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性别不一致[a](英语:gender incongruence)的特点是个人认同的性别与天生的性别之间存在显著且持续的不一致[1]。其在DSM-5中对应为性别不安(英语:gender dysphoria)[b][c]。
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“性别认同障碍”(或称:易性症[7]、性身份障碍、性别识别障碍)在DSM-5(2013年出版)中被重新分类为“性别不安”,以消除与术语“障碍”相关的污名。[8]在ICD-11(2022年生效)中,其被重新命名为“性别不一致”。
性别不安与非常规性别不同。[9]根据美国精神医学学会的说法,性别不安的关键因素是“临床上的显著痛苦”。[3]一些跨性别和研究人员支持性别认同障碍的重新分类,因为他们说诊断会使非常规性别病理化,并强化了性别二元论的模型。[10][11][12]
有研究证据表明,性别不安存在遗传原因。[13][14]性别不一致的治疗可能涉及支持患者改变性别表现。透过性别肯定激素治疗(GAHT)或性别肯定手术可以用来协助这种改变。[5][4]治疗还可能包括心理咨询或心理治疗。[4]
许多性别不安者都有强烈的、持久的愿望,希望过一种“符合”或实现其性别认同的生活。他们通过改变自己的外表和行为方式来实现这一愿望。[15]
一些性别不安者,但不是所有的人,可能想使用激素,有时想通过手术来表达他们的性别认同。[15]
性别不安不是一种精神疾病,但有些人可能因为性别不安而产生心理健康问题。[15]
性别不安与性倾向无关。性别不安者可能会认为自己是异性恋、男同性恋、女同性恋或双性恋。[15]
一个人感觉到的性别与被分配的性别(通常在出生时)不一致而产生的困扰是性别不一致的主要症状[16][17]。
出生时被分配为男性的人的性别不一致(通常被称为AMAB)倾向于遵循两种广泛的轨迹之一:早发或晚发。早发的性别不一致在童年时行为上就很明显。有时,这一群体的性别不一致会停止一段时间,他们会在一段时间内认同为同性恋者,然后再复发性别不一致。这类人在成年后通常会被其出生时的性别所吸引,通常被认定为异性恋。迟发的性别不一致并不包括早期儿童时期的明显迹象,但有些人报告说,他们在童年时曾有过成为异性的愿望,但没有向他人报告。[18]出生时被分配为男性的人,如果有迟发的性别不一致,通常会因性兴奋而变装。[19]出生时被分配为男性的跨性别者,如果经历晚发的性别不一致,通常会被女性所吸引,并可能被认定为女同性恋或双性恋者,而早发的通常会被男性所吸引。[18]类似的模式也发生在出生时被分配为女性的人(AFAB)身上,经历早发的性别不一致的人最有可能被女性吸引,而晚发的人最有可能被男性吸引并被认定为同性恋。[18]在AFABs中,早发的性别不一致是最常见的。[18][19]
性别不一致儿童通常有以下情况:喜欢异性典型的玩具、游戏或活动;讨厌自己的生殖器;以及非常喜欢异性玩伴。[20]一些儿童也可能经历与与同龄层的社会隔离,焦虑,孤独和抑郁。[21]据美国心理学会称,跨性别儿童比其他儿童更容易在学校,寄养,住宿治疗中心,无家可归者中心和少年司法方案中遭受骚扰和暴力。[22]
在青少年和成年人中,症状包括渴望成为另一性别并被当作另一性别对待。[20]成年性别不一致者面临更大的压力、孤独、焦虑、抑郁、自卑和自杀风险。[21]跨性别者还面临饮食失调[23]和药物滥用[24]的高风险。
在许多案例中性别不一致通常是在小时候就会出现,但也有在青春期或成人时才出现的可能,并且随着年纪增长而越来越强烈[25]。由于许多文化并无法接受跨性别的行为,这种感觉往往为当事人以其家人、朋友带来许多问题。在许多案例的报告中,也有人的不适感是觉得自己的身体“出了差错”,或从一开始就不应该是如此。
当一个人因性别认同而感到不满时,性别不一致就会存在,从而导致他们情绪低落。[26]研究人员对性别不一致者的痛苦和损伤的本质持不同意见。一些研究人员认为,性别不一致者受苦是因为他们受到羞辱和暴力。[27]而且,如果社会性别分化不那么严格,跨性别就会遭受少一点的痛苦。[28]
性别不一致的确切成因尚未明确。[15]有研究证据表明,遗传因素在性别不一致的发展中起主要作用[29][30],性别认同被认为可能反映了生物、环境和文化因素的复杂相互作用。[31]
根据《国际疾病与相关健康问题统计分类》第十版(1993),列出与性别认同有关的几种疾病:[32][33]
- 易性症(F64.0):渴望成为及被接受为相反性别的成员,通常伴随着性别重置手术和激素治疗的欲望。
- 儿童性别认同障碍(F64.2):一个人对于自身的指定性别而持续强烈的痛苦,并且在青春期之前表现出来。
- 其他性别认同障碍(F64.8)
- 性别认同障碍,不明确(F64.9)
- 性成熟障碍(F66.0):关于一个人的性别认同或性取向的不确定性,导致焦虑或痛苦。[34]
根据《精神疾病诊断与统计手册》第四版(1994),要被诊断判定为“性别认同障碍”前,须达到五项条件:
[35]
- 必须要有证据显示有强烈且持续的跨性别认同感。
- 跨性别认同感不可以是因为认为另一种性别在文化上有更多优势而产生的。
- 同时也必须要有证据显示对于天生的性别有持续性的不适应感,或是无法适应自己所属性别的性别角色。
- 当事人不可同时拥有身体上的双性人状态(例如睾脂酮不敏症候族或先天性肾上腺增生症)。
- 必须要有临床上的证据能显示当事人在社交、工作或其他重要领域上遭遇显著的挫折或伤害。
根据《精神疾病诊断与统计手册》第五版(2013),要被诊断判定为“性别不安”前,青少年或成人须至少符合两个标准以及持续至少六个月:[36]
儿童性别不安诊断需要表现为下列至少六项且持续至少六个月:[37]
- 强烈抵抗指定性别的装扮,强烈偏好指定性别以外性别装扮。
- 在假扮或幻想游戏中强烈希望扮演指定性别以外性别角色
- 强烈希望成为或坚持自身就是指定性别以外的性别。
- 强烈偏好另一种性别通常使用的玩具或参与的活动
- 强烈希望第一或第二性征与自己体验的性别相匹配
- 强烈偏好另一种性别玩伴
- 强烈厌恶自身性生理特征
此外,该病症必须与临床上显著的痛苦或损害相关。[36]
DSM-5将性别不安从性偏离中移除,并将其纳入其他的类别。[36]在性别认同障碍被批评为污名后,该诊断被重新命名为性别不安,[38]并删除了子类别中的性取向。儿童的诊断与成人的诊断被分开,如“儿童性别不安”。为儿童建立一种特定的诊断反映了儿童较少有能力洞察他们正在经历的事情,或者让他们表达自身正在经历的事情。[39]如果一个人不符合性别不安的标准但仍有临床上显著的痛苦或损伤,则可以诊断出“其他性别不安”或“性别不安,不明确”。[36]
根据《国际疾病与相关健康问题统计分类》第十一版(2019),对性别认同相关疾病的分类进行重大修订,[40]将“性别认同障碍”从精神障碍的分类中移除,更名为“性别不一致”,并重新归入“性健康”一栏。[41]截至2018年8月 (2018-08)[update],ICD-11这种情况列为“性别不一致”。[42]
- 青春期或成年期性别不一致(HA60):取代 F64.0
- 童年期性别不一致(HA61):取代 F64.2
- 未特指的性别不一致(HA6Z):取代 F64.9
在ICD-11中,由于缺乏公共卫生或临床意义,双重角色异装癖被移除。[43]此外,已经移除了性成熟障碍。[44]
在ICD-11中,其解释类似于DSM-V的定义,但不需要明显的痛苦或损害。[42]
在ICD-10中,按照当时的惯例,性别认同障碍被列入精神障碍一章。在整个20世纪,ICD和DSM都从精神病理学的角度探讨了跨性别,因为跨性别呈现出某人的性别指定和他们的性别认同之间的差异。由于这可能导致精神痛苦,因此被认为是一种精神障碍,痛苦或不适是核心诊断特征。[45][46][47]在2000年代和2010年代,这种观念受到了越来越多的挑战,因为一些人认为将跨性别视为一种精神障碍是一种耻辱。有人认为,跨性别者的痛苦和功能障碍应被视为社会对具有性别差异外表和行为的个人的排斥、歧视和(性)暴力的结果,这样做更为恰当。[48]研究表明,跨性别者比其他人群更有可能出现心理健康问题,但针对跨性别者的健康服务往往不足或不存在。由于通常需要一个正式的ICD代码来获得治疗和报销,世界卫生组织认为将跨性别从ICD-11中全部删除是不明智的。因此,决定将这一概念从精神障碍章节移至新的性健康章节。[43]
诊断为性别不一致的治疗可能包括心理咨询、支持患者的性别表达、激素治疗或手术。这可能涉及到医疗干预(如激素治疗、生殖器手术、电解或激光脱毛、胸部/乳房手术或其他重建手术)导致的身体过渡。[15]治疗的目标可能仅仅是减少患者跨性别状态引起的问题,例如:为患者提供咨询,以减少与变装相关的内疚感。[49]
已有机构制定了指导方针来帮助临床医生。世界跨性别人士健康专业协会(WPATH)的护理标准被一些临床医生用作治疗指南。治疗指南通常遵循“减少伤害”模式。[50][51][52]
Davidson, Michelle R. (2012). A Nurse's Guide to Women's Mental Health. Springer Publishing Company. p. 114. ISBN 0826171133
Gender Dysphoria (PDF). American Psychiatric Publishing. [December 24, 2016]. (原始内容 (PDF)存档于2016-12-29).
American Psychiatric Association, DSM-5 Fact Sheets, Updated Disorders: Gender Dysphoria (页面存档备份,存于互联网档案馆) (Washington, D.C.: American Psychiatric Association, 2013): 2 ("DSM-5 aims to avoid stigma and ensure clinical care for individuals who see and feel themselves to be a different gender than their assigned gender. It replaces the diagnostic name 'gender identity disorder' with 'gender dysphoria', as well as makes other important clarifications in the criteria.").
Bryant, Karl. Gender Dysphoria. Encyclopædia Britannica Online. 2018 [August 16, 2018]. (原始内容存档于2020-04-18).
Fraser, L; Karasic, D; Meyer, W; Wylie, K. Recommendations for Revision of the DSM Diagnosis of Gender Identity Disorder in Adults. International Journal of Transgenderism. 2010, 12 (2): 80–85. S2CID 144409977. doi:10.1080/15532739.2010.509202.
Newman, L. Sex, Gender and Culture: Issues in the Definition, Assessment and Treatment of Gender Identity Disorder. Clinical Child Psychology and Psychiatry. July 1, 2002, 7 (3): 352–359. S2CID 145666729. doi:10.1177/1359104502007003004.
Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T'Sjoen G. Gender identity disorder in twins: a review of the case report literature. The Journal of Sexual Medicine. March 2012, 9 (3): 751–7. PMID 22146048. doi:10.1111/j.1743-6109.2011.02567.x. Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same‐sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P = 0.005)... These findings suggest a role for genetic factors in the development of GID.
Diamond, Milton. Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation. International Journal of Transgenderism. 2013, 14 (1): 24–38. S2CID 144330783. doi:10.1080/15532739.2013.750222. Combining data from the present survey with those from past-published reports, 20% of all male and female monozygotic twin pairs were found concordant for transsexual identity... The responses of our twins relative to their rearing, along with our findings regarding some of their experiences during childhood and adolescence show their identity was much more influenced by their genetics than their rearing.
Zucker, Kenneth J.; Lawrence, Anne A.; Kreukels, Baudewijntje P.C. Gender Dysphoria in Adults. Annual Review of Clinical Psychology. 2016, 12: 217–247. PMID 26788901. doi:10.1146/annurev-clinpsy-021815-093034. [For DSM-5] a reconceptualization was articulated in which 'identity' per se was not considered a sign of a mental disorder. Rather, it was the incongruence between one’s felt gender and assigned sex/gender (usually at birth) leading to distress and/or impairment that was the core feature of the diagnosis.
Lev, Arlene Istar. Gender Dysphoria: Two Steps Forward, One Step Back. Clinical Social Work Journal. 2013, 41 (3): 288–296. S2CID 144556484. doi:10.1007/s10615-013-0447-0. [Despite some misgivings], I think that the change in nomenclature from the DSM-IV to the DSM-5 is a step forward, that is, removing the concept of gender as the site of the disorder and placing the focus on issues of distress and dysphoria.
Ansara, Y. Gavriel; Hegarty, Peter. Cisgenderism in psychology: pathologising and misgendering children from 1999 to 2008. Psychology and Sexuality. 2012, 3 (2): 137–60. doi:10.1080/19419899.2011.576696.
Harmon, A., & Oberleitner, M. G. (2016). Gender dysphoria. In Gale (Ed.), Gale encyclopedia of children's health: Infancy through adolescence (3rd ed.). Farmington, MI: Gale.
Davidson, Michelle R. (2012). A Nurse's Guide to Women's Mental Health. Springer Publishing Company. p. 114. ISBN 0826171133
Bryant, Karl Edward. The Politics of Pathology and the Making of Gender Identity Disorder. Ann Arbor, Michigan: ProQuest Dissertations & Theses (PQDT). 2007: 222. ISBN 9780549268161.
Giordano, Simona (2012). Children with Gender Identity Disorder: A Clinical, Ethical, and Legal Analysis. New Jersey: Routledge. p. 147. ISBN 0415502713.
Heylens G, De Cuypere G, Zucker KJ, Schelfaut C, Elaut E, Vanden Bossche H, De Baere E, T'Sjoen G. Gender identity disorder in twins: a review of the case report literature. The Journal of Sexual Medicine. March 2012, 9 (3): 751–7. PMID 22146048. doi:10.1111/j.1743-6109.2011.02567.x. Of 23 monozygotic female and male twins, nine (39.1%) were concordant for GID; in contrast, none of the 21 same‐sex dizygotic female and male twins were concordant for GID, a statistically significant difference (P = 0.005)... These findings suggest a role for genetic factors in the development of GID.
Diamond, Milton. Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation. International Journal of Transgenderism. 2013, 14 (1): 24–38. S2CID 144330783. doi:10.1080/15532739.2013.750222. Combining data from the present survey with those from past-published reports, 20% of all male and female monozygotic twin pairs were found concordant for transsexual identity... The responses of our twins relative to their rearing, along with our findings regarding some of their experiences during childhood and adolescence show their identity was much more influenced by their genetics than their rearing.
Potts, S; Bhugra, D. Classification of sexual disorders. International Review of Psychiatry. 1995, 7 (2): 167–174. doi:10.3109/09540269509028323.
American Psychiatry Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) 5th. Washington, DC and London: American Psychiatric Publishing. 2013: 451–460. ISBN 0-89042-555-8.
Reed GM, Drescher J, Krueger RB, Atalla E, Cochran SD, First MB, Cohen-Kettenis PT, Arango-de Montis I, Parish SJ, Cottler S, Briken P, Saxena S. Disorders related to sexuality and gender identity in the ICD-11: revising the ICD-10 classification based on current scientific evidence, best clinical practices, and human rights considerations. World Psychiatry. October 2016, 15 (3): 205–221. PMC 5032510 . PMID 27717275. doi:10.1002/wps.20354.
Cohen-Kettenis PT, Pfäfflin F. The DSM diagnostic criteria for gender identity disorder in adolescents and adults. Archives of Sexual Behavior. April 2010, 39 (2): 499–513. PMID 19838784. S2CID 16336939. doi:10.1007/s10508-009-9562-y. The DSM has consistently approached gender problems from the position that a divergence between the assigned sex or “the” physical sex (assuming that “physical sex” is a one-dimensional construct) and “the” psychological sex (gender) per se signals a psychiatric disorder. Although the terminology and place of the gender identity disorders in the DSM have varied in the different versions, the distress about one’s assigned sex has remained, since DSM-III, the core feature of the diagnosis.
Lawrence AA. Gender Dysphoria. Beidel DC, Frueh BC (编). Adult Psychopathology and Diagnosis 8th. John Wiley & Sons. 2018: 634 [2022-01-08]. ISBN 978-1-119-38360-4. (原始内容存档于2022-01-08). The World Professional Association for Transgender Health (WPATH), for example, defined GD as “discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics)”
Leiblum, Sandra. Principles and Practice of Sex Therapy, Fourth Edition. The Guilford Press. 2006: 488–9. ISBN 978-1-59385-349-5.
Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. July 2013, 132 (1): 198–203. PMID 23796746. doi:10.1542/peds.2013-1282 . However, adolescents with multiple or anonymous partners, having unprotected intercourse, or having substance abuse issues should be tested at shorter intervals.
APA Policy Statements on Lesbian, Gay, Bisexual, & Transgender Concerns (PDF). American Psychological Association. 2011 [August 27, 2013]. (原始内容存档 (PDF)于2022-01-21). BE IT FURTHER RESOLVED that APA recognizes the efficacy, benefit, and necessity of gender transition treatments for appropriately evaluated individuals and calls upon public and private insurers to cover these medically necessary treatments;