The document discusses gender identity development from childhood through adulthood. It covers several theories of gender development including psychoanalytic, social learning, and cognitive theories. It defines key terms like sex, gender, gender identity and discusses factors that influence gender identity formation such as parenting, socialization, and cognitive development. The document also covers gender dysphoria and criteria for diagnosis. It discusses treatments for gender dysphoria at different stages of life as well as for intersex conditions.

1. By Dr Wasim
UNDER GUIDANCE OF
Dr R.K.SOLANKI

3.  Sex: The biological status of being male
or female.
 Gender: The meanings that societies and
individuals attach to being male or
female.
 Gender Role: The societal expectations for
appropriate female and male
behavior.
 Gender Identity: How one psychologically perceives
oneself as either male or female.

4.  By the age of 3, children know if they are male or
female
Gender Role Development begins . . .
at birth

5.  Psychoanalytic Theories
 Freud
 Erikson
 Social-Learning Theory
 Cognitive-developmental Theory
 Gender-Schema Theory

6.  Freud
 Ages 3 to 5, children feel sexually attracted to their other-
sex parent
 Ages 5 to 6, children feel guilt and anxiety over their
attraction
 Connection with same sex parent is crucial to long-term
mental health and sex drive.
 Erikson
 An extension of Freud’s Theory
 Based on sexual differences between men and women to
explain psychological differences
 Due to differing genital structures, males more intrusive and
aggressive, and females more inclusive and passive

7.  Emphasis on the power of the immediate situation
and observable behaviors
 Two ways children learn their gender roles:
 They receive rewards or punishments for specific
gender role behaviors
 They watch and imitate the behavior of others
 Belief that children imitate the same-sex parent
 Does not believe that child feels guilt or anxiety over a
supposed attraction to the other-sex parent
 Socialization of children is one of the major causes of
gender differences between boys and girls.

8.  Children are encouraged to do the appropriate sex-
typed activities by the following:
 Parents
 traditional roles feed to children in traditional families
 Media
 portrays traditional roles for females and males; female
is still placed in the traditional domestic role
 Schools
 transmit the information of gender role stereotypes to
children

9.  Children’s own cognitions are primarily responsible for
gender role development
 Kohlberg
 children identify with and imitate same-sex parents, and
others of their same gender
 after children label themselves as male or female, the
development of gender related interests and behavior
quickly follow
 Stages:
 Gender Identity: children develop a concept of what sex
category they belong to.
 Gender Consistency: children realize that their gender and that
of other do not change with age, dress, or behavior.

10.  appropriate female or male activities identified and
imitated, once gender consistency established.
 external world rewards or punishes them for their choices.

11.  Theory suggests that children
 use gender as a schema to organize and guide their
view of the world.
 acquire gender-specific behaviors through social-
learning.
 own thought processes encourage gender development
 A combination of the social-learning and
cognitive-developmental approaches.

13.  The term gender dysphoria appears as a diagnosis
for the first time DSM-5 to refer to
“those persons with a marked incongruence between
their experienced or expressed gender and the one
they were assigned at birth.”
It was known as gender identity disorder in the
previous edition of DSM.

14.  Gender identity: the sense one has of being male or
being female which corresponds, normally, to the
person's anatomical sex.
 The affective component of GID is gender dysphoria,
discontent with one's designated birth sex and a desire
to have the body of the other sex, and to be regarded
socially as a person of the other sex.

15.  Resting state of tissue in mammals is initially female
& as fetus develops, a male is produced only if
androgen is introduced by Y chromosome.
 maleness and masculinity depend on fetal and
perinatal androgens.
 Testosterone can increase libido and
aggressiveness in women, and estrogen can
decrease libido and aggressiveness in men.
 Masculinity, femininity, and gender identity result
more from postnatal life events.

16.  Children usually develop a gender identity
consonant with their sex of rearing (also known as
assigned sex).
 The formation of gender identity is influenced by
the interaction of children's temperament and
parents' qualities and attitudes.
 Sex-role stereotypes are the beliefs,
characteristics and behaviors of individual cultures
that are deemed normal and appropriate for boys
and girls to possess.

17.  Mother and child relationship - relationship in the first
years of life is paramount in establishing gender identity.
During this period, mothers normally facilitate their
children’s awareness of, and pride in, their gender:
Children are valued as little boys and girls.
 Separation individualization process- the separation–
individuation process is unfolding. When gender problems
become associated with separation–individuation
problems, the result can be the use of sexuality to remain
in relationships characterized by shifts between a
desperate infantile closeness and a hostile, devaluing
distance.

18.  Role of mother- devaluing, hostile mothering can result
in gender problems, can also be triggered by a mother’s
death, extended absence, or depression, to which a young
boy may react by totally identifying with her—that is, by
becoming a mother to replace her.
 Abused child- Some children are given the message
that they would be more valued if they adopted the gender
identity of the opposite sex. Rejected or abused children
may act on such a belief.
 father’s Role - The father’s role is also important in the
early years, and his presence normally helps the
separation–individuation process. Without a father, mother
and child may remain overly close. For a girl, the father is
normally the prototype of future love objects; for a boy, the
father is a model for male identification.

19.  Sigmund Freud believed that gender identity
problems resulted from conflicts experienced by
children within the Oedipal triangle.
 In his view, these conflicts are fueled by both real
family events and children’s fantasies.
 Whatever interferes with a child’s loving the
opposite-sex parent and identifying with the same-
sex parent, interferes with normal gender identity
development.

20.  A definite difference between experienced/expressed
gender and the one assigned at birth of at least 6 months
duration. At least six of the following must be present:
 Persistent and strong desire to be of the other sex or insistence that
they belong to the other sex
 In males a strong preference for cross-dressing and in female
children a strong preference for wearing typical masculine clothing
and dislike or refusal to wear typical feminine clothing
 Fantasizing about playing opposite gender roles in make-belief play
or activities
 Preference for toys, games, or activities typical of the opposite sex.
 Preference for playmates of the other sex.

21.  Rejection of toys, games and activities conforming to one’s own sex.
In boys avoidance of rough-and-tumble play and in girls rejection of
typically feminine toys and activities
 Dislike for sexual anatomy. Boys may hate their penis and testes and
girls dislike urinating sitting.
 Desire to acquire the primary and/or secondary sex characteristics of
the opposite sex.
 The gender dysphoria leads to clinically significant distress
and/or social, occupational and other functioning impairment.
There may be an increased risk of suffering distress or
disability.
The subtypes may be ones with or without defects or defects
in sexual development.

22. A definite mismatch between the assigned gender and
experienced/expressed gender for at least 6 months duration
as characterized by at least two or more of the following
features –
 Mismatch between experienced or expressed gender and gender
manifested by primary and/or secondary sex characteristics at puberty
 Persistent desire to rid oneself of the primary or secondary sexual
characteristics of the biological sex at puberty.
 Strong desire to possess the primary and/or secondary sex
characteristics of the other gender
 Desire to belong to the other gender
 Desire to be treated as the other gender
 Strong feeling or conviction that he or she is reacting or feeling in
accordance with the identified gender.

23.  The gender dysphoria leads to clinically significant distress
and/or social, occupational and other functioning impairment.
There may be an increased risk of suffering distress or disability.
 The subtypes may be ones with or without defects or defects in
sexual development.

24. F64.0 Transsexualism
A. Desire to live and be accepted as a member of the opposite
sex, usually accompanied by a sense of discomfort with one’s
anatomic sex and the wish to have hormonal treatment and
surgery to make one’s body as congruent as possible with the
preferred sex.
B. Presence of the transsexual identity for at least two years
persistently.
C. Not a symptom of another mental disorder, such as
schizophrenia, or associated with intersex, genetic or
chromosomal abnormality.

25. F64.1 Dual-role transvestism
A. Wearing clothes of the opposite sex in order to experience temporarily
membership of the opposite sex.
B. Absence of any sexual motivation for the cross-dressing.(f 65)
C. Absence of any desire to change permanently into the opposite sex

26. F64.2 Gender identity disorder of childhood
For females:
A. Persistent and intense distress about being a girl, and a
stated desire to be a boy (not merely a desire for any
perceived cultural advantages from being a boy), or
insistence that she is a boy.
B. Either (1) or (2):
(1)Persistent marked aversion to normative feminine
clothing and insistence on wearing stereotypical masculine
clothing, e.g. boys' underwear and other accessories.

27. (2) Persistent repudiation of female anatomic structures, as
evidenced by at least one of the following:
(a) an assertion that she has, or will grow, a penis
(b) rejection of urinating in a sitting position
(c) assertion that she does not want to grow breasts or
menstruate.
C. The girl has not yet reached puberty.
D. The disorder must have been present for at least six
months.

28. For males:
A. Persistent and intense distress about being a boy and an
intense desire to be a girl or, more rarely, insistence that
he is a girl.
B. Either (1) or (2):
(1) Preoccupation with female stereotypical activities, as
shown by a preference for either cross-dressing or
simulating female attire, or by an intense desire to
participate in the games and pastimes of girls and
rejection of male stereotypic toys, games and activities.

29. (2) Persistent repudiation of male anatomic structures, as
indicated by at least one of the following repeated
assertions:
(a) that he will grow up to become a woman (not merely in
role)
(b) that his penis or testes are disgusting or will disappear
(c) that it would be better not to have a penis or testes.
C. The boy has not yet reached puberty.
D. The disorder must have been present for at least six
months.

30.  At present, no convincing evidence indicates that
psychiatric or psychological intervention for children
with GID affects the direction of subsequent sexual
orientation.
 The treatment of GID in children is directed largely at
developing social skills and comfort in the sex role
expected by birth anatomy. To the extent that
treatment is successful, transsexual development may
be interrupted.
 No hormonal or psychopharmacological treatments for
GID in childhood have been identified.

31.  Adolescents whose GID has persisted beyond
puberty present unique treatment problems.
 Treatment management is to slowing down or
stopping pubertal changes expected by anatomical
birth sex and then implementing cross-sex body
changes with cross-sex hormones.
 Parents must also be informed of the non-
pathological nature of same-sex orientation. The
goal of family intervention is to keep the family
stable and to provide a supportive environment for
the teenager.

32.  Adult patients coming to a gender identity clinic
usually present with straight forward requests
for hormonal and surgical sex reassignment.
 No drug treatment has been shown to be
effective in reducing cross-gender desires per
se.
 When patient gender dysphoria is severe and
intractable, sex reassignment may be the best
solution.

33.  Sex reassignment surgery for a person born
anatomically male consists principally of removal of
the penis, scrotum, and testes, construction of labia,
and vaginoplasty. Some clinicians attempt to
construct a neoclitoris from the former frenulum of the
penis. The neoclitoris may have erotic sensation.
 Postoperative complications include urethral
strictures, rectovaginal fistulas, vaginal stenosis, and
inadequate width or depth.
 Female-to-male patients typically may undergo
bilateral mastectomy and construct a neophallus.
Because of increased technical skills in phalloplasty,
more female-to-male patients are now electing these
procedures.

34.  Persons born male are typically treated with daily doses of oral
estrogen- conjugated equine estrogens or ethinylestradiol which
produce breast enlargement, testicular atrophy, decreased
libido, and diminished erectile capacity.. Facial hair removal is
required by laser treatment or electrolysis.
 Biological women are treated with monthly or three weekly
injections of testosterone. The pitch of the voice drops
permanently into the male range as the vocal cords thicken. The
clitoris enlarges to two or three times its pretreatment length and
is often accompanied by increased libido. Hair growth changes
to the male pattern, and a full complement of facial hair may
grow.
 Cross-sex steroid hormones affect general body fat and muscle
distribution as well as promote breast development in patients
born male.

35.  This category is included for coding disorders in gender
identity that are not classifiable as a specific GID. Examples
include
1. Intersex conditions (e.g., partial androgen insensitivity
syndrome or congenital adrenal hyperplasia) and
accompanying gender dysphoria
2. Transient, stress-related cross-dressing behavior
3. Persistent preoccupation with castration or penectomy
without a desire to acquire the sex characteristics of the other
sex

36.  Intersexuality: person’s biological sex cannot be
classified as clearly male or female.
 It refers to intermediate or atypical combinations
of physical features that usually distinguish
female from male and is usually congenital
involving chromosomal, morphologic and genital
anomalies.

37. Intersex
condition
Description
Congenital
virilizing
adrenal
hyperplasia
Sex karyotype: XX. Most common cause of sexual ambiguity, overproduction of adrenal
androgens and virilization of the female fetus, androgenization can range from mild clitoral
enlargement to external genitals that look like a normal scrotal sac, testes, and a penis, but
hidden behind these external genitals are a vagina and a uterus.
Androgen
insensitivity
syndrome
Sex karyotype: XY. Normal female look at birth and so raised as girl. Cryptorchid testes,
clitoromegaly, micropenis co-exist in some. Testosterone do not respond to tissue. Minimal or
absent internal sexual organs (uterus, ovary, cervix).
Turner’s
syndrome
Sex karyotype: XO. Children have female genitalia, are short, anomalies like shield-shaped
chest and a webbed neck. Tx: exogenous estrogen to develop female secondary sex
characteristics.
Klinfelter’s
syndrome
Sex karyotype: XXY. normal male at birth. Excessive gynecomastia may occur in adolescence.
Small testes without sperm production. They are tall with reduced fertility.
Higher rate of GID.
5-α-
Reductase
Deficiency
Sex karyotype: XY. unable to convert testosterone to dihydrotestosterone (DHT). ambiguous
genitalia at birth with some sexual anomaly. Affected person appears to be female. Children are
sometimes misdiagnosed as having AIS.
Pseudoher
maphroditis
m
Infants born with ambiguous genitals, True hermaphroditism: presence of both testes and
ovaries.
Male pseudohermaphroditism: incomplete differentiation of the external genitalia even though a
Y chromosome is present; testes are present but rudimentary.
Female pseudohermaphroditism: presence of virilized genitals in person who is XX

38.  Management of intersex can be categorized into one of the following
two:
1. Treatments: Restore functionality (or potential functionality) – generally
undertaken before age 3
2. Enhancements: Give the ability to identify with “mainstream” – breast
enlargement surgery
 It is easier to assign a child to be female than to assign one to be male,
because male-to-female genital surgical procedures are far more
advanced than female-to-male procedures.
 The exact procedure of the surgery depends on what is the cause of a
less common body phenotype in the first place. There is often concern
as to whether surgery should be performed at all.
 The goal of treatment is to have genitals concordant with chromosomal,
biological, physiological, and other genetic antecedents, thus allowing
the development of a person with healthy gender identity.

39.  If the disorder is not stress related, persons who cross-dress are classified
as having transvestic fetishism, which is described as a paraphilia in DSM-
IV-TR. An essential feature of transvestic fetishism is that it produces
sexual excitement. The DSM-IV-TR lists cross-dressing- dressing in
clothes of the opposite sex- as a gender identity disorder if it is transient
and related to stress.
 A cross-dresser is a person who has an apparent gender identification with
one sex, and who has and certainly has been birth-designated as
belonging to one sex, but who wears the clothing of the opposite sex.
Cross-dressers may not identify with opposite gender & do not adopt
behaviors of the opposite gender, and generally do not want to change
their bodies medically.
 Cross-dressing can coexist with paraphilias, such as sexual sadism,
sexual masochism, and pedophilia.
 The disorder is most common among female impersonators.

40.  A combined approach, using psychotherapy and
pharmacotherapy, is often useful in the treatment of
cross-dressing.
 Antianxiety and antidepressant agents, is used to treat
the symptoms as cross-dressing can occur impulsively,
medications that reinforce impulse control may be
helpful, such as fluoxetine (Prozac).

41.  The category of preoccupation with castration is
reserved for men and women who have a persistent
preoccupation with castration or penectomy without a
desire to acquire the sex characteristics of the opposite
sex.
 They are clearly uncomfortable with their assigned sex
and their lives are driven by the fantasy of what it would
be like to be a different gender.
 They may be asexual and lack sexual interest in either
men or women.