NCP Gender Identity Disorder

DSM-IV

GENDER IDENTITY DISORDERS

302.6 Gender identity disorder in children

302.85 Gender identity disorder in adolescents and adults (specify: sexually attracted to males/females/both/neither)

302.6 Gender identity disorder not otherwise specified (intersex conditions, androgen insensitivity syndrome, or congenital adrenal hyperplasia and gender dysphoria)

313.82 Identity problem (specific to sexual orientation and behavior)

Sexuality is a product of one’s genetic identity, gender identity, gender role and sexual orientation. As all of these are independent components, there is a 4 3 4 interaction that can result in 16 distinct possibilities of sexual identity. In a society in which clear differences between the sexes is the expected norm, any individual challenging this dichotomy is deemed problematic. However, in the mental health arena, sexual orientation is a concern only when the individual experiences persistent and marked distress regarding uncertainty about issues relating to personal identity—in this case, sexual orientation and behavior.

Consensual homosexuality in adults is no longer viewed as a mental disturbance. Homosexual individuals in general have no more psychopathology than heterosexuals, and when they do seek treatment it is for the same reasons as heterosexuals—psychiatric disorders (e.g., bipolar disorder, borderline personality), relationship problems, and stress. Therefore, it is important to avoid mistakenly attributing psychiatric symptoms to the individual’s sexual orientation.

In gender identity disorder, the individual does not view himself or herself as homosexual; rather, there is a strong and persistent cross-gender identification and discomfort with one’s gender or a sense of inappropriateness in the assigned gender role exists (e.g., a male “trapped” in a female’s body). This perception results in clinically significant distress/functional impairments (e.g., social, occupational).

In addition, this plan of care also addresses the diagnosis of Identity Problem for homosexuals who are uncertain about multiple issues relating to their identity, such as sexual orientation and behavior, moral values, friendship patterns, and group loyalties.

ETIOLOGICAL THEORIES

Psychodynamics

The libido is seen as the force that expresses sexual instinct and develops gradually during the oral stage, which focuses on the mouth and lips. The central concern of the anal stage is the anus and the elimination/retention of feces. During the phallic stage, the male is concerned with love of his mother, is jealous of his father, and has castration anxiety (Oedipus complex). The female has penis envy, loves her father, and rejects her mother (Electra complex). This theory focuses on the biological inferiority of women because they do not have penises, with subsequent envy of the male.

Developmental theories suggest that sexuality develops throughout life and especially during the formative years. Confusion about one’s individual personality and sexual identity affects the ability to be intimate, interfering with sexual development.

Biological

Although adult endocrine levels are usually normal in individuals who are homosexual, a “hormonal wash” may have occurred at a critical time of embryonic development, sensitizing brain cells in as yet immeasurable ways. Androgen is necessary for masculinization in the fetal male, with the fetus developing as female without the addition of this hormone. When androgenic influences in the fetal hypothalamus are decreased in the male or increased in the female, homosexuality may occur. Some research sources report that there is a neuroendocrine factor (e.g., that the fetus was exposed to large amounts of androgenic hormones or that the mother may have received synthetic hormones at a crucial fetal developmental period, preventing adequate stimulation for neural differentiation).

Current research allows monitoring of normal fetal exposure to testosterone in utero. When subsequent behavior is linked to this information, we will understand more than has been previously available from studies of abnormal exposure of the fetus to high levels of androgen, overdoses due to drugs, or adrenal malfunction. Research continues into the effect of prenatal brain-sexing on homosexual development. We know that lack of male hormone at a crucial state of male fetal development can lead to a feminine brain in a male body. It is clear that, as with other aspects of behavior, sexual orientation is crucially mediated by hormonal influences on the developing brain in utero. It is believed that abnormal hormones interact with neurotransmitters, the chemicals that direct the construction of the brain, affecting the sex centers, mating centers, and the so-called gender-role centers, which assume their structure at different times of brain development (Moir & Jessel, 1991).

Family Dynamics

Role-modeling of gender-specific behaviors is believed to play a part in the development of these disorders as well as the negative effect of a disturbed relationship with one or both parents. Imprinting and classic conditioning may affect the development of gender identity.

In males with gender identity disorders, a symbiotic relationship appears to exist between mother and child. The father is usually absent, ineffectual, or hostile and is perceived as weak and distant, with the mother seen as strong and protective.

In females with these disorders, the child may not be valued as a girl, or the mother may be absent, depressed, or suffer from other illness, resulting in inadequate mothering. The father may treat the daughter as his little boy, expecting “masculine” behavior.

CLIENT ASSESSMENT DATA BASE

Ego Integrity

Believes feelings/reactions are typical of other sex

May report considerable anxiety and depression, attributable to difficulty of living in role of assigned gender

Hygiene

Exhibits a persistent, marked aversion to wearing gender-appropriate clothing

Neurosensory

Moderate to severe coexisting personality disturbance may be noted

Mental Status: May reveal intense distress (e.g., ego-dystonic homosexuality) about general identity or coexisting psychiatric disorders

Mood and affect may reveal evidence of increased anxiety and depression

Safety

May have been victim of assault

History of suicide attempts

Sexuality

Higher incidence in males than females (may be owing to narrow study base)

Incongruence between assigned gender and the sense of knowing to which gender one belongs

May report a persistent and intense distress about his or her assigned gender and the desire to be/insistence that he or she is of the other gender; belief by males that penis/testes are disgusting/will disappear, or by females that they will not develop breasts/menstruate; or desires medical/surgical intervention to alter sexual characteristics to simulate the other gender

Possible preoccupation with stereotypic activities/toys designed for the opposite gender, and/or repudiation of anatomical structures noted/reported in childhood

Sexual responsiveness/romantic attraction to individual of same gender

Social Interactions

Impairment in social/occupational functioning, often experiencing peer isolation, bullying

May report family alienation

Teaching/Learning

May present at any age; can be identified in childhood but most often in late adolescence or early adulthood, although possibly later

Substance use/abuse

DIAGNOSTIC STUDIES

Psychological testing to rule out concomitant psychiatric conditions.

Screens for sexually transmitted diseases (STDs), including HIV/AIDS.

NURSING PRIORITIES

1. Help client reduce level of anxiety.

2. Promote sense of self-worth.

3. Encourage development of social skills/comfort level with own sexual identity/preference.

4. Provide opportunities for client/family to participate in group therapy/other support systems.

DISCHARGE GOALS

1. Anxiety reduced/managed effectively.

2. Self-esteem/image enhanced.

3. Accepts and is comfortable with identity as established.

4. Client/family are participating in ongoing treatment/support programs.

5. Plan in place to meet needs after discharge.