The physician administering or performing surgical (genital) sex reassignment is guilty of professional misconduct if he or she does not receive written recommendations in favor of such procedures from at least two clinical behavioral scientists; at least one of which is a doctoral level clinical behavioral scientist and one of whom has known the patient in a professional relationship for at least 6 months.

Miscellaneous

4.12.1 Principle 22.

The care and treatment of sex reassignment applicants or patients often causes special problems for the professionals offering such care and treatment. These special problems include, but are not limited to, the need for the professional to cooperate with education of the public to justify his or her work, the need to document the case history perhaps more completely than is customary in general patient care, the need to respond to multiple, non-paying, service applicants and the need to be receptive and responsive to the extra demands for services and assistance often made by sex reassignment applicants as compared to other patient groups.

4.23.2 Principle 23.

Sex reassignment applicants often have need for post-therapy (psychologic, hormonal and surgical) follow-up care for which they are unable or unwilling to pay.

4.12.3 Principle 24.

Sex reassignment applicants often are in a financial status which does not permit them to pay excessive professional fees.

4.12.4 Standard 12.

It is unethical for professionals to charge sex reassignment applicants "Whatever the traffic will bear," or excessive fees far beyond the normal fees charged for similar services by the professional. It is permissible to charge sex reassignment applicants for services in advance of the tendering of such services even if such an advance fee arrangement is not typical of the professional's practice. It is permissible to charge patients, in advance, for expected services such as post-therapy follow-up and/or counseling. It is unethical to charge patients for services which are essentially research and which services do not directly benefit the patient.

4.13.1 Principle 25.

Sex reassignment applicants often experience social, legal and financial discrimination not known, at present, to be prohibited by federal or state law.

4.13.2 Principle 26.

Sex reassignment applicants often must conduct formal or semiformal legal proceedings (i.e., in-court appearances against insurance companies or in pursuit of having legal documents changed to reflect their new sexual and genderal status., etc..).

4.13.3 Principle 27.

Sex reassignment applicants, in pursuit of what are assumed to be their civil rights as citizens, are often in need of assistance (in the form of copies of records, letters of endorsement, court testimony, etc.) from the professionals involved in their case.

4.13.4 Standard 13.

It is permissible for a professional to charge only the normal fee for services needed by a patient in pursuit of his or her civil rights. Fees should not be charged for services for which, for other patient groups, such fees are not normally charged.

4.14.1 Principle 28.

Hormonal and surgical sex reassignment has been demonstrated to be a rehabilitative, or habilitative, experience for properly selected adult patients.

4.14.2 Principle 29.

Hormonal and surgical sex reassignment are procedures which must be requested by, and performed only with the agreement of, the patient having informed consent. Sex reannouncement or sex reassignment procedures conducted on infantile or early childhood intersexed patients are common medical practices and are not included in or affected by the present discussion.

4.14.3 Principle 30.

Sex reassignment applicants often, in their pursuit of sex reassignment, believe that hormonal and surgical sex reassignment have fewer risks than such procedures are known to have.

4.14.4 Standard 14.

Hormonal and surgical sex reassignment may be conducted or administered only to persons obtaining their legal majority (as defined by state law) or to persons declared by the courts as legal adults (emancipated minors).

4.15.1 Standard 15.

Hormonal and surgical sex reassignment may be conducted or administered only after the patient applicant has received full and complete explanations, preferably in writing, in words understood by the patient applicant, of all risks inherent in the requested procedures.

4.16.1 Principle 31.

Gender dysphoric sex reassignment applicants and patients enjoy the same rights to medical privacy as does any other patient group.

4.16.2 Standard 16.

The privacy of the medical record of the sex reassignment patient shall be safeguarded according to procedures in use to safeguard the privacy of any other patient group.

5. Explication

5.1 Prior to the initiation of hormonal sex reassignment:

5.1.1

The patient must demonstrate that the sense of discomfort with the self of the genitalia and the wish to live in the genetically other sex role have existed for at least 2 years.

5.1.2

The patient must be known to a clinical behavioral scientist for at least 3 months and that a clinical behavioral scientist must endorse the patient's request for hormone therapy.

5.1.3

Prospective patients should receive a complete physical examination which includes, but is not limited to, the measurement of SGPT in persons to receive testosterone and the measurement of SGPT, bilirubin, triglycerides and fasting glucose in persons to receive estrogens.

5.2 Prior to the initiation of genital or breast sex reassignment

(Penectomy, orchidectomy, castration, vaginoplasty, mastectomy, hysterectomy, oophorectomy, salpingectomy, vaginectomy, phalloplasty, reduction mammoplasty, breast amputation):

5.2.1

See 5.1.1 , above.

5.2.2

The patient must be evaluated at least once by a clinical behavioral scientist other than the clinical behavioral scientist specified in 5.1.2 above and that second clinical behavioral scientist must endorse the patient's request for genital sex reassignment. At least one of the clinical behavioral scientists making the recommendation for genital sex reassignment must be a doctoral level clinical behavioral scientist.

5.2.3

The patient must have been successfully living in the genetically other sex role for at least one year.

5.3 During and after services are provided:

5.3.1

The patients right to privacy should be honored.

5.3.2

The patient must be charged only appropriate fees and these fees may be levied in advance of services.

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* The drafts of these Standards of Care dated 2/79 and 1/80 require that all recommendations for hormonal and/or surgical sex reassignment be made by licensed psychologists or psychiatrists. That requirement was rescinded, and replaced by the definition in section 3.5, in 3/81.

** The present standards provide no guidelines for the granting of non-genital/breast cosmetic or reconstructive surgery. The decision to perform such surgery is left to the patient and surgeon. The original draft of this document did recommend the following however (rescinded 1/80): "Non-genital sex reassignment facial, hip, limb, etc.) shall be preceded by a period of at least 6 months during which time the patient lives full-time in the social role of the genetically other sex."

(1) DSM-III-R , Diagnostic and Statistical Manual of Mental Disorders (Third Edition-Revised) Washington, D.C.The American Psychiatric Association, 1987. (A newer edition of this document has been published, DSM IV, and exerpts are included here.)

*** This standard, in the original draft, recommended that the patient must have lived successfully in the social/gender role of the genetically other sex for at least 3 months prior to the initiation of hormonal sex reassignment. This requirement was rescinded 1/80.

**** In the original and 1/80 version of these standards, one of the clinical behavioral scientists was required to be a psychiatrist. That requirement was rescinded in 3/81.

***** This requirement was rescinded 1/90

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January 1996

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A newer version of the DSM, DSM IV, has been published. (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) Washington, D.C.The American Psychiatric Association, 1994)

These are the relevant sections of that document:

DSM-IV

SEXUAL AND GENDER IDENTITY DISORDERS

Gender identity Disorders

Gender Identity Disorder

Diagnostic Features

There are two components of Gender Identity Disorder, both of which must be present to make the diagnosis. There must be evidence of a strong and persistent cross-gender identification, which is the desire to be, or the insistence that one is of the other sex (Criterion A). This cross-gender identification must not merely be a desire for any perceived cultural advantages of being the other sex. There must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role of that sex (Criterion B). The diagnosis is not made if the individual has a concurrent physical intersex condition (e.g.: androgen insensitivity, syndrome or congenital adrenal hyperplasia) (Criterion C). To make the diagnosis, there must be evidence of clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion D).

In boys, the cross-gender identification is manifested by a marked preoccupation with traditionally feminine activities. They may have a preference for dressing in girls' or women's clothes or may improvise such items from available materials when genuine articles are unavailable. Towels, aprons, and scarves are often used to represent long hair or skirts. There is a strong attraction for the stereotypical games and pastimes of girls. They particularly enjoy playing house, drawing pictures of beautiful girls and princesses, and watching television or videos of their favorite female characters. Stereotypical female-type dolls, such as Barbie, are often their favorite toys, and girls are their preferred playmates. When playing "house," these boys role-play female figures. most commonly "mother roles," and often are quite preoccupied with female fantasy figures. They avoid rough-and- tumble play and competitive sports and have little interest in cars and trucks or other nonaggressive but stereotypical boy's toys. They may express a wish to be a girl and assert that they will grow up to be a woman. They may insist on sitting to urinate and pretend not to have a penis by pushing it in between their legs. More rarely, boys with Gender Identity Disorder may state that they find their penis or testes disgusting, that they want to remove them, or that they have, or wish to have, a vagina.

Girls with Gender Identity Disorder display intense negative reactions to parental expectations or attempts to have them wear dresses or other feminine attire. Some may refuse to attend school or social events where such clothes may be required. They prefer boy's clothing and short hair, are often misidentified by strangers as boys, and may ask to be called by a boy's name. Their fantasy heroes are most often powerful male figures, such as Batman or Superman. These girls prefer boys as playmates, with whom they share interests in contact sports, rough-and-tumble play. and traditional boyhood games. They show little interest in dolls or any form of feminine dress up or role-play activity. A girl with this disorder may occasionally refuse to urinate in a sitting position. She may claim that she has or will grow a penis and may not want to grow breasts or to menstruate. She may assert that she will grow up to be a man. Such girls typically reveal marked cross- gender identification in role-play, dreams, and fantasies.

Adults with Gender Identity Disorder are preoccupied with their wish to live as a member of the other sex. This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation. Adults with this disorder are uncomfortable being regarded by others as, or functioning in society as, a member of their designated sex. To varying degrees, they adopt the behavior, dress, and mannerisms of the other sex. In private. these individuals may spend much time cross-dressed and working on the appearance of being the other sex. Many attempt to pass in public as the other sex. With cross- dressing and hormonal treatment (and fur males, electrolysis). many individuals with this disorder may pass convincingly as the other sex. The sexual activity of these individuals with same-sex partners is generally constrained by the preference that their partners neither see nor touch their genitals. For some males who present later in life, (often following marriage), sexual activity with a woman is accompanied by the fantasy of being lesbian lovers or that his partner is a man and he is a woman.

In adolescents, the clinical features may resemble either those of children or those of adults, depending on the individual's developmental level, and the criteria should be applied accordingly. In a younger adolescent, it may be more difficult to arrive at an accurate diagnosis because of the adolescent's guardedness. This may be increased if the adolescent feels ambivalent about cross-gender identification or feels that it is unacceptable to the family. The adolescent may be referred because the parents or teachers are concerned about social isolation or peer teasing and rejection. In such circumstances, the diagnosis should be reserved for those adolescents who appear quite cross- gender identified in their dress and who engage in behaviors that suggest significant cross-gender identification (e.g., shaving legs in males). Clarifying the diagnosis in children and adolescents may require monitoring over an extended period of time.

Distress or disability in individuals with Gender Identity Disorder is manifested differently across the life cycle. In young children, distress is manifested by the stated unhappiness about their assigned sex. Preoccupation with cross-gender wishes often interferes with ordinary activities. In older children, failure to develop age-appropriate same-sex peer relationships and skills often leads to isolation and distress, and some children may refuse to attend school because of teasing or pressure to dress in attire stereotypical of their assigned sex. In adolescents and adults, preoccupation with cross-gender wishes often interferes with ordinary activities. Relationship difficulties are common and functioning at school or at work may be impaired.

Specifiers

For sexually mature individuals, the following specifiers may be noted based on the individual's sexual orientation: Sexually Attracted to Males, Sexually Attracted to Females, Sexually Attracted to Both, and Sexually Attracted to Neither. Males with Gender Identity Disorder include substantial proportions with all four specifiers. Virtually all females with Gender Identity Disorder will receive the same specifier-Sexually Attracted to Female~although there are exceptional cases involving females who are Sexually Attracted to Males.

Recording Procedures

The assigned diagnostic code depends on the individual's current age: if the disorder occurs in childhood, the code 302.6 is used; for an adolescent or adult, 302.85 is used.

Associated Features and Disorders

Associated descriptive features and mental disorders. Many individuals with Gender Identity Disorder become socially isolated. Isolation and ostracism contribute to low self-esteem and may lead to school aversion or dropping out of school. Peer ostracism and teasing are especially common sequelae for boys with the disorder. Boys with Gender Identity Disorder often show marked feminine mannerisms and speech patterns.

The disturbance can be so pervasive that the mental lives of some individuals revolve only around those activities that lessen gender distress. They are often preoccupied with appearance. especially early in the transition to living in the opposite sex role. Relationships with one or both parents also may be seriously impaired. Some males with Gender Identity Disorder resort to self- treatment with hormones and may very rarely perform their own castration or penectomy. Especially in urban centers, some males with the disorder may engage in prostitution, which places them at high risk for human immunodeficiency virus (HIV) infection. Suicide attempts and Substance-Related Disorders are commonly associated.

Children with Gender Identity Disorder may manifest coexisting Separation Anxiety Disorder, Generalized Anxiety Disorder, and symptoms of depression. Adolescents are particularly at risk for depression and suicidal ideation and suicide attempts. In adults, anxiety and depressive symptoms may be present. Some adult males have a history of Transvestic Fetishism as well as other Paraphilias. Associated Personality Disorders are more common among males than among females being evaluated at adult gender clinics.

Associated laboratory findings. There is no diagnostic test specific for Gender Identity Disorder. In the presence of a normal physical examination, karyotyping for sex chromosomes and sex hormone assays are usually not indicated. Psychological testing may reveal cross-gender identification or behavior patterns.

Associated physical examination findings and general medical conditions. Individuals with Gender Identity Disorder have normal genitalia (in contrast to the ambiguous genitalia or hypogonadism found in physical intersex conditions). Adolescent and adult males with Gender Identity Disorder may show breast enlargement resulting from hormone ingestion, hair denuding from temporary or permanent epilation, and other physical changes as a result of procedures such as rhinoplasty or thyroid cartilage shaving (surgical reduction of the Adam's apple). Distorted breasts or breast rashes may be seen in females who wear breast binders. Postsurgical complications in genetic females include prominent chest wall scars, and in genetic males, vaginal strictures, rectovaginal fistulas, urethral stenoses, and misdirected urinary streams. Adult females with Gender Identity Disorder may have a higher than expected likelihood of polycystic ovarian disease.

Specific Age and Gender Features

Females with Gender Identity Disorders generally experience less ostracism because of cross-gender interests and may suffer less~from peer rejection, at least until adolescence. In child clinic samples, there are approximately five boys for each girl referred with this disorder. In adult clinic samples, men outnumber women by about two or three times. In children, the referral bias toward males may partly reflect the greater stigma that cross- gender behavior carries for boys than for girls.

Prevalence

There are no recent epidemiological studies to provide data on prevalence of Gender Identity Disorder. Data from smaller countries in Europe with access to total population statistics and referrals suggest that roughly 1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment surgery.

Course

For clinically referred children, onset of cross-gender interests and activities is usually between ages 2 and 4 years, and some parents report that their child has always had cross-gender interests. Only a very small number of children with Gender Identity Disorder will continue to have symptoms that meet criteria for Gender Identity Disorder in later adolescence or adulthood. Typically, children are referred around the time of school entry because of parental concern that what they regarded as a phase~ does not appear to be passing. Most children with Gender Identity Disorder display less overt cross-gender behaviors with time, parental intervention, or response from peers. By late adolescence or adulthood, about three-quarters of boys who had a childhood history of Gender Identity Disorder report a homosexual or bisexual orientation, but without concurrent Gender Identity Disorder. Most of the remainder report a heterosexual orientation, also without concurrent Gender Identity Disorder. The corresponding percentages for sexual orientation in girls are not known. Some adolescents may develop a clearer cross-gender identification and request sex- reassignment surgery or may continue in a chronic course of gender confusion or dysphoria.

In adult males, there are two different courses for the development of Gender Identity Disorder. The first is a continuation of Gender Identity Disorder that had an onset in childhood or early adolescence. These individuals typically present in late adolescence or adulthood. In the other course, the more overt signs of cross-gender identification appear later and more gradually, with a clinical presentation in early to mid-adulthood usually following, but sometimes concurrent with, Transvestic Fetishism. The later-onset group may be more fluctuating in the degree of cross-gender identification, more ambivalent about sex- reassignment surgery, more likely to he sexually attracted to women, and less likely to be satisfied after sex-reassignment surgery. Males with Gender Identity Disorder who are sexually attracted to males tend to present in adolescence or early adulthood with a lifelong history of gender dysphoria. In contrast, those who are sexually attracted to females, to both males and females, or to neither sex tend to present later and typically have a history of Transvestic Fetishism. If Gender Identity Disorder is present in adulthood, it tends to have a chronic course, but spontaneous remission has been reported.

Differential Diagnosis

Gender Identity Disorder can be distinguished from simple nonconformity to stereo-typical sex role behavior by the extent and pervasiveness of the cross-gender wishes, interests, and activities. This disorder is not meant to describe a child's nonconformity to stereotypic sex-role behavior as, for example, in "tomboyishness" in girls or "sissyish" behavior in boys. Rather, it represents a profound disturbance of the individual's sense (if identity with regard to maleness or femaleness. Behavior in children that merely does not fit the cultural stereotype of masculinity or femininity should not be given the diagnosis unless the full syndrome is present, including marked distress or impairment.

Transvestic Fetishism occurs in heterosexual (or bisexual) men for whom the cross-dressing behavior is for the purpose of sexual excitement. Aside from cross-dressing. most individuals with Transvestic Fetishism do not have a history of childhood cross- gender behaviors. Males with a presentation that meets full criteria for Gender Identity Disorder as well as Transvestic Fetishism should be given both diagnoses. If gender dysphoria is present in an individual with Transvestic Fetishism but full criteria for Gender Identity Disorder are not met, the specifier With Gender Dysphoria can be used.

The category Gender Identity Disorder Not Otherwise Specified can be used for individuals who have a gender identity problem with a concurrent congenital intersex condition (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia).

In Schizophrenia, there may rarely be delusions of belonging to the other sex. Insistence by a person with a Gender Identity Disorder that he or she is of the other sex is not considered a delusion, because what is invariably meant is that the person feels like a member of the other sex rather than truly believes that he or she is a member of the other sex. In very rare cases, however, Schizophrenia and severe Gender Identity Disorder may coexist.

Diagnostic criteria for Gender Identity Disorder

A. A strong and persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex).

In children, the disturbance is manifested by four(or more) of the following:

  1. repeatedly stated desire to be, or insistence that he or she is, the other sex
  2. in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing
  3. strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex
  4. intense desire to participate in the stereotypical games and pastimes of the other sex
  5. strong preference for playmates of the other sex
In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.

B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.
bullet In children, the disturbance is manifested by any of the following: in boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis. or aversion toward rough-and tumble play and rejection of male stereotypical toys, games, and activities; in girls. rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.
bullet In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.
C. The disturbance is not concurrent with a physical intersex condition.

D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Code based on current age:
bullet 302.6 Gender Identity Disorder in Children
bullet 302.85 Gender Identity Disorder in Adolescents or Adults
Specify if (for sexually mature individuals):
bullet Sexually Attracted to Males
bullet Sexually Attracted to Females
bullet Sexually Attracted to Both
bullet Sexually Attracted to Neither

302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity that are not classifiable as a specific Gender Identity Disorder.
Examples include
  1. Intersex conditions (e.g., androgen insensitivity syndrome or congenital adrenal hyperplasia) and accompanying gender dysphoria
  2. Transient, stress-related cross-dressing behavior
  3. Persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex

END HIBGDA SOC

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January 1996