Gender identity disorders 2

Psychiatry , social work, LGBT, transgender, anxiety ect.

1. Gender Identity disorders/ gender dysphoria Deblina Roy M.Sc. Psychiatric nursing 2 nd Year

2. Introduction Transgender

3. Definition: Gender  dysphoria or  gender identity disorder  (GID) is the dysphoria (distress) a person experiences as a result of the  sex  and  gender  they were assigned at birth . According to the DSM V: gender dysphoria refers to those persons who have marked incongruence between their experienced of the expressed gender and the one they were assigned at birth. ICD 10: F64 A disorder characterized by a strong and persistent cross-gender identification (such as stating a desire to be the other sex or frequently passing as the other sex) coupled with persistent discomfort with his or her sex (manifested in adults, for example, as a preoccupation with altering primary and secondary sex characteristics through hormonal manipulation or surgery).

4. Epidemiology Children : less than 3 years start showing the gender confirmatory behaviors. 10 % of the boys aged 12 years who were referred for clinical problems showed desires to be of other gender, and in girls the ratio was found to be 5%. A dults : The estimates in Europe from the Hormonal / surgical clinics are 1 -11000 male assigned, for female assigned people it is about 1- 30,000.

5. Cont. DSM 5 reports the prevalence rate ranging from the 0.005 to 0.014 for the male assigned and 0.002-0.003 in female assigned gender . Overall the prevalence of the male to female dysphoria is greater as there is social acceptance of the females to be dressed as males (tomboys) than there is birth assigned males acting as females (so called sissies). Some researchers speculate that one in 500 adults may fall somewhere in the transgender spectrum based on the population data.

6. ETIOLOGY

7. Biological factors The resting state of the tissue is initially female. The male is produced because there is androgen and the presence of the Y chromosome Basically the gender dysphoria occurs due to more of the postnatal factors . Brain organization theory. Genetic causes are still under study Incidental finding suggests that the transgender persons are left handed

8. Psychosocial factors Children usually develop a gender identity consonant with their assigned sex. Unresolved oedipal and Electra complex in the formative years of childhod .

9. Diagnosis and clinical features Children Differential diagnosis in children Trans gender as adults Intersex

10. Adolescents and adults they show incongruence with their own assigned gender Gender-queer DIFFERNTIAL DIAGNOSIS: Delusional thinking, schizophrenia. Body dysmorphic disorder Trnasvestic disorders P araphilic disorders

11. Course and the prognosis of the disorder

12. Children Gender identity is typically established by the age f three years Anxiety regarding the gender assigned and the strong will to change the gender. Various research studies have shown that the children diagnosed with the gender identity disorders in childhood later identify with the birth assigned gender when they reach adult hood. ( Wallein MSC, Cohen KP , 2008)

13. Co- morbidities in the children Higher rates of anxiety ( Adelson Sl.2011) Higher rates o f depression Some researches also find that the children tend to fall into the Autism spectrum.( Spack NP Edward LL, 2012 ).

14. Adults They recall the continuous identity of the development of the transgender identities . In the meantime they turn into stereotypical activities and job roles of the assigned gender. Many people identify themselves as Gay , Lesbian, or Bisexual before coming out as a transgender .

15. Co morbidities in the Adults Increased rates of anxiety and depression, also have self harming activities , suicidality and substance abuse . Life time rate of suicidal thoughts in the transgender people is about 40 %. DSM5 reports that persons wit late onset gender dysphoria may have greater fluctuations in the extent of their distress and more ambivalence and less satisfaction after the sex reassignment surgery.

16. TREATMENT

17. CHILDEREN TYPICALLY consists of the various therapies Individual Family Group therapy . Reparative or conversion therapy

18. ADOLESCENTS As gender non confirming children approach puberty, some show intense fear and preoccupation related to the physical changes experienced by them. Pharmacologically : in such cases GnRH Agonists are used.( they delay the pubertal symptoms

19. Adults Psychotherapy ( to explore the gender issues) Hormonal treatment Surgical treatment These modalities may decrease depression and may improve the quality of life.

20. Mental health treatment lack of support from the mental health professional has led to reduction in the health seeking behaviors of the trans identified people. The world professional Association for the transgender health (WAPTH) Standards of care (SOC) has become more open to the informed consent models. Some mental health professionals are specializing in the transgender populations that is increasing

21. Hormones Transgender men it is: testosterone( weekly ) Side effects : Increased acne Muscle mass Increased libido. Cessation of menses Deepening of the voice Increased body hair Enlargement of the clitoris Monitoring of the other parameters : (LFT, Lipid profile ) Fertility counseling

22. Transgender woman : they mainly take Estrogen , testosterone blockers , or progesterone or in combination. These hormones can cause the softening of the skin and the redistribution of the fat. As well as breast growth and breast development. Sex drive may decrease and there might be erections and ejaculations. Body hair may decrease but not as desired. Voice coaching may be done for training. Monitoring of the parameters : (LFT, Blood pressure cholesterol, prolactin level) They may develop prolactinomas . Reproductive counseling is very important as there may be permanent sterility.

23. Surgery Many fewer people go for the gender related surgeries , many don’t want them, most cant afford them, and few are not satisfied with the results presently available. Most common surgery is top surgery.( chest , breast). Then is bottom surgeries that is for the woman Sex reassignment surgeries ( vagino plasty ) and for men clitoris is freed from the ligament attached to it. Then more mass is added and penis is formed then scrotoplasty and testicular implants .

24. http:// www.dailymail.co.uk/femail/article-3509357/Parts-melt-world-pain-Transgender-woman-shares-graphic-account-really-feels-like-undergo-gender-reassignment-surgery.html#v-2593855332742379662

25. Male to female gender reassignment surgery

26. Female to male gender reassignment surgery

27. Intersex dsoreders According to the DSM IV TR intersex disorders are diagnosed when gender dysphoria is present, as gender identity disorders not other wise specified .

28. Congenital virilizing adrenal hyperplasia This disorder was formerly called as adrenogenital syndrome. Its an enzymatic defect in the production of cortisol in the prenatal period, leads to the over production of adrenal androgens and virilization of the female foetus. With the early diagnosis children develop gender identity consistent with the chromosomal or the gonadal sex . But girls tend to be tomboyish. Higher rates of bisexual and homosexual behaviors have been reported. Treatment : hormonal therapies and surgical feminization , enzymatic replacement

29. Androgen insensitivity syndrome It was formerly called testicular feminization. In these persons with XY karyotype , the tissue cells are unable to use testosterone. Therefore the person is born as a girl and raised as a girl they have reported to be satisfied with their feminity. Persons with partial androgen insensitivity has been associated with the gender change from female to male

30. Turner syndrome In turner syndrome 1 sex chromosome is missing so the karyotype is X. they may have shield shaped chests and webbed neck. Due to dysfunctional ovaries they need hormonal support in the development of the female sexual characteristics. They identify themselves as female they are infertile .

31. Kleinefelter Syndrome An extra X chromosome is present so the karyotype is XXY. At birth the people are born as the normal males, there may be excessive gyneacomastia in the adolescence usually they are tall. Testes are small without sperm production. They are tall and bodily habitus is eunuchoid . Reportedly having gender identity disorder.

32. 5-alpha reductase deficiency Deficiency of the enzyme 5 alpha reductase for the conversion of the testosterone to dihydroxy-testosterone . So the person is normally born with a female characteristics and then at puberty there is virilization of the genitalia The person identifies himself as a male gender.

33. Early life surgeries for the intersex children. Controversy has developed over surgery of the genitalia for anatomically inter-sexed children. Many people whose sex change surgeries had been done in childhood now complain regarding the mutilation of the and limited full erotic arousal. currently there had been a professional movement in the delay in implementing the surgeries

34. Nursing management of the patients with gender identity disorders Assessment : anxiety level, Depression level Stress related to the dysphoric identity of biological and identified gender Stress level of he family members related to the dysphoric gender identity. Coping strategies of the patient and the family and the available services in mental health

35. Nursing diagnosis Anxiety related to incongruence between the identified gender and the biological gender as evidenced by verbalization of the patient. Persistent stress related to the thoughts of changing own biological gender as evidenced by visits to hormone and surgical clinics Maladaptive coping related to the inability to cope with the desire to change the gender as evidenced by abuse of substances. Low self confidence related to humiliation at the school / office / home as evidenced by shy and avoidant behavior.

36. Interventions to reduce anxiety Assess the level f anxiety. Teach the client various techniques to reduce anxiety. Tell the patient that it is not completely his/ her fault that they have this problem Mutually explore the various methods of reducing anxiety through the meditation, and group activity. Give small tasks to the client according to the gender preferences so that the patient has reduced anxiety. Short a cting benzodiazepines and newer anxiolytics can be given to the patient.

37. Interventions for coping Assess the coping strategies commonly used by the patient . Accept the patient as he/she is. Inform the patients regarding the various coping mechanisms. Involve the patients in group therapy so that patient can discuss the methods of coping wit the similar people. mutually explore the various coping strategies and collaborate and coordinate with the psychologist and the therapists for the improvement in the coping strategies

38. Measures to improve self confidence Assess the patients level of self confidence Provide various activities to improve self esteem give supportive psychotherapy to help understand the conditions Family therapy should be given Referral to the appropriate support groups Avoidance of risky behavior .

39. Research article related to gender identity

40. Transgender Patient Perceptions of Stigma in Health Care Contexts Kosenko , Kami PhD * ; Rintamaki , Lance PhD † ; Raney, Stephanie BA * ; Maness, Kathleen BA Objectives: Transgender individuals, or those who cross or transcend sex categories, commonly experience stigma and discrimination. Anecdotal evidence indicates that this transphobia manifests in health care settings, but few studies address the forms of mistreatment experienced in this context. This study was designed to explore transgender patients’ experiences with health care. This brief report focuses on their negative experiences. Methods: A total of 152 transgender adults were recruited to complete an online questionnaire about their health care. Participants were asked if and how they had been mistreated, and responses were analyzed by qualitative content analysis. Results: Participants’ descriptions of mistreatment coalesced around 6 themes: gender insensitivity, displays of discomfort, denied services, substandard care, verbal abuse, and forced care. Conclusions: These findings provide insight into transgender patients’ perceptions of and sensitivity to mistreatment in health care contexts. This information might be used to increase providers’ cultural competency and inform their interactions with transgender patients .

41. summary

42. Discussion

43. Androgens and the Evolution of Male-Gender Identity among Male Pseudohermaphrodites with 5 α- Reductase Deficiency Julianne Imperato -McGinley, M.D., Ralph E. Peterson, M.D., Teofilo Gautier, M.D., and Erasmo Sturla , M.D. N Engl J Med 1979; 300:1233-1237 May 31, 1979 DOI: 10.1056/NEJM197905313002201 Abstract: To determine the contribution of androgens to the formation of male-gender identity, we studied male pseudohermaphrodites who had decreased dihydrotestosterone production due to 5α-reductase deficiency. These subjects were born with female-appearing external genitalia and were raised as girls. They have plasma testosterone levels in the high normal range, show an excellent response to testosterone and are unique models for evaluating the effect of testosterone, as compared with a female upbringing, in determining gender identity. Eighteen of 38 affected subjects were unambiguously raised as girls, yet during or after puberty, 17 of 18 changed to a male-gender identity and 16 of 18 to a male-gender role. Thus, exposure of the brain to normal levels of testosterone in utero, neonatally and at puberty appears to contribute substantially to the formation of male-gender identity. These subjects demonstrate that in the absence of sociocultural factors that could interrupt the natural sequence of events, the effect of testosterone predominates, over-riding the effect of rearing as girls. (N Engl J Med 300:1233–1237, 1979 )

44. Bibliography SaddockBJ . SaddockVA . Synopsis of psychiatry, 11 th ed , walterkluers publicaion , Philladelphia PA USA ;2015. pp - 600-618 Saddock BJ, SaddockVA,Ruiz P. Kaplan and saddocks comprehensie text book of psychiatry 9 th ed. Wolterkluer,Philladelphia PA USA; 2012.pp-2099-2111. Kosenko K, Rintamaki L, Raney S,Maness K. Transgender Patient Perceptions of Stigma in Health Care Contexts. Medical care ; Sep 2013 vol-29 :19[819-822] BAhttp ://journals.lww.com/lww-medicalcare/Abstract/2013/09000/Transgender_Patient_Perceptions_of_Stigma_in.10.aspx