GENDER IDENTITY DISORDER

DSM-IV
GENDER IDENTITY DISORDERS
302.6 Gender identity disorder in children
302.85 Gender identity disorder in adolescents and adults (specify: sexually
attracted to males/females/both/neither)
302.6 Gender identity disorder not otherwise specified (intersex conditions,
androgen insensitivity syndrome, or congenital adrenal hyperplasia and gender
dysphoria)
313.82 Identity problem (specific to sexual orientation and behavior)

Sexuality is a product of one’s genetic identity, gender identity, gender role and
sexual orientation. As all of these are independent components, there is a 4 3 4
interaction that can result in 16 distinct possibilities of sexual identity. In a society in
which clear differences between the sexes is the expected norm, any individual
challenging this dichotomy is deemed problematic. However, in the mental health
arena, sexual orientation is a concern only when the individual experiences
persistent and marked distress regarding uncertainty about issues relating to
personal identity—in this case, sexual orientation and behavior.
Consensual homosexuality in adults is no longer viewed as a mental
disturbance. Homosexual individuals in general have no more psychopathology than
heterosexuals, and when they do seek treatment it is for the same reasons as
heterosexuals—psychiatric disorders (e.g., bipolar disorder, borderline personality),
relationship problems, and stress. Therefore, it is important to avoid mistakenly
attributing psychiatric symptoms to the individual’s sexual orientation.
In gender identity disorder, the individual does not view himself or herself as
homosexual; rather, there is a strong and persistent cross-gender identification and
discomfort with one’s gender or a sense of inappropriateness in the assigned gender
role exists (e.g., a male “trapped” in a female’s body). This perception results in
clinically significant distress/functional impairments (e.g., social, occupational).
In addition, this plan of care also addresses the diagnosis of Identity Problem for
homosexuals who are uncertain about multiple issues relating to their identity, such
as sexual orientation and behavior, moral values, friendship patterns, and group
loyalties.

ETIOLOGICAL THEORIES

Psychodynamics
The libido is seen as the force that expresses sexual instinct and develops
gradually during the oral stage, which focuses on the mouth and lips. The central
concern of the anal stage is the anus and the elimination/retention of feces. During
the phallic stage, the male is concerned with love of his mother, is jealous of his
father, and has castration anxiety (Oedipus complex). The female has penis envy,
loves her father, and rejects her mother (Electra complex). This theory focuses on
the biological inferiority of women because they do not have penises, with
subsequent envy of the male.
Developmental theories suggest that sexuality develops throughout life and
especially during the formative years. Confusion about one’s individual personality
and sexual identity affects the ability to be intimate, interfering with sexual
development.
Biological
Although adult endocrine levels are usually normal in individuals who are
homosexual, a “hormonal wash” may have occurred at a critical time of embryonic
development, sensitizing brain cells in as yet immeasurable ways. Androgen is
necessary for masculinization in the fetal male, with the fetus developing as female
without the addition of this hormone. When androgenic influences in the fetal
hypothalamus are decreased in the male or increased in the female, homosexuality
may occur. Some research sources report that there is a neuroendocrine factor (e.g.,
that the fetus was exposed to large amounts of androgenic hormones or that the
mother may have received synthetic hormones at a crucial fetal developmental
period, preventing adequate stimulation for neural differentiation).
Current research allows monitoring of normal fetal exposure to testosterone in
utero. When subsequent behavior is linked to this information, we will understand
more than has been previously available from studies of abnormal exposure of the
fetus to high levels of androgen, overdoses due to drugs, or adrenal malfunction.
Research continues into the effect of prenatal brain-sexing on homosexual
development. We know that lack of male hormone at a crucial state of male fetal
development can lead to a feminine brain in a male body. It is clear that, as with
other aspects of behavior, sexual orientation is crucially mediated by hormonal
influences on the developing brain in utero. It is believed that abnormal hormones
interact with neurotransmitters, the chemicals that direct the construction of the
brain, affecting the sex centers, mating centers, and the so-called gender-role
centers, which assume their structure at different times of brain development (Moir
& Jessel, 1991).

Family Dynamics
Role-modeling of gender-specific behaviors is believed to play a part in the
development of these disorders as well as the negative effect of a disturbed
relationship with one or both parents. Imprinting and classic conditioning may affect
the development of gender identity.
In males with gender identity disorders, a symbiotic relationship appears to exist
between mother and child. The father is usually absent, ineffectual, or hostile and is
perceived as weak and distant, with the mother seen as strong and protective.
In females with these disorders, the child may not be valued as a girl, or the
mother may be absent, depressed, or suffer from other illness, resulting in
inadequate mothering. The father may treat the daughter as his little boy, expecting
“masculine” behavior.

CLIENT ASSESSMENT DATA BASE

Ego Integrity
Believes feelings/reactions are typical of other sex
May report considerable anxiety and depression, attributable to difficulty of living in
role of assigned gender

Hygiene
Exhibits a persistent, marked aversion to wearing gender-appropriate clothing

Neurosensory
Moderate to severe coexisting personality disturbance may be noted
Mental Status: May reveal intense distress (e.g., ego-dystonic homosexuality)
about general identity or coexisting psychiatric disorders
Mood and affect may reveal evidence of increased anxiety and depression

Safety
May have been victim of assault
History of suicide attempts

Sexuality
Higher incidence in males than females (may be owing to narrow study base)
Incongruence between assigned gender and the sense of knowing to which gender
one belongs
May report a persistent and intense distress about his or her assigned gender and
the desire to be/insistence that he or she is of the other gender; belief by males
that penis/testes are disgusting/will disappear, or by females that they will not
develop breasts/menstruate; or desires medical/surgical intervention to alter
sexual characteristics to simulate the other gender
Possible preoccupation with stereotypic activities/toys designed for the opposite
gender, and/or repudiation of anatomical structures noted/reported in childhood
Sexual responsiveness/romantic attraction to individual of same gender

Social Interactions
Impairment in social/occupational functioning, often experiencing peer isolation,
bullying
May report family alienation

Teaching/Learning
May present at any age; can be identified in childhood but most often in late
adolescence or early adulthood, although possibly later
Substance use/abuse

DIAGNOSTIC STUDIES
Psychological testing to rule out concomitant psychiatric conditions.
Screens for sexually transmitted diseases (STDs), including HIV/AIDS.

NURSING PRIORITIES
1. Help client reduce level of anxiety.
2. Promote sense of self-worth.
3. Encourage development of social skills/comfort level with own sexual
identity/preference.
4. Provide opportunities for client/family to participate in group therapy/other
support systems.

DISCHARGE GOALS
1. Anxiety reduced/managed effectively.
2. Self-esteem/image enhanced.
3. Accepts and is comfortable with identity as established.
4. Client/family are participating in ongoing treatment/support programs.
5. Plan in place to meet needs after discharge.
 NURSING DIAGNOSIS ANXIETY [severe]
May Be Related to: Ego-dystonic gender identification
Unconscious conflicts about essential
values/beliefs
Threat to self-concept; unmet needs
Possibly Evidenced by: Increased tension/helplessness (hopelessness)
Feelings of inadequacy, apprehension,
uncertainty
Increased wariness; insomnia
Focus on self; impaired daily functioning
Desired Outcomes/Evaluation Criteria— Verbalize awareness of feelings of anxiety and
Client Will: healthy ways to deal with them.
Appear relaxed and report anxiety is reduced to
a manageable level.
Demonstrate problem-solving skills and use
resources effectively.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Assess level of anxiety and degree of interference Necessary information to identify the
extent of
with daily activities/life. problem for the individual and plan appropriate
interventions.
Review drug/substance use history (e.g., Drugs (including alcohol) may have been used to

prescription/illicit), familial/physiological factors handle anxious feelings in the past. Other factors

(e.g., mental/physical illness, family disorganization). contribute to anxiety and may affect
individual’s
ability to handle stress of dealing with own
identity problems.
Help client identify feelings, conveying empathy Identification of feelings within a safe,
therapeutic
and unconditional positive regard. Encourage free environment can help the client begin to
explore
expression of feelings in appropriate ways. causes of anxiety and begin to move toward
acceptance of self as a worthwhile person.
Acknowledge reality of anxiety/fear. (Do not deny Helps client accept own feeling(s) and learn trust

or reassure client that everything will be all right.) in self. Denial of these feelings
contributes to
increased anxiety. Platitudes lack factual basis,
and
 providing false reassurance can damage trust
and
may increase client’s anxiety.
Provide accurate information to assist client to Anxiety may be the result of misinterpretation or
clarify reality base, reframe sexuality, and delineate lack of knowledge about sexuality/gender
boundaries. identity, and client may fantasize unrealistic
ideation.
Accept the client as he or she is. Lack of self-acceptance is the basis of much
anxiety, and other’s unacceptance increases
anxiety.
Identify things client has done previously when Helps client see which previous actions have
been
feeling nervous/anxious. beneficial and can be used in this situation,
increasing sense of control/capability and
allaying
anxiety.
Assist with developing program of exercise (e.g., Strenuous activity releases opiate-like
endorphins,
brisk walking, aerobic class). which create sense of well-being and decrease
anxiety. However, exercise therapy need not be
aerobic or intensive to achieve the desired effect.

NURSING DIAGNOSIS ROLE PERFORMANCE, altered/PERSONAL

IDENTITY disturbance
May Be Related to: Crisis in development, in which person has
difficulty knowing/accepting to which gender he
or she belongs or to which he or she is attracted
Sense of discomfort and inappropriateness about
anatomical sex characteristics
Possible Evidenced by: Confusion about sense of self, purpose or
direction in life, sexual identification/preference
Verbalization of desire to be/insistence that
person is the opposite gender
Change in self-perception of role; conflict in roles
Desired Outcomes/Evaluation Criteria— Talk with family/significant other(s) about
situation
Client Will: and changes that are occurring/have occurred.
Develop realistic plans for adapting to new
role/role changes as appropriate.
Verbalize realistic perception and acceptance of
self.

ACTIONS/INTERVENTIONS RATIONALE
Independent
Show acceptance of the client as he or she is These clients are sensitive to others’ beliefs and
presented. will pick up on prejudicial feelings. The client
needs to be free to express any views/feelings to
begin to solve the problems being faced.
Determine type of role dysfunction/distress client Lack of self-acceptance and conflicting feelings
is expressing (e.g., ego-dystonic heterosexual/ regarding sexual expression requires therapeutic
homosexual feelings, gender dysphoria). intervention. Lack of public and religious
acceptance, few legal protections for same-sex
couples along with lack of role clarity/boundaries
can create significant stressors for the client.
Note:
When the individual views sexual
expression/feelings/behavior as adaptive, a
healthy attitude exists, and intervention is
unnecessary when behavior is within legal
boundaries.
Identify beliefs and values of the individual aboutClient may be ignorant of the facts and base
fears
hetero/homo/transsexuality. Discuss client’s beliefs on hearsay, prejudice, and religious
beliefs.
and ideas in detail, providing information as Learning the facts and discussing them with an
appropriate. unbiased person provides an opportunity to
make
informed decisions. Note: Transsexuals who are
attracted to members of their own biological
gender do not view themselves to be
homosexual
and may consider the term “gay” or “lesbian” to
be an insult.
Explore client’s feelings about gender identity The client who feels strongly that he or she is in
a
(transsexuality) and review options for change (e.g., body of the “wrong” gender needs to
have
hormonal therapy, psychotherapy, surgical complete information about available choices to
reassignment). help begin to accept self and feel comfortable
with
the decision. Note: Not all transsexuals choose
to
have surgery.
Ascertain degree of openness client feels about Degree to which client previously shared
sexual orientation concerns. individual situation has an impact on one’s level
of
concern/comfort and degree of conflict present.
The process of sharing or withholding one’s
situation requires much emotional energy.
Determine presence of support system (e.g., family, May feel “different” and isolate self from
usual
social, work). support systems. May be pressured by family/
friends to be heterosexual, which creates conflict
 within self.
Role-play sexual disclosure encounters. Once the decision to disclose sexuality is made,
open discussion and practice of responses is
necessary to the success of disclosure.
Assist client to develop strategies to cope with threat Provides protection and gives client a
sense of
to identity. control to have thought about/decided on actions

that can be taken when feeling threatened.

Assess response of family/SO. (Refer to NDs: Family May be in shock when first learning of
client’s
Coping, ineffective: compromised; Family Coping:concerns and then may either reject or rally to
potential for growth.) support client.
Encourage client to deal with situation in small steps. Helps client cope with the “larger picture”
when
in stress overload.
Provide accurate information about threat to and Knowledge about gender identity issues helps
potential consequences for the individual. client assess own situation and make decisions
based on fact.
Be aware of one’s own biases. Seek assistance/ Personal values/beliefs and conflicts or biases
can
terminate therapeutic role as appropriate. have a negative impact on the therapeutic
relationship and effectiveness of interventions.

Collaborative
Identify available resources/support groups. Can provide positive role models, opportunity to
discuss shared concerns, and facilitate problem-
solving. Group therapy/peer support can be
especially helpful to adolescent/early adult
homosexuals who are struggling with their
identity and need support for future life choices.
Refer to professionals who are expert in the field of Client needs to be known to the therapist
for a
human sexuality and gender reassignment. period of at least 3–6 months and demonstrate a
sense of discomfort with self and a desire to live
in
the opposite gender role before a major life-
changing decision is finalized.
Refer to a therapist who is an expert in the field of Because these procedures are not
reversible, the
gender reassignment for a second opinion when client needs to be sure the correct decision has
surgery is contemplated. been made and demonstrate success in living in
the opposite role for a period of 1–2 years.
 NURSING DIAGNOSIS SEXUALITY PATTERNS, altered
May Be Related to: Ineffective or absent role models
Conflicts with sexual orientation and/or
preferences
Impaired relationship with a significant other
Possibly Evidenced by: Verbalizations of discomfort with sexual
orientation and/or role
Lack of information about human sexuality
Desired Outcomes/Evaluation Criteria— Verbalize understanding of sexuality and
Client Will: acceptance of self.
Demonstrate behaviors directed at lifestyle
changes necessary to achieve desired effects.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Have client describe problem in own terms, noting It may be difficult for client to talk about
comments of client/SO that may reveal discounting situation/express feelings, and client may
joke,
by overt/covert sexual expressions. make oblique remarks, or use sarcasm to
convey/cover concerns.
Take sexual history, including perception of normal Provides information about level of
knowledge
function, use of vocabulary, and concerns about about anatomy/physiology of human sexuality
identities/clarifies concerns to be dealt with by the and gender identity.
client/nurse.
Note cultural and religious/value factors and Provides opportunity to give information/discuss
conflicts that may exist. resources available to client who may believe
thoughts and feelings are sinful, and feel guilty.
Explore knowledge of alternative sexual responses May have knowledge gained only in
discussions
and expressions. with friends, from myths, and from
misconceptions.
Inquire about drug use, including OTC/prescription Drug use can affect sexual functioning.
drugs, illicit drugs, and alcohol. Additionally, client may use substances to dull
pain of indecision/anxiety of identity.
Provide atmosphere in which discussion of sexualEssential to identification and resolution of
problems is encouraged, promoting free expression problems. Client may have concerns
about sexual
of feelings. behavior and diseases, such as AIDS.
Encourage discussion of possibilities and alternatives Full range of discussion can help client
reach a
for client situation. (Refer to ND: Role Performance, decision about the identity that is
comfortable and
altered/Personal Identity disturbance.) the course to pursue.
Review hormonal therapy as indicated. Transsexuals who elect to undergo surgical
reassignment, and those who for economic or
other reasons choose to live in the transsexual
role,
usually receive long-term, high-dose estrogen or
testosterone therapy. Client needs to understand
the implications of hormone therapy before
making the decision to pursue this course of
therapy.

Collaborative
Refer to resources as indicated (e.g., homosexual/ These organizations are reference groups
that
lesbian support group; LAMBDA, AA, Gay and provide information/support for homosexuals
Lesbian; Common Bond; gender identity clinics, and families. Information from these groups can
Exodus International). help client reach a decision about sexual
preference
and/or provide support once decision has been

made. Exodus International is a Christian-based

group that directs efforts to assist the client
toward
a decision to become heterosexual.

NURSING DIAGNOSIS FAMILY COPING, ineffective: compromised

May Be Related to: Inadequate/incorrect information or
understanding
Temporary preoccupation by a significant person
who is trying to manage emotional conflicts and
personal suffering and is unable to perceive or to
act effectively in regard to client’s needs
Temporary family disorganization and role
changes
Client providing little support in turn for the
primary person
Possibly Evidenced by: Client expressing/confirming a concern or
complaint about family/SO(s) response to client’s
gender/sexual concerns
SO describing preoccupation with own personal
reactions to client’s situation
Family attempting supportive behaviors with less
than satisfactory results/withdraw support when
needed
 Desired Outcomes/Evaluation Criteria— Identify resources within itself to deal with
Family Will: situation
Interact appropriately with client and staff,
providing support and assistance as indicated.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Determine individual situation and identify factors Individuals may have problems of their
own that
that may contribute to difficulty family is having in interfere with ability to extend themselves
to the
providing needed assistance/support for the client. client. Problems of prejudice,
myth/misinformation,
values may also cause separation
between/among
family members.
Note behaviors of family members (e.g., withdrawn, Identifies individual needs and steps to be
taken to
rejecting, supportive, willing to learn). (Refer to ND: resolve family disorganization/assist the
family in
Family Coping: potential for growth.) moving toward growth.
Discuss underlying reasons for behaviors client isHelps family understand and accept the person
as
expressing/exhibiting. having different beliefs/values.
Encourage each individual to be responsible for The concept of “who owns the problem” can help

own self, not taking on problem(s) of others. clarify issues of who has responsibility for
solution
of specific problems.
Encourage free expression of feelings and ideas Promotes an atmosphere in which individual can
about homosexuality/gender identity issues. reveal feelings of self-blame, revulsion, confusion

and anger, or blaming of other(s). Once these

have
been expressed, members can move on to
resolution.
Provide information as appropriate. Because much of the problem may center around

lack of knowledge, information can help

individuals make informed decisions/choices
about what is happening.
Discuss options for individuals in regard to client’s Family members may have difficulty
accepting
decision about sexual partner, gender identity/ client’s alternative sexual expression/sexual
surgical reassignment (e.g., separation/divorce for reassignment. Individual needs to make
decision
spouses, resolution of parent/child issues). about willingness to accept other person in
altered
role. Children of transsexuals have questions
such
as “Who am I, as the daughter of a father who is
now a woman?”
Provide time to talk with family to discuss views/ Opportunity to ventilate feelings, ask questions,
concerns about situation, feelings toward client’s and express ideas helps resolve problems.
sexual partner.
Assist members to develop effective communication Helpful in dealing with current situation as
well as
skills (e.g., Active-listening, I-messages, problem- providing skills that will assist with resolution of
solving process). Provide role model with which the future problems. Role-modeling shows
individuals
family may identify. Include SO as appropriate. that the skills can be helpful to them. Including
partner provides opportunity for resolution of

conflict, incorporation into family.

Collaborative
Identify/refer to support groups/classes that deal Talking with others who have been through
with similar problems, (e.g., Parents/Friends of similar experiences can provide opportunity for
Lesbians and Gays [PFLAG], gender identity clinics). members to learn/accept client.
Refer for marriage counseling as appropriate. May be needed to help couple decide whether
separation/divorce is in the best interests of each

person, or whether they want to work out their

problems and stay together.

NURSING DIAGNOSIS FAMILY COPING: potential for growth

May Be Related to: Individual’s basic needs are sufficiently gratified
and adaptive tasks effectively addressed to
enable goals of self-actualization to surface
Possibly Evidenced by: Family members attempt to describe growth
impact of crisis on their own values, priorities,
goals, or relationships
Family members are moving in direction of
health-promoting and enriching lifestyle that
supports client’s search for self
Family members choosing experiences that
optimize wellness
Desired Outcomes/Evaluation Criteria— Express willingness to look at its own role in the
Family Will: family’s growth.
 Verbalize knowledge and understanding of
client’s gender/sexual orientation.
Express desire to understand tasks leading to
change.

ACTIONS/INTERVENTIONS RATIONALE

Independent
Listen to family’s expressions of hope, planning, Provides clues to opportunities that exist to help
and effect on relationships/life. family move toward growth and positive
relationships. When family members are doing
this, client is free to move toward a positive
resolution of own life.
Help the family in supporting the client in meeting Significant other(s) may not have
skills/know-how
own needs/making own decision. to give support even when desired, and giving
information and providing support enables them
to learn and grow.
Note expressions of change of values (e.g., “He/she Indicators of beginning of acceptance of
the
is still my son/daughter even though homosexual/ situation as it is and willingness to learn
and
lesbian, or contemplating sex-change surgery.”). support child.
Provide a role model with which the family may Modeling of accepting behaviors/communication
identify. skills enables family members to learn new ways
of interacting with the client.
Discuss importance of open communication and Open communication allows all participants to
harm secretive behavior produces. have access to all information, enhancing
resolution of problems/understanding of what is
happening.
Encourage open discussions of concerns about Individuals may have unexpressed fears, and this

lifestyle changes, fear of AIDS and other sexually provides the opportunity to ask questions and
get
transmitted diseases. accurate answers; make informed decisions.
Provide experiences for the family (e.g., involvement Helps them learn ways of
assisting/supporting
with other families facing similar decisions). client.

Collaborative
Refer to community resources (e.g., same-gender, Provides ongoing support as client/family
make
transsexual groups). necessary lifestyle changes, go on with their
lives.