Sexual Orientation /Gender Identity Disorder and Suicide in Children and Adolescents

1. Sexual Orientation /Gender Identity Disorder and Suicide in Children and Adolescents By Yulonda Williams, LMSW

2. Personal Experiences 1. A tormented and abused teen 2 . A 3 year old boy who identified more with activities associated with girls 3. A child (9 yrs of age) diagnosed with Gender Identify Disorder 4. Close family member who struggled with sexual orientation and gender identify issues as a child

3. American Association of Suicidology • Many studies have found that LGB youth attempt suicide more frequently than straight peers. Garafalo et al. (1999) found that LGB high school students and students unsure of their sexual orientation were 3.4 times more likely to have attempted suicide in the last year than their straight peers. • Eisneberg and Resnick (2006) found that LGB high school students were more likely as their straight peer to have attempted suicide.

4. Evidence from a National Study • The American Public Health Association (2001) conducted a study that examined sexual orientation and suicidality, using data that included critical youth and suicide risk factors. • Methods: Data from the National Longitudinal Study of Adolescent Health were examined. Survey of logistic regression was used to control for sample design effects.

5. Finding from the National Study • The findings showed that there is a strong link between adolescent sexual orientation and suicidal thoughts and behaviors. • The strong effect of sexual orientation and suicidal thoughts is mediated by critical youth suicide risk factors, which include:

6. Suicide Risk Factors • Depression • Hopelessness • Alcohol abuse • Recent suicide attempts by a peer or family member • Experiences of victimization

7. Findings Related to Minority Youth • The findings also provided strong evidence that sexual minority youths are more likely than their peers to think about and attempt suicide.

8. For Colored Boys Only By Keith Boykin • Boykins addresses colored boys who have contemplated suicide “When the Rainbow is still Not Enough.” Boykins addresses longstanding issues of sexual abuse, suicide, HIV/AIDS, racism, and homophobia in the African American, Latino, and Asian communities, and more especially among gay men of color.

9. The 2009 Boston Study • Emotional distress among 9th -12th grade students in Boston Massachusetts was evaluated. • This study examined whether the association between being lesbian, gay, bisexual, and/or transgendered (LGBT), and emotional distress was mediated by perceptions of having been treated badly or discriminated against because others thought they were gay.

10. Data from Boston School Survey • 10% were LGBT and 58% were female and ages ranged from 13 to 19 years. • About 45% were Black and 31% were Hispanic, and 14 % were White. • LGBT youth scored significantly higher on the scale of depressive symtomatology

11. Boston School Survey Cont’d • LGBT youth were more likely than heterosexual non-transgendered youth to report suicidal ideation (30% vs. 6%,p < 0.0001) and self-harm(21% vs. 6%, p < 0.0001). • Mediation analysis showed that perceived discrimination accounted for increased depressive symtomatology among LGBT youth males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males.

12. Results from the Boston Study • The mediation analysis showed that perceived discrimination accounted for an increased depressive symptomatology among LGBT males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LGBT males.

13. Boy Scouts of America

14. What is Sexual Orientation? • According the American Psychological Association (APA)“Sexual orientation refers to an enduring pattern of emotional, romantic, and/or sexual attractions to men, women, or both sexes.” • Sexual orientation also refers to a person’s sense of identity based on those attractions, related behaviors, and membership in a community of others who share those attractions.

15. Sexual Orientation Cont’d • Research over the years has demonstrated that sexual orientation ranges along a continuum, from exclusive attraction to the other sex to exclusive attraction to the same sex. • Sexual orientation also refers to a person’s sense of identity based on those attractions, related behaviors, and membership in a community of others who share those attractions.

16. Sexual Orientation Cont’d • However, sexual orientation is usually discussed in three categories. Those three categories are: heterosexual, gay/lesbian and bisexual. • Heterosexual (having emotional, romantic, or sexual attractions to members of the other sex) • Gay/lesbian ( having emotional, romantic, or sexual attractions to members of one’s own sex) • Bisexual (men or women attracted to both sexes).

17. How do people know if they are Lesbian, gay or bisexual? According to current scientific and professional understanding, the core attractions that form the basis for adult sexual orientation typically emerge between middle childhood and early adolescence. • These patterns of emotional, romantic and sexual attraction may arise without any prior sexual experience.

18. How do people know if they are lesbian, gay or bisexual ? Cont’d Different lesbian, gay, and bisexual people have very different experiences regarding their sexual orientation • Some people know that they are gay, or bisexual for a long time before they actually pursue relationships with other people

19. Terminology • Sexrefers to attributes that collectively and usually harmoniously, characterize biological maleness and femaleness. • In humans, the most well-known attributes that constitute biological sex include the sex-determining genes, the sex chromosomes, the H-Y antigen, the gonads, sex hormones, the internal reproductive, and the external genitalia (Migeon & Wisniewski, 1999).

20. Terminology Cont’d • Over the past couple of decades, there has been great interest in the possibility that the human brain has certain sex-dimorphic neuroanatomic structures that perhaps emerge during the process of prenatal physical sex differentiation. • For resent developments see Arnold, 2003; Grumbach, Hughes & Conte, 2003;Haqq & Donahoe, 1998; Vilain, 2000; and chaper 11, this volume).

21. Terminology Cont’d • Gender is used to refer to psychological or behavioral characteristics associated with males and females (Ruble, Martin, & Berenbaum, 2006). From a historical perspective gender is a technical term much younger than the technical term sex (Haig, 2004). • Fifty years ago, for example, the term gender was not even part of the professional literature that purported to study psychological similarities and differences between male and females. • In fact, the first terminology introduced literature gender role not gender (Money, 1955).

22. Terminology cont’d • There has been a tendency to conflate the usage of the term sex and gender. In addition, it is not always clear if one is referring to the biological or the psychological characteristics that distinguish males from females (Gentile, 1993). • The usage of the above terms sex and gender sot that it is not always clear if one is referring to the biological or the psychological characteristics that distinguish males from females (Gentiles, 1993).

23. Terminology Cont’d • The use of these assumptions have also been related to assumptions about causality in that the former is used to refer exclusively to biological processes and latter is used to refer exclusively to psychological or sociological processes (see Maccoby, 1988; Money, 1985). • As a result, some researchers who study humans employ such terms as sex-typical, sex-dimorphic, and sex-typed to characterize sex differences in behavior, as terms of this kind are descriptively more neutral with regard to reputed etiology.

24. Terminology Cont’d • Gender Identity isone’s own perception to one’s sex (Martin Martin, Ruble, & Szkrybalo, 2002). • Gender Identity was introduced into the professional glossary by Hooker and Stoller almost simultaneously in the early 1960s (see Money, (1985). • Stoller for example, used a slightly different term called core gender identity to describe a young child’s developing which is a “fundamental sense of belonging to one sex” p. (453).

25. Terminology Cont’d • Core gender identity was later adopted by cognitive-developmental psychologists such as Kohlberg (1966), who defined gender identity as the child’s ability to accurately discriminate males from females and then to identify his or her own gender status correctly- a task considered by some to be the first “stage” in gender constancy development, the end state of which is the knowledge of gender invariance (Martin, Ruble, & Szkrybalo, 2002).

26. Terminology Cont’d • Gender role has been used extensively by developmental psychologist to refer to behaviors, attitudes, and personality traits that a society, in a given culture and historical period, designates as masculine or feminine, that is, more “appropriate” to or typical of the male and female role (Ruble et al.,2006). • From a descriptive point of view, the measurement of gender role behavior in young children includes several easily observable phenomena, including affiliative preference for the same-sex versus opposite-sex peers, roles in fantasy play, toy interest, dress-up play, and interest in rough and tumble play.

27. Terminology Cont’d Gender RoleCont’d • In older children or adolescents, gender role has also been measured using personality attributes with stereotypic masculine or feminine connotations or with regard to recreation and occupational interests and aspirations (Ruble et al.,2006; Zuker, 2005).

28. Terminology Cont’d Sexual Identity • It is important to separate the construct of sexual orientation from the construct of sexual identity. • For example, a person may be predominately aroused by homoerotic stimuli, yet not regard himself or herself to be gay or lesbian. • According to the Nursing Outcomes Classification (NOC) sexual identity is defined as the acknowledgment and acceptance of one's own sexual identity.

29. Terminology Cont’d • Transvestic Fetishism The wearing of cloths of the opposite sex (cross-dressing) principally to obtain sexual excitement and to create the appearance of a person of the opposite sex (referred to as “autogynephilla”). • Fetisistic transvestism is distinguished from transsexual transvestism by it’s clear association to with sexual arousal and strong desire to remove the clothing once orgasm occurs. After sexual orgasm occurs, sexual arousal declines.

30. Terminology Cont’d • Transgender is an umbrella term fro people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth, including but not limited to transsexuals, cross dressers, and androgynous people, genderqueers, and gender non-confirming people. Transgender is a broad term and is good for non-transgender people to use. Trans is shorthand for “transgender” (National Center for Transgender Equality, 2008).

31. Terminology Cont’d • Transsexualism a desire to live and be accepted as a member of the opposite sex, usual accompanied by a sense of discomfort with, or inappropriateness of, one’s anatomic sex, and a wish to have surgery and hormonal treatment to one’s body as congruent as possible with one’s preferred sex • Transsexual a person who has undergone medical and surgical procedures to alter external sexual characteristics to those of the opposite sex

32. Transsexual Subtypes (Male-to-Female) • Exclusively attracted to men • Overly feminine during childhood • Rated as more feminine by observers • Not sexual aroused by cross dressing • Usually transition in 20s • My be attracted to women, women and men, or neither sex • Not overtly feminine during childhood • Rated as less feminine by observers • Sexually aroused by cross-dressing currently or in the past • Usually transition in 30s or later Homosexual Nonhomosexual

33. Transsexual Subtypes Female-to-Male • Almost exclusively attracted to women • Overly masculine during childhood • Sexual attitudes are more male-typical • Greater desire for phalloplasty • Less comorbid psychopathology • Usually transition in 20s • May be primarily attracted to men or women and men • Usually less overtly masculine during childhood • Sexual attitudes are less male typical • Less desire for phalloplasty • More comorbidpsychopahology • Usually transition in 20s Homosexual Nonhomosexal

34. Gender Identity Disorder (GID)

35. Diagnostic Criteria for Gender Identity Disorder (DSM-IV-TR) Diagnostic Criteria for Gender Identity Disorder (DSM-IV-TR) • A. A strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). • In children, the disturbance is manifested by four or more of the following: • Repeatedly stated desire to be, or insistence that he or she is, the other sex • In boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

36. Diagnostic Criteria for Gender Identity Disorder (cont’d) (3) Strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex (4) Intense desire to participate in the stereotypical games and pastimes of the other sex (5) Strong preference for playmates of the other sex

37. Diagnostic Criteria for Gender Identity (Cont’d ) In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex B. Persistent discomfort with his or her sex sense of inappropriateness in he gender role of the sex.

38. Diagnostic Criteria for Gender Identity Disorder (cont’d) In children, the disturbance is manifested by any of the following: • in boys, assertion that his penis or testes are disgusting • or will disappear or assertion that it would be better not to have a penis or testes are disgusting or • or aversion toward rough-and-tumble play and rejection of the male stereotypical toys, games, and actives • In girls, the rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breast or menstruate, or marked aversion toward normative feminine clothing.

39. Diagnostic Criteria for Gender Identity Disorder (cont’d) • In adolescents and adults, the disturbance is manifested by symptoms such as pre-occupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery or procedures to physically alter sexual characteristics to stimulate the other sex) or belief that he or she was born the wrong sex. • C. The disturbance is not concurrent with a physical • intersex condition. • D. The disturbance causes clinically significant • distress or impairment in social, occupational, or • other important areas of functioning

40. Diagnostic Criteria for Gender Identiy Disorder (cont’d) • Code Based on current age: • 302.6 Gender Identity Disorder in Children • 302.85 • Gender Identity Disorder in Adolescents or Adults Specify if (for sexually mature individuals): Sexually attracted to males Sexually attracted to females Sexually attracted to both Sexually attracted to neither

41. Sex Differences in Referral Rates • The onset of most behaviors occurs during the preschool years (2-4 years), if not earlier. Clinical referrals often occur when parents begin to feel that the pattern of behavior is no longer a “phase,” a common initial parental appraisal, threat their child will “grow out of (Stoller, 1997; Zuker, 2000). • From a developmental perspective, the onset occurs during the same period that more sex-dimorphic behaviors can be observed in young children

42. Sex Differences in Referral Rates • Among children between the ages of 3 to 12, boys are referred clinically more often than girls for concerns regarding gender identity (Cohen-Kettenis, Wwen, Kaijser, Bradley, and Zucker (2003). • An office in Toronto Canada, reported a sex ratio of 5.75:1 of boys to girls based on consecutive referrals from 1975 to 2000. • Comparative data were available on children evaluated at a clinic in the Netherlands. Although the sex ratio was significantly smaller (2.93:1), boys referral rates were still higher as oppose to girls (Zuker, 2005).

43. Why Higher Referral Rates Among Boys? • One possibility is that prevalence data from the general population are lacking and this remains a matter of speculation (Zucker & Bradly, 1995). • Social factors- for example it is well established that parents, teachers, and peers are less tolerant of cross-gender behavior in boys than in girls, which might result in the sex-differential in clinical referrals (Zucker & Bradly, 1995). • Another factor could affect the sex referral rates relates to the salience of cross-gender behavior in boys verses girls.

44. Sex Differences in Referral Rates • For example, It has been long observed that the sexes differ in the extent to which they display sex-typical behavior; when there is significant between-sex variation, it is almost always the case that girls are more likely to engage in masculine behaviors than boys are to engage in feminine behaviors (Zuckers, 2005).

45. DSM-IV-TR versus DSM-V The DSM not only determines how mental disorders are defined and diagnosed, it also impacts how people see themselves and how we see each other. While diagnostic terms facilitate clinical care and access to insurance coverage that supports mental health, these terms can also have a stigmatizing affect. Source: Gender Dysphoria. American Pyschiatric Association, 2013.

46. Gender Identity Disorder vs. Gender Dyshoria Gender Identity Disorder/ Gender Dysphoria • Respecting and ensuring care • DSM-V aims to avoid the stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. • It replace the diagnostic name “gender identity disorder with gender dysphoria,” as well as makes other important clarifications in the criteria. • It is important to note hat gender nonconformity is not in itself a mental disorder. The critical element of gender dysphoria is the presence of clinically significant distress associated with the condition.

47. Gender Identity Disorder vs. Gender Dyshoria (cont’d) Characteristics of the Condition For a person diagnosed with gender dysphoria, there a clear or marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

48. Gender Identity Disorder vs. Gender Dyshoria (cont’d) • Gender dysphoria is manifested in a variety of ways, including strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions of the other gender.

49. Gender Identity Disorder vs. Gender Dyshoria (cont’d) • The DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change). This ensures treatment access for individual who continue to undergo hormone therapy, related surgery, or psychotherapy or counseling to support their gender transition. • Gender dysphoria will have its own chapter in DSM-5 and will be separated for Sexual dysfunctions and Paraphilic Disorders.

50. Gender Identity Disorder vs. Gender Dyshoria (cont’d) • Persons experiencing gender dysphoria need a diagnostic term that protects their access to care and won’t be used against them in social occupational, or legal areas. • When it comes to access to care, many of the treatment options for this condition include counseling, cross-sex hormones, gender reassignment surgery, and social and legal transition to the desired gender. • To get insurance coverage for the medical treatments, individuals need a diagnosis. The Sexual and Gender Identity Disorder Swork Group was concerned that removing the condidtion as a psychiatric diagnossis—as some suggested—would jeoporadizeacess to care.