Standards
Of Care For Gender Identity Disorders - Sixth Version (February 2001) - Part One
| I.
Introductory Concepts - |
***
The
Purpose of the Standards of Care -
***
The major purpose of the Standards
of Care (SOC) is to articulate this international organization's professional
consensus about the psychiatric, psychological, medical, and surgical management
of gender identity disorders. Professionals may use this document to understand
the parameters within which they may offer assistance to those with these
conditions. Persons with gender identity disorders, their families, and
social institutions may use the SOC to understand the current thinking
of professionals. All readers should be aware of the limitations of knowledge
in this area and of the hope that some of the clinical uncertainties will
be resolved in the future through scientific investigation. |
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The
Overarching Treatment Goal -
***
The general goal of psychotherapeutic,
endocrine, or surgical therapy for persons with gender identity disorders
is lasting personal comfort with the gendered self in order to maximize
overall psychological well-being and self-fulfillment. |
***
The
Standards of Care Are Clinical Guidelines -
***
The SOC are intended to provide
flexible directions for the treatment of persons with gender identity disorders.
When eligibility requirements are stated they are meant to be minimum requirements.
Individual professionals and organized programs may modify them. Clinical
departures from these guidelines may come about because of a patient's
unique anatomic, social, or psychological situation, an experienced professional's
evolving method of handling a common situation, or a research protocol.
These departures should be recognized as such, explained to the patient,
and documented both for legal protection and so that the short and long
term results can be retrieved to help the field to evolve. |
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The
Clinical Threshold -
***
A clinical threshold is passed
when concerns, uncertainties, and questions about gender identity persist
during a person's development, become so intense as to seem to be the most
important aspect of a person's life, or prevent the establishment of a
relatively unconflicted gender identity. The person's struggles are then
variously informally referred to as a gender identity problem, gender dysphoria,
a gender problem, a gender concern, gender distress, gender conflict, or
transsexualism. Such struggles are known to occur from the preschool years
to old age and have many alternate forms. These reflect various degrees
of personal dissatisfaction with sexual identity, sex and gender demarcating
body characteristics, gender roles, gender identity, and the perceptions
of others. When dissatisfied individuals meet specified criteria in one
of two official nomenclatures--the International Classification of Diseases-10
(ICD-10) or the Diagnostic and Statistical Manual of Mental Disorders--Fourth
Edition (DSM-IV)--they are formally designated as suffering from a gender
identity disorder (GID). Some persons with GID exceed another threshold--they
persistently possess a wish for surgical transformation of their bodies. |
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Two
Primary Populations with GID Exist - Biological Males and Biological Females
-
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The sex of a patient always is
a significant factor in the management of GID. Clinicians need to separately
consider the biologic, social, psychological, and economic dilemmas of
each sex. All patients, however, should follow the SOC. |
***
| II.
Epidemiological Considerations |
***
Prevalence
-
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When the gender identity disorders
first came to professional attention, clinical perspectives were largely
focused on how to identify candidates for sex reassignment surgery. As
the field matured, professionals recognized that some persons with bona
fide gender identity disorders neither desired nor were candidates for
sex reassignment surgery. The earliest estimates of prevalence for transsexualism
in adults were 1 in 37,000 males and 1 in 107,000 females. The most recent
prevalence information from the Netherlands for the transsexual end of
the gender identity disorder spectrum is 1 in 11,900 males and 1 in 30,400
females. Four observations, not yet firmly supported by systematic study,
increase the likelihood of an even higher prevalence: |
***
1.
Unrecognized gender problems are occasionally diagnosed when patients are
seen with anxiety, depression, bipolar
||||disorder,
conduct disorder, substance abuse, dissociative identity disorders, borderline
personality disorder, other sexual
||||disorders
and intersexed conditions;
2. Some nonpatient male transvestites, female impersonators, transgender
people, and male and female homosexuals
||||may have
a form of gender identity disorder;
3. The intensity of some persons' gender identity disorders fluctuates
below and above a clinical threshold;
4. Gender variance among female-bodied individuals tends to be relatively
invisible to the culture, particularly to mental
||||health professionals
and scientists. |
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Natural
History of Gender Identity Disorders -
***
Ideally, prospective data about
the natural history of gender identity struggles would inform all treatment
decisions. These are lacking, except for the demonstration that, without
therapy, most boys and girls with gender identity disorders outgrow their
wish to change sex and gender. After the diagnosis of GID is made the therapeutic
approach usually includes three elements or phases (sometimes labeled triadic
therapy): a real-life experience in the desired role, hormones of the desired
gender, and surgery to change the genitalia and other sex characteristics.
Five less firmly scientifically established observations prevent clinicians
from prescribing the triadic therapy based on diagnosis alone: |
***
1.
Some carefully diagnosed persons spontaneously change their aspirations;
2. Others make more comfortable accommodations to their gender identities
without medical interventions;
3. Others give up their wish to follow the triadic sequence during psychotherapy;
4. Some gender identity clinics have an unexplained high drop out rate;
5. The percentage of persons who are not benefited from the triadic therapy
varies significantly from study to study. |
***
|
Many persons with GID will desire all three elements of triadic therapy.
Typically, triadic therapy takes place in the order of hormones ==> real-life
experience ==> surgery, or sometimes: real-life experience ==> hormones
==> surgery. For some biologic females, the preferred sequence may be hormones
==> breast surgery ==> real-life experience. However, the diagnosis of
GID invites the consideration of a variety of therapeutic options, only
one of which is the complete therapeutic triad. Clinicians have increasingly
become aware that not all persons with gender identity disorders need or
want all three elements of triadic therapy. |
***
Cultural
Differences in Gender Identity Variance throughout the World -
***
Even if epidemiological studies
established that a similar base rate of gender identity disorders existed
all over the world, it is likely that cultural differences from one country
to another would alter the behavioral expressions of these conditions.
Moreover, access to treatment, cost of treatment, the therapies offered
and the social attitudes towards gender variant people and the professionals
who deliver care differ broadly from place to place. While in most countries,
crossing gender boundaries usually generates moral censure rather than
compassion, there are striking examples in certain cultures of cross-gendered
behaviors (e.g., in spiritual leaders) that are not stigmatized. |
***
| III.
Diagnostic Nomenclature |
***
The
Five Elements of Clinical Work -
***
Professional involvement with
patients with gender identity disorders involves any of the following:
diagnostic assessment, psychotherapy, real-life experience, hormone therapy,
and surgical therapy. This section provides a background on diagnostic
assessment. |
***
The
Development of a Nomenclature -
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The term transexxual emerged
into professional and public usage in the 1950s as a means of designating
a person who aspired to or actually lived in the anatomically contrary
gender role, whether or not hormones had been administered or surgery had
been performed. During the 1960s and 1970s, clinicians used the term true
transsexual. The true transsexual was thought to be a person with a characteristic
path of atypical gender identity development that predicted an improved
life from a treatment sequence that culminated in genital surgery. True
transsexuals were thought to have: |
***
1.
Cross-gender identifications that were consistently expressed behaviorally
in childhood, adolescence, and adulthood;
2. Minimal or no sexual arousal to cross-dressing;
3. No heterosexual interest, relative to their anatomic sex. |
***
True transsexuals could be of either sex. True transsexual males were distinguished
from males who arrived at the desire to change sex and gender via a reasonably
masculine behavioral developmental pathway. Belief in the true transsexual
concept for males dissipated when it was realized that such patients were
rarely encountered, and that some of the original true transsexuals had
falsified their histories to make their stories match the earliest theories
about the disorder. The concept of true transsexual females never created
diagnostic uncertainties, largely because patient histories were relatively
consistent and gender variant behaviors such as female cross-dressing remained
unseen by clinicians. The term "gender dysphoria syndrome" was later adopted
to designate the presence of a gender problem in either sex until psychiatry
developed an official nomenclature.
***
The diagnosis of Transsexualism
was introduced in the DSM-III in 1980 for gender dysphoric individuals
who demonstrated at least two years of continuous interest in transforming
the sex of their bodies and their social gender status. Others with gender
dysphoria could be diagnosed as Gender Identity Disorder of Adolescence
or Adulthood, Nontranssexual Type; or Gender Identity Disorder Not Otherwise
Specified (GIDNOS). These diagnostic terms were usually ignored by the
media, which used the term transsexual for any person who wanted to change
his/her sex and gender. |
***
The
DSM-IV -
***
In 1994, the DSM-IV committee
replaced the diagnosis of Transsexualism with Gender Identity Disorder.
Depending on their age, those with a strong and persistent cross-gender
identification and a persistent discomfort with their sex or a sense of
inappropriateness in the gender role of that sex were to be diagnosed as
Gender Identity Disorder of Childhood (302.6), Adolescence, or Adulthood
(302.85). For persons who did not meet these criteria, Gender Identity
Disorder Not Otherwise Specified (GIDNOS) (302.6) was to be used. This
category included a variety of individuals, including those who desired
only castration or penectomy without a desire to develop breasts, those
who wished hormone therapy and mastectomy without genital reconstruction,
those with a congenital intersex condition, those with transient stress-related
cross-dressing, and those with considerable ambivalence about giving up
their gender status. Patients diagnosed with GID and GIDNOS were to be
subclassified according to the sexual orientation: attracted to males;
attracted to females; attracted to both; or attracted to neither. This
subclassification was intended to assist in determining, over time, whether
individuals of one sexual orientation or another experienced better outcomes
using particular therapeutic approaches; it was not intended to guide treatment
decisions.
***
Between the publication of DSM-III
and DSM-IV, the term "transgender" began to be used in various ways. Some
employed it to refer to those with unusual gender identities in a value-free
manner -- that is, without a connotation of psychopathology. Some people
informally used the term to refer to any person with any type of gender
identity issues. Transgender is not a formal diagnosis, but many professionals
and members of the public found it easier to use informally than GIDNOS,
which is a formal diagnosis. |
***
The
ICD-10 -
***
The ICD-10 now provides five
diagnoses for the gender identity disorders (F64): |
***
| Transsexualism
(F64.0) has three criteria: |
***
1.
The desire to live and be accepted as a member of the opposite sex, usually
accompanied by the wish to
||||make his
or her body as congruent as possible with the preferred sex through surgery
and hormone
||||treatment;
2. The transsexual identity has been present persistently for at least
two years;
3. The disorder is not a symptom of another mental disorder or a chromosomal
abnormality. |
***
| Dual-role
Transvestism (F64.1) has three criteria: |
***
1.
The individual wears clothes of the opposite sex in order to experience
temporary membership in the
||||opposite
sex;
2. There is no sexual motivation for the cross-dressing;
3. The individual has no desire for a permanent change to the opposite
sex. |
***
| Gender
Identity Disorder of Childhood (64.2) has
separate criteria for girls and for boys. |
***
***
1.
The individual shows persistent and intense distress about being a girl,
and has a stated desire to be a
||||boy (not
merely a desire for any perceived cultural advantages to being a boy) or
insists that she is a boy;
2. Either of the following must be present: |
***
a.
Persistent marked aversion to normative feminine clothing and insistence
on wearing
||||stereotypical
masculine clothing;
b. Persistent repudiation of female anatomical structures, as evidenced
by at least one of the
||||following: |
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1)
An assertion that she has, or will grow, a penis;
2) Rejection of urination in a sitting position;
3) Assertion that she does not want to grow breasts or menstruate. |
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3.
The girl has not yet reached puberty;
4. The disorder must have been present for at least 6 months. |
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***
1.
The individual shows persistent and intense distress about being a boy,
and has a desire to be a girl, or,
||||more rarely,
insists that he is a girl.
2. Either of the following must be present: |
***
a.
Preoccupation with stereotypic female activities, as shown by a preference
for either
||||cross-dressing
or simulating female attire, or by an intense desire to participate in
the games
||||and pastimes
of girls and rejection of stereotypical male toys, games, and activities;
b. Persistent repudiation of male anatomical structures, as evidenced by
at least one of the
||||following
repeated assertions: |
***
1)
That he will grow up to become a woman (not merely in the role);
2) That his penis or testes are disgusting or will disappear;
3) That it would be better not to have a penis or testes. |
***
3.
The boy has not yet reached puberty;
4. The disorder must have been present for at least 6 months. |
***
| Other
Gender Identity Disorders (F64.8) has no specific
criteria. |
***
| Gender
Identity Disorder, Unspecified has no specific
criteria. |
***
Either of the previous two diagnoses could be used for those with an intersexed
condition.
***
The purpose of the DSM-IV and
ICD-10 is to guide treatment and research. Different professional groups
created these nomenclatures through consensus processes at different times.
There is an expectation that the differences between the systems will be
eliminated in the future. At this point, the specific diagnoses are based
more on clinical reasoning than on scientific investigation. |
***
Are
Gender Identity Disorders Mental Disorders? -
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To qualify as a mental disorder,
a behavioral pattern must result in a significant adaptive disadvantage
to the person or cause personal mental suffering. The DSM-IV and ICD-10
have defined hundreds of mental disorders which vary in onset, duration,
pathogenesis, functional disability, and treatability. The designation
of gender identity disorders as mental disorders is not a license for stigmatization,
or for the deprivation of gender patients' civil rights. The use of a formal
diagnosis is often important in offering relief, providing health insurance
coverage, and guiding research to provide more effective future treatments. |
***
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Notes
On The Standards Of Care
***
The
Standards of Care are provided on this site for informational purposes
only -
***
The Standards of Care are intended
for use as guidelines, designed to promote the health and welfare of persons
with gender identity disorders, and exist for the protection of both the
patient and the theraputic provider of such treatment. As such, they are
not cast in stone but rather open to interpretation on a case by case basis
between the patient and the treatment professional involved, both should
be aware of these guidelines and the treatment standards they are designed
to maintain. |
***
| The
Standards of Care are created and maintained by - |
***
The
Harry Benjamin International Gender Dysphoria Association, Inc. (HBIGDA)
1300 South Second Street, Suite 180
Minneapolis, MN 55454 USA
(612) 625-1500
http://www.hbigda.org/ |
***
These
standards are updated and revised as new scientific information becomes
available -
***
The current edition of the Standards
of Care presented here was released in 2001, and is the sixth version since
the original 1979 document. Previous revisions were in 1980, 1981, 1990,
and 1998. See archives
for versions previously presented on this site. |
***
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