|Year : 2014 | Volume
| Issue : 2 | Page : 157-159
Management challenges in a case of gender identity disorder
Anubhav Rathi, Manjeet Singh Bhatia
Department of Psychiatry, UCMS and GTB Hospital, Delhi University, New Delhi, India
|Date of Web Publication||18-Feb-2015|
Manjeet Singh Bhatia
D-1, Naraina Vihar, New Delhi - 110 028
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Gender identity disorder (GID) is a complex disorder and can be defined as a group of disorders whose common feature is a strong and persistent preference for living as a person of the other sex. It is associated with significant impairment in social, occupational, interpersonal, and other areas of functioning. We describe the case of an adolescent, biologically male who was brought to our outpatient department primarily with symptoms of adjustment disorder with GID and the management provided. The role of a psychiatrist in the management, ethical and legal issues involved is also discussed.
Keywords: Adolescent, gender identity disorder, transgender, transsexual
|How to cite this article:|
Rathi A, Bhatia MS. Management challenges in a case of gender identity disorder. Ind Psychiatry J 2014;23:157-9
Gender identity disorder (GID) is a complex disorder and can be defined as a group of disorders whose common feature is a strong and persistent preference for living as a person of the other sex.  GID or transsexualism according to International Classification of Diseases 10 th revision (ICD-10)  is a desire to live and be accepted as a member of the opposite sex, usually accompanied by a sense of discomfort with, or inappropriateness of one's own anatomic sex and a wish to have hormonal treatment and surgery to make one's body as congruent as possible with the preferred sex. For the diagnosis to be made, the transsexual identity should have been present persistently for at least 2 years and must not be a symptom of another mental disorder, such as schizophrenia or associated with any intersex, genetic or sex chromosome abnormality. Both ICD and Diagnostic and Statistical Manual of Mental Disorders (DSM) consider GID to be a medical disorder. DSM-5 has replaced this category with "Gender Dysphoria." 
Gender identity disorder is associated with significant impairment in social, occupational, interpersonal, and the other areas of functioning. The best prevalence estimates of the GID in adults are from Europe with a prevalence of 1 in 30,000 in men and 1 in 100,000 in women. , The worldwide lifetime prevalence is estimated to be 0.001-0.002%. Many researches show a sex ratio of 3-5 male for each female patient but all these estimates come from clinical samples. ,
As the age advances, problems faced due to cross-gender identification increase. This may lead to the development of significant psychological problems which may require additional interventions. Depression, anxiety disorders, adjustment disorders, substance abuse disorders and personality disorders are frequently co-morbid with GID. , Apart from psychiatric and medical management, this diagnosis is almost uncomparable in the complexity of its social, ethical, and political ramifications. We hereby report management challenges in the case of a male to female transsexual with maladjustment to life events leading to a suicide attempt and adjustment disorder.
| Case Report|| |
A 17-year-old biological male, currently studying in 11 th standard was brought to our psychiatry outpatient department (OPD) with complaints of anger and irritability, decreased sleep and repeated threats of running away from home and harming himself for past 7-8 days. In addition to these complaints, the patient (referred to as "he/his" in this report) reported persistent dissatisfaction with his biological sex and repeated conflicts and adjustment problems with family members over this issue for past many years.
Personal history revealed that he was born full term with normal vaginal delivery. He was the youngest sibling with one sister who was 2 years elder to him and a brother who was 8 years elder to him. He apparently had normal motor, social, and language development except for girlish behavior since early childhood. Being the youngest one in the family, he was protected and pampered by his mother and elder sister while his father and elder brother were mostly aloof and had minimal interaction with him during his preschool years. He loved to play with dolls and would prefer the company of his sister and her female friends. He completely avoided all outdoor sports like cricket and football and also avoided the company of boys. He used to dress like his mother and sister and style his hair like a girl.
Initially, there was no familial discouragement, but later when he persisted with girlish activities and expressed repeated desire to develop a body and to dress like a female, conflicts started arising with the family members. Whenever his family tried to impose restrictions on these activities, the patient would become angry and would refuse to comply. He would often report that he had a body of the male, but he feels like a female from inside. He was scolded several times at school for wearing lipstick and nail paint. He was ostracized and regularly teased by the peers (mostly boys) and was often called a eunuch. The patient was distressed when he started developing secondary sexual characters during adolescence and apparently attempted suicide (by overdose of painkillers) at the time when he tried waxing to remove extensive growth of hairs all over his body and was stopped by his family.
Gradually, he found himself getting attracted to males and at around 16 years of age started having a relationship with a boy (classmate). He always thought of himself to be a female in the relationship and described that relationship as heterosexual. The patient reported being physically intimate with his classmate on numerous occasions in school but denied ever having any intercourse. The reason that he gave was that since he lacked a vagina, so he was unable to have intercourse with his classmate. He frequently reported wishing to have a vagina and to get rid of the penis so that he can enjoy a normal relationship with his classmate. He was average in studies and was an active participant in extra-curricular activities in school. He preferred having female friends most of the time as he would feel out of place in the company of males. 10 days prior to coming to psychiatry OPD, his male friend (with whom he was in a relationship) had a fight with him and ran away from his home and did not contact him for 1 week.
Thorough physical examination including genital examination was normal. There were no signs suggestive of hormonal dysfunction and intersex on an expert assessment by an endocrinologist and physician. There was no family history of any psychiatric disorder or any history of substance abuse.
On mental status examination, he had a preoccupation with his biological sex and showed repeated displeasure with the same. He would report feeling sad and anxious at times because of the same reason but this sadness would not be persistent and pervasive. He would report having occasional thoughts of ending his life but apart from one attempt around 4 years back, there were no other attempts and no definite plans. He expressed persistent desire to live as a female. There was no evidence of the body delusion, effeminate homosexuality or transvestism. The possibility of paraphilias and other disorders of sexual preferences were ruled out. He was diagnosed as a case of GID of childhood (F64.2) with adjustment disorder with mixed disturbance of emotions and conduct (F43.25) as per the diagnostic criteria of ICD-10. His laboratory investigations including routine blood investigations, serum testosterone, Follicle stimulating hormone, luteinizing hormone, thyroid function tests, and serum prolactin were within normal range. His IQ was found to be 100.
The initial focus of the treatment was three-fold: To help the patient develop appropriate coping strategies to deal with conflicts, to psycho-educate the patient and family members regarding the condition and to decide on the future course of management. The patient and the family, through a combination of individual and group sessions, were psycho-educated about the issue at hand, the difference between sex and gender and the spectrum of sexual orientation and gender identity. It was emphasized during these sessions that having a different sense of gender than one's biological sex do not necessarily mean psychiatric illness. The patient was encouraged to develop an attitude of self-acceptance and not to blame anyone (including himself) for his sense of gender. Adequate opportunity was given to both the patient and the family to ventilate the array of emotions which were generated during these discussions. The focus of the family was gradually shifted from "trying to change the patient's gender identity according to his biological sex" to "unconditional acceptance of their child and not to consider it as pathological." Various issues like "stigma in society," "future in terms of marriage" and "ability to have children" were elaborately discussed.
As the sessions progressed, there was improvement in patient's mood and day to day coping abilities and functioning. A discussion was also held regarding the treatment options available (hormonal and surgical). However, both the patient and the family declined any further treatment for GID.
| Discussion|| |
Gender identity disorders are frequently difficult disorders to deal with. This case highlights some of the conflicts faced by the individuals having GID and the challenges which a mental health professional faces in the management of GID. On one hand is the concern of the family who wants the psychiatrist to "cure" their "patient" while on the other hand is the person who is battling with myriad of emotions and seeks psychiatric help to make sense of the situation. The number of other difficult questions are faced by the psychiatrist  and his role varies according to the situation. An important aspect of the management part is counseling the patient about the range of treatment options and their implications, ascertaining eligibility for hormones and surgical therapy, making formal recommendations to medical and surgical colleagues, a letter of recommendation documenting relevant details and being available for follow-up after treatment. 
The controversies raged post Supreme Court Judgement in 2013 which quashed the earlier Delhi High Court Judgement on Article 377 has raised multiple legal and ethical questions in this area. In this country, where a transsexual individual is often an outcast, specific guidelines for the management of transsexualism are complicated by the ambiguous and often discriminatory laws. In India, none of the state governments except Tamil Nadu has made provision for changing transgender (TG) people's birth name and sex in official gazette and official identity documents either after realizing their gender identity or undergoing sex reassignment surgeries (SRS).  In some states, post-SRS medical certificate issued by qualified SRS service providers was helpful for some TG individuals in getting ID documents in new/self-assigned gender. At present, passports are given as "female" based on post-SRS medical certificate or self-reported TG and "emasculation" status although there are no official guidelines from the Union government. Thus, male to female sex change in official documents appears to be possible only for postoperative transsexuals, leaving out preoperative TG people (waiting to undergo SRS), TG people who are medically unfit for surgery, and self-identified TG people unwilling to undergo surgery.  However, a recent landmark Judgement by Supreme Court of India on 15 th April 2014 has identified TG people as the third gender and has ordered the government to provide TG people with quotas in jobs and education in line with other minorities, as well as key amenities.  However, there is a long way to go before people with GID are freed from the stigma. This case thus highlights few of the important issues that are faced by the psychiatrists in dealing with families of and people with GID.
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