Treatment Implications
of the Relationship
between Gender
Dysphoria and
Dissociative Identity
Disorder
Heather Kacos, M.S.
[email protected]Steven Gold, Ph.D.
[email protected]Nova Southeastern University
The Case of Jane
• 21 year-old, single, Caucasian, transgender (MtF) female
• Referred from her college counseling center
• Reason for Referral – recent suicide attempt and marked
symptoms of depression, including withdrawal from all but 1
class
• Presenting Problems:
• Depression
• Anxiety including panic attacks and PTSD symptoms
• Dissociation
• Presented with ~8 alters, 2 predominant, both male and female
• Reported losing time, feeling as if surroundings are suddenly not real, or
people or places suddenly become unfamiliar
• Gender Dysphoria
• Self-injury, severe agoraphobia, no family/social support
History of Presenting Problem
• Physical and verbal/emotional abuse from mother and older brother
• Sexual abuse for several years from brother’s male friend
• Long standing history of cutting, depression, suicidality since early
teens
• Reported first alter around age 9 – 10; female
• Began to go by female name in online forums and feel discomfort in
male gender around age 11
• Stopped thinking of herself as male ~12 years old
• HRT began at end of highschool began passing during freshman
year of college
Interesting Points
• Jane dressed “tom-boyish”
• Identified as pan-sexual (not uncommon necessarily)
• Uncomfortable with “non-feminine” features
• However, does not want reassignment surgery
• Has means and information to change her legal name, yet has
not
• Jane’s main alters are female
Notes on Gender Dysphoria
• Natal gender/gender assignment = biological, initial assignment of
gender
• Gender identity = social identity factor
• Gender Dysphoria = individual’s affective/cognitive discontent with
the assigned gender
• Can refer to distress from incongruence between one’s experienced or
expressed gender and one’s assigned gender
• DSM-V diagnosis focuses more on the dysphoria and less on identity
• Transsexual = once person starts passing as opposite gender in
society and typically utilizes HRT and seeks reassignment surgery
• Most common comorbidity = Anxiety and Depressive Disorders
• DSM-V does not list any dissociative disorders as differential or
comorbid diagnoses
• However, research has shown that DID is recognized/diagnosed in patients
diagnosed with GID/GD (Schwartz, 1988; Saks, 1998; Devor, 1994; Rosik, 2012)
Notes on Dissociative Identity Disorder
• Most prevalent comorbidity is PTSD
• DSM-V does not describe GD as a differential diagnosis or
comorbid diagnosis
• Individuals can experience feeling as if their body is different
(i.e., the opposite gender)
• Alterations in sense of self, loss of personal agency… leading to feeling as
if one is not in control
• In cases of prolonged abuse…individuals may not feel they are entitled to
control over their own body…if an opposite gender alter is prominent,
individual may feel inclined to “obey” and or “submit” to this identity and
live life as this identity and engage in behaviors to enhance this identity
(e.g., living as the opposite gender)
Gender Dysphoria and DID
• Notice of relationship between GD and DID dates back to the 80’s, and
continues to be identified in the literature, albeit still limited (Schwartz,
1988; Saks, 1998; Devor, 1994; Rosik, 2012; Gijs & DeCuypere, 2014)
• Despite DSM-V, literature has given voice to a relationship between GD
and DID, along with other dissociative disorders (Steinberg, 1995; Lai et al.,
2010; Rosik, 2012; Colizzi, Costa, Todarello, 2014; Colizzi, Costa, Todarello, 2015)
• Study of Taiwanese university students reporting GD, 16.3% of males
and 14.2% of females reported concomitant dissociative disorders (Lai,
Chiu, Gadow, Gau, & Hwu, 2010)
• Study in Italy identified lifetime prevalence of dissociative disorders
among patients with GD at 29.6% (n=118) (Colizzi, Costa, & Todarello, 2015)
• This is not to say GD and DID always go together, or that most
patients with GD are not good candidates for SRS, as most are, often
with significant improvement in functioning post-op (Cohen-Kettenis &
Gooren, 1999; Bonierbale et al., 2004; Weyers et al., 2009; Mullen & Moane, 2013; Colizzi,
Costa, & Todarello, 2014)
• Childhood abuse, including neglect seem to play a role in GD and DID
(Pauly, 1974; Lothstein, 1983; Devor, 1994; Kersting et al., 2003; Gehring & Knudson,
2005; Lai et al, 2010)
Treatment Implications
• Consider various options (e.g., HRT, SRS, non-medical
therapies)
• When GD is present, DID and other dissociative disorders
should be assessed for, particularly if history of childhood
abuse exists:
• SCID-D
• DES-II
• DDIS
• Use of a collaborative, non-coercive treatment that allows
patients to identify their own goals and work collaboratively
with the therapist
Contextual Model (Gold, 2000)
Ineffective, invalidating family environment consisting of:
• Insecure attachments
• Deficient and defective social learning
• Ineffective coping skills
• Ineffective family environment paired with a history of
trauma, leads to impairments in adulthood functioning and
increases vulnerability to victimization
Dissociation
• Inconsistent caretakers foster development of
disorganized attachment, which prevents attainment of a
cohesive sense of self
• Chaotic family environment coupled with severe trauma
leads to the more extreme end of dissociation, (i.e., DID)
Contextual Therapy
• Treatment focuses on remediating these deficits and
impairments in development through:
• A collaborative therapeutic alliance (and modeling secure attachment)
• Client-guided conceptualization
• Skills transmission
• Treatment is conducted as a series of priorities, in order to
meet the client where they are at and focus on their specific
needs
• Priority 1: Learning to manage distress
• Priority 2: Fostering experiential presence and continuity
• Priority 3: Developing critical thinking and judgment
• Priority 4: Breaking and replacing maladaptive patterns of behavior
• Priority 5: Trauma Processing (if appropriate)
• Priority 6: Expansion of adaptive living skills
**Emphasis of treatment goals are dependent on the needs of the client
WPATH
• World Professional Association for Transgender
Health (WPATH)
• Established guidelines for assessing individuals with gender
dysphoria prior to receiving reassignment surgery
• “The psychiatric evaluation consists of verifying the following
main criteria: to accurately diagnose the gender dysphoria
(DSM criteria fulfilled); to verify the persistence of the request;
to diagnose/treat any comorbid psychiatric conditions. It is
important to note that gender nonconformity is not in itself a
mental disorder” (Coleman, et al. 2012; Colizzi, Costa,
Todarello, 2014).
(Coleman et al., 2012)
Future Directions
• Research surrounding those utilizing HRT only and not
seeking SRS
• Limited research has been done on the impact of hormone therapy (see
Murad et al., 2011 for a review)
• Understanding dissociation in the context of GD
• Longitudinal studies with larger sample sizes
• Research conducted in this country (societal and cultural
implications may make it difficult to generalize research done
in other countries to a transgender/transsexual population in
America)
References
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