Review Article - Volume 2 - Issue 4
Health Psychology Gender Identity Disorder Clinical Picture - Types - Epidemiology
Theofilidis Antonis*
Department of Occupational Therapy, Clinical Neuropsychologist University of Western Makedonia, Greece.
Received Date : June 07, 2022
Accepted Date : July 01, 2022
Published Date: July 22, 2022
Copyright:© Theofilidis Antonis 2022
*Corresponding Author : Theofilidis Antonis, Clinical Neuropsychologist
Occupational Therapy Department University of Western Makedonia – Greece. Tel: +30 6978 802 810.
Email:antonis109@yahoo.gr
DOI: Doi.org/10.55920/2771-019X/1198
Abstract
This paper is a literature review of scientific articles covering a period from 1970 to 2020. It addresses the issue of gender identity disorder in children, adolescents and young adults. The purpose of this paper is to present the issue of gender disorder, through the prism of modern psychological data. Reference is made to the etiology, the clinical picture.
Keywords: Gender Identity Disorder; Epidemiology; Types; Clinical picture.
Introduction:
The development and shaping of gender identity is a complex process that evolves in interaction with individual, biological, family, social, cognitive and psychological factors [1]. People with behaviors, expressions and gender identities that differ from the social and cultural expectations and rules that result from their biological sex at birth are often referred to as transgender. Many, but not all, experience the feeling of gender discomfort, which corresponds to the intense dissatisfaction resulting from the mismatch between congenital anatomical, biological sex and the expressed, desired sex [2].
Clinical Picture of Gender Identity Disorder
The age period of 2-4 years is the one during which the typical gender behaviors usually appear [3]. According to Green, the first reported inconsistent behaviors regarding anatomical gender occur during the preschool years and often before the age of 2 years [3]. The main characteristic is the desire and insistence of the child that he belongs to the other sex or to no sex, and his discomfort for his anatomical sex and the role attributed to it. This behavior, according to researchers, could sometimes be thought of as an early-onset gender identity disorder. According to Blanchard in the early onset form, in biological males sexual orientation is essentially homosexual, while in biologically female individuals, according to Lawrence is almost always homosexual [4]. But before the child's own verbal expression of his gender, the indirect expression through his play precedes, as the children choose their toys, their clothes, the imaginary roles in the role-plays, their company, and even the way use the toilet according to the gender they feel they belong to. The majority of children, those who have strong dissatisfaction with their anatomical sex during childhood, do not seem to maintain it during the period after adolescence. In terms of sexual orientation, for children the image of gender disorder remains in adolescence, it is homosexual or bisexual [5].
Girls
The clinical picture of girls has generally been less studied. One of the most common first signs is the intense discomfort for their anatomical sex and the persistent rejection of women's clothing, especially dresses. Often, in cases where they have to dress in women's clothing, e.g. for a social event, they express themselves with intense anger. They insist or wish, growing up to become men, and often insist that they have anatomical male organs, but they are hidden [3]. They prefer groups with boys and participate mainly in boyish games, with aggressive and violent character, such as weapons, war, football, etc. In their verbal expression, they use more masculine expressions.
Teenagers-Young Adults
Adolescence as a period is characterized by the appearance of secondary gender characteristics, which in girls, appears much earlier than boys [6]. Identity issues gender in adolescence is perceived as a spectrum, as other adolescents have long-term discomfort, beginning in childhood and wishing to be the opposite sex, while others present with a more recent onset of gender discomfort, sometimes in the context of more widespread identity confusion. despite a clear definition of their identity as the opposite sex.
In adolescence and the first years after adulthood, the verbal expression of discomfort about their anatomical gender and desire to be members of the opposite sex is more pronounced. The majority, retrospectively, report having had feelings of discomfort since childhood [7]. Nevertheless, adolescents who experienced discomfort in childhood, only 27% continued into adolescence, while 43% no longer showed it [5]. The insistence to dress in the clothes of the sex they want is also common. However, it is not excluded that they choose clothes that are gender neutral, so that they do not attract attention [8].They fantasize about themselves as people of the opposite sex. They want and often demand that others treat them as people of the desired sex. Their persistence is often expressed by trying to cover up or hide their primary anatomical features, girls their breasts and boys their penis, as well as avoiding or delaying secondary features, hair growth for boys, menstruation for girls. They participate in activities of the desired sex, denying activities of their biological sex. They adopt behaviors and expressions and often movements (body, upper limbs) of the desired sex. Usually there is a bad relationship with peers it is the period when they choose to make it known, first in the immediate family environment and then in their indirect and closest and closest social circle, often with a potentially bad outcome. They seem to want to follow professions followed by people of the desired sex. However, there are adolescents who do not openly express dissatisfaction with their gender and may have as the main first manifestations, emotional disorders such as anxiety, depression, drop in school performance, social withdrawal, attempts at self-destruction, eating disorders, antisocial behavior, substance use [9].
Permanent and Disappearing Sex Disease Of Childhood
In some young children who exhibit behaviors incompatible with their biological sex and express discomfort about it, it seems that during adolescence and adulthood, this set of behaviors ceases to be expressed and they identify with the given sex at birth. Their Nevertheless, there is a correlation between this phenomenon and sexual orientation. In a study by [5] which included 77 children (59 boys and 18 girls) with a mean age 8.4 years, their transgender identity and behavior and dissatisfaction with their biological sex and the role it entailed were measured and recorded. In the follow-up after about 10 years, 27% (12 boys, 9 girls) remained dissatisfied with their biological sex and 43% (28 boys, 5 girls) were identified with their biological sex. Of the group that remained uncomfortable, almost all reported homosexual or bisexual sexual orientation, while of the group identified with their biological sex, all girls and half of the boys reported heterosexual orientation, while the other half reported boys. bisexual sexual orientation. So it seemed that one in five boys remained uncomfortable, while about 50% of the girls remained. Also, the more intense the dissatisfaction and discomfort for the biological sex during childhood, the more likely these children were to develop a gender disorder during adolescence and young adulthood. A recent study by [7]. found that the 10-13 age group was the most important period for adolescents, during which they fully realized the persistent or disappearing side of their childhood discomfort about biological their gender.Important determinants were found to be the change of the social environment, with the expected changes in the relations and contacts with peers, the appearance of secondary gender characteristics during adolescence, feminization and masculinization of the body, the experience of sexual attraction and the feeling of love. In terms of sexual orientation, this study also showed that the group with persistent discomfort had a homosexual sexual orientation, while the group with the disappearing discomfort, although half reported imaginatively homosexual attraction, were more sexually oriented. Late onset seems to occur more frequently in biological males, without excluding biologically female individuals [10] and has previously been associated with intra-fetish fetishism. However, it now appears that in late-onset disorder, androphilic-homosexual sexual orientation is less common [11].
Acute Beginning of Sexual Dissatisfaction In Teenagers And Young Adults (Rapid Onset Gender Dysphoria - Rogd)
In recent years, the occurrence of another phenomenon associated with the rapid onset of symptoms in the late adolescent form has been recognized, with a more frequent occurrence in biologically female individuals without having a history of childhood sex disorder [12]. Peer groups and their influence, the use of the internet with the new ways of communication, socialization and transmission of information, the high rate of diagnosis of mental disorders before the diagnosis of gender identity disorder seem to be factors that influence and favor the rapid appearance and psychosocial stress stimuli [11]. The systematic study of [10], based on reports from 256 parents of people with gender identity disorder, who met the criteria of the study, found an acute onset mainly in biologically female individuals with a mean age of 16.4 years, at a rate of 82.8%, of which 41% with homosexual sexual orientation and 62.5% with at least one diagnosis of mental or neurodevelopmental disorder prior to the diagnosis of gender identity disorder. It is noteworthy that, within the same group of teenagers, those who are later identified as transgender people amount to 36.8%. After the coming out of the adolescents, a bad relationship with parents is reported and an obvious change in social behavior with withdrawal from non-transgender friends and distrust towards them, attempt to withdraw from their families, and trust and information on gender and transgender issues. issues only from corresponding sources. Littman observed similarities between this phenomenon and eating disorders, especially psychogenic anorexia, as they occur in adolescent girls and are strongly influenced by social norms and peer groups. To explain the phenomenon, he made two hypotheses:
- a) The significant influence of the social model and
- b) The acute onset of gender identity disorder, as a bad adaptive mechanism to stressful stimuli and events.
Epidemiology
The epidemiological studies of the last decades can partially orient the number of people (children and adolescents / young adults) with gender identity disorder, as they are studies that have been carried out on people who address specific clinics or health professionals and not on the general population. The results of these, for many researchers are not considered accurate and need more research, as: a) they have been performed in clinics of different countries with different socio-cultural background, with a difference in access to treatment and tolerance for gender disorder, b) use different diagnostic tools, each focusing on other parameters [13]. In recent years, it is a fact that the number of children and adolescents referred to specialized clinics and trained health professionals has increased. According to de Vries, Klink & Cohen-Kettenis this may have been due to: a) the appearance of more transgender characters on television, in the cinema, in the theater, b) the de-psychiatry and the attempt to de-stigmatize the phenomenon, c) the greater and perhaps easier availability of biomedical treatments, including the reception d) the organization of transgender people into formal groups, with the recognition of their basic human rights by several countries around the world. Within this general increase in the number of transgender people, there appears to be a change in the sex ratio, with an increase in the number of adolescent girls versus boys, which may be due to the earlier onset of puberty in girls [6] and in the unchanged disproportionate stigma faced by biological boys versus biological girls, in the process of self-disclosure [14].
The exact number of cases of children under the age of 10-11 is not known, as most studies are based on their ex-personal reports, during adolescence or adulthood, and reports from their parents, who often, even if they detect deviant or incompatible behaviors according to anatomical gender, do not turn to specialists, unless their children enter adolescence and the behavioral signs remain or become more intense, with an increase in discomfort-dissatisfaction for their anatomical sex. As reported by [4], who looked at the number of children and adolescents in the years 1976-2004 who had to address the specific clinical gender identity disorder in Canada, there was a large increase in the number of children during the years 1988-1991, with the number stabilizing by 2004, in contrast to the number of adolescents which appeared to increase during the years 2004-2007. According to a parallel study by [3] at the Canadian Clinic in 1976-2011, who studied the number of children and adolescents, the sex ratio, as well as their sexual orientation, showed the same results in number as in the study of [4] but with an increase in adolescents in the years 2008-2011. In terms of gender ratio, children were found to have a sex ratio of 4.49: 1 boys: girls and adolescents 1.04: 1 boys: girls. Regarding the sexual orientation of adolescents, who were divided into homosexuals and non-homosexuals, the percentage of homosexual teenage girls seemed to be higher than the percentage of homosexual adolescent boys.
In a comparative study between clinics in Canada and the Netherlands [15], in the years 1976-2013 for Canada and in the years 1989-2013 for the Netherlands, there was a marked increase in the number of adolescents and a change in the proportion between biological males and females, with females outnumbering males in the years 2006-2013. Sexual orientation was also studied, dividing adolescents into those with a homosexual (homosexual) and a non-homosexual (non-homosexual) orientation, for males, and a homosexual (homosexual) and a non-homosexual, non-homosexual (non-homosexual). An equally recent increase in the number of transgender adolescents with a higher proportion of biological females than biological males can be seen in an even more recent study by Arnoldussen, Steensma, Popma, van der Miesen, Twisk & de Vries (2019), in Netherlands.
References
- Möller B, Schreier H, Li A, & Romer G. Gender identity disorder in children and adolescents. Current problems in pediatric and adolescent health care, 2019; 39(5): 117-143. https://doi.org/10.1016/j.cppeds.2009.02.001.
- Olson-Kennedy J, Cohen-Kettenis PT, Kreukels BP, Meyer-Bahlburg HF, Garofalo R, Meyer, et al. Research priorities for gender nonconforming/transgender youth: gender identity development and biopsychosocial outcomes. Current opinion in endocrinology, diabetes, and obesity, 2016; 23(2): 172-179. https://doi.org/10.1097/MED.0000000000000236.
- Bradley SJ & Zucker KJ. Gender identity disorder and psychosexual problems in children and adolescents. Canadian journal of psychiatry. Revue canadienne de psychiatrie, 1990; 35(6): 477-486. https://doi.org/10.1177/070674379003500603.
- Zucker KJ & Seto MC. Gender dysphoria and paraphilic sexual disorders. Chapter 69. In A. Thapar, et al. (Eds.), Rutter's child and adolescent psychiatry (6th ed.). London: John Wiley & Sons. 2015.
- Wallien MS & Cohen-Kettenis PT. Psychosexual outcome of gender- dysphoric children. Journal of the American Academy of Child and Adolescent Psychiatry, 2018; 47(12): 1413-1423. https://doi.org/10.1097/CHI.0b013e31818956b9.
- Papadimitriou A & Chrousos GP. Reconsidering the sex differences in the incidence of pubertal disorders.Hormone and metabolic research = Hormon und Stoffwechselforschung = Hormones et metabolisme, 2005; 37(11): 708-710. https://doi.org/10.1055/s-2005-870586.
- Steensma TD, Biemond R, de Boer F & Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: a qualitative follow-up study. Clinical child psychology and psychiatry, 2011; 16(4): 499-516. https://doi.org/10.1177/1359104510378303.
- Cohen-Kettenis PT & Klink D. Adolescents with gender dysphoria. Best practice & research. Clinical endocrinology & metabolism, 2015; 29(3): 485-495. https://doi.org/10.1016/j.beem.2015.01.004.
- Bonifacio JH, Maser C, Stadelman K & Palmert M. Management of gender dysphoria in adolescents in primary care. CMAJ : Canadian Medical Association journal = journal de l'Association medicalecanadienne, 2019; 191(3): 69-75. https://doi.org/10.1503/cmaj.180672.
- Littman L. Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS ONE, 2018; 13(8). https://doi.org/10.1371/journal.pone.0202330.
- Zucker K J. Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of sexual behavior, 2019; 48(7): 1983-1992. https://doi.org/10.1007/s10508-019-01518-8.
- Nieder TO, Herff M, Cerwenka S, Preuss WF, Cohen‐Kettenis PT, De Cuypere G, et al. Age of onset and sexual orientation in transsexual males and females. The journal of sexual medicine, 2011; 8: 783-791. https://doi.org/10.1111/j.1743- 6109.2010.02142.x.
- Schneider C, Cerwenka S, Nieder TO, Briken P, Cohen-Kettenis PT, et al. Measuring Gender Dysphoria: A Multicenter Examination and Comparison ofthe Utrecht Gender Dysphoria Scale and the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults. Archives of sexual behavior, 2016; 45(3): 551-558. https://doi.org/10.1007/s10508-016-0702-x.
- Leibowitz S & de Vries AL. Gender dysphoria in adolescence. International review of psychiatry (Abingdon, England), 2016; 28(1): 21-35. https://doi.org/10.3109/09540261.2015.1124844.
- Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, et al. Evidence for an Altered Sex Ratio in Clinic-Referred Adolescents with Gender Dysphoria. The Journalof Sexual Medicine, 2015; 12(3): 756-763. https://doi.org/10.1111/jsm.12817.
