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Gender Identity Disorder: Diagnosis and Treatment 1

Gender Identity Disorder:

Diagnosis and Treatment

Joshua Brian Krebs

Trevecca Nazarene University


Gender Identity Disorder: Diagnosis and Treatment 2

Gender Identity Disorder: Diagnosis and Treatment

Gender Identity Disorder, sometimes called Gender Dysphoria, is one of the most controversial

diagnoses in the Diagnostics and Statistical Manual. While Homosexuality has already been removed,

many are of the opinion that GID should be removed as well do to a growing cultural acceptance of

transgenders. To this end it is likely that in the coming DSM-V this disorder will be removed.

Following the sexual revolution of the 1960s and '70s, homosexuality, bisexuality, and cross-genders

have gradually gaining acceptance in the United States and other countries around the world. However,

since many who suffer from GID also suffer from anxiety or depression related to acceptance or social

pressure, there is still at least a perceived lack of acceptance. With the invention of sex-reassignment

surgery many people who feel they are trapped in a body of the wrong sex may have their biology

changed to match who they feel they are. While the number of people with GID that have this surgery

is still statistically small, they must be screened by a mental health provider prior to approval for the

surgery. This means that in the future, whether GID remains a diagnosis or not, it is likely that

individuals that seek care for GID will likely be looking for said screening, or the treatment of anxiety

and depression, rather than overcoming the disorder itself.

The Diagnosis

According to Seligman and Reichenberg (2007), “People with GID typically prefer activities,

occupations, and dress associated with the gender other than their biologically assigned gender.”

Because this is a disorder that can be diagnosed in both children and adults the age of onset varies

greatly. For children with GID it is very common for boys and girls to start cross-dressing before their

third birthday. Boys, of course, dress effeminately, and girls dress like tomboys. This tomboyish

attitude for clothing can often result in the original referral of girls with GID (Zucker & Bradley, 2007).

When playing, children with GID will often choose playmates of the opposite biological gender and

usually take on roles in play traditionally assigned to the opposite gender. When these activities are
Gender Identity Disorder: Diagnosis and Treatment 3

combined with the expressed dislike of their biological gender, specifically through verbal statements,

or a desire to have the opposite sexual anatomy, it points strongly to GID.

In adults GID is considered much less common (Carroll, 2007), and adults with GID compare

well with the general population as far as the occurrence of psychopathology. According to Seligman

and Reichenberg (2007), those suffering from GID are “otherwise emotionally healthy people who

have the strong belief that they are in the wrong body.” Gender Identity Disorder does, however, often

coincide with considerable social and occupational difficulties due to cultural or societal ideas about

gender. Generally, however, people with GID have no interest in the treatment of the order directly.

For most, their primary concern is not to make their self-image match their biology, but rather their

biology match their self-image. While sometimes this desire to match their biology to their self-image

results in the desire for hormone treatments or even sex-reassignment surgery, more often they find

other ways, such as cross-dressing, to fulfill this need.

The desire for sex-reassignment surgery can be one of the reasons someone with GID is

referred, causing the therapist to have to determine if they are really in a place to make such a decision.

This can make it very difficult for a therapist who is uncomfortable with GID, or disapproves of sex-

reassignment surgery, to make an ethical and accurate statement of the client's readiness for surgery or

other treatments.

Another interesting note about GID is that since the disorder is considered to be developed

before sexual orientation in most cases, sexual desire is considered a separate issue nearly altogether.

Someone with GID may tend towards same-sex orientation, but they can have heterosexual or bisexual

orientation. In many cases, people with GID show little or no sexual desire at all.

As mentioned above, one of the main reasons someone with GID is referred for therapy is that

they are dealing with anxiety or depression. This is often brought on by peer pressure, especially for

adolescents, and can result in social withdrawal, adjustment conditions or disorders, and social
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difficulties in relationships. Sometimes these pressures and feelings result in acting-out behavior, but

more often this is specifically an adolescent reaction. Adults more often express feelings of depression

related to social relationships, or anxiety related to their occupation and work.

Interventions

Because adult clients with GID rarely come in for treatment of their self-image, but rather the

symptoms that relate to their self-image not matching their biological sex, therapy focuses on these

symptoms. The goal of therapy is not to bring the self-image in line with the client’s biological

sexuality, but there is the option of referring on clients to receive hormone treatments or surgery to

bring their biology in line with their self-image. For children, however, there is more controversy.

Some have suggested that intervention should be used to help children with their unhappiness towards

their biological gender. Others have argued that by the time a child is old enough for therapy to be

effective, three to five years old, the therapist would, in effect, be attempting to change who the child

is. Green (1987) showed that this is further compounded by the fact that as many as 75 percent of

adolescent boys who showed signs GID in childhood show strong homosexual preferences.

Importantly, Green's study also showed that many boys, in fact most boys, who showed signs of GID in

childhood seemed to grow out of their displeasure with their own sexuality. This suggests that GID in

children might be a good predictor of homosexual orientation in adolescence and adulthood. This

would seem to imply that therapy for children should focus on helping them cope with the feelings they

have towards their gender and the depression and anxiety brought about by those feelings. Because of

this, play therapy could be useful and certainly it is important to involve these children in activities not

specifically assigned a gender. Seligman and Reichenberg (2007), suggest an activity such a board

game can create an socially rewarding experience without pressuring a child into a gender specific role.

Apart from medical interventions, attempting to change the biological gender of a client, the

goals of intervention for adults should focus on improving life satisfaction and adjustment (Seligman &
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Reichenberg, 2007). Because a therapist is treating more symptomatic issues, usually depression or

anxiety, interventions used with treating conditions and disorders more specifically related to

depression and anxiety will be the most effective.

Cognitive-Behavioral Therapy would likely be a good first step in helping a client battling

depression due to societal pressure or relational difficulties. Since clients with GID are often dealing

with more acute relational or occupational issues, as required by the diagnosis, the skills CBT teaches

regarding personal effectiveness and independence could be particularly helpful to the client. Helping

the client learn how to understand the relationship between what they are thinking and how they are

feeling could definitely relieve some of the pain they feel based on their perception of others feelings

towards them. One danger of CBT for GID clients is that by delving into how others perceive there is a

danger that people around them do perceive them in a very negative way. This risks reinforcing their

feelings of depression of anxiety rather than relieving them.

Another form of treatment, especially for those who present more with anxiety, would be

Affective Therapy. Using the acronym AWARE, Affective Therapy helps the client to accept and

normalize the way they feel when they are anxious, watch their anxiety by seeking objectivity, act with

their anxiety by confronting their fears, repeat the steps in order to make them natural, and to expect the

best. For clients working through their anxiety related to GID, particularly the acts of seeking

objectivity and confronting their fears are important. By seeking objectivity they can gain a little

distance from their anxiety and see that it is situational and learn to deal with it within those situations.

By doing this they are able to control how their anxiety affects them and then confront these situations

prepared to overcome and expect the best. Additionally, family or couples therapy may be necessary

when applicable, since one of the primary diagnostic pieces of this disorder is relational dysfunction or

impairment.

Regardless of the intervention used, the therapist must remember to be kind and open, as it is
Gender Identity Disorder: Diagnosis and Treatment 6

essential that the client not feel judged by the therapist in any way. Since the symptoms stem nearly

entirely from how the client believes others see them, if they believe that their therapist views them

negatively it will destroy the client-therapist relationship. The danger of poor ethical choices abounds

in the treatment of GID due to societal norms and medical considerations, and the therapist must be

very mindful of their own thoughts and feelings regarding the client.
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References

Carroll, R. A. (2007). Gender dysphoria and transgender experiences. In S. R. Leiblum (Ed.),

Principles and practice of sex therapy (4th ed., pp. 477-508). New York: Guilford Press.

Green, R. (1987). The “sissy boy syndrome” and the development of homosexuality. New Haven: Yale

University Press.

Seligman, L., & Reichenber, L. W.. (2007). Selecting effective treatments: a comprehensive, systematic

guide to treating mental disorders (3rd ed.). San Fransisco: Jossey-Bass.

Zucker, K. J., & Bradley, S. J. (2004). Gender identity and psychosexual disorders. In J. M. Weiner &

M. K. Dulcan (Eds.), The Amercian Publishing textbook of child and adolescent psychiatry (3rd

ed., pp. 813-835). Washington, DC: American Psychiatric Association.


Gender Identity Disorder: Diagnosis and Treatment 8

Client Map

Name: John Smith (legal name) goes by Joanna

Date: 2-17-11

Reasons for referral: Strong negative feelings towards biological gender, frustration in gender “on the

outside” not matching gender “on the inside”, fear of others perceptions, dresses in contrast with

biological gender (very effeminate), desire to take female gender roles despite male biological gender,

experiences severe depression and dysfunction due to trouble finding friends and work, poor family

relationships.

Diagnosis:

Axis I: 302.85 Gender Identity Disorder

Axis II: None at this time.

Objective of treatment: To improve overall quality of life, especially in relational and occupation

functionality. Decrease symptoms of depression. Work with

Assessments:

Beck Depression

Beck Anxiety

MMPI-II

Clinician characteristics: The clinician needs to be very capable of unconditional positive regard, able

to show empathy and understanding, positive and supportive.

Location: Outpatient, office.

Interventions: CBT, Affective Therapy, Family Therapy.

Emphasis: Supportive and Explorative.

Numbers: Individuals, Family, possibly group.

Timing: Once a week short term (6-12 weeks), then group therapy or individual therapy once a month
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for 1 year.

Medications: Med Eval., but none expected at this time.

Adjunct services: Medical exam

Prognosis: The prognosis for the depression, anxiety, and family relationships is good. Recurrence of

the symptoms is likely, however, since the cross-gender desire will most likely remain.
Gender Identity Disorder: Diagnosis and Treatment 10

Film Clip

Film: Boys Don't Cry (Hillary Swank, Chloë Sevigny) 1999, Fox Searchlight.

Link:

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