|Diagnosis|   |Differential| 

Diagnosis

Assessment of present mental state is not an elaborate process in psychiatry. It consists of observation of the patient and the eliciting of the presence or absence of symptoms of known psychiatric disorders.

Diagnosis, however, requires a thorough review of how mental state changes or persists over time, together with a review of the patient’s entire life history, covering family history, both social and medical; past medical history; review of family dynamics; sexual history; educational history; history of relationships; social history; employment history; cultural review; and exploration of all major events and life features that may impinge on the patient. This process invariably takes more than one session, and may take several. The resulting picture is continually updated by further revelations as the patient becomes confident to make them, and by further events in the patient’s life. Biochemical and other tests may be required.

Diagnosis cannot be firm until some time after initial interview. In many cases a differential diagnosis may be arrived at - a list of possible diagnoses, one or more of which may eventually be accepted once further information has been gained.

Clearly, a substantial issue in eliciting such a history is the achievement of rapport with the patient. This is a delicate matter with patients with gender issues who may be attached to a particular interpretation of their experience (eg, "I am a woman in a man’s body"). Trust must be established to a sufficient degree that the patient can, first, acknowledge all aspects of their experience, and second, be open to suggestions of a nature contrary to their preconceptions{1}, if this proves necessary.

Considerations in the diagnosis of GID

It is important to begin any consideration of gender disorders with the disorder as it occurs in childhood since many adult expressions of a persistent transgendered identity or behaviour would have in an individual’s early years been seen as a Gender Identity Disorder of Childhood{2}. Most male transsexuals claim that their desire to be a member of the opposite sex started at an early age{3}. About 40% said below the age of six and 51% said their earliest recollections were of these feelings. (Rattnam et al, 1991) Beatrice in a 1985 study, found all Transsexuals ‘screened for surgery’ recalled pre-pubertal urges to cross-dress between the ages of six and ten. (Arndt, 1991)

Of course there are many exceptions, but generally there is evidence to suggest the early development of a female gender identity will determine either adult expression of that identity or a homosexual orientation. For Primary Transsexuals there is usually both. Blanchard noticed that there seemed to be a correlation between the age of onset of Gender Dysphoria in boys and the sexual orientation consequently established. This supports the finding of Bullogh (1983) that 82% of Primary Transsexuals prefer men as partners. (Arndt, 1991) Green also in 1987 had demonstrated that most boys with Gender Identity Disorder of Childhood grew up to be homosexual men as adults. (Bockting and Coleman (Eds), 1992) Of those homosexuals, the most extremely gender dysphoric would be homosexual Transsexuals. True Transsexuals, however, would not see themselves as homosexual males as they detest their genitals and often view homosexuality with disgust. (Arndt, 1991) They would see that the ‘woman’ inside is choosing men and this congruent with a ‘heterosexual’ identity. It is however only ‘pseudo-heterosexuality’ as in reality the original male is an ego-dystonic homosexual. (Davis, 1995) This phenomenon can be observed in the quote of a sympathetic journalist reporting on transsexuality in Melbourne’s Age newspaper recently. "More often they are heterosexuals whose interest in the opposite sex was disguised by being born in the wrong gender." (Debelle, 1995:1)

Requirements for a diagnosis of GID

To qualify for a major disorder, the boy must display a least one of these behaviours: cross dressing, expressed wish to be a girl who will grow to being a woman, assume a female role in fantasy games, and imitate feminine mannerisms. Minor behaviours are: dislike for rough and tumble play, preference for artistic pursuits, playing permanently with girls, graceful movement, and being teased as a sissy. A common measure used to discover a child’s gender identity is to observe the sex of the first figure drawn when the child is asked to draw a person. (Arndt, 1991)

Lothsein (1987) observed a group of boys with Gender Identity Disorder and found that as well as the above behaviours, a high percentage of them presented with severe and incapacitating separation anxiety and displayed rage tantrums and suicidal behaviour when separated from their mother. Many also showed profound depressive symptoms expressed as Genital Dysphoria and a desire for genital mutilation and auto-castration. Coates and Person (1985) also reported that 4% of gender disturbed boys despised their anatomy. (Bockting and Coleman (Eds), 1992)

 |Diagnosis|   |Differential| 

Differential

Non-Conformity

When speaking of effeminate mannerisms as a ‘disorder’, one must be careful not to define them too easily as those originating from cross-gender identification through the process of unhealthy or imbalanced ‘rearing’ patterns. These behaviours may be natural characteristics that have emerged in the process of normal healthy development, such as artistic or musical capabilities or a gentle temperament. Unfortunately society labels such things as feminine qualities, so a person is predisposed to be labelled as ‘effeminate’ which would of course increase the likelihood of unhealthy over-identification with the opposite sex. It is a rather vicious cycle. Understandingly, Wolfe (1979) found in children that it was difficult to differentiate between gender-role non-conformity and gender identity disturbance. (Ardnt, 1991)

Transvestism

It has been suggested that homosexuals identify with female sexuality, the transvestites with the social role that is ‘put on’ over a male one, and the transsexual with emotions and attitudes that are more imbedded. (Arndt, 1991). The age of incorporation of a female identity is an important determiner of outcomes.

There is a great difference in the expression of transsexed behaviour between a Transvestite and a Transsexual. Stoller suggests (1985) in childhood the degree of development of an opposite sex ‘core gender identity’ will determine the degree of gender identity disorder and orientation. (Arndt, 1991) Transvestism or cross-dressing develops after a masculine core gender identity is formed to a certain extent, which is why most cross-dressers are heterosexual and still see themselves as male and do not wish to be rid of their genitals. The behaviour usually involves placing a female identity which may represent the mother-son symbiotic fusion, ‘over the top’ of their male identity, as it were, so it is their gender role that is distorted, as we will discuss further. Bullough’s 1983 findings confirm this theory in that most transvestites studied were not effeminate as boys. (Arndt, 1991) It can be suggested transsexuality, the most extreme gender identity disorder has formed when the child’s core identity is believed by himself to be female which is why his genitals and male characteristics are an ‘enemy’ to him. His subjective male identity has never actually been allowed to emerge out of the symbiotic mother-son fusion.

Paternal relationships

For transvestites there is often an exaggerated conception of masculinity, which heightens his own sense of inferiority and unworthiness as a man. Consequently he feels he must ‘escape’ from this intolerable pressure. Also rage against his father may be displaced onto the part of himself that symbolised father and maleness.

Maternal relationships

It is interesting that for all the different manifestations of gender disturbances the ‘learning’ of female characteristics display themselves in different ways and in different intensities. The findings for transvestites, in regard to responses to mother differ slightly from those of transsexuals.

Mothers of transvestites have been reported by Newcombe (1985) to be more dominant, independent and aggressive than the father. Usually they fall in to two categories; the symbiotic warm and seductive mother termed a ‘Stoller Mother’, and the symbiotic hostile mother who is angry, destructive and domineering. Interestingly women depicted in transvestite literature were similarly domineering or seductive. (Arndt, 1991)

The ‘Stoller Mother’ has been observed to be confused about her own gender identity and discouraging the child’s separation from her.

The ‘symbiotic hostile’ mothers, rather than being close, were emotionally distant and neglected their son’s emotional needs. It is suggested that the mother often because of her own physical illness, helplessness or irresponsibility, rejects him whilst he yearns to re-unite with her. She allows separation in gender unrelated areas, giving him some sense of maleness, but inhibits the formation of a stable masculine identity due to her domineering qualities. Later in life he regresses from a fragile gender identity to desire a primitive fusion with mother, represented by female clothing. (Arndt, 1991)