The Gender Identity Disorder in the DSM-IV Classification: A Critical Evaluation

Abstract

Objective: The DSM-IV classification in its definition and description of the gender identity disorder omits a number of diagnostically significant features. This paper attempts to correct the deficiencies.

Method: The text under the headings: ‘Diagnostic features’, ‘Specifiers’, ‘Associated disorders’, ‘Laboratory findings’, ‘Prevalence’, ‘Course’ and ‘Differential diagnosis’ is subjected to a detailed scrutiny, using the author's experience as consultant psychiatrist to the Monash University Gender Dysphoria Clinic over a period of 25 years as source and background. Results of two studies of male-to-female and female-to-male transsexuals are given in the Table.

Results: DSM-IV criteria are augmented and the symptomatology focused. The existing gaps in the delineation of specifiers and associated features are closed by providing additional clinical material. The description of the course and the differential diagnosis are enriched.

Conclusions: Although the critical analysis of the DSM-IV classification of the gender identity disorder has shown the manual to be adequate, it nevertheless has shortcomings which may impede exact diagnosis.

Within the boundaries of our present scientific knowledge, the gender identity disordered patient presents to the physician as a physically, endocrinologically and genetically normal individual. All biochemical, radiological or other investigations are therefore negative. Consequently, the diagnosis emerges during a process we call ‘the clinical interview’. As Murray, in his paper, points out, ‘the process is inescapably subjective, relating to private experiences such as thoughts, feelings, impulses’ [1]. He goes on to say that ‘the physician's understanding and assessment again requires reference to his own subjectivity’. The information we receive is filtered through our accumulated experience and matched against our stored memory of the transsexual phenomenon, and the diagnosis is then formulated. Physicians who treat transsexuals often prefer to spread or share responsibility by forming teams. We insist on a lengthy observation period prior to surgery, and the ultimate decision to operate is a majority ruling, based on the ‘balance of probabilities’ principle. We would like the procedure to be accepted as objective and scientific. It is not.

The situation in the case of the gender identity disordered patient is made even more problematic because the patient wishes to present the symptomatology in impressive and favourable terms. The patient is well prepared through extensive reading on the subject and information from clubs and postoperative patients; during the initial interview the clinical picture of classical transsexualism is conjured up and subsequently it has to be verified, challenged, modified or even rejected by the interviewer. Furthermore, surgical sex reassignment has been accepted as the only effective treatment of the gender identity disorder. It is virtually the only major surgical procedure carried out without preliminary physical investigations to confirm the diagnosis, which must be based on the clinical interview. The unhappy consequences of a ‘wrong diagnosis’ and inappropriate surgery, subsequently regretted by the patient, are obvious.

The classification

At present, the DSM-IV [2] is accepted worldwide as a classificatory authority and is used not only by psychiatrists but increasingly by general practitioners and postgraduates prior to obtaining their higher qualification. As Maj [3] points out in his critique of the DSMIV criteria for schizophrenia: ‘for some it will remain the only source of knowledge about psychiatric disorders’. Furthermore, detailed and in-depth knowledge of transsexualism even within psychiatry remains rare. Yet the usual referral chain consists of the general practitioner as first contact, psychiatrist as the second link and gender dysphoria specialist as final authority. It is therefore imperative that the text of the DSM-IV, the guidelines to an exact diagnosis, remains precise, informative and correct in all its aspects. The present critique is based on experience as a consultant psychiatrist to the Gender Dysphoria Clinic of Monash University between 1975 and 2000, and will identify omissions and limitations in the sections on diagnostic features, specifiers, associated features and disorders, prevalence, course and differential diagnosis [4]. It is supported by studies of 202 postoperative male-to-female and 49 female-to-male transsexuals. Summaries of results are given in Tables 1 and 2 [5].

Table 1.

Statistics of postoperative male-to-female transsexuals

Table 2.

Statistics of postoperative female-to-male transsexuals

Diagnostic features

Two components are quoted as essential for the diagnosis of gender identity disorder: persistent cross-gender identification and evidence of discomfort about one's assigned sex. Both are acceptable criteria. Two further criteria are added: the absence of a concurrent physical intersex condition, and significant distress or impairment in social, occupational or other areas of functioning.

Although the absence of an anatomical sexual abnormality is a ‘sine qua non’ for the diagnosis, the last mentioned criterion (impairment of social and other functioning) is by no means present in every patient and its absence should not refute the diagnosis. Some, and particularly female-to-male, transsexuals manage to live reasonably well-adjusted existences in society, either still playing the gender role of their biological sex or even after they have crossed over into the gender of their choice.

Conversely, not emphasized enough by the DSM-IV in the hierarchy of criteria for transsexualism, is the preoccupation or the overwhelming desire of the patient to acquire the anatomical sexual characteristics of the chosen gender; in fact the absence of such a wish would throw grave doubt on the correctness of the diagnosis. The sentence in the DSM-IV: ‘This preoccupation may be manifested as an intense desire to adopt the social role of the other sex or to acquire the physical appearance of the other sex through hormonal or surgical manipulation’, should be altered by replacing the ‘or’ with the word ‘and’.

The symptomatology of the adolescent transsexual is well described; one would only add the occasional presence of masturbatory activities with fantasies of sexual contact with a person of the same anatomical sex, seen by the patient as a heterosexual scenario. The DSM-IV does not, however, stress sufficiently the fact that crossgender identification of the adult primary transsexual almost invariably starts prior to puberty, and crossdressing first practised in adolescence or adulthood makes the diagnosis at least questionable.

Puberty is felt as a period of considerable stress by the transsexual, as anatomical and physiological changes contradict the adolescent's wish to change or be changed by God, magic or the natural growth process. Adults with gender identity disorder are at times sexually aroused by their cross-dressing activity and engage in masturbation. Decades ago this occurrence almost disqualified him or her from a diagnosis of transsexualism.

Anal intercourse, in the preoperative phase of the male-to-female transsexual is at times practiced and explained as a wish for penetration and therefore femininity, and occasionally enjoyed. Marriage in the maleto- female transsexual is by no means uncommon; reasons given are social pressure, loneliness or belief in a spontaneous cure for the condition, and almost invariably ends in separation. It is rare in the female-to-male variant and sometimes initiated by the wish to have a child.

Specifiers

Sexual orientation is listed under four headings: ‘Attracted to males’, ‘Attracted to females’, ‘Attracted to both sexes’, ‘Attracted to neither sex’. It is correctly pointed out that males with gender identity disorder include all four specifiers, whereas females are nearly all attracted to females.

It should, however, be added that the majority of maleto- female transsexuals who are attracted to males (approximately two-thirds of all male transsexuals) reject homosexual partners and desire virile, heterosexual males.

Associated features and disorders

The text rightly highlights the social isolation commonly seen in males, particularly during adolescence, but also in adulthood, and the frequency of an anxietydepression syndrome or a personality disorder. One could however, disagree with the term ‘personality disorder’ and rather call it a ‘personality change’ emanating from parental and social pressures exerted on a maturing and gender-disturbed individual. Although the relative absence of peer ostracism in girls and therefore a less common ‘personality disorder’ incidence is hinted at, it should be stressed that ‘tomboys’ are usually tolerated or even admired by their peers, live through a comparatively tension-free adolescence, and as adults, if they are gender disturbed, impress as stable, sensible individuals, able to deal effectively with their problem. Engagement in prostitution and consequent risks for male transsexuals are mentioned; far more common however, are activities such as engagement as female impersonators or strippers, selected as a kind of role playing which allows free expression of their femininity.

Associated laboratory findings

The DSM-IV correctly pointed out that there is at present no diagnostic test specific for gender identity disorder, and kariotyping for sex chromosomes as well as sex hormone assays are consequently dismissed as unnecessary. One may take issue with this conclusion. Apart from the fact that an occasional Klinefelder Syndrome in a gender-disturbed individual would be missed, recent findings of sex-determining genes, such as the SRY gene on the Y chromosome [6] and the DAX femininizing gene on the X chromosome [7], may eventually lead to a biological interpretation of gender disorders. Endocrinologists will also confirm that hormone administration without initial and subsequent hormone assays is associated with risks.

Associated physical examination findings and general medical condition

Under this heading, physical details such as the presence of normal genitalia, hormonal breast enlargement, the results of electrolysis and cosmetic operations on the nose, thyroid cartilage and others are discussed by the DSM-IV. One could add to this list the presence of mammoplasty, present prior to surgical sex reassignment in 30% of our patients. Postsurgical complications are listed for the male-to-female transsexual; phalloplasty and its complications are however, omitted.

Prevalence

Data quoted in the DSM-IV suggest that one per 3000 adult males and one per 100 000 adult females seek sex reassignment. Incidence figures of the general population from Sweden of 0.17 per 100 000 of the population over 15 years, and a gender ratio of transsexuals of 1:1 in Sweden, England and Wales would considerably enrich this segment.

Course

The developmental history of transsexualism is well described, stressing the relatively uncommon end result, namely a true gender identity disorder beginning with childhood cross-dressing activities. The different courses in males are outlined: either a continuous dysphoria from childhood through adolescence into adulthood, or a late onset in early or even mid-adulthood, sometimes concurrent with transvestic fetishism.

It nevertheless should be pointed out that not infrequently the progressive, continuous course in the maleto- female transsexual is interrupted by a phase in early adulthood characterized by a return of gender identity to the anatomically correct one, accompanied by exaggeratedly male, almost ‘macho’ behaviour and an occupational or recreational choice matching the return to masculinity (enlistment in the armed forces, professional car racing, buckjumping, mountain climbing). As far as late onset is concerned, desire for permanent femininity or even surgical reassignment in a middle-aged transvestite does not often represent a gender identity disorder. It may rather be a desire born out of diminishing sex drive, love of clothes or jewellery, or an attraction to a nonaggressive, ‘feminine’ existence.

Differential diagnosis

Under the headings of (A) Nonconformity to stereotypical sex role behaviour, (B) Transvestic fetishism, (C) Congenital intersex conditions and (D) Schizophrenia, the distinguishing symptomatology is discussed. The DSM-IV restricts ‘nonconformity’ to children's assumption of gender role; the term should, however, also embrace adult nonconformity such as cross-dressing by professional female impersonators, who are by no means all transvestites or ‘drag queens’, and should fall into the category of ‘adult nonconformity’. The controversial aspects of transvestism in the DSM-IV text have already been mentioned: males with a presentation which meets full criteria for gender identity disorder as well as transvestic fetishism are given both diagnoses. Some doubts about this classificatory decision must be expressed. A diagnosis of comorbidity is either unwarranted or extremely rare. One should also remember that the definite diagnosis of gender identity disorder encourages both therapist and patient to turn to surgical sex reassignment as the desirable treatment, a course which in a late middle-aged transvestite, possibly under stress, may well be the wrong choice.

Schizophrenia is dealt with in a rather cursory manner; delusions of belonging to the other sex are mistakenly thought to occur rarely. In my experience, schizophrenic patients presenting behind a mask of gender dysphoria not uncommonly apply for surgery. In 1966 Gittleson and Levine [8] found the presence of genital somatic delusions and delusions of sex change in 30% and 25% of male schizophrenics, respectively. In 1967 the survey was repeated with female schizophrenics [9], and again genital hallucinations were found in 36%, ideas of change in genital size and shape in 24%, and definite delusions of changing sex in 25% of all subjects. In some cases, a definite diagnosis of schizophrenia only emerges at a later stage of the observation period, one of the reasons why a lengthy time span of careful monitoring prior to surgery is essential.

Homosexuality as a diagnostic label has for very good reasons disappeared from any classification of psychiatric disorders. One assumes that this is the reason why the term does not appear in the differential diagnosis of gender identity disorder in the DSM-IV. Admittedly, the male homosexual infrequently and only half-heartedly approaches a gender disorder clinic or team with the wish for surgery, however, the possibility must be kept in mind. Person and Ovesey [10] recognize two subgroups of those patients, the effeminate homosexual and the ‘drag queen’. In the former, the authors stress effeminacy during childhood and fantasies of being a girl, but no real belief in their ‘femaleness’; core gender identity remains male and cross-dressing occurs largely for narcissistic gratification, and the personality type is ‘passive/hysterical’. The drag queen, on the other hand, presents with aggressive and histrionic behaviour which is often accompanied by drug dependency and soliciting. Demand for surgery often follows the breakdown of a homosexual relationship. It is more often the middle-aged homosexual, conventional in his lifestyle, sometimes married and not even homosexually active, who may decide to choose female gender identity and eventually surgery to be able to spend the remainder of his life in a dependant, secure, non-aggressive female role. Meyer [11] calls him the stigmatized homosexual, consciously rejecting his sexual orientations as socially unacceptable and ‘seeking medical rationalization for his homosexuality through genital surgery’. The Monash Gender Dysphoria Team has been approached by only two diagnostically doubtful female homosexuals who desired a gender change and phalloplasty.

Gender identity disorder not otherwise specified

This section of the DSM-IV needs some clarification. The first item, intersex conditions (androgen insensitivity, congenital adrenal hyperplasia) and accompanying gender dysphoria, is already quoted as an exclusion criterion for the diagnosis of gender identity disorder (criterion C), and its re-appearance under the rubric 302.6 defies the basic principles of classification. The second category, transient, stress-related cross-dressing behaviour, is a symptom which may occur across the whole spectrum of male cross-dressers (transsexuals, transvestites, homosexuals) and may even include casual or professional female impersonators, and does not deserve a special item number in the section on gender identity disorder. The third item, persistent preoccupation with castration or penectomy without a desire to acquire the sex characteristics of the other sex, does not rank as a disorder. It rather constitutes a clinical symptom, occurring in schizophrenia, dysmorphophobia, phobic conditions or culture-bound reactive psychoses.

Conclusion

Despite intensive biological and psychological research, the aetiology of the gender identity disorder remains an enigma. It may well be an interaction of genetic, hormonal and subtle psychodynamic factors awaiting elucidation. In the meantime, consistent, careful and informed classification is of paramount importance to diagnosis and treatment.