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.
Considerations for managing adolescents with gender issues include treating the comorbid conditions (if any) first, and then educating the patient about the realities of a sex change.
The clinician can assist the adolescent in developing 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 inherent in gender identity issues among adolescents include the personal struggles of the patient with his or her identity; fears of rejection, attack, or humiliation; desires to keep gender preference a secret; concerns about parental reaction; problems in school and community settings; and the range of differences in professional attitudes and opinions 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.
“People come to the Menninger Clinic after multiple hospital admissions and with multiple diagnoses–several of which have changed over time,” Dr. O'Malley said. Many patients with gender issues also have mood disorders and substance abuse disorders, and a history of multiple suicide attempts. They often have serious family problems. 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, and discussion of what to do with them,” 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. They often suffer enormous humiliation, especially in cases where they have revealed the problems to others.
A controversy persists between those professionals who support psychodynamic therapy and those who back sex reassignment for these patients, Dr. O'Malley said. The psychodynamic supporters ask how one can possibly think about changing the anatomy when the discontent is rooted in psychopathology. Supporters of sex reassignment, on the other hand, recognize that the condition is usually permanent and that people denied a change might become suicidal, he noted.
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, rather than 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.
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.