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| HBIGDA STANDARDS OF CARE - 1998 (version 5) |
SECTIONS |
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I.
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 adults were stated as 1 in 37,000 males and
1 in 107,000 females. The most recent information of the transsexual end
of the gender identity disorder spectrum from Holland 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 a higher
prevalence: 1) unrecognized gender problems are occasionally diagnosed
when patients are seen with anxiety, depression, conduct disorder,
substance abuse, dissociative identity disorders, borderline personality
disorder, other sexual disorders and intersexed conditions; 2) some
nonpatient male transvestites, female impersonators, 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 variant behavior among
female-bodied individuals tends to relatively invisible to the culture,
particularly to mental health professionals and scientists.
Natural
History of Gender Identity Disorders. In the past, so
much attention had been paid to the therapeutic sequence of cross-gender
living, administration of cross-sex hormones, and genital (and other)
surgeries that some made the erroneous assumption that a diagnosis of
GID inevitably should lead to this sequence. A diagnosis of GID actually
only creates a serious consideration of an array of complex options,
only one of which is medical support for this triadic therapeutic
sequence. Ideally, prospective data about the natural history of gender
identity struggles would inform all treatment decisions. These are
lacking except for the demonstration that most boys with gender identity
disorder outgrow their wish to become a girl without therapy. Five less
firmly scientifically established factors prevent clinicians from
prescribing the triadic therapeutic sequence 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 sequence
varies significantly from study to study.
Cultural
Differences in Gender Identity Disorders Throughout the World. Even if
epidemiologic 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 the disorder. Moreover, access to treatment,
cost of treatment, the therapies offered and the social attitudes
towards the afflicted and the professionals who deliver care differ
broadly from place to place. While in most countries, crossing gender
boundaries more reliably generates moral outrage rather than compassion,
there are striking examples in certain cultures how the cross-gendered
behaviors of spiritual leaders 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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