Gender Identity Dysphoria: Diagnosis or Self-Diagnosis?

Gender Identity Disorders • According to Section F.64 of the ICD-10 of the WHO, the following gender identity disorders (GIDs) are classified as health problems: • *Transsexualism (F.64.0 and F.64.2) • *Crossdressing (F.64.1) • *Transgenderism (F.64.8), which is included under gender identity disorders not otherwise specified (GIDNOS) • It is important to note that gender identity disorders have nothing to do with the issue of sexual orientation, and that gender dysphoric persons may be heterosexual, homosexual, or bisexual. • Although gender identity disorders are recognized as health problems, the choice of sexual orientation--whether heterosexual, homosexual or bisexual—is in no way a health problem because it is simply a matter of taste. • WHO-World Health Organization, from UN. • ICD-10 – 10th edition of the International Code of Desiases.

What Is Gender Therapy? • *It includes the diagnosis of gender identity disorders (GID and GIDNOS) per Section F.64 of the ICD-10 of the WHO. • *It includes the post-diagnosis treatment of these persons, which may involve gender transition and hormone replacement therapy (HRT). • *It includes psychological counseling for these persons during the diagnosis and possible transition stages. • *Transition can involve surgery to correct secondary sex characteristics, including possible sex reassignment surgery (SRS) in cases where it may be advisable. • *It includes psychotherapy and sexual counseling after sexual reassignment surgery. • *It is equally beneficial in male-to-female (MtF) cases as in female-to-male (FtM) ones.

Diagnosis of both MtF and FtM cases of Gender Identity Dysphoria

SELF-DIAGNOSIS • *Every person who has some form of GID, whether transsexual (F.64.0 or F.64.2) or transgender (F.64.8), knows as a young child or as an adolescent that he or she is different from other people, even if he or she does not know exactly why or how. Many times these people confuse themselves with homosexuals, because families and societies often mistakenly classify them in that way. • *All of these people possess, for different reasons and in different situations, an unexpected femininity (MtF) or masculinity (FtM). Even when they do not openly reveal this to society, they are privately aware of it. • *The person with GID is intimately aware of being different, and knows that the difference has to do with identity, particularly gender identity. • *In light of this awareness, the GID diagnosis involves an element of self-evaluation by the patient, a process that needs to be encouraged and properly evaluated by the psychotherapist. • *The psychotherapist does not diagnose; he or she only stimulates the patient to self-diagnose, and guides him or her in this process.

Diagnostic Tools • *Two useful diagnostic tools are available to assist in the patient’s self-diagnosis: the life history (anamnesis) and Gendercare tests of unexpected femininity or masculinity. • *The life history can be charted through face-to-face consultation, in which the therapist identifies with the patient and leads him or her to open up to reveal a complete history. The events in this history will allow the therapist to understand the patient’s motivations and the reasoning behind the self-diagnosis, so that the therapist will be able to judge if the reasoning and self-diagnosis are or are not reasonable and coherent. • *A high-quality life history can be effectively obtained through emailing, without the direct presence of the psychotherapist.We suggest always email anamnesis for all MtF and FtM patients.

*The second diagnostic tool is the use of specific tests to evaluate the presence and origin of an unexpected femininity or masculinity. *Gendercare has developed the MFX and FMX tests expressly for this purpose. *The patient can take these tests either in person or online, which is convenient and also minimizes the possibility of outside interference with the results. *These tests probe the various stages of the patient’s life, trying to stimulate the patient’s memory, especially his or her self-view and feelings during these life stages. *In other words, these diagnostic tools lead the patient to a systematic and objective self-diagnosis and reveal the developmental dynamic of his or her unexpected femininity or masculinity.

*With the results of the patient’s life history and the test of unexpected gender expression in hand, the therapist will be able to verify how the patient expresses himself/herself and how in reality he or she identifies. • *When a gender identity disorder exists, it will be possible to verify how the patient self-diagnoses. • *The patient’s self-diagnosis must always be respected by the therapist. The therapist’s function is to clarify the self-diagnosis for the patient, especially to show him or her at certain key moments (such as when deciding between the choices of transsexualism and transgenderism, or between crossdressing and transgenderism) the pros and the cons of each option, in order to help the patient self-diagnose and deal with the eventual life adjustments that are required.

Trauma • *As we already mentioned in other presentations, the great majority of cases of crossdressing and transgenderism originate from trauma, as do some cases of transsexualism. • *In the life history we can detect the presence or absence of trauma based on: • a) Maternal rejection • b) Paternal violence (physical or sexual) • c) Family violence (by the father against the mother and/or siblings) • d) Later sexual abuse (father, siblings, cousins, friends, etc.) • e) Miscellaneous • *In the test of unexpected gender identity, trauma is usually indicated by a lack of structure and stability throughout the patient’s lifetime.

Biological Etiology • *The majority of cases of transsexualism have a biological etiology, determined by genetic and endocrinological factors, often aggravated by the emotional state of the mother during pregnancy. • *These conditions always result in cases of transsexualism (but do not result in crossdressing or transgenderism), but do not cause subsequent psychological problems like those that occur as the result of childhood trauma. Consequently, a certain calmness and passivity is characteristic of transsexuals. • *Transgenderists differ in being more aggressive and possibly even violent. This is the result of a long-standing and continual aggressiveness which ultimately is expressed socially, and which is the person’s sole defense mechanism. • *A patient’s aggressive and defensive attitudes indicate prior trauma and a more likely diagnosis of transgenderism than of transsexualism. This is not an ironclad rule, but it is a high probability. • *The life history and the tests of unexpected gender identity easily permit differentiation between these types of cases.

The therapist’s diagnostic capability • *It’s ordinarily difficult for any therapist to remain aware that a diagnosis always arises from the patient’s reality--never from the preconceived and theoretical ideas of the analyst. • *Therefore all GID analysts should always learn to identify with the patient. This is the only way he or she can fully understand the diagnosis of GID in all of its nuances and with all the varied forms GID expression may take. • *The therapist should be adequately prepared to work with GID cases. A doctorate in psychology or psychiatry (which is recommended by the HBIGDA) is not in itself sufficient unless the therapist is also capable of identifying with the GID patient. • *Even more questionable is the value of psychotherapy by analysts who have obtained doctoral and master’s degrees by conducting theoretical “research” from outside the area of patient-oriented (clinical)practice. • *No one can effectively study a culture without being immersed in it for some time. In order for a therapist to understand the self-diagnosis of GID patients, it’s indispensable to have a strong initiatory experience as a GID person in a GID environment.

Learning with Ethnology • *Consider the writing of Juana Elbein dos Santos, Ph.D., from her doctoral dissertation in ethnology at the Sorbonne in the 1970’s: • *”The ethnologist, with rare exceptions, lacks background experience and does not live sufficient time within the group, and so the majority of the time his or her observations are imposed “from without” and are colored by his or her own frame of reference; it’s rare that the ethnologist speaks the language of the study subjects, and he or she often relies on information from study participants who in turn speak the language of ethnology poorly.” • *In her dissertation, she goes on to say: “To be initiated, to learn the features and values of a culture from the inside through a dynamic relationship within the heart of the group, and at the same time to be able to derive from that empirical reality a group’s organizing principles, dynamic meanings and their symbolic relationships, in a conscious effort of abstraction as an outsider—this is a highly ambitious undertaking against which the odds of success are stacked.”

Initiatory Experience • *Individuals with GID always live in a social and cultural existential ghetto that results from the ignorance of society about who they are and why they are like they are. Many are prostitutes who lead a sub-human existence. Trauma abounds in their lives, beginning in their infancy, permeating their adolescence and culminating in their adulthood. • *What psychotherapeutic approach can best help alleviate such debilitating stresses? • *Regardless of the psychotherapist’s background, as an outsider it’s necessary that he or she have “initiatory experience,” that is, have the radical and prolonged experience of being at minimum a crossdresser, openly and publicly, for a period of months or even years in his or her customary social environment. This is the initiation we propose in order to meet Elbein dos Santos’s requirements to establish the credentials of a psychotherapist coming “from the outside.”

The Language • *After the initiatory experience we are proposing, it will be easy for the therapist to understand the language of GID. • *Only after experiencing a profound real-life initiatory experience can a psychotherapist “from the outside” understand the violence resulting from post-traumatic stress disorder (PTSD), spontaneous weeping, loss of hope and attempts at suicide. • *In this way it will be possible through the language of GID to establish a therapy regime based on identification with the patient, engaging in social and psychological interchange, rather than employing pre-conceived theories from the outside and analyzing patients as if they were laboratory animals. • *The language of GID is the language of empathizing with another in his or her desperation. It is also the language of identification with nature’s vital forces, which the Egyptians in the time of the Pharaohs knew well how to tap. • *Still, the best solution will always come “from the inside toward the outside,” even though the opposite approach is not, strictly speaking, impossible.

Conclusion • *To the psychologist or psychiatrist, the sexologist or other analyst of GID cases: do you want to learn how to deal with these cases, but you are not personally gender dysphoric? • *1. Make yourself gender dysphoric—experience a real-life initiatory experience as a crossdresser, publicly exposing yourself to the hostility of society for six months or a full year. • *2. Learn the language of gender dysphoric suffering by suffering as a gender dysphoric person does. • *3. Identify with your GID patients, using techniques of psychological identification. • *4. Learn how to work with them, and to make contact with their inner reality that you have already personally experienced (even if to a lesser degree). • *Then, using a good life history and Gendercare’s MFX and FMX tests of unexpected gender identity/ expression, a diagnosis will be easy and the treatment will be simple, and it will be possible to anticipate a cure or at minimum a significant alleviation of the problem. • *But always remember: Transsexual GID generally has a biological etiology and involves a discordance between the patient’s mental gender and his or hersexual organs, caused by genetic and hormonal factors aggravated by the mother’s emotional state during pregnancy. However, transgenderism and crossdressing almost always are the consequence of trauma. And only the patient himself or herself knows the deepest truth about the possible roots of the problem. • *Identify with the patient…help him or her to self-diagnose. • *Then, you will have made yourself a real gender therapist!

Bibliography • Colapinto, J.—As Nature Made Him—Harper Collins, 2000 ; • Elbein dos Santos, J --- Os Nagô e a Morte --- Editora Vozes, 1975; • Freitas, M.C. --- Meu Sexo Real --- Editora Vozes, 1998.

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Gender Identity Dysphoria: Diagnosis or Self-Diagnosis?