Archives of Sexual Behavior, Vol. 7, No. 4, 1978

GENDER DYSPHORIA SYNDROME: TOWARDS STANDARDIZED DIAGNOSTIC CRITERIA

K. Roy MacKenzie, M.D., F.R.C.P.

(C)

University of Calgary Calgary, Alberta, Canada

T2N IN4

"A person who believes himself or herself to properly belong to the opposite sex and who, while not denying his or her sexual anatomy, attempts to live in the chosen social role and seeks out sex reassignment procedures"--a standard definition of the Gender Dysphoria Syndrome. This broader term~ replacing transsexualism, has permitted the introduction of appropriate subgroups, but has failed to resolve the dilemma, well described by Kubie (i) almost a decade ago, of defining a clinical syndrome on the basis of treatment seeking behavior. Admittedly, it is somewhat comforting that the great majority of patients express no regrets over surgery and that most seem to function more competently on a variety of outcome measures (2)(3)(4). Experienced clinicians agree that a profound disturbance of gender identity can occur, the problem lies in adequate descriptions and theories to deal with it. As Edgerton (5) commented at the previous Stanford symposium on Gender Dysphoria Syndrome, the first step was to make it professionally respectable to even study such material. It is now crucial that the second step be undertaken--the development of more rigorous definitions so that data can be accumulated and compared from the numerous centers involved in case assessment and treatment.

THE PROBLEM The Gender Dysphoria Syndrome has demonstrated a proclivity for the creation of self-fulfilling, self-validating, reinforcing cycles on a number of different levels. 251 0004-0002/78/0700-025i$05.00/0 © 1978 Plenum Publishing Corporation

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The first such self-fulfilling prophecy is eloquently described by Green (6) in his work with feminine boys. The young child who demonstrates feminine behavioral qualities for whatever reason, will elicit predictable interaction sequelae both within the family and within his peer group. This tends to polarize attitudes, making alterations increasingly difficuit, with the result that the child's only refuge for maintenance of self-esteem is to doggedly retrench further into established patterns. This is a close parallel to Harlow's unsocialized monkeys (7). k~en placed in an adult colony their obviously inappropriate behavior elicits instantaneous and permanent rejection by the group. However, these same unsocialized monkeys when placed with infant monkeys who do not reject them, are able to acquire social graces--a close primate parallel to a self-fulfilling prophecy based upon response to social behavior. The second self-fulfilling prophecy operates at the diagnostic level. As Fisk has indicated (8), as long as the word was out that only classical transsexual histories were welcome, io and behold, only classical cases appeared. Such is the pervasive influence of the underground press and the street grapevine that we would be wise to treat most historical information with the same skepticism shown towards the ingestion histories of individuals with addictive problems. We all have an understandable tendency to file information into predictable and familiar patterns and, therefore, can easily fall victim to this second self-fulfilling prophecy. There is yet a third self-fulfilling cycle which, of the three, causes most concern. This is in regard to scientific conceptualization. Behavioral science has been the victim, albeit the willing victim, to successive waves of "ologies" and "isms". Unfortunately, human behavior is so exceedingly complex that one can make a case for almost any interpretation. To say that all theories are valid and "just another way of looking at the data" is really a cognitive cop-out. The Gender Dysphoria Syndrome is a theorist's paradise--for in the absence of any objective criteria, the stage is clear for a happy Collusion of fantasies between therapist and patient. And so the theoretical spotlight may pick an overly close mother in this corner, a seductive babysitter here or a neighborhood of girls there.

Gender Dysphoria Syndrome

2 53

Such a situation is obviously open to ~he elaboration of theories which the f~cts~ being infinite, can be selectively chosen to fit by both patient and professional. A welcome exception to this is Green's recent book, SEXUAL IDENTITY CONFLICT IN CHILDREN AND ADULTS (9). Here we have a prototype of the kind of basic research required, not just in regard to gender identity, but for the entire gamut of developmental and behavioral syndromes. Green's material combined with Money and Ehrhardt's, MAN AND WOMAN BOY AND GIRL (i0), forms a base for a hard science of gender. Unfortunately, this material is not of immediate value to the clinician assessing a candidate for sex reassignment. I believe it is clear to all of us that at the adult clinical level we are dealing, as in schizophrenia and most neurotic disorders, with a common symptom pattern having more similarity to a headache than a positive Australian antigen. The historical approach at this stage of understanding of a syndrome is to develop a phenomenological set of criteria until clear subgroups emerge with etiologic consistency. For example, hypertension is an umbrella term much as gender dysphoria. As specific entities with known etiology have emerged, a specific label is applied, for example, "hypertension due to renal artery stenosis", while the remainder remains lumped under the term "essential hypertension". That term, by the way, indicates that not just psychiatry has trouble with suitable terminology. ! believe that we should be prepared at this meeting, or as an immediate outcome from it, to make a commitment to a standardized methodology of case reporting with firm and necessary criteria, since most investigative gender identity clinics are represented at this meeting, such a move could have immediate and significant impact in ordering data collections. We may not all agree on the details but at least we could agree to talk a common language and argue about the significance later. CLASSIFICATION If we agree that the term ~'Gender Dysphoria Syndrome" is a non-specific descriptive clumping term, then there are a number of subcategories with known etiology which can be identified. These include Gender Dysphoria Syndrome related to:

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1.

2. 3. 4. 5.

.

Chromosomal abnormalities Endogenous hormonal abnormalities Exogenous hormonal abnormalities Temporal lobe phenomena Psychosis. While the etiology may not be known, for our purposes such a diagnosis based upon the usual criteria quite apart from gender implications, adequately serves to isolate this subgroup. Psychopathic personality disorder. This is more difficult, but certainly the usual non-gender related criteria must be present, plus the conclusion that the sex conversion seeking behavior is based upon motives related to social manipulation, not personal confusion regarding gender identity. This subcategory cannot stand apart solely on the basis of a co-existing diagnosis of personality disorder and gender dysphoria syndrome. The issue of motivation must be established and this presents formidable problems to behaviorally operationalize. I would hope this potential subcategory is seldom used.

We have remaining under our umbrella of gender dysphoria three intertwined entities with no established etiologies but a welter of theories. At this time, we cannot justifiably segment off any one of these. I refer, of course, to classic transsexualism, effeminate homosexuality in the male and hypermasculine homosexuality in the female, and transvestism. CRITERIA SCALES I shall present a set of phenomenological criteria for describing abnormalities in gender orientation in the hope that clear subgroups or at least critical variables may emerge with both etiologic and treatment significance. It is crucial that at this stage such categorization not be linked directly to the surgical decision-making process less the self-fulfilling diagnostic prophecy earlier mentioned be repeated. The surgical decision properly requires criteria in addition to the diagnostic ones such as depth of patient motivation, ability to cope in chosen role, general emotional stability, and social support system.

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Six criteria scales are presented, all tapping aspects of history or present behavior relevant to the current state of the literature concerning the Gender Dysphoria Syndrome. The scales are as follows: I. Childhood Cross Gender Behavior (CHILD) II. Adult Cross Gender Scale (ADULT) III. Homophile Scale (HP) IV. Heterophile Scale (HTP) V. Genital Erotic Focus (GEN) VI. Transvestite Scale (TV) For each of these, there is a weighted scale with maximum scores of ten; these may be graphed in a fashion similar to an MMPI. This display system is preferable to the triangular system suggested by Pearson (ii) for it allows the addition of additional scales and avoids problems in matrixing. These scales do not contain new diagnostic material but form a system for the organization of variables with which we are all basically familiar. I. Childhood Cross Gender Behavior (CHILD). This scale refers to data relating only to the first four years of life. It is preferable that all data be confirmed by a third party, parents, siblings, neighbors, family, friends, etc. If the information is obtained only through the patient, the score should be circled to indicate that it is of lower reliability, This variable clearly relates to core gender identity formation which should be well consolidated by age four. It would most commonly be found in those patients giving a classical transsexual history. The variable is of such fundamental importance and relevance to known data regarding gender development that it deserves to be ranked as an independent measure. Criteria i.

Repeatedly stated belief that one is of the other sex or of the desire to be of the other sex.

2.

Repeated cross-dressing or ~ttempts to do so against parental prohibition.

3.

Routinely adopting other role in sexual and fantasy games.

Weishted Value

256

4. 5. 6. 7.

MacKenzie

Clearly evident adoption of the physical mannerisms of the other sex. Toy preferences almost always appropriate for other sex Strong preference for other sex playmates. Enjoyment of rough play and body contact sports (score if absent for boys, present for girls).

1 1 1

1 i0

II, Adult Cross Gender Scale (ADULT)~ This scale attempts to quantify the degree of adoption of the chosen gender role. The scoring should be based upon clinical information available in regard to the twelve month period prior to the date of assessment. Criteria i.

2.

3.

4.

Weighted Value

Estimation by the interviewer of the effectiveness of chosen gender physical mannerisms: extremely crude or nonexistant = 0; present but distinctly maximum 2 obvious = i; effective simulation = 2. Persistence of chosen gender role in fantasy activity, i.e., during masturbation, dreams or daydreams: seldom or never present = 0; approximately equal alternation between chosen and anatomical roles = i; chosen gender maximum 2 role present almost always = 2. Frequency of cross-dressing for role assumption, do not score cross-dressing used primarily for erotic arousal: done privately at a frequency less than once per month = i; done privately at a frequency greater than once per month = 2; done publicly at a frequency greater than once per month = 3; done publicly maximum 4 on a daily basis = 4. Vocational choice, estimate on the basis of usual sexual vocational choice for your area taking into account cultural and socioeconomic factors if vocational choice is: clearly of a same sex nature

Gender Dysphoria Syndrome = 0~ of a neutral nature = i; of a clearly chosen gender nature = 2.

257

maximum 2 i0

III~ H o m o p h i l e Scale (HP)° This scale relates to sexual object choice, it should not take into account whether this relationship is seen as a homosexual relationship or whether the patient views his participation as that of the chosen gender role. It refers specifically to active genital activity. Criteria I.

2o

3.

Sexual relationship with same sex partner occurring more than ten times before the age of 18. Sexual relationship with same sex partner: occurring more than ten times after the age of 18 = 2; occurring at a frequency of at least once per month on an average over a two year period = 4, over a five year period = 6 Marital relationship w i t h one same sex partner lasting at least twelve months.

Weighted Value

maximum 6

i0 IV. Heterophile Scale (HTP)° This scale also relates to sexual object choice regardless of the fantasied relationship qualities. It refers to genital intravaginal intercourse. Criteria i.

2.

Sexual relationship with opposite sex partner occurring more than ten times before the age of 18. Sexual relationship with opposite sex partner: occurring more than ten times after the age of 18 = 2; occurring at a frequency of at least once per month on an average over a two year period = 4; over a five year period = 6.

Weighted Value

maximum 6

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3.

MacKenzie

Marital relationship with one opposite sex partner lasting at least twelve months I0

V. Genital Erotic Focus (GEN). These must usually be obtained primarily form the patient, confirmatory data should always be sought from past or present sexual partners when available. It is important that a detailed explicit description of sexual behavior be obtained. Generalizations and assumptions are to be avoided. One would predict this variable to be higher in homosexual and transvestite syndromes; however, it represents a variable which cuts across syndromes and has considerable theoretical interest regarding postsurgical adaptation, ability to shift focus, etc. Criteria i. 2.

3.

4.

5.

MasturBation more than ten times as an adolescent. Masturbation as an adult: more than ten times in lifetime experience = i; more than six times per year = 2; more than once per month on the average = 3. Erection or high arousal during heterosexual or homosexual intercourse: more than ten times in lifetime experience = i; if greater than ten occasions and on more than 25% of total lifetime occasions = 2. Ejaculation or climax during heterosexual or homosexual intercourse on more than ten occasions including vaginal, anal or oral techniques. Heterosexual or homosexual genital activity with an average frequency of intercourse at least once per month at any period of adult life lasting: at least two years = I; at least five years = 2.

Weighted Value

maximum 3

maximum 2

maximum 2 i0

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VI. Transvestite Scale (TV). The principal concern here is fetishistic cross-dressing, often accompanied by otherwise normal heterosexual activity. This pattern may often merge into one of a double gender role playing. The scale is generally of use for males only. Criteria i.

2.

3.

4.

Weighted Value

Ritualistic cross-dressing with erotic arousal on at least ten occasions before the age of 18. Ritualistic cross-dressing with erotic arousal with an average frequency of at least once per month: over a two year period = 2; over a five year period = 4. Routine utilization of female underclothing with male attire: over a two year period = i, over a five year period = 2. Role playing of two personalities, one masculine with male attire and one feminine with female attire, over a period of at least two years.

2

maximum 4

maximum 2

2 i0

OBJECTIVE DATA I will conclude with some comments regarding techniques to be explored in obtaining more objective assessment data. A patient's self report is open to considerable distortion, as are the more obvious psychological questionnaires such as the MMPI and Body Image scores. Projective testing offers tantalizing possibilities, for example, scoring for body boundary definiteness and penetration scores, but again such tests are imprecise, heavily dependent on administration and scoring, and are open to deception by the knowledgeable patient. A technique offering possibilities to be explored is that of physiologic response to erotic imagery. Surprisingly little has been reported in the literature utilizing penile plethysmography response to erotic imagery in transsexuals. While this technique is useful only in the anatomical male, it is this group which offers most diagnostic

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challenges. An advantage of this technique is that changes being recorded are often below threshold of awareness and so are less subject to volitional control. Visual imagery has been increasingly used as a valid treatment technique to simulate real life situations, for example, desentization techniques such as reciprocal inhibition and implosion all basically utilize real or fantasized visual imagery. Sexual behavior studies clearly indicate that, for many species, visual cues are an important and necessary component for mating behavior. Similarly, vivid erotic imagery has its onset with wet dreams in adolescence, apparently as a function of testosterone levels (i0). Suffice to say, that from a variety of sources, there is strong evidence for a fundamental association among visual imagery, sexual behavior, and gender orientation, including differing quality of response for males and females. In the most comprehensive study reported, Barr (12) reports the comparative response of male transsexuals, male homosexuals, and a male control group to stimulation with male and female erotic material. All but two of the 24 transsexuals scored highly on arousal to male slides and most showed a negative penile volume response to female slides. The two exceptions had a less than classical transsexual history. Barlow, Reynolds, and Agras (13) reported an intriguing behavioral approach to what by description must be seen as a classic transsexual history in a 17-year-old male. By careful dissection of mannerisms and fantasies, a gradual reversal to a male orientation was achieved. Progress in b e h a v i o r a l m e a s u r e s was paralleled by a change of penile engorgement from male to female imagery. Freund (14) also reports on penile measurement in a small sample, including response to stimuli over a wide age range as well as response to pictures of the patient himself. The cumulative impression from these articles suggests that penile plethysmography has a potential as a more objective measure to add to the spectrum of data in patient assessment. More standardization of technique is required, with stimuli covering females, heterosexual males and homosexual males, as well as more precise consideration in re-

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gard to the effects of endogenous and exogenous hormone levels. In conclusion, a plea is made that more standardized reporting procedures be utilized to allow comparability of clinical data and isolation of significant variables. While it is inevitable that much of our historical information must continue to be obtained solely from the patient, all efforts should be extended to obtain third party validation. In addition, further work needs to be done to develop more objective criteria. Without these steps, we may continue to wander in a miasma of self~fulfilling prophecies which undermine scientific data collection and may lead to inadequate or harmful patient care. REFERENCES i.

Kubie~ L,S. and Mackie, J.B.: Critical issues raised by operation for gender transmutation. Journal of Nervous and Mental Disease 147:1431, 1968.

2.

Randell, J.: Preoperative and postoperative status of male and female transsexuals, In TRANSSEXUALISM AND SEX REASSIGNMENT, Edited by R. Green and J. Money. The Johns Hopkins University Press, Baltimore, 1969.

3.

Gandy, P.; Follow-up on 74 gender dysphoric patients treated at Stanford. In PROCEEDINGS OF THE SECOND INTERDISCIPLINARY SYMPOSIUM ON GENDER DYSPHORIA SYNDROME, Edited by D. Laub and P. Gandy. Stanford, 1974o

.

Hastings, D.: Experience at the University of Minnesota with transsexual patients. In PROCEEDINGS OF THE SECOND INTERDISCIPLINARY SYMPOSIUM ON GENDER DYSPHORIA SYNDROME, Edited by D. Laub and P. Gandy. Stanford, 1974.

5.

Edgerton, M.: Introduction. In PROCEEDINGS OF THE SECOND INTERDISCIPLINARY SYMPOSIUM ON GENDER DYSPHORIA SYNDROME, Edited by D. Laub and P. Gandy. Stanford, 1974.

. Green, R., Newman, L. and Stoller, R.: Treatment of boyhood transsexualism: An interim report of four years v duration. Archives of General Psychiatry 26: 213, 1972.

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7.

.

.

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Suomi, S.J., Harlow, H.F. and McKinney, W.T.: Monkey psychiatrists. American Journal of Psychiatry 128: 927, 1972. Fisk, N: Gender dysphoria syndrome--the conceptualization that liberalizes indications for total gender reorientation and implies a broadly based multidimensional rehabilitative regime. Western Journal of Medicine 120: 386, 1974. Green, R.: SEXUAL IDENTITY CONFLICT IN CHILDREN AND ADULTS. Basic Books, New York 1974; Gerald Duckworth, London, 1974; New York, Penguin, 1975.

i0. Money, J.W, and Ehrhardt, A.A.: MAN AND WOMAN; BOY AND GIRL. The Johns Hopkins University Press, Baltimore, 1972. ii. Pearson, M.J.: A diagnostic survey of 23 patients applying for gender surgery. In PROCEEDINGS OF THE SECOND INTERDISCIPLINARY SYMPOSIUM ON GENDER DYSPHORIA SYNDROME, Edited by D. Laub and P. Gandy. Stanford, 1974. 12. Barr, R.F.: Responses to erotic stimuli of transsexual and homosexual males. British Journal of Psychiatry 123: 579, 1973. 13. Barlow, D.H., Reynolds, E.J. and Agras, W.S.: Gender identity change in a transsexual. Archives of General Psychiatry 28:569, 1973. 14. Freund, K., Langvin, R., Zajac, Y., Steiner, B. and Zajac, A.: The transsexual syndrome in homosexual males. Journal of Nervous and Mental Disease 158:145, 1974.

Gender dysphoria syndrome: towards standardized diagnostic criteria.

Archives of Sexual Behavior, Vol. 7, No. 4, 1978 GENDER DYSPHORIA SYNDROME: TOWARDS STANDARDIZED DIAGNOSTIC CRITERIA K. Roy MacKenzie, M.D., F.R.C.P...
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