Gender Identity Disorder Not Otherwise Specified (GID NOS)

DSM-IV-TR Diagnostic Criteria for GID NOS

-GID NOS is reserved for persons who cannot be classified as GID (e.g. gender
dysphoria and a desire to be regarded socially as persons of the other sex)
Types of GID NOS include:
1. Intersex Conditions and accompanying gender dysphoria
2. Transient, stress related cross dressing behavior
3. Persistent pre-occupation with coctration perectomy without a desire to acquire the sex
characteristics of the other sex
Intersex Conditions:
-Include a variety of syndromes in which a persons have gross anatomical or physiological
aspects of the opposite sex. A condition where there is a discrepancy between the external
genitals and the internal genitals (testes and ovaries). Hence, they cannot classify clearly as
male or female. This is congenital, involving chromosomal, morphologic, genital or gonadal
anomalies or sex developmental differences.
- The older term for this condition is called Hermaphroditism, came from joining the names of
Greek God of male sexuality Hermes and Aphrodite, Goddess of female sexuality, love and
beauty.
-Aforesaid term was later replaced by experts because they are misleading confusing and
insensitive .
-Intersexuality is a term adopted by medicine during the 20
th
century.
-This group of conditions is being called likewise as disorders of sex development (DSDs)
Six Types of Intersex Conditions:
1. Congenital Virilizing Adrenal Hyperphasia or CAH is a genetic or inherited disorder
characterized by:
A) Deficiency in the hormone cortisol ( secreted by adrenal cortex for maintenance of body
fluids, electrolyte and sense organ levels) and aldosterone ( secreted by adrenal glands to
maintain salt and water balance in the body)
B) Overproduction of androgen hormone (steroid hormone that cause masculination) that
affect sexual development.
CAH produces in females following features:
- Enlarged clitoris and masculinization of features such as deepening of voices, facial hair,
failure to menstruate or abnormal periods at puberty
- Females with severe level of CAH may be mistaken as males at birth

CAH produces in males following features:
- Genitals are normal at birth but the child becomes muscular, penis enlarges, pubic hair
appearance and voice deepens long before puberty sanctions as early as two to three years of
age.
CAH or androgenization can range from mild clitoral enlargement to external genitals that look
like a normal scrotal sac, testes, and a penis, but hidden behind these external genitals are a
vagina and a uterus.
At birth, the genitals look female, they are assigned and reared as female and the result is a clear
sense of femaleness.
At birth, the genitals look like male, they are assigned and reared as male and usually result in
clear sense of maleness.
If parents are uncertain about the sex of their child, Hermaphrodite identity results.
In severe salt waisting form of CAH, newborns vomit, dehydrated, electrolyte change and there is
arythmia.
2. Androgen Insensitivity Syndrome or AIS is formerly known as testicular feminization, is when a
person who is genetically male (has one X and one Y chromosome) is resistant to male hormones
called androgens. As a result, the person has some or all of the physical characters of a woman
despite of having a genetic make-up of a man.
Causes:
- AIS is caused by various genetic defects on the X chromosome that makes it unable to
respond to the hormones responsible for the male appearance.
2 Main Categories:
1. Complete AIS prevents the development of penis and other male body parts the child
born appearance to be girl. They appear to be female but no uterus with very little
auxiliary and pubic hair.
2. Incomplete AIS degree of sexual ambiguity varies such as breast development in men,
failure of one or two scrotum to descend after birth and hypospadias where the opening
of the uterus is penis. Likewise infertile male syndrome. May have both male and female
physical characters, many have partial closing of the outer vaginal lips, enlarged clitoris
and a short vagina. A vagina with no cervix or uterus.
Tests:
- Blood work to check levels of testosterone, luteinizing hormone (LH) and follicle
stimulating hormone
- Genetic testing
- Pelvic ultrasound
Treatment:
- Undescended testicle should be removed until child completes puberty.
- ERT is prescribed after puberty
- Gender assignment must be individualized because of psycho-social issues
3. Turners Syndrome - is a genetic disorder that affects a girl's development. The cause is a
missing or incomplete X chromosome. Girls who have it are short, and their ovaries don't work
properly.
Physical features typical of Turner syndrome are:
Short, "webbed" neck with folds of skin from tops of shoulders to sides of neck
Low hairline in the back
Low-set ears
Swollen hands and feet
Failure of breast development
Lack of pubic hair


Treatment:
- Growth hormone often helps girls reach heights that are close to average. Hormone
replacement can stimulate sexual development. Assisted reproduction techniques can help
some women with Turner syndrome get pregnant.

4. Klinefelters Syndrome is a condition that occurs in men who have an extra X chromosome in
most of their cells. The syndrome can affect different stages of physical, language and social
development. The most common symptom is infertility.
Physical features typical of Klinefelters Syndrome are:
less facial and body hair and may be less muscular than other boys
they may have trouble using language to express themselves.
they may be shy and have trouble fitting in
Treatment:
Educational services
Physical, speech and occupational therapy
Medical treatments including testosterone replacement
5. 5-alpha-Reductase Deficiency - is an autosomal recessive sex-limited condition resulting in the
inability to convert testosterone to the more physiologically active dihydrotestosterone (DHT).
Because DHT is required for the normal masculinization of the external genitalia in utero,
genetic males with 5-alpha-reductase deficiency are born with ambiguous genitalia (ie, 46,XY
DSD).
- A person with 5-alpha-reductase deficiency classically present with striking ambiguity of the
genitalia, with a clitoral-like phallus, markedly bifid scrotum, pseudovaginal perineoscrotal
hypospadias, and a rudimentary prostate.

- They appear more masculinized; they may lack a separate vaginal opening, have a blind vaginal
pouch that opens into the urethra, and have isolated penile hypospadias

or even a penile
urethra.

6. Pesudohermaphroditism - a condition in which the individual has a single chromosomal and
gonadal sex but combines features of both sexes in the external genitalia, causing doubt as to
the true sex.

-True Hermaphroditism- is characterized by the presence of both testes and ovaries in the same
person.
- Female pseudohermaphroditism refers to an individual with ovaries but with secondary sexual
characteristics or external genitalia resembling those of a male.
- Male pseudohermaphrodites are genetic males (45,XY) who develop female configurations and
identities. These individuals have testes, but their genital ducts and external genitalia are
female.
Treatment:
- In many instances, gender identity has been established by the age of 18 to 24 months, and
changes in sexual identity thereafter should be attempted only after careful consideration.
Intra-abdominal testes should be removed because of an increased risk of tumor formation.


TREATMENTS:
Because intersex conditions are present at birth, treatment must be timely and some physicians
believe the conditions to be true medical emergencies.
The appearance of the genitalia in diverse condition is often ambiguous, and a decision must be
made about the assigned sex (boy or girl) and how the child should be reared.
Problems should be addressed as early as possible, so that the entire family can regard the child in a
consistent, relaxed manner.
This is particularly important because intersex patients may have gender identity problems because
of complicated biological influences and familial confusion about their actual sex.
When intersex conditions are discovered, a panel of pediatric, urological, and psychiatric experts
usually determines the sex of rearing on the basis of clinical examination, urological studies, buccal
smears, chromosomal analyses, and assessment of the parental wishes.
Education of parents and presentation of the range of options open to them is essential, because
parents respond to the infants genitalia in ways that promote the formation of gender identity.
One option for parents to decide against immediate surgery for ambiguous genitalia, but assign the
label of boy or girl to the infant on the basis of chromosomal and urological examination.
If the parents decide on surgery to normalize genital appearance, it is generally undertaken before
the age of three years.
It is easier to assign a child to be female than to assign one to be male, because male-to-female
genital surgical procedures are far more advanced than female-to-male procedures.

Prepared and Lectured by:
PERPETUA I. TOBIAS