Treatment of Gender Identity Disorder

At its September 2011 meeting, the Board of Trustees (BOT) of the American Psychiatric Association (APA) voted to approve as a Resource Document the report of the Task Force on Treatment of Gender Identity Disorder (GID). Both the diagnosis and treatment of GID are controversial as reflected in the professional literature as well as in popular discourse where they have recently garnered considerable attention. In contrast to the treatment of other DSM diagnoses where emphasis is on changing thoughts, feelings and behaviors, the treatment of GID from adolescence onward often emphasizes modification of the body. Although psychiatric diagnosis and treatment are inextricably linked, they are separate issues and the DSM does not evaluate and compare the benefits and risks of alternative treatments. As the DSM-V workgroups were deliberating, the BOT, therefore, formed a task force to address concerns that go beyond those in the purview of the DSM-V work group addressing GID. The Task Force was 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 present a report to the BOT that would include an opinion as to whether or not sufficient credible literature exists for the APA to take the next step and develop treatment recommendations. Separate sections of the report assess the treatment literature in children, adolescents, adults, and individuals of any age with disorders of sex development (DSDs, aka intersex conditions; DSM-IV criterion C excludes individuals with DSDs from the diagnosis of GID. If they meet other criteria, they receive the diagnosis of GID Not Otherwise Specified. The current DSM-5 proposal recommends replacing GID with Gender Dysphoria and designating two subtypes, without and with a DSD.).

The randomized double blind control trial is the study design that affords the highest quality evidence regarding the comparative efficacy of alternative treatments; however, no such trials have been conducted to address any aspect of the treatment of GID. Given the very nature of GID, such trials, or even unblinded trials with random assignment to treatment groups, are not likely to be forthcoming due to a lack of feasibility and/or ethical concerns. Absent such studies, the quality of evidence pertaining to most aspects of treatment for GID was determined to be low. The Task Force, therefore, delineated aspects of treatment where broad clinical consensus appears to be either present or lacking. The Task Force concluded that consensus is sufficient to support recommendations for the treatment of GID in all subgroups reviewed and that, with subjective improvement as the primary outcome measure, evidence is sufficient to support recommendations for the treatment of adults in the form of an APA Practice Guideline with gaps in the empirical database supplemented by clinical consensus.

While several existing guidelines, policy statements and standards of care are available to guide mental health professionals in providing care to individuals with GID, the report identifies several reasons that recommendations specifically targeted to psychiatrists would be desirable. Although the practice of psychiatry overlaps with that of other mental health fields, psychiatry is unique in several respects. Psychiatry often has the primary role in the diagnosis and treatment of the major mental illnesses in which gender identity concerns may arise as epiphenomena (e.g., psychotic disorders) as well as in the pharmacological management of psychiatric disorders that may coexist with GID (e.g., mood and anxiety disorders), and in monitoring symptoms that may emerge with endocrine manipulation. By virtue of their medical training, psychiatrists are in a unique position among mental health professionals to liaise with other medical specialists who provide GID care. Further, recommendations from the APA would facilitate opportunities for training in the provision of services to individuals with GID and address the current shortage of mental health professionals working in this area.

The report recommends that additional steps pertaining to gender variance (GV) be taken by the APA beyond drafting treatment recommendations for GID. These include issuing a policy statement to clarify the APA's position regarding the medical necessity of treatments for GID, the ethical bounds of treatments for minors with GID or GV, and the rights of persons of any age who are gender variant, transgender or transsexual.

The full Resource Document accompanies the online version of this APA Official Action (ajp.psychiatryonline.org).