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Gender Identity Disorder from DSM IV

Copyright 1994 American Psychiatric Association


Diagnostic Features

There are two components of Gender Identity Disorder, both of whichmust be present to make the diagnosis. Thee must be evidence of astrong and persistent gross-gender identification, which is the desireto be, or the insistence that one is of the other sex (Criteria A).This cross-gender identification must not merely be a desire for anyperceived cultural advantages of being the other sex. there must alsobe evidence of persistent discomfort about oneís assigned sex or asense of inappropriateness in the gender role of that sex (Criteria B).The diagnosis is not made if the individual has a concurrent physicalintersex condition (e.g., androgen insensitivity syndrome or congenitaladrenal hyperplasia) (Criteria C). To make the diagnosis, there must beevidence of clinically significant distress or impairment in social,occupational, or other important areas of functioning (Criteria D).

In boys, the cross gender identification is manifested by a markedpreoccupation with traditionally feminine activities. They may have apreference for dressing in girls' or womens' clothes or may improvisesuch items from available materials when genuine articles areunavailable. Towels, aprons, and scarves are often used to representlong hair or skirts. There is a strong attraction for the stereotypicalgames and pastimes of girls. They particularly enjoy playing house,drawing pictures of beautiful girls and princesses, and watchingtelevision or videos of their favorite female-type dolls, such asBarbie, are often their favorite toys, and girls are their preferredplaymates. When playing house, these boys role-play female figures.Most commonly mother roles, and often are quite preoccupied with femalefantasy figures. They avoid rough-and-tumble play and competitivesports and have little interest in cars and trucks or otherno-aggressive but stereotypical boy's toys. They may express a wish tobe a girl and assert that they will grow up to be a woman. They mayinsist on sitting to urinate and pretend not to have a penis by pushingit in between their legs. More rarely, boys with Gender IdentityDisorder may state that they find their penis or testes disgusting,that they want to remove them, or that they have, or wish to have, avagina.

Girls with Gender Identity Disorder display intense negative reactionsto parental expectations or attempts to have them wear dresses or otherfeminine attire. Some may refuse to attend school or social eventswhere such clothes may be required. They prefer boy's clothing andshort hair, are often misidentified by strangers as boys, and may askto be called a boy's name. their fantasy heroes are most often powerfulmale figures, such as Batman or Superman. these girls prefer boys asplaymates, with whom they share interests in contact sports,rough-and-tumble play and traditional boyhood games. They show littleinterest in dolls or any form of feminine dress up or role-playactivity. A girl with this disorder may occasionally refuse to urinatein a sitting position. She may claim that she has or will grow a penisand may not want to grow breasts or menstruate. She may assert that shewill grow up to be a man. Such girls typically reveal markedcross-gender identification in role-play, dreams and fantasies.

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

In adolescents, the clinical features may resemble either those ofchildren or those of adults, depending on the individualísdevelopmental level, and the criteria should be applied accordingly. Inyounger adolescents, it may be more difficult to arrive at an accuratediagnosis because of the adolescentís guardedness. This may beincreased if the adolescent feels ambivalent about cross-genderidentification or feels that it is unacceptable to the family. Theadolescent may be referred because the parents or teachers areconcerned about social isolation or peer teasing and rejection. In suchcircumstances, the diagnosis should be reserved for those adolescentswho appear quite cross-gender identified in their dress and who engagein behaviors that suggest significant cross-gender identification(e.g., shaving legs in males). Clarifying the diagnosis in children andadolescents may require monitoring over an extended period of time.

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


For sexually mature individuals, the following specifiers may be notedbased on the individualís sexual orientation: Sexually Attracted toMales, Sexually Attracted to Females, Sexually Attracted to Both, andSexually Attracted to Neither.Males with Gender Identity Disorder include substantial proportionswith all four specifiers. Virtually all females with Gender IdentityDisorder will receive the same specifier, Sexually Attracted to Female,although there are exceptional cases involving females who are sexuallyAttracted 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 anadolescent or adult, 302.85 is used.

Associated Features and Disorders

Associated descriptive features and mental disorders.
Many individuals with Gender Identity Disorder become sociallyisolated. Isolation and ostracism contribute to low self esteem and maylead to school aversion or dropping out of school. Peer ostracism andteasing are especially common sequelae for boys with the disorder. Boyswith Gender Identity Disorder often show marked feminine mannerisms andspeech patterns.

The disturbance can be so pervasive that the mental lives of someindividuals revolve only around those activities that lessen genderdistress. they are often preoccupied with appearance, especially earlyin the transition to living in the opposite sex role. Relationshipswith one or both parents also may be seriously impaired. Some maleswith Gender Identity Disorder resort to self-treatment with hormonesand may very rarely perform their own castration or penectomy.especially in urban centers, some males with the disorder may engage inprostitution, which places them at a high risk for humanimmunodeficiency virus (HIV) infection. Suicide attempts andSubstance-Related Disorders are commonly associated.

Children with Gender Identity Disorder may manifest coexistingSeparation Anxiety Disorder, Generalized Anxiety Disorder, and symptomsof depression. Adolescents are particularly at risk for depression andsuicidal ideation and suicide attempts. In adults, anxiety anddepressive symptoms may be present. Some adult males have a history ofTransvestic Fetishism as well as other paraphilias. AssociatedPersonality Disorders are more common among males than among femalesbeing evaluated at adult gender clinics.

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

Associated physical examination findings and general medical conditions.
Individuals with Gender Identity Disorder have normal genitalia (incontrast to the ambiguous genitalia or hypogonadism found in physicalintersex conditions). Adolescents and adult males with Gender IdentityDisorder may show breast enlargement resulting from hormone ingestion,hair denuding from temporary or permanent epilation, and other physicalchanges as a result of procedures such as rhinoplasty or thyroidcartilage shaving (surgical reduction of the Adams Apple). Distortedbreasts or breast rashes may be seen in females who wear breastbinders. Postsurical complications in genetic females include prominentchest wall scars, and in generic males, vaginal strictures,rectovaginal fistulas, urethral stenoses, and misdirected urinarystreams. Adult females with Gender Identity Disorder may have a higherthan expected liklihood of polycystic ovarian disease.

Specific Age and Gender Features

Females with Gender Identity Disorders generally experience lessostracism because of cross-gender interests and may suffer less frompeer rejection, at least until adolescence. In child clinic samples,there are approximately five boys for each girl referred with thisdisorder. In adult clinic samples, men outnumber women by about two orthree times. In children, the referral bias towards males may partlyreflect the greater stigma that gross-gender behavior carries for boysthan for girls.


There are no recent epidemiological studies to provide data onprevalence of Gender Identity Disorder. Data from smaller countries inEurope with access to total population statistics and referrals suggestthat roughly 1 per 30,000 adult males and 1 per 100,000 adult femalesseek sex-reassignment surgery.


For clinically referred children, onset of cross-gender interests andactivities is usually between ages 2 and 4 years, and some parentsreport that their child has always had cross-gender interests. Only avery small number of children with gender Identity Disorder willcontinue to have symptoms that meet criteria for Gender IdentityDisorder in later adolescence or adulthood. Typically, children arereferred around the time of school entry because of parental concernthat what they regarded as a phase does not appear to be passing. Mostchildren with Gender Identity Disorder display less overt cross-genderbehaviors with time, parental intervention, or response from peers. Bylate adolescence or adulthood, about three-quarters of boys who had achildhood history of Gender Identity Disorder report a homosexual orbisexual orientation, but without concurrent Gender Identity Disorder.Most of the remainder report a heterosexual orientation, also withoutconcurrent Gender Identity Disorder. The corresponding percentages forsexual orientation in girls are not known. some adolescents may developa clearer cross-gender identification and request sex-reassignmentsurgery or may continue in a chronic course of gender confusion ordysphoria.

In adult males, there are two diferent courses for the development ofGender Identity Disorder. The first is a continuation of GenderIdentity 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-genderidentification appear later and more gradually, with a clinicalpresentation in early to mid-adulthood usually following, but sometimesconcurrent with, Transvestic Fetishism. The later-onset group may bemore fluctuating in the degree of cross-gender identification, moreambivalent about sex-reassignment surgery, more likely to be sexuallyattracted to women, and less likely to be satisfied aftersex-reassignment surgery. Males with Gender Identity disorder who aresexually attracted to males tend to present in adolescence or earlychildhood 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 ofTransvestic Fetishism. If Gender Identity Disorder is present inadulthood, it tends to have a chronic course, but spontaneous remissionhas been reported.

Differential Diagnosis

Gender Identity disorder can be distinguished from simple noncomformity to stereo-typical sex role behavior by the extent andpervasiveness of the cross-gender wishes, interests, and activities.This disorder is not meant to describe a child's nonconformity tostereotypic sex-role behavior as, for example, in tomboyishness ingirls or sissyish behavior in boys. Rather, it represents a profounddisturbance of the individual's sense of identity with regard tomaleness or femaleness. Behavior in children that merely does not fitthe cultural stereotype of masculinity or femininity should not begiven the diagnosis unless the full syndrome is present, includingmarked distress or impairment.

Transvetic Fetishism occurs in heterosexual (or bisexual) men for whom the cross-dressingbehavior is for the purpose of sexual excitement. Aside fromcross-dressing, most individuals with Transvetic Fetishism do not havea history of childhood cross-gender behaviors. Males with presentationthat meets full criteria for Gender Identity Disorder as well asTranvestic Fetishism should be given both diagnoses. If genderdysphoria is present in an individual with Transvetic Fetishism butfull criteria for Gender Identity Disorder are not met, the specifierWith Gender Dysphoria can be used.

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

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

Diagnostic Criteria for gender Identity Disorder

302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity thatare not classifiable as a specific Gender Identity Disorder. Examplesinclude:

  1. Intersex conditions (e.g., androgen insensitivity syndrome orcongenital adrenal hyperplasia) and accompanying gender dysphoria
  2. Transient, stress-related cross-dressing behavior
  3. Persistent preoccupation with castration or penectomy without a desireto acquire the sex characteristics of the other sex

The information from DSM-IV included in this reprint are verbatim excerptsfrom:
The Diagnostic and Statistical Manual of Mental Disorders, fourth edition,DSM-IV
Published By The American Psychiatric Association, Washington, DC
Copyright © 1994 American Psychiatric Association (APA)

We express our sincere appreciation to the APA for permission to reprintexcerpts.
Copyright © 1995

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