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| HBIGDA STANDARDS OF CARE - 2001 (version 6) |
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II.
Epidemiological Considerations
Prevalence. When the gender
identity disorders first came to professional attention, clinical
perspectives were largely focused on how to identify candidates for sex
reassignment surgery. As the field matured, professionals recognized
that some persons with bona fide gender identity disorders neither
desired nor were candidates for sex reassignment surgery. The earliest
estimates of prevalence for transsexualism in adults were 1 in 37,000
males and 1 in 107,000 females. The most recent prevalence information
from the Netherlands for the transsexual end of the gender identity
disorder spectrum is 1 in 11,900 males and 1 in 30,400 females. Four
observations, not yet firmly supported by systematic study, increase the
likelihood of an even higher prevalence: 1) unrecognized gender problems
are occasionally diagnosed when patients are seen with anxiety,
depression, bipolar disorder, conduct disorder, substance abuse,
dissociative identity disorders, borderline personality disorder, other
sexual disorders and intersexed conditions; 2) some nonpatient male
transvestites, female impersonators, transgender people, and male and
female homosexuals may have a form of gender identity disorder; 3) the
intensity of some persons' gender identity disorders fluctuates below
and above a clinical threshold; 4) gender variance among female-bodied
individuals tends to be relatively invisible to the culture,
particularly to mental health professionals and scientists.
Natural
History of Gender Identity Disorders. Ideally,
prospective data about the natural history of gender identity struggles
would inform all treatment decisions. These are lacking, except for the
demonstration that, without therapy, most boys and girls with gender
identity disorders outgrow their wish to change sex and gender. After
the diagnosis of GID is made the therapeutic approach usually includes
three elements or phases (sometimes labeled triadic therapy): a real
life experience in the desired role, hormones of the desired gender, and
surgery to change the genitalia and other sex characteristics. Five less
firmly scientifically established observations prevent clinicians from
prescribing the triadic therapy based on diagnosis alone: 1) some
carefully diagnosed persons spontaneously change their aspirations; 2)
others make more comfortable accommodations to their gender identities
without medical interventions; 3) others give up their wish to follow
the triadic sequence during psychotherapy; 4) some gender identity
clinics have an unexplained high drop out rate; and 5) the percentage of
persons who are not benefited from the triadic therapy varies
significantly from study to study. Many persons with GID will desire all
three elements of triadic therapy. Typically, triadic therapy takes
place in the order of hormones = = > real life experience = = >
surgery, or sometimes: real life experience = = > hormones = = >
surgery. For some biologic females, the preferred sequence may be
hormones = = > breast surgery = = > real life experience. However,
the diagnosis of GID invites the consideration of a variety of
therapeutic options, only one of which is the complete therapeutic
triad. Clinicians have increasingly become aware that not all persons
with gender identity disorders need or want all three elements of
triadic therapy.
Cultural
Differences in Gender Identity Variance throughout the World. Even if
epidemiological studies established that a similar base rate of gender
identity disorders existed all over the world, it is likely that
cultural differences from one country to another would alter the
behavioral expressions of these conditions. Moreover, access to
treatment, cost of treatment, the therapies offered and the social
attitudes towards gender variant people and the professionals who
deliver care differ broadly from place to place. While in most
countries, crossing gender boundaries usually generates moral censure
rather than compassion, there are striking examples in certain cultures
of cross-gendered behaviors (e.g., in spiritual leaders) that are not
stigmatized.
| Some
of the resources in this section contain differing viewpoints comprising
a variety of authors, committees, and interest groups. Additionally,
some of these materials are delivered in an advisory context, covering
legal, ethical, medical and social issues. These materials do not
necessarily represent the guidelines of TransGenderCare or
the philosophies of our staff. |
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