Abstract
Both the diagnosis and treatment of Gender Identity Disorder (GID) are controversial. Although linked, they are separate issues and the DSM does not evaluate treatments. The Board of Trustees (BOT) of the American Psychiatric Association (APA), therefore, formed a Task Force charged to perform a critical review of the literature on the treatment of GID at different ages, to assess the quality of evidence pertaining to treatment, and to prepare a report that included an opinion as to whether or not sufficient credible literature exists for development of treatment recommendations by the APA. The literature on treatment of gender dysphoria in individuals with disorders of sex development was also assessed. The completed report was accepted by the BOT on September 11, 2011. The quality of evidence pertaining to most aspects of treatment in all subgroups was determined to be low; however, areas of broad clinical consensus were identified and were deemed sufficient to support recommendations for treatment in all subgroups. With subjective improvement as the primary outcome measure, current evidence was judged sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus. The report recommends that the APA take steps beyond drafting treatment recommendations. These include issuing position statements to clarify the APA’s position regarding the medical necessity of treatments for GID, the ethical bounds of treatments of gender variant minors, and the rights of persons of any age who are gender variant, transgender or transsexual.
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Notes
Epidemiological studies are lacking so that no strong conclusions about the prevalence of GID can be drawn (Zucker & Lawrence, 2009). The DSM-IV estimates that roughly 1:30,000 natal males and 1:100,000 natal females ultimately seek SRS. These are underestimates for the prevalence of GID since not all adults who meet criteria for GID seek SRS, and GID diagnosed in childhood usually does not persist into adolescence and adulthood.
Since the completion of this report, version 7 of the WPATH SOC has been published and is available at www.wpath.org.
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Acknowledgments
This report, chaired by William Byne, was approved by the Joint Reference Committee, July 2011 and by the APA Board of Trustees, September 2011. The findings, opinions, and conclusions of this report do not necessarily represent the views of the officers, trustees, all members of the task force, or all members of the APA. The views expressed are those of the authors of the individual chapters. Task Force Reports are considered a substantive contribution of the ongoing analysis and evaluation of problems, programs, issues, and practices in a given area of concern. We would like to thank the following for reading and providing comments on the initial draft of the report: Peggy T. Cohen-Kettenis, Ph.D., Jack Drescher, M.D., Sharon Preves, Ph.D., and Nada Stotland, M.D. This report is published in Archives of Sexual Behavior with permission from the American Psychiatric Association.
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Appendices
Appendix 1: Other APA Policy Concerns Regarding GV
In addition to the issue of treatment recommendations, several concerns regarding gender identity and the rights of persons who are gender variant are potential subjects for policy development within the APA. These include:
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1.
Support for treatment resources for gender variant and gender transitioning adults, and removal of barriers to care, including insurance coverage for accepted treatments, similar to AMA House of Delegates Resolutions 114 (A-08) and 122, and the American Psychological Association Council of Representatives Policy Statement regarding Gender Identity, Transgender and Gender Expression Non-discrimination.
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Support for reasonable revision of identity documents for gender transitioning persons, including United States passports and birth certificates, which are currently difficult to correct.
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3.
Specific support for the marriage, adoption and parenting rights of transgender and gender transitioning persons, similar to existing APA policies regarding same gender couples.
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4.
Support for the rights of incarcerated persons who are gender variant or gender transitioning to personal safety and comprehensive healthcare, including transgender health services.
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5.
Support for transgender health services for members of the uniformed services and veterans, and opposition to the use of transgender or GV as grounds for discharge or rejection from enlistment.
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6.
Support for the most appropriate placement of persons who are transgender in gender-segregated treatment facilities, including inpatient psychiatric units, residential addiction treatment programs, and geriatric care centers.
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7.
Support for the inclusion and fair, collegial treatment of gender variant persons in all aspects of professional life, including medical schools, residency programs and fellowships in psychiatry, and the APA.
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8.
Support for professional and public education regarding transgender and GV, including:
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(a)
Scientifically sound, non-stigmatizing information about GV for patients and members of the general public.
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(b)
The inclusion of affirming, non-discriminatory information regarding GV and gender transition in the curricula of medical schools and psychiatric residencies and fellowships.
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(c)
Sponsorship of CME activities regarding transgender, such as presentations at the APA annual meeting and written materials in CME publications, particularly those used for maintenance of certification (MOC).
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(d)
Inclusion of questions about transgender on the ABPN certifying and MOC examinations.
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(e)
Tasking a specific APA Component or other group within the APA to monitor progress with regard to these activities.
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(a)
Appendix 2: Other APA Concerns Regarding DSD
Because of the multiplicity of DSDs, the complex differences among them and their implications for integrated interdisciplinary care that includes mental health services; because not all DSDs are associated with either gender ambiguity or gender dysphoria; and because the needs of individuals with DSDs and gender dysphoria overlap incompletely with the needs of individuals with gender dysphoria in the absence of a DSD, the Task Force recommends that the APA create a separate mechanism for assessing the mental health needs of individuals with DSDs, whether or not gender dysphoria is present, and for working toward better integration of mental health professionals into the interdisciplinary teams that provide their care. This would include involvement with parents as soon as the DSD comes to attention, which increasingly occurs during pregnancy.
Areas identified to be addressed within this mechanism include (1) psychoeducation of parents or primary caregivers; (2) assessment of indications and readiness for gender confirming surgeries and procedures related to them; (3) age appropriate disclosure of DSD status and related medical/surgical history; (4) issues related to gonadectomy and infertility; (5) DSD-associated stigma including that related to genital anomalies and other body image issues as well as feelings of shame and guilt; (6) revealing DSD status to others, and (7) the impact of DSD status on relationship issues including sexual intimacy.
The recommendation to create a mechanism to address the mental health needs of individuals with DSDs, whether or not gender concerns are present, is not intended to exclude individuals with DSDs from APA recommendations pertaining to GID, GIDNOS or other manifestations of GV.
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Byne, W., Bradley, S.J., Coleman, E. et al. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav 41, 759–796 (2012). https://doi.org/10.1007/s10508-012-9975-x
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DOI: https://doi.org/10.1007/s10508-012-9975-x