Kirk Greenwood
Prof. Andrews
PSYC280-N02
15 November 2018
Historical antecedents:
•
•
•
•
•
Anthropological/Prehistoric
History, anthropology, biology show non-binary gender identities,
gender transformations and transpositions, in the animal kingdom
and human societies throughout history and across cultures (Lev,
2013, p. 291).
Religious
Most world religions codify socially acceptable expressions of
gender and sexuality.
Western societies, particularly America, are influenced by JudeoChristian religious beliefs about the proper roles of men and
women.
Ancient religious texts stipulate punishments, up to and including
death, for gender-role transgression.
Passages in the Hebrew Bible/Old Testament explicitly forbid
cross-dressing (Deuteronomy 22:5) and physical alterations of
male/female sex organs (Leviticus 22:24 ) (Drescher, 2010, p. 440).
Historical antecedents:
Scientific Naturalism
• As Western Europe modernized and secularized in the 19th
century, scientific and medical explanatory models supplanted
religious and supernatural explanations of natural phenomena
(Drescher, 2010, p. 440).
• Such ‘sins’ were reclassified as ‘illnesses’: demonic possession
redefined as insanity, drunkenness as alcoholism, and sodomy
as an illness called homosexuality (Drescher, 2010, p. 440).
Sexual Deviance
• “In the mid-1880s, there was an explosion of anthropological,
sociological, psycho-medical, and judicial explorations into
abnormal sexual behavior, with a specific focus on libidinous
desire, particularly in women and children, and sexual
deviations, like inversion (cross-gendered homosexuality) and
hermaphroditism (intersexuality)” (Lev, 2005, p. 38).
Early Clinical Accounts:
Karl Heinrich Ulrichs
(1825-1895)
Ulrichs (1870) theorized that some
men, whom he called urnings, were
born with a ‘woman’s spirit;’ likewise,
some women, called urningins, had a
man’s spirit trapped inside a woman’s
body. (Drescher, 2014, p. 430)
Ulrichs’ 1870 tract,
Uranus
In his seminal Psychopathia Sexualis (1886), KrafftEbing documented cases of gender dysphoric and
gender variant individuals born to one sex, yet
living as another. (Drescher, 2010, p. 436)
Krafft-Ebing’s 1886 tract,
(1840Psychopathia Sexualis
Hirschfeld was the firstRichard von Krafft-Ebing
1902)
clinician to distinguish homosexuality from transgenderism. His patient, Lili Elbe,
born male, was the first
documented person to
successfully complete sex
reassignment surgery.
Lili Elbe, born Einar Mogens Wegener,
(Drescher, 2010, p.436)
Magnus Hirschfeld (1868-1935), seated at right, with friends at
a party at his Institute for Sexual Research in Berlin.
before and after her transition in 1930.
Early Reactions to Transsexualism in U.S.: 1950-1970
• In 1952, George Jorgensen has sex reassignment surgery
(SRS) in Denmark, returning to U.S. as Christine Jorgensen.
• Doctors who performed Jorgensen’s SRS publish a report in
Journal of the American Medical Association.
• Increase in popular and scientific awareness in U.S. of
individuals wishing to ‘cross over’ (Drescher, 2010, p. 436)
Sensationalist New York Daily News headline about George
Jorgensen’s transition to Christine.
U.S. psychiatry tended to view transsexuals as “confused
homosexuals, neurotics, transvestites, [or] schizophrenic”
in need of psychotherapy and ‘reality testing’ (Drescher,
2010, p. 438) Psychoanalytic ego psychology, the reigning paradigm in U.S. psychiatry at mid-century,
viewed gender fluidity, or uncertainty, as pathological. (Drescher, 2010, p. 434)
Green (1969) surveyed 400 psychiatrists and
other medical specialists regarding their
opinions of a transsexual requesting SRS.
Patient characteristics:
Requested procedures:
“30-year-old biological male”
“very effeminate in his mannerisms, interests, and daydreams”
“removal of both testes, his penis”
“breasts be made to appear like a woman’s”
wants to “dress exclusively in women’s clothes”
“breasts be made to appear like a woman’s”
sexual desire for men
feels and expresses “he is a female trapped in a male body”
*Respondents informed that procedures are
“medically possible” (Green, 1969, p. 236)
Results:
• 15% of responding
clinicians considered the
patient “psychotic”
• 8% considered him
“severely neurotic
• Most opposed his request
•
•
•
•
Medical Model of Transsexualism: 1960-1980
Disputed psychoanalytic view that gender dysphoric people were psychotic/neurotic
Founded gender clinics where gender dysphoric people could receive medical care and SRS
Expanded professional awareness and knowledge about gender identity and SRS
Changed psychiatric and public opinion regarding the authenticity of transsexualism
(Drescher, 2010, p. 442)
Leading Figures:
Harry Benjamin (1885-1986), endocrinologist
• Gender dysphoria exists a continuum, from transsexual to transvestite (Lev, 2005)
• Male-to-female (MF) transsexualism was a biological disorder caused by brain being
‘feminized’ in utero (Drescher, 2010)
• Pioneered treatment of gender dysphoric people using sex hormones (Drescher, 2010)
• Treated and befriended ~1000 transsexuals in U.S. (Drescher, 2010)
• Harry Benjamin International Gender Dysphoria Association, a professional organization
dedicated to health of gender dysphoric people (now called WPATH), named in his honor
upon its founding in 1979 (Drescher, 2010)
John Money (1921-2006), psychologist
• Studied gender assignment in children with disorders of sex developmentEarly
psychosocial environment, particularly the family, plays key role in gender formation
• Individual gender identity fixed by 3 years old; difficult or impossible to change with
psychotherapy
• Coined the term “gender role” – “things a person says or does to disclose himself or
herself as having the status of boy or man, girl or woman”
• Viewed gender identity as the private experience of gender role and gender role as the
public manifestation of gender identity
• Headed the Johns Hopkins Gender Identity Clinic in 1965, the first of 40 academic gender
clinics to perform SRS in the U.S.
(Drescher, 2010, p. 437-438)
• 6 revisions of DSM since it was first published
• DSM-I or DSM-II do not mention gender
Gender Identity and the DSM:
1980-2000
DSM-I (APA, 1952)
DSM-II (APA, 1968)
DSM-III (APA, 1980):
• Transsexualism & Gender Identity Disorder of
Childhood (GIDC) added
DSM-III-R (APA, 1987):
• Gender Identity Disorder of Adolescence and
Adulthood, non-transsexual type added
DSM-IV (APA, 1994):
• Gender Identity Disorder of Adolescence and
Adulthood, non-transsexual type (removed)
• Transsexualism and GIDC conflated into
Gender Identity Disorder (GID), a single
diagnosis with different criteria sets for
children and adolescents/adults
(Lev, 2013, p. 291)
Despite these permutations, the core
criteria for transsexualism or GID remain
consistent after 1980:
(Cohen-Kettenis & Pfäfflin , 2010, p. 505)
In the Diagnostic and Statistical Manual of Mental Disorders (5th ed.)
(APA, 2013)
In the Diagnostic and Statistical Manual of Mental Disorders (5th ed.)
(APA, 2013)
Biogenetic Risk Factors:
Genetic Heritability:
• Gender dysphoria is more common in people who have sibling with the disorder
• A study of 23 pairs of identical twins found that when one of the twins displayed gender dysphoria, the other
twin displayed it as well in 9 of the pairs
Brain Structure and Function:
• People with gender dysphoria tend to have different blood flow patterns in brain areas related to sexuality and
consciousness
–
–
increased blood flow to insula and reduced
decreased blood flow in the anterior cingulate cortex
Area of the hypothalamus called the bed nucleus of stria terminalis (BST) was smaller in a sample of six MF
transsexuals than in cisgendered men
–
–
Cisgendered women usually have smaller BST than men
BST thought to affect sexual behavior in male rats
357)
(Comer, 2014, p.
Prenatal Development:
Hare et al. (2009) found variation in genes coding for
androgen receptors may be related to the development
of gender dysphoria in fetuses with XY sex
chromosomes (i.e., biological males)
(Davy, 2015, p. 1170)
Fluctuations in production or absorption of androgen in
fetuses with may predispose them to developing gender
dysphoric symptoms
(Zucker & Lawrence, 2009, p. 12)
Psychosocial Risk Factors:
Herschkowitz (2000) warns against overrelying on the biogenetic explanations citing
“constant close interaction of genome, environment, and behavior” in postnatal child
development: Genes code for proteins, and not directly for behavior. The proteins are a
basis for metabolism, structure formation and physiological functions. Gene
realization, however is modulated by environmental factors. (p. 451)
TGNC persons encounter pervasive
discrimination and systemic oppression in the
United States… and, as a result, are
susceptible to higher rates of mental health
disparities. (McCullough, Dispenza, Parker,
Viehl, Chang, & Murphy, 2017, p. 423)
According to a study of 6,450 TGNC
participants in the United States, over 86%
reported experiencing sexual and physical
assault, career-related discrimination, school
bullying and harassment, homelessness,
relationship losses, and denial of medical
services (McCullough et al., 2017, p. 423)
[M]ental health concerns can be by-products of
discrimination and prejudice experienced by
TGNC persons. The stigma against TGNC persons
may increase the likelihood that they will utilize
mental health services at a rate similar to sexual
minority populations.
(McCullough et al., 2017, p. 423)
Assessing Gender Dysphoria in Children
1). Child Behavior Checklist (Achenbach & Edelbrock, 1981):
a widely used parent-report behavior problem questionnaire, which includes two
items (out of 118) that pertain to cross-gender identification: “behaves like opposite
sex” and “wishes to be of opposite sex.” (Zucker & Lawrence, 2009, p. 10)
2). Gender Identity Questionnaire for Children (Johnson et al., 2004):
a parent-report measure of gender identity and
gender role behavior with 16 items covering a range
of sex-typed behaviors corresponding to DSM
criteria for Gender Identity Disorder in children
• Questions: peer affiliation, roles in fantasy play, sexof-playmate preference, toy interests, cross dressing;
gender identification; anatomic dysphoria
• Items rated on a 5-point scale for frequency; lower
scores reflect more cross-gendered behavior
• Short, targeted, quantitative, and standardized
• Useful screening tool for front-line clinicians
(Johnson et al., 2004)
Assessing GD in Adolescents/Adults
1). Biographical Questionnaire for Transsexuals and Transvestites (Doorn et al., 1994):
• structured interview used in all Dutch gender clinics
• 211 items about sociodemographic information, childhood and preadolescent gender behavior,
gender development in adolescence/adulthood, transvestite practice, sexual orientation
2). Utrecht Gender Dysphoria Scale (Cohen-Ketternis & van Goozen, 1997; Doorn et al., 1996):
• 12 questions given on a 5-point scale, from “agree completely” to “disagree completely”
• Higher score indicates more gender dysphoria (range 12-60)
• Designed for first Dutch follow-up of SRS to evaluate outcomes
• Modified for use in other Dutch and international follow-up studies
• Separate versions for natal males and natal females
Other
Gender Identity/Gender Dysphoria
Questionnaire for Adolescents and Adults
(Deogracias et al., 2007; Singh et al., 2010)
• 27-item dimensional assessment of gender identity/dysphoria
• Conceptualizes gender identity as a bipolar continuum with a
male pole and a female pole and varying degrees of gender
gender uncertainty, or gender identity
dysphoria,
transitions between the poles
Prevalence of Gender Dysphoria in Children
•
Zucker and Lawrence (2009) state that estimates of prevalence in children rely on indirect
methods of data collection, such as:
– parental endorsement of behavioral items pertaining to gender dysphoria on omnibus questionnaires for
children
– referral rates to clinics specializing in the treatment of childhood gender dysphoria
•
•
Surveys of U.S. mothers indicate that about 1.5 percent of young boys wish to be a girl, and
3.5 percent of young girls wish to be a boy. (Comer, 2014, p. 357)
Internationally, Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker (2003) compared historical
on children referred to two clinics for gender dysphoric behavior:
Gender Identity Clinic
Centre for Addiction and Mental Health
Toronto, Canada (1974-2000)
• Sex ratio of 5.75:1 of boys to girls in
358 children (ages 3-12)
Gender Clinic
Department of Child & Adolescent
Psychiatry, University Medical Center
Utrect, Netherlands (1988-2000)
• Sex ratio of 5.75:1 of boys to girls
in 358 children (ages 3-12)
• At both clinics, girls
showed higher average
levels of cross-gender
behavior than boys.
• Despite this, girls were
referred for treatment an
average of 10 months
later than boys.
(Cohen-Kettenis et al., 2003)
Prevalence of Gender Dysphoria in Adolescents/Adults
•
•
As with children, the best indirect method to measure population prevalence of gender
dysphoric adults is data on patients at hospital- and university-based gender clinics, which
serve as gateways for SRS. (Zucker & Lawrence, 2003, p. 13)
DSM 5 (APA, 2013): Population prevalence of gender dysphoria among U.S. adults is:
0.005-0.014% of natal males and 0.002-0.003% of natal females
•
Figures “likely modes underestimates” because not all adults seek the full complement of
SRS services at gender clinics (APA, 2013, p. 454)
Coleman et al. (2012) suggested clinics are not “affordable, useful, or
acceptable” to meet the needs of all gender dysphoric individuals. (p. 7)
•
Thus, indirect estimates fail to account for:
– People seeking care elsewhere (e.g., individual/family therapy, peer support, facial surgery)
– Those not seeking treatment (p. 7)
Zucker and Lawrence (2009) analyzed records from 25 gender clinics
worldwide and developed “crude estimates” of trends in adult prevalence:
•
•
More MFs attend clinics than FMs by a ratio of roughly 2:1
FMs apply for and undergo SRS at younger ages than MFs (p. 13)
1960s-1990s: 300-800% increase in gender dysphoric patients
presenting at Western European clinics (p. 16)
Comorbidities: GD Children & Teens
Children:
•
•
•
Co-occurring disorders in clinically referred children with gender dysphoria include
“internalizing disorders,” such as anxiety and depression and “externalizing disorders,” such
as disruptive and impulse-control disorders
Gender dysphoric children also have higher rates of autism spectrum disorders than the
general population. (APA, 2013, pp. 458-459; Coleman at al., 2010, p. 12)
Children and adolescents who do not conform to socially prescribed gender norms may
experience harassment in school… putting them at risk for social isolation, depression, etc.
(Coleman et al., 2010, p. 14)
Adolescents:
•
•
•
Co-occurring disorders in clinically referred adolescents with gender dysphoria include
anxiety, depression, autism spectrum disorders, and the externalizing disorder,
oppositional-defiant disorder. (APA, 2013, p. 459; Coleman et al., 2010, p. 13)
Comorbid symptoms are sometimes more prevalent and intense in adolescents when
compared to children. (Coleman et al., 2010, p. 13)
Prior to reassignment procedures, adolescents (and adults) with gender dysphoria are at
increased risk for suicidal ideation, suicide attempts, and suicides.
– Suicide risk may persist after procedure(s).
(APA, 2013, p. 454)
Comorbidities: Gender Dysphoric Adults
All age groups: Gender dysphoria… is associated with high levels of stigmatization,
discrimination, and victimization, leading to negative self-concept, increased rates of
mental disorder comorbidity, school dropout, and economic marginalization, including
unemployment, with attendant social and mental health risks, especially in individuals
from resource-poor backgrounds. (APA, 2013, p. 458)
Cole, O’Boyle, Emory, and Meyer (1997) evaluated 435 self-reported transsexuals
applying for SRS at a gender clinic for histories of substance abuse, psychiatric
disorders, self-harm, and suicidality.
•
•
•
•
Sample:
318 MFs & 117 FMs, respective average ages 32 & 30
A authentic sample would show “commitment and
involvement in the ‘real life’ transition process” (p. )
>60% undergoing hormone therapy
~30% MtF & 50% FtM previously underwent facial
surgery and/or chest augmentation/reduction
(Cole et al., 1997, p. 15-17)
Research Methods:
• 1-2 hour clinical interview
• Intake questionnaire
collecting
biographical/sociodemograph
ic, medical-psychosocial
information
• 93 MFs and 44 FMs also
completed MMPI
(Cole et al., 1997, p.
15)general population.
Findings: Incidence of diagnosable psychiatric issues similar to
A majority of individuals had long-term employment, lasting friendships and relationships,
and fulfilling lifestyles.
(Cole et al., 1997, p. 21)
Cole et al. (1997), Cont.
Substance Abuse
• 29% MF & 26% FM reported
past substance abuse that:
•
•
Negatively affected a
job/relationship OR
Required treatment through
counseling or a recovery
program
• All above participants stated
substance use was a way of
coping with gender dysphoria
(Cole et al., 1997, p. 17-18)
Suicidality
• 12% MF & 21% FM had
attempted suicide at least
once
•
•
•
•
•
•
Subjective descriptions:
“feeling isolated”
“not able to talk to others”
familial or social rejection
“disgust with anatomic state”
hopelessness
(Cole et al., 1997, p. 19)
Mental Health:
• 9% of participants had been treated for mood,
psychotic, personality, and/or nuerodevelopmental
disorders
• Depression was the most common treated disorder
• ~60% of patients with mood or psychotic disorders
were receiving ongoing drug therapy
(Cole et al., 1997, p. )
Prognosis: Gender Dysphoric Children & Adolescents
Children:
• Gender dysphoria in childhood does not inevitably continue into adulthood.
• Cohen-Kettenis (2001) and Zucker and Bradley (1995) conducted follow-up
studies of children (mainly boys) referred to clinics for gender dysphoria:
– 6-23% of these children experienced a persistence of symptoms into adulthood
– Boys in these studies were more likely to identify as gay in adulthood than
transgender
• 12-27% persistence rate in newer studies with more female participants
(Coleman et al., 2010, p. 11)
Adolescents:
• The persistence of gender dysphoria into adulthood appears to be much higher
for adolescents.
• In a follow-up study of 70 adolescents who were diagnosed with gender
dysphoria and given puberty suppressing hormones, all continued with actual
sex reassignment
• (Coleman et al., 2010, p. 11)
Prognosis: Gender Dysphoric Adults
• Studies as early as 1990 saw adult patient satisfaction with SRS to be as high as
87% in MFs and 97% in FMs
• Steady increase in patient satisfaction with SRS outcomes over the years
• Quality of surgical results is a strong predictor of future satisfaction
• Meta-analyses of follow-up studies of SRS patients show improved sense of
wellbeing, ratings of physical attractiveness, sexual function… even income levels
Cole et al. (1997) comorbidity study
(Coleman et al., 2012, pp. 7-8)
produced subjective reports of
increased happiness, competency,
and productivity in work and leisure
pursuits. Participants credited SRS
with decreasing in self-destructive
behaviors, including substance abuse,
self-harm, suicide attempts (p. 24)
Johansson et al. (2010) reviews Swedish literature on risk
factors for negative outcomes of SRS, which cites poor or lacking
familial and social support, severe psychopathology, unfavorable
physical appearance, and poor surgical result. (p. 1430)
(De Cuypere et al., 2005)
Note: Data typically reflects
outcomes for adults receiving
both hormone therapy and
SRS. Current methods make it
difficult to determine efficacy
of hormone therapy alone in
relieving gender dysphoria.
Dutch study of SRS outcomes in adolescents & adults
•
Smith, Van Goozen, Kuiper, & Cohen-Kettenis (2005) studied outcomes for adult and
adolescent patients seeking SRS at the VU University Medical Centre in Amsterdam or
University Medical Centre, Utrecht.
• Patients tracked by age, sex, sexual orientation, onset age of gender dysphoria, crossgender symptoms in childhood, and gender dysphoria at assessment. Gender
dysphoria, body dissatisfaction, evaluation of treatment and surgical results, and
psychological, social, sexual functioning were assessed between one and four years
after surgery.
• Of the 325 patients who applied for sex reassignment therapy, 222 started hormone
treatment and 188 completed sex reassignment surgery (Smith et al., 2005, p. 91).
• All patients who underwent both hormonal and surgical intervention showed
improvements in their mean gender dysphoria scores on the Utrecht Gender Dysphoria
Scale.
• 91.6% were satisfied or very satisfied with their overall appearance after surgery.
• 98.4% of patients expressed no regrets about sex reassignment after surgery (Smith et
al., 2005, p. 94).
*One MtF expressed deep regrets. She indicated that professional guidance regarding
adverse consequences (i.e., intolerance of society, family and her own children), would
have made the transition more endurable (p. 97)
Dutch study, cont.
Satisfaction with surgery:
• Overall, MtFs showed greater satisfaction with surgical results than FtMs, perhaps due
to the fact that FtMs are generally advised to postpone metaidoioplasty
(transformation of the hypertropic clitoris into a micropenis) or phalloplasty in view of
steadily improving surgical techniques.
• 70% of MtFs were satisfied with their vaginoplasty.
• 65.4% MtFs were satisfied with their breast augmentation.
• 28.9% of FtMs were satisfied with breast removal; 57.9% were not completely satisfied
(Smith et al., 2005, p. 95)
*“Dissatisfaction with appearance predicted poor post-operative functioning, either
because it directly and adversely affected psychological stability or mood, or it indirectly
affected the way they were socially treated (or a combination of both)” (Smith et al., 2005,
p. 98).
Relationships and sexuality:
• 88.5% of participants who had a sexual partner at follow-up were satisfied with their
sex lives.
• 82.4% of participants were sexually active at follow-up (Smith et al., 2005, p. 95).
• MtFs and FtMs showed equal satisfaction with their sex lives (Smith et al., 2005, p. 97)
Dutch study, cont.
Psychological functioning:
• The psychological functioning of patients was measured using two indexes:
– Dutch Short MMPI – 83 items measuring negativism, somatization, shyness, psychopathology,
and extroversion
– Symptom Check List – 90 items inquiring into recent symptoms of agoraphobia, anxiety,
depression, somatization, obsession/compulsion, suspicion, hostility, and sleep disturbance
(Smith et al., 2005, p. 92)
•
MMPI scores in most categories of psychological functioning were within average
ranges for the Dutch population as a whole both before and after treatment, the
exceptions being high pre-test scores for somatization and low post-test scores for
extroversion.
• MMPI scores showed varying degrees of improvement in negativism, shyness,
somatization, psychopathology, and extroversion in MtF and FtM patients.
• MtFs rated as more depressed than FtMs on the Symptom Check List post-test (Smith,
2005, p. 94).
*“A non-homosexual orientation, with more psychopathology and dissatisfaction with
secondary sex characteristics predicted unfavourable post-operative functioning” (Smith et
al., 2005, p. 98).
Dutch study, cont.
Social adjustment and acceptance:
• 42% of patients had jobs or were students; 56.3% were unemployed.
• 56.2% lived independently and 25.7% cohabitated with another adult without children
(Smith et al., 2005, p. 94).
• 98% felt they were completely taken seriously by most people.
• 89% felt accepted by most people, 7.9% by some, 3% by no one.
• 83.2% felt supported in their new gender role by everyone or almost everyone they
knew.
• 96.1% reported they could rely on at least some others during difficult times.
• 20% felt they were sometimes being laughed at or had been ridiculed by strangers
(Smith, 2005, p. 95)
Five-year follow-up study of Swedish adults
•
•
•
•
•
•
•
•
Johansson, Sundbom, Höjerback, and Bodlund (2010) investigated the clinicians’
and patients’ evaluations of the sex reassignment process at a Swedish gender
clinic after five years and/or two years after surgery
Patients (42 MtFs & 17 FtMs) responded to semi-structured interview questions
about relief of gender dysphoria, use of mental health services, state of physical
health, employment and finances, quality of intimate, family, and social
relationships, and sexuality
95% of patients rated themselves as “globally improved,” with no difference
between sexes
90% of patients satisfied with hormone therapy; 67% satisfied with genital surgery
38% of patients had a partner: 36% of MtFs & 41% of FtMs
62% of patients were employed or students
95% of patients reported their sex life as improved or unchanged after sex
reassignment and hormone therapy
Clinicians rated 62% of patients as “globally improved,” 24% as “unchanged,” and
14% as “worse” based on work situation, social relationships, financial situation,
romantic partnerships, use of psychiatric care and Global Assessment of
Functioning
References
Arcelus, J., Bouman, W. P., Van Den Noorgate, W., Claes, L., Witcomb, G., Fernandez-Aranda, F. (2015). European Psychiatry, 30, 807-815.
Bockting, W. O., Knudson, G., & Goldberg, J. M. (2006). Counseling and mental health care for transgender adults and loved ones. International Journal of
Transgenderism, 9(3/4), 35-82.
Cohen-Kettenis, P. T., & Pfäfflin, F. (2010). The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior,
39(2), 499-513.
Cohen-Kettenis, P. T., Wallien, M., Johnson, L. L., Owen-Anderson, A. F. H., Bradley, S. J., & Zucker, K. J., (2006). A parent- report gender identity questionnaire
for children: A cross-national, cross-clinic comparative analysis. Clinical Child Psychology and Psychiatry, 11(3), 397-405.
Cole, C. M., O’Boyle, M., Emory, L.E., & Meyer III, W. J. (1997). Comorbidity of gender dysphoria and other major psychiatric diagnoses. Archives of Sexual
Behavior, 26(1), 13-26.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., De Cuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., & Monstrey, S., (2012).
Standards of care for the health of transsexual, transgender, and gender-nonconforming people (7th version). Minneapolis, MN: The World Professional
Association for Transgender Health.
De Cuypere, G., T’Sjoen, G., Beerten, R., Selvaggi, G., De Sutter, P., Hoebeke, P. … Rubens, R. (2005). Sexual and physical health after sex reassignment
surgery. Archives of Sexual Behavior, 34(6), 679-690.
Deogracias, J. J., Johnson, L. L., Meyer-Bahlburg, H. F. L., Kessler, S. J., Schober, J. M., Zucker, K. J., (2007). The gender identity/gender dyphoria questionnaire
for adolescents and adults. Journal of Sex Research, 44(4), 370-379.
Devor, A. H. (2004). Witnessing and mirroring: A fourteen stage model. Journal of Gay and Lesbian Psychotherapy, 8(1/2), 41-67.
Doorn, C. D., Poortinga, J., Verschoor, A. M., (1994). Cross-Gender Identity in Transvestites and Male Transsexuals. Archives of Sexual Behavior, 23(2), 185201.
Johansson, A., Sundborn, E., Höjerback, T., & Bodlund, O. (2010). A five-year follow-up study of Swedish adults with gender identity disorder. Archives of
Sexual Behavior, 39(6), 1429-1437.
Johnson, L. L., Bradley, S. J., Birkenfeld-Adams, A. S., Radzins Kuksis, M. A., Maing, D. M., Mitchell, J. N., Zucker, K. J, (2004). A parent-report gender identity
questionnaire for children. Archives of Sexual Behavior, 33(2), 105-116.
Knudson, G., De Cuypere, G., & Bockting, W. (2010b). Recommendations for revision
of the DSM diagnoses of gender identity disorders: Consensus statement of The World
Professional Association for Transgender Health. International Journal of
Transgenderism, 12(2), 115-118.
Smith, Y. L. S., Van Goozen, S. H. M., Kuiper, A. J., & Cohen-Kettenis, P. T., (2005). Sex
reassignment: Outcomes and predictors of treatment for adolescent and adult
trannsexuals. Psychological Medicine, 35(1), 88-99.
Zucker, K. J., & Lawrence, A. A. (2009). Epidemiology of gender identity disorder:
Recommendations for the standards of care of The World Professional Association for
Transgender Health. International Journal of Transgenderism, 11(1), 8-18.